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Eur Radiol (2008) 18: 1506–1512

DOI 10.1007/s00330-008-0909-x MUSCULO SKELETAL

Jongmin Lee
Yang Soo Lee
Percutaneous chemical nerve block
with ultrasound-guided intraneural injection

Received: 19 September 2007 Y. S. Lee musculocutaneous nerves. After iden-


Revised: 6 December 2007 Departement of Physical Medicine and tification of the spastic muscle and
Accepted: 5 January 2008 Rehabilitation, Kyungpook National target nerve, an ultrasound-guided,
Published online: 21 March 2008 University Hospital, intraneural injection was administered
# European Society of Radiology 2008 50, Sam-deok 2 Ga,
through a 25–G needle. The average
Jung Gu, Daegu 700–721, South Korea
e-mail: leeysu@knu.ac.kr effective duration was 9.1±19.6 days
in the lidocaine injection group and
was 164.5±169.4 days in the perma-
Abstract Ultrasound-guided, intra- nent blocking group with phenol
neural chemical nerve block was injection. The ultrasound-guided in-
J. Lee (*) performed to control intractable limb traneural injection technique was
Department of Diagnostic Radiology, convincing. Intraneural injection of
Kyungpook National University spasticity and its feasibility was eval-
Hospital, uated. Twenty-nine patients showing phenol achieved long-lasting im-
50, Sam-deok 2 Ga, spastic limb were controlled by 53 provement of spasticity.
Jung Gu, Daegu 700–721, South Korea intraneural injections of chemical
e-mail: jonglee@knu.ac.kr
agents, either lidocaine or phenol. The Keywords Nerve block . Muscle
Tel.: +82-53-4205472
main targets were the sciatic, tibial and spasticity . Ultrasonic imaging
Fax: +82-53-4222677

Introduction flaccid paralysis and atrophy. Although selective, posterior


rhizotomy has evolved as the predominant neurosurgical
Muscular spasticity has been defined as “a condition in procedure for the reduction of spasticity in children with
which there is a velocity-dependent increase in resistance spastic cerebral palsy, peripheral neurectomy has become
of the muscle group to passive stretch with a ’clasp-knife’ popular to overcome postoperative flaccid paralysis. In
type component associated with hyperactive tendon addition, other ablative and non-ablative procedures have
reflexes” [1]. On the basis of Sherrington’s studies, a been used for the successful reduction of spasticity in
neurophysiological knowledge of muscle tone and patho- certain patients [3]. Munro et al. [4] tried sciatic and sacral
genesis of spasticity was developed [2]. nerve block by intraneural injection of procaine after
To relieve a spasm of the appendicular skeletal muscle surgical dissection of target nerves. Other injections into
caused by neurological disorder, various surgical proce- the muscle belly were performed using an electrode needle
dures have been tried [3]. To interrupt either afferent or after identification of the motor point with a surface
efferent components of the spinal nerve root, posterior or electrode [3].
anterior rhizotomies were performed [2, 3]. Anterior On the other hand, ultrasound-guided, perineural blocks
rhizotomy resulted in a flaccid extremity instead of have recently become popular in the anesthetic literature
muscular spasm [3, 4]. Posterior rhizotomy succeeded, for temporary local anesthesia. Ultrasonography has come
but at the expense of sensory loss. However, these to be regarded as a useful aid, whether to locate arteries, to
procedures are no longer applied because of the resulting mark the skin for unguided blocks or to act as a real-time
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guide of needle or catheter position relative to the nerve or 1 year and who could extend their fingers. Our institutional
related blood vessels. Ultrasonography can also be used to review board approved all aspects of this retrospective
define the spread of local anesthetics [5]. Recently, Gruber study. Informed consent was obtained from all patients or
et al. [6] reported the successful results of ultrasound- their parents in the case of children prior to the procedure.
guided phenol injection into painful stump neuromas. A board-certified physiatrist with 9–year experience
In this study, the ultrasound guidance technique and evaluated all the patients’ spasticity according to the
intraneural chemical nerve block technique were inte- Ashworth scale before and after the intraneural injections.
grated. The purpose of this study was to evaluate the For Ashworth scaling, patients laid down in supine position
feasibility of ultrasound guidance during intraneural injec- and relaxed all muscles. Resistance of extremity during its
tion and the effect of intraneural chemical block of normal- passive movement was stratified as follows: 0= no increase
featured nerves to control intractable limb spasticity in tone, 1= slight increase in tone giving a ‘catch’, 2= more
originating from central neurological abnormality. The marked increase in tone, but limb easily flexed, 3=
feasibility evaluation of the nerve block technique was considerable increase in tone-passive movement difficult
performed retrospectively after 3-year clinical application. and 4= limb rigid in flexion or extension [7].
