Recommendations for Ultrasound Guidance for Diagnostic Nerve Blocks for Spasticity. What are the Benefits?

  • Paul Winston
    Corresponding author Paul Winston, MD, Division of Physical Medicine and Rehabilitation, University of British Columbia, Victoria, BC, Canada.
    Division of Physical Medicine and Rehabilitation, University of British Columbia, Canada

    Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada
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  • Rajiv Reebye
    Division of Physical Medicine and Rehabilitation, University of British Columbia, Canada

    Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada
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  • Alessandro Picelli
    Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada

    Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, Neuromotor and Cognitive Rehabilitation Research Center, University of Verona, Verona, Italy
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  • Romain David
    Physical Medicine and Rehabilitation Unit, Poitiers University, Poitiers, France
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  • Eve Boissonnault
    Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Kingston, Canada

    Division of Physical Medicine and Rehabilitation, University of Montreal, Canada
    Search for articles by this author
Published:February 03, 2023DOI:


      The diagnostic nerve block (DNB) for spasticity is the percutaneous application of an anesthetic to an individual peripheral nerve trunk (mixed motor sensory nerve), nerve branch to a muscle or an intramuscular branch. The DNB causes a temporary paralysis to assess the contribution of muscle(s) on the spastic pattern and may unmask a fully or partially increased joint range of motion. The anesthetic literature supports the use of ultrasound (US) guidance to improve nerve blocks for sensory targets. This communication summarizes the potential advantages that support the use of US to improve DNB technique. Nerves are much smaller than muscle targets and have various known innervation patterns. US allows for rapid localization of the target before injection, particularly in complex anatomy patterns. The nerve trunks are typically found adjacent to or encapsulating blood vessels, which can be quickly identified with or without color Doppler, allowing the clinician to scan from the vessels to the target and avoid intravascular injection. Lower stimulation levels can be used as the targeted muscle(s) can be seen stimulating rather than only on the surface. A shorter needle insertion time and lower stimulation levels should cause less discomfort to the patient. Smaller volumes of anesthetic may be used as the fluid is seen reaching its target and cessation of stimulation is observed. Further study is needed to identify evidence supporting US utilization with electrical stimulation in DNBs for spasticity management, as US use during nerve blocks for perineurial anesthesia has demonstrated improved patient safety and procedural efficiency.


      List of abbreviations:

      DNB (diagnostic nerve block), e-stim (electrical stimulation), US (ultrasound)
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        • Wissel J
        • Ward AB
        • Erztgaard P
        • et al.
        European consensus table on the use of botulinum toxin type a in adult spasticity.
        J Rehabil Med. 2009; 41: 13-25
        • Elovic EP
        • Esquenazi A
        • Alter KE
        • Lin JL
        • Alfaro A
        • Kaelin DL
        Chemodenervation and nerve blocks in the diagnosis and management of spasticity and muscle overactivity.
        PM R. 2009; 1: 842-851
        • Chan AK
        • Finlayson H
        • Mills PB
        Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review.
        Clin Rehabil. 2017; 31: 713-721
        • Kristi Henzel M
        • Munin MC
        • Niyonkuru C
        • Skidmore ER
        • Weber DJ
        • Zafonte RD
        Comparison of surface and ultrasound localization to identify forearm flexor muscles for botulinum toxin injections.
        PM R. 2010; 2: 642-646
        • Lagnau P
        • Lo A
        • Sandarage R
        • et al.
        Ergonomic recommendations in ultrasound-guided botulinum neurotoxin chemodenervation for spasticity: an international expert group opinion.
        Toxins (Basel). 2021; 13: 249
        • Alter KE
        • Karp BI
        Ultrasound guidance for botulinum neurotoxin chemodenervation procedures.
        Toxins (Basel). 2018; 10: 18
        • Winston P
        • Hashemi M
        • Vincent D.
        Ultrasound with e-stimulation diagnostic nerve blocks for targeted muscle selection in spasticity.
        Am J Phys Med Rehabil. 2021; 100: e167
        • Kaymak B
        • Kara M
        • Gürçay E
        • Aydin G
        • Özçakar L.
        Selective peripheral neurolysis using high frequency ultrasound imaging: a novel approach in the treatment of spasticity.
        Eur J Phys Rehabil Med. 2019; 55: 522-525
        • Sindou MP
        • Simon F
        • Mertens P
        • Decq P.
        Selective peripheral neurotomy (SPN) for spasticity in childhood.
        Childs Nerv Syst. 2007; 23: 957-970
        • Pham M
        • Bäumer P
        • Meinck HM
        • et al.
        Anterior interosseous nerve syndrome.
        Neurology. 2014; 82: 598-606
        • Gras M
        • Leclercq C.
        Spasticity and hyperselective neurectomy in the upper limb.
        Hand Surg Rehabil. 2017; 36: 391-401
        • Picelli A
        • Chemello E
        • Verzini E
        • et al.
        Anatomical landmarks for tibial nerve motor branches in the management of spastic equinovarus foot after stroke: an ultrasonographic study.
        J Rehabil Med. 2019; 51: 380-384
        • Fletcher D
        • Raymond Poincaré H
        • Publique-Hôpitaux de Paris A
        • et al.
        Anesthésie Loco-Régionale périnerveuse (ALR-PN) Groupe d'experts de la SFAR.
        Sfar. 2016; : 1-14
        • Tardieu G
        • Tardieu C
        • Hariga J
        • Gagnard L.
        Treatment of spasticity by injection ofdilute alcohol at the motor point or by epidural route: clinical extension of an experiment on the decerebrate cat.
        Dev Med Child Neurol. 1968; 10: 555-568
        • Leclercq C.
        Selective Neurectomy for th e Spastic Upper Extremity.
        Hand Clin. 2018; 34: 537-545
        • Ghai A
        • Garg N
        • Hooda S
        • Gupta T.
        Spasticity - pathogenesis, prevention and treatment strategies.
        Saudi J Anaesth. 2013; 7: 453-460
        • Genet F
        • Schnitzler A
        • Droz-Bartholet F
        • et al.
        Successive motor nerve blocks to identify the muscles causing a spasticity pattern: example of the arm flexion pattern.
        J Anat. 2017; 230: 106-116
        • Spittler H
        • Laffont I
        • Fournier-Mehouas M
        • et al.
        Diagnostic nerve blocks in spasticity management: E-survey of current practices in physical rehabilitation medicine in France.
        Ann Phys Rehabil Med. 2021; 64101513
        • Bollens B
        • Gustin T
        • Stoquart G
        • Detrembleur C
        • Lejeune T
        • Deltombe T.
        A randomized controlled trial of selective neurotomy versus botulinum toxin for spastic equinovarus foot after stroke.
        Neurorehabil Neural Repair. 2013; 27: 695-703
        • Bollens B
        • Deltombe T
        • Detrembleur C
        • Gustin T
        • Stoquart G
        • Lejeune T.
        Effects of selective tibial nerve neurotomy as a treatment for adults presenting with spastic equinovarus foot: a systematic review.
        J Rehabil Med. 2011; 43: 277-282
        • Deltombe T
        • Bleyenheuft C
        • Gustin T.
        Comparison between tibial nerve block with anaesthetics and neurotomy in hemiplegic adults with spastic equinovarus foot.
        Ann Phys Rehabil Med. 2015; 58: 54-59
        • Deltombe T
        • Wautier D
        • De Cloedt P
        • Fostier M
        • Gustin T.
        Assessment and treatment of spastic equinovarus foot after stroke: guidance from the mont-godinne interdisciplinary group.
        J Rehabil Med. 2017; 49: 461-468
        • Bahner DP
        • Goldman E
        • Way D
        • Royall NA
        • Liu YT.
        The state of ultrasound education in U.S. Medical schools: results of a national survey.
        Acad Med. 2014; 89: 1681-1686
        • Reaume M
        • Siuba M
        • Wagner M
        • Woodwyk A
        • Melgar TA.
        Prevalence and scope of point-of-care ultrasound education in internal medicine, pediatric, and medicine-Pediatric Residency Programs in the United States.
