Chapters Transcript Video Ultrasound (US) Applications in Neuro-Rehab: How US Changes Clinical Practice Katharine E. Alter, M.D. presents at the Johns Hopkins Department of PM&R’s Grand Rounds on January 29, 2019. Yes. Yeah. So I want to thank you all for inviting me. I mean, the first thing we're gonna do is dim the lights because I'm talking about ultrasound and tends to occur in the dark. So you need to learn to live in a low light conditions here. You see, when you go to radiology, you see the radiologists sitting in these dark rooms and they come out and they're squinting and you know, some of us as physical medicine doctors are like that too because we spend all of our time doing ultrasound. So I I'm um it is, I was introduced, I'm a technically I'm a pediatric physical medicine. First of all, are you guys psychiatrists or physiatrists? Iii I always have to ask this question about, you know, whether I'm being politically incorrect to say psychiatrist because I grew, I grew up medically in Ohio and we're physiatrists there. So, you know, I'm gonna say psychiatrist and if I'm offending anybody, I'm I'm sorry. Um and I, I'm a pediatric psychiatrist, but I spend at least 50 to 60% of my time treating adults. And people think of me also as a in the neuro field. But I also spend a significant percentage of my time in the muscular skeletal field. And I think that many people when they think about ultrasound applications in physical medicine, really think about it for MS K applications, tendon problems, joint problems, procedural guidance for MS K applications. But really there's a big, a big need for this in the neuro side of our field as well. And that's I sort of shifted my talk when Stephanie and I initially talked about me coming up, I was going to talk about ultrasound guidance for chemo innovation procedures, which is a large, a big part of what I do. But I wanted to expand that to talk really about ultrasound applications in neuro rehab. And I'm not trying to do this to exclude the MS K side, but I just couldn't do that in an hour. So these are my disclosures and already mentioned that, you know, so ultrasound is really a great application for both MS K and for neuro rehab. And in both of those fields, it can be used for diagnostic imaging or procedural guidance. And I want to talk about both of those things, but really mostly on the neuro rehab field and, and talk a little bit about how ultrasound imaging sort of changes my practice or has changed my practice and my my ability to approach patients. And because it's really useful as an extension of the physical exam, it's not just an imaging technique. It really is an extension of your exam. It's used, I use it every day for diagnostic imaging and every day for procedural guidance. So it's, it's a big piece of, of, of my practice. I, if you're not familiar with the NIH is a large institution, um maybe not quite as spread out as Hopkins or as rabbit warranty as Hopkins. You guys are hard to find and hard to find your way around. But we're, we're located inside of a big fence because of security issues after 9 11. But there are I think 60 different buildings on campus and the clinical center. My first slide is the largest brick building, fun fact, largest brick building in the world and of those 27 institutes, if if all the patients come to come with some type of research problem, they are entered into a research study. But some of those studies are management of clinical care. So we may have natural history studies that patients come in and we follow over time for our clinical problems. And within all those institutes like the Eye institute, Neurology Institute, Heart Lung and Blood Cancer Institute, we have all these patients, there has to be a hospital that takes care of those patients. So there's a clinical center, the clinical center functions in a hospital just like, well, not just like any other hospital, but we have all the departments of any other hospital including rehabilitation medicine, which is where my office is I run the motion analysis laboratory within rehab medicine. We conduct our own independent research and we in rehab medicine and we in my lab provide support to other protocols, but we also run our own independent protocols. And with that, we see patients with musculoskeletal problems, we see patients with neurological problems and, and if you're an MS K person, you really need to understand neurological problems. And if you're a neurological person, you need to understand MS K issues because patients don't know that they're only supposed to present with one thing or another. You know, we see patients all the time who present with what's thought of as a musculoskeletal problem when really they have a neurological problem and I'm going to show a video of this. So my example here is a patient who has a test specific dystonia. This patient presents with an abnormal git and running and is referred to 20 different orthopedic surgeons and a physical medicine doctor. And eventually gets either to a movement disorders PM and R doctor or a movement disorders neurologist and is diagnosed with runners dystonia or in my CP world, an adult with cerebral palsy who has horrible hip pain and everybody thinks well, they just have hip pain because they have CP. But the person really has femoral tabular impingement syndrome as a result of mild lateral luxation of their hip. And so you need to be able to go back and forth between these different fields and not just exclusively silo yourself into one field or the other. If you're going into sports medicine, you still need to know neurological problems. And if you're going into a neurological field, you still need to understand musculoskeletal disorders. So that's sort of my soapbox about why we need to do this. So this is a video of a patient that was referred to me with an abnormal gate. And as I said, she's a 45 year old long distance runner who's been running for many, many years. And those videos show test specificity. So you can see that when she walks forward, she's got this abnormal oops come back here. She can't flex her knee, her right knee is stiff and everybody, they looked at her knee, she had an MRI of her knee, somebody aspirated her knee, she had steroid injections in her knee. Um And if you notice when you walk backwards, her gate was on was normal. So she came to us and we said you have, you have runners dystonia and the treatment of this largely is her neurological exam otherwise was completely normal. Her m imaging was completely normal. This is a disease that's a software issue, not a hardware issue. This is four weeks after botulinum toxin injections in erectus feri and you can see the before and after how much better she is, she was able to go back to running, but she'd spent five years not being able to run first and then not being able to walk correctly and had to change her occupation. She was a flight attendant and couldn't work because, and was on disability because she hadn't been diagnosed. And because the, the people in MS K had never heard of runners, Dystonia and I presented her case at the teach the teachers course at, at the A PM and R and also brought another patient of mine, a runner who I have no idea what's wrong with this guy and brought him into MS K people because I don't think he has runners, Dystonia. And we were trying to figure out from a musculoskeletal side, what is wrong with this guy? So we both learn from one another. So this is sort of my example of why you need to know both things. So I'm gonna focus just on the neuro side and talk a little bit about diagnostic imaging and procedural guidance and talk about evaluation of peripheral nerve and muscle. I'm not going to talk about joint and tendon and then talk for procedural guidance. I'm going to limit myself really to chemo innervation other than briefly mention inter operative ultrasound, which I also do. Um So what about this diagnostic applications? So we use ultrasound increasingly for evaluation of peripheral nerve disorders, including inherited or acquired generalized polyneuropathies, entrapment, uropathy or masses or tumors. There's a large field now of evaluation of ultrasound, including normative databases for nerve size conduction velocity. So acoustic appearance, the diagnosis, for instance, carpal tunnel syndrome can be established with ultrasound imaging. You can evaluate for masses or tumors. And then for neuromuscular diseases looking at both primary and acquired disorders of muscle. And I see kids who have congenital muscular dystrophy or other muscle disorders. And I also see uh probably the largest group of patients that are followed with late onset ta a disease who develop abnormal muscle. And we are studying these patients and selective weakness in these patients as well. So these all of these things can be looked at with ultrasounds. So I'm going to look at a few of these things including entrapment, neuropathies, masses and then neuromuscular focusing more on the congenital muscular dystrophy case study on these. So for peripheral nerve disorders, again, I said, you know, the probably the most common entrapment neuropathies, our median nerve at the wrist or carpal tunnel syndrome and cubital tunnel syndrome for the ulnar nerve, but also radial nerve as well. And we have available data that can help us with ultrasound, provide quantitative measures of peripheral nerve enlargement, son acoustic properties that can complement the sort of gold standard of emg or electromyography, nerve conduction testing. And it really is a useful extension to your exam. For instance, in a patient here, this is a patient was referred for a palmer mass and full disclosure, this was actually me, I had this mass in my in my hand for a while and I was going to go get it taken out and I ultrasounded it with a standard ultrasound machine and it looked like a ganglion. And then I was teaching at a Peral Nerve course using a very specialized ultrasound machine that has the transducers go up to 70 megahertz, which the resolution is like one or two microns for this thing. So what this thing actually was, was a schwa noma in the palmer cutaneous branch of the median nerve. So if I'd had this thing taken out, I would have had a patch of numbness in my hand as a result of excising this peripheral nerve rather than excising just the schwa. So just, I ended up having this thing taken out because we have to write a case report about the use of the high frequency ultrasound machine. And, and it was the MRI imaging, which was part of the protocol to get this thing taken out, said that it was a gangland and the pathology was Schwannoma. And the ultrasound said Schwannoma. So sometimes the ultrasound is more accurate than, than M I, it's certainly less expensive than MRI. It costs about $150 to do an ultrasound and it cost several $1000 to do an MRI and MRI wasn't particularly useful in this situation. So let's look at it. No, no, I know. But you know, I, they, they made me get it taken. Well, not they didn't make me get it taken out. But if, you know, Jeff stows at Ohio State, he's very persuasive and he said no, we really need to get this thing taken out so we can prove it's a s so I did, I was compliant. It's the only time I was compliant about anything. Uh, so what about carpal tunnel syndrome at the wrist? Why do you need ultrasound? We've got, we've got, we've got nerve conduction testing. Emg isn't particularly helpful but nerve conduction testing. I mean, we know, you know, slowed conduction across the, you know, carpal tunnel. So, you know, you can come up with lots of good diagnostic imaging. But what that doesn't show you is variations. So what ultrasound adds for you is things like looking at a bio median nerve or persistent median artery that you can't tell when you're doing nerve conduction testing. It also can show things like a lipoma. That's actually the cause of the carpal tunnel syndrome rather than entrapment within the, you know, under the transverse carpal limit ligament. This is actually extrinsic compression of the median nerve from a lipoma. And if they had gone in there and released her carpal tunnel, especially endoscopically, they wouldn't have seen this thing if they, if they, if they had done an open release, they still might not have seen it because it was asymmetric to the nerve. So it really does provide this additional benefit to standard nerve conduction testing. And another problem with crowding of the median nerve is intrusion of the flexo digital superficiality within the carpal tunnel, that the muscle fascicle actually extend more distal than is normal. And when you flex your fingers, the muscle actually intrudes into the carpal tunnel and traps the nerve. So there's a whole bunch of different things with ul nerve. You can do dynamic imaging of the ulnar nerve, doing subluxation maneuvers and prove that the nerve is either subluxing or not in a patient that you think has cubital tunnel syndrome. So it really does provide this additional benefit. What about other unusual peripheral nerve entrapments? So everything I do is or almost everything I do is unusual at NIH because nobody has sort of standard things. So I I work on a study of patients with Melas, which is a rare proliferative bone disorder that leads to a enlargement of a number. It can be any bone in the body and in some people, it's regional, some people, it's very localized, but this was a patient who had mass in her tia in the anti tibia and also in her, her fibula and she had a many year history of neurotic pain within the distribution of the saphenous nerve. And I work in the EMG lab as well as the gate lab at NIH and the neurologist that did her nerve conduction testing, suspected of a saphenous nerve entrapment from this bony enlargement of the tibia dysli but the nerve conduction testing was totally unrevealing. She couldn't even find the, the nerve because of all this bony enlargement. So we went and did ultrasound on her and we were able to show this is actually we were able to, I was able to track the saphenous nerve from proximal to distal and