Injected agents were 2~5 ml of a solution containing 2%
lidocaine or 7% phenol. The 7% phenol solution was made
Materials and methods by dissolving pure phenol in distilled water. Lidocaine was
used for temporary nerve block and phenol for permanent
Twenty-nine patients, 23 male and 6 female, showing block. Ultrasonography (HDI-5000, Philips, Eindhoven,
muscular contracture of their extremities were controlled The Netherlands) equipped with 7–15 MHz linear
by 53 intraneural injections of chemical agents. Patient age transducers was used. The lidocaine injection group
ranged from 2 to 75 years old, with a mean age of 34. All comprised 19 patients and 41 intraneural injections. The
patients showed spasticity during forced passive motion or target nerves were sciatic nerve (n=25), tibial nerve (n=11),
intentional voluntary motion of their extremities, but none musculocutaneous nerve (n=2), anterior interosseous nerve
complained of spasm. The causes of neurological deficit (n=1), median nerve (n=1) and ulnar nerve (n=1), whereas
were cerebral palsy (n=11), cerebral stroke (n=5), traumatic the phenol injection group comprised 10 patients and 12
brain (n=10) and spinal cord (n=3) injuries (Table 1). The injections. In this group, the target nerves were the
inclusion criterion for the sciatic and tibial nerve block was musculocutaneous nerve (n=10), anterior interosseous
patients with a spastic tip toe or crouched gait that was nerve (n=1) and tibial nerve (n=1).
refractory to conventional rehabilitation for more than As an initial step of the nerve-blocking procedure, the
6 months. The exclusion criteria were patients who could physiatrist re-confirmed a spasticity of extremity based on
not walk without support and were not treated with an the patient’s complaint and defective movement. Subse-
adequate rehabilitation technique. For the musculocutane- quently, a major causative muscle for the spasticity was
ous nerve block, the inclusion criteria were marked identified through a physical examination, and the nerve
spasticity of the elbow flexor muscles, spasticity for more innervating the muscle was targeted. The blocking agent
than 1 year after onset and severe finger flexor spasticity was decided according to the literature-based knowledge
resulting in a non-functional hand. The exclusion criteria about the proportion of motor and sensory neural
were patients who had spasticity in the elbow for less than components. If the muscle was a mixed motor and sensory
nerve, lidocaine was chosen as blocking agent since the
Table 1 Patient data of lidocaine and phenol injection groups risk of dysesthesia was high, whereas the nerves with low
Lidocaine injection Phenol injection
risk of dysesthesia, such as musculocutaneous and obtu-
rator nerves, were blocked using phenol [7, 8]. A
group group
permanent blocking agent could be applied for the pure
motor nerve, such as the musculocutaneous and anterior
Age (years) 23.0±20.2 51.8±16.5
interosseous nerves. However, a local anesthetic drug was
Male ofemale ratio 16: 3 7: 3
the first choice for preliminary and temporary nerve block
Cerebral palsy (persons) 7 4 for a nerve containing both sensory and motor components,
Traumatic brain injury 6 4 such as the sciatic, tibial, radial and ulnar nerves.
