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Anaesthesiology Ultrasound Handbook
Ultrasound-guided Peripheral Nerve Blocks
Dr. Gotaro Shiragami

Professor, Anaesthesiology and Pain Clinic, Kagawa University Hospital
Dr. Hiroyuki Fujiwara

Professor, Anaesthesiology, Aichi University Hospital

Edited by Dr. Alwin Chuan
MB BS (Hons), FANZCA
Consultant Anaesthetist, Sydney, Australia
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Anaesthesiology Ultrasound Handbook
Ultrasound-guided Peripheral Nerve Blocks
01 Basics of Ultrasound
01-1) Ultrasound-Guided Peripheral Nerve Blocks ………………………… 4
1. Basics of ultrasound ………………………… 4
2. Injection methods ………………………… 6
02 Nerve Blocks: Surgery

02-1) Upper Extremity Blocks ………………………… 10
1. Brachial plexus block: Interscalene approach ………………………… 10
2. Brachial plexus block: Supraclavicular approach ………………………… 12
3. Brachial plexus block: Subclavicular approach ………………………… 14
4. Brachial plexus block: Axillary approach ………………………… 16
02-2) Lower Extremity Blocks ………………………… 18
1. Femoral nerve block ………………………… 18
2. Lateral femoral cutaneous nerve block ………………………… 20
3. Obturator nerve block ………………………… 22
4. Sciatic nerve block: Subgluteal approach ………………………… 24
5. Sciatic nerve block: Anterior approach ………………………… 26
6. Sciatic nerve block: Popliteal approach ………………………… 28
02-3) Trunk Blocks ………………………… 30
1. Ilioinguinal nerve/ Iliohypogastric nerve block ………………………… 30
2. Rectal sheath block ………………………… 32
3. Transverse abdominus plane (TAP) block ………………………… 34
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03 Nerve Blocks: Pain Clinics
03-1) Upper Extremity Blocks ………………………… 38
1. Stellate ganglion block ………………………… 38
2. Cervical ganglion block ………………………… 40
03-2) Lower Extremity Blocks ………………………… 42
1. Iliac fascia block ………………………… 42
2. Psoas compartment block ………………………… 44
3. Lumbar facet block

(blocking the medial branch of the dorsal branch of the lumbar nerve) ………………………… 46
03-3) Trunk Blocks ………………………… 48
1. Intercostal nerve block ………………………… 48
2. Thoracic paravertebral block ………………………… 49
04 Future Developments
04-1) Epidural Block/Spinal Subarachnoid Block ………………………… 54
04-2) 3D/4D ………………………… 56
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01
Basics of Ultrasound
01-1) Ultrasound-Guided Peripheral Nerve Block

Professor, Anaesthesiology and Pain Clinic,
Kagawa University Hospital

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01-1) Ultrasound-Guided Peripheral Nerve Blocks

1. Basics of ultrasound
How peripheral nerves are visualised
- On short-axis images, in areas near nerve roots (e.g., brachial plexus root),
peripheral nerves are hypoechoic and circular/elliptical, with even internal
structures surrounded by hyperechoic frames (nerve outer membrane).
- Peripheral nerves appear as hypoechoic grape bunches, honeycombs, or
lotus root, with hyperechoic surrounding tissue (nerve outer membrane and
perineurium). On long-axis images, internal structures form reticular strings.
- How peripheral nerves appear can depend on the probe angle – a property
called anisotropy. Peripheral nerves can be clearly seen by positioning the
probe perpendicular to the direction of innervation.
How perineural tissue is visualised

- The skin is hyperechoic. Subcutaneous tissue and fat are hypoechoic with
linear stripes inside the skin, nearly parallel to the skin surface.
- On short-axis images, tissue around tendons is hyperechoic, and the
inside of the tendons appears as hypoechoic bundles that are difficult to
differentiate from neural tissue. Moving the probe proximally or distally
will reveal tendons merging into a muscle belly, while nerves continue
throughout the length of the limb. On long-axis images, tendons appear as
hypoechoic stripes with hyperechoic septi.
- Vessels often accompany nerves, and their identification is important for
safe injections. Vessels can be differentiated by color Doppler imaging.
Blood inside vessels is hypoechoic or non-echoic. Veins are easily
flattened with a probe, but arteries remain circular and pulsatile. When
compressed forcefully, veins can be flattened and rendered invisible. If a
local anaesthetic fails to spread properly, the anaesthetic may have been
administered into a vessel.
- Muscles appear as hypoechoic uneven structures with hyperechoic mottled
crests (resembling a starry night). The fascia surrounding muscular tissue is
hyperechoic. Many nerves travel within fascias.
- In general, bones reflect ultrasound, and bone surfaces are highly hyperechoic.
Tissue behind bones is black and cannot be seen, due to the acoustic shadow.
- Although lymph nodes sometimes resemble veins, lymph nodes have more
valves than veins. The core of lymph nodes is hyperechoic, while their
margins form hypoechoic circular/elliptical structures with clear borders.
Color Doppler imaging will sometimes show a vessel at the center.
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- Local anaesthetics are non-echoic. Administering a drug solution around a
nerve can sometimes render neural tissue more clearly.
- Air bubbles are hyperechoic artifacts. The tissue behind air bubbles is black.
- The pleura appears as a hyperechoic line because the lung contains air and
strongly reflects ultrasound. In some cases, resonance renders deep areas
of the pleura hyperechoic (resembling comet-tail artifacts). Breathing causes
the pleura to glide.
- Behind the abdominal wall, the peritoneum appears as a smooth hyperechoic
line. Like the pleura, it sometimes appears as a comet tail. Occasionally,
intestinal tract movements will be visible inside the abdominal cavity.
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01-1) Ultrasound-Guided Peripheral Nerve Blocks

2. Puncture methods
In-plane method
- Insert parallel to the probe (long-axis). This method requires a distance about
two to three times longer than the out-of-plane method.
- The angle for needle insertion should be less than or equal to 30 degrees
to maximise visibility. The needle cannot be observed when 1 mm from the
ultrasound window.
- Multiple reflections cause the needle to appear as multiple images.
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Out-of-plane method
- Insert perpendicular to the probe (short axis).
- Only the tip or part of the needle is visualised as a dot. An acoustic shadow
occasionally appears behind the needle.
Needle
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Electric nerve stimulation

