WS 434 US Guidance for Upper Limb Chemodenervation Procedures AAPM&R 2015

Transcription

1 WS 434 US Guidance for Upper Limb Chemodenervation Procedures AAPM&R 2015 Katharine E Alter MD Zach Bohart MD Robert Cooper MD Elie Elovic MD Heakyung Kim MD John McGuire MD Michael Munin MD Jeff Strakowski MD

2 Faculty/Disclosures Katharine Alter: Royalties Demos, Honorarium NANA John McGuire: speaker fee Allergan Jeff Strakowski: Royalties Demos Medical Publishing

3 Handouts Handouts are provided online Review of US guidance techniques for upper limb BoNT/chemodenervation Review of US Guidance/Physics * Review of Evidence comparing various guidance techniques for BoNT procedures* To provide adequate hands on scanning only a brief didactic review will be presented Please refer to the online handouts for full handouts

4 Objectives Review of US Basics: Physics Scanning and Procedural Techniques Hands on US Training for Muscle Identification for Upper Limb Chemodenervation Procedures At the conclusion of the Workshop participants will Be familiar with ultrasound appearance of key upper limb muscles Gain skills in US knobology/transducer handling skills Be familiar with various US guided procedural techniques

5 Course Agenda Introduction/Review of US Basics & Scanning Techniques/Tips: 15 minutes Hands on Scanning: 75 minutes Demonstration/projection of muscle groups Followed by practice scanning lead by table trainers Table trainers will rotate during the course

6 Hands On Course Agenda US identification of muscles Demonstration Procedural Guidance Techniques 10 In plane and Out of plane Rotate to this station to practice during down time Proximal Muscles/Nerves: Pectoralis Major/Subscapularis/Latissimus Dorsi 15 min Biceps/Brachialis/Brachioradialis : 15 minutes Forearm 20 minutes FCR/ FCU, Pronator Teres, FDS/FDP, FPL Nerves 15 min

7 Chemodenervation Procedures Botulinum Toxin (BoNT) AbobotulinumtoxinA (Dysport) IncobotulinumtoxinA (Xeomin) OnabotulinumtoxinA (Botox) RimabotulinumtoxinB (Myobloc/Neurobloc) Nerve/Motor Point Blocks Diagnostic nerve blocks Local anesthetics Neurolytic blocks Phenol 4-6% Ethyl alcohol 30-50%

8 Why use US for Chemodenervation Procedures? Correct targeting is important for Efficacy Minimizing risk/adverse events Reduce the required effective dose (potentially) Traditional localization techniques have recognized limitations Comparative studies indicate that US guidance is more accurate than other techniques

9 Why you should consider using US for BoNT Injections? ADVANTAGES OF US GUIDANCE FOR CHEMODENERVATION PROCEDURES

10 US for BoNT Injections: Advantages Improved accuracy Localization is limited by complex or overlapping anatomy Very small/large patients Difficult to estimate muscle depth Identifies safest path to the target Location Depth Transverse View, Proximal Forearm Transverse View, Mid-forearm

11 US for BoNT Injections: Advantages Visualize/isolate target structures Quickly Easily Accurately Less painful Smaller needles Pediatric patients often require no sedation Distract patients during procedure US Photo from Steffen Berweck MD

12 US for BoNT Injections: Advantages High risk targets Avoid untargeted Muscles Structures Vessels/nerves/organs High stakes muscles SCM Scalenes Oromandibular muscles Pterygoids Subscapularis Sternocleidomastoid Transverse Scan Out of Plane Injection Adductors, Transverse Doppler

13 US for BoNT Injections: Advantages Upper Motor Neuron Syndromes Improved accuracy when localization is limited by: Involuntary muscle activity Co-contraction Motor control Patient cooperation US does not require AROM to isolate muscle Muscle identification is based on pattern recognition

14 US for BoNT Injections: Advantages Focal dystonia Identify individual muscle fascicles Ex: FDS digit 3 vs. 4 Increased accuracy and speed when identifying muscle fascicles Reduced pain Smaller needles FDS longitudinal view, mid forearm Short axis view of needle Longitudinal View, FDS

15 US for BoNT Injections: Advantages Non-muscle targets: Salivary Glands Prostate Salivary gland: Correct localization is critical to reduce the risk of dysphagia Parotid EMG and E-Stim do not help localization of non-muscle targets Submandibular

16 US for BoNT Injections: Advantages Visualize injectate Confirms correct site Provides info on volume of injectate/distension of muscle Reduces risk of over injection at one site Minimize spread to adjacent muscles or structures

17 US for Chemodenervation Procedures: Advantages Nerve Blocks Diagnostic Blocks Local Anesthetics Therapeutic blocks Phenol Ethyl Alcohol Musculocutaneous Nerve

18 US for Chemodenervation Procedures: Advantages US + E-Stim for Nerve Blocks US speeds the localization of a nerve or nerve branch Reduces risk of nerve injury Reduces risk of tissue damage when injecting phenol Reduces risk of injury to organs, vessel penetration Interscalene block Video from John Lin MD, Sheppard Center

19 Transverse view, proximal forearm Ultrasound and Procedural Guidance Disadvantages Equipment related factors Availability Cost Clinician related factors Lack of experience/training Limited access to training specific for chemodenervation Steep learning curve

20 Ultrasound for Chemodenervation: Summary Localization techniques Palpation EMG Nerve stimulators Ultrasound All have advantages & disadvantages Best Strategy: Be skilled in multiple techniques Be aware of The limitations of each technique Evidence supporting/refuting the accuracy of the various techniques

21 Comparison of Injection Techniques Palpation EMG Stimulation Sonography Accuracy +/- +/ Practicability + - +/- ++ Availability +/- +/- +/- + Pain + - +/- +++ Speed +/- - +/- ++ Evaluation +/- - +/- +++ Future research

22 ULTRASOUND BASICS

23 See online handout for review ULTRASOUND PHYSICS

24 Ultrasound Equipment Basics: Soundwaves are produced by piezoelectric crystals Cystal arrays are placed into transducers Transducers Determine the frequency of US waveform ( λ) Frequency of US λ determines Depth of penetration Resolution of the image

25 Ultrasound: Transducer Selection Select size and shape to match the clinical application Size/Shape of transducer Linear: Best for flat surfaces Curvilinear: Best for abdomen/pelvic/gyn Hockey stick: Hand Small irregular surfaces

26 US Basics: Transducer Frequency MHz Depth/Penetration Application cm OB/GYN cm Deep muscles cm Leg 10 5cm Forearm cm Hand, face Select transducer to match required penetration depth MHz for superficial structure Hand, forearm 3-5 MHz for deep muscles Piriformis, iliacus, quadratus lumborum Most transducers have mixed frequencies 3-5, 7-12 etc

27 Transducer Handling/Orientation To correctly orient the transducer on the patient Look for a manufacturer s mark on one end of the transducer The marked end = screen left on display To confirm this orientation: Tap the end of the transducer to confirm the orientation Notched end

28 US Basics: View convention Top of image is superficial i.e. skin Bottom deeper structures Transverse view Conventions vary Right always to patient right Medial always to right Longitudinal view Left proximal Right distal Patient R or Medial Deep Superficial Patient Left or Lateral Transverse view, flexor forearm

29 US Basics: View convention Longitudinal view Convention Place the transducer on the patient so that Proximal = screen left Distal = screen right Qadriceps tendon and patella Superficial Proximal Distal Deep

30 US Basics: Transducer Orientation Long Axis of Transducer Short Axis of Transducer

31 US Appearance of a Tissue is Determined by its Acoustic Impedance Speckle from scattering in tissue. L~ λ Weak scattering from blood and fluids with low impedance to US λ Tissues will appears dark or hypoechoic Strong echoes from mirror-like interfaces will appear bright or hyperechoic

32 US Basics: Tissue Properties Muscle Hypoechoic background (contractile elements/fascicles) Interspersed hyperechoic bands of fibroadipose tissue Long axis CT appears as parallel hyperechoic lines, less uniform than in tendon Short Axis CT intramuscular tendons, aponeurosis appear as bands and streaks Longitudidal view Transverse view Transverse view

33 Holding the transducer Grasp the transducer lightly using your Thumb + index or Thumb + index+ middle finger Do not over grip Keep hand in contact with the patient at all times to avoid slipping Using heel of hand or 4 th and 5 th finger Correct : Maintaining contact with patient Incorrect : No contact with patient

34 Anatomic Plane/Transducer Orientation Be aware that the Anatomic plane and transducer orientation may not always match Example Pronator Quadratus Pronator Quadratus Longitudinal Muscle Scan Transverse Upper Limb Scan Pronator Quadratus Transversel Muscle Scan Longitudinal Upper Limb Scan

35 Scanning Tips/Techniques: Injection Techniques In Plane: Needle Inserted Along Long Axis of Transducer Out of Plane: Needle Inserted Across the Short Axis of the Transducer

36 Interventional MS US: Clinical Pearls In plane/long Axis needle view: Keep needle parallel to transducer Insert needle at flat angle Poor needle visualization Oblique position Steep angle needle Out of plane/short axis needle view: Keep needle tip under US beam If needle tip is outside of US beam, visualization is lost May be in untargeted structure or muscle Walk down technique Follow movement of needle tip passing through tissues planes to target

37 Interventional MS Ultrasound: Clinical Pearls Real time injection Whatever technique is used: Keep needle within the ultrasound beam If needle tip is outside of the narrow US beam visualization is lost Tip may not be in target structure

38 Interventional MS Ultrasound: Pearls of Wisdom Larger needles are easier to see than small needles Larger needles hurt more 27g needles are easily seen particularly in an in plane view Non-insulated needles are visualized better than insulated. Etched Needles are also available Small amount of air (.2-.3 ml) helps define needle location Agitate injectate: increases reflection from bubbles Agitating may denature the toxin Billing: In the USA, to charge/bill for US, a picture or cineloop must be saved to document the procedure Billing Code: 76942: Ultrasound for Needle guidance, aspiration

39 US Muscle identification Identification of muscles is based on pattern recognition of Contour lines Adjacent structures Bones Vessels Other muscles Real-time Use AROM/PROM to assist muscle identification Pronator teres FCR

40 US Scanning Demonstration Transducer handling/manipulation Scanning limbs/structures Injection Techniques In plane Out of plane

41 Hands On Course Agenda Demonstration/projection of muscle groups Following the demonstration each group will practice scanning The following key muscles will be demonstrated Pectoralis Major/Teres/Subscapularis Biceps/Brachialis/Musculocutaneous nerve FCR/FCU/Pronator Teres FDS/FDP/FPL Procedural Guidance Techniques Rotate to this station when you are waiting to scan or finished scanning

42 Slides will be available on line MUSCLE IDENTIFICATION/REVIEW

43 Trapezius Middle Fibers/Upper Shoulder Transverse Sccan R and L Out of Plane Injection Video Link:Trap R L OP Inj NS.wmv

44 VideoLink:Teres Maj Tv OP BB Teres Major Transverse View: Teres/Lat Out of Plane Injection Teres Maj Tv

45 Pectoralis Major/Minor Page from Ultrasound Guided Chemodenervation Procedures, Text and Atlas Demos Medical 2012

46 Biceps/Brachialis Transverse Scan, Out of Plane Inejction Biceps, Transverse Mid Arm Out of Plane Injection Video Link: Biceps Tv OP P AVI Video Link: Biceps Tv OP

47 Brachioradialis Transverse Scan, Out of Plane Transverse Scan Picture Link: BR TV K1.png

48 Flexor Forearm, Proximal Page from Ultrasound Guided Chemodenervation Procedures, Text and Atlas Demos Medical 2012

49 Flexor Forearm Transverse Scan, Proximal Forearm Flexor forearm Transverse FOREARM

50 FDS FDS Transverse Transducer Location Forearm transverse, AROM FDS Tv Video: FDS AROM TV mpg

51 FDP Typical Approach for FCU/FDP Longitudinal Scan:,FDP F FDP FCU LA OP

52 Flexor Pollicis Longus Longitudinal Scan Longitudinal Scan AROM Picture Link: FPL Long LAx1.jpg Picture Link:FPL LA CN1.png Video Link:FPL LA AROM CN1.wmv

53 Ultrasound for BoNT Therapy For many reasons, clinicians who use US consider it to be a more/the most accurate localization method for BoNT Owing to Direct visualization of target structure and needle placement Image quality Access to portable US systems Expertise of clinicians