(persons) Subsequently, a permanent nerve block was performed
Cerebral stroke (persons) 4 1 only when the spasticity-free effect overwhelmed the
Spinal cord injury 2 1 sensory deficit. A temporary block was preceded in cases
(persons) where the effect and the safety of the permanent block were
Subject number (persons) 19 10 not definite. In this study, four patients received temporary
Duration of illness 67.9±46.1 44.6±32.6
nerve block prior to permanent block. These cases
comprised two musculocutaneous, anterior interosseous
(months)
and tibial nerves as target nerves. The other six patients
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received permanent block of their musculocutaneous cross-sectional area of the target nerve doubled even before
nerves without preliminary testingof the temporary block. the full pre-loaded dose had been injected. The intraneural
The rationale for temporary nerve block by intraneural injection was determined to be successful when the
injection of local anesthetic drugs is firstly, checking the injected nerve expanded and immediate improvement of
possibility of blocking mixed sensory and motor nerves the muscular contracture was noted. Usually, the assistants
permanently and secondly, temporary but hopefully longer holding the distal limb could feel the sudden effacement of
relief of spasticity than a blinded injection of local rigidity when the intraneural injection of the blocking agent
anesthetic drug around a target nerve. The intraneural started. Since either the phenol or lidocaine and either
injection procedures were performed by a board-certified intraneural or perineural injections might show immediate
radiologist with 12-year experience of ultrasound-guided improvement of the spasticity right after the procedure, in
targeting of the internal structures, such as the joints, this study, the immediate post-procedure effect was not
masses, blood vessels and nerves in a 1,000-bed general regarded as an index for the feasibility. Instead, an
hospital. evaluation of the effective duration after the intraneural
After ultrasonographic identification of the target nerve, nerve block was the main focus of this study. The degree of
a 25-gauge needle with beveled tip was inserted into the improvement in spasticity varied according to the blocking
nerve with real-time guidance. The general technique used level of the target nerve and the presence of co-working
to locate the nerves precisely involved with an ultrasono- nerves or muscles. The whole process of the intraneural
graphic scan from the point where the target nerve could be block took approximately 15 min even though the time
depicted easily. For example, the radial nerve was readily needed to depict the target nerve varied.
identified at the wrist around the radial artery, and the radial The patients were educated to revisit to our outpatient
nerve was then traced proximally up to the point of the clinic immediately when spasticity was felt to have
block. The ulnar nerve was traced from the cubital tunnel. recurred. In the outpatient clinic, the post-procedure
The musculocutaneous nerve was identified beneath the follow-up evaluation was performed by a physiatrist who
biceps brachii muscle and lateral to the brachial artery in evaluated the patients initially. The spasticity-free ‘effec-
the supine position. After identifying the musculocutane- tive duration’ was defined as the time between the moment
ous nerve, the needle was inserted into the antero-lateral of nerve block and that when the patients felt recurring
aspect of the proximal arm until it reached the target spasticity in their extremities. In cases when the spasticity-
through the biceps brachii muscle. The tracing of the tibial free interval lasted until the last follow-up time, the
nerve and sciatic nerve began from the popliteal fossa effective duration was defined as the interval between the
distally and proximally. The blocking level of the sciatic date of nerve block and the finishing date of data collection
nerve was at the level of the gluteal fold, and the entry point for this study after reconfirming via telephone. The
was the posterior or posterolateral aspect of the proximal influence of blocking agents and target nerves on the
thigh at the prone position. The median nerve tracing effective duration was evaluated.
started from either the axilla or anterior midline of proximal
arm. On the way down to the wrist, the anterior interos-
seous nerve could be identified. The anterior interosseous Results
nerve was the branch of the median nerve at the proximal
level of the distal arm, which reached the anterior aspect of In all 53 injections, the nerve expanded, and the spasticity
the interosseous membrane. The blocking of the anterior was immediately released, indicating a technical success
interosseous nerve was performed at the mid-level of the rate of 100%. At the initial moment of intraneural injection,
distal arm. in all cases, pricking pain occurred shortly and subse-
A small amount of nerve blocking agent was initially quently disappeared during the other period of injection.
injected when the needle tip was within the target nerve. No intraneural injection was stopped due to patient’s
Due to real-time ultrasonographic guidance, the intraneural intolerance to the pain in both the lidocain- and phenol-
injection could be retried until the expanding nerve was injection groups. The diameter expansion ratio of the target
visualized during the initial small injection. The full dose of nerve ranged from 1.2 to 3.8 with a mean of 2.1 (Figs. 1, 2).
phenol was injected after reconfirmation by the initial test In the lidocaine injection group (n=19), the mean pre-
injection. For even distribution of the agents, multiple, injection Ashworth scale was 2.6±0.8. If the three patients
small-amount injections were done moving the tip of the who were lost to follow-up were excluded, the average pre-
needle along the whole area of the nerve. The pre-loaded injection Ashworth scale of the remaining 16 patients was
volume of the sclerosing agent was determined according 2.5±0.7. Although the spasticity disappeared immediately
to the size of the target nerve. For the sciatic nerve block, in all cases given the lidocaine injection, the spasticity
the musculocutaneous and tibial nerve block, radial and recurred at the first follow-up in all cases except for one.
ulnar nerve block, and anterior interosseous nerve block, All patients except for two (n=14) were evaluated within
5-ml, 4-ml, 3-ml and 2-ml of the agents were loaded, 4 weeks. The follow-up evaluation period ranged from 3 to
respectively. However, the injection was stopped when the 120 days with mean and standard deviation of 12.6±
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Fig. 1 Phenol sclerotherapy of the musculocutaneous nerve successful intraneural injection. The echogenecity of the swollen
performed for a 59-year-old female patient complaining of spastic nerve (+) is slightly decreased due to injected phenol. Six months
elbow after cerebral stroke. In the initial transverse (a) and after the procedure, follow-up ultrasonography (f) revealed an
longitudinal (b) ultrasonography using 5–12 MHz linear transducer, atrophic musculocutaneous nerve (arrow) and biceps brachii muscle
the musculocutaneous nerve (+) was identified beneath the biceps (*), implying the effect of neurectomy. Despite non-functioning
brachii muscle (*). A 25-guage needle (arrows) was inserted into the biceps muscle, the patient was able to flex her elbow intentionally
musculocutaneous nerve and subsequently 5-ml phenol was slowly by relying on the function of the brachialis muscle, which is
injected by moving the tip in the whole area of the nerve (c). innervated by the radial nerve. In addition, the patient did not
Postprocedure transverse (d) and longitudinal (e) ultrasonography complain of any spasticity of her elbow
revealed a swollen musculocutaneous nerve (+), suggesting

21.8 days. The effective duration could not be measured who were lost to follow-up were excluded, the average pre-
numerically since spasticity-recurrence time was declared injection Ashworth scale was 3.1±0.4. In contrast to the
based on patient’s memory during the first follow-up, and lidocaine injection group, the phenol injection group
no physical exam was performed during the spasticity-free showed statistically significant improvement in the average
interval. The post-injection Ashworth scale of the 16 post-injection Ashworth scale of 2.1±0.8 during the follow-
patients was 2.4±0.8. In this study protocol, there was no up evaluation (p<0.05 in Wilcoxon signed rank test). The
significant improvement in the Ashworth scale after the first follow-up interval ranged from 3 to 420 days with
lidocaine injection. mean and standard deviation of 97.0±144.1 days (p<0.01).
The phenol injection group (n=10) showed an average The follow-up evaluation was performed within 4 weeks in
pre-injection Ashworth scale of 3.1±0.3. If the two patients four patients. The other four patients were evaluated after

Fig. 2 A 32-year-old male suffering from spastic pronation of the nerve (+) beneath the flexor pollicis longus muscle (*) at the level of
forearm after brain injury by motor vehicle accident became a the distal forearm. During intraneural injection of phenol (c), the
candidate for phenol sclerotherapy of the anterior interosseous needle (arrows) and swelling anterior interosseous nerve (+) can be
nerve. Preprocedure transverse (a) and longitudinal (b) ultrasonog- identified
raphy using a 5–12-MHz transducer revealed an anterior interosseous
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4 weeks. In the phenol injection group, the average by successful, non-destructive, sciatic and sacral nerve
effective duration ranged from 3 to 420 days with mean and block by intraneural or perineural injection of procaine, the
standard deviation of 164.5±169.4 days. Two patients intraneural chemical blocking technique was recruited as
showed recurring original spasticity at the first follow-up an alternative method to control the spasticity [4]. Common
evaluation on the 5th and 12th days. The other patients did target nerves of intraneural injection were the median and
not show any aggravation of the improved spasticity during ulnar nerves for wrist and finger spasticity, the musculo-
the follow-up evaluation up to the 420th day (Table 2). cutaneous nerve for elbow spasticity, the obturator nerve
Although temporary and tolerable, causalgia with a for scissoring and the tibial nerve for equinus deformity [3].
