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PROCEDURES PERFORMED: Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.

PROCEDURE CODES: 64640 times three, 64614 times four, 95873 times four.

PREOPERATIVE DIAGNOSIS: Spastic quadriparesis secondary to traumatic brain injury, 907.0.

POSTOPERATIVE DIAGNOSIS: Spastic quadriparesis secondary to traumatic brain injury, 907.0.

ANESTHESIA: MAC.

COMPLICATIONS: None.

DESCRIPTION OF TECHNIQUE: Informed consent was obtained from the patient's brother. The patient was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation. Approximately 7 mL was injected on the right side and 5 mL on the left side. At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol. The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation. Approximately 5 mL of 5% phenol was injected in this location. Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.

Muscles injected with botulinum toxin were identified using active EMG stimulation. Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.

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