show this local area of enlargement of the saphenous nerve. It should be about 1/10 that size of that nerve. When a nerve gets entrapped, it gets enlarged proximally. So we were able to measure this and then I ended up doing a nerve block. So I did an ultrasound guided LICA nerve block and her pain went away for the first time in seven or eight years. I wasn't able to sometimes you can hybrid dissect these things, you can go in and just lift the nerve or the bone away. But she had, she was so surrounded in, in, in her calcified bone that I couldn't do this. So we sent her to a plastic surgeon, an orthopedic surgeon who, you know, essentially tunneled this nerve out and gave her pain relief. So the ultrasound, the electro diagnostic testing was, we knew what the problem was. But the, but the ed testing didn't, wasn't helpful, but the ultrasound really gave us this additional piece of information. So, entrapment or oath, it's really useful to add as an extension of your electro diagnostic testing. I'm not saying it replaces it. It's an extension of this. And then what about masses? I mean, I think probably even if you're not used to seeing ultrasound images and, and you know, when, when you first start doing ultrasound or looking at ultrasound, everything looks gray and white or gray and black, just like when somebody told you if you, when you did emg for the first time that this was a fib or this was a positive sharp wave and you're like, yeah, right? Um The same thing with ultrasound, you train your eye to see these things, but I don't think that it takes much training to see this giant mass sort of a mixed echotexture mass of gray or white. And you can see there's actually this is the nerve on either side of this. This is a uh you can see a mouse. Oh You don't see your mouse. I'm sorry. Is there a rat? I gonna point her. I'm sorry about that. I've been pointing at things all along, but just a all right. That thing is a mask. This is the skin so superficial is the top of the image deep is at the bottom of the image. And this is an imaging of the fibular nerve, right? And this is this giant mask in the fibular nerve. Um And this is a more distal uh this is a long ax access you extended field of view image. So I can I could image the entire length of the nerve, the ultrasound machine stitches the images together to give you this extended field of view because this was a uh 13 centimeter long tumor. So this is a patient with neurofibromatosis, two a known diagnosis. And this is a rare disease or relatively rare autosomal dominant. But it's a curious disease in that you actually have to have two copies of the gene to be symptomatic. So you inherit one or have a spontaneous mutation and then later in life, develop a somatic mutation in the other gene chromosome and then develop this condition. And these people developed multiple Schwannoma typically in the acoustic nerve and their death. But then in all these other peripheral nerves. So her neurosurgeon referred her to me because they were going to do a tumor resection, but they wanted to know what the extent of the lesion was and wanted to go from there. So I did preoperative imaging to show the sites for the incision for them. And then inter operatively went in and helped them with the dissection using ultrasound and it reduced the benefit of the ultrasound. Is it identified additional swan that hadn't been picked up in other portions of the more proximal portion of the fibular nerve and also distill that they wouldn't have excised if we hadn't had the ultrasound imaging. And then inter operatively rather than taking her in and out of the MRI scan, having to wait a for the, the, the um having to wait for the one or with an inter operative MRI we were able to do this in another or, and reduce the mr time and you know, it just sped up the surgery procedure significantly. So those are peripheral nerve things. What about um neuromuscular diseases? Um So I am a pediatric physical medicine doctor. And so I see people that are not only adult patients that are referred to funny looking Gates to me, but this is a little guy that the physical therapist called me up and said, I have this kid with a funny g where you do Botox injections. And I said, well, I've learned, I mean, I've been in practice long and I've said, send me a video because you know, I wanted to see what this was. So you can see this kid, he is very weak, right? He doesn't have spasticity, he can't get up from the floor. Um And you know, he uses a modified gower maneuver to get up from the floor. When he stands, he stands in this lodo posture and you know, he has this very disappearance of an abnormal gate but appears weak. He does not appear, I mean, we all agree, it doesn't appear that he has plasticity, right? His motor control is really good. That's not the issue. The issue is primarily weakness. His history was completely unremarkable from a medical standpoint. His speech and cognitive and fine motor skills were normal, but he had gross motor delays he had not started walking until he was about 18 months old. And on exam, he had no evidence of facial weakness, but he had significant proximal girdle limb weakness. Uh more so than distal weakness and was a reflex in both the upper and lower limbs. So this pointed us in the direction of this kid has some type of neuromuscular disease or peral nerve problem, but more likely a muscle disease, he also have a significant muscle atrophy. So we did um as an extension of our physical exam, you know, at bedside when the patient came in um ultrasound imaging and it it was to guide further evaluations as we do this on all the patients that come in. And we did two D imaging and the thing that was most apparent if I can see here, uh I'll see if I can get this. But so this is a short access view of the thigh posterior. So for you not again, not used to looking at these images. Top of the screen is superficial, bottom of the screen is deep. Um this is lateral and this is medial and this is the images of the hamstrings in short axis. And this is the biceps for Morris. This is the semimembranosus and right here is the semi tendinosis normally muscle has this. So a appearance of a mixed dark or hypo aic image mixed with um in short axis, a speckled appearance of the intramuscular connective tissue which is a more reflective of ultrasounds. So it's brighter or hyper. And so if you look here, he's got this, you know, the semi tendinosis looks relatively normal. But if you look at the other two hamstring muscles, the biceps Morris and the semi merinos, the muscles have this sort of uniform white appearance or high echo white appearance. And that's because these muscles are more selectively involved than their selective sparing of the semi tendinosis muscle in this patient. So this is a poster view of the rector spine muscle and there's essentially no muscles. All you're seeing is skin and this tiny little bit of muscle of erect spine. So this appearance of the profound atrophy of the rector spine and selective sparing of the semitendinosus