- Stimulate by targeting a motor nerve (an A-fiber).
- Use a block needle designed for nerve stimulation.
- The cathode is on the stimulating needle side. The anode is on the patient
skin side.
- Start with a stimulation time of 0.1 to 0.2 msec, stimulation frequency of 1
to 2 Hz, and current of 1 mA to identify a location resulting in target muscle
contraction. More current is needed in cases involving diminished nerve
reactivity, as with elderly and diabetic patients.
- To place the needle tip closer to the nerve, identify a location where muscle
contraction occurs with low current (e.g. 0.3 to 0.5 mA) but does not occur
with lower current (e.g. 0.1 to 0.2 mA). If muscle contraction is observed with
current of 0.2 mA or lower, the needle tip may be inside the nerve.
- Lowering the voltage and repeatedly altering the location of the needle tip to
identify the right location will increase the probability of nerve damage.
- Combine ultrasound-guided nerve block with electric nerve stimulation
to identify a target nerve (dual-guide). Keep in mind that there is no need
to place the needle tip right next to the nerve. The nerve block is achieved
when the drug solution surrounds the nerve.
Continuous block
- Place a catheter near a nerve. In general, administer 10-20 ml of a drug solution
to create a space around the nerve, then place the catheter in this space. Position
no more than 4 cm beyond the needle tip. Sterility should be maintained during
the procedure following local guidelines.”
- In general, the catheter is kept in place for 48 to 72 hours. Monitor the
catheter insertion site daily (for catheter location, hematoma, infection, etc.).
Drug solution
- In surgery lasting less than two hours, use 1-2% lidocaine or mepivacaine. In
surgery lasting longer, use 0.5-0.75% ropivacaine.
- For analgesia during or after surgery, use 0.2-0.375% ropivacaine.
- When administering a drug solution, confirm the absence of blood regurgitation
and inject in small doses. Confirm that the solution spreads around the nerve
using ultrasound. If the drug solution fails to spread properly, change the
location of the needle tip. If local anaesthesia spread cannot be visualized,
either the probe position is incorrect or suspect intravascular injection. In both
situations, confirm needle position before injecting further local anaesthesia.
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02
Nerve Blocks: Surgery
02-1) Upper Extremity Blocks

02-2) Lower Extremity Blocks
02-3) Trunk Blocks

Professor, Anaesthesiology and Pain Clinic,
Kagawa University Hospital

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1. Brachial plexus block: Interscalene approach

Indications
- Anaesthesia and analgesia during surgery involving the shoulder or proximal
upper arm; postoperative analgesia.
- Analgesia, passive shoulder exercise, and physical therapy.
- Sympathetic nerve block.
Anatomical and clinical points

- The brachial plexus consists of the anterior branches of the spinal nerve from
C5 to T1 (occasionally C4 and T2). The roots of five (to seven) nerves form three
nerve trunks, upper (C5-6), middle (C7), and lower (C8-T1) trunks, in the
supraclavicular area. These nerve roots and trunks travel between the anterior
and middle scalene muscles (interscalene groove).
- With the interscalene approach, nearby cervical plexus may also be
incidentally blocked. In particular, phrenic nerve paralysis is a risk and the
technique is contraindicated in patients with reduced lung function. Do not
perform a bilateral block.
- The out-of-plane method poses the risk of pneumothorax if the needle tip is
placed too far to the caudal side.
Sternocleidomastoid muscle
Anterior scalene muscle
Common Middle scalene

carotid artery muscle
Brachial plexus
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Important considerations
- Use a high-frequency linear probe.
- Place the patient in the supine position, with the patient’s head facing
opposite the block.
- At the height of the annular cartilage, position the probe perpendicular
to the neck. Move the probe toward the sternocleidomastoid muscle to
visualise the common and internal carotid arteries and to delineate the
anterior and middle scalene muscles inferolateral to the sternocleidomastoid
muscle. Lean the probe slightly caudal to visualise three (sometimes two to
five) circular/elliptical hypoechoic structures (brachial plexus) between the
scalene muscles. If identifying the brachial plexus is difficult, position the
probe in the supraclavicular region, confirm structures resembling a grape
bunch (the brachial plexus), and move the probe along the nerve to the
interscalene groove. This technique is called traceback.
- This is necessary to confirm the position of the cervical pleura and to avoid
puncturing the pleura.
- Inject via the in-plane or out-of-plane method while avoiding the external
carotid vein (generally visible on the same screen).
- When combining with electric nerve stimulation, confirm muscle contraction
from the shoulder to the hand. Do not administer a local anaesthetic to an
area with diaphragmatic contraction (phrenic nerve stimulation).
- Administer in small doses to envelop the plexus with local anaesthetic. The
drug solution will not spread around the nerve if it does not pass the scalene
fascia.
- Local anaesthetic administration: Single injection <20 ml using USGRA;
continuous infusion 4 ml/hr using a low-concentration infusion (e.g. 0.2%
ropivacaine).
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2. Brachial plexus block: Supraclavicular approach

Indications
- Anaesthesia and analgesia during surgery involving the upper arm, forearm
or hand; postoperative analgesia.

- The brachial plexus approaches the armpit by passing between the anterior
and middle scalene muscles and between the clavicle and first rib. The three
nerve trunks bifurcate into anterior and posterior branches on the dorsal
side of the clavicle.
- The brachial plexus is usually cephaloposterior to the subclavicular
artery near the pleura. The posterior scapular artery bifurcates from the
subclavicular artery, occasionally crossing the brachial plexus.
Suprascapular or transverse cervical artery
Brachial plexus
Subclavicular artery
Pleura
First rib
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- Use a high frequency linear probe.
- Position the patient in the supine position, with the patient’s head facing
opposite the block.
- Position the probe nearly parallel or slightly caudal to the clavicle in
the supraclavicular fossa to delineate the subclavicular artery. Confirm
the presence of hypoechoic structures resembling bunches of grapes
cephaloposterior to the subclavicular ar ter y (brachial plexus). The
hyperechoic lines below the subclavicular artery and brachial plexus are the
first rib and pleura, respectively.
- Using the in-plane method, inject from the lateral side to the inferior region
of the brachial plexus. The out-of-plane method causes higher risk of
pneumothorax.
- Occasionally the suprascapular or transverse cervical artery is seen just
above the brachial plexus. Avoid vessels while making the injection.
from the upper arm to the hand.
- Local anaesthetic administration: Single injection up to 25 ml; continuous
infusion 4 ml/hr.
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3. Brachial plexus block: Infraclavicular approach

Indications
- Anaesthesia and analgesia during surgery involving the elbow, forearm, or
hand; postoperative analgesia.
- Physical therapy.
- Sympathetic block.