duration of several days developed in seven cases given the The most common agent injected was 2–5% phenol acting
tibial nerve block using lidocaine. No other significant by protein denaturation, followed by alcohol, anesthetics
complication occurred. During the follow-up, one patient such as lidocaine and procaine, botulinum toxin inhibiting
whose musculocutaneous nerve had been blocked using release of acetylcholine from the presynaptic terminals and
phenol revisited the interventional suite due to slightly blocking neuromuscular transmission [4, 9]. Since blind
increasing arm spasticity. The dynamic ultrasonography nerve blocking techniques had a failure rate of up to 20%,
during the voluntary motion revealed atrophic and non- surgical dissection of nerve or electrophysiological guid-
functioning biceps brachii muscle, suggesting a successful ance was required for successful intraneural or perineural
musculocutaneous block. The non-functioning muscle was injection of blocking agents [10].
documented by ultrasonography when the axial thickening Botulinum type-A toxin injections have been widely
and decrease in echogenecity did not occur during the used to control spasticity in a variety of disorders,
voluntary contraction of the muscle. The recurrent spas- including cerebral palsy. The advantages of botulinum
ticity was concluded to be due to a hypertrophied brachialis type-A toxin are the easy administration. However, several
muscle, and no further neurolysis was performed (Fig. 1). drawbacks of botulinum type-A toxin have been reported.
The other patients (n=7) were followed up clinically, and The toxin is expensive [11]. Since botulinum toxin attacks
no ultrasonographic evaluation of the target nerve and the neuromuscular junction, the injection should be
muscle atrophy was performed. performed at the motor point of the muscle [12]. In
addition, since the blockade is reversible after several
weeks, repeated injections every 3–6 months are essential
Discussion for a sustained effect [13]. In addition, resistance to the
botulnium toxin by autoantibiodies has been reported [14].
In the literature, various peripheral neurectomies have been In this study, botulinum toxin was not used because it was
applied to control intractable appendicular spasticity with not feasible for both intraneural injections and achieving a
favorable results, despite undesirable side effects, such as permanent blockade.
weakness, atrophy and sensory loss. The target nerves were A perineural infiltration of phenol solution has been used
the obturator nerve, musculocutaneous nerve, tibial nerve, for many decades to treat spasticity [15]. The phenol
sciatic nerve and brachial plexus collaterals [3]. Triggered neurolytic block was performed under electrophysiological

Table 2 Clinical results during follow-up evaluation after intraneural phenol injection
Injection Target Pre-injection The 1st follow-up date The 1st follow-up The 2nd follow-up date The 2nd follow-up
number nerves AS (day) AS (day) AS

1 Rt MCN 3 12 3
2 Rt MCN 3
3 Lt AION 3 5 3
4 Lt MCN 3 420 2
5 Lt MCN 3
6 Rt MCN 3
7 Rt MCN 3 3 1
8 Rt MCN 3 90 1 180 1
9 Lt MCN 3
10 Rt MCN 3 60 2
11 Lt MCN 3 180 2 180 2
12 Rt TN 4 6 3 180 3
AS, Ashworth scale; Rt, right; Lt, left; MCN, musculocutaneous nerve; AION, anterior interosseous nerve; TN, tibial nerve
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guidance, such as nerve stimulation technique [16, 11, 17]. for the distal muscles supplied by small nerves, such as
A Teflon-coated needle connected to the nerve stimulator, interosseous or obturator nerves. For example, in one case
was slowly advanced until the maximum muscle contrac- of a phenol block, two intraneural injections were
tion had occurred at a pre-set electric current. Subse- performed at the musculocutaneous and anterior interos-
quently, the phenol solution was injected until the muscle seous nerves to simultaneously release both the elbow
contraction ceased [17]. The advantages of phenol neuro- flexion and forearm pronation. The spastic elbow flexion
lysis are the low cost and long-lasting effect [17]. However, disappeared completely, whereas the spastic pronation of
dysesthesia, numbness and hematoma were the reported the forearm recurred in 5 days. The smallest nerve in the
side effects of phenol neurolysis [18]. In the literature, it phenol group, the anterior interosseous nerve, achieved the
has been reported that phenol blocks were temporary and shortest effective duration. However, due to an insufficient
generally lasted 3–12 months [19]. In this study, phenol number of small nerves in the phenol group, the relation-
was injected exactly into target nerves due to real-time ship between the nerve size, dose of the blocking agent and
ultrasound guidance. In contrast to the perineural infiltra- the effective duration could not be clarified.
tion techniques, the intraneural injection technique Causalgia and dysesthesia, cardiac arrhythmias and
achieved a longer effective duration (Table 2). In contrast permanent neurological deficits are complications com-
to phenol, lidocaine block lasted variously by subjects and monly reported during perineural block. Since the periph-
target nerves. Although it was not used in this study, eral nerve usually consists of both motor and sensory
multilevel intraneural injections of a lidocaine solution at a components, an intraneural chemical block may destroy the
single nerve might extend the effective period. sensory fibers resulting in dysesthesia or causalgia [23]. In
In recent decades, the ultrasonographic examination of this study, no complication was encountered in the phenol
peripheral nerves has become popular due to development group, while mild temporary causalgia occurred in seven
of ultrasonographic equipment and further understanding cases of the lidocaine group. The causalgia occurred as a
of ultrasonographic feature of nerves [20, 21]. Ultrasound complication because the lidocaine group included nerves
has become a useful aid for locating nerves and a real-time containing sensory fibers, such as sciatic, tibial and ulnar
guide of needle during an injection of local anesthetics [5]. nerves. The estimated reasons for the causalgia were nerve
Ultrasonographic guidance has been applied in the intra- fiber damage caused by a needle-related intraneural
lesional injection of alcohol to ablate Morton’s neuroma physical injury and lidocaine-induced chemical injury
and stump neuroma [1, 22], whereas, to our knowledge, (unpublished experimental data), as well as causalgia-
there has been no report about the application of ultrasound mimicking pain by an altered ergonomic mechanism of the
guidance during intraneural nerve block for spasticity extremity. In our consideration, the slow infusion of agent
control. For more specific block of the motor component, a at multiple points within a nerve reduced physical injury
chemical block in the motor point of the muscle belly was and subsequent complications. In addition, to prevent
also tried, with an effect lasting up to 6 months [19]. Since possible, severe sensory deficit, partial ablation might be a
the motor point cannot be delineated by ultrasonography, solution. Based on the detailed anatomical information
blind block at the presumed motor point area should be using high-resolution ultrasonography, a partial area can
performed. However, even in such a case, ultrasonography intentionally be saved from needle penetration during the
can still facilitate reaching the motor point by showing procedure. In cases of a sciatic nerve block, high-resolution
adjacent anatomical structures. ultrasonography could differentiate the peroneal and tibial
In the phenol injection group, the effective duration was nerve components, and a focused intraneural injection of
satisfactory to either patient or physician in 75% (six out of lidocaine into the tibial nerve component could be
eight). During the follow-up of a musculocutaneous nerve performed.
block case, ultrasonography revealed that the recurring arm In this study, we concluded that ultrasonography was a
spasticity was due to partially hypertrophied brachialis perfect guiding tool for intraneural injection. In addition,
muscle innervated by the radial nerve. In this case, the ultrasound-guided nerve block was suitable for controlling
biceps brachii muscle that had been innervated by muscu- spasticity of the extremities, either temporarily or perma-
locutaneous nerve was atrophied. Therefore, it was nently. Intraneural injection of phenol achieved long-
assumed that the recurring spasticity was due to the lasting improvement of spasticity. One caveat is that
strengthened adjuvant muscles, which perform alternative achieving an acceptable balance between reduction of
tasks, and not by the resumed function of the ablated nerve spasticity and possible sensory change should precede the
itself. Furthermore, these phenomena should be more likely intraneural injection of the permanent-blocking agent.
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