Journal of Medical Ultrasound (2015) 23, 104e106

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CASE REPORT

Ultrasound-guided Perineural Vitamin

B12 Injection for Peripheral
Neuropathy
Chien-Hua Chen 1,2*, Yin-Kai Huang 1,2, Fu-Shan Jaw 2

1 2
Clive Chen Clinic, Taichung City, and Institute of Biomedical Engineering, Taipei, Taiwan

Received 14 May 2014; accepted 27 January 2015

Available online 25 March 2015

KEY WORDS The objective of this article is to present an innovative treatment for peripheral neuropathy
methylcobalamin, using ultrasound-guided perineural vitamin B12 injection. A 37-year-old patient presented with
peripheral a progressive dropped foot for 2 months. Preceding trauma was denied. On examination, se-
neuropathy, vere weakness of ankle dorsiflexion was revealed. Ultrasound showed peroneal nerve swelling.
ultrasound guidance, Nerve conduction velocity and electromyography study showed results compatible with pero-
vitamin B12 neal neuropathy. Under the diagnosis of peroneal neuropathy, the patient was given 500 mg of
methylcobalamin around the peroneal nerve under ultrasound guidance two times, with an in-
terval of 2 weeks. The patient showed improvement of muscle power within 2 weeks. Full mus-
cle power was regained after 3 months. There was no adverse symptom after ultrasound-
guided perineural vitamin B12 injection. Ultrasound-guided perineural vitamin B12 has the
advantage of precise delivery of high-dose vitamin B12 directly around the defective nerve.
ª 2015, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine.
Open access under CC BY-NC-ND license.

Introduction [1]. Vitamin B12 is required for many methylation re-

Vitamin B12 is a water-soluble vitamin that is essential for
the normal functioning of the peripheral nervous system
Conflicts of interest: The authors have no conflicts of interest to
declare.
* Correspondence to: Dr Chien-Hua Chen, Clive Chen Clinic, 1F,
Number 6, Fuzhong 3rd Street, Xitun District, Taichung City 407,
Taiwan.
E-mail address: clivetaiwan@yahoo.com (C.-H. Chen).
actions, including those involving DNA and myelin basic
protein [10]. In previous studies, local application of
vitamin B12 to treat the peripheral nerve has shown effi-
cacy in animals with peripheral neuropathy [11]. Only a
small proportion of the vitamin B12 gets absorbed when it
is taken orally. Therefore, a precise delivery technique is
required for treatment of peripheral nerves with high-dose
vitamin B12. Ultrasound-guided perineural vitamin B12 in-
jection has the advantage of high-dose B12 delivery to
defective nerves.

http://dx.doi.org/10.1016/j.jmu.2015.02.001
0929-6441/ª 2015, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. Open access under CC BY-NC-ND license.
Ultrasound-guided Perineural B12 Injection
With the advent of high-resolution ultrasound, there
has been a widespread use of ultrasound in peripheral
nerve assessment and ultrasound-guided peripheral nerve
block [2,4]. Using a similar technique such as ultrasound-
guided peripheral nerve block [2,12], vitamin B12 can be
given precisely around the nerve. This article presents
an innovative strategy of treating peripheral neuropathy
using ultrasound-guided perineural vitamin B12 injection.
Case Report
Patient
A 37-year-old patient presented with progressive dropped
foot for 2 months. Preceding trauma was denied. On ex-
amination, severe weakness of ankle dorsiflexion was
revealed. Ultrasound showed focal peroneal nerve
swelling at the level of popliteal fossa (Fig. 1). Nerve
conduction velocity and electromyography study reports
showed active denervation over the right anterior tibialis
muscle compatible with peroneal neuropathy. Urgent
treatment was desired to prevent Wallerian degeneration.
Perineural vitamin B12 injection
Under the diagnosis of peroneal neuropathy, the patient
was given 500 mg of methylcobalamin around the peroneal
nerve (at the location just outside the epineurium), under
ultrasound guidance, two times with an interval of 2 weeks.
The patient showed improvement of muscle power
within 2 weeks. Full muscle power was regained after 3
months. Ultrasound imaging more than 3 months after
treatment demonstrated a reduction in peroneal nerve
swelling (Fig. 2). There was no adverse symptom after
ultrasound-guided perineural vitamin B12 injection.
Fig. 1 Ultrasound image of the peroneal and tibial nerves at
the popliteal fossa shows peroneal nerve swelling with a loss of
normal reticular pattern (arrow). Reticular pattern is pre-
served in the tibial nerve (arrowhead).
105
Fig. 2 Ultrasound image of the peroneal and tibial nerves at
the popliteal fossa shows reduced peroneal nerve swelling
(arrow). Tibial nerve can also be seen (arrowhead).
Discussion
Ultrasound-guided perineural B12 injection is an innovative
therapy for peripheral neuropathy. Vitamin B12 promotes
myelination and transport of the axonal cytoskeleton,
helps maintain the nervous system, facilitates axonal
maturation, and regenerates peripheral nerves [5e8]. An
inspiring study shows that direct B12 injection at the
injured site of the nerve promotes peripheral nerve repair
[11]. A high dose of 500 mg/kg shows significantly faster
compound muscle action potential recovery in acrylamide
neuropathy [3]. From the two studies, either a direct B12
injection at the nerve or a systemic high dose can promote
nerve regeneration. Although B12 is considered to pose no
risks to humans, as a rule, a local high dose is preferable to
a systemic high dose. With the development of high-
resolution ultrasound guidance technique, B12 could be
delivered directly and safely around the defective nerve.
The differential diagnosis of a swelling of the nerve in-
cludes entrapment neuropathy, traumatic neuroma, and
inflammatory disorder [4,9]. The pathology is either
demyelination or axonal degeneration. Vitamin B12 is
beneficial in either pathology [7,8].
Improvement of neurological function was seen within 2
weeks after the administration of perineural vitamin B12 in
the presented case of peripheral neuropathy. However, the
definite value of perineural vitamin B12 needs more clinical
data to confirm.
Ultrasound-guided perineural injections have been
applied for various indications. It has been used in the
treatment of carpal tunnel syndrome [13], intractable pain
due to sciatic nerve injury [12], peripheral nerve block [2],
and cervical spine radicular pain [14]. With ultrasound
guidance, blood vessels can be visualized and avoided in
the trajectory of the needle. Ultrasound may help avoid the
complication of a vascular injection [14].
In conclusion, ultrasound-guided perineural vitamin B12
has the advantage of precise delivery of high-dose vitamin
B12 directly around the defective nerve.
106
Acknowledgments
The authors express their gratitude to Hong-Jen Chiou for
assisting in ultrasound imaging.
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