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Ultrasound with e-stimulation diagnostic anesthetic nerve blocks for targeted muscle selection in spasticity.

Video Author: Paul Winston
Published on: 07.02.2021

Diagnostic nerve blocks have been used for decades in spasticity. They allow for the direct assessment of the contribution of individual muscles to spasticity and the differentiation between a true musculotendinous contracture versus a reversible spastic deformity due to spastic muscle overactivity. There is a paucity of studies that show the use of ultrasound with e-stimulation to improve accuracy and the speed of localization of nerves. Ultrasound allows for the easy localization of the blood vessels around which nerve and their fascicles course and allows for direct localization of the nerve and visualizes targeted muscle stimulation.

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Creator: Ricci Vincenzo
Duration: 0:08
In physiological conditions, regular gliding of the subscapularis muscle-tendon unit can be observed at the level of the coracoid/subcoracoid space. No snapping phenomena or fluid collection is visible during dynamic assessment. Note that the subscapularis muscle belly - visible at the end of external rotation - should not be misinterpreted as an anechoic pathology.
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Creator: Ricci Vincenzo
Duration: 0:08
Complete injury of the subscapularis muscle-tendon unit (medially retracted) is associated with an anterior translation of the humeral head. During active rotations of the glenohumeral joint, it is possible to visualize the rolling of the naked humerus just below the fibers of the deltoid muscle with a mechanical conflict in the proximity of the coracoid bone.
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Creator: Ricci Vincenzo
Duration: 0:16
During dynamic scanning, the synovial fluid is pushed from the glenohumeral joint to the anterior compartment of the subacromial/subdeltoid bursa, confirming the full-thickness rotator cuff tear. Note that the peculiar pathway of fluid is related to the dynamic pressure gradient i.e. greater inside the joint and lower in the bursal cavity.
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Creator: Ricci Vincenzo
Duration: 0:17
In a patient with no ultrasonographic findings of subacromial-subdeltoid bursitis or rotator cuff tear, articular effusion is pushed from the glenohumeral cavity to a large superior subscapular recess during active shoulder external rotation. This phenomenon is related to the presence of Weitbrecht foramina at the level of the anterior glenohumeral capsule.
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Creator: Ricci Vincenzo
Duration: 0:27
The dynamic evaluation clearly shows friction between the (enlarged) proximal segment of the LHBT and the anterior deltoid muscle fibers. Herein, the - highly innervated - subdeltoid fascia should also be considered among the potential pain generators.
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Creator: Ricci Vincenzo
Duration: 0:29
The shape of the bicipital groove and the surrounding stabilizing structures (soft tissues) ensure a correct function of the LHBT during active shoulder movements. Note the anatomical continuity of the transverse humeral ligament with the subscapularis tendon fibers.
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Creator: Ricci Vincenzo
Duration: 0:22
The LHBT floats inside the effusion of the synovial sheath but does not shift out of the bicipital groove during dynamic scanning, confirming its mechanical stability.
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Creator: Ricci Vincenzo
Duration: 0:15
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Creator: Ricci Vincenzo
Duration: 0:17
Regular gliding of the rotator cuff and synovial bursa (under the coracoacromial arch) during dynamic assessment. No snapping phenomena or fluid collection is visible.
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Creator: Ricci Vincenzo
Duration: 0:08
During dynamic assessment, transient snapping of the bursal nodule is clearly visualized under the coracoacromial ligament. Note that the mechanical conflict between the soft tissues can be painful and related to a feeling of click complained by the patient.
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Creator: Ricci Vincenzo
Duration: 0:21
A partially fragmented calcific deposition (located inside the rotator cuff tendons) impinges with the coracoacromial ligament during the dynamic evaluation - also reproducing the patient’s complaint.
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Creator: Ricci Vincenzo
Duration: 0:15
In a patient with massive full-thickness tear of the superior portion of the rotator cuff, the thickened proximal segment of the LHBT, snapping under the coracoacromial ligament is clearly visible during the dynamic assessment.
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Creator: Ricci Vincenzo
Duration: 0:26
Regular gliding of the superior portion of the rotator cuff and subacromial/subdeltoid bursa (under the acromion) during active shoulder abduction. No mechanical impingement or fluid displacement is visible.
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Creator: Ricci Vincenzo
Duration: 0:10
Dynamic US imaging of the acromiohumeral space during abduction and adduction shows snapping of a bursal nodule under the inferior edge of the acromion.
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Creator: Ricci Vincenzo
Duration: 0:10
Dynamic assessment of the acromioclavicular joint (during horizontal adduction) shows misalignment of the articular surfaces with capsular bulging, confirming the posttraumatic joint instability.
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Creator: Ricci Vincenzo
Duration: 0:16
Dynamic assessment of the rotator interval (using the simplified Crass maneuver) shows the normal stabilization of the intraarticular portion of the LHBT by the soft tissues (the pulley). However, small amount of effusion is pushed from the glenohumeral joint into a delaminated rotator cuff tear, passing through a focal defect of the anterolateral capsule.
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Creator: Ricci Vincenzo
Duration: 0:29
During dynamic assessment, physiological rolling of the humeral head inside the glenoid is visualized. There is no synovial fluid or gas microbubbles slipping between the glenoid and the biceps-labral complex, confirming the anatomical integrity. The acoustic shadow on the left side of the screen is related to the acromion.
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Creator: Ricci Vincenzo
Duration: 0:05
Regular gliding of the posterior rotator cuff and the glenohumeral capsule - at the level of the posterior retroacromial space - during active shoulder internal rotation.
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Creator: Ricci Vincenzo
Duration: 0:27
Intraarticular effusion can be squeezed from the anterior to the posterior compartment of the glenohumeral capsule using active shoulder rotations. External rotation of the shoulder puts tension on the anterior capsule, pushing the fluid in the posterior capsule-synovial compartment i.e. between the infraspinatus muscle-tendon unit and the posterior labrum.
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Creator: Ricci Vincenzo
Duration: 0:10
Dynamic assessment clearly shows an advanced/degenerative deformity of the humeral head (associated with complete injury of the posterior rotator cuff and/or joint capsule) and severe subdeltoid effusion, impinging posteriorly with the glenoid bone. During active shoulder rotations, the fluid is pushed from the glenohumeral cavity to the subdeltoid collection, increasing the local pressure and exacerbating the pain.
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