Accepted Manuscript
A Novel Use of Regional Anesthesia for Spastic Hemiplegia Evaluation and
Treatment: A Case Report
Ameet S. Nagpal, MD, MS, MEd, Maxim S. Eckmann, MD, Jon Benfield
PII:

S1934-1482(15)00919-3

DOI:

10.1016/j.pmrj.2015.07.010

Reference:

PMRJ 1550

To appear in:

PM&R

Received Date: 18 May 2015
Revised Date:

17 July 2015

Accepted Date: 25 July 2015

Please cite this article as: Nagpal AS, Eckmann MS, Benfield J, A Novel Use of Regional Anesthesia
for Spastic Hemiplegia Evaluation and Treatment: A Case Report, PM&R (2015), doi: 10.1016/
j.pmrj.2015.07.010.
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Title Page

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Ameet S. Nagpal, MD, MS, MEd
University of Texas Health Science Center at San Antonio
Department of Anesthesiology
Westgate - Medical Center
5282 Medical Drive , Ste 614
San Antonio, Texas 78230
NagpalA@uthscsa.edu
Phone: 210-450-9850
Fax: 210-450-6095

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Authors’ full names and affiliation

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Title: A Novel Use of Regional Anesthesia for Spastic Hemiplegia Evaluation and Treatment: A
Case Report

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Maxim S. Eckmann, MD
University of Texas Health Science Center at San Antonio
Department of Anesthesiology
Westgate - Medical Center
5282 Medical Drive , Ste 614
San Antonio, Texas 78230
Eckmann@uthscsa.edu
Phone: 210-450-9850
Fax: 210-450-6095

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Corresponding Author
Jon Benfield D.O.
University of Texas Health Science Center San Antonio
The Department of Rehabilitation Medicine
7703 Floyd Curl Dr. (MC 7843)
San Antonio, TX 78229-3900
Telephone: 210-838-4722
Fax: 210-567-5354
Email: benfield@uthscsa.edu
This material was not presented at an AAPM&R Annual Assembly. No funding sources
including NIH grants were used or obtained for this paper.

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Title: A Novel Use of Regional Anesthesia for Spastic Hemiplegia Evaluation and Treatment: A

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Case Report

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Unstructured abstract

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Spastic hemiplegia is a common sequela of stroke. Spasticity not optimally reduced with

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systemic therapy is often treated with intramuscular botulinum toxin injections. Spastic tone can

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increase the difficulty of appropriately positioning the patient for botulinum toxin injections,

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lengthen procedure duration, and increase peri-procedural pain. Our case is a 53-year-old female

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unable to be adequately positioned to receive botulinum toxin injections to her left upper

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extremity due to challenging flexion synergy posturing and related positional pain. A left

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interscalene brachial plexus local anesthetic block under ultrasound guidance was employed to

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produce both temporary dense muscle relaxation and profound anesthesia, facilitating for

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successful and comfortable botulinum toxin injections in this patient.

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Keywords: stroke, botulinum toxin, regional anesthesia, spasticity

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Introduction

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Spastic hemiplegia is a common sequela of stroke, usually appearing in the flexors and adductors

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of the upper extremity and extensors and adductors of the lower extremity.1 Oral spasticity

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medications include centrally acting agents like baclofen, clonidine, and tizanidine;

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anticonvulsants like diazepam and gabapentin; and peripherally acting medications like

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dantrolene. Interventional and surgical procedures include focal injections of botulinum toxin,

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phenol or alcohol, intrathecal baclofen pump implantation, and less frequent surgical treatments

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include tendon transfer, tendon lengthening, dorsal rhizotomy and neurectomy, cordotomy, and

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myelotomy.1-4 When dosage and frequency are maximized and medications are ineffective or

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limited by side effects, botulinum toxin injections2-3 and/or intrathecal baclofen pump

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placement1-2,4 following a successful intrathecal baclofen trial have been shown to improve

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spastic hemiplegia. A thorough examination is necessary to differentiate types of tone, and

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identify from muscle and tendon contractures as their treatments can differ.1 Types of

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hypertonicity include clonus, co-contraction, dystonia, spastic dystonia, paratonia, hypertonia,

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myoclonus, rigidity, spasticity and tremors. 6 Spasticity can be evaluated and monitored with

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different scales.1 Three common scales are the Ashworth Scale5, Modified Ashworth Scale6

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(MAS) and Tardieu Scale7. Additionally, spastic tone can increase the difficulty of appropriately

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positioning the patient for botulinum toxin injections and increase intra- and post- procedure

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pain. This often leads to lengthened procedure times.3

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Case Presentation

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We present a 53-year-old female with left spastic hemiplegia and complex regional pain

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syndrome (CRPS) type I following a right middle cerebral artery ischemic stroke with increased

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spasticity within two weeks of her stroke. After acute inpatient rehabilitation, she was initially

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treated with oral baclofen 10mg three times daily which was titrated up to 20 mg four times daily

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and tizanidine 4mg oral four times daily with no change in her MAS scores. Additionally, she

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had previously undergone a left stellate ganglion block and left lumbar sympathetic block for her

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CRPS five months and eight months respectively after her stroke. The stellate ganglion block

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reduced upper extremity pain from numeric rating scale (NRS) 8/10 down to 0/10 for at least one

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month; lumbar sympathetic block produced immediate effect of NRS reduction from 6/10 to

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0/10 in the leg.

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Due to uncontrolled spasticity and no change in MAS scores in her extremities with oral

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medications and physical therapy, she had a Synchromed II intrathecal baclofen pump (ITBP)

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implanted. Despite improvement to her left lower extremity from the ITBP, the patient’s upper

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extremity spastic tone did not improve with intrathecal baclofen. She was evaluated and elected

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to have a botulinum toxin chemodenervation procedure to her left upper extremity. MAS scores

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pre-botulinum toxin injections are listed in Table 1. Unfortunately, there was significant

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difficulty performing the procedure due to patient discomfort and inability to position her

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appropriately secondary to severe flexion synergy posturing dystonia. Consequently, the

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procedure was technically inadequate and subsequently stopped. After discussion, the patient

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was rescheduled for botulinum toxin injections to be facilitated with a left brachial plexus local

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anesthetic block. Six weeks later, a left interscalene brachial plexus block was performed prior to

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the botulinum toxin chemodenervation procedure. The rationale for the brachial plexus block

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included:

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1. To improve examination of the muscle spasticity component versus contracture.

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2. To improve relaxation of the patient's severe dystonia to facilitate motor point

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stimulation.

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3. To provide excellent analgesia while positioning her left upper extremity and while

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placing the needles for botulinum toxin injection.

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The brachial plexus block was done under ultrasound guidance to identify the left subclavian

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artery and vein, the first rib, and the pleura of the apex of the lung. The brachial plexus was

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identified at this level and traced proximally to the level of the roots of the brachial plexus

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between the anterior and middle scalene muscles (figure 1). Under direct ultrasonographic

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visualization, a 22 gauge, 2-inch, blunt, 30-degree bevel needle was advanced towards the

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brachial plexus from an anterior-lateral approach and tip placed immediately adjacent the nerve

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cluster. Then, ten mL of 2% lidocaine was injected into this area with ultrasonographic

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confirmation of the local anesthetic spread around the entirety of the plexus. There were no

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complications. After 20 minutes, botulinum toxin injections were performed. The patient's left

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upper extremity was now relaxed, but she still had noted flexion and pronation of the elbow

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likely from soft tissue contracture formation. The degree of flexion and pronation was much less

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than baseline, indicating that the majority of this deformity is dystonic and spastic, not

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contracture. Next, 400 units of botulinum toxin were injected with a 25 gauge, 50 mm Teflon

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insulated injection needle guided by electrical stimulation (E-stim) while identifying the motor

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point in each individual muscle (Table 1).

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At follow-up, three weeks later, she had a significant decrease in her left upper extremity

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spasticity with the exception of a portion of bicep flexion and forearm pronation. MAS scores

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post interscalene brachial plexus block and botulinum toxin injection improved and are

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compared to pre-procedure MAS scores in Table 1.

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Discussion

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This case demonstrates a novel use of regional anesthesia to facilitate both examination and

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injection procedures on the upper extremity in a patient with the combination of severe spastic

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hemiplegia and CRPS I with co-existing soft tissue contractures. Regional anesthesia provides

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the ability to block motor and sensory nerve transmission at any peripheral level that is

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technically accessible to the provider. Brachial plexus blocks, in particular, can produce

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anesthesia at the level of the nerve roots (interscalene block), trunks (supraclavicular block),

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cords (infraclavicular block), or peripheral nerves (axillary block).8 These choices can be

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employed to block the shoulder and upper arm down to the distal arm and hand, depending on

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choice of injection site. Depending on local anesthetic choice and dose, both motor and sensory

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block can be achieved for at least two hours8 with motor function returning before sensory

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function. Although the brachial plexus has been located using both paresthesia and nerve

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stimulation techniques based on structural landmarks, ultrasonography increases the accuracy of

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location, ease of plexus identification, and safety of nerve blockade such that serious

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complications are rare9. Practitioners should be well trained in the delivery of these nerve blocks

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and prepared for emergent resuscitation in the event of rare but life-threatening complications

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such as systemic local anesthetic toxicity or inadvertent intrathecal or epidural injection10.

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Traditionally, plexus blocks are administered by anesthesiologists in the surgical setting, but

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practitioners in pain medicine and emergency medicine are beginning to adopt techniques in

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regional anesthesia. Use of an ultrasound guided left interscalene brachial plexus block allowed

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for the ability to position the limb appropriately, accurate identification of motor points with an

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E-stim unit during botulinum toxin injections of the left upper extremity, evaluation of what

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portion of her left upper extremity limited range of motion was due to spasticity versus soft

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tissue contractures, and appropriate intra-procedure analgesia.

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Conclusion

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The authors hope to highlight the benefit of performing a regional anesthesia prior to botulinum

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toxin injections in patients with severe extremity spasticity unable to undergo the

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chemodenervation procedure initially due to limb pain, pain with proper procedure positioning,

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and/or co-existing hyperalgesia, allodynia, or CRPS. However, we caution that such anesthesia

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be delivered by appropriately trained practitioners who are equipped with robust skills relevant

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to the neuroanatomy, pharmacokinetics, and potential complications of regional anesthesia.

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References
1. Elovic E, Baerga E, White BF. Associated Topics in Rehab: Spasticity. In: Cuccurillo SJ.

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2nd edition Physical Medicine & Rehabilitation Board Review. New York, NY: Demos

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Medical; 2010, 811-822.

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2. Chang E, Ghosh N, Yanni D, Lee S, Alexandru D, and Mozaffar T, A Review of

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Spasticity Treatments: Pharmacological and Interventional Approaches. Crit Rev Phys

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Rehabil Med. 2013; 25(1-2): 11–22.

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3. Walker HW, Lee MY, Bahroo LB, Hedera P, Charles D. Botulinum Toxin Injection

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Techniques for the Management of Adult Spasticity. PM R. 2015;7(4):417-427

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hypertonia from stroke. Stroke 2001; 32:2099-109.

5. Brashear A, Zafonte R, Corcoran M, Galvez-Jimenez N, Gracies JM, Gordon MF,

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McAfee A, Ruffing K, Thompson B, Williams M, Lee CH, Turkel C. Inter- and intrarater

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4. Meythaler JM, Guin-Renfroe S, Brunner RC, Hadley MN. Intrathecal baclofen for spastic

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reliability of the Ashworth Scale and the Disability Assessment Scale in patients with
upper-limb poststroke spasticity. Arch Phys Med Rehabil. 2002; 83(10):1349-54.

6. Ansari NN, Naghdi S, Mashayekhi M, Hasson S, Fakhari Z, Jalaie S. Intra-rater

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reliability of the Modified Ashworth Scale (MMAS) in the assessment of upper-limb

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muscle spasticity. NeuroRehabilitation. 2012;31(2):215-22.
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7. Li F, Wu Y, Xiong L. Reliability of a new scale for measurement of spasticity in stroke
patients. J Rehabil Med. 2014;46(8):746-53

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8. Brown DL. Brachial plexus anesthesia: an analysis of options. Yale J Biol Med. 1993
Sep-Oct;66(5):415-31.

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9. Nadeau MJ, Lévesque S, Dion N. Ultrasound-guided regional anesthesia for upper limb
surgery. Can J Anaesth. 2013 60(3):304-20.

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10. Yanovski B, Gaitini L, Volodarski D, Ben-David B. Catastrophic complication of an

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interscalene catheter for continuous peripheral nerve block analgesia. Anaesthesia.

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2012;67(10):1166-9.

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Muscle

# of injection
sites

Units

Pre-procedure
MAS

Pectoralis Major

2

60

3‡

2†

176

Bicep (bicep

2

60

3‡

2†

177

Brachioradialis

1

50

3‡

PT

1

40

3‡

FCR

1

40

2 with clonus†

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Table 1 –Botulinum Toxin injection muscle, # of sites, units injected, and motor point
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identification

FCU

1

40

2 with clonus†

FDS

2

80

4§

FPL

1

30

flexion)

3 week Post
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Procedure MAS

2†

178

3‡

179

193

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2, no clonus† 180
3‡
3‡

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Table 1 Legend: Modified Ashworth Scale (MAS)1, 6
*MAS 0: No increase in tone
**MAS 1: Slight increase manifested by catch and release or minimal resistance at the end of ROM
*†MAS 1+: slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the
ROM
†MAS 2: marked increased in muscle tone through most of the ROM, but affected part(s) easily moved,
‡MAS 3: considerable increase in muscle tone, passive movement difficult
§MAS 4: affected part(s) rigid in flexion or extension.

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4§

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2, no clonus†

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Table 1: Tone rated in table one was completed using the Modified Ashworth Scale (MAS) 1, 6

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by the same physician pre and post procedure. This physician was also the injector of the

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neurotoxin.

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Figure 1. Ultrasound image of brachial plexus at the interscalene level prior to injection. Depth

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markers on the right indicate ½ cm increments. (Legend: SCM = sternocleidomastoid muscle;

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ASM = anterior scalene muscle; MSM = middle scalene muscle; SA = subclavian artery; C5-C7

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= some roots of the brachial plexus.)

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