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. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT Title Page M AN U 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 SC Authors’ full names and affiliation RI PT Title: A Novel Use of Regional Anesthesia for Spastic Hemiplegia Evaluation and Treatment: A Case Report TE D 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 AC C EP 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. ACCEPTED MANUSCRIPT 1 Title: A Novel Use of Regional Anesthesia for Spastic Hemiplegia Evaluation and Treatment: A 2 Case Report RI PT 3 4 Unstructured abstract 6 Spastic hemiplegia is a common sequela of stroke. Spasticity not optimally reduced with 7 systemic therapy is often treated with intramuscular botulinum toxin injections. Spastic tone can 8 increase the difficulty of appropriately positioning the patient for botulinum toxin injections, 9 lengthen procedure duration, and increase peri-procedural pain. Our case is a 53-year-old female 10 unable to be adequately positioned to receive botulinum toxin injections to her left upper 11 extremity due to challenging flexion synergy posturing and related positional pain. A left 12 interscalene brachial plexus local anesthetic block under ultrasound guidance was employed to 13 produce both temporary dense muscle relaxation and profound anesthesia, facilitating for 14 successful and comfortable botulinum toxin injections in this patient. 17 18 M AN U TE D EP 16 Keywords: stroke, botulinum toxin, regional anesthesia, spasticity AC C 15 SC 5 19 20 1 ACCEPTED MANUSCRIPT Introduction 22 Spastic hemiplegia is a common sequela of stroke, usually appearing in the flexors and adductors 23 of the upper extremity and extensors and adductors of the lower extremity.1 Oral spasticity 24 medications include centrally acting agents like baclofen, clonidine, and tizanidine; 25 anticonvulsants like diazepam and gabapentin; and peripherally acting medications like 26 dantrolene. Interventional and surgical procedures include focal injections of botulinum toxin, 27 phenol or alcohol, intrathecal baclofen pump implantation, and less frequent surgical treatments 28 include tendon transfer, tendon lengthening, dorsal rhizotomy and neurectomy, cordotomy, and 29 myelotomy.1-4 When dosage and frequency are maximized and medications are ineffective or 30 limited by side effects, botulinum toxin injections2-3 and/or intrathecal baclofen pump 31 placement1-2,4 following a successful intrathecal baclofen trial have been shown to improve 32 spastic hemiplegia. A thorough examination is necessary to differentiate types of tone, and 33 identify from muscle and tendon contractures as their treatments can differ.1 Types of 34 hypertonicity include clonus, co-contraction, dystonia, spastic dystonia, paratonia, hypertonia, 35 myoclonus, rigidity, spasticity and tremors. 6 Spasticity can be evaluated and monitored with 36 different scales.1 Three common scales are the Ashworth Scale5, Modified Ashworth Scale6 37 (MAS) and Tardieu Scale7. Additionally, spastic tone can increase the difficulty of appropriately 38 positioning the patient for botulinum toxin injections and increase intra- and post- procedure 39 pain. This often leads to lengthened procedure times.3 40 Case Presentation 41 We present a 53-year-old female with left spastic hemiplegia and complex regional pain 42 syndrome (CRPS) type I following a right middle cerebral artery ischemic stroke with increased AC C EP TE D M AN U SC RI PT 21 2 ACCEPTED MANUSCRIPT spasticity within two weeks of her stroke. After acute inpatient rehabilitation, she was initially 44 treated with oral baclofen 10mg three times daily which was titrated up to 20 mg four times daily 45 and tizanidine 4mg oral four times daily with no change in her MAS scores. Additionally, she 46 had previously undergone a left stellate ganglion block and left lumbar sympathetic block for her 47 CRPS five months and eight months respectively after her stroke. The stellate ganglion block 48 reduced upper extremity pain from numeric rating scale (NRS) 8/10 down to 0/10 for at least one 49 month; lumbar sympathetic block produced immediate effect of NRS reduction from 6/10 to 50 0/10 in the leg. 51 Due to uncontrolled spasticity and no change in MAS scores in her extremities with oral 52 medications and physical therapy, she had a Synchromed II intrathecal baclofen pump (ITBP) 53 implanted. Despite improvement to her left lower extremity from the