        J Ultrasound Med. 2019; 38: 1433-1439
        • Chui J
        • Lavi R
        • Hegazy AF
        • et al.
        Identifying barriers to the use of ultrasound in the perioperative period: a survey of southwestern Ontario anesthesiologists.
        BMC Health Serv Res. 2019; 19: 1-8
        • Mulchandani H
        • Awad IT
        • McCartney CJL.
        Ultrasound-guided nerve blocks of the lower limb.
        Atlas of ultrasound-guided procedures in interventional pain management. Springer New York, New York, NY2011: 239-258
        • Yelnik AP
        • Hentzen C
        • Cuvillon P
        • et al.
        French clinical guidelines for peripheral motor nerve blocks in a PRM setting.
        Ann Phys Rehabil Med. 2019; 62: 252-264
        • Mccartney CJL
        • Xu D
        • Constantinescu C
        • Abbas S
        • Chan VWS.
        Ultrasound examination of peripheral nerves in the forearm.
        Reg Anesth Pain Med. 2007; 32: 434-439
        • Mahan MA
        • Spinner RJ.
        Nerves of the upper extremity.
        Bergman's Compr Encycl Hum Anat Var. 2016; : 1068-1112
        • Yang ZX
        • Pho RWH
        • Kour AK
        • Pereira BP.
        The musculocutaneous nerve and its branches to the biceps and brachialis muscles.
        J Hand Surg Am. 1995; 20: 671-675
        • Matsumoto ME
        • Berry J
        • Yung H
        • Matsumoto M
        • Munin MC
        Comparing electrical stimulation with and without ultrasound guidance for phenol neurolysis to the musculocutaneous nerve.
        PM R. 2018; 10: 357-364
        • Matsuda H
        • Oka Y
        • Takatsu S
        • et al.
        Ultrasound-guided block of selective branches of the brachial plexus for vascular access surgery in the forearm: a preliminary report.
        J Vasc Access. 2016; 17: 284-290
        • Kong K
        • Chua KSG.
        Neurolysis of the musculocutaneous poststroke elbow flexor spasticity nerve with alcohol to treat.
        Arch Phys Med Rehabil. 1999; 80: 1234-1236
        • Munirama S
        • McLeod G.
        A systematic review and meta-analysis of ultrasound versus electrical stimulation for peripheral nerve location and blockade.
        Anaesthesia. 2015; 70: 1084-1091
        • Abrahams MS
        • Aziz MF
        • Fu RF
        • Horn JL.
        Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials.
        Br J Anaesth. 2009; 102: 408-417
        • Rubenstein J
        • Harvey AW
        • Vincent D
        • Winston P.
        Cryoneurotomy to reduce spasticity and improve range of motion in spastic flexed elbow. A visual vignette.
        Am J Phys Med Rehabil. 2020; 100: e65
        • Picelli A
        • Bonetti P
        • Fontana C
        • et al.
        Relationship between ultrasonographic, electromyographic, and clinical parameters in adult stroke patients with spastic equinus: an observational study.
        Arch Phys Med Rehabil. 2012; 37: 1564-1570
        • Picelli A
        • Tamburin S
        • Cavazza S
        • et al.
        Is spastic muscle echo intensity related to the response to botulinum toxin type a in patients with stroke? A cohort study.
        Arch Phys Med Rehabil. 2020; 2100071
        • Moreta MC
        • Fleet A
        • Reebye R
        • et al.
        Reliability and validity of the Modified Heckmatt Scale in evaluating muscle changes with ultrasound in spasticity.
        Arch Rehabil Res Clin Transl. 2020; 2100071
        • Yoshida T
        • Nakamoto T
        • Kamibayashi T.
        Ultrasound-guided obturator nerve block: a focused review on anatomy and updated techniques.
        Biomed Res Int. 2017; 20177023750
        • Helweg-Larsen J
        • Jacobsen E.
        Treatment of spasticity in cerebral palsy by means of phenol nerve block of peripheral nerves.
        Dan Med Bull. 1969; 16: 20-25
        • Halpern D
        • Meelhuysen FE.
        Phenol motor point block in the management of muscular hypertonia.
        Arch Phys Med Rehabil. 1966; 47: 659-664
        • Dahlin LB
        • Dahlin L.
        Techniques of peripheral nerve repair.
        Scand J Surg. 2008; 97: 310-316
        • Carty S
        • Nicholls B.
        Ultrasound-guided regional anaesthesia.
        Contin Educ Anaesth Crit Care Pain. 2007; 7: 20-24
        • Winston P
        • Vincent D.
        Atlas of ultrasound guided nerve targeted procedures for spasticity.
        Quintessence, Berlin2023
        • Ghassemi J.
        Musculocutaneous nerve block.
        Atlas Ultrasound-Guided Reg Anesth. 2019; : 117-124
        • Keenan MAE
        • Tomas ES
        • Stone L
        • Gersten LM.
        Percutaneous phenol block of the musculocutaneous nerve to control elbow flexor spasticity.
        J Hand Surg Am. 1990; 15: 340-346
        • Botter A
        • Oprandi G
        • Lanfranco F
        • Allasia S
        • Maffiuletti NA
        • Minetto MA.
        Atlas of the muscle motor points for the lower limb: implications for electrical stimulation procedures and electrode positioning.
        Eur J Appl Physiol. 2011; 111: 2461-2471
        • Moon JY
        • Hwang TS
        • Sim SJ
        • Chun S I
        • Kim M.
        Surface mapping of motor points in biceps brachii muscle.
        Ann Rehabil Med. 2012; 36: 187
        • Filippetti Mirko
        • Di Censo R
        • Varalta V
        • et al.
        Is the outcome of diagnostic nerve block related to spastic muscle echo intensity ? A retrospective observational study.
        J Rehabil Med. 2022; 54: jrm00275