Good afternoon, good afternoon, hello, good afternoon everyone. So we're about to start right now, I want to thank you all for being here. My name is Javier Gonzalez, I'm a brain injury physician in Puerto Rico and I'm going to be the first one to start this discussion. I'm going to talk about ultrasound based advanced anatomy for nerve blocks in the upper extremity. I have nothing to disclose. So the objectives for this lecture is just review functional anatomy of the arm muscles and review the muscle innervation zones. And so to start, I mean, we all know the importance of anatomy, right? But if you're doing spasticity management, you need to understand functional anatomy, right? What muscle is involved in which posture and which movement so that you can have precise muscle intervention. And then if you're doing neuralysis, the motor branch location is important, but the sensory location is also important to know just so that you know what not to inject, right? We don't want to cause sensory disturbances in these patients. And the main nerve trunk or the mixed sensory motor nerve is also important to avoid as much as possible and whenever possible, just so that we can avoid also that neuropathic pain. And obviously, you know, blood vessels are also important to avoid. We don't want to do any intravascular injection. So starting off with the median nerve, once the nerve takes off from the brachial plexus, it descends medial to the axillary artery in the upper arm. At the antecubital fossa, it lies medial to the biceps tendon and brachial artery. This is a spot that many of us are familiar with if you're doing proximal medial nerve stimulation when doing nerve conduction studies. Then the nerve continues between the two heads of the pronator teres. It is at this level that it supplies the motor branches to the flexor, to the pronator teres itself, the FDS, the flexor carpi radialis, and the pulmonary longus and those people that have this muscle. Distal to the pronator teres, it becomes the anterior interosseous nerve. And then it is at this point where it supplies the motor branches to the flexor deuterium profundus, the digits one, two, and three, flexor pollicis longus and pronator quadratus. This ultrasound image highlights the median nerve at the level of the arm. The main trunk continues distally to the wrist where it goes through the carpal tunnel. Distal to the carpal tunnel, it innervates the opponents, the abductor pollicis brevis and the superficial head of the flexor pollicis brevis. It is actually a motor branch that takes off from the main nerve. And the nerve itself ends by supplying the first and second lumbricals. And in the ultrasound image, we have the median nerve at the carpal tunnel. This is just a very nice representation, summary of everything I just said for those of you who are more visual. Notice how at the level of the, a little bit distal to the elbow, we see that anterior interosseous nerve just branching off from the main median nerve. So going specifically to the median innervated muscles, we have the pronator teres. This is the one responsible for that pronated forearm in our brain, in our spasticity patients. The motor branch, it's been reported to have, in some individuals, more than one motor branch. But in most, it's only one motor branch that enters approximately one to five centimeters distal to the medial epicondyle. It's important to remember that this, at this point is where the main nerve goes through. So if you're not looking to do the median nerve, you know, the entirety of the muscles innervated by the median nerve, you need to avoid the main nerve as it goes through the pronator teres. The brachial artery as well, which is very close, closely nearby. And then we have the flexor carpi radialis, which is the one responsible for that flexed wrist and maybe some radial deviation as well. It's important to understand the motor branch pierces the muscle approximately five to ten centimeters medial from the, you know, from the medial epicondyle. In the ultrasound picture, we have the medial nerve at the elbow. So ideally, you would like to find this image when you're doing the ultrasound and scan distally so that you can find the motor branches piercing the muscle that you want to target. Going to the flexor deuterum superficialis, it has two motor branches. One that pierces muscle approximately five centimeters from the medial epicondyle and the other branch no more distal than 80% of the forearm length. So if you want to target that distal motor branch, it's not, you have to go by forearm length. It's not like you have to, it's not like going calculating finger breaths or measuring like a standard measure. You have to go by 80% of the length of the forearm if you want to target this. And then the flexor deuterum profundus, important to know, to remember it's innervated along the course of the anterior interosseous nerve. So distal to the pronator teres is where you will find this, the AIN branching off the main median, you know, the median nerve. And then remember that it supplies the flexor deuterum profundus for the digits 2 and 3. The FPL, the motor branch, pierces the muscle at approximately 20 to 50% of the length of the forearm. Remember, the FPL is the one responsible for that thumb flexion at the interphalangeal joint. For the intrinsic hand muscles, the opponents, the flexor deuterum, flexor positus brevis and the abductor positus brevis, they are innervated by the recurrent branch of the median nerve just distal to the carpal tunnel. So if you have patients that have the thumb and palm or an abducted thumb, you may consider targeting this branch of the median nerve. Just remember to do it distal to the carpal tunnel to avoid risk of sensory disturbances. And if you wanted to target the lumbricals, which are the ones implicated in the flexed MCP joint, you would also do it this way, although remember, if you target the median nerve, the risk of dysesthesia is very high. Going on to the ulnar nerve, it courses medial in the arm without any motor or sensory branches until it goes on to the level of the elbow, where it will know if it courses between the olecranon process and the medial epicondyle, the cubital tunnel. This is the place where we do the proximal ulnar nerve stimulation while doing nerve conduction studies. It continues through the medial forearm between the FCU and the FDP until it reaches the wrist. Now approximately five to eight centimeters proximal to the wrist, remember the dorsal ulnar cutaneous branch, which is a purely sensory branch, just proximal to the wrist. Now the wrist, the nerve, once it goes through Goyang's canal, the anatomy can become very complex. But just remember that you keep in mind the sensory branch, which also gives some innervation to the palmaris brevis, and the deep palmar branch, which supplies most of the hand intrinsic muscles. In the ultrasound picture, you see the ulnar nerve as it's going through the Goyang's canal. That bony structure that we see at the bottom, that's the pisiform, that's your landmark. And this is just a picture summarizing the ulnar nerve course. Now going to the ulnar innervated muscle, we have the FCU, which is the other main wrist flexor. We may see this in patients with flexed wrists, but also some ulnar deviation. This is the first muscle innervated by the ulnar nerve. The motor branch pierces the muscle no more distal than 50% of the length of the forearm. So you want to just scan very, find the ulnar nerve at the elbow and just scan distally until you find the motor branch. Also I forgot to mention that in order to do a more precise muscle intervention, one suggested approach is not only to use ultrasound, but also do electrical stimulation. For the FTP, the motor branch pierces the muscle approximately 5 to 10 centimeters from the middle