ITBP, the patient’s upper 54 extremity spastic tone did not improve with intrathecal baclofen. She was evaluated and elected 55 to have a botulinum toxin chemodenervation procedure to her left upper extremity. MAS scores 56 pre-botulinum toxin injections are listed in Table 1. Unfortunately, there was significant 57 difficulty performing the procedure due to patient discomfort and inability to position her 58 appropriately secondary to severe flexion synergy posturing dystonia. Consequently, the 59 procedure was technically inadequate and subsequently stopped. After discussion, the patient 60 was rescheduled for botulinum toxin injections to be facilitated with a left brachial plexus local 61 anesthetic block. Six weeks later, a left interscalene brachial plexus block was performed prior to 62 the botulinum toxin chemodenervation procedure. The rationale for the brachial plexus block 63 included: 64 AC C EP TE D M AN U SC RI PT 43 1. To improve examination of the muscle spasticity component versus contracture. 3 ACCEPTED MANUSCRIPT 2. To improve relaxation of the patient's severe dystonia to facilitate motor point 66 stimulation. 67 3. To provide excellent analgesia while positioning her left upper extremity and while 68 placing the needles for botulinum toxin injection. RI PT 65 The brachial plexus block was done under ultrasound guidance to identify the left subclavian 70 artery and vein, the first rib, and the pleura of the apex of the lung. The brachial plexus was 71 identified at this level and traced proximally to the level of the roots of the brachial plexus 72 between the anterior and middle scalene muscles (figure 1). Under direct ultrasonographic 73 visualization, a 22 gauge, 2-inch, blunt, 30-degree bevel needle was advanced towards the 74 brachial plexus from an anterior-lateral approach and tip placed immediately adjacent the nerve 75 cluster. Then, ten mL of 2% lidocaine was injected into this area with ultrasonographic 76 confirmation of the local anesthetic spread around the entirety of the plexus. There were no 77 complications. After 20 minutes, botulinum toxin injections were performed. The patient's left 78 upper extremity was now relaxed, but she still had noted flexion and pronation of the elbow 79 likely from soft tissue contracture formation. The degree of flexion and pronation was much less 80 than baseline, indicating that the majority of this deformity is dystonic and spastic, not 81 contracture. Next, 400 units of botulinum toxin were injected with a 25 gauge, 50 mm Teflon 82 insulated injection needle guided by electrical stimulation (E-stim) while identifying the motor 83 point in each individual muscle (Table 1). 84 At follow-up, three weeks later, she had a significant decrease in her left upper extremity 85 spasticity with the exception of a portion of bicep flexion and forearm pronation. MAS scores AC C EP TE D M AN U SC 69 4 ACCEPTED MANUSCRIPT post interscalene brachial plexus block and botulinum toxin injection improved and are 87 compared to pre-procedure MAS scores in Table 1. 88 Discussion 89 This case demonstrates a novel use of regional anesthesia to facilitate both examination and 90 injection procedures on the upper extremity in a patient with the combination of severe spastic 91 hemiplegia and CRPS I with co-existing soft tissue contractures. Regional anesthesia provides 92 the ability to block motor and sensory nerve transmission at any peripheral level that is 93 technically accessible to the provider. Brachial plexus blocks, in particular, can produce 94 anesthesia at the level of the nerve roots (interscalene block), trunks (supraclavicular block), 95 cords (infraclavicular block), or peripheral nerves (axillary block).8 These choices can be 96 employed to block the shoulder and upper arm down to the distal arm and hand, depending on 97 choice of injection site. Depending on local anesthetic choice and dose, both motor and sensory 98 block can be achieved for at least two hours8 with motor function returning before sensory 99 function. Although the brachial plexus has been located using both paresthesia and nerve 100 stimulation techniques based on structural landmarks, ultrasonography increases the accuracy of 101 location, ease of plexus identification, and safety of nerve blockade such that serious 102 complications are rare9. Practitioners should be well trained in the delivery of these nerve blocks 103 and prepared for emergent resuscitation in the event of rare but life-threatening complications 104 such as systemic local anesthetic toxicity or inadvertent intrathecal or epidural injection10. 