sort of pointed us in the direction of what the diagnosis might be based on the based on ultrasound, not based on clinical history. And rather than sending this child for a a muscle biopsy or, you know, whole exome sequencing, we got AC K level and a single gene mutation analysis for Laminin ac congenital myopathy because that's what we suspected based on this ultrasound appearance. So we saved the patient a muscle biopsy and the mutation was positive for laminin ac congenital myopathy. And the first thing is that we save the patient in invasive procedure and we were able to immediately get the patient into referral to cardiologists because these patients have a high risk of cardiac problems and we're able to counsel the family about this as well. And so it really, it, it's better for the patient because there's less invasive procedures that are done. For instance, you can do muscle imaging with MRI. But in a child that's 21 months old, you would have had to sedate him. And the risk for that in a kid with a neuromuscular disease is pretty high. So this was, I think a great addition for him was the use of ultrasound to help establish the diagnosis. So what about I'm gonna move on to procedural guidance which you know, people um have probably heard some of my talks before about this at some of the meetings. But so why should you consider and I'm only going to talk about chemo denervation procedures. I'm not going to talk about joint injections or aspirations. I'm not going to really talk about musculoskeletal applications because the time doesn't really allow. So, but why should you consider this? We have other guidance techniques that we've used for years. Um You know Emg and eem are both useful for isolating muscles. But my first question for everybody is how many of you use an atomic guidance when you're doing toxin injections? If how many of you do toxin injections? So anybody that does toxin injections uses an atomic guidance. Because if you don't know anatomy, none of the other guidance techniques are going to help you, right? I mean, Emg isn't going to help you if you don't know where the muscle is, right E stem isn't going to help you if you don't know where the nerve is. And ultrasound certainly isn't going to help you if you don't know cross sectional anatomy. So, the basis upon which all of the other guidance techniques that we use for these injections is really our knowledge of cross sectional anatomy and functional anatomy. You need to know that the flex superficialis flexes at the proximal at the P IP, not the D IP. And that it's the FDP that flexes at the D IP. But that when you flex the D IP, you're going to see movement in the F DS as well because the tendons are moving together, you know, you can't not move one with the other or functionally if you think about foot inversion. So you have a patient that has a quus a kid with cerebral palsy, an adult with stroke, somebody with TB I and the patient presents with a, either in 1 ft or both feet. And you need to know that it's not just the tibialis posterior that causes foot inversion. That the tibialis enter is also an inverter of the foot that the flexor longest, anything that crosses the medial ankle can invert the foot. And so you need to have that knowledge of anatomy if you're going to do these injections. But beyond that, we've been using EMG and E for years, why use ultrasound, well, particularly for chemo denervation, we know that accurate targeting is important. It's important for safety and minimizing risk. The issue of targeting errors and causing unintended weakness in untargeted structures or procedural adverse events that you inject the wrong thing or medication side effects, side effects, particularly of toxins is generally weakness in adjacent structures or distant structures. And you want to minimize this. And what about procedural effectiveness? I mean, not only if you target the wrong muscle, not only are you going to get weakness in the muscle that you injected? That wasn't the target, but you're also not going to get any effect in the target muscle because you're not in the target muscle. So we're all about trying to be precise about where we put things and potentially one of the things we're looking at right now in a study is, does the use of ultrasound reduce the required effective dose for toxins if you're more precise in placement of the toxin, does that reduce the dose that's required? And you're not because you're not relying on diffusion of the, of the toxin to the target structure. So there's lots of different reasons. And then for pal the same thing for PH or ethanol alcohol blocks, for either motor point blocks or nerve blocks, you really want to be precise when you place that toxin to or I'm saying that agent that because it causes dena of protein. If you're on the wrong site you're going to cause damage rather than a nerve block. So what does ultrasound provide for us? Um It, it, it gives us information about complex deep overlapping muscles. It shows us the length of the muscle, the position of the muscle and a safe path to the target. You can identify individual muscle face and you look at an atomic rearrangements. So I was going to just look at all those little aspects. So one of the things when you, when you start looking at ultra sound and I sort of put this anatomical image with the ultrasound superimposed on it. All of ultrasound imaging is for muscle is based on pattern recognition. So there are certain muscles that have certain sona a properties and based upon that you identify that structure and then the surrounding structures based on contour lines, adjacent structures. So for instance, in view here, I hope you can see it's labeled which is nice. Unfortunately, the ultrasound machine doesn't label the images for you. You actually have to learn what they are. So the flexo Cary Rais has this characteristic. So acoustic appearance of this little nose that it wraps around the underlying pronator terry. So on this image media is screen left and lateral screen, right, this is a short axis you and this is the skin, this is the flexor carpi radialis just medial to that. And this person is the palmera longest muscle, just lateral and deep is the pro and just deep to the flexor carpi radialis. And this image is the flexor superficialis and below the F DS is the FDP. And it takes once you know this image and this pattern, you immediately can identify these structures and very quickly inject and target these, these muscles. Um So I'm going to talk a little bit about some of the advantages. Besides this, an I'm going to go through all those things we talked about. But one of the things that is really important for chemo innovation is this issue of disability related changes in muscle. So we know that over time, people that have the more impaired you are and the longer the disability or the impairment lasts, the more likely that you're going to have changes real logic changes in your muscle. Even though you have a brain or spinal cord disorder, there's an effect in the muscle and the muscle becomes abnormal secondarily. So this is a a MRI of two, these are identical twins, same age, same size, the patients weigh the same, then they both have cerebral palsy. If you haven't done your pens rotation yet, a gross motor functional classification scale is a scale that we use to evaluate impairment in Children with cerebral palsy and for kids with GMFCS, one level, they can walk and run. They have essentially no functional impairments, but they still have cerebral palsy. And GMFC S3 is a patient that uses some type of assistive device to walk like a walker or a cane and usually used as a OS. So this is an MRI image of these twins. They both have P VL. The twin with GMFC three has more severe PV. But the most important thing to look at here is we're measuring the thickness of the soli muscle in those two twins that are the same size, right? But the twin that's more impaired, the muscle is about half the size of his unimpaired sibling. So if you're targeting, because the patients have the same size limbs and you're targeting under emg at the same depth for both patients. In one patient, you're going to be in one muscle and another patient, you're going to be in another muscle because you can't estimate the depth based on this atrophy. You also will see when you start doing ultrasound is that you'll see the son acoustic appearance in the muscle. You saw that in the patient with muscular dystrophy where the muscle instead of having this normal appearance of sort of mixed hyper and hypo aic. In other words, dark or light appears almost like the cut end of a broom. In short axis, the muscle will become white and the wider the muscle is the higher the echo content. That means there's been fibro fatty replacement of the muscle, the contractile elements and that appearance may change what you inject how much you inject and whether you target that muscle. So that's another thing that ultrasound helps you with. So you can quickly isolate things that are hard to isolate. For instance, people sometimes are worried about injecting the ilio muscle because of the adjacent vascular structures. But this so acoustic appearance, the residents are going to work together next week on these, on these images and do some live scanning. But this is this appearance of the femoral head and sitting right on top of the thermal head is the alias. So as men to it, as the neurovascular structures, you've got the recti fem and the sartorius muscle right here. And you can just pop through in most patients with a 30 gauge one inch needle to get these injections done. It's relatively painless because you can use a very small needle because you can see the muscle, you can see what the depth is and this isn't an adult patient. So you can see how superficial the muscle is here at this point. Same thing tibialis posterior and I have a video of this for later in a short axis view. You can see the end of the medial gastro, the sous and then in between the tibia and the fibula sits the tibi ellis posterior. We tend to name all of our images like the FCR is the nose muscle here. This is the bathtub muscle looks a little like a bathtub, right? And the tin poster sits in the bathtub. It's trying to get you to remember what these things are, but you can see, you can walk yourself down just from superficial to deep. And if you're going to inject gastro sous and tibialis poster, you can inject all three with a single needle penetration. So you inject the gastro superficially, then go to the solu and then go to poster and you save the patient three or four sticks which most of our pediatric patients, even adult patients appreciate. Most people don't like being stuck. What about an atomic variations? We know that there are a lot of an atomic variations, particularly in the upper limb, whether muscle is either present, you know where its location is in our patients with disabilities, the anomic rearrangements that occurs a result of long standing spasticity and and the ultrasound really does help you. Here's another image here. This is the flexo Cary Radio. Remember that nose muscle that we're talking about. There's the nose muscle here. But I want you to look at me to the FCR. In this patient is a palmera longest muscle, but in this patient, there is no palmera longest muscle. So this is all flexo tom superficialis because the palmeri longest is absent and the presence or absence of that muscle can again lead to targeting errors which can be a problem. So in this next slide, so it really does this is the same set of images here, but here's flexo carpi radialis and this is all flexo digital superficiality and what we know, is that up in this corner right here is that it's fast to FD four. It always is in this position. Five tends to be down here. But again, if you target, if you, if you don't realize the patient has an absent palmeri, or if you're trying to target F DS and you don't know that the patient has a Palmeri, you're likely to have a, a targeting error. And I treat a lot of patients with vocal hand dystonia musicians, violinists, pianists, guitarists, who you're trying to be very, very precise in injecting only F DS to D four or only FDP to D two. And if you're off by a millimeter, you're going to be in the wrong facile and you're going to cause this patient to be more disabled than they currently are. First of all, you're not going to make their focal dystonia better and you give them weakness in the wrong muscle. So it's a really, it's a problem with this targeting issue. And you can see that there's lots of options with ultrasound. You can determine how big is that. For instance, here, this is Palmeri in this patient. This is the size of the palmeri in this person. So the size variation is huge and, and in a patient, let's say you've got a patient with spasticity that has a large Palmeri longus and has wrist flex and spasticity. You might actually want to target that muscle because it may likely be contributing to the patient's flex risk posture. But you aren't going to know if they have a large palmera lucus unless you have ultrasound images. So again, an added benefit. What about structures? You know, these issues of structures to be avoided before I used ultrasound. I mean, I knew when I was doing neck injections and I was doing strongly master, I knew the carotid artery was there and I knew that when I was doing scaling injections, that the lung was near where I was going. But it really gives you pause once you start doing ultrasound imaging, because if you look here, you see these three large hypo circular structures that look kind of like vessels if you're looking at images. But when we turn Doppler on that image, these are actually the trunks of the brachial plexus. And this is the an inter scaling. This is the middle scaling and running right in the facial plane of the anti scaling muscle is the Frank nerve. So if you target in this right here where the arrow is there and this is anti scaling here. So not only do you have to miss the lungs and the brachial plexus, but you need to miss the phrenic nerve, the vagus nerve, the super scapular nerve, all of which are exiting in this region when we're doing these injections in the neck and we're doing Lavado scali lung, Musca, we're doing all of these neck injections. And if you don't have ultrasound, you know, where these structures are. And the only time we've ever had at the NIH Movement disorders training protocol, the injection training protocol that I do. The only time that we've had a pneumothorax in a patient with a middle scaling injection was a patient that was not injected under ultrasound. So we now will not inject scaling muscles unless we have ultrasound because there's the patient, it was a very mild pneumothorax. The patient was not really very symptomatic, but we had to admit her to the hospital. We had to file a protocol deviation. The patient has three little kids. She wasn't really happy staying overnight in the hospital. The IRB wasn't very happy, nobody was happy. So we try to avoid this. So what about I said I have to continue my structures to be avoided. There are certain muscles that are, I would consider high risk and the scales are one of them. The other is the Sterno Mastoid. So here we've got a view here. This is a short axis view, the neck, this is the Sterno Mastoid and you've got the jugular carotid trachea here. So this is the same view, but it's going to be a video. And I always have to say before I show this video, I was holding the ultrasound transducer. It was at a training program and I was training people to do ultrasound and the attendant that was there doing the injections does emg guidance and they didn't want the ultrasound because they don't do it. And they didn't want the patient to have ultrasound because they didn't want the patient to then ask why they weren't getting ultrasound when they came back to the next time. But I said, well, look, these people all came to see the ultrasound guidance. So you at least just have to let me hold the transducer and this is what happened. hopefully. So here is again, steroid mastoid. This is, I think that pulse, anything you can agree is the carotid artery and there's the needle in the carotid artery because they went right through and I was able to redirect them to this portion of the SCM that's away from the car artery. So let's play that again, right? I always. So here is the needle going in. All right. So what's the problem with that? Um Well, the first problem is you weren't trying to do a carotid stick, right? I was able to say, ok, and I was in, in front of a group of about 100 people when this happened. And so I just put my hand on the physicists hand and I said, could you just pull the needle out and they sort of looked at me and so just pull it out, we're just going to do that again. And I put him in a different place and we injected over in this part of the SCM, which the crowd ends over here and now you're here in this part of the SCM, there's no vessel there, right? So what, what happened in this situation? What happened was this is a patient with cervical dystonia that's been injected multiple times. And I think that the attending was correct in the position of the needle for either one or two injections ago. But when you inject toxin, the toxin causes the muscle to atrophy. So the muscle is now thinner than it was two injections ago. And you needed to change the depth of target to avoid the carotid artery. And you can't appreciate how much atrophy you get without direct imaging of ultrasound. Um Well, the other question is then, well, what's the problem of, you know, if you did inject the toxin in the crowded artery? Right. Well, certainly that wasn't your target. And we know that toxin spreads centrally, right? I mean, there's no question about that. You know, when you inject peripherally, it's absorbed into nerves and it's, it, it migrates approximately, but you weren't trying to, you know, get toxin to go in the carrot artery. So more importantly, if you injected, theoretically, the person would have aspirated before they injected. But I see people all the time that inject without aspirating. So if they had injected, probably there would have been no effect, but more importantly, there would have been no effect. So the patient comes back six weeks later and says I got no benefit from these injections didn't work at all. So you say, well, ok, I'm gonna, when you come back in six weeks, I'm gonna increase the dose in the SCM because obviously we need to increase the dose. Well, you didn't need, so you increase the dose and now the patient has dysphagia and neck weakness because they didn't really need an increased dose. They needed the muscle to be targeted correctly. Right? So that's the biggest problem is if you have a targeting error, you think you're in one muscle, you're in another muscle and you keep increasing the dose, you're gonna cause weakness. And that's really the problem. Um Besides the fact that you don't want to stick needles and carotid arteries or you don't want to give somebody a stinger. Um when you do a uh scaling injection, which has happened, you know, I've done, I've, even with ultrasound, you have to be very careful in some very thin females who have very thin long necks that are kind of gray style, the muscle and the nerve are right next to each other and you have to be careful. So for rehab docs, particularly for us as rehab docs, another thing that ultrasound helps me with is this issue of multiple approaches to the same muscle. So for the tibialis posterior, the typical approach that most people do is the medial anterior approach and this is the tibia here, this is the skin, this is actually the medial head of the gas rock and the solis over here and you can see how far anterior, the solis and, and the medial gas truck actually run. But this must right here. This little triangular muscle is the F DS and line just deep to it. That little white line there is the facial plane between the F DS and the tip posterior. So you can come straight down here. And if you, you may be injecting F DS and, and I'm sorry, FDP and TI posterior. If you're injecting both, you just do first, the FDP FDL sorry, there's many F um flex term long and then just go deep to get the TDLS posterior if the patient also has toe flexion and you think it needs to be injected. Um But what about the patients, patient weighs £220. You don't have a Hoyer lift for whatever reason they're sitting in the wheelchair and a patient has spinal cord injury. They will not let you transfer them out of their wheelchair because you are not their aid and you are not going to get them back in the wheelchair correctly. And they're going to have to sit there for six more hours in the wrong position because you can't get them in the position correctly, but you need to eject their tid posterior. So you can have the patient sitting in the wheelchair. This is an, an approach, this is tibi ellis anterior. This is flex extensor, digital longus, this is the anus membrane right here. The anti artery and just below the intra membrane is ti posterior. So you can just come down through the tibialis anterior. When the patient is sitting in the wheelchair, you don't have to transfer them. You can get right in and you can miss the anti tibial artery, which you don't really want to penetrate going through because you don't really want that leaking. Most of these patients are on anticoagulants and you don't want them to bleed, you can't compress this vessel. You know, if you, if you stick through it. So this is another approach to doing it. And then here's this poster approach you've already seen in the bathtub view. Um So I choose these approaches depending on what other muscles I'm injecting. So if I'm injecting the, the flex longus, I'm going to use this approach. If I'm going to be injecting ti bs anterior and posture, because they're both causing inversion, then I'm going to use this approach. If I'm doing the soli and tim posterior, I'm gonna use that approach. So it gives you multiple approaches in our patients with movement disorders or in patients with uh let's see if this is going to play here. This was a video. Yeah. So this is a isolation of um individual faces of the uh this is somebody practicing on me. That's why I keep grabbing the transducer, those of you that have worked with me will know I grab transducers from people but you can um you can isolate these individual. Let me see if I can get this to play again, may not be the best view, but you can have dynamically, you can have the patient moving the muscle or you can do this passively and just look for movement of individual fales and target that. So if you have a patient with spasticity who has D four and five flexion, more than D two and three, you can target those fales more easily using ultrasound. It doesn't take as long, you can do this with emg as well or E stem. It just you have to use, it takes a little longer with those techniques and other targeting techniques. We now have an approval for Botox for inox toxin A forsa. And you know, the salivary glands can't be identified with EMG or E stem. You can use an atomic guidance. And actually the study, the labeling study for inco toxin A or Zin actually showed that an atomic guidance and ultrasound guidance were both effective in localizing salivary glands. But the I find it really useful to avoid vessels because these structures are highly vascular and you can also avoid the perrodin duct which sits right in the middle of the para gland. So I think that they're pretty easily. It's a nice technique when you're doing these guidance for salivary glands to use ultrasound. And you can also visualize the this is a long. So this is a long axis view. Oh Sorry, I'm using my arrow again. This is a long axis view of steroid. As opposed to that short axis view we've been looking at before carrot and jugular down here. This is proximal, this is distal that right there is the needle in plane. So it's long axis view of the needle in the SCM. And what you can see is you can actually see the toxin as it's injected. And you can see the diffusion and spread of the toxin and it has changed my injection pattern. So they don't over inject at one site because if you inject too much toxin at one site, the facial planes of that muscle are not toxin tight. If you put the muscle under a lot of pressure, the toxin is more likely to escape into adjacent structures. So it's changed how we inject and what about other applications? So I do a lot of diagnostic nerve blocks um prior to doing toxin injections, it's a patient that you don't know whether is this a contracture? Is this severe asbestos or dystonia? And you don't really want to do toxin injections, which are going to cost a couple of $1000 if the patient has a contracture. So you can do a nerve block. So this is a isolation right there. I'm gonna try to pause this there. Um And this may be asking a lot for you guys to see this. But right, sorry, this circular structure right there. It's got sort of a honeycomb appearance. You have to squint and believe me, that's the tibial and fibular nerves together before they split at the plaza. But nerve has this honeycomb appearance and you can identify the poster tibial nerve and you can follow it. Now, the fibular nerve is moving off to the side here, but you can track the the poster tibial nerve down. And you can do either this is the needle coming in and you can see the stem, we are doing a diagnostic block and this is actually inject going in to surround the nerve. So for diagnostic block, it's really great. You can do this block, it lasts for an hour or two. It also if you do motor point blocks, you can kind of give the patient a test drive of what spasticity reducing their specs would be like. Instead of doing a nerve block, you do a motor point block, you go into the muscle and isolate little motor points. You can give them a bit of a test drive of the toxin or phenol. More more likely that I would do it for phenol than toxin. And it, it really allows patients decide do they really want to do this more permanent procedure? Now, I use a as you noticed from that, that picture or that video, I use electrical stimulation and ultrasound for nerve blocks and for motor point blocks as well. Now, with the current transducer technology that we have, we can't visualize motor end plates, but you can see this micro stimulation in the muscle. So we isolate when I, when I say I use ultrasound, it doesn't mean that I don't use EMG and I don't use E stem as well. I use, I use ultrasound plus EMG for almost all of our cervical injections in patients with cervical dystonia. Because ultrasound tells you where you are. The EMG tells you is that muscle actually contributing to this patient's posture. Their head is in this position, multiple muscles can be causing that posture and the EMG tells you is that muscle really actually contributing to the patient's posture. So these are not mutually exclusive techniques. Um So what about for phenol injections? So this is a, this is I'll try to pause this, this is superficial. This is the longest and then Brevis is here and Magnus is below the, the operator nerve. The an branch runs in the facial plane between the longest and the Brevis and the poster branch runs between the longest and the magnus. So you can use EMG or E stem plus ultrasound and it speeds the process, but you can see the stem and the needle is right here targeting the facial plane where this is running. Um And this is a more right on the, at this point, there's the stimulation and inject it going in as well. So what it does is when you're using E stem combined with ultrasound is it reduces the stem time on time of the stem procedure and reduces the volume of the inject. It's been shown in a number of studies that it reduces the volume of phenol that you have to use and then potentially reduces adverse effects effects for this um and potentially paraesthesias. So sort of my summary here and I'll show hopefully a couple of videos here. Just I don't know if these are gonna be. Yeah. So this is a here's that bathtub view. You guys are