- The upper, middle, and lower nerve trunks of the brachial plexus each bifurcate
into anterior and posterior branches. After passing the interscalene groove,
they pass between the clavicle and first rib and head toward the armpit. The
three nerve bundles—i.e., lateral (the anterior branch of the upper and middle
nerve trunks), posterior (the posterior branch of the upper, middle and lower
nerve trunks), and medial (the anterior branch of the lower nerve trunk)—head
toward the upper arm along the axillary artery.
- The brachial plexus wraps around the axillary artery and the named cords
correspond to their positions relative to the axillary artery. Occasionally, the
cephalic vein crosses superficial to the brachial plexus.
- The infraclavicular approach blocks at the nerve bundle.
Pectoralis major
Axillary artery
Pleura Axillary vein

Brachial plexus
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- Use either a linear or micro-convex probe.
- Place the patient in the supine position.
- Position the probe along the lower margin of the clavicle to first identify the
axillary artery, then confirm the axillary vein medial to the artery and the
pleura dorsal to the artery and the vein. Identify the hyperechoic lotus root-like
structures anterior, lateral, or posterior to the axillary artery (branchial plexus).
Adjust the probe angle so that it is perpendicular to the artery and plexus.
- With the in-plane method, approach from the lateral side, tareting an area
below the axillary artery. With the out-of-plane method, approach from the
armpit toward the direction of the cervical interscalene groove. Administer
a local anaesthetic in small doses to envelop the nerve bundle. When it is
difficult to identify individual nerve bundles, inject toward the dorsal side of
the axillary artery to allow the drug solution to spread around the artery,
particularly in the cephaloposterior aspect below the axillary artery.
from the wrist to the hand.
- Local anaesthetic administration: Single injection up to 25 ml; continuous
infusion 4 ml/hr.
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4. Brachial plexus block: Axillary approach

Indications
- Anaesthesia and analgesia during surgery involving the elbow, forearm, or
hand; postoperative analgesia.
- Physical therapy.

- At the axillary peak, the brachial plexus forms three nerve bundles—i.e.,
lateral, posterior and medial. Near the lower margin of the pectoral minor
muscle, it forms the median nerve (the medial side of the lateral nerve
bundle and the lateral side of the medial nerve bundle), ulnar nerve (part
of the medial side of the medial cord), radial nerve (posterior nerve bundle)
and musculocutaneous nerve (the lateral side of the lateral nerve bundle). In
the armpit, the median, ulnar, and radial nerves are physically close in most
cases, but the musculocutaneous nerve is located away from these nerves
and often travels within the region inside the coracobrachial muscle or
between the biceps and coracobrachial muscles.
- The presence of numerous veins raises the risk of injecting into a vessel.
Median nerve Axillary artery
Biceps muscle Ulnar nerve
Radial nerve
Musculocutaneous
nerve
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- Place the patient in the supine position, with the patient’s head slightly
facing opposite the block. Abduct the block-side upper extremity 90 degrees
and supinate the forearm. Alternatively, bend the elbow joint.
- In the armpit, position the probe perpendicular to the arrangement of the
axillary artery to first identify the axillary artery (one artery in most cases),
then identify one or two nearby axillary veins. On the lateral, medial and
dorsal sides of the axillary artery, respectively, the medial, ulnar, and radial
nerves will often appear hyperechoic.
- The musculocutaneous nerve often lies lateral to the other nerves. In the
proximal region, the nerve is circular and hyperechoic. In the distal region, it
is triangular and hyperechoic.
- With the in-plane method, advance the needle from the superior side of the
probe toward the axillary artery. With the out-of-plane method, enter from
the lateral side toward the cranial side.
- Administer a drug solution in small doses to surround each nerve. Block
the radial, ulnar and medial nerves first, then block the musculocutaneous
nerve.
- When combining with electric nerve stimulation, confirm the movements of
the medial nerve (wrist and finger flexion and thumb opposition), ulnar nerve
(ulnar flexion of the wrist, thumb adduction and third-fifth digit flexion), radial
nerve (dorsal flexion of the wrist, thumb abduction and finger extension) and
musculocutaneous nerve (elbow flexion or extension).
- Local anaesthetic administration: Single injection 5-10 ml per nerve for a
total of 20 ml.
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1. Femoral nerve block

Indications
- Anaesthesia and analgesia during surgery involving the lower extremity in
combination with a proximal sciatic nerve block; postoperative analgesia.
- Analgesia of the anterior surface of the femur (e.g., skin graft) and passive
joint exercise.
- Analgesia: Femoral shaft/head fracture, after knee surgery, or after anterior
cruciate ligament reconstruction, etc.

- The femoral nerve is the largest branch of the lumbar plexus and is
composed of the anterior branch of the L1 (occasionally T12) to L4
(occasionally L5) spinal nerves.
- In the inguinal region, the femoral nerve innervates the anterior surface of the
iliopsoas muscle, just lateral to the fe moral artery. Occasionally the nerve innervates
the region between the femoral artery and vein or inside the iliopsoas muscle.
- If a relatively large amount of local anaesthetic is administered, the drug
solution will spread below the iliac fascia and also block the femoral
cutaneous nerve (iliac fascia block). If an even greater amount is injected,
the obturator nerve is blocked as well, potentially resulting in a 3-in-1 block.
The likelihood of blocking the obturator nerve is low.
- With a femoral nerve block, patients can fall when their knees buckle after they
put weight on the block-side leg. Explain this risk to patients when performing
day surgery. At the same time, certain considerations, including preparation of
axillary crutches or adjusting the dosage accordingly are required.
Femoral fascia
Femoral nerve
Iliac fascia
Femoral artery
Femoral vein
Iliopsoas muscle
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- Place the patient in the supine position and slightly rotate the block-side leg
externally.
- In the inguinal region, position the probe parallel to the inguinal canal just
distal to the canal to identify the femoral artery first, followed by the femoral
vein in the medial side. The femoral nerve is visible lateral to the femoral
artery as a slightly hyperechoic elliptical or flat triangular structure.
- With the in-plane method, advance the needle from the lateral to medial
side of the femoral artery.
- Administer in small doses to surround the nerve.
- When combining with electric nerve stimulation, confirm quadriceps muscle
contraction (patella dancing).
- Local anaesthetic administration: Single injection 20 ml; continuous infusion
4 ml/hr.
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2. Lateral femoral cutaneous nerve block

Indications
- Surgery involving the lower extremities in combination with a femoral/sciatic
nerve block
- Femoral lateral skin graft and muscle biopsy.
- Sensory abnormal femoral nerve pain: following THA, etc.

- In general, the lateral femoral cutaneous nerve originates from the L2/3
anterior branch, proceeds toward the anterior superior iliac spine at an
angle across the iliac muscle, goes around the inguinal ligament, penetrates
above or below the sartorius muscle, and reaches the anterolateral surface
of the femur.
- An iliac fascia block also tends to block the lateral femoral cutaneous nerve.
This technique is used when a femoral nerve block is insufficient.
Femoral fascia
Lateral femoral Iliopsoas muscle

cutaneous nerve
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- Place the patient in the supine position and slightly abduct the block-side leg.
- Position the probe parallel on the inguinal ligament to identify the anterior
superior iliac spine. By moving the probe slightly caudal to the anterior
superior iliac spine, confirm the sartorius muscle attached to the anterior
superior iliac spine. Immediately medial to the anterior superior iliac spine,
the lateral femoral cutaneous nerve is the hyperechoic circular or cord-like
structure seen above, below or inside the sartorius muscle.
- Inject via either the in-plane or out-of-plane method. Administer a local
anaesthetic after confirming the absence of blood.
- If the nerve cannot be identified, administer a drug solution by penetrating
the anterior fascia of the sartorius muscle (femoral fascia) near the anterior
superior iliac spine and injecting the drug solution to hydrodissect the
underlying iliac fascia. Occasionally, the lateral femoral cutaneous nerve will
be visible between the femoral and iliac fascias.
- Local anaesthetic administration: Single unilateral injection 5-10 ml.
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3. Obturator nerve block

Indications
- TUR for ipsilateral bladder wall tumor.
- Supplement incomplete 3-in-1 block.
- Diagnose and treat hip pain syndrome.
- Femoral adductor muscle spasm.

- The obturator nerve generally originates from the L2-4 anterior branch,
enters the obturator canal along the lateral bladder wall, and generally
bifurcates into anterior and posterior branches inside the obturator canal.
The anterior branch innervates the region between the adductor muscles,
while the posterior branch lies between the short and greater adductor
muscles. The motor branches of the anterior branch innervate the lateral
obturator, long adductor and gracilis muscles, and the motor branches of
the posterior branch innervate the lateral obturator, greater adductor and
femoral quadratus muscles. Sensory branches generally innervate the
medial side of the thigh, the posterior surface of the knee, and the hip joint,
but individual differences can be significant.
- Even when the obturator nerve is completely blocked, adductor muscle
contraction can occur due to the existence of an accessory obturator nerve.
Obturator nerve
anterior branch
Adductor longus
Adductor brevis
Pectineus muscle
Obturator nerve
posterior branch
Adductor magnus
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- Place the patient in the supine position, extend the lower extremity, and
slightly abduct the block-side leg.
- Position the probe parallel to the inguinal ligament to identify the femoral
artery and vein. By moving the probe medial to the thigh, identify the
pectineus, long adductor, and short adductor muscles. These muscles form
a hyperechoic triad (resembling the Mercedes-Benz logo), and the anterior
branch of the obturator nerve is located within. The posterior branch of the
obturator nerve is present between the short and greater adductor muscles.
- Combine with electric nerve stimulation (1 mA) to visualise adductor muscle
contraction. In elderly and diabetic patients, contractions may only become
visible with increased current.
- With the in-plane method, inject from either the lateral or medial side.
- Since the obturator artery and vein may be present nearby, confirm by
color Doppler imaging. After confirming the absence of blood aspiration
in the muscle triad and between the short and greater adductor muscles,
administer a local anaesthetic.
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4. Sciatic nerve block: Subgluteal approach

Indications
- Surgery involving the lower extremity in combination with a lumbar plexus
or femoral nerve block.
- Analgesia: Flexor muscle-side of the knee and lower extremity.

- The sciatic nerve (L4 to S3) is a branch of the sacral plexus (L4 to S4). Below
the piriform muscle, the nerve passes through the greater sciatic foramen,
innervates the region between the gluteus and quadriceps muscles, goes
between the greater trochanter of the femur and the ischial tuberosity,
and innervates the posterior surface of the thigh. The posterior femoral
cutaneous nerve, another branch of the sacral plexus, lies in the region
immediately medial to the sciatic nerve.
Gluteus maximus
Ischial tuberosity Greater trochanter
Sciatic nerve
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- Use a medium to high-frequency linear probe. Use a convex probe with
obese patients.
- Place the patient in the prone or lateral position. In the lateral position, place
the non-block-side leg below the block-side leg and extend the non-block-
side leg. Bend the hip and knee joints of the block-side leg, then lean slightly
forward at the waist to lift the hips upward. Since the sciatic nerve is located
deeper, electric nerve stimulation can be useful.
- Along the line connecting the greater trochanter and ischial tuberosity,
position the probe perpendicular to the femur. Confirm the greater
trochanter by ultrasound and move the probe toward the ischial bone
to confirm the ischial tuberosity. The sciatic nerve is visible close to the
midpoint of the two structures underneath the gluteus muscle as a
hyperechoic elliptical/crescent or belt-like structure. The posterior femoral
cutaneous nerve or the tendons for the femoral biceps, semitendinosus, or
semimembranosus muscles is sometimes hyperechoic, and the sciatic nerve
is found laterally (greater trochanter-side). The inferior gluteal artery can
sometimes be seen medial to the sciatic nerve.
- Confirm the absence of blood aspiration and administer a local anaesthetic

in small doses. Confirm that the drug solution spreads around the nerve. If
the drug solution fails to spread properly, reposition the needle and re-bolus.
- Can be performed by in-plane or out-of-plane method.
- Local anaesthetic administration: Single injection 10-20 ml; continuous

infusion 4 ml/hr.
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5. Sciatic nerve block: Anterior approach

Indications
- Surgery involving the lower extremity in combination with a lumbar plexus
or femoral nerve block.
- Analgesia.

- The sciatic nerve lies within the mediodorsal side of the femur between
the lesser trochanter and ischial tuberosity while covered by the gluteus
muscle on the lateral and dorsal sides, the biceps/semitendinosus/
semimembranosus muscle on the medial side, and the adductor magnus on
the anterior side.
- Useful when a patient with a lower leg fracture cannot be placed in the
lateral or prone position; possible in the same body position as the femoral
nerve block.
- With the anterior approach, analgesia is often unsuccessful in the posterior
surface of the thigh (posterior femoral cutaneous nerve).
Femoral artery
Adductor magnus
Lesser trochanter
Sciatic nerve
26
- Use a low-frequency convex probe.
- Place the patient in the supine position. Bend the hip and knee joints slightly
and slightly rotate the lower extremities externally. At this height (lesser
trochanter), since the sciatic nerve is deep, electric nerve stimulation is
useful.
- At about 8 cm below the inguinal canal, position the probe parallel to the
canal to identify the femoral artery and vein. Identify the lesser trochanter
on the lateral dorsal side and the adductor magnus muscle on the medial
dorsal side. The sciatic nerve is elliptical/triangular and hyperechoic in the
mediodorsal region of the lesser trochanter.
- Puncture by either the in-plane or out-of-plane method. Note that visually
confirming the location of the puncture needle may be difficult.
infusion 4 ml/hr.
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6. Sciatic nerve block: Popliteal approach

Indications
- Anaesthesia and analgesia during surgery; postoperative analgesia: Foot/
ankle, and surgery distal to the knee
- Sympathetic block, achillodynia, diabetic gangrene, and blood flow
disturbance/ulcer