epicondyle. This, you can find these motor branches very in close proximity to the, where you would see the FCU, that thickest portion of the FCU in the proximal forearm, which is what's pictured in the slide. You can see the ulnar nerve just deep to the FCU. For the lumbricals, they're supplied by the deep motor branch distal to gluons canal. And this is what we actually see in the ultrasound picture. This is a, we can see the ulnar nerve next to the blood vessel, just distal to that bony landmark, the pisiform. This is where you can get the deep motor branch. Now one important point for patients with the flexed MCP joint, we typically do the lumbricals for, to treat this pattern, right? However, some surgeons believe that the inner ossi are more, much more involved in the, in the flex MCP. Sometimes once they do releases to these muscles that you can correct the deformity. So some people actually believe that we're getting results by doing the inner ossi, not the lumbricals. So picture there, I mean, I think if you do spasticity at some point, you would see a patient with a posture similar to this one, right? Especially if you pay attention to that second digit, there's not, you don't only see the flexed MCP, but also some PIP and DIP extension. So this is a patient that you would, if you see, you would target more the inner ossi rather than the lumbricals. Moving on to the radial nerve, after it exits the brachial plexus, it continues between the lateral and middle halves of the triceps. It pierces the lateral intermuscular septum, distal to the radial tuberosity. Distal in the arm travels between the brachialis and the brachioradialis. And at the antecubital fossa, it divides into the superficial and deep branches. The superficial branch is the superficial radial nerve. And the deep radial motor branch is the one that continues through the heads of the supinator. And we have this, we see this in the ultrasound, in the picture, you see the neurovascular bundle here, and we have one head of the supinator here and one head of the supinator under it. That's your landmark. The medial branch, which is the recurrent branch, innervates the superficial dorsal layer. I'm talking about the wrist, you know, the wrist dorsal compartment. And the lateral branch, known as the descending branch, innervates the deep dorsal layer. And here we have a picture just summarizing what I just talked about. The radial nerve is a very heavy image. The radial innervated muscles, we have the extensor carpi radialis longus and brevis. These are the ones implicated in the extended wrist pattern, not such a common pattern that we see, but every once in a while we may see a patient that has an extended wrist. So here we, you know, going back to the functional anatomy patients that have the extended wrist with a little bit of radial deviation, these are the ones that you may consider targeting these muscles. The motor branch pierces the ECRL between one to three centimeters proximal to the transepicondylar line and for the ECRB just proximal to the supinator muscle. The extensor carpi ulnaris or ECU, the one, again, it's another wrist extensor, but if we see more ulnar deviation, we may think this is the muscle that's mostly implicated. Motor branch pierces the muscle at approximately 10 centimeters from the transepicondylar line. Very important to keep in mind that the dorsal interosseous artery lies close to this muscle, so please avoid. So finger extensors, we have the extensor deuterum communis, the extensor digiti minimi, and the extensor pollicis brevis. The motor branch for each muscle pierces each muscle at 10, 12, and 15 centimeters respectively. So just basically a helpful tip is just to find the radial nerve and just scan distally, of course, using motor stimulation so that you can find each individual branch for each muscle. So to conclude, the distal upper limb anatomy is very complex. Could be variable. Some anatomical variants, as I mentioned in the early conference, like some patients, most patients have only one or two motor branches, but it's been reported in cadaver studies that they may have more branches, so it's something to keep in mind if you're not having immediate results when you're doing the injection. The motor branches need to be identified to avoid the neuropathic pain, which is why it's very highly suggested that you use both ultrasound and electrical stimulation. And another thing to keep in mind is for patients that have had spasticity and have a lot of weakness, there may be some muscle changes, you know, fatty infiltration inside the muscle, which may further obscure and pose new challenges when doing stimulation. And then always remember that torsional anatomy may add a lot of complexity, because most of our patients are doing our, they have their limbs in abnormal postures, so this may change anatomy, I mean, the way that we see it on the ultrasound, so just keep in mind when doing this. These are some of my references. Thank you for your time and attention. If you have any questions, I don't know if we do this now or at the end. Thank you. Okay, good afternoon, everyone. Thanks for coming to our session. So I will be talking about the phenoneuralysis for spasticity management in the upper extremity. Dr. Gonzalez just laid a great foundation for us about the ultrasound-based advanced anatomy that make our ultrasound-guided nerve block possible. And as we know, the phenoneuralysis was the main intervention we physiatrists used for spasticity management before neurotoxin came on board. But then when the neurotoxin came on board, and then it gradually fades away, and now it's a time to revisit because of the advanced guiding techniques with the combined e-stem and ultrasound. So this is my disclosure. And today what I'm going to talk is to go through a list of clinical questions related to phenoneuralysis, and with a specific point on the can-phenoneuralysis for the distal limbs, distal muscles in the upper limb. And I will also want to highlight, as of today, the phenol is not FDA approved for specificity management, but there's ongoing phase two clinical trial and for FDA approval. So how does phenol work? Put it in a short sentence is phenol touches where, phenol burns the tissue wherever it touches. So if it's injected to the peripheral nerve, it will damage the nerve axons. If you touch only the myelin, it will burn the myelin. And also if it's injected into the muscles, it will cause muscle necrosis. But the earlier animal study have shown that all these with near complete regeneration and recovery. So what's the concentration we use for neurolysis purposes? And we use about a five to seven percent. And at a tear, we use six percent. So there's also another phenomenon that's called dose-dependent phenomena from the phenol neurolysis. But I have to highlight that this is based on the animal study, but it's a very low dose. And since we was, I will show you later, that's how we injected in human patients and the dose is much higher than that. So we needed to interpret this result with caution. So the dosing part. The dosing part, so I usually with a reference that lethal dosing is about 8.5 gram. And I usually not going to exceed 20 ml per procedure for the total body. And I will often ask the first sign of the systematic reaction overdosing is how do you taste? How's your taste, any change? Some of my patients, they got a metallic taste that tastes so weird, like fish. And for the first time, about five or six ml. But when the next time the patient came back and patient may be able to take up to 12, 15 ml. So it depends. And I monitor this reaction. So we know this phenol is the immediate effect, onset effect. So, and the immediate effect as we've shown here by the relaxation of the elbow joint. For this patient, I inject a musculocutaneous nerve and follow up in two weeks and further relaxed. Now, we measured, quantified this resting angle position as a way to quantify the phenoduralysis effect. And we compared this as we can show here. We followed up a pre-injection immediate two hours, a day off, seven days post, two weeks, six weeks. And we can see immediate effect is, have an immediate effect. This immediate effect have a next step up in about a week and then remain for the follow up six weeks. So that will give me some of the guideline. The immediate effect is approximately 60% of the peak effect. And its effect, the peak effect peaks around one week after injection. So how long does the pheno-injection last? And this is the table I got it from the specific book. And it varies. As we can see, it varies from 10 days to 28 months. And in my observation, my patients usually last about four to eight months. And there's a few factors to consider. There's concentration, how much dose, location, and post-injection therapy, coupled with e-stim or aggressive stretching, casting, et cetera. And the way how you measure it, depending on the patient's subjective report, patient will say, no, not much difference. But we actually see significant increase in range of motion. And there's a report of cumulative effect because of the tissue fibrosis will lead to less response in the subsequent injection. But among these factors, based on my more than 1,000 cases experience, I think this is the location is the key. It depends on how accurate you target the nerve. So side effects, there's two type of side effects. One is the needle pain and bleeding associated with needle itself. And the other is a phenospecific side effects that include some of the weakness or overcorrection. That means, for example, for some of the spinal cord injury patients with spastic quads, and if we do femoral nerve block, we weaken the muscle and the patient is not able to stand. And so this is overcorrection. But there's lots of useful motor function. There's a temporary sensory loss or dysesthesia. But this is not immediate, but delayed after like seven days to two weeks. And usually, it will subside. Usually, it's not that significant or disabling. But it will last about two to four weeks after its onset. The treatment for this was a repeated injection, but it's very difficult to convince the patient to get another injection for the problem the patient received from previous injection. So, and the medications used for garbapenting will help. So, here is based on our experience that Dr. Jerry Carey did a chart review to summarize our tier experience. This is a total of 185 cases and a total of about 300 procedures, repeated procedures for the same patients. Overall, I would say there's only about less than 4%. And some patients have multiple side effects or symptoms from the injection. And here's a breakdown of the side effects. So mainly, got the most side effects is from tibial nerve. And the reason is that tibial nerve has a lot of variations in its sensory branch. So it's, if we target close to the pubertal fossa level, and it's easy to get this side effects. And here is a list of the nerves we inject at a tier. And we can see from the upper extremity and the lower extremity, almost, this is not a complete list, but this is a list we frequently inject. And we can see here, we inject from head down to toe. Now, today I will just share a study that we did and showed a few cases with videos. So, Dr. Gonzalez just showed very nicely how complicated the nerve branch variation on the ultrasound. And he said, it's shown here by, from the picture posted by the surgeons. And we can see it. For example, this is the FDS. And the branches can be anywhere from here to here. So, and the multiple branches to this muscles. So it makes it very difficult to localize precisely the branch, but with the combined guidance of e-stim and ultrasound, especially I like e-stim because it provides me the physiological evidence that I really targeted this branch. So here is the setting. Usually I will have, this is the example of the settings. I would say I would not do the very advanced nerve blocker for distal limb muscles without these combined guidance techniques because it's really difficult to target these. And here is the one example I use. In this video, I would just target the nerve, radial nerve branches to wrist extensors. And then we can see, I will inject while the wrist is doing extension. That gives me the confidence that I really targeted these nerve branches. And with the guidance of ultrasound, it makes me, it's really easy to get the area that I can explore with a needle and to confirm the location. And this is the pre and post picture. And we can see there's immediate effect of the wrist is resting down after targeted to the wrist extensors. And this is Dr. Darji when he was a resident with us and doing the fenal injection to medial nerve branches to FDS. As we can see, he's facing the ultrasound screen and find the nerve and do the, with the finger is flexing, this is a confirmation from eStem. And this is pre-post, the immediate effect after fenal injection. So here is one study Dr. Carey did another summary, chart of review to summarize our experience with the fenal for upper extremity. So there's a total 57 patients and 102 procedures, total 130, 940 nerves and branches. The mostly the TBI and the stroke patients. So here is the breakdown and we do mostly this got the radial branches, brachioradialis, triceps, there's unspecified some of the wrist extensors work into that category. And the medial nerve branches, we usually just add that to the FDS, FDP, FCR, FPL, they group it together. And the ulnar branches, the deep ulnar motor branches at the guion canal or up to for the near the elbow level. So here the average is only 1.8 ml really per nerve and the branch is much smaller, much lower dose than as compared to the upper, to the lower limb. And we follow up with the patients, for the inpatient part before patient is discharged, so average about 40 days. And for outpatient, we follow up in the clinic and we follow up with patients during the next visit and we will call, ask a patient whether any sensory or dysesthesia or any other side effects. Now we have a system, we will give the patient our contact information. If they have any concerns, discomfort, they will call us right away. So there's, based on these follow-ups, we have only three procedures and about at least 3% with prolonged pain and no other pain was reported. So I will just show you a few cases, what we did as a clinical application. So correction for the disordered motor control in spastic hemiparesis. So this patient is about three years out of the right MCA stroke with a left spastic hemiparesia. Her main complaint is the shrinking wings of the left arm during walking. So when patient start out, the left arm is on the side of the body when she continues to walk and now this is bent into 90 degree of the elbow flexion. So this is called spasticity or associated reaction and we did, I did this 1.5 mL to muscular cutaneous nerve and helped suppress the associated reaction and improved the gait. So the question associated with this is that patient was able to flex her elbow joint before the, and the concern is how much strength that we have taken away by doing pheno. This is the amount. So patient got rid of, well patient is getting weaker, that's for sure because we did a pheno injection to the muscular cutaneous nerve but is still able to do elbow flexion. Now there's another patient that we did is two years out after the right ICH stroke and got a left spastic hemi and this is a clenched fist presentation. There's no opening at all for this patient and this is what I did with the medial nerve, medial nerve motor branches to FPL and FDS and the ulnar nerve to deep motor branches to intrinsic muscles. As Dr. Gonzalez mentioned earlier in his talk that the intracranial muscles are very important for the hand opening, especially at MCP joint. So we did a pheno at a Guyon Canal targeted deep motor branch and this is immediate after phenoblock. Mostly after we take care of the finger flexor, finger flexor spasticity, not only open up the clenched fist, that patient got some potential to the hand closing and since then, patient send to OT and to do the E-stem coupled with the therapy. So pheno, in my mind, now is the time we really need to revisit that this is a dying art and that merits the revival. But now I also want to, now is the perfect time to translate it to Dr. Paul Winston and he has something eye-opening to show today. Thank you. And there's volume on the videos, great thank you. Okay thank you so much. So I wouldn't be able to do most of what I have been doing without having become friends with Dr. Lee on Twitter. So we share cases, it's a Texas Canadian sharing, on how we give back function or return function. So we're going to talk about cryoneurolysis, which is really old for the pain literature people but very new for spasticity. These are my disclosures. And before I talk, I wanted to let you know, so this is Lisa Boivin, we're exactly the same age. But because she was born in Northern Canada and her father had polio, he was a cripple incapable of looking after a child. So she was taken away and raised by a white family and didn't know she was indigenous. So her PhD right now is about creating safe spaces for people of all cultures. And we're going to talk a lot about changing people and their disability today. So just to let you know that these are patients that have shared their story with you today. It's part of them. We're going to change who they are and I want you to acknowledge that it's very emotional for me and for them to tell their story. So the first thing that Dr. Lee just proved to you today that these deformities are reducible. We thought they were contractures, but they actually have more range of motion than we thought they did. We told them there was nothing more you could do for them. So for me, by the use of doing ultrasound-guided nerve walks, so I do all patients with anesthesia, with lidocaine, before I treat them with toxin or cryonolysis, I tell them what their function and potential is the first day I see them by doing nerve walks. So this is a patient sent to me by a physiatrist. She said he's maxed out on toxin. So his elbow is very tight. She had done his pecs, his elbow, and his wrist flexors. But with a couple dollars worth of lidocaine, I can get his shoulder way overhead, no pain. His elbow comes out from just biceps. I'm going to add in brachialis because he's still tight. But look at the hand. So it did the whole ulnar nerve above the elbow, the trunk, the mixed motor sensory. He's floppy. And by just getting rid of that MCP function, the hand opens. If you're interested, there is a free open access video on AJPMR on how we do these diagnostic anesthetic nerve walks. And this was the first paper we published in 2019 on cryonolysis. And we've come a long way. So this is a patient who has a contracture of her biceps, right? But I do cryonolysis to the musculocutaneous, exactly the way Dr. Gonzalez showed the anatomy, thank you, and Dr. Lee. And you can see the stretching on her skin. So she had a stroke a year and a half ago. Toxin didn't touch it. It was too much tone. So some patients have too much tone. And now she needs to learn to use that arm. This is one of the most classic cases I've done. So we've done over 50 whole tibial nerve trunks. This is the mixed motor sensory. I'm not worried about with cryonolysis, about dysesthesia in most of my cases because everyone gets a diagnostic nerve block and their foot doesn't go numb and tingly. She had MS. So this is $10,000 US in toxin a year for obturator and tibial. And she has reduction, no clonus, and is walking without a gait aid. So we have over 50 of these patients. This is how we do it. So I'm going to explain more, but this is like a surgical real-time procedure. So this is a man. His main complaint is hemiplegic shoulder pain, the fourth most common cause of disability after stroke. He has an old stroke and his shoulder is really tight. It's a non-functioning limb. And you can see the pectoral tendon. That is a forced contracture. So we're going to do a suprascapular sensory block for his pain in the shoulder and then medial and lateral pec for pec major and minor. That tendon disappears. This was not a contracture. It was simply too much spasticity. Now immediately after you take someone who's tight, they always say, my hand is open. So when you take that co-contracture synergy that Dr. Lee talks about a lot, other parts go loose. So now he's saying, oh, I can't open my hand. What's going on? So it's loose, but I'm not happy yet. His elbows out, his shoulders relaxed, and we are going forward in time. So 15 minutes after the procedure, the shoulder is really loose. The hand is loose, but they're still tight, and I can't dorsiflex his wrist. So now I'm going to do a whole median nerve above the elbow. I've already done it with lidocaine. He has no dysesthesia. So now the fingers go loose and the wrist dorsiflex completely. So we have a patient within 35 minutes going from a contracture to no contracture and full out. So we are quite happy. Now he doesn't have function, but the resting position is better. Now Mark Mahan is a wonderful neurosurgeon in Salt Lake City. He's all the pictures that Dr. Gonzalez are in a book that we are all authors on. So this will be coming out very soon. This is what a surgical dendrectomy looks at versus a percutaneous. I really want to thank my clinical fellow, Dr. Yves Boissonneau from Montreal, who spent the year with me putting up all of our algorithms for coronary lysis. So when I decided to do nerve blocks, which is a European technique, so Tardieu, the French surgeon, physiatrist Tardieu, when they came up with the Tardieu scale, they talked about alcohol and they talked about diagnostic nerve blocks. In France, multiple centers do nerve blocks on every patient. And I really liked their technique, except for they didn't use ultrasound. So it took a lot. It was a lot of stimming. You didn't know where you are. We saw all those blood vessels. So I decided to ask an anesthesiologist at home, how do we do this with ultrasound? Super simple. We learned in a day. And he's a pain interventionist. He said, let's do cryo instead because it'll last. I said he was crazy. But we found an abstract from 1998 on an operator. So we decided to do it. Now, cryo has been done in America, which is the world leading center for decades. China has tens of thousands of case series. So coronary lysis is a safe percutaneous procedure done for sensory nerves. So I'm not worried about dysesthesia because it's actually designed for sensory. So this is the device that I now use. We started with a console. This is the Gen 1 I'm using. We're moving to Gen 2. It's a company from here in the US. And this is what we do. We inject a probe in the skin. This is a whole tibial nerve trunk. We're going to do three lesions of 106 seconds around it. And that spasticity will melt away. We will ultrasound guide, stimulate the branch we want, melt it away. This is what the probe looks like. So we are not injecting anything into the skin. It is a canister of nitrogen that rapidly cools to minus 88 degrees by freezing the liquid in their body. So there's no drug. There's no toxicity. It's not burning anything like Dr. Lee mentioned. And this is how it works. What's the amazing property is that when you touch a nerve, you get a secondary axon amnesis. So at plus 10 to minus 20, you get a bit of a conduction block. However, when you go between minus 20 to minus 100, you get a complete secondary axon amnesis. So you lose your myelin and you lose your axon. They're gone. But not like phenol. You're not burning anything. You're not opening up the tube. You're not going to get neurotrophin escape. You're not going to get an aroma. You will not touch the blood vessels. You will not touch the muscles. They are all stronger. They are heat sinks. This is what you would do for a cancer with cryo at a much colder temperature. So what we basically are is we get a temporary axon amnesis that will regrow in a length of dependent fashion over about six months. So their blood vessels are fine. So I can literally go right next to the blood vessel and not worry. So in our book coming out, you will see that we have mapped out where the blood vessel and nerves are mainly lying within the fascial planes for every nerve and muscle that we need. And this is sort of what it looks like when we map out the body. And there's going to be videos here so you can teach yourself as well. And a lot of this I had to take from Dr. Lee. I text him, go, how do I get this branch? I don't know where it is. This is how we do our stimulator setup. Very similar. I use a nerve stem, much lower stem than the clavis, because I want to stimulate at less than 0.8 milliamps. I don't want to stimulate the muscle. Just want to do the nerve. So the only scale you need to know today is we all know the Ashore scale, but the Tardieu scale is very important because we want to give improved range of motion. So with the Tardieu scale, V3 is that first catch and V1 is the maximum length we can get. So my colleague, François Genet in France, showed that if we look at the elbow, we can often find one major contributor. So is it the brachialis, which we often do, or is it a biceps contracture? And if not, it's the brachioradialis. So I do nerve blocks to decide which is the one. So this was our very first nerve block in Canada that we did. So he's about 16 months after stroke. My colleague, Dr. Ribai, he's showing that there's a fast catch and a maximum and then 40 degrees of contracture. So what we do is we do a nerve block and the nerve block gets rid of the fast catch, the V3. So it gets rid of spasticity, but you are left with the tightness in the muscle. So this is when my colleague that said, well, why don't we do cryoneuralysis on him? So six months later, we brought him back. We used our localization technique right into the brachialis and boom, gone. No spasticity, contracture is gone. So what we thought was a contracture was just too much tone. Now I said to him, can you move your arm? He said, no. I said, how do you know this? Never tried. So now he's going to use his arm and now he's back to the exact same degree as his original contracture, 140 degrees. So I start saying, well, let's practice, go to physio. So I started putting botulinum toxin in the muscles I didn't inject because I wanted to maintain strength. By six months, he's re-innervating. So he's strong, lifting up his grandkids, pushing the lawnmower. We put the toxin in the hand, the hand started opening up and we've since done cryo to the hand and it's going really well. So this is him at 26 months. He came back after a hiatus with COVID and the tone is gone and he's strong. He's actually going to push me, pull me on my chair here. I'm going to speed up so I don't go over time. So this is how we do it. So when I want to do a brachialis, I go, so at the distal forearm, where the brachialis branch comes off, right off the blood vessels, I will locate the nerve branch. I will freeze it, minus 88 degrees, 106 seconds for the lesion. And then I will move my probe over a little bit, try to stim again. And if I get stimulation, I will freeze that branch. I do the same thing more approximately for the biceps. So this is a biceps case. So this is a young man with cerebral palsy. So this man has never had full function, this boy. And you can see how tight and spindly that muscle is. So everybody asks me, aren't you going to induce atrophy here? Because toxin can induce atrophy. Well, we're actually going to lengthen the muscle. So that muscle goes from this really spindly Popeye to a big, sexy, longer muscle that looks quite normal. He was like, oh, I like it. I like it. And at two months, you can see how long. So we basically popped up to the maximum length. The contracture is an elbow bony contracture, because this is a cerebral palsy patient. So we also can do radial to the brachial radialis. And what we do now is when we do nerve blocks, if the brachialis doesn't work, I add in a biceps or brachioradialis, depending on the hand position. So we do cryo and boom. Then we get both to full extension. And it's real time. So if I don't get full extension, I do the next. Now, this was a near and dear heart. So in Canada, where I live, botulism talks and it's free for all inpatients. We keep our patients for as long as they need, one month, three months, six months. So we treat all of their hemiplegic pain in one go. So very comfortable with this type of paradigm. So this is a picture of the pec, the easiest nerve to do. So what you see is there's the lateral pectoral nerve that is going through the chest. The blood vessel is beating inside that there. So all I have to do is target it. Really easy to do nerve block here. And it's off label in America for toxins, right? You can't do it on label. So we stimulate both the medial pectoral nerve, which is to the pec minor and the lateral to the pec major. At the beginning, we only did pec major and we discovered they all had this band of contracture. We have to take out both in order to get full range of motion. If I just get it with lateral pectoral, I don't do pec minor. So this is Dr. Boissoneau. She's demonstrating real time cryoneuralysis. You see the blood vessel right encased in the nerve. We are not worried about it. We will not harm it. So this is a classic case. This gentleman has had it all over his body. And this is my anesthesiologist. We used to have an old constitutor unit. He did all the first two years of the procedure. I just sent the patients. And this patient is demonstrating how, oh, I can actually raise my arm now. Because the first time we ask him to raise his arm, look what he does on the left side screen. He uses his right arm to lift it. He doesn't even have the motor processing. So we bring him back at one month and he's like loosey goosey, People tell me that I'm violent with my patients, but we're usually giggling. So he's really happy. Now with gravity eliminated, he can't lift it overhead himself, but lying down he can. What about cerebral palsy? So this was a case report. This was a child frequently in an ICU because of aspiration. And I can tell you we have several cases of kids with barrel chest pecs. Their breathing goes so much easier when we get rid of that tone. Very scared of toxin in the pectoral region because of spread. So this is a boy who, it was really for pain. His mom said it was so hard to do pericare, sorry, personal care. And you can see we do bilaterally really loose. And he actually come back to us about eight months after this was the first follow up after the pandemic. Hadn't been in the ICU. Maybe that's because they didn't go out anywhere, but really well-maintained. So these are our results going on for years. So this is a boy So these are our results going on for years. The most important change we also made for the shoulder was to get rid of the pain. So suprascapular nerve block, well described from our anesthesia and pain PMR folks for shoulder pain. We do that to the shoulder first to get rid of the pain. And then we attack the spasticity. So this is one of my really near and dear patients. She's been with me for years. She had a tumor. So she's hemiparetic on the right leg and left arm because of tone and pain is her real problem. Is there volume on this? Okay. So she's having a lot of pain in this arm and she's quite limited. And when I, particularly when I try to externally rotate, it's agonizing for her. So this is right after the procedure and you can see how she actually says, you know, I'm like a rag doll. She is moving all over. So we did the brachialis. We did the suprascapular and the packs just showing that right away. She's better. And she sent me an email and our whole clinic was crying what she said she could do within the next month. And we did her right whole tibial trunk. And she said, my walking is so much better. So CP is painful. So the sound is not going, unfortunately. I don't know if we can try enabling it. He's going out. So he's a stroke on top of CP. He's in agony. This is with my surgeon. And we're showing after a median nerve block, we relax the muscles, but we also completely desensitize the pain receptors. So he's going from screaming to no pain at all. This is another patient. So the volume, he was the patient with the floppy arm. He forced us to do the median nerve. All the time. And why did you, so you were the very first person that we. So he was, we were the, he actually begged us to do the median nerve. We were scared to do it because of the mixed motor sensory. But he just said, I stink all the time. It's embarrassing. I don't want to go out. I can't clean my hand. And he's actually starting to get a little bit of hand function back. He's got a lot of extensor tone, which keeps his hand open. We have about 20 patients who now have functional grip after releasing them. And this is the map of how we show how we select our nerves. Because again, we can do the whole trunk as a mixed motor sensory, Dr. Munin, who would like me to say that. So this is how we would do a median coronary lysis. We go above and below that nerve, just passing the blood vessel. So this is a classic case that I have. He is a contracture in the wrist. He had, my colleague said not responding to botulinum toxin. His main complaint is my fingers are on fire. So he doesn't want me to touch his fingers. So I kind of move my hand back. We do whole median nerve. I made a mistake. I did below the elbow. So I didn't get pronator teres. I repeated it after to get pronator teres to help with supination, but you can see how I can no pain in the fingers, open them up. And now I'm just going to start, this is immediate. I'm going to break that fibrotic tissue in the forearm and his wrist is going to start going into extension. That's the first follow-up. When I see him again, I will start really, I'm not sure if you can get that to play. It will go into full extension. That's okay. So his wrist goes fully back. So now like Dr. Lee showed, we do FDS all the time because FDS, we do a block and a lot of people that have a closed palm, if you just do FDS, their hand opens and they use FTP to close it. So my favorite thing is to take out FDS and leave FTP. And this is how good we are with our stimulation. So we can pick off each. This was my resident first attempt doing a fascicular box of FDS. So this would be a classic case of someone who has a non-functioning hand, but she doesn't like the smell. She doesn't like the clenched and we do FDS how easy it is to open the hand. And of course we'll put in a resting night splint. We'll give her some OT stim, but the hand is learning to open and she has motor to close it back. So she was paralyzed. And can we get sound for this too? So this is a contracture. So in the United States, 66% of nursing home patients have contracture. How does this feel? Good. So median and ulnar above the elbow for pure pain. And I'm just putting in an IIT to study nursing home patients for contracture. And you can see that he was smelling of pseudomonas and it was coming from the elbow. So we did a brachialis. So we did both hands and the elbow. But for him, it was just to relieve the pain more than to induce range of motion. So ulnar nerve for me is the most important one for hand function because Dr. Gonzalez mentioned the interossei is favorite of the surgeons. So we do a lot of these ulnars about the elbow. So this is another lovely young woman with cerebral palsy. She's nonverbal, but you can see we do the pecs. This is immediately after. You can see her bandage. She's got a bruise there from the procedure. But the shoulder is so much easier. But what's really great is that by doing the whole median and ulnar above the elbow, because she's non-functioning, we can open the hand up. So that hand has not seen the air before. Now this is one of my favorite patients. She's a university student. She is a spastic dystonia. She's a very bright woman. The left hand has this dystonia, almost hemiballismus. It opens and does its own thing. But she has never opened her right hand, her mom said, in her life. We had one of the surgeons come up from the States who's originally from Texas. She was born in Texas. So they really hit it off. But you can see how stiff she is. And I'm having to pry open that hand. The left hand will open on command when you ask. She doesn't have control. But you can see how tight it is. Look at her fingers. And so now she comes back five months later. She's working a lot with physiotherapy. And now she's never used her hand in her life. So I've actually got her working on a Wii and video games to try to figure out a way to... Because it's neuroplasticity. She doesn't know how to use her hand. Never used it before. So we're focusing on there, but a few legs today. So in someone who has good sensory function, we will do a medial lateral gastroc and a soleus. But if we can, if they have a quinivarous foot, we do the whole tibial nerve trunk. And this is a... If you can put sound on. Oh, this. Can you try to hit the video for me to hit play? Okay. Unfortunately, I can't make this. There's no mouse here. So she starts putting her foot and she goes, it's moving. She's about 80. And she's like, my leg is moving. It never moves. So she's really, really happy. So this is Dr. Boissoneau showing how we do the whole tibial nerve trunk. And this is painful for the patients because they immediately start fasciculating and crapping. You see it on ultrasound, everything breaking down as it comes down. I can do a lidocaine rescue, but I want to know it works. And they start dorsiflexing from the cramp and they get to full 90 really quickly. And we do three sides to make sure they don't have a dysthesia. So this was one of our first tibials. This was a pregnant woman who couldn't take her toxin, of course, because she was pregnant. She's got three kids and she couldn't wear her AFO because of pregnancy weight. So she was really stuck running around her kids. So this is her four weeks after cryo, step through gait. Now, she's done really well. She came back 10 months later. She's over-corrected by her AFO. She can walk barefoot. I wasn't happy, so I sent her to surgery and she's now had a splat procedure and Achilles lengthening. But a lot of our patients don't want surgery. They're happy, but I've convinced way more to have surgery now after we get rid of their tone that their gait can be improved because they were told there was no improvement. So here is the, this is the typical patient I get. We call him Mr. Giddyup because he giddyups. So he is learning. And what you see is when you take out the gastrocnemius, you immediately get a bent knee and the soleus is not hyperextending. So they start walking with a bent knee, but this is right away. This is not surgical recovery, casting, that kind of thing. So six months later, this was during COVID. He wasn't going out very much. So he's showing me how well he's walking, but I hated his gait because he hadn't had any physiotherapy. So he comes back to clinic. He's working with our clinic research physiotherapist on his gait. And now he dorsiflexes so nicely. And this is without a brace. So this is one of my favorite early cases. He has a crazy toe claw and a hand dystonia. They relax at rest. But if you, we would spy on him, actually. We told him one day, we spied on you because we couldn't believe your claws of your hand and your foot because when we move you, there's no tone, but it disappeared. So he has a non-functioning hand. Box and block, he had like nine blocks. We got him up to 20. So now his hand opens and closes when we did his median nerve. So just another obturator here. So anterior and posterior divisions. So for those of you who do kids and phenol, very, very common. And this is one of our favorite patients. So high-functioning woman, has a good government job. ♪ You're a one of a kind ♪ ♪ A one of a kind ♪ ♪ That you only find once in a lifetime ♪ ♪ Made to fit in ♪ And this is one of our four ongoing studies as obturators. So I didn't put in a femoral, but I do whole femoral directus femoris all the time, particularly in MS patients because they are very weak in their hip flexors. And if we knock out the rect fem, it allows them to walk very nicely and clear their foot a lot better. So we have four studies going, a whole upper extremity right now. We have a H-reflex. So we're doing an H-reflex, and the H-reflex diminishes for the first one to six months, and then it comes back to baseline. We want them to re-innervate. And then we have an obturator. The fourth study that we just started is an inpatient study, and we put in two more IITs, investigator. So we do use goal attainment for our studies. We do lots of measurements based on their function. I'm not gonna show much data because we're gonna be presenting that at AAP because that's when the posters came out. But just to show you a trend is we get a huge change in the first three months. So our Ashworth scores really drop, and then we get an improvement in the maximum range of motion, and then it maintains. So the vast majority of our patients we're only treating once. Almost everyone we've retreated is because we now have more nerve options for them. So a couple of things to show. We also have a very low side effect profile. Now, the difference between Dr. Li and mine, and I checked with him, most of our patients have at least one pure sensory branch, mixed motor sensory. So we are purposely going after the sensory targets. It's, again, tibial that they have the most complaints with, but now we just tell them, you're gonna have a bit of tingling there. Because we're not breaking the epineurium, we're not getting the pain, though, and we're not harming, and nothing else is being damaged. So this is my new study coming in. So this is my classic stroke patient having a really hard time participating in physio and OT because his shoulder is really sore. So I'm asking him, and he's got clonus. So we name our patients Mr. Clonus when they've got a lot of clonus. So he has clonus in his flexor carpi radialis, and he has clonus in his pronator teres, which is really making it difficult for him to use his hand. He's got really good finger function, but the clonus gets in. So in this case, we wanted to spare his fingers, so I do an intramuscular branch of flexor carpi radialis, and an intramuscular branch of the pronator teres, FCR pronator teres. I did suprascapular and brachialis and PEX. So he's only a few weeks after his stroke, but already his arm is going up, and he has no pain. So he was participating, so he's still an inpatient. So we wanna do 30 patients inpatient so we can get them pain-free, reduced tone while they're still in hospital. And this is one of our new staff we've just hired. I taught him cryo and ultrasound guidance, and he did that case his first week, so it wasn't that hard. So just last two cases to round up here. This was a young man who's agreed to share their story. They're from the States, and they knew someone who worked with the company that I'm doing the product. He's an anoxia at age of four, so contractures everywhere. He's getting phenol and toxin to his adductors in Minnesota where he lives, and they just wanted to know if we could do anything. So we determined that his hip, I think, is dislocated here. Remember, he's not CP, so he had an acetabulum at birth. Really tight hamstrings, and he's in constant suction. He's like this, so really, really high need for suction. So we decided that the pecs were reducible, the wrist and elbows were not, but we could get improvements by doing the whole sciatic nerve and the whole operator, so mixed motor sensory. So this is him the next day from their hotel room showing that he's seated for the first time on his wheelchair with his buttocks flat on the plate. They have not done that. He always sleeps on his right side with his pelvis in the air with a pillow. So now he's flat out. His legs are already starting to extend again. This is just the first day. There's been very little valerian degeneration here. I actually pushed his hip out, and we all heard this big clunk, and I think I pushed his right hip back into the socket. And what was really crazy is during the procedure, everybody said, what's going on? The dad stopped suctioning because after we did the pecs, his breathing just went really, really calm, and his dad said, we don't have to suction him nearly as much. So this is his position after. So this, again, they told the family, there's no more we can do unless they were, for some reason, they're afraid of orthopedic surgery. Now these are Americans to me. So she's from Texas, and I told her her rehab, because she comes up to Canada every few months, I want you to do boxing because she's really tough. So this is her using boxing with her hemiplegic arm, but this was her before the procedure. So she's a TBI, and we did her obturator because she's really tight, and we did her shoulder girdle, and we did brachialis, I believe. So you can see her, no external rotation, difficulties, and now she's boxing. And thankfully, she's got maintenance of the hand, so the hand works. Lift your wrist up and down. Beautiful, open and close your hands. Okay, here we go, just relax. Okay, and so this is my team. So when I started, it was just me in practice. I don't have a rehab team in my hospital, and through my research and grants, I've been able to have a team to provide care. And I would encourage all of you to join our webinars on CANOSS, Canadian Association Advances in Neuro-Orthopedics. It's an international organization. We have about 50 to 70 countries, a lot from the developing world that tune in for free education. And these are a lot of my mentors who are orthopedic surgeons and plastic surgeons from around the world. And our atlas that Dr. Lee has so generously and Dr. Gonzalez contributed to will have all of these cases, phenol, surgery, toxin maximization, everything on how to use nerve blocks to maximize your practice. I'm just on the final edits, and it has about 60 videos. Okay, I think that's it. Thank you. Thank you. All right, we are now taking questions if you have. That was great. I've been doing this for close to 30 years, and I'm still learning a lot of things. Maybe you can clarify a few things for me. For the hand, you'll find the FDS blocks. The FDP can flex the DIP and the PIP joint. So the study downstairs is a block of the anterior interosseous nerve, and about 20% of the patients wide open. So it would be interesting to see a study to identify, is it the FDP, the FDS, or both? Remember, the objective is to produce a functional hand. So I thought that was interesting about the FDS. And that's really great, because that's the whole point of doing nerve blocks before, so we can experiment, which we can do the FDP, the FDS, and decide for that patient, which is the money muscle. So we will try all of them. Right, good. The second thing, Sheng, you said, it's a dying art that merits revival. Why would anybody want to do these phenom nerve blocks with the incidence of dysesthesias that's sometimes upwards of 30%? Well, the answer is that, and in Carrie's study, I just looked at that last week, he's putting on, in reviewing the literature in his hospital, they were going up to eight ML of phenol per nerve. Nobody should be permitted to do that. In fact, there's no need to put on more than one ML of phenol. Remember, we're trying to block the 1A afferents to inactivate the muscle spindle. And by putting on so much phenol, it's going to spread and catch those sensory fibers, especially around the tibial nerve, but elsewhere as well. Okay, so there's a different approach in terms of how we do phenol. As I mentioned earlier, with the combined ultrasound and the e-STEM guidance, we can precisely localize and attack a motor branch, not a sensory. So that's why then we can go higher and go completely knock out of the nerve without a sensory problem. The last thing is the tibial nerve. The studies by Deltomi in Belgium and France show that the primary muscle for ankle clonus, 75% of the time is the soleus, 13% of the time it's the gastrocnemius. Most of us are going for the gastrocnemius first. We're putting a lot of phenol on, and in fact, in some of the studies, they just keep running the phenol on up to 10 ml or so until the clonus goes away. So to me, if the soleus was the muscle, that means that that phenol had to spread. So the poster session downstairs shows a phenol block at the popliteal crease. Block the clonus for 70% of the patients, 13% didn't because it was the gastroc, but the amount of phenol put on was about 0.4, 0.5 ml. So I like this cryo. Unfortunately, a lot of us don't have that, and I think if we do the phenol, we need to be thinking about very small amounts, 0.5 ml and less. Regarding, well, there's a few things I want to point out. One is the way how we do things differently now with advanced technology, especially combined guidance with the e-stim and ultrasound. We can go after motor branches precisely, so not mix the sensory motor nerve. So when I do nerve blocks with phenol for the ankle and the foot, I will go specifically to the motor branches, to medial gastroc, lateral gastroc, and the soleus. And for the real practice purposes, I don't care which one causes the clonus, my goal is to make it go away. And I will block each of the branches until the clonus disappear. So in the last picture of our mentors, so one of the founders of TANOSC is Deltome from Belgium. We all speak French, so we're really good friends. In Belgium, they don't reimburse toxin for the lower extremity, so the Belgians came up with all these surgical norectomies. So they do a norectomy to the soleus. So that's why when we do blocks, we usually wanna target the soleus for the clonus and the gastroc for the length if there's a contracture. So that's why I like, as you said, doing the whole tibial nerve trunk in most patients to get the motor sensory, because you need to knock out the sensory component also to get rid of clonus for a lot of these patients because there's a sensory component. So that's why we get our best results when we do motor sensory. So now, if I do a nerve block and the foot is tingly, I bring them back again and I just block medial gastroc, lateral gastroc, soleus. It's all in Deltome's paper. I copy it exactly. So it takes me about one minute to block all three, and then I do a cryo to all three motor branches leaving the sensory. So I agree with you that soleus is super important. Hi, Jared Levin, Peace Rehab at WashU. Thank you very much for the presentation. That was very appreciated. Dr. Winston, kind of a two-part question, and I apologize for it. Am I understanding correctly? Oh, I can talk into the microphone, I suppose. Am I understanding correctly that the lack of dysestesias with the cryo, or that there is the mechanism itself is what is allowing you to avoid dysestesias? So, no. So if you look at, there's just a paper by Neil Siegel from Kansas that when they do ankle cryo, that there's a high incidence of temporary dysestesias in normal, non-stroke patients. So when you do cryo for pain like he does, you want to dysesthesia. You want to get rid of, it's a numbness, right? But not a pain. So for most of these patients, they don't get a painful neuritis, they get a numbness. Now, in most of our neuro population, because part of their sensory neglect, limb neglect, when we do a block, they don't feel any different after the procedure. If they say, oh, now my hand is numb and tingly, I have to not do the mixed motor sensory and only do the intramuscular or motor branches. So it's related to their primary CNS disease, whether or not they can get numbness, but they don't seem to get dysesthesia because of the lack of damage to the surrounding structures and neurotransmitters getting out. Then you kind of answered the second part. So that's the purpose of the lidocaine block in advance. Yes, it's to establish who we can do how much to. Okay, thank you. Easy question. We don't have access to cryo where I am, but we do have radiofrequency ablation. Any studies related to that? So when we did the literature review, there was one radiofrequency ablation. And in Canada, we're allowed to do pulse modulation. So, and I know some of the Americans here do that kind of under the table, which is a lower temperature. So there's no reason why you could not starting pulse, particularly suprascapular, the pure motor ones. I would love you to, because we don't know. Like we just started doing cryo on our own to prove it. And we have four studies now going. There's no reason why you can't. At ISPRM, a group from Spain presented a lovely case on a median nerve, pulse modulation. They had good result. It's all the same. It's whether you're doing phenol, whether you're doing a nerectomy, whether you're doing pulse, it's all targeting the nerve rather than muscle. So the question is just try it and let me know, please. But cryo, you know, it's available all over the US. It's an American device I'm using. Hi, we are actually, I'm from the Boston VA. We're waiting for ours to come in and get approved. My question is, you, Dr. Winston, you mentioned that you usually just go in once, but you have brought them back. And I just want to clarify, you bring them back to do other nerves, not to redo it. So the vast majority of times, so when we first started out, you know, I would just do brachialis, and I knew they needed brachioradialis. Or they come back, I did their leg, and like, can you please do my arm? So usually it's another session. There are patients that we've now, after two years, the patients that have a true dystonia, like they seem to, once they reinnervate, they will go back to their dystonic pattern. Because really, it's not a spasticity, it's a movement disorder. So for those, if I have to repeat them at a year or two, it's no big deal. The cost is so much cheaper. And so some of them probably will get more tone and maybe we didn't do enough. Or maybe because we did the brachialis, now the tone is channeling to the brachioradialis. So it's really not onerous to go back and do it again. And in the pain, they do it, we've got some pain people here who do knees, they do their patient three or four times a year or every couple years. So repeating it, unlike phenol, you're not induced, it's actually designed to be repetitive. So it should be safe to do as many times. Awesome, thank you. Thank you. Thank you. Any other questions? Okay, thank you for coming.

functional anatomy

nerve blocks

upper extremity

muscle innervation zones

motor branch locations

ultrasound images

electrical stimulation

cryoneurolysis

spasticity

contractures

precise nerve targeting