getting used to seeing that. Now, a poster calf superficial, this transverse view here and I'm using an out of plane walk down technique and you, you don't really see the needle, but you can see the tissue moving as we go from superficial to deep into the tid posterior. And then once you're in there, we sort of perturbate the needle a little bit. You can see the inject how much is blowing up the tid posterior just by injecting that small amount of volume. And this is, I think this is, oh sorry, this is the or this is a patient in the or we're doing. I thought I got rid of the sound. Sorry about that. This is the Flexor Carpi Radio. I don't think that one is going to show very well. I was in Germany doing that. So it might be in German, not in English, but so that sort of the end of my, my talk is to say that I hope that at least gave you an idea of what incorporating ultrasound into your practice as a neuro rehab doc can do is that it's not just exclusively for procedural guidance. It really does provide a added as a part of your physical exam. And, you know, sort of an extension of this I didn't put into the into this talk was this issue of using quantitative measures of ultrasound because most people think of ultrasound as a qualitative measure. But in research, we're actually using quantitative ultrasound measures to measure changes in muscle. We've got a couple of studies that we're doing when patients are either getting gene therapy or other interventions. And we're trying to track inner degenerative conditions to try to track whether or not there are changes in the muscle over time. And one of those techniques is a technique called elastography that looks at muscle stiffness. Another is a quantitative measure of echo texture of the muscle. And there are ways rather than just sort of subjectively saying the muscle is either too wide or not wide enough, you can actually look at quantitative speckle analysis of the muscle. So there are quantitative measures in a research way as well. And I I hope that you agree that there are some benefits from a procedural standpoint as far as safety accuracy, speed, comfort and efficacy. And I'm hoping that maybe I'll spur some of you guys into thinking about incorporating an ultrasound into your practice and I'll stop there and take questions. I do, I, I do use Hemet scale. So heck scale is a published scale from a number of years ago. It's used both in the neuromuscular and in the um it was devised for muscle diseases, primary muscle diseases. But we use it a lot in patients with upper motor neuron syndromes as well. So, yes, I use it on a fairly regular basis and change the, you know, if they have a four, which is, you know, the muscle is white it out essentially. And you can't discriminate the facial planes between individual muscles. Then I'm going to probably use ultrasound plus emg and listen to the emg activity of that muscle as well to determine. Should I really even inject that muscle or is the muscle just so fibrotic that it's not contracting? But that's where emg may help you in addition to the ultrasound. Yeah. Uh Say that again for limb injections for virtually all the limb injections that I do. I do ultrasound alone. Um I train residents and fellows though and I'm training them to do all the techniques. So for the residents and fellows, we oftentimes are doing both. But if I'm doing it by myself, I do only ultrasound and once the residents or fellows are proficient in all the techniques, I let them choose whether they want to do both or one. And most people will choose only to do ultrasound because you can use, rather than using the Teflon coated monopolar injection needles that you have to use for E stem or emg those needles. If anybody that injects, they're hard to get through the skin, they hurt more to inject. You think, with Teflon on them, they would slide through the skin but they don't, they're thicker. The gauge of the needle is whatever it says it is, but the Teflon makes the gauge bigger. Um So it hurts more to get those through and not a commercial. This is not a commercial message, but I found that the amoo needles hurt less than the, that for instance, Botox makes needles that you can buy. But the amoo needles seem to insert better. Um So with, with ultrasound alone, I just use Hypodermic needles and the vast majority of the injections I'm doing with it for upper limb, even in an adult, I'm using the 30 gauge one inch needle and patients a lot of times don't even feel it or I use a 27 1.5 inch needle, Hypodermic and for deep seated pelvic muscles that I can't get with one of those, I use a 25 gauge 2.5 inch spinal needle and it just, they insert so much better than those EMG needles. So when I use the combination of emg and E or EMG and ultrasound as I already alluded to is with, for, um, cervical muscles. Almost always. I would say 80% of the time I use that combination. And the only time I use EIM is if I'm doing, um, nerve blocks because patients don't like it. And if you have kids, you have to put them to sleep to do E stem. You heard that, you heard that and the em, you know, I was doing the Flexy radio so you could hear the or stuff because the kid had to be asleep because we were doing pal injections in the abductors and we, and we had to do um and we had to put the kid to sleep. So that's sort of my practice. Um Other people do and EMG or em and emg plus all the time for everything. It's your choice, right? Any other questions? Ok. Um Do you incorporate hyen section into your practice often or is it more a compliment member? I, I do it a fair amount for peripheral nerve hydro dissection? Uh Because that's what I'm seeing a lot of. Um And so yeah, I, I would, it depends on what you mean by a lot but I do a fair amount of peripheral nerve hydro dissection. Um um I'm just, I'm using, I'm typically using just Saline because that's what I've got access to. It's everything that I do is under a research protocol and that would require a protocol amendment. Um So it's just, you know, it and the, and the sailing works. So, yes, yeah, many do. It depends. You have to choose your patient and you have to choose the problem. But if it, when we're using it as patients that are, are not operative candidates or in our research protocols, um because of the protocol, it would break protocol to do for them to have a surgical procedure. But I can do, I can do the hydro dissection is allowed. But having the patient have a surgical procedure, it would get them out of, let's say an NC protocol. And they're getting a study drug that they're benefiting from and they've got this peripheral nerve entrapment and I don't want them to get kicked out of the study. So that's when I'm doing my applications are odd. You know, patients are all under other protocols. Thank you. Yeah. Which is right. So, the current studies show that there are a number of the number and that's why they just wanna say thank you. It's great to meet your person through Steve. And how are you? Created by
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