- At the popliteal region, the sciatic nerve bifurcates into two branches: the
common peroneal nerve on the medial side and the tibial nerve on the
lateral side. The sciatic nerve is located between the biceps femoris and
semimembranosus muscles lateral to the popliteal artery and vein.
- If surgery involves the medial side of the lower leg, it becomes necessary to
combine with either the femoral or saphenous nerve block.
Semitendinosus
muscle
Biceps femoris
Semimembranosus
muscle
Sciatic nerve
28
- Use a medium to high-frequency linear probe.
- When placing the patient in the supine position, place a pillow between the
lower legs to create a space to maneuver the probe below the popliteal
region. Other options include the prone position or lateral position with the
block side on top. When combining with electric nerve stimulation, lift the
ankle to observe ankle movements.
- In the supine position, visual orientation can be made easier by flipping the
top and bottom ultrasound images.
- At 5 to 10 cm cranial to the popliteal groove, position the probe parallel to
the popliteal groove. The sciatic nerve is circular/elliptical and hyperechoic.
Ankle dorsal and plantar flexion will pull on the nerve, causing the sciatic
nerve to appear to swing in the ultrasound (seesaw sign).
- When it is difficult to identify the nerve, position the probe in the popliteal
groove and identify the popliteal artery and vein by color Doppler imaging.
The tibial nerve is visible immediately lateral to the popliteal artery and vein,
and the common peroneal nerve is observed lateral to the nerve. By moving
the probe cranially, one can see that both nerves merge. The nerve block is
administered prior to bifurcation (rarely, the nerves will bifurcate from the
beginning and fail to merge).
- Puncture by the in-plane or out-of-plane method. When administering a
single injection via the in-plane method in the supine position, enter more or
less parallel to the probe from the lateral side of the thigh. Since the probe
and injection site are physically separate, the probe need not be sterile. After
confirming the absence of blood aspiration, administer a local anaesthetic.
Confirm that the drug solution spreads properly around the nerve.
infusion 4 ml/hr.
29
02-3) Trunk Blocks
1. Ilioinguinal nerve/ Iliohypogastric nerve block

Indications
- Analgesia during surgery and postoperative analgesia: Inguinal hernia,
hydrocele testis, cryptorchidism and lower abdominal section.
- Pain after inguinal hernia surgery, and postherpetic neuralgia.

- The ilioinguinal nerve (L1, some Th12) and iliohypogastric nerve (L1, some L2)
emerge from the outer margin of the greater psoas muscle. They innervate
the abdominal side of the quadratus muscle, penetrate the transverse
abdominal muscle near the anterior superior iliac spine, pass between the
transverse abdominal and internal abdominal oblique muscles, go through
the internal and external abdominal oblique muscles to innervate the
inguinal region, medial upper thigh region, and scrotum, but variations are
common.
- With only an ilioinguinal/iliohypogastric nerve block, visceral pain and
traction pain cannot be suppressed, and another anaesthesia/analgesia is
required for treatment.
External abdominal
oblique muscle
Internal abdominal
oblique muscle Anterior
superior
iliac spine
Transverse
abdominal
muscle Ilioinguinal nerve
Iliohypogastric nerve
30
- Supine position.
- Position the probe lateral to the line connecting the navel and anterior
superior iliac spine to first identify the anterior superior iliac spine. Next, on
the other side of the anterior superior iliac spine, identify the three-layer
structure consisting of the external abdominal oblique, internal abdominal
oblique, and transverse abdominal muscles. In young people, the ilioinguinal
nerve (lateral side) and iliohypogastric nerve (medial side) can often be seen
between the internal abdominal oblique and transverse abdominal muscles.
Position the probe perpendicular to the nerve arrangement. Under the highly
hyperechoic peritoneum, the peristaltic intestinal tract is visible.
- Enter via either the in-plane or out-of-plane method. Penetrating the fascia
will result in a popping sensation. Strong skin resistance during needle
insertion raises the risk of intestinal tract damage. To avoid this, either make
an incision using an 18 G needle or decrease the angle of puncture.
- Once the nerve is identified, advance the needle near the nerve. After
conf irming the absence of blood regurgitation, administer a local
anaesthetic. If the nerve cannot be identified, administer the drug solution
between the internal abdominal oblique and transverse abdominal muscles
and between the external and internal abdominal oblique muscles. Confirm
that the drug solution spreads around the nerve and between the muscles.
31
02-3) Trunk Blocks
2. Rectal sheath block

Indications
- Analgesia during surgery and postoperative analgesia: Middle abdominal
resection, laparoscopy, umbilical hernia and abdominal incisional hernia.

- The anterior central region of the abdominal wall consists of the abdominal
rectus muscle covered by the rectal sheath. The rectal sheath is the
aponeurotic extension of the external abdominal oblique, internal abdominal
oblique, and transverse abdominal muscles. Above the navel, the rectal
sheath divides into the anterior and posterior layers to cover the abdominal
rectus muscle; only the anterior layer is present below the navel.
- The lateral cutaneous branches of the inferior intercostal nerves (Th7 to 12)
pass between the internal abdominal oblique and transverse abdominal
muscles, penetrate the abdominal rectus muscle from directly below, then
turn into the anterior cutaneous branch and innervate the center of the
abdominal wall.
- At above or below the navel, the abdominal wall artery or vein will occasionally
be present within the rectal sheath.
Subcutaneous tissue
Abdominal rectus muscle
Peritoneum
Inside the abdominal cavity
32
- Supine position.
- In some cases, this may be done after inducing general anaesthesia.
- Position the probe on the abdominal wall to observe axial sections of the
abdominal rectus muscle. The abdominal rectus muscle is covered by the
hyperechoic rectal sheath, causing the posterior layer of the rectal sheath
and the abdominal rectus fascia to appear as a double-layer structure.
Under the hyperechoic peritoneum, the peristaltic intestinal tract is visible.
No nerves are visible.
- Injecxt via either the in-plane or out-of-plane method. Penetrating the fascia
will result in a popping sensation.
- Confirm the location of the abdominal wall artery and vein by color Doppler
imaging. Avoid puncturing the adjacent tissue.
- Once the needle tip reaches the region between the abdominal rectus fascia
and the posterior lobe of the abdominal rectal sheath (double-layer), confirm
the absence of blood aspiration and administer a local anaesthetic. Confirm
that the drug solution spreads inside the compartment in a spindle-shaped
manner.
- Local anaesthetic administration: Bilateral injection total 20-30 ml.
33
02-3) Trunk Blocks
3. Transverse abdominus plane (TAP) block

Indications
- Analgesia during surgery and postoperative analgesia: Lower abdominal
resection, obstetric laparoscopy, and inguinal surgery.

- Before innervating the anterior abdominal wall, intercostal nerves originating
from Th6 to 11, subcostal nerve originating from Th12, and iliohypogastric
nerve originating from L1 pass between the internal abdominal oblique and
transverse abdominal muscles (neurovascular surface).
- Administering a local anaesthetic to the bilateral neurovascular surfaces
suppresses somatic pain in the anterior abdominal wall, in particular from
below the navel to the pubic symphysis. Unilateral surgery is covered by
unilateral administration.
- This is an alternative analgesic procedure used to avoid complications
associated with epidural or spinal subarachnoid anaesthesia (lower
extremity motor paralysis, epidural hematoma, etc.).
- Since visceral pain cannot be suppressed by transverse abdominal fascia
block alone, another analgesic procedure must be used (multimodal
analgesia).
Subcutaneous tissue
External abdominal Needle

oblique muscle
Internal abdominal
oblique muscle
Transverse abdominus
Peritoneum Inside the

abdominal cavity
図10. 腰椎椎間関節ブロック注釈つき
34
- Place the patient in the supine position and abduct the upper extremities.
- Position the probe between the iliac crest and costal margin along the middle
axillary line in the flank region to identify the three-layer structure consisting
of the external abdominal oblique, internal abdominal oblique, and transverse
abdominal muscles. Fascias are more hyperechoic than muscles. Below the
peritoneum, the intestinal tract is peristaltic. No nerves are visible.
- Approach via the in-plane method on a horizontal section. Penetrating the
fascia of the external and internal abdominal oblique muscles will result in a
popping sensation. Position the needle tip dorsal to the middle axillary line.
- Note the risk of vascular puncture, intraabdominal cavity puncture, and
(occasionally) liver puncture.
- Once the needle tip reaches the neurovascular surface between the internal
abdominal oblique and transverse abdominal muscles, confirm the absence
of blood aspiration and administer a local anaesthetic. Confirm that the drug
solution spreads through the neurovascular surface in a spindle manner.
- Local anaesthetic administration: Single unilateral injection 20 ml; continuous
infusion 6-8 ml/hr.
35
36
03
Nerve Blocks: Pain Clinics

03-3) Trunk Blocks

Professor, Anaesthesiology,
Aichi University Hospital
37
03 Nerve Blocks: Pain Cliniacs
1. Stellate ganglion block

Indications
- Face or upper extremities shingles; postherpetic neuralgia.
- Complex regional pain syndrome
- Muscle-contraction headache
- Atypical facial pain
- The stellate ganglion is formed when the inferior cervical ganglion fuses
with the first and second thoracic ganglions. It is generally found at the first
thoracic vertebra level.
- As mentioned below, when administering a stellate ganglion block at the
sixth cervical vertebra level, since no stellate ganglion is present at the level,
the cervical sympathetic nerve trunk, middle cervical ganglion, and gray
communicating branch are blocked.
- At the sixth cervical vertebral level, the sympathetic nerve trunk, along with
the longus colli muscle and anterior scalene muscle, are covered by the
prevertebral layer. They are positioned anterolateral to the longus colli muscle.
- Since the vagus and recurrent nerves innervate the region in front of the
prevertebral layer, a sympathetic block can be administered more efficiently
by injecting a local anaesthetic behind the prevertebral layer under ultrasound
guidance, avoiding the complications associated with such nerve blocks.
Medial Lateral
Sternomastoid Common
muscle carotid artery
Thyroid
Longus colli muscle
Cervical transverse process
38
- Place the patient in the supine position and extend the neck region.
- Use either a micro-convex or high-frequency linear probe.
- At the level at which the sixth cervical transverse process is delineated,
firmly place the probe between the thyroid and common carotid artery to
move the common carotid artery to the lateral side, ensuring the pathway
for the block needle and shortening the distance from the skin to the longus
colli muscle.
- Using color Doppler imaging, ascertain the configuration of the vertebral
artery and vessels.
- Advance the block needle by the in-plane method or by the out-of-plane
method. Administer a local anaesthetic into the longus colli muscle posterior
to the prevertebral layer.
- The location of the needle tip cannot be ascer tained directly when
advancing the needle by the out-of-plane method. Estimate the location of
the needle tip based on tissue movements.
- When advancing the needle by the in-plane method, puncture from the
lateral side of the probe. Note that the thyroid may get in the way of the
block needle.
- Anaesthetic: 1% mepivacaine 5 ml. Adjust based on symptoms.
39
2. Cervical ganglion block

Indications
- Radicular diseases associated with cervical vertebral hernia.
- Upper extremity shingles and postherpetic neuralgia.
- Shoulder periarthritis.

- Anterior and posterior tubercles are present in the transverse process from
the third to sixth cervical vertebra. The transverse process is shaped like a
rain gutter.
- The cervical nerve root exiting from the intervertebral foramen passes
through this rain gutter to form either the cervical or brachial plexus.
- However, there is no anterior tubercle for the seventh cervical vertebra.
Such morphological features are useful for identifying individual cervical
vertebrae.
- The seventh nerve root along the vertebral artery innervates the region
anterior to the seventh cervical transverse process. The vertebral artery
enters the sixth cervical transverse foramen and ascends.
Lateral side Medial side
Sternocleidomastoid muscle
Common
Anterior scalene muscle carotid artery
Anterior tubercle of
Posterior 　　 transverse process
tubercle
Nerve root (C6)
40
- Place the patient in either the supine position (when inserting the block
needle from the anterior direction) or the lateral position (when inserting the
block needle from the posterior direction).
- Identify the target of block (nerve root) based on the shape of the transverse
process or by following the brachial plexus from proximal to center.
- The nerve root is circular/elliptical and hypoechoic. Once the nerve root is
detected between the anterior and posterior tubercles, place the needle
from either the lateral or medial side by the in-plane method to inject a local
anaesthetic around the nerve root.
- Anaesthetics: 0.25-0.5% mepivacaine or 0.1-0.25% ropivacaine 2 ml.
Sometimes 2 mg of dexamethasone may be mixed. Adjust accordingly
based on symptoms.
41
1. Iliac fascia block

Indications
- Thigh shingles and postherpetic neuralgia.
- Meralgia paresthetica.

- The technique of iliac fascia block administers a local anaesthetic between
the iliac fascia and iliopsoas muscle in the inguinal region and concurrently
blocks the femoral nerve, lateral femoral cutaneous nerve, and obturator
nerve innervating the compartment. However, in reality, the likelihood of
blocking the obturator nerve is regarded to be low.
- The femoral nerve innervates the anterior surface and medial side of the
thigh and the medial side of the lower leg. The lateral femoral cutaneous
nerve innervates the lateral side of the thigh.
Femoral 　
　 fascia
Iliac fascia
Femoral artery
Femoral nerve
Iliopsoas muscle
42
- Place the patient in the supine position.
- At 1 cm below the line connecting the anterior superior iliac spine and pubic
tubercle, position the probe parallel to the line to identify the femoral artery
and vein, femoral nerve, femoral fascia, iliac fascia, and iliopsoas muscle
(differentiating the femoral fascia from the iliac fascia by ultrasound is often
difficult).
- With the in-plane method, insert the block needle from the lateral side;
with the out-of-plane method, insert from the foot side. While confirming
movements of the needle tip and tissue, penetrating each of the femoral
and iliac fascias will result in a popping sensation. After confirming that the
needle tip is placed under the iliac fascia, inject a local anaesthetic.
- Anaesthetic: 0.25-0.5% mepivacaine or 0.1-0.25% ropivacaine 20 ml. Adjust
accordingly based on symptoms.
43
2. Psoas compartment block

Indications
- Anaesthesia during surgery involving the lower extremity (thigh or knee) and
postoperative analgesia
- Thigh shingles and postherpetic neuralgia.
- Lumbar and lower leg pain associated with such condition as spinal stenosis.

- Lumbar plexus: Consists of the first to fourth lumbar nerves and includes
the iliohypogastric/ilioinguinal nerve, genitofemoral nerve, lateral femoral
cutaneous nerve, femoral nerve, and obturator nerve.
- Inside the psoas muscle, the lumbar plexus innervates the fascia dividing the
anterior and posterior muscles.
- The spinal erector muscle lies posterior to the psoas muscle. The lumbar
quadratus muscle lies lateral to the psoas muscle.
Spinal erector
muscle
Lumbar quadratus
muscle
Medial side Lateral side
Psoas muscle
Lumbar vertebra Lumbar plexus
44
- Place the patient in either the lateral or prone position.
- Palpate the fourth lumbar spinous process and position the probe at the
process to identify it via ultrasound. Next, identify the articular process and
transverse process of the fourth lumbar vertebra. Move the probe to the
lateral side in a parallel manner to confirm the presence of the spinal erector
muscle lateral to the spinous process. Move the probe from the location at
which the transverse process has been confirmed to either the cranial or
caudal side. Ultrasound beams will pass through the transverse process
to identify the psoas muscle in the deep region and the lumbar quadratus
muscle lateral to the psoas muscle. The kidney and inferior vena cava are
visible further anterior to the psoas.
- With the in-plane method, insert the block needle from the lateral side of the
probe.
- In clinical settings, the lumbar plexus itself is not always visible. Within the
psoas muscle, the lumbar plexus is located in the dorsal third of the muscle.
Electric nerve stimulation is recommended for accurate nerve blocks.
- Anaesthetic: 0.2-0.5% mepivacaine or 0.1-0.25% ropivacaine 20 ml. Adjust

accordingly based on symptoms.
45
3. Lumbar facet block

(blocking the medial branch of the dorsal branch of the lumbar nerve)
Indications
- Treatment and diagnosis of intervertebral joint disorders

- The vertebral space consists of the anterior intervertebral disk and the
posterior left and right intervertebral joints.
- The medial branch of the posterior branch of each spinal nerve innervates
the intervertebral joint.
- Immediately after exiting the intervertebral foramen, the spinal nerve
bifurcates into anterior and posterior branches. The posterior branch
bifurcates into medial and lateral branches at the medial margin of the
intertransverse ligament.
- The medial branch innervates the posteromedial side between the transverse
process and superior articular process caudal to the vertebra and sends
articular branches to the intervertebral joint and the joint immediately below.
Lateral side
Articular
　process
Medial side
Transverse
process
46
- Position the probe parallel to the body axis along the spinal column to
identify a target lumbar vertebra.
- Rotate the probe 90 degrees to generate cross-sectional images of the
lumbar vertebra. Move the probe parallel to the block side to identify the
articular and transverse processes of the vertebra.
- Insert the block needle from the lateral side of the probe, advance the needle
to the groove formed by the articular and transverse processes, and inject a
local anaesthetic.
- Use 0.5-1% mepivacaine or 0.25-0.5% ropivacaine 1-2 ml. Adjust accordingly

based on symptoms.
47
03-3) Trunk Blocks
1. Intercostal nerve block

Indications
- Intercostal neuralgia.
- Chest shingles and postherpetic neuralgia.

- The intercostal nerve is an anterior branch of the thoracic nerve. Within the
costal groove, it innervates in the anterior direction below the intercostal
artery and vein.
- Around the costal angle, the intercostal nerve passes between the innermost
and internal intercostal muscles.
- Since the intercostal nerve, artery, and vein are hidden in the costal groove,
they usually are not visualised by ultrasound.
Intercostal Rib
muscle
Pleura
Lung
48
- Use either a linear probe or micro-convex probe.
- Identify a target intercostal space.
- Position the probe near the costal angle parallel to the body axis.
- The surface is hyperechoic, and ribs are visible as acoustic shadows. Confirm
the adjacent intercostal muscle and observe the pleura in the deep tissue.
- Differentiating the external and internal intercostal muscles by ultrasound is

often difficult.
- Advance the block needle from the caudal side by the in-plane method.
After advancing the needle to the rib, adjust the needle direction toward
the deep tissue and advance the needle by about 0.5 cm. Administer a local
anaesthetic into the costal groove.
- Anaesthetic: 0.5-1% mepivacaine or 0.25-0.5% ropivacaine 2 ml
Adjust accordingly based on symptoms.
49
03-3) Trunk Blocks
2. Thoracic paravertebral block

Indications
- Intercostal neuralgia.
- Chest shingles and postherpetic neuralgia.

- The paravertebral space is a cuneate space surrounded by the parietal
pleura in the anterior direction, the vertebral body in the medial direction,
and the rib and superior rib transverse ligament in the posterior direction.
- The paravertebral space includes the sympathetic trunk and the spinal
nerve exiting the intervertebral foramen.
- In the lateral side, the paravertebral space is connected to the intercostal
space. This means a local anaesthetic can spread inside the paravertebral
space in the craniocaudal direction, achieving a broad-range block.
However, if a local anaesthetic spreads along the intercostal space, the
range of the block may be limited to the level of needle insertion.
Medial side Lateral side
Thoracic Pleura
transverse
process
Lung
50
- Place the patient in either the prone or lateral position.
- Use either a linear or convex probe, depending on patient body type.
- The probe can be positioned either parallel or perpendicular to the spinal
column.
- Position the probe about 2.5 cm lateral to the spinous process of a target
spine level.
- When positioning the probe perpendicular to the spinal column, after
identifying the transverse process of a target thoracic vertebra, adjust the
direction of the probe slightly so that ultrasound beams enter between
transverse processes to visualise the pleura or cuneate paravertebral space.
Advance the block needle by the in-plane method from the lateral side of the
probe. Inject a local anaesthetic when the needle penetrates the superior
costotransverse ligament. In practice, since the superior costotransverse
ligament cannot always be confirmed, advance the needle tip as close to the
pleura as possible. On a trial basis, administer a local anaesthetic to push
forward the pleura to ensure that the needle tip is inside the paravertebral
space.
- Position the probe parallel to the spinal column to visualise the pleura
anterior to and between the transverse process of a few vertebrae. Insert
the block needle from either the cranial or foot side by the in-plane method
and administer a local anaesthetic once the needle tip is near the pleura.
Note that the transverse process can interfere with efforts to advance the
block needle into the paravertebral space.
- Use 0.5-1% mepivacaine or 0.25-0.5% ropivacaine 10 ml. Adjust accordingly
based on symptoms.
51
52
04
Future Developments
04-1) Epidural Block/Spinal Subarachnoid Block

04-2) 3D/4D

Professor, Anaesthesiology,
Aichi University Hospital
53
04-1) Epidural Block/Spinal Subarachnoid Block
Indications
- Confirm the direction, site, and depth of the epidural/subarachnoid puncture.

- Structures that can be confirmed by ultrasound: Spinous process, vertebral
arch, articular process, transverse process, vertebral body, yellow ligament,
and dura mater
- Particularly in children, the spinal cord and cauda equina may sometimes be
found within the medullary cavity.
- An ultrasound-guided epidural block is mostly administered as part of a
preliminary scan to confirm the distance from the skin to the dura mater
and to ascertain the feasibility of a puncture. Real-time ultrasound-guided
epidural punctures have been performed by researchers at many facilities,
but this procedure has not been established as clinical practice, due to the
absence of significant advantages.
Spinous process
Articular process
Transverse
process Dorsal dura
mater
54
- Use a low-frequency convex probe. Identify a target vertebra using
body-surface features. Position the probe along the body axis at the
lumbosacral junction to confirm the sacrum and fifth lumbar vertebra
and to identify the spinous process of the target vertebra.
- Position the probe perpendicular to the body axis to delineate the spinous
process at the center of the monitor and to confirm the articular and
transverse processes on both sides. Adjust the probe position in the
superoinferior direction slightly to allow ultrasound beams to pass between
the spinous processes and identify two hyperechoic linear structures in
front of the spinous process. The shallower one is the dorsal dura mater; the
deeper one is the ventral dura mater.
- Measure the distance from the skin to the dorsal dura mater. At a location
where the dura mater can be confirmed, mark the location for needle
insertion on the skin by inserting a marker between the probe and skin.
- Advance the block needle based on the distance from the marked insertion
site to the dura mater. In most cases, the distance to the dura mater during
puncture is greater than that measured by ultrasound.
55
04-2) 3D/4D
The most significant advantage of an ultrasound-guided nerve block is the

capacity to confirm locations of target nerves, the block needle, local anaesthetic
and surrounding anatomical structures in real-time. The most difficult task with
ultrasound-guided nerve blocks is delineating the block needle. The thickness of
the ultrasound beam is a mere 2 mm, and some degree of training is necessary
to accurately position the block needle using ultrasound beams.
To overcome these technical difficulties, ultrasound-guided techniques using

three-dimensional images have been closely studied. Past developments
involving three-dimensional image reconstruction by ultrasound has generally
occurred in relation to obstetrics and cardiovascular surgery. Ultrasound-guided
nerve blocks using three-dimensional images remove the need to align block
needles with ultrasound beams. In theory, this can be highly useful in capturing
the anatomical structures of target nerves and surrounding tissue in three
dimensions.
Here, 3D refers to a technique for reconstructing still three-dimensional images

using a special ultrasound probe capable of reconstructing three-dimensional
images. 4D refers to a technique for reconstructing three-dimensional videos in
real-time.
Three-dimensional images of sciatic nerve block (after local anaesthetic injection)
56
Despite reports of ultrasound-guided nerve blocks using 3D/4D techniques,
techniques have yet to be established. Since 3D/4D techniques originated in the
fields of obstetrics and cardiovascular surgery, probe frequency is low for nerve
blocks. Reconstructions of 4D images tend to have low frame counts per unit
of time, resulting in images that skip. In obstetrics and cardiovascular surgery,
targets tend to be surrounded by liquids with low attenuation rates, such as
amniotic fluid and blood, and boundaries can be clearly depicted. However
nerves are surrounded by tissue with similar ultrasound characteristics, such
as muscle and connective tissue, making it difficult to differentiate nerves from
other tissue. In any case, a special 4D ultrasound machine for nerve blocks is
needed when using 3D/4D in clinical settings.
57
www.gehealthcare.com
GE Healthcare Australia
Building 4B
21 South Street
Rydalmere, NSW 2116
Customer call center:

Australia 1300 722 229
New Zealand 0800 434 274
www.gehealthcare.com
Rev.1.0 00・00-00 (KM) CI D32A1-3

DOC1088750-02.12-EN-Asia Pacific Printed in China February 2012

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Anaesthesiology Ultrasound Handbook

Ultrasound-guided Peripheral Nerve Blocks

Dr. Gotaro Shiragami

Dr. Hiroyuki Fujiwara

1. Basics of ultrasound ………………………… 4

2. Injection methods ………………………… 6

02 Nerve Blocks: Surgery

1. Brachial plexus block: Interscalene approach ………………………… 10

2. Brachial plexus block: Supraclavicular approach ………………………… 12

3. Brachial plexus block: Subclavicular approach ………………………… 14

4. Brachial plexus block: Axillary approach ………………………… 16

02-2) Lower Extremity Blocks ………………………… 18

1. Femoral nerve block ………………………… 18

2. Lateral femoral cutaneous nerve block ………………………… 20

3. Obturator nerve block ………………………… 22

4. Sciatic nerve block: Subgluteal approach ………………………… 24

5. Sciatic nerve block: Anterior approach ………………………… 26

6. Sciatic nerve block: Popliteal approach ………………………… 28

02-3) Trunk Blocks ………………………… 30

1. Ilioinguinal nerve/ Iliohypogastric nerve block ………………………… 30

2. Rectal sheath block ………………………… 32

3. Transverse abdominus plane (TAP) block ………………………… 34

1. Stellate ganglion block ………………………… 38

2. Cervical ganglion block ………………………… 40

03-2) Lower Extremity Blocks ………………………… 42

1. Iliac fascia block ………………………… 42

2. Psoas compartment block ………………………… 44

3. Lumbar facet block

03-3) Trunk Blocks ………………………… 48

1. Intercostal nerve block ………………………… 48

2. Thoracic paravertebral block ………………………… 49

04-2) 3D/4D ………………………… 56

Dr. Gotaro Shiragami

Edited by Dr. Alwin Chuan

01-1) Ultrasound-Guided Peripheral Nerve Blocks

How perineural tissue is visualised

01-1) Ultrasound-Guided Peripheral Nerve Blocks

Electric nerve stimulation

02-1) Upper Extremity Blocks

Dr. Gotaro Shiragami

Edited by Dr. Alwin Chuan

1. Brachial plexus block: Interscalene approach

Anatomical and clinical points

Anterior scalene muscle

Common Middle scalene

2. Brachial plexus block: Supraclavicular approach

Anatomical and clinical points

Suprascapular or transverse cervical artery

3. Brachial plexus block: Infraclavicular approach

Anatomical and clinical points

Pleura Axillary vein

4. Brachial plexus block: Axillary approach

Anatomical and clinical points

Median nerve Axillary artery

Biceps muscle Ulnar nerve

1. Femoral nerve block

Anatomical and clinical points

2. Lateral femoral cutaneous nerve block

Anatomical and clinical points