In this instructional video, we will present the use of needle in-plane technique for ultrasound-guided botulinum toxin injections in the lower limb. This video was created by Dr. Jeffrey Smith, who is a fellowship-trained spinal cord injury specialist along with Drs. Justin Webner and Sarah Reiser in the Department of Physical Medicine and Rehabilitation at the University of Virginia. The authors of this video have nothing to disclose. Objective number one, perform ultrasound-guided botulinum toxin injections with increased confidence by utilizing the needle in-plane technique for the following target muscles, tibialis posterior, flexor hallucis longus, soleus, flexor digitorum longus. Objective number two, describe the ergonomic challenges and methods for management of ultrasound-guided lower limb botulinum toxin injections. Objective number three, utilizing diagnostic ultrasound, identify the relevant anatomical landmarks, lower limb target muscles, and neurovascular structures to avoid when performing botulinum toxin injections. In this video, we will describe the rationale for the use of needle in-plane technique for botulinum toxin injections in the lower limb. We will discuss ergonomic challenges inherent to these injections. We will demonstrate the use of electrical stimulation and isolated passive muscle movement to improve injection accuracy. We will demonstrate injections for tibialis posterior, flexor hallucis longus, soleus, and flexor digitorum longus. Finally, we will conclude with a review of key points from this instructional video. The idea for this video was born out of the article titled, Prevalence of Bleeding Complications Following Ultrasound-Guided Botulinum Toxin Injections in Patients on Anticoagulation or Antiplatelet Therapy. Dr. Jeffrey Smith was the principal investigator on this study. Dr. Smith evaluated the use of needle in-plane ultrasound guidance for these injections. With the use of this technique, bleeding complications were found to occur less than 1% of the time. All bleeding complications identified on post-injection hematoma scan were subclinical. Thus, ultrasound guidance may provide added assurance for practitioners performing office-based procedures in patients at higher risk for bleeding complications. This rationale includes the following benefits. Visualizing the length of the needle in-plane during injection. Visualizing injection of botulinum toxin in the target muscle. Decreasing the risk of injury to vascular structures and bleeding complications. And performing a post-injection ultrasound to screen for hematomas in order to provide early identification of bleeding complications. Here we will demonstrate the in-plane needle technique. When the needle is inserted in long axis, the entire needle may be visualized. Note the positioning of the practitioner's hands in relation to the transducer and needle. Now we will demonstrate the out-of-plane needle technique. When the needle is inserted in the short axis, a cross-sectional view of the needle will be seen on ultrasound, appearing as a small dot on the display. Note that the needle only crosses the ultrasound beam once. Again, take note of the positioning of the practitioner's hands in relation to the transducer and needle. In contrast to the out-of-plane technique, the in-plane technique allows for constant visualization of the needle tip as it is being inserted. This allows the practitioner to guide the needle tip away from important anatomical structures, such as blood vessels and nerves, as well as to confirm position of the needle tip in the target muscle.

needle in-plane technique

ultrasound-guided botulinum toxin injections

lower limb

ultrasound

anatomical landmarks