105 Traditionally, plexus blocks are administered by anesthesiologists in the surgical setting, but 106 practitioners in pain medicine and emergency medicine are beginning to adopt techniques in 107 regional anesthesia. Use of an ultrasound guided left interscalene brachial plexus block allowed 108 for the ability to position the limb appropriately, accurate identification of motor points with an AC C EP TE D M AN U SC RI PT 86 5 ACCEPTED MANUSCRIPT E-stim unit during botulinum toxin injections of the left upper extremity, evaluation of what 110 portion of her left upper extremity limited range of motion was due to spasticity versus soft 111 tissue contractures, and appropriate intra-procedure analgesia. 112 Conclusion 113 The authors hope to highlight the benefit of performing a regional anesthesia prior to botulinum 114 toxin injections in patients with severe extremity spasticity unable to undergo the 115 chemodenervation procedure initially due to limb pain, pain with proper procedure positioning, 116 and/or co-existing hyperalgesia, allodynia, or CRPS. However, we caution that such anesthesia 117 be delivered by appropriately trained practitioners who are equipped with robust skills relevant 118 to the neuroanatomy, pharmacokinetics, and potential complications of regional anesthesia. M AN U SC RI PT 109 122 123 124 125 EP 121 AC C 120 TE D 119 126 127 6 ACCEPTED MANUSCRIPT 128 References 1. Elovic E, Baerga E, White BF. Associated Topics in Rehab: Spasticity. In: Cuccurillo SJ. 130 2nd edition Physical Medicine & Rehabilitation Board Review. New York, NY: Demos 131 Medical; 2010, 811-822. RI PT 129 132 2. Chang E, Ghosh N, Yanni D, Lee S, Alexandru D, and Mozaffar T, A Review of SC 133 Spasticity Treatments: Pharmacological and Interventional Approaches. Crit Rev Phys 135 Rehabil Med. 2013; 25(1-2): 11–22. M AN U 134 136 137 3. Walker HW, Lee MY, Bahroo LB, Hedera P, Charles D. Botulinum Toxin Injection 138 Techniques for the Management of Adult Spasticity. PM R. 2015;7(4):417-427 139 142 hypertonia from stroke. Stroke 2001; 32:2099-109. 5. Brashear A, Zafonte R, Corcoran M, Galvez-Jimenez N, Gracies JM, Gordon MF, 144 McAfee A, Ruffing K, Thompson B, Williams M, Lee CH, Turkel C. Inter- and intrarater 145 AC C 143 TE D 141 4. Meythaler JM, Guin-Renfroe S, Brunner RC, Hadley MN. Intrathecal baclofen for spastic EP 140 146 147 148 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 149 reliability of the Modified Ashworth Scale (MMAS) in the assessment of upper-limb 150 muscle spasticity. NeuroRehabilitation. 2012;31(2):215-22. 7 ACCEPTED MANUSCRIPT 151 153 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):746-53 155 156 RI PT 154 8. Brown DL. Brachial plexus anesthesia: an analysis of options. Yale J Biol Med. 1993 Sep-Oct;66(5):415-31. 157 159 9. Nadeau MJ, Lévesque S, Dion N. Ultrasound-guided regional anesthesia for upper limb surgery. Can J Anaesth. 2013 60(3):304-20. M AN U 158 SC 152 10. Yanovski B, Gaitini L, Volodarski D, Ben-David B. Catastrophic complication of an 162 interscalene catheter for continuous peripheral nerve block analgesia. Anaesthesia. 163 2012;67(10):1166-9. 166 167 168 169 170 171 EP 165 AC C 164 TE D 160 161 172 173 8 ACCEPTED MANUSCRIPT 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† RI PT Table 1 –Botulinum Toxin injection muscle, # of sites, units injected, and motor point 174 identification FCU 1 40 2 with clonus† FDS 2 80 4§ FPL 1 30 flexion) 3 week Post 175 Procedure MAS 2† 178 3‡ 179 193 194 195 SC M AN U TE D 192 2, no clonus† 180 3‡ 3‡ 181 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. EP 191 4§ AC C 182 183 184 185 186 187 188 189 190 2, no clonus† 196 9 ACCEPTED MANUSCRIPT Table 1: Tone rated in table one was completed using the Modified Ashworth Scale (MAS) 1, 6 198 by the same physician pre and post procedure. This physician was also the injector of the 199 neurotoxin. 200 Figure 1. Ultrasound image of brachial plexus at the interscalene level prior to injection. Depth 201 markers on the right indicate ½ cm increments. (Legend: SCM = sternocleidomastoid muscle; 202 ASM = anterior scalene muscle; MSM = middle scalene muscle; SA = subclavian artery; C5-C7 203 = some roots of the brachial plexus.) SC RI PT 197 M AN U 204 205 206 207 211 EP 210 AC C 209 TE D 208 10 AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT