Peripheral Nerve Blocks and Peri Operative Pain Relief 2nd Ed

Peripheral Nerve Blocks & Peri-Operative Pain Relief
Commissioning Editor: Michael Houston

Development Editor: Sharon Nash
Project Manager: Srikumar Narayanan
Design: Stewart Larking
Illustration Manager: Gillian Richards
Marketing Manager(s) (UK/USA): Richard Jones/Cara Jespersen
Peripheral
Nerve Blocks &
Peri-Operative
Pain Relief
Second Edition
Dominic Harmon FFARCS(I) FRCA
Consultant in Anaesthesia/Pain Medicine
Department of Anaesthesia and Pain Medicine
Mid-Western Regional Hospital and University of Limerick
Limerick, Ireland
Jack Barrett FFARCS(I) Dip. Pain Medicine

Consultant Anaesthetist
Department of Anaesthesia and Intensive Care Medicine
University College Cork
Cork University Hospital
Cork, Ireland
Frank Loughnane FCA(RCSI)

Consultant Anaesthetist
Cork, Ireland
Brendan Finucane FRCA FRCP(C)

Professor and Residency Program Director
Department of Anesthesiology and Pain Medicine
University of Alberta
Edmonton, Alberta, Canada
George Shorten FFARCS(I) FRCA MD PhD

Professor of Anaesthesia and Intensive Care Medicine
Cork, Ireland
© 2011, Elsevier Limited. All rights reserved.
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First edition 2004
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ISBN: 978-0-7020-3148-9
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Peripheral nerve blocks and peri-operative pain relief.—

2nd ed.
1. Nerve block. 2. Pain—Treatment.
I. Harmon, Dominic.
617.9′6—dc22
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Contents
Foreword to first edition ix
Foreword to second edition xi
Preface xiii
List of Contributors xv
Acknowledgements xvii
Part I: PRINCIPLES
1 Introduction 3
George Shorten
2 Regional anesthesia in perspective: history, current role, and the future 7
Frank Loughnane
3 Local anesthetics 11
Frank Loughnane
4 General indications and contraindications 19
Frank Loughnane
5 Complications, toxicity, and safety 31
Frank Loughnane
6 Peripheral nerve block materials 41
Frank Loughnane
7 Principles of ultrasound-guided regional anesthesia 47
Vladimir Alexiev · Dominic Harmon
8 Peripheral nerve blockade for ambulatory surgery 60
Stephen Mannion · Xavier Capdevila
9 Which block for which surgery? 72
Dora Breslin · Stewart Grant
10 Training in peripheral nerve blockade 82
Frank Loughnane
Part II: PERIPHERAL NERVE BLOCKS

11 Cervical plexus block 99
Dominic Harmon · Jack Barrett
12 Orbital blocks 105
John McAdoo
13 Wound local anesthetic infusions 112
Jack Barrett
14 Brachial plexus anatomy 117
Dominic Harmon
15 Interscalene block 121
v
Contents
16 Supraclavicular block 128

17 Suprascapular block 134
18 Vertical infraclavicular block 138
19 Axillary block 144
20 Midhumeral block 151
21 Elbow blocks 157
22 Wrist blocks 164
23 Lumbar and sacral plexus anatomy 171
Dominic Harmon
24 Posterior sciatic block 175
25 Anterior sciatic block 180
26 Femoral nerve block 185
27 Psoas block 192
28 Iliacus block 198
29 Lateral cutaneous nerve of thigh block 203
30 Popliteal block 207
31 Ankle block 215
32 Paravertebral block 224
33 Intercostal block 229
34 Transversus abdominis plane block 234
John McDonnell · Brian O’Donnell
35 Inguinal field block 239
Jack Barrett · Dominic Harmon
Index 245
vi
Contents list of video clips on expertconsult
Clip No Clip Title Video contributor(s) Length

0.1 Peripheral Nerve Stimulation: Technique 1 Dominic Harmon 00:04:59
0.2 Peripheral Nerve Stimulation: Technique 2 Dominic Harmon 00:06:48
11.1 Cervical plexus block: Surface Anatomy Dominic Harmon 00:02:58
11.2 Cervical plexus block: Cadaveric Anatomy Dominic Harmon 00:05:26
11.3 Cervical plexus block: Technique Dominic Harmon 00:03:25
12.1 Orbital blocks: Surface Anatomy John McAdoo 00:02:25
12.2 Orbital blocks: Cadaveric Anatomy John McAdoo 00:06:49
12.3 Orbital blocks: Peribulbar Technique John McAdoo 00:02:39
12.4 Orbital blocks: Retrobulbar Technique John McAdoo 00:05:11
12.5 Orbital blocks: Sub-Tenons Technique John McAdoo 00:03:27
15.1 Interscalene block: Surface Anatomy Dominic Harmon 00:01:59
15.2 Interscalene block: Cadaveric Anatomy Dominic Harmon 00:03:52
15.3 Interscalene block: Technique Dominic Harmon 00:02:06
16.1 Supraclavicular block: Surface Anatomy Dominic Harmon 00:01:15
16.2 Supraclavicular block: Cadaveric Anatomy Dominic Harmon 00:02:37
16.3 Supraclavicular block: Technique Dominic Harmon 00:02:02
17.1 Supraclavicular block: Surface Anatomy Dominic Harmon 00:00:33
17.2 Supraclavicular block: Cadaveric Anatomy Dominic Harmon 00:01:49
17.3 Supraclavicular block: Technique Dominic Harmon 00:01:10
18.1 Vertical infraclavicular block: Surface Anatomy Dominic Harmon 00:01:19
18.2 Vertical infraclavicular block: Cadaveric Anatomy Dominic Harmon 00:02:20
18.3 Vertical infraclavicular block: Technique Dominic Harmon 00:02:06
19.1 Axillary block: Surface Anatomy Dominic Harmon 00:02:44
19.2 Axillary block: Cadaveric Anatomy Dominic Harmon 00:02:11
19.3 Axillary block: Technique Dominic Harmon 00:01:47
20.1 Midhumeral block: Surface Anatomy Dominic Harmon 00:01:23
20.2 Midhumeral block: Cadaveric Anatomy Dominic Harmon 00:01:24
20.3 Midhumeral block: Technique Dominic Harmon 00:03:50
21.1 Elbow blocks: Surface Anatomy Dominic Harmon 00:01:45
21.2 Elbow blocks: Cadaveric Anatomy Dominic Harmon 00:03:19
21.3 Elbow blocks: Technique Dominic Harmon 00:03:36
22.1 Wrist blocks: Surface Anatomy Dominic Harmon 00:01:23
22.2 Wrist blocks: Cadaveric Anatomy Dominic Harmon 00:01:50
22.3 Wrist blocks: Technique Dominic Harmon 00:03:53
vii
Contents list of video clips on expertconsult
Clip No Clip Title Video contributor(s) Length

24.1 Posterior sciatic block: Surface Anatomy Dominic Harmon 00:02:22
24.2 Posterior sciatic block: Cadaveric Anatomy Dominic Harmon 00:01:53
24.3 Posterior sciatic block: Technique Dominic Harmon 00:01:39
25.1 Anterior sciatic block: Surface Anatomy Dominic Harmon 00:00:59
25.2 Anterior sciatic block: Cadaveric Anatomy Dominic Harmon 00:02:07
25.3 Anterior sciatic block: Technique Dominic Harmon 00:01:58
26.1 Femoral nerve block: Surface Anatomy Dominic Harmon 00:01:40
26.2 Femoral nerve block: Cadaveric Anatomy Dominic Harmon 00:02:02
26.3 Femoral nerve block: Technique Dominic Harmon 00:02:18
27.1 Psoas block: Surface Anatomy Dominic Harmon 00:00:55
27.2 Psoas block: Cadaveric Anatomy Dominic Harmon 00:01:59
27.3 Psoas block: Technique Dominic Harmon 00:02:01
28.1 Iliacus block: Surface Anatomy Dominic Harmon 00:00:56
28.2 Iliacus block: Cadaveric Anatomy Dominic Harmon 00:01:47
28.3 Iliacus block: Technique Dominic Harmon 00:01:28
29.1 Lateral cutaneous nerve of thigh block: Surface Anatomy Dominic Harmon 00:00:34
29.2 Lateral cutaneous nerve of thigh block: Cadaveric Anatomy Dominic Harmon 00:01:36
29.3 Lateral cutaneous nerve of thigh block: Technique Dominic Harmon 00:01:11
30.1 Popliteal block: Surface Anatomy Dominic Harmon 00:01:43
30.2 Popliteal block: Cadaveric Anatomy Dominic Harmon 00:03:05
30.3 Popliteal block: Technique Dominic Harmon 00:04:32
31.1 Ankle block: Surface Anatomy Dominic Harmon 00:01:37
31.2 Ankle block: Cadaveric Anatomy Dominic Harmon 00:03:08
31.3 Ankle block: Technique 1 Dominic Harmon 00:03:24
31.4 Ankle block: Technique 2 Dominic Harmon 00:03:30
32.1 Paravertebral block: Surface Anatomy Dominic Harmon 00:00:55
32.2 Paravertebral block: Cadaveric Anatomy Dominic Harmon 00:01:17
32.3 Paravertebral block: Technique Dominic Harmon 00:02:32
33.1 Intercostal block: Surface Anatomy Dominic Harmon 00:01:13
33.2 Intercostal block: Cadaveric Anatomy Dominic Harmon 00:01:37
33.3 Intercostal block: Technique Dominic Harmon 00:02:15
34.1 Transversus abdominis plane block: Cadaveric Anatomy Brian O’Donnell 00:01:04
34.2 Transversus abdominis plane block: Surface Anatomy Brian O’Donnell 00:01:08
34.3 Transversus abdominis plane block: TAP Block Technique Brian O’Donnell 00:01:42
35.1 Inguinal field block: Surface Anatomy Dominic Harmon 00:00:46
35.2 Inguinal field block: Cadaveric Anatomy Dominic Harmon 00:03:04
35.2 Inguinal field block: Technique Dominic Harmon 00:02:35
Total running time 02:46:52
viii
Foreword to first edition
Regional anesthesia has come to stay. Its development and training programs do not provide formal training in peri-
progress have been slow, principally because the anesthetist pheral blockade. Experienced clinicians and trainees must
must have an accurate knowledge of anatomy and a high both have access to anatomic sections and simulators,
degree of technical skill in order that the anesthesia may be allowing the proceduralist to explore the anatomical
safe and satisfactory, and that the operation not be delayed. relationships between nerves and related structures prior
These words by surgeon William J. Mayo opened the fore- to patient contact.
word to Gaston Labat’s Regional Anesthesia, its Technic and From this perspective, I have found the content, organiza-
Application.1 Published in 1922, Labat’s text focused on the tion, and multimedia components of Peripheral Nerve Blocks
peri-operative management of patients undergoing intra- and Perioperative Pain Reliefs both thorough and com-
abdominal, head and neck, and extremity procedures using prehensive. The authors present the superficial and deep
infiltration, peripheral, plexus, and splanchnic blockade anatomical relationships using text, line drawings, still pho-
(using recently introduced procaine); neuraxial techniques tographs, MR images, and video clips. The block techniques
were not widely applied at the time. themselves are depicted in still photographs and video
The art and science of regional anesthesia have progressed demonstrations, often with associated MR images of local
significantly over the last century, resulting in improved anesthetic distribution. Thus, the text and DVD-ROM com-
safety and increased success rates. The frequency of serious plement each other and provide the reader with a knowl-
complications related to neural blockade continues to edge base that builds on itself to describe safe, efficacious
decrease and is similar, if not superior, to that of general and efficient peripheral blockade.
anesthesia. Improved methods of neural localization and Labat1 concluded in his 1922 text, ‘Regional anesthesia is
imaging such as fluoroscopy, high-resolution ultrasound an art.’ Nearly a century later, Peripheral Nerve Blocks and
and stimulating catheters have facilitated accurate needle/ Perioperative Pain Relief characterizes the current state of the
catheter placement. Most importantly, prospective random- art (and science) of regional anesthesia. I applaud the
ized clinical investigations have demonstrated improved authors for their accomplishments.
outcomes for patients undergoing major surgical proce-
dures when regional anesthesia and analgesia is utilized. Terese T Horlocker MD
Thus, issues regarding safety, success rate, and efficacy have Professor of Anesthesiology
been addressed. Mayo Clinic College of Medicine
However, it is noteworthy that several of the early con- Rochester, MN, USA
cerns have changed little. For example, an understanding President
of anatomic relationships, neural innervation, and physio- American Society of Regional Anesthesia and Pain Medicine
logy remain paramount in the application of regional anes-
thetic and analgesic techniques. Many clinicians do not
have ready access to an anatomy laboratory, and classic
anatomical atlases were constructed by anatomists, not Reference
regional anesthesiologists, resulting in illustrations that
depict neural anatomy with the ‘wrong’ limb orientation 1. Labat G. Regional Anesthesia: Its Technic and Clinical
and/or cross-sectional view. Finally, the majority of resident Application. Philadelphia: W. B. Saunders; 1922.
ix
This page intentionally left blank
Foreword to second edition
In his classic text, Regional Anesthesia, Its Technic and Applica- Part II conclude with “clinical pearls”, the editors’ expert
tion1, Gaston Labat noted, “The practice of regional anes- advice in improving neural visualization and success rates
thesia is an art. It requires special knowledge of anatomy, or avoiding complications.
skill in the performance of its various procedures, experi- A major reason for the renewed interest in regional anes-
ence in the method of handling patients, and gentleness in thesia in the last decade is the use of ultrasound. In response,
the execution of surgical procedures.” Six years ago, Barrett the lead editor for this edition, Professor Dominic Harmon,
et al defined the contemporary “art” of peripheral regional himself an editor of a textbook on the perioperative appli-
techniques in Peripheral Nerve Blocks and Perioperative Pain cations of ultrasound, supplements each chapter in this
Relief. The field of regional anesthesia has made major new edition with practical and evidence-based advice on
advances in the intervening period. The editors of this up- how to incorporate ultrasound into the practice of peri-
to-date second edition once again present a practical guide pheral blockade. The additional images and subject matter
in the current application, performance, and management allow for second edition nearly 50% longer than the origi-
of peripheral nerve blocks. As with the first edition, the nal. As the practice of peripheral nerve block has expanded,
textbook is in two parts. Part I covers the history, pharma- so has the editors’ skill in providing a thorough and
cologic principles, and clinical applications of peripheral comprehensive foundation for safe, effective and efficient
nerve blockade as well as the materials and equipment. peripheral blockade.
New chapters on block selection, principles of ultrasound-
guided regional anesthesia and training in peripheral nerve Terese T Horlocker MD
blockade have been added. Professor of Anesthesiology
Each chapter in Part II addresses a single block and Professor of Orthopedics
includes original images depicting the surface (cadaveric Department of Anesthesiology
and volunteers) and internal (magnetic resonance and Mayo Clinic
ultrasound) anatomy, figures depicting the positions of the Rochester, MN, USA
patient and the proceduralist, as well as injectate spread
during peripheral blockade. The techniques are described
in detail, including needle redirection cues based on the Reference
associated bony, vascular, and neural structures. On the
accompanying website the anatomy and block technique 1. Labat G. Regional Anesthesia: Its Technic and clinical
are demonstrated “live” using video clips. The chapters in Application. Philadelphia, W. B. Saunders, 1922.
xi
Preface
The first edition of this textbook (2004) was born out of recognized experts in the field of ultrasound-guided PNB
a cadaver-based workshop on peripheral nerve blockade and supplemented each chapter in this new edition with
(PNB) offered each year since 2000 at Cork University practical advice and examples on how to use this modality
Hospital in Ireland. The intent was to provide a detailed to greatest effect. The intent is to provide an all-in-one
foundation upon which clinicians might develop their resource for the learner of PNB. That is not to say that by
expertise in PNB. The feedback which the editors have using this book one will become a competent practitioner
received suggests that the textbook with accompanying of PNB; rather, we hope that it will maximize any learner’s
multimedia elements was effective for that purpose. We benefit from the clinical learning opportunities afforded
have received many letters and communications explaining him or her. Specifically, each block is described in terms of
that it has become a well thumbed textbook, regularly on its relevant anatomy, its ultrasonographic anatomy and its
personal and departmental library shelves. clinical performance. We have tried to ensure that the
During the past six years, the practice of PNB has changed content is practical and evidence based.
greatly both in magnitude and nature. However, we believe We will be very grateful for your comments, suggestions
that certain fundamental principles still apply: a thorough or corrections, in particular those that point out how we
understanding of surface and internal anatomy is essential could have done better! We believe that this textbook and
for its safe and effective practice. Magnetic resonance images its accompanying Web site will be a useful companion to
are useful in acquiring this prerequisite anatomical knowl- you whether you intend to acquire or maintain competence
edge. Studied in conjunction with high resolution images in PNB.
of cadaver dissection, and of human volunteers, a learner
can visualize structures, their relations and the relevant George Shorten
surface anatomy. Crucially, this permits the learner to map
‘real’ or ‘visualized’ anatomy to the 2D renderings acquired
using an ultrasound probe.
The lead editor for this edition, Professor Dominic Reference
Harmon, has produced a widely acclaimed textbook on the
peri-operatiove applications of ultrasound.1 Using this 1. Harmon, D. Perioperative Diagnostic and
experience, he has gathered the expertise of internationally Interventional Ultrasound. Saunders; 2007.
xiii
List of Contributors
Vladimir Alexiev MD FCARCSI EDIC DESA Stephen Mannion MD MRCPI FCARCSI
Registrar in Anaesthesia and Intensive Care Consultant Anaesthetist
Department of Anaesthesia and Pain Medicine Department of Anaesthesiology
Mid-Western Regional Hospital Victoria University Hospital
Limerick Cork
Ireland Ireland
Dora Breslin MD John McAdoo MD

Consultant Anaesthetist/Senior Lecturer Consultant Anaesthetist
St Vincent’s University Hospital/University College Cork University Hospital
Dublin Cork
Ireland Ireland
Xavier Capdevila MD PhD John McDonnell MB MD FCARCSI

Professor of Anesthesiology and Critical Care Medicine, Consultant Anaesthetist
Head of Department Galway University Hospitals
Department of Anesthesiology and Critical Care Medicine Senior Clinical Lecturer in Anaesthesia,
Lapeyronie University Hospital and Montpellier School National University of Ireland, Galway
of Medicine Galway
Montpellier Ireland
France
Brian O’Donnell MB FCARCSI MSc
Stewart Grant MD Consultant Anaesthetist and Honorary Senior Lecturer
Professor of Anesthesiology BreastCheck & Cork University Hospital
Duke University Medical Center Cork
Durham, NC Ireland
USA
xv
Acknowledgements
The authors wish to acknowledge the following for their Misericordiae University Hospital, Dublin for all new
advice, support and hard work in assembling the material photography in the second edition.
contained in this book. Mr Tomás Tyner for still photography on the first edition
Contributing authors who added immensely to the and Mr Tony Perrott, Director of the Department of Audio-
second edition of this book. Visual Services at University College Cork, Ireland.
Professor John Fraher, Professor of Anatomy, University All the volunteers and patients who so willingly made
College Cork, Ireland for facilitating the preparation of themselves available to have the blocks performed on them
the cadaver dissections (Mr Paul Dansie) and allowing use for video production and the acquisition of MRI and ultra-
of his department for the video production of cadaver sound images.
anatomy. Theatre staff of the Mid-Western Regional Hospital,
Mr Aidan Maguire, Television Director for Video Produc- Limerick and Cork University Hospital, Cork. Dr Vladimir
tion, and his team comprising Dr Tony Healy, Mr Gerry Alexiev for proof reading.
Ryan, Mr Garry Finnegan and Mr Joseph Peake.
Mr Peter Murphy, Manager, Open MRI Centre, Cork for Dominic Harmon
producing, labeling and editing the MR images. The pro- Jack Barrett
prietors of the Open MRI Centre and the Victoria/South Frank Loughane
Infirmary Hospital, Cork, Ireland for use of their facility. Brendan Finucane
Dr Michelle Reardon, Lecturer in Anatomy, University George Shorten
College Cork, Ireland for her advice and assistance with 2010
both cadaver and MR anatomy.
Ms Florence Grehan for still photography on the
second edition; Director of Clinical Photography, Mater
xvii
PART I
Principles
PART I Principles
CHAPTER
1
Introduction
George Shorten
Within anesthetic practice, the role of regional anesthesia ulators and ultrasound for nerve localization and the use
– including peripheral nerve block – has expanded greatly of indwelling catheters for ‘continuous’ techniques.
over the past two decades. In 1998, a national survey dem-
onstrated that 87.8% of US anesthesiologists make use of
regional techniques.1 This widespread use arises in part The content
from the widely held belief (to some extent evidence-
based) that, at least in some settings, anesthetic techniques This publication comprises a textbook, atlas, and practical
that avoid general anesthesia offer real advantages in terms guide to peripheral nerve block, which presents material as
of patient outcome.2 For instance, Chelly and colleagues text and images, including video clips, magnetic resonance
have demonstrated clearly that continuous femoral infu- (MR) images, ultrasound images, still photographs, and
sion of ropivacaine 0.2% in patients undergoing total knee line drawings. It is probably best regarded and used as an
replacement provides better postoperative analgesia than educational tool.
epidural or patient-controlled analgesia. Critically, this The textbook is in two parts. Part I covers the history,
technique accelerated early functional recovery and was pharmacologic principles, and clinical applications of
associated with decreased duration of hospital stay, post- peripheral nerve blockade as well as the materials and
operative blood loss, and incidence of serious postopera- equipment currently in use. It also covers training in peri-
tive complications.3 pheral nerve blockade. In Part II, each chapter addresses a
A second reason that accounts for the recent increase in single block and describes its specific indications, relevant
peripheral nerve block practiced in developed countries is anatomy (including surface anatomy), and how the proce-
the greater proportion of surgical procedures carried out dure is performed. The anatomy is presented using photo-
as ‘day cases’. Regional anesthesia plays a fundamental graphs of cadaveric dissections and volunteers (for surface
role in the future of day case or ambulatory anesthesia, anatomy), MR images, ultrasound images, and sometimes
both as an intrinsic component of the anesthetic tech- line drawings. On the accompanying DVD-ROM, the
nique and for effective postoperative analgesia.4 Currently, anatomy and block technique are demonstrated using
60–70% of all surgical procedures performed in the USA video clips; ‘live’ anatomy and spread of injectate are
are day cases. It is likely that peripheral nerve block, used demonstrated using MR images. Chapters in Part II contain
appropriately in the ambulatory setting, decreases the time ‘clinical pearls’ intended to impart specific advice for
to discharge from hospital, improves patient satisfaction improving success rates or avoiding problems. Associated
and postoperative analgesia, facilitates rehabilitation, and with each chapter is a self-assessment section aimed at
results in fewer complications than conventional analgesic providing a means of evaluating both retention and com-
techniques. prehension of the information presented. This can be found
Third, the practice of peripheral nerve block has increased at the associated website.
because of advances in technique, equipment, and our We have carefully selected the blocks for inclusion as
understanding of how and when it is indicated. These those that are currently an established part of clinical
advances include the use of superior peripheral nerve stim- anesthetic practice. We have attempted to describe
©2011 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-0-7020-3148-9.00009-8
PART I Principles
those that will be of greatest interest and use to clinicians block is essential to ensure that a successful block is con-
learning or practicing peripheral nerve blockade today. For sistently and safely achieved. The anatomic material pre-
instance, although parasacral, subgluteal, popliteal, and sented comprises text, line drawings, still photographs,
other approaches have been described for block of the video clips, and MR images. Our suggestion is that the
sciatic nerve, we have opted to describe only the more relevant anatomy sections be read from the textbook with
widely practiced classic anterior and posterior approaches. immediate reference to the accompanying still images in
We have also excluded central neuraxial blocks (spinal and order to reinforce conceptualization of the structures. This
epidural techniques) and pediatric peripheral nerve blocks. represents the first step to forming a mental image or model
of the region. The second step entails playing the video clips
of cadaveric dissection from the DVD-ROM and revising the
The readership most likely to benefit still images, which are also displayed on the DVD-ROM for
convenience. The next step in learning the relevant anatomy
It is widely recognized that anesthetists are incompletely is to play the surface anatomy video clip, because this rep-
trained unless they are proficient in the performance of resents the bridge between the mental anatomic model that
peripheral nerve block.5 Anesthetists comprise the single has been formed and the block technique, displayed imme-
largest group of hospital doctors. Approximately 5% of all diately after the surface anatomy on each video clip.
physicians in the USA practice anesthesia. In some coun- Third, readers who wish to refresh their memory on a
tries, anesthesia is also practiced by nurse anesthetists. particular block, or commence learning about a new block,
The material contained in both the textbook and the should first read the appropriate chapter in the textbook
DVD-ROM will be of greatest use to those practicing or and then use the corresponding chapter in the DVD-ROM
learning anesthesia as a specialty. This group includes anes- to reinforce (using video clips and MR images) the informa-
thetists (anesthesiologists), anesthetic trainees, and nurse tion they have read.
anesthetists. Used in slightly different ways, this publica- Fourth, it is advisable that the self-assessment sections be
tion will provide a useful introduction to the practice of undertaken only after all the material on a particular block
peripheral nerve blockade, a means of preparing for exami- has been covered. The questions are designed to test both
nations (boards and fellowships), and a means of extend- retention of information about and understanding of
ing the range of practitioners’ techniques or refreshing them the relevant anatomy, technique, and clinical application
with regard to a particular technique that they have not of the block.
performed for some time. We have made no assumptions Finally, as readers may not be familiar with viewing
as to the background or experience of our readers. Therefore MR images, a brief outline of the equipment used, principles,
the techniques and practice are explained from first prin- and image characteristics is presented below. This is worth
ciples: anatomic, pharmacologic, and safety. Occasional reading before attempting to collate the MR images with
practitioners of peripheral nerve blockade – whether anes- either the cadaveric or surface anatomy images presented.
thetists, emergency medicine physicians, or surgeons – are
strongly advised to review Part I before moving to Part II
to learn how to perform a particular block. Magnetic resonance imaging
Equipment
How to use the content most effectively
We use MR images in this textbook and DVD-ROM because
First, it is important that readers who have little or no expe- of the excellent soft tissue contrast they provide, without
rience with peripheral nerve blocks – such as anesthetic exposing our volunteers to the ionizing radiation associated
trainees commencing the ‘regional’ or peripheral nerve with computerized tomography and X-ray. Using the com-
block module of their training program – learn the prin- bination of a strong magnetic field and radiofrequency
ciples underlying peripheral nerve blockade, outlined in pulses, magnetic resonance imaging (MRI) obtains a digi-
Part 1 of the textbook, before studying specific blocks. This tized image of an anatomic area.
is intended to avoid the risk of training or being trained as We used the Toshiba 0.35T OPART, open system.6 This
a technician. It is essential that peripheral nerve blocks be scanner uses superconducting technology and high-speed
performed only by a practitioner with a sound understand- gradients to produce high-quality images. The scanner was
ing of how neural blockade is pharmacologically induced. selected on the basis of its well-documented advantages;
This is to ensure that informed decisions are made regard- namely, that its open architecture allows comfortable vol-
ing the suitability of a patient for peripheral nerve blockade unteer positioning, easy access for injection, and prevents
or how best to treat a complication. problems associated with claustrophobia.7–9 A number of
Second, an understanding of the anatomy (surface land- transmit and receive coils were used, appropriate to the
marks, nerves, plexuses, and their relations) relevant to a anatomic area being scanned.
4
CHAPTER
Introduction 1
Physical principles Image characteristics

The images produced by MRI display contrast resolution There are a number of different sequences available to
between tissues, due to the differences in their T1 recovery MRI scanners. We used T1-weighted spin echo sequences
and T2 decay times. Tissues, at a subatomic level, are influ- primarily, supplemented by fat-saturated sequences.
enced by the magnetic field, which is both static and varying T1-weighted MR images show very good soft-tissue contrast
(gradients). Different tissues have different T1 recovery and and also show enhancement from Gd-based contrast agents.
T2 decay times, due to differences in their precessional As explained, due to differing relaxation times of fat and
rates. Fat has a very short T1 time and water a long T1 time, water on T1-weighted tissues, fat displays as high signal
such that fat displays as bright (high) signal and water (bright) and water displays as low signal (dark).10 In the
displays as dark (low) signal in T1-weighted images. For T2 images where contrast is displayed, the short relaxation
weighting, the time to echo must be long enough for the time of the Gd-based contrast agent enables the contrast to
T2 decay times of fat and water to differentiate, and when have high signal. On some images, the high signal of both
this occurs, fat has a shorter T2 time than water. fat and contrast may be similar, but by comparing with
In diagnostic MRI, contrast agents are used to enhance precontrast images and fat-saturated images it is possible to
the contrast between normal tissue and pathology. This is differentiate between the signals.
more important on T1-weighted images, where water and A number of sequences were performed for each region.
tumors demonstrate similar low-signal intensities. The use In some instances, image windowing and magnification
of contrast agents selectively affects the T1 and T2 times of were performed in order to clearly demonstrate the struc-
these tissues.10 We used contrast to imitate and visualize the tures. The images that best illustrate the anatomy and con-
degree of spread of local anesthetic and to highlight ana- trast spread were selected for inclusion in the atlas. As in
tomic structures. many clinical MR images, motion artifact is detectable in
some images. These have only been included if the image
has educational value despite the artifact.
Contrast agent
The contrast agent used is a gadolinium (Gd)-based agent; References
Gd is a paramagnetic material that has a positive effect on
the local magnetic field. When it is near water, which has 1. Hadzic A, Vloka JD, Kuroda MM, et al. The practice
long T1 and T2 times, it causes a change in the local mag- of peripheral nerve blocks in the United States: a
netic moment of the adjacent water molecules. This has the national survey. Reg Anesth Pain Med 1998;23:
effect of reducing the T1 relaxation time of water, which 241–246.
allows water to give higher signal intensity on T1-weighted 2. Mingus ML. Recovery advantages of regional
images. Thus Gd and other paramagnetic substances are compared with general anesthesia: adult patients.
known as T1 enhancement agents.11 J Clin Anesth 1995;7:628–633.
As a free ion, Gd is quite toxic and has a biological 3. Chelly JE, Greger J, Gebhard R, et al. Continuous
half-life of several weeks, the kidneys and liver demon- femoral nerve blocks improve recovery and outcome
strating greatest uptake. For this reason, Gd is aligned with of patients undergoing total knee arthroplasty.
a substance known as a chelate. The chelate works by Arthroplasty 2001;16:436–445.
attaching to eight of the nine free-binding sites of the
4. White PF, Smith I. Ambulatory anesthesia: past,
Gd molecule. This reduces Gd’s toxic effect because it
present and future. Int Anesthesiol Clin 1994;32:
facilitates faster excretion. The contrast agent that we
1–16.
used was gadopentetate dimeglumine (Magnevist), which
has the Gd molecule attached to a chelate called 5. Kopacz DJ, Bridenbaugh CD. Are anesthetic
diethylenetriaminepenta-acetic acid (DTPA). This pro- residencies failing regional anesthesia? Reg Anesth
duces the complex molecule Gd-DTPA and is a relatively 1993;18:84–87.
safe, water-soluble contrast agent. However, the addition 6. Toshiba Corp. MRI system, OPART, product
of a chelate affects the ability of the Gd to reduce the T1 information. Toshiba Corp, 1998.
recovery time of the adjacent tissue. Thus the use of a 7. Dworkin JS. Open field magnetic resonance imaging;
chelate must take into consideration the rate of uptake of system and environment. The technology and
the Gd-DTPA agent, the relative T1 recovery time of the potential of open magnetic resonance imaging.
tissue, and the safety of the complex.12 The contrast was Berlin: Springer-Verlag; 2000:45–56.
diluted to 1 : 250 in order to obtain the best signal. This 8. Kaufman L, Carlson J, Li A, et al. Open-magnet
level of dilution was selected following serial testing (on technology for magnetic resonance imaging. In:
‘phantoms’) using different degrees of dilution. Open field magnetic resonance imaging: equipment,
5
PART I Principles
diagnosis and interventional procedures. Berlin: 11. Muroff L. MRI contrast: current agents and issues.
Springer-Verlag; 2000:25–30. Appl Radiol 2001;30(8):8–14.
9. Spouse E, Gedroyc WM. MRI of the claustrophobic 12. Runge V. The safety of MR contrast media: a literature
patient: interventionally configured magnets. Br J review. Appl Radiol 2001;30(8):5–7.
Radiol 2000;73:146–151.
10. Westbrook C, Kaut C. MRI in practice. 2nd edn.
Oxford: Blackwell Science; 1998:252–258.
6
PART I Principles
CHAPTER
Regional anesthesia in perspective

2
history, current role, and the future
Frank Loughnane
The doctrine of specific energies of the senses, proclaimed of infiltration anesthesia, first with water and later with
by Johannes P. Mueller (1801–58) in 1826 – that it is the weak solutions of cocaine.11,12
nerves that determine what the mind perceives – opened Anesthesia as a specialty had not yet developed at this
up a new field of scientific thought and research into nerve stage, because the surgeon infiltrated as he operated. Victor
function.1 This led directly to the theory that pain is a sepa- Pauchet (1869–1936) was the first to point out a new tech-
rate and distinct sense, formulated by Moritz S. Schiff nique of regional anesthesia in which the procedure was
(1823–96) in 1858.2 Yet by 1845, Sir Francis Rynd (1801– carried out by an assistant in advance. In his 1914 textbook
61) had already delivered a morphine solution to a nerve L’Anesthésie Régionale, the first of its kind, he stated that
for the purpose of relieving intractable neuralgia (Box 2.1).3 he had witnessed Reclus’s technique at first hand 25 years
This appears to be the first documented nerve block as we before, and now wished to emphasize the novel concept of
understand the term today. Rynd, however, delivered his regional anesthesia and the emergence of anesthesia or
solution by means of gravity through a cannula. The first anesthesiology as a specialty.13
use of a syringe and hypodermic needle was not recorded Sydney Ormond Goldan (1869–1944), describing him-
until 10 years later, in 1855, by Alexander Wood (1817–84) self as an anesthetist, had published the first anesthesia
in Edinburgh.4 Wood used a graduated glass syringe and chart in 1900.14 It was designed for monitoring the course
needle to achieve the same end as Rynd. of ‘intraspinal cocainization’ and helped lay the foundation
Carl Koller (1857–1944) was an intern at the Ophthal- for the careful record-keeping that is a cornerstone of
mologic Clinic at the University of Vienna in 1884. He was modern anesthesia.
searching for a topical local anesthetic and, on the advice Gaston Labat (1876–1934) worked and trained under
of Sigmund Freud (1856–1939), studied cocaine. Follow- Pauchet in France in 1917–18.15 He learned much from
ing self-experimentation, Koller performed an operation for treating the casualties of World War I, and in 1922 pub-
glaucoma under topical anesthesia on September 11, 1884. lished the first edition of Regional Anesthesia: Techniques and
He immediately wrote a paper for the Congress of Ophthal- Clinical Applications, one of the first English-language texts
mology (held on September 15 of that year), which was on the subject.16 Many of his illustrations and techniques
published soon after in the Lancet.5 The remarkable effec- continue to have relevance today.
tiveness of cocaine as an anesthetic agent led to its immedi- On September 29, 1920, Labat arrived at the Mayo Clinic,
ate widespread use in this area.6,7 Rochester, Minnesota, to teach regional anesthesia to the
In the same year as Koller’s achievement, 1884, William clinic’s surgeons. From his brief 9-month period there and
Stewart Halsted (1852–1922) performed the first docu- following tenure at Bellevue Hospital, New York University,
mented brachial plexus anesthetic under direct vision at he was to have a major influence on the development of
Johns Hopkins,8 although it was 1911 before Hirschel and the specialty of anesthesia in the USA.17 His influence on
Kulenkampff performed the first percutaneous axillary and practitioners such as John Lundy, Ralph Waters, and Emory
supraclavicular brachial plexus blocks.9,10 By the 1890s, Carl Rovenstine – pioneers in the development of the specialty
Ludwig Schleich (1859–1922) in Germany and Paul Reclus – was substantial, and the American Society of Regional
(1847–1914) in France were seriously writing on the subject Anesthesia was initially to have been named after him.18
DOI: 10.1016/B978-0-7020-3148-9.00010-4
PART I Principles
Box 2.1 Box 2.2

Medical history: the first hypodermic injection Development of regional anesthesia
18th May 1844 1826 Mueller: doctrine of specific energies of the senses
She thought the eye was being torn out of her head, and her 1845 Rynd: first nerve block
cheek from her face; it lasted about two hours, and then sud- 1855 Wood: needle and syringe
denly disappeared on taking a mouthful of ice. She had not 1858 Schiff: pain defined as a specific sense
had a return for three months, when it came back even worse 1884 Koller: cocaine used for topical anesthesia
than before, quite suddenly, one night on going out of a warm Halsted: first brachial plexus block
room into the cold air. On this attack she was seized with chilli- 1890 Schleich & Reclus: infiltration anesthesia
ness, shivering, and slight nausea; the left eye lacrimated pro- 1900 Goldan: anesthesia charts
fusely, and became red with pain; it went in darts through her 1911 Hirschel & Kulenkampff: percutaneous brachial
whole head, face, and mouth, and the paroxysm lasted for plexus block
three weeks, during which time she never slept. She was bled Stoffel: galvanic current applied to nerve
and blistered, and took opium for it, but without relief. It 1914 Pauchet: L’Anésthesie Régionale
continued coming at irregular intervals, but each time more 1922 Labat: Regional Anesthesia: Techniques and
intense in character, until at last, weary of her existence, she Clinical Applications
came to Dublin for relief. 1923 American Society of Regional Anesthesia founded
On the 3rd of June a solution of fifteen grains of acetate of 1930 Labat: posterior approach to the stellate ganglion
morphia, dissolved in one drachm of creosote, was introduced 1939 Rovenstine & Wertheim: cervical plexus block
to the supra-orbital nerve, and along the course of the tempo- 1940 Patrick: current supraclavicular brachial plexus
ral, malar, and buccal nerves, by four punctures of an instru- technique
ment made for the purpose. In the space of a minute all pain 1946 Ansboro: continuous brachial plexus block
(except that caused by the operation, which was very slight) 1954 Moore: paratracheal approach to stellate ganglion
had ceased, and she slept better that night than she had for 1958 Burnham: axillary brachial plexus perivascular
months. After an interval of a week she had a slight return of technique
pain in the gums of both upper and under jaw. The fluid was 1964 Winnie & Collins: subclavian brachial plexus block
again introduced by two punctures made in the gum of each 1970 Winnie: interscalene brachial plexus block
jaw, and the pain disappeared. 1973 Montgomery, Raj: nerve stimulator in
contemporary practice
Francis Rynd (1801–61) 1993 Collum, Courtney: lateral popliteal approach to
FRCSI 1830; appointed Surgeon to the Meath Hospital 1836
the sciatic nerve
From Rynd 1845.3
1995 Kilka: vertical infraclavicular brachial plexus block
The American Board of Anesthesiology was formed in Continuous peripheral nerve blocks using catheters have
1938 and held its first written examinations in March 1939. been in use since 1946.23 They have been shown to provide
Here, Labat’s legacy continued. In the anatomy section all effective postoperative analgesia, be opioid-sparing, and
five questions related to regional anesthesia blocks; two of result in improved rehabilitation and high patient satisfac-
the five pharmacology questions dealt with local anesthet- tion.24–26 With refining of the techniques over the interven-
ics in regional anesthesia; and one of the pathology ques- ing half-century, a number of clinicians have used them
tions dealt with regional anesthesia.19 with great effectiveness. To date, however, their use has
Developments continued in the subspecialty through the been largely confined to inpatients because worries about
20th century (see Box 2.2) to the point where, in 1980, a motor weakness, patient injury, catheter migration, and
survey of American anesthesiology residency programs local anesthetic toxicity have persisted. Concurrently, up to
reported the use of regional anesthesia in 21.3% of cases, in 70 or 80% of patients complain of severe pain following
1990 in 29.8% of cases, and in 2000 in 30.2% of cases.20–22 ambulatory surgery, requiring continued opioid medica-
The majority of these cases, however, involve obstetric anes- tion for up to a week in many cases.27,28
thesia or pain medicine, which has raised concern in some In the early 2000s, a number of authors reported the use
quarters as to the future place of peripheral nerve blockade of continuous peripheral nerve catheters in the ambulatory
in peri-operative anesthetic practice. This future, indeed, setting with a high degree of success, few complications,
may lie in the areas of acute pain management and patient and good levels of patient acceptance and satisfaction.29–32
satisfaction. As these techniques are still in their infancy, a number of
8
CHAPTER
Regional anesthesia in perspective – history, current role, and the future 2
special precautions were taken in these studies to ensure 5. Koller C. On the use of cocaine for producing
safety in the home environment. In addition, as the early anaesthesia on the eye. Lancet 1884;2:990–992.
pioneers had to defend their practice, it is certain these new 6. Hepburn NJ. Some notes on hydrochlorate of
pioneers will have to do likewise with these new develop- cocaine. Med Rec (NY) 1884;26:534.
ments. Further research will likely define the indications 7. Bull CS. The hydrochlorate of cocaine as a local
and limitations of this technology. anaesthetic in ophthalmic surgery. NY Med J
Long-acting peripheral nerve block has been used with a 1884;40:609–612.
high degree of efficacy, safety, and satisfaction in the ambu- 8. Halsted WS. Surgical papers. Baltimore: Johns
latory setting, and is practiced by many anesthetists.33,34 Hopkins Press; 1925:167.
Single-injection extended-duration (72h) local anesthetic
9. Hirschel G. Anaesthesia of the brachial plexus for
agents have been heralded for many years.35 When, and if,
operations on the upper extremity. Med Wochenschr
they become a reality we may see a rapid expansion in the
1911;5:1555–1960.
use of regional anesthetic techniques as well as the resur-
rection of the original infiltration techniques as practiced 10. Kulenkampff D. Die Anasthesia des plexus brachialis.
by Schleich and Reclus. Zentralbl Chir 1911;38:1337.
The concept of patient satisfaction has been often dis- 11. Schleich CL. Zur Infiltrations anasthesie.
missed as a parameter too difficult to measure. Unfortu- Therapeutisch Monatshefte 1894;8:429.
nately, the lack of an accepted model of patient satisfaction 12. Reclus P. Analgésie locale par la cocaine. Rev Chir
has hindered progress.36 In recent years, however, a few 1889;9:913–916.
authors have described the development of global measure- 13. Pauchet V, Sourdat P. L’Anésthesie Régionale. Paris:
ment tools and psychometrically constructed question- Octave Doin et Fils, Editeurs; 1914.
naires that produce reliable results; these tools have been 14. Goldan SO. Intraspinal cocainization for surgical
applied prospectively in large patient populations.37,38 anaesthesia. Phila Med J 1900;6:850–853.
Parameters such as improved pain relief and reduced post-
15. Brown DL, Winnie AP. Biography of Louis Gaston
operative nausea and vomiting are some of the factors influ-
Labat, MD. Reg Anesth 1992;22:218–222.
enced positively by regional anesthesia, and these are also
indicators of high patient satisfaction. It can be said that 16. Labat G. Regional anesthesia: techniques and clinical
patient satisfaction has become an important indicator of applications. Philadelphia: WB Saunders; 1922.
quality of medical care and an important endpoint in out- 17. Bacon RD, Gaston Labat, John Lundy, Emery
comes research.39 Rovenstine, and the Mayo Clinic. The spread of
Ultrasound has been used over the last 15 years to facili- regional anesthesia in America between the World
tate peripheral nerve blockade. The Vienna group, includ- Wars. J Clin Anesth 2002;14:315–320.
ing Drs Kapral and Marhofer, were early advocates. 18. Betcher AM, Ciliberti PM, Wood PM, et al. The
Ultrasound allows real-time identification of nerves and jubilee year of organized anesthesia. Anesthesiology
observation of appropriate local anesthetic spread around 1956;17:226–264.
nerves. The popularity of ultrasound guidance has grown 19. Bacon DR, Darwish H, Emory A. To define a
enormously with improved block success and decreased specialty: a brief history of the American Board of
performance time. Anesthesiology’s first written examination. J Clin
Anesth 1992;4:489–497.
20. Bridenbaugh L. Are anesthesia resident programs
failing regional anesthesia? Reg Anesth 1982;7:
References 26–28.
21. Kopacz DJ, Bridenbaugh LD. Are anesthesia residency
1. Riese W, Arrington GE Jr. The history of Johannes programs failing regional anesthesia? The past,
Muller’s doctrine of the specific energies of the senses: present, and future. Reg Anesth 1993;18:84–87.
original and later versions. Bull Hist Med 22. Kopacz DJ, Neal JM. Regional anesthesia and pain
1963;37:179–183. medicine: residency training–the year 2000. Reg
2. Dallenbach KM. Pain: history and present status. Am Anesth Pain Med 2002;27:9–14.
J Psychol 1939;52:331. 23. Ansboro F. Method of continuous brachial plexus
3. Rynd F. Neuralgia – introduction of fluid to the block. Am J Surg 1946;71:716–722.
nerve. Dublin Med Press 1845;13:167–168. 24. Selander D. Catheter technique in axillary plexus
4. Wood A. New method of treating neuralgia by the block. Acta Anaesth Scand 1977;21:324–329.
direct application of opiates to the painful points. 25. Dahl J, Christiansen C, Daugaard J, et al. Continuous
Edinb Med Surg J 1855;82:265–281. blockade of the lumbar plexus after knee surgery–
9
PART I Principles
postoperative analgesia and bupivacaine plasma 32. Grant SA, Nielsen KC, Greengrass RA, et al.
concentrations. A controlled clinical trial. Anaesthesia Continuous peripheral nerve block for ambulatory
1988;43:1015–1018. surgery. Reg Anesth Pain Med 2001;26:209–214.
26. Capdevila X, Barthelet Y, Biboulet P, et al. Effects 33. Klein SM, Nielsen KC, Greengrass RA, et al.
of perioperative analgesic technique on the Ambulatory discharge after long-acting peripheral
surgical outcome and duration of rehabilitation nerve blockade: 2382 blocks with ropivacaine. Anesth
after major knee surgery. Anesthesiology 1999;91: Analg 2002;94:65–70.
8–15. 34. Klein SM, Pietrobon R, Nielsen KC, et al. Peripheral
27. Chung F, Mezei G. Adverse outcomes in ambulatory nerve blockade with long-acting local anesthetics: a
anesthesia. Can J Anesth 1999;46:R18–R26. survey of the Society for Ambulatory Anesthesia.
28. McHugh GA, Thoms GMM. The management of pain Anesth Analg 2002;94:71–76.
following day-case surgery. Anaesthesia 35. Klein SM. Beyond the hospital: continuous peripheral
2002;57:270–275. nerve blocks at home [editorial]. Anesthesiology
29. Ilfeld B, Morey T, Enneking F. Continuous 2002;96:1283–1285.
infraclavicular block for postoperative pain control 36. Wu CL, Naqibuddin M, Fleischer LA. Measurement of
at home: a randomized double-blind placebo- patient satisfaction as an outcome of regional
controlled study. Anesthesiology 2002;96:1297– anesthesia and analgesia: a systematic review. Reg
1304. Anesth Pain Med 2001;26:196–208.
30. Ilfeld BM, Morey TE, Wang DR, et al. Continuous 37. Myles PS, Williams DL, Hendrata M, et al. Patient
popliteal sciatic nerve block for postoperative pain satisfaction after anaesthesia and surgery: results of a
control at home: a randomized, double-blinded, prospective study of 10,811 patients. Br J Anaesth
placebo-controlled study. Anesthesiology 2000;84:6–10.
2002;97:959–965. 38. Tong D, Chung F, Wong D. Predictive factors in
31. Rawal N, Allvin R, Axelsson K, et al. Patient- global and anesthesia satisfaction in ambulatory
controlled regional analgesia (PCRA) at home. surgical patients. Anesthesiology 1997;87:856–864.
Controlled comparison between bupivacaine and 39. Schug SA. Patient satisfaction–politically correct
ropivacaine brachial plexus analgesia. Anesthesiology fashion of the nineties or a valuable measure of
2002;96:1290–1296. outcome? Reg Anesth Pain Med 2001;26:193–195.
10
PART I Principles
CHAPTER
3
Local anesthetics
Frank Loughnane
The peripheral nerve Ionic basis of conduction
Applied anatomy A special membrane protein, the Na+–K+ ATPase pump, is

responsible for the transmembrane concentration gradient
The typical nerve cell has been traditionally described in of these ions peculiar to nerve cells. It transports sodium
terms of having a cell body (perikaryon), multiple den- out of the cell and potassium into it.3 At rest, the mem-
drites, and a single axon (Fig. 3.1). Sensory neurons are branse is selectively permeable to K+, resulting in an efflux
classified as unipolar; that is, they have an axon that divides of positive charge. Thus, the interior of the cell is negatively
to extend a branch to both the spinal cord and the periph- charged relative to the exterior; this resting membrane
ery. Motor neurons are classified as multipolar because, in potential is in the order of 70–80 mV. Because of its chemi-
addition to an axon, they possess many dendrites. Impulses cal and electrical gradient, there is a tendency for Na+ to
arriving via the dendrites and cell body are integrated at the enter the cell.
axon hillock, a specialized area of the cell body. Summa- Temporal and spatial summation of excitatory and
tion of excitatory and inhibitory impulses occurs at the inhibitory potentials occurs at the axon hillock. Small net
axon hillock and determines whether impulses are gener- depolarizations of 15–20 mV will raise the membrane
ated or not. potential to −55 mV, resulting in a voltage-dependent
The axon is always enclosed within a nutriprotective opening of Na+ channels and a rapid change in transmem-
Schwann cell envelope. Most are further invested in a brane potential to +40 mV.4–6 This is shortly followed by
myelin sheath formed by a single Schwann cell wrapped the opening of K+ channels, and the subsequent outward
many times around the axon and interrupted periodically flow of K+ returns the membrane potential to normal and
at the nodes of Ranvier. Many unmyelinated nerves, on the beyond (the refractory period where it is more difficult to
other hand, may have their axons enclosed within the folds stimulate the nerve).3 The Na+−K+ pump then serves to
of a single Schwann cell (Fig. 3.2). restore the chemical gradient to its initial state. These
The nerve cell membrane, in common with all cells of the changes in transmembrane potential account for the
body, comprises a phospholipid bilayer traversed by pro- familiar action potential (Fig. 3.4). The electrical changes
teins that selectively regulate the influx and efflux of ions occurring during the action potential serve to open adja-
and molecules, act as hormone and transmitter receptors, cent voltage-dependent Na+ channels, and so the action
are involved in cell-to-cell interactions, and enhance the potential is propagated along the axon. Because the area
structural integrity of the membrane (Fig. 3.3). It is the immediately preceding the action potential is in the refrac-
specialized nature of some of these proteins that is respon- tory period, the action potential is propagated in one
sible for the unique character of nerve cells.2 direction only.
DOI: 10.1016/B978-0-7020-3148-9.00011-6
PART I Principles
Interneuron Dorsal root Schwann cell Schwann Node of

(multipolar) ganglion cytoplasm cell nucleus Ranvier
Sensory neuron (unipolar)

Axon
A
Sensory receptor
Schmidt-Lanterman cleft Myelin
Effector (smooth muscle)
Effector (blood vessel)
Postganglionic Myelinated axon Schwann cell nucleus

autonomic neuron
Schwann cell cytoplasm
Sympathetic Axon
Motor neuron Preganglionic ganglion
(multipolar) autonomic neuron Myelin
B
Figure 3.1 The nerve cell. Sensory neuron with a cell body (perikaryon)
and an axon with long peripheral and short central branches (unipolar
A Schwann cell and its
nerve cell); interneuron with numerous dendrites, a cell body, and one
group of unmyelinated axons
short axon (multipolar nerve cell); motor neuron with a great many
dendrites, a cell body, and a long peripheral axon (multipolar). (From
Ref. 1, Strichatz GR. Neural Physiology and Local Anesthetic Action. In: Schwann
Cousins MJ, Bridenbaugh PO (eds). Neural blockade in clinical anesthe- cell nucleus
sia and management of pain, 3rd edn. Philadelphia: © Lippincott-Raven;
1998.)
Axons
C Schwann cell cytoplasm
Structure and function of local Figure 3.2 The axon. Myelinated axon in longitudinal section (A),
showing the relation of the myelin sheath to the nodes of Ranvier, and
anesthetics transverse section (B), showing how the Schwann cell wraps around
one axon many times to form the multiple layers of the myelin sheath.
Local anesthetics consist of a lipophilic aromatic ring con- A Schwann cell and its group of unmyelinated axons (C); many unmy-
nected by a hydrocarbon chain to a hydrophilic tertiary elinated axons are embedded in the folds of a single Schwann cell.
amine (Fig. 3.5). The lipophilic moiety is responsible for (From Ref. 1, Strichatz GR. Neural physiology and local anesthetic action.
the anesthetic activity of the molecule. The drugs are clas- In: Cousins MJ, Bridenbaugh PO (eds). Neural blockade in clinical anes-
thesia and management of pain, 3rd edn. Philadelphia: © Lippincott-
sified as amide or ester local anesthetics based on the nature
Raven; 1998.)
of the bond linking the hydrocarbon chain and the aro-
matic ring. The ester drugs are rapidly hydrolyzed by plasma
and other esterases,8–12 and have been associated with aller-
gic and hypersensitivity reactions linked to their breakdown
product para-aminobenzoic acid.13 In contrast, amides are
relatively stable compounds, are metabolized in the liver, tions. Thus, local anesthetics will more readily bind Na+
and allergic reactions to them are exceedingly rare. The channels of stimulated or active nerves.
comparative pharmacology of local anesthetics is shown in Two possible binding sites for local anesthetics have been
Table 3.1. identified on the Na+ channel.15,18 The first site is thought
Local anesthetics produce conduction blockade through to be responsible for phasic block and is situated near the
reversible inhibition of Na+ channel function.15,16 Physio- channel pore. Binding and unbinding from this site is rela-
logical studies have demonstrated that local anesthetics tively slow. The second site is on the inner aspect of the
inhibit stimulated channels more readily than resting chan- channel in the hydrophobic center of the membrane.
nels; this is known as phasic block and tonic block, respec- Binding and dissociation at this site is rapid.
tively.17 The modulated receptor hypothesis has been
proposed to explain these features.18,19 It is based on the
fact that Na+ channels pass through various states during Pharmacodynamics
membrane depolarization. They begin in the resting state
Local anesthetics are poorly water-soluble bases and
(R), pass through an intermediate closed form (C), to reach
are therefore prepared as hydrochloride salts. The ionized
an open form (O), and then close to reach an inactivated
and non-ionized forms of local anesthetics exist in
state (I). According to the modulated receptor hypothesis,
equilibrium:
local anesthetics have greater affinity for Na+ channels in
the O and I configurations than in the C and R configura- B + H+ BH+
12
CHAPTER
Local anesthetics 3
Carbohydrate
R O I
Membrane +40
Lipid potential
bilayer (mV) 0
-70
0 1 2
ms
Integral protein Peripheral protein Integral protein Cytoplasm
outward
Figure 3.3 The axonal membrane. A phospholipid bilayer traversed by
proteins. Carbohydrate molecules attached to proteins and lipids on the
extracellular surface of the membrane form a ‘cell coat’. The lipid bilayer
consists of densely packed phospholipids. Integral proteins and periph-
Ionic current 0
eral proteins only on the cytoplasmic surface are associated with enzy-
matic and receptor functions. (From Strichatz GR. Neural Physiology and
Local Anesthetic Action. In Cousins MJ, Bridenbaugh PO (eds). Neural
inward
blockade in clinical anesthesia and management of pain, 3rd edn.
Philadelphia: © Lippincott-Raven; 1998.)
Their ratio is given by the Henderson–Hasselbach

IK+
equation:
Ii
pKa = pH − [B].[BH+ ] INa+
Both the ionized and non-ionized forms can inhibit Na+

channels.20–23 The observations that tertiary amine local
Figure 3.4 A propagating action potential and the membrane cur-
anesthetics are more potent when applied externally at an
rents that produce it. See text for details. IK+, outward K+ current; INa+,
alkaline pH, or applied directly internally, suggest that the inward Na+ current; Ii, net ionic current across the membrane. (From
neutral form of the local anesthetic traverses the mem- Strichatz GR. Neural Physiology and Local Anesthetic Action. In: Cousins
brane, where it assumes its ionized form once again to MJ, Bridenbaugh PO (eds). Neural blockade in clinical anesthesia and
become active at the internal aspect of the Na+ channel.24 management of pain, 3rd edn. Philadelphia: © Lippincott-Raven; 1998.)
Following injection, the alkaline pH of the tissues releases
the base:
B.HCl + HCO3−B + H2 CO3 + Cl− CH3
C2H5
Physiochemical properties of local anesthetics NHC CH2 CH2 N
O C2H5
Ionization
CH3
The degree of ionization depends on the pKa of the agent Lipophilic Intermediate Hydrophilic
and the ambient pH. The pKa is defined as the negative chain
logarithm of the dissociation constant (Ka) of the conjugate Figure 3.5 Structure of local anesthetics. Local anesthetics comprise a
acid. It is equal to the pH at which the local anesthetic is lipophilic and a hydrophilic portion separated by a connecting hydro-
50% ionized. The greater the pKa of the base, the smaller carbon chain. (From Ref. 7, Stoelting RK. Pharmacology and physiology
the proportion existing in its non-ionized form at any pH, in anesthetic practice. 2nd edn. Philadelphia: © JB Lippincott; 1991.)
and so the slower the speed of onset.25,26
Lipid solubility in general, high lipid solubility is associated with increased

The lipid solubility of local anesthetics may be expressed in potency and duration of effect.26,27
terms of their water:oil partition coefficient. A high coeffi-
cient indicates a high degree of lipid solubility and ready Protein binding
penetration of nerve fibers. While balanced by the high The duration of action of local anesthetics is related to their
fraction of drug that is therefore in the non-ionized state, degree of protein binding. The bound fraction constitutes
13
PART I Principles
Table 3.1 Comparative pharmacology of local anesthetics

Classification for Duration after Maximum single
(adult, mg)* Potency Onset infiltration (min) dose infiltration
Esters
Procaine 1 Slow 45–60 500
Chloroprocaine 4 Rapid 30–45 600
Tetracaine 16 Slow 60–180 100 (topical)
Amides
Lidocaine 1 Rapid 60–120 300
Mepivacaine 1 Slow 90–180 300
Bupivacaine 4 Slow 240–480 175
Etidocaine 4 Slow 240–480 300
Prilocaine 1 Slow 60–120 400
Ropivacaine† – – – –
Fraction nonionized (%)
Toxic plasma concentration Protein
Classification (µg/ml) pK pH 7.2 pH 7.4 pH 7.6 binding (%)
Esters
Procaine – 8.9 2 3 5 6
Chloroprocaine – 8.7 3 5 7 –
Tetracaine – 8.5 5 7 11 76
Amides
Lidocaine >5 7.9 17 25 33 70
Mepivacaine >5 7.6 28 39 50 77
Bupivacaine ∼1.5 8.1 11 15 24 95
Etidocaine ∼2 7.7 24 33 44 94
Prilocaine >5 7.9 17 24 33 55
Ropivacaine† >4 8.1 – – 94 –
Volume of Clearance Elimination half-time
Classification Lipid solubility distribution (L) (L/min) (min)
Esters
Procaine 0.6 – – –
Chloroprocaine – – – –
Tetracaine 80 – – –
Amides
Lidocaine 2.9 91 0.95 96
Mepivacaine 1.0 84 9.78 114
Bupivacaine 28 73 0.47 210
Etidocaine 141 133 1.22 156
Prilocaine 0.9 – – –
Ropivacaine† – – – –
*Use only as a guideline; dose may be increased if solution contains epinephrine.
†
Resembles bupivacaine
(From Covino & Vassallo 1976,14 with permission of Grune and Stratton.)
14
CHAPTER
Local anesthetics 3
a functional reservoir that is released as the free drug is

distributed or eliminated. Because it is only the unbound
fraction of drug that is active, a high degree of protein Mepivacaine 8
(mg/mL)
binding will also result in a slower onset rate.28
6
4
Pharmacokinetics
2
Local distribution
The local distribution of local anesthetics is affected by the 0
2% 1% 2% 2% 2% 1% 2% 1% 1% 1% 2% 1% 1% 1%
physiochemical properties of the agent; the site of injection; IC IC C E C C IC IC BP SF E SF BP C
the volume, mass, and concentration injected; and the pres-

solution without epinephrine
ence or absence of vasoconstrictor substances.
solution with epinephrine
The mass movement or bulk flow of an agent is a physical
process and as such depends on the volume of drug injected,
the rate of injection, and the physical barrier of the sur- Figure 3.6 Systemic absorption of mepivacaine in humans after
rounding fibrous and fatty tissue. various regional block procedures as indicated by mean (± SEM)
Fick’s Law explains the relations between the various maximum plasma drug concentrations. IC: intercostal block; C: caudal
factors affecting diffusion of a substance through a block; E: epidural block; BP: brachial plexus block; SF: sciatic or femoral
membrane: block; w/o: solution without epinephrine; w: with epinephrine. 1 : 200
000 (shaded). (From Tucker et al 1972,29 with permission.)
dQ dT = D.A.K.∆C δ
where dQ/dT is the rate of passive diffusion; D the diffusion
• a distribution half-life, corresponding to the distribu-
coefficient of the drug in the membrane; A the area of the
tion of drug in tissues rich in blood supply
membrane; K the aqueous membrane partition coefficient
of the drug; ∆C the concentration gradient; and δ the thick- • a transfer half-life, corresponding to the distribution in
ness of the membrane. poorly vascularized tissues; and
Local clearance of drug depends on the vascularity of the • an elimination half-life, corresponding to the time nec-
injection site and the degree of tissue binding. Therefore a essary to eliminate 50% of the administered dose.
rich capillary bed and little surrounding fatty tissue coupled The volume of distribution in a steady state (VDss) is based
with a low water:oil partition coefficient favors systemic on unbound plasma concentrations and reflects net tissue
absorption. The rate of absorption, and hence initial plasma binding.
concentrations as a function of site of injection, vary as The half-life of elimination can be calculated following
follows: spinal < plexus block < epidural < caudal < inter- the intravenous injection of a bolus of drug. It allows one
costal < intrapleural (Fig. 3.6). to anticipate the risk of drug accumulation in case of rein-
Following absorption into the systemic circulation, local jection. For example, lidocaine has an elimination half-life
anesthetics are subjected to substantial sequestration by the of 96min and bupivacaine 210 min.14 Therefore as a rough
lungs.30,31 This is because of a high lung:blood partition guide one may readminister half the initial dose 1.5 and
coefficient and ion trapping of drug secondary to the low 3.5h following the first injection, and in this way avoid
extravascular pH of the lungs. The drugs also bind plasma drug accumulation.
proteins, showing high affinity and low capacity for alpha1-
acid glycoprotein, and low affinity and high capacity for Metabolism and excretion
albumin. This binding is increased in the presence of cancer,
trauma, chronic pain, and inflammatory disease, as well as Amide local anesthetics are metabolized in the liver and
in the postoperative period; it is significantly decreased in their elimination depends on their hepatic clearance. They
neonates because of their low plasma concentrations of can be divided into two groups, depending on whether
alpha1-acid glycoprotein. Further binding of drug takes their hepatic extraction ratio is high (e.g. lidocaine, >50%)
place in the tissue. The long-acting group of amide local or low (e.g. bupivacaine, <40%). Those drugs with a high
anesthetics are bound in plasma and tissue to a greater ratio have, therefore, perfusion-dependent clearance; those
extent than the short-acting ones.32–37 with a low ratio are subject to induction and inhibition of
The distribution of local anesthetics obeys the laws gov- hepatic enzyme systems.38
erning a three-compartment model of distribution and As stated above, the ester drugs are rapidly hydrolyzed by
elimination. This can be described by: plasma and other esterases, limiting their potential for
15
PART I Principles
toxicity.8,9,11,39,40 Renal excretion of local anesthetics is of and Aβ) are spared. This is known as differential nerve
little importance, accounting for less than 6% of the dose. block. A number of possible explanations for this phenom-
This may be increased, however, to 20% following acidifi- enon have been postulated. First, the time taken for a drug
cation of the urine.41 to diffuse into and along the course of a nerve, and so affect
various fibers, may result in the clinical features observed.
Second, the presence or absence of a myelin sheath may
Nerve block in clinical practice affect local anesthetic activity and penetration. Third, not
all axons have the same sensitivity to local anesthetic agents
Nerve fibers because of variations in Na+ channel and membrane lipid
content.43,44
Nerve fibers have been categorized into A, B, and C fibers.
A fibers have been further divided into α, β, γ, and δ fibers. Nerve penetration
The important features of each category of nerve fiber are
outlined in Table 3.2. A fibers are myelinated somatic Peripheral nerves are organized so that the fibers innervat-
nerves, B fibers are myelinated preganglionic autonomic ing the distal portions of a limb are in the center of the
nerves, and C fibers are unmyelinated nerves. The suscepti- nerve trunk and the more proximal structures are supplied
bility of nerves to local anesthetics, in general, depends on
their caliber, degree of myelination, and speed of conduc-
Nerve trunk
tion. However, as outlined below, further factors also come
into play.
Mantle bundle
Minimum blocking concentration Care bundle
The minimum blocking concentration (Cm) is the lowest
concentration of a local anesthetic agent that will block
conduction in a nerve in vitro. In vivo, the drug is injected
in and about nerve trunks, fibrous sheaths, fatty tissue, and Proximal: early block
blood vessels. Therefore, before reaching a nerve, it is
Distal: delayed block
subject to dilution, dispersion, fixation, destruction, and
systemic absorption. Under these conditions, the minimum
concentration necessary to block a nerve is much greater
than the Cm. Consequently, lidocaine 1% is necessary to
block a mixed somatic nerve that has a Cm for lidocaine of
approximately 0.07%.42
Figure 3.7 Somatopic distribution in peripheral nerve. Axons in large
nerve trunks are arranged so that the outer fibers innervate the more
Differential nerve block proximal structures. The inner fibers innervate the more distal parts
of a limb. (From Ref. 45, de Jong RH. Physiology and pharmacology of
Within a single peripheral nerve, one may observe complete local anesthesia. Springfield, IL, 1970. Courtesy of Charles C. Thomas
block of pain fibers (Aδ and C) while motor and touch (Aα Publishers, Ltd, Springfield, Illinois, USA.)
Table 3.2 Characteristics of different categories of nerve fiber

Aα Aβ Aγ Aδ B C
Diameter (µm) 12–20 5–12 5–12 1–4 1–3 0.5–1
Conduction speed 70–120 30–70 30–70 12–30 14.8 1.2
Myelination +++ ++ ++ + + –
Function Motor Pressure, Proprioception Pain, temperature Vasoconstriction Pain, temperature
touch
Onset of block 5th 4th 3rd 2nd 1st 2nd
(From Strichatz GR. Neural Physiology and Local Anesthetic Action. In: Cousins MJ, Bridenbaugh PO (eds). Neural blockade in clinical anesthesia and
management of pain, 3rd edn. Philadelphia: © Lippincott-Raven; 1998.)
16
CHAPTER
Local anesthetics 3
from the outer layers of the trunk. Following deposition of 13. Fisher MM, Graham R. Adverse responses to local
the drug, one may therefore observe anesthesia of the more anaesthetics. Anaesth Intensive Care 1984;12:325–
proximal limb structures before the distal ones (Fig. 3.7). 327.
Regression of block is primarily dependent on diffusion 14. Covino BG, Vassalo HL. Local anesthetics:
from the nerve and absorption into the local vasculature. mechanisms of action and clinical use. New York:
Drugs with high lipophilic solubility diffuse slowly from Grune and Stratton; 1976:73.
local tissues for reasons stated earlier, while the addition of 15. Butterworth JF, Strichartz GR. Molecular mechanisms
adrenaline to local anesthetics results in local vasoconstric- of local anesthesia: a review. Anesthesiology
tion and an increase of up to 50% in block duration.46–48 1990;72:711–734.
16. Cahalan M, Shapiro BI, Almers W. Relationship
between inactivation of sodium channels and
References block by quarternary derivatives of local
anesthetics and other compounds. In: Fink BR, editor.
1. Strichartz GR. Neural physiology and local anesthetic Molecular mechanisms of anesthesia (Progress in
action. In: Cousins MJ, Bridenbaugh PO, editors. anesthesiology, Vol. 2). New York: Raven Press;
Neural blockade in clinical anesthesia and 1980.
management of pain. 3rd edn. Philadelphia: 17. Courtney KR. Structure-activity relations for
Lippincott-Raven; 1998:35–54. frequency-dependent sodium channel block in
2. Kandel ER, Schwartz JH, Jessel T, editors. Principles nerve by local anesthetics. J Pharmacol Exp Ther
of neural science. 2nd edn. New York: Elsevier/ 1980;213:114–119.
North-Holland; 1992. 18. Hille B. Local anesthetics: hydrophilic and
3. Rang HP, Ritchie JM. On the electrogenic sodium hydrophobic pathways for the drug-receptor reaction.
pump in mammalian non-myelinated nerve fibers J Gen Physiol 1977;69:497–515.
and its activation by various cations. J Physiol 19. Hille B. Local anesthetic action on inactivation of the
1968;196:183–221. Na+ channel in nerve and skeletal muscle: possible
4. Hille B. Ionic channels of excitable membranes. 2nd mechanisms for antiarrhythmic agents. In: Morad M,
edn. Sunderland, MA: Sinauer Associates; 1991. editor. Biophysical aspects of cardiac muscle. New
5. Hodgkin AL, Huxley AF. A quantitative description of York: Academic Press; 1978:55–74.
membrane current and its application to conduction 20. Frazier DT, Narahashi T, Yamada M. The site
and excitation in nerve. J Physiol 1952;117:500–544. of action and active form of local anesthetics.
6. Stühmer W, Conti F, Harukazu S, et al. Structural II. Experiments with quaternary compounds.
parts involved in activation and inactivation of the J Pharmacol Exp Ther 1970;171:45–51.
sodium channel. Nature 1989;339:565–644. 21. Strichartz GR. The inhibition of sodium currents in
7. Stoelting RK. Pharmacology and physiology in myelinated nerve by quaternary derivatives of
anesthetic practice. 2nd edn. Philadelphia: JB lidocaine. J Gen Physiol 1973;62:37–57.
Lippincott; 1991. 22. Chernoff DM, Strichartz GR. Tonic and phasic block
8. Kuhnert PM, Kuhnert BR, Philipson EH, et al. The of neuronal sodium currents by 5-hydroxyhexano-
half-life of 2-chloroprocaine. Anesth Analg 1986;65: 2′,6′-xylidide, a neutral lidocaine homologue. J Gen
273–278. Physiol 1989;93:1075–1090.
9. O’Brien JE, Abbey V, Hinsvark O, et al. Metabolism 23. Ritchie JM, Ritchie BR. Local anaesthetics: effect of
and measurement of chloroprocaine, an ester-type pH on activity. Science 1968;162:1394–1395.
local anesthetic. J Pharm Sci 1979;68:75–78. 24. Narahashi T, Frazier D, Yamada M. The site of action
10. DuSouich P, Erill S. Altered metabolism of and active form of local anesthetics. I. Theory and pH
procainamide and procaine in patients with experiments with tertiary compounds. J Pharmacol
pulmonary and cardiac diseases. Clin Pharmacol Ther Exp Ther 1970;171:32–44.
1977;21:101. 25. Sanchez V, Arthur GR, Strichartz G. Fundamental
11. Reidenberg MM, James M, Dring LG. The rate of properties of local anesthetics. I. The dependence of
procaine hydrolysis in serum of normal subjects and lidocaine’s ionization and octanol:buffer partitioning
diseased patients. Clin Pharmacol Ther on solvent and temperature. Anesth Analg 1987;66:
1972;13:279–284. 159–165.
12. Foldes FF, Davidson GN, Duncalf D, et al. The 26. Strichartz GR, Sanchez V, Arthur GR, et al.
intravenous toxicity of local anesthetic agents in man. Fundamental properties of local anesthetics. II.
Clin Pharmacol Ther 1965;40:328–335. Measured octanol:buffer partition coefficients and
17
PART I Principles
pKa values of clinically used drugs. Anesth Analg I. Relationships between binding, physiochemical
1990;71:158–170. properties and anesthetic activity. Anesthesiology
27. Truant AP, Takman B. Differential physical-chemical 1970;33:287–303.
and neuropharmacologic properties of local 38. Tucker GT. Pharmacokinetics of local anaesthetics.
anesthetic agents. Anesth Analg 1959;38:478–484. Br J Anaesth 1986;58:717–731.
28. Tucker GT. Plasma binding and disposition of local 39. Calvo R, Carlos R, Erill S. Effects of disease and
anesthetics. Int Anesthesiol Clin 1975;13:33–59. acetazolamine on procaine hydrolysis by red cell
29. Tucker GT, Moore DC, Bridenbaugh PO, et al. enzymes. Clin Pharmacol Ther 1980;27:179–183.
Systemic absorption of mepivacaine in commonly 40. Javaid JI, Musa MN, Fischman M, et al. Kinetics of
used regional block procedures. Anesthesiology cocaine in humans after intravenous and intranasal
1972;37;277–287. administration. Biopharm Drug Dispos 1983;4:9–
30. Jorfeldt L, Lewis DH, Lofstrom B, et al. Lung uptake 18.
of lidocaine in healthy volunteers. Acta Anaesthesiol 41. Tucker GT, Mather LE. Clinical pharmacokinetics of
Scand 1979;23:567–574. local anaesthetic agents. Clin Pharmacokinet 1979;4:
31. Lofstrom B. Tissue distribution of local anesthetics 241–278.
with special reference to the lung. Int Anesthesiol 42. Gissen AJ, Covino BG, Gregus J. Differential
Clin 1978;16:53–71. sensitivity of mammalian nerve fibers to local
32. Denson DD, Coyle DE, Thompson G, et al. Alpha1- anesthetic drugs. Anesthesiology 1980;53:467–474.
acid glycoprotein and albumin in human serum 43. Heinbecker P, Bishop GH, O’Leary J. Pain and touch
bupivacaine binding. Clin Pharmacol Ther fibers in peripheral nerves. Arch Neurol Psychiatr
1984;35:409–415. 1933;20:771–789.
33. Kraus E, Polnaszek CF, Scheeler DA, et al. Interaction 44. Raymond SA, Gissen AJ. Mechanisms of differential
between human serum albumin and alpha1-acid block. In: Strichartz GR, editor. Handbook of
glycoprotein in the binding of lidocaine to purified experimental pharmacology, Vol. 81. Berlin: Springer-
protein fractions and sera. J Pharmacol Exp Ther Verlag; 1987.
1986;239:754–759. 45. de Jong RH. Physiology and pharmacology of local
34. Mather LE, Long GJ, Thomas J. The binding of anesthesia. Springfield, IL: Charles C Thomas;
bupivacaine to maternal and foetal plasma proteins. 1970.
J Pharm Pharmacol 1971;23:359–365. 46. Kristerson L, Nordenram Å, Nordqvist P. Penetration
35. Mather LE, Thomas J. Bupivacaine binding to plasma of radioactive local anaesthetic into peripheral nerve.
protein fractions. J Pharm Pharmacol 1978;30:653– Arch Int Pharmacodyn 1965;157:148–151.
654. 47. Winnie AP, LaVallee DA, Sosa BP, et al. Clinical
36. Routledge PA, Barchowsky A, Bjornsson TD, et al. pharmacokinetics of local anesthetics. Can Anaesth
Lidocaine plasma protein binding. Clin Pharmacol Soc J 1977;24:252.
Ther 1980;27:347–351. 48. Winnie AP, Tay CH, Patel KP, et al. Pharmacokinetics
37. Tucker GT, Boyes RN, Bridenbaugh PO, et al. Binding of local anesthetics during plexus blocks. Anesth
of anilide-type local anesthetics in human plasma. Analg 1977;56:852–861.
18
PART I Principles
CHAPTER
4
General indications and contraindications
Frank Loughnane
successful regional anesthetic practice and the avoidance of

Peripheral nerve block: indications many of its complications.
The dermatomes and myotomes of the body and limbs
Surgery are shown in Figures 4.1–4.9.5 The selection of a regional
anesthetic technique appropriate to a particular surgical
A thorough knowledge of descriptive and topographic intervention becomes more straightforward when one can
anatomy, especially with regard to nerve distribution, answer the following questions:
is beyond discussion. It is a condition which anyone • What dermatomes, myotomes, and osteotomes are
desirous of attempting the study of regional anesthesia involved?
should fulfil. The anatomy of the human body must, • Will a tourniquet be used to provide a bloodless field?
besides, be approached from an angle hitherto unknown • How much pain can be expected in the postoperative
to the medical student and with which the average period?
surgeon is not at all familiar.1 • Is the surgery to be performed on an ambulatory basis?
• Is there a specific contraindication to the proposed
Gaston Labat wrote these words at a time when deep ether technique?
anesthesia was required to provide adequate muscle relax- • Are both surgeon and patient in agreement with the
ation, especially for abdominal surgery. The problems asso- proposed technique?
ciated with deep ether anesthesia included nausea, vomiting,
and atelectasis and subsequent pneumonia. Therefore, the Management of acute pain
benefits of regional anesthesia were readily apparent. The
practice of regional anesthesia still holds attraction, possi- Pain arises from the direct activation of primary afferent
bly because of its positive effects on secondary outcomes neurons. It is often associated with tissue damage and an
such as postoperative nausea and vomiting, postoperative inflammatory response, especially in the clinical setting.
confusion, and rapid return to ‘street fitness’. Evidence of a The inflammatory response has both cellular and neuro-
positive influence on the ‘hard’ postoperative outcomes genic components. Activation of lymphocytes, macro-
of morbidity and mortality is more difficult to come by, phages, and mast cells, and the release of neuropeptides
although a number of studies have shown benefit in spe- such as substance P and neurokinin A result in the further
cific circumstances.2–4 Practicing regional anesthesia is also release of inflammatory mediators such as histamine, bra-
an opportunity for anesthesiologists to employ their dykinin, and the products of arachidonic acid metabo-
individual skills, and so can be an important source of lism.6–9 These chemicals can sensitize high-threshold
professional satisfaction. Practitioners are responsible for nociceptors to produce the phenomenon of peripheral sen-
acquainting themselves with the anatomy to which Labat sitization. The resultant area of primary hyperalgesia is
refers and to which a large part of this textbook and characterized by an increased responsiveness to thermal
DVD-ROM is directed. This knowledge lies at the core of and low-threshold mechanical stimuli at the site of injury.
DOI: 10.1016/B978-0-7020-3148-9.00012-8
PART I Principles
Anterior Posterior
B C T R
C3
C4 C4 C4
C4 T2
C5
T3 T2
2 C5 C5 C5
5 C6
3 T2
C6
C7
l C7
p
C8
m T1 C6 C6
T1 T1
T1
T2
C8 C8
7 C7 C7
9 Figure 4.3 Dermatomes of the upper limb.
8
10
11 17 18 5 16 15 14 13 4 19
Figure 4.1 Brachial plexus. R, roots (ventral rami of spinal nerves); T, In addition to the area of primary hyperalgesia, a zone of
trunks (superior, middle, and inferior); C, cords (lateral, posterior, and secondary hyperalgesia develops in the uninjured tissues
medial); B, terminal branches; P, pectoralis minor muscle.1, Dorsal scap- surrounding the site of injury. No changes occur in the
ular nerve; 2, suprascapular nerve; 3, nerve to subclavius muscle; 4,
superior pectoral nerve; 5, lateral pectoral nerve; 6, axillary artery; 7,
threshold to stimuli of the nerves in this area. Changes in
musculocutaneous nerve; 8, median nerve; 9, axillary nerve; 10, radial the dorsal horn of the spinal cord and elsewhere account
nerve; 11, ulnar nerve; 12, axillary vein; 13, medial pectoral nerve; 14, for this central sensitization.10 Changes that occur in the
superior subscapular nerve; 15, thoracodorsal (middle subscapular) dorsal horn in association with central sensitization include
nerve; 16, inferior subscapular nerve; 17, medial cutaneous nerve of the an expansion in receptive field size, increased response
forearm; 18, medial cutaneous nerve of the arm; 19, long thoracic nerve. to stimuli, and a reduction in threshold. These changes
are important in the development of both acute and
chronic pain.11,12
Non-steroidal anti-inflammatory drugs (NSAIDs) exert
their action by blocking the cyclo-oxygenase (COX) enzyme
pathway. With traditional agents, this has involved the
inhibition of both the COX1 and COX2 isoforms. Reduc-
Anterior Posterior
tions in pain scores and opioid requirements have been
Supra- Supra- reported with their use. The COX2 isoform is predomi-
clavicular clavicular nantly induced by the inflammatory process, and the recent
nerve C3, 4 nerve C3, 4
development and introduction into clinical practice of
Axillary Axillary specific COX2 inhibitors, holds promise for a reduction in
(circumflex) (circumflex) side-effects of these drugs.13 Evidence also exists to support
nerve C5, 6 nerve C5, 6 a central mechanism of action of NSAIDs in the modifica-
tion of pain mechanisms.14
Radial nerve Radial nerve
C5, 6
Medial
C5, 6 The role of opioid drugs in the modification of central
cutaneous pain mechanisms has been long recognized. They act pre-
nerve
Musculo- Musculo- synaptically to inhibit the release of neurotransmitters
cutaneous cutaneous from the nociceptive primary afferent neuron. Peripheral
nerve C5, 6 C8, T1 nerve C5, 6
nerves are known to manufacture opioid receptors in the
cell body and transport them to both the periphery and
Radial nerve Radial nerve
C7, 8
Ulnar nerve
C7, 8 the dorsal horn. Following tissue injury, the peripheral
C8, T1
receptors become active.15,16 Initial interest in exploiting
Median Median these features has waned somewhat as equivocal results
nerve nerve following the intra-articular administration of morphine
C6, 7, 8 C6, 7, 8 to treat arthroscopic procedure-related pain have been
Figure 4.2 Cutaneous innervation of the upper limb. published.17
20
CHAPTER
General indications and contraindications 4
Anterior Posterior Anterior Posterior

Axillary Axillary T12
nerve nerve L1
L2
L3
Musculo- L4
cutaneous T12 L5
Radial
nerve
nerve
Radial
nerve L1 S2 S3
Ulnar
Median nerve S4
nerve L2
Ulnar
nerve
L3 S2 S1 L5
L4
Figure 4.4 Myotomes of the upper limb.
L3
Anterior
C6 C5
L5
C7
C8 T1
S1
CS C5
C6
C7
L4
L5
Posterior
C6
Figure 4.6 Dermatomes of the lower limb.

C7
T1
C8 feature utilized during their systemic administration for
C5 C6 C6
the treatment of neuropathic pain.19 Local anesthetic field
block combined with wound infiltration has been shown
C5
to significantly reduce pain scores and opioid requirements
C6 for up to a week following hernia repair.20 Wound infiltra-
C7 tion is an integral part of this technique; however, definitive
C8 C7 C7
evidence showing prevention in the development of the
Figure 4.5 Osseous innervation of the upper limb. above changes remains lacking.
The concept and effectiveness of pre-emptive analgesia
remain controversial.21 At its heart, however, is the hypoth-
Damage to peripheral nerves results in pathophysiologic esis that the prevention of noxious inputs occurring during
changes in the nerves themselves.18 Such damage manifests and after surgery will prevent the development of central
as spontaneous firing, increased sensitivity to non-noxious sensitization. Although it has been demonstrated that early
stimuli, demyelination, and the sprouting of nerve fibers. postoperative pain is a predictor of long-term pain, it is
These changes form the basis for the development of not known what degree of noxious input is required, or
peripheral chronic pain states. Low concentrations of local for how long it must be present to produce long-term
anesthetic can reduce ectopic activity in damaged nerves, a changes in the nervous system.22 The logic of combining
21
PART I Principles
Ilioinguinal Posterior
nerve L1 rami S1, 2, 3 Iliohypogastric
nerve L1
Genitofemoral
nerve L1, 2 Subcostal
nerve T12 Obturator
Subcostal nerve
nerve T12 Posterior rami
L1, 2, 3
Lateral cutaneous
nerve of thigh Lateral cutaneous
L2, 3 nerve of thigh Femoral Sciatic
L2, 3 nerve nerve
Obturator
L2, 3, 4 Posterior
cutaneous
Medial and nerve S1, 2,3
intermediate
cutaneous Obturator
nerve L2, 3 nerve L2, 3, 4
Lateral cutaneous Medial cutaneous Common

nerve of calf nerve of calf peroneal Tibial
L5, S1, 2 L4, 5, S1 nerve nerve
Superficial Lateral cutaneous
peroneal nerve of calf Tibial
(musculocutaneous) L4, 5, S1 of leg nerve
nerve L4, 5, S1
Sural nerve
Sural nerve S1, 2 L5, S1, 2
Saphenous
Deep peroneal nerve L3, 4 Tibial nerve
nerve L4, 5 S1, 2
Figure 4.7 Cutaneous innervation of the lower limb.
NSAIDs, opioids, and a regional anesthetic technique (with

or without perineural catheter) appears self-evident, yet
definitive evidence of benefit in the clinical setting is Figure 4.8 Muscular innervation of the lower limb.
lacking, and the standardization of study methods is
required to allow firm conclusions to be drawn.23–25
relief in the inpatient and ambulatory settings, early post-
Chronic pain operative rehabilitation, continuous sympathectomy fol-
lowing re-implantation procedures, and the diagnosis and
The indications for somatic peripheral nerve block in the treatment of chronic pain syndromes.27–31 Indeed, there
management of chronic pain are limited, and the results have been published reports of improved surgical outcomes
require careful interpretation. A common indication has with these techniques, in addition to improved secondary
been to determine the likelihood of success following surgi- outcomes.32
cal decompression or neurolysis of a peripheral nerve. The concerns regarding continuous techniques have
Small volumes of local anesthetic need to be used in this related to infection, catheter migration, high plasma levels
setting to prevent spread to other nerves, and long-acting of local anesthetic, local myelotoxicity, and neurologic
agents allow one to differentiate the results from the placebo complications. Infection has been reported, yet despite a
effect, which in itself tends to be short-lived.26 colonization rate of up to 27%, overt problems appear to
be rare.33 Catheter migration can be detected early with
regular and routine examination of catheter site and assess-
Continuous nerve block ment of the nerve block.
Plasma levels of local anesthetic may rise progressively
Continuous catheter techniques are gaining widespread use during an infusion. Although the peri-operative rise in α1-
in a number of clinical settings. These include acute pain acid glycoprotein (GP) has been shown to ameliorate the
22
CHAPTER
Anterior Posterior tance. However, it can produce significant patient discom-

Femoral fort, persistent paresthesias, and occasionally be severe and
nerve extensive. The administration of anticoagulant medication
is a risk factor for the development of prolonged bleeding
Lateral following venous or arterial puncture. Precautions to be
cutaneous
nerve observed for the peri-operative use of anticoagulants have
of thigh Posterior been outlined by the American Society of Regional Anes-
cutaneous thesia and Pain Medicine (see Table 4.1, Guidelines) as well
Obturator nerve
nerve as equivalent organizations outside the USA.38 These guide-
of thigh
lines have been informed by the contrasting US and Euro-
pean experiences in neuraxial block, specifically in relation
Sciatic
nerve to the occurrence of spinal and epidural hematoma. Until
and unless further studies suggest otherwise, it appears
Tibial prudent to observe the same recommendations when per-
Saphenous nerve forming peripheral nerve block, particularly if the nerves
nerve
are deep or lie in proximity to non-compressible vessels.
Common
peroneal
Common nerve Heparin
peroneal
nerve Intravenous heparin has a half-life of 1.5–2 h and is cleared
Sural within 4–6 h of administration. It stimulates the formation
Superficial nerve
peroneal of antithrombin III, which forms a complex with activated
nerve thrombin, thus neutralizing thrombin activity and prevent-
Deep Tibial ing the conversion of fibrinogen to fibrin. Its effects can be
peroneal nerve reversed with protamine; 1 mg per 100 U of heparin. Prot-
nerve amine forms an inactive complex with heparin. The activity
Sural of heparin can be measured with the activated partial
nerve thromboplastin time (APTT) and the activated clotting
time, both being sensitive tests of heparin function. There
Figure 4.9 The main nerves of the lower limb. is a wide variation in dose responses between individuals;
this variation is further affected by diet, liver function, renal
function, and cardiac status.40 Laboratory testing should be
performed on patients who have received heparin prior to
effect, a seizure rate of 1.2 per 1000 procedures has been
nerve block.
reported.34,35 Postoperative protocols, education of carers,
Subcutaneous heparin, 5000 U 12-hourly, displays
and patient cooperation are necessary to detect the early
maximal activity at 50 min and is effective for 4–6 h. The
signs of local anesthetic toxicity and ensure the optimal use
APTT very often remains unchanged. Low molecular weight
of this technology.
heparin (LMWH), however, has a higher bioavailability,
The incidence of neurologic complications is less than
longer half-life, and smaller effect on platelet function.
1% with the use of perineural catheters. This is similar to
the rates recorded following multiple single-dose tech-
niques.36 Whether the incidence of complications can be Non-steroidal anti-inflammatory drugs
reduced further using ultrasound to guide catheter place- The NSAIDs inhibit thromboxane synthesis as well as the
ment remains to be seen. It should be noted that catheter release of adenosine diphosphate by platelets and their
techniques are often used in major joint surgery such as subsequent aggregation. This effect is permanent in the case
distraction interposition arthroplasty, which carries an of aspirin and lasts the lifetime of the platelet (approxi-
inherent high risk of nerve injury.37 mately 10 days).
Coumarin derivatives
Peripheral nerve block: The coumarin derivatives, principally warfarin, inhibit syn-
contraindications thesis of vitamin K-dependent clotting factors (II, VII, IX,
and X). The international normalized ratio (INR) may not
Anticoagulant medication reflect levels of factors II and X for some time following the
discontinuation of warfarin. Vitamin K reverses warfarin’s
Hematoma formation following peripheral nerve block is effects, although doses up to 50 mg may be required for
considered to be uncommon and usually of little impor- complete reversal. For elective surgery, discontinuation of
23
PART I Principles
Table 4.1 Neuraxial* Anesthesia in the Patient Receiving Thromboprophylaxis

UFH
Antiplatelet
Medications Subcutaneous Intravenous LMWH
German Society for NSAIDs: no Needle placement 4 hrs Needle placement Neuraxial technique
Anaesthesiology contraindication; after heparin; heparin and/or catheter 10Y12 hrs after
and Intensive- hold LMWH, 1 hr after needle removal 4 hrs after LMWH; next dose
Care Medicine† fondaparinux placement or catheter discontinuing 4 hrs after needle
36Y42 hrs removal heparin, heparinize of catheter
Thienopyridines and 1 hr after neuraxial placement
GP IIb/IIIa are technique; delay Delay block for
contraindicated bypass surgery 24 hrs after
12 hrs if traumatic therapeutic dose
Belgian Association NSAIDs: no Not discussed Heparinize 1 hr after Neuraxial technique
for Regional contraindication neuraxial technique 10Y12 hrs after
Anesthesia‡ Discontinue Remove catheter LMWH; next dose
ticlopidine 14 d, during normal 4 hrs after needle
clopidogrel 7 d, aPTT; reheparinize or catheter
GP IIb/IIIa 1 hr later placement
inhibitors Delay block for
87Y48 hrs in 24 hrs after
advance therapeutic dose
American Society of NSAIDs: no No contraindication with Heparinize 1 hr after Twice-daily dosing:
Regional contraindication. twice-daily dosing and neuraxial LMWH 24 hrs after
Anesthesia and Discontinue total daily dose technique, remove surgery, regardless
Pain Medicine ticlopidine 14 d, G10,000 U, consider catheter 2Y4 hrs of technique;
clopidogrel delay heparin until after last heparin remove neuraxial
7 d, GP IIb/IIIa after block if technical dose; no mandatory catheter 2 hrs
inhibitors 8Y48 hrs difficulty anticipated. delay if traumatic before first LMWH
in advance The safety of neuraxial dose
blockade in patients
receiving doses greater
than 10,000 units of
UFH daily, or more
than twice daily dosing
of UFH has not been
established.
Single-daily dosing:
according to
European
statements BUT
with no additional
hemostasis-
altering drugs
Therapeutic dose:
delay block for
24 hrs
24
CHAPTER
Direct Thrombin
Warfarin Fondaparinux Inhibitors Thrombolytics Herbal Therapy
INR G 1.4 for needle/ Needle placement Needle placement Absolute No contraindication
catheter insertion 36Y42 hrs after last 8Y10 hrs after contraindication
and withdrawal dose, wait 6Y12 hrs dose; delay
after catheter subsequent
removal for doses 2Y4 hrs
subsequent dose after needle
placement
INR G1.4 for needle/ Needle placement Needle placement Absolute Not discussed
catheter insertion 36 hrs after last 8Y10 hrs after contraindication
and withdrawal dose. Indwelling dose; delay
epidural catheter subsequent
not recommended doses 2Y4 hrs
after needle
placement
Normal INR (before Single injection, Insufficient Absolute No evidence for

neuraxial atraumatic needle information contraindication mandatory
technique); placement or Suggest discontinuation
remove catheter altermate avoidance of before neuraxial
when INR e 1.5 thromboprophylaxis. neuraxial technique; be
(initiation of Avoid indwelling techniques aware of
therapy) catheters. potential drug
interactions
Continued
25
PART I Principles
Table 4.1 Neuraxial* Anesthesia in the Patient Receiving Thromboprophylaxis—cont’d

UFH
Antiplatelet
Medications Subcutaneous Intravenous LMWH
American College of NSAIDs: no Needle placement Needle placement Needle placement
Chest Physicians§ contraindication 8Y12 hrs after dose; delayed until 87Y12 hrs after
Discontinue subsequent dose 2 hrs anticoagulant effect dose; subsequent
clopidogrel 7 d after block or catheter is minimal dose 2 hrs after
before neuraxial withdrawal block or catheter
block. withdrawal.
Indwelling
catheter safe with
twice-daily dosing
Therapeutic dose:
delay block for
18+ hrs
*For patients undergoing deep plexus or peripheral block, follow ASRA recommendations for neuraxial techniques.
†
Adapted from the German Society of Anesthesiology and Intensive Care Medicine Consensus guidelines.103
‡
Adapted from the Belgian Association for Regional Anesthesia. Working party on anticoagulants and central nerve blocks.68
§
Adapted from the American College of Chest Physicians.7
Source: Ref 39. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy. (The third
ASRA and PMEB guidelines neuraxial anesthesia and anticoagulation). Reg Anesthesia Pain Med 2010;35:92–94.
warfarin 3–4 days prior to surgery is usually sufficient. For with normal pulmonary function can tolerate this embar-
acute reversal, fresh frozen plasma and factor concentrates rassment easily. However, those with poor respiratory
will achieve the same end. reserve are at risk of developing acute respiratory failure.
The wisdom of performing these blocks in such patients
New anticoagulants must be questioned, and bilateral blocks are absolutely
The hirudin derivatives inhibit free and clot-bound throm- contraindicated. An FEV1 < 1 L, FVC < 15–20 mL/kg, FEV/
bin, and fondaparinux inhibits factor Xa. The use of direct FVC < 35%, PEFR < 100 L/min, and pCO2 > 50 mmHg are
thrombin inhibitors and direct Xa inhibitors has increased predictors of serious respiratory compromise following
greatly and is likely to increase further. These newer drugs supraclavicular block.45 Further absolute contraindications
are becoming more widely used, but the risk of neuraxial to interscalene brachial plexus block include a history of
hematoma is unknown. pre-existing contralateral hemidiaphragmatic paralysis or
contralateral pneumonectomy.
Respiratory disease Any procedure in which a needle is directed toward the
lung carries a risk of pneumothorax. The incidence of pneu-
The phrenic nerve (C3, 4, 5) is a branch of the cervical mothorax with supraclavicular blocks has variously been
plexus, its three roots usually joining at the lateral border reported as being 6–25%.46,47 A sudden cough or inspira-
of the scalenus anterior muscle. The nerve passes across the tory effort should alert the operator to the possibility of
anterior aspect of the muscle and descends to enter the pneumothorax, because the symptoms and signs may not
thorax, having passed between the subclavian artery and develop for hours or until the pneumothorax reaches 20%
vein. The incidence of ipsilateral phrenic nerve paresis of lung volume. Radiographic evidence may take 24 h to
following supraclavicular block ranges from 36%, regard- develop. Interest in the supraclavicular block has been res-
less of technique used, to 100% with the interscalene urrected in more recent times with the widespread adoption
approach.41,42 With ultrasonographic assessment, this 100% of ultrasound-guided techniques. The ability to identify
incidence remains, despite a reduction in the mass of local vital structures in addition to relevant nerves holds the
anesthetic used. A 25% reduction in forced vital capacity promise of this becoming a safe block in the hands of
(FVC) and forced expiratory volume in 1s (FEV1), as well appropriately trained and experienced practitioners.
as a reduction in peak expiratory flow rate (PEFR), can be The performance of intercostal or paravertebral nerve
expected following interscalene block. This persists for the block for analgesia is preferable to no analgesia or high-
duration of action of the anesthetic agent.43,44 The patient dose narcotics, especially in the elderly. Dilute solutions
26
CHAPTER
Direct Thrombin
Warfarin Fondaparinux Inhibitors Thrombolytics Herbal Therapy
Avoid or limit Single-injection spinal Not addressed Not addressed Not addressed
epidural analgesia safe
to G48 hrs. Avoid epidural
Remove catheter analgesia
when INR G 1.5
sufficient to provide analgesia without significant motor more especially, spinal anesthesia have been implicated in
blockade should be advocated, because case reports of exacerbations of multiple sclerosis.50 Theories to explain
respiratory failure secondary to intercostal motor block and this suggest that demyelinated nerves may be more suscep-
without pneumothorax following intercostal block have tible to the neurotoxic effects of local anesthetic agents.51
appeared.48,49 While peripheral nerve block is performed at a ‘safe’ dis-
tance from the disease process of multiple sclerosis, there
always exists the potential for exacerbations secondary to
Neuromuscular disease stress or infection in the peri-operative period. Patients
should be informed of this and their neurologic status doc-
Pre-existing or unstable neuromuscular disease is often
umented before and after any intervention.
considered to be a contraindication to regional anesthesia.
These patients, however, are very often at increased risk of
respiratory failure, autonomic dysfunction, and myocardial Amyotrophic lateral sclerosis
dysfunction in the peri-operative period. They should have
a detailed neurologic assessment documented, as well as Amyotrophic lateral sclerosis is a degenerative disease of
an appropriate assessment of other body systems that may upper and lower motor neurons and the motor nuclei of
be affected by the disease process. Changes in the peri- the brainstem. Its cause is unknown. Amyotrophic lateral
operative period are often seen in these patients as a sclerosis is associated with bulbar muscle weakness, the risk
consequence of fatigue, stress, and infection. A careful risk– of aspiration, autonomic system dysfunction, and poor
benefit analysis may, nevertheless, allow the anesthesiolo- ventilatory reserve. Little information exists on the safety of
gist to affect positively the postoperative outcome of these performing peripheral nerve blocks in patients with amyo-
patients. trophic lateral sclerosis. Epidural block has been success-
fully employed, suggesting that it may be safe to use local
anesthetic agents in this group.52
Multiple sclerosis
Multiple sclerosis is a demyelinating disease of the brain Myasthenia gravis
and spinal cord characterized by a series of remissions and
exacerbations occurring over many years. Multiple sclerosis Myasthenia gravis is an autoimmune disease affecting the
does not affect the peripheral nervous system. Epidural and, neuromuscular junction. Up to 90% of myasthenia patients
27
PART I Principles
have anti-acetylcholine receptor antibodies, and the disease

Table 4.2 Contraindications to peripheral nerve block
is characterized by skeletal muscle weakness exacerbated by
activity. Patients with myasthenia are extremely sensitive Absolute Relative
to non-depolarizing neuromuscular-blocking drugs. In
Patient refusal Respiratory compromise as
addition, the relaxant effects of volatile anesthetic agents
Local infection outlined
are markedly pronounced in these patients, and reduced
plasma cholinesterase activity may prolong the elimination Full anticoagulation Neuromuscular disease as outlined
half-life of ester local anesthetics. Allergy to local Diabetes
The following factors identify patients at high risk of anesthetic
respiratory compromise and the need for postoperative
ventilation:53
• the presence of disease for 6 years or more
• a vital capacity of less than 2.9 L Summary
• coexisting chronic obstructive airway disease, and
The contraindications to peripheral nerve block are broadly
• a pyridostigmine requirement of more than 750 mg/ summarized in Table 4.2. The reader is advised to consult
day. the text relating to specific blocks for further detail of indi-
Peripheral nerve block is an obvious choice of anesthetic vidual contraindications.
technique in these patients, unless it carries the risk of
interfering with respiratory or bulbar function.
References
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surgical repair of femoral neck fractures: a meta-
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responsible. It is characterized by the cephalad progression 3. Urwin SC, Parker MJ, Griffiths R. General versus
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58–63.
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primary afferent nociceptor. J Neurosci 1993;13:2273–
Diabetes is a disease that produces multi-organ dysfunc-
2286.
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of peri-operative myocardial ischemia, hypoglycemia, auto- chronic pain. Trends Pharmacol Sci 1994;15:190–
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essary. Motor responses may be difficult to elicit at normal 9. Perl ER. Sensitization of nociceptors and its relation
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1989;248:1269–1275. outcome and duration of rehabilitation after major
17. Aasbo V, Raeder JC, Grogaard B, et al. No additional knee surgery. Anesthesiology 1999;91:8–15.
analgesic effect of intraarticular morphine or 33. Gaumann DM, Lennon RL, Wedel DJ. Continuous
bupivacaine compared with placebo after elective axillary block for postoperative pain management.
knee arthroscopy. Acta Anaesthesiol Scand Reg Anesth 1988;13:77–82.
1996;40:585–588. 34. Bergman BD, Hebl JR, Kent J, et al. Neurologic
18. Devor M. The pathophysiology of damaged complications of 405 consecutive continuous axillary
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Textbook of pain. 3rd edn. London: Churchill 35. Brown DL, Ransom DM, Hall JA, et al. Regional
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analgesics. J Pain Symptom Manage 1994;9:491–499. cardiovascular changes. Anesth Analg 1995:81:321–
20. Dahl JB, Moiniche S, Kehlet H. Wound infiltration 328.
with local anesthetics for postoperative pain relief 36. Horlocker TT, Kufner RP, Bishop AT, et al. The risk of
[editorial]. Acta Anaesthiol Scand 1994;38:7–14. persistent paresthesia is not increased with repeated
21. Kissin I. Preemptive analgesia: why its effect is not axillary block. Anesth Analg 1999;88:382–387.
always obvious. Anesthesiology 1996;84:1015– 37. Cheng SL, Morrey BF. Treatment of the mobile,
1019. painful arthritic elbow by distraction interposition
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after thoracic surgery predicts long-term post- 238.
thoracotomy pain. Clin J Pain 1996;12:50–55. 38. Horlocker TT. Regional anesthesia in the
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29
PART I Principles
39. Horlocker TT, Wedel DJ, Rowlingson JC, et al. 46. Brand L, Papper EM. A comparison of supraclavicular
Regional anesthesia in the patient receiving and axillary techniques for brachial plexus blocks.
antithrombotic or thrombolytic therapy. (The third Anesthesiology 1961;22:226–229.
ASRA and PMEB guidelines neuraxial anesthesia 47. De Jong RH. Local anesthetics adverse effects. In:
and anticoagulation). Reg Anesthesia Pain Med Chambers C, editor. Local anesthetics. Springfield, IL:
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41. Farrar MD, Scheybani M, Nolte H. Upper extremity 49. Cory PC, Mulroy MF. Postoperative respiratory failure
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1981;6:133–134. 418–419.
42. Urmey WF, Talts KH, Sharrock ME. One hundred 50. Bamford C, Sibley W, Laguna J. Anesthesia in
percent incidence of hemidiaphragmatic paresis multiple sclerosis. Can J Neurol Sci 1978;5:41–44.
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43. Pere P, Pitkanen M, Rosenberg P. Effect of continuous 52. Kochi T, Oka T, Mizuguchi T. Epidural anesthesia for
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1999:1–30. 1086.
30
PART I Principles
CHAPTER
5
Complications, toxicity, and safety
Frank Loughnane
Systemic toxicity of local anesthetic drugs

Complications and toxicity
Toxic reactions following local anesthetic drug administra-
tion can involve the CNS and/or the cardiovascular system.
Principles underlying complications and errors
CNS toxicity is more common, occurs in association with
A complication is an undesirable, unexpected event occur- lesser plasma drug concentrations, and responds more
ring in the course of an intervention. It is necessary to dif- readily to treatment.
ferentiate between such events and the side-effects one can
normally expect to encounter in clinical practice. Side- Central nervous system toxicity
effects, in general, are predictable occurrences, and their The signs and symptoms of local anesthetic-induced CNS
prompt recognition and treatment can avoid more serious toxicity are shown in Figure 5.1. An initial phase of CNS
sequelae. Complications, however, may occur as a result of excitability, as demonstrated by light-headedness, dizzi-
human factors on the part of the anesthesiologist, or may ness, visual and auditory disturbance, muscle twitching,
be attributable to environmental or equipment factors, or and convulsions, is followed by CNS depression, with
may occur secondary to ‘system’ factors. coma, then respiratory depression and arrest. This sequence
Human factors can be defined as lapses in, or lack of, safe of events occurs because of an initial inhibition, at lesser
habit, or the occurrence of a vigilance decrement resulting concentrations, of inhibitory pathways in the amygdala.
from sleep deprivation, fatigue, recent alcohol or drug At greater concentrations, both inhibitory and excitatory
ingestion, or boredom. Inexperience on the part of the pathways are inhibited, resulting in generalized CNS
anesthesiologist is likely to contribute to poor decision- depression.5–8
making or an error in judgment. An important component The toxic potential of each anesthetic drug is related to
in the avoidance of complications arising from these factors its potency as an anesthetic agent (Table 5.1),9 and the rate
is awareness of anesthesiologists as individuals and of their at which it is injected or absorbed (Fig. 5.2). Hypercapnia
role in complication development. They should thus seek and acidosis lower the convulsive threshold for local anes-
to establish safe working practices and individual self- thetic drugs. This occurs in a number of ways. A high pCO2
discipline that may act to counterbalance these risks.1–3 will increase cerebral blood flow, resulting in greater rates
Environmental factors leading to complications may of drug delivery; decreased intracellular pH facilitates the
include lack of appropriate patient-monitoring systems and formation of the cationic form of drug, i.e. the active form;
protocols, inadequate drug identification systems, or pres- and hypercapnia and acidosis result in diminished protein-
sures originating from practice managers, surgeons, or binding of drug, thereby making available a greater propor-
financial concerns. tion of free drug.10
Patient selection and management are dealt with briefly Local anesthetic-induced seizures are effectively termi-
in this chapter. Selection of an anesthetic technique that nated by administration of barbiturate or benzodiazepine
fits the patient, surgeon, and anesthesiologist at a parti- drugs.11,12 The doses required are small and one should
cular point in time will form the basis of a successful remain mindful that their myocardial depressant effects are
intervention. additive to those of local anesthetic drugs.

DOI: 10.1016/B978-0-7020-3148-9.00013-X
PART I Principles
Cardiovascular system toxicity convulsions. It is approximately 7.1 for lidocaine and 3.7
The depolarization phase of the action potential in cardiac for bupivacaine, suggesting a greater margin of safety in the
tissue differs from nerve tissue in that the fast influx of Na+ use of lidocaine.19 The high lipid-solubility of bupivacaine
is followed by a slow influx of Ca2+. This influx of Ca2+ is results in a slow rate of dissociation from the tissues, and
responsible for the spontaneous depolarization that is char- thus a persistent effect on Vmax. Cardiovascular collapse
acteristic of cardiac tissue (Fig. 5.3, Table 5.2). Local anes- resulting from bupivacaine is therefore resistant to treat-
thetic drugs depress the maximal depolarization rate of the ment. The potential for cardiac toxicity is enhanced in preg-
cardiac action potential, Vmax, secondary to inhibition of nancy, for reasons not fully understood, and also in the
Na+ conductance. With increasing concentrations of local presence of hypoxia and hypercapnia.20–22 These factors
anesthetics, prolongation of conduction times occurs, pro- enhance the toxic potential of bupivacaine to a greater
ducing an increase in the P–R interval and QRS duration. degree than they do lidocaine.
At greater concentrations this is followed by sinus brady-
Treatment of Local Anesthetic Systemic Toxicity
cardia, sinus arrest, and atrioventricular dissociation.14,15
Local anesthetics also profoundly depress cardiac contrac- Following the demonstration that lipid emulsion could
tility, a phenomenon that may be related to the displace- reverse local anesthetic systemic toxicity in rat and canine
ment of Ca2+ from the sarcolemma.16–18
The CC/CNS ratio is that of the dosage required for car- Arterial 20
diovascular collapse (CC) to the dosage required to produce plasma
concentration
(mg/mL)
15
Plasma 24 CVS depression

concentration 10
(mg/mL) 20 Respiratory arrest
16 Coma
Convulsions 0
12 0 1 2 3 4 5
Unconsciousness
Muscular twitching Time (min)
8
Visual and auditory disturbances
0.1-min injection
4 Light-headedness
Numbness of tongue 2.0-min injection
0
Toxicity
Figure 5.2 Arterial plasma concentrations following intravenous injec-
tion of 100 mg of lidocaine hydrochloride over 0.1 and 2 min to simu-
Figure 5.1 Relations of signs and symptoms of local anesthetic toxicity late concentrations of an inadvertant intravenous injection during a
to plasma concentrations of lidocaine. (From Ref. 4, Covino BG, block procedure. Prolonging injection time reduces peak concentra-
Wildsmith JAW. Clinical pharmacology of local anesthetic agents. In: tions. (From Ref. 4, Covino BG, Wildsmith JAW. Clinical pharmacology of
Cousins MJ, Bridenbaugh PO (eds). Neural blockade in clinical anesthe- local anesthetic agents. In: Cousins MJ, Bridenbaugh PO (eds). Neural
sia and management of pain, 3rd edn. Philadelphia: © Lippincott-Raven; blockade in clinical anesthesia and management of pain, 3rd edn.
1998.) Philadelphia, © Lippincott-Raven; 1998.)
Table 5.1 Effect of pCO2 on the convulsive threshold (CD100) of various local anesthetics in cats
CD (mg/kg)
Agent pCO2 25–40 mmHg pCO2 65–81 mmHg Change in CD100
Procaine 35 17 51
Mepivacaine 18 10 44
Prilocaine 22 12 45
Lidocaine 15 7 53
Bupivacine 5 2.5 50
(From Ref. 4, Covino BG, Wildsmith JAW. Clinical pharmacology of local anesthetic agents. In: Cousins MJ, Bridenbaugh PO (eds). Neural blockade in clinical
anesthesia and management of pain, 3rd edn. Philadelphia: © Lippincott-Raven; 1998.)
32
CHAPTER
Complications, toxicity, and safety 5
been explained as being due to stimulation of spontaneous

myogenic activity at low concentrations and inhibition of
mV 20 1
2 the same at greater concentrations.
0 Following an inadvertent intravascular injection of an
amide local anesthetic, should the plasma concentration
-20 reach levels sufficient to produce CNS toxicity, one may also
-40
0 3 observe an increase in blood pressure, heart rate, and cardiac
output. As the plasma concentration increases, reversible
-60 Effective refractory
TP
cardiovascular depression ensues, associated with a decrease
TP period in cardiac output and systemic blood pressure. Finally, myo-
-80
4 cardial contractility becomes profoundly depressed, marked
-100 peripheral vasodilatation occurs, and cardiac arrest ensues.
mV 20 Nerve injury
0 Nerve stimulation is one effective technique for locating a
peripheral nerve. Prospective studies have demonstrated
-20 0 that a paresthesia technique can significantly increase the
-TP 3 risk of postblock neuropathies (2.8%), while the transarte-
-40 rial approach to the brachial plexus is associated with
-60
paresthesia in as many as 40% of cases,24,25 producing neu-
4
ropathy in 0.8% (Table 5.3). In contrast, a nerve stimula-
-80 tion technique aims to avoid nerve contact and has been
shown to produce important block-related neuropathies in
only 0–0.3% of cases.27
Figure 5.3 Cardiac action potential recorded from a ventricular The risk of penetrating a nerve fascicle is reduced when a
contractile cell (A) or atrial pacemaker cell. (B) TP, threshold potential. short-bevel (45°) needle is used, compared with a standard
(From Ref. 13, Stoelting RK. Heart. In: Pharmacology and physiology in
long-bevel (15°) needle, the reason being that nerve fas-
anesthetic practice. 2nd ed. Philadelphia, © JB Lippincott; 1991.)
cicles tend to roll away more readily from the advancing
short-bevel needle tip.28 Although the incidence of injury is
Table 5.2 Ion movement during phases of the cardiac less with short-bevel needles, when injury does occur it is
action potential more severe.
Intraneural needle position is associated with painful par-
Phase Ion Movement across cell membrane
esthesias on injection, and intraneural injection causes
0 Na+ In nerve damage and cell death by mechanical disruption,
1 K +
Out disruption of the blood–nerve barrier, high endoneural
−
pressure (above capillary perfusion pressure) (Fig. 5.4), and
Cl In direct neurotoxicity of local anesthetic agent. This situation
2 Ca 2+
In is further aggravated if the solution contains epineph-
rine.29,30 Therefore it is important to maintain verbal contact
K+ Out
with the patient, avoid paresthesias, administer small incre-
+
3 K Out mental doses of drug, and reposition the needle if pares-
4 Na +
In thesias are elicited.
In attempting to establish the etiology of nerve lesions in
(From Ref. 13, Stoelting RK. Heart. In: Pharmacology and physiology in the postoperative period, the differential diagnosis must
anesthetic practice. 2nd ed. Philadelphia: © JB Lippincott; 1991.) initially take into account patient positioning, tourniquet
use, surgical trauma, and the presence of tight casts or dress-
models, and the publication of case reports demonstrating ings.31–33 Follow-up of the patient in the immediate post-
similar effects in humans, ASRA has published a practice operative period will help to avoid inaccurate labeling of
advisory outlining the evidence and providing guidance. the deficit as ‘anesthesia-related’.
Peripheral vasculature Allergic reactions

Local anesthetic drugs have a biphasic action on vascular Allergic reactions to local anesthetics occur rarely.34 Indeed,
smooth muscle.23 At low concentrations they produce most ‘allergic reactions’ to local anesthetics are in fact
vasoconstriction. As the concentration increases, the effect adverse reactions. Nevertheless, para-aminobenzoic acid is
becomes one of vasodilatation. These observations have a product of the hydrolysis of ester local anesthetics and is
33
PART I Principles
Table 5.3 Survey of reported neuropathies after upper extremity block*

Reference Block No. of cases Neural complications (%)
Bonica et al (1949)64 Supraclavicular plexus 1100 0
65
Moberg & Dhunér (1951) Supraclavicular plexus 300 5.7
66
Woolley & Vandam (1959) Supraclavicular plexus 106 7.5
67
Brand & Papper (1961) Supraclavicular plexus 230 2.2
68
Schmidt et al (1981) Supraclavicular plexus 342 0.9
69
Brand & Papper (1961) Axillary 246 0.8
De Jong (1961)70 Axillary 94 1.1
71
Hamelberg et al (1962) Axillary 250 1.2
72
Wall (1975) Axillary 431 0.2
73
Moore et al (1978) Axillary and plexus 652 0
74
Selander et al (1979) Axillary paresthesia 290 2.8
Axillary, no paresthesia 243 0.8
Plevak et al (1983)75 Axillary paresthesia 477 2.9
Axillary transarterial 239 0.8
76
Winchell & Wolfe (1985) Axillary 816 0.4
77
Tourtier et al (1989) Axillary paresthesia 758 0.9
Axillary transarterial 642 0.3
78
Davis et al (1991) Axillary 530 0
Stan et al (1995)79 Axillary transarterial 1000 0.2
80
Löfström et al (1966) Intraulnar 25 12
81
Mogensen & Mattsson (1980) Intramedian 53 7.5
*Note the higher frequency of postblock neuropathies with paresthesia technique, which was also used for supraclavicular blocks and after intraneural blocks.
(From Ref. 26, Selander D. peripheral nerve injury after regional anesthesia. In: Finucane, BT (ed). Complications of regional anesthesia. Philadelphia: Churchill
Livingstone, 1999, with permission from the American Society of Regional Anesthesia and Pain Medicine.)
a known allergen.35–37 Allergy to amide local anesthetics is be taken in this regard.40 Unfortunately, no recommenda-
still rarer. However, some preparations contain methylpara- tions exist as to aseptic technique for spinal, epidural, or
ben (an allergen), because of its excellent bacteriostatic and peripheral nerve block.41 A review of the literature serves to
fungistatic properties.38 After a case of allergy to a local highlight the following points:40
anesthetic agent, intradermal testing of the full range of
• The combined use of cap and mask should be encour-
anesthetic agents is worthwhile, because allergy to one
aged for the duration of the procedure. Caps should be
agent does not necessarily imply allergy to another.37,39
required of the patient also.42–47
Infection • Long-sleeved sterile gowns should be used for catheter
The presence of infection at the site of puncture is generally techniques.48
accepted as being a contraindication to regional anesthesia. • Effective hand-washing is the single most cost-effective
The paucity of reports detailing infective complications of part of any aseptic techniques. Only nails and subun-
peripheral nerve block suggests that local and generalized gual regions should be brushed.49
infections following nerve blocks are rare. Disastrous infec- • Chlorhexidine and polyvinylpyrrolidone-iodine (PVPI)
tive complications continue to be reported following central are equally effective.50
neuraxial block, however, and the increasing use of periph- • Hand-washing must precede the donning of sterile
eral nerve catheters suggests some elementary precautions gloves, because microperforations can occur.
34
CHAPTER
Myotoxicity of local anesthetics

Intraneural 800 Injection of local anesthetic into muscle results in focal
pressure 700 necrosis; the more potent the agent, the greater the degree
(ng/mL) of injury that results. This effect is localized and regeneration
600
500 has been shown to be complete within 2 weeks. The changes
are of a subclinical nature and do not appear to contribute
400
to the peri-operative morbidity of regional anesthesia.56
300
Some concern has been raised, however, regarding the role
200
of local anesthetic drugs in the development of diplopia
100
following cataract surgery performed under regional anes-
0 thesia. A 0.25% incidence of diplopia related to anesthetic
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
factors has been reported.57 It appears to be more common
Time (min) following peribulbar block than retrobulbar block and does
not occur following topical or general anesthesia. The infe-
rior rectus muscle is typically involved following infraorbital
Figure 5.4 Recordings of intraneural pressure during and after injec- injection. Possible mechanisms underlying this complica-
tion of 100 µL in the sciatic nerve of a rabbit using an injection pump.
Note the slow pressure decrease after intrafascicular injection. Green
tion are direct muscle injury from the block needle, vascular
line, intrafascicular injection; blue line, epineural injection; arrows, start compromise secondary to elevated local pressures, and myo-
and end of injection; orange line, estimated endoneural capillary perfu- toxicity of the local anesthetic.
sion pressure. (From Ref. 26, Selander D. Peripheral nerve injury after
regional anesthesia. In: Finucane, BT (ed). Complications of regional
anesthesia. Philadelphia, Churchill Livingstone, 1999, with permission
from the American Society of Regional Anesthesia and Pain Medicine.)
Safe conduct of regional anesthesia
Patient selection
Appropriate patient selection for a regional anesthetic tech-
nique involves consideration of patient factors, the medical
• The European Committee for Standardization recom- history, specific investigations, psychological preparation,
mends 60% isopropanol, in two portions of 3 mL the planned surgical intervention, and the expertise of the
each applied as a hand-rub for 60 s, as the most effec- anesthesiologist.
tive method of reducing bacteria. No solution is When general anesthesia poses serious risks – for example
sporicidal.51 in the patient with a full stomach, difficult airway, or poor
• The American Society of Anesthesiologists recommends general medical condition – regional anesthesia is quite
PVPI, chlorhexidine, iodine tincture, or ethanol 70% for often the anesthetic technique of choice. However, there are
skin asepsis. A skin contact period of at least 2 min is various medical conditions where the choice of anesthetic
required for any to be effective.52 technique remains controversial. These include degenera-
• Chlorhexidine appears to have a more prolonged effect tive neurologic disease, diabetes, and severe cardiovascular
and should be used when an indwelling catheter is and respiratory disease. These conditions are dealt with in
inserted.53 more detail in Chapter 4. As for all patients, a thorough
• When aspirating drugs from non-sterile ampoules, a pre-anesthetic medical and laboratory evaluation is indi-
0.2-µm filter should be used to avoid contamination cated in order to perform an appropriate risk–benefit
from small glass fragments, and the ampoules should analysis.
be wiped with alcohol before opening.54 Morbid obesity, physical deformities, arthritis, fractures,
local infection, or locally enlarged lymph glands may serve
Neural toxicity of local anesthetics to hinder the administration of an adequate block and so
All clinically used local anesthetic agents are potentially should be noted prior to the formulation of an anesthetic
toxic at high concentrations. Under normal conditions, the plan. The disoriented or psychologically deranged patient
drug is rapidly diluted and absorbed. However, if the nerve may not only make intra-operative management difficult,
is ischemic or the drug is injected intraneurally, the nerve but render the safe performance of a block impossible. A
is exposed to greater than normal concentrations of local history of concurrent medication, such as anticoagulants
anesthetic and for a longer than expected period of time. (Box 5.1) or vasoactive drugs, should also be taken into
This situation is exacerbated with epinephrine-containing account because of the implications for the performance
solutions.55 Lidocaine was shown to have a greater neuro- and administration of regional anesthesia (see Ch. 4).
toxic potential in this regard than the other clinically used The evaluation of the patient must also include systemic
agents. disease, current medications, previous anesthetics, allergies,
35
PART I Principles
Box 5.1 Table 5.4 Example of fasting protocol for sedation and
analgesia for elective procedures*
Precautions for combined use of anticoagulants and
neuraxial block Solids and non- Clear
• Strict patient selection to exclude other possible bleeding Patient group clear liquids† liquids
diastheses Adults 6–8 h or none after 2–3 h
• Perform regional anesthesia only when clotting variables 12 midnight‡
are acceptable
Children >36 months old 6–8 h 2–3 h
• Use atraumatic technique; if tap bloody, postpone surgery
and perform under general anesthesia 24 h later Children 6–36 months 6h 2–3 h
• Full heparinization no sooner than 60 min after initiation old
of block
Children <6 months old 4–6 h 2h
• Monitor clotting times throughout and maintain 1.5–2
times baseline value; reverse heparin effect if necessary *Gastric emptying may be influenced by many factors including anxiety,
• Remove spinal or epidural catheters at least 120 min after pain, abnormal autonomic function (e.g. diabetes), pregnancy, and
mechanical obstruction. Therefore the suggestions above do not guarantee
stopping heparinization and with normal clotting time that complete gastric emptying has occurred. Unless contraindicated,
• Maintain strict neurologic surveillance. children should be offered clear liquids until 2–3 h before sedation to
minimize the risk of dehydration.
†
This includes milk, formula, and breast milk. (High fat content may delay
(From Ref. 58, Vandermeulen EP, VanAken H, Vermylen J: Anticoagulants gastric emptying.)
‡
and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165.) There are no data to establish whether a 6–8-h fast is equivalent to an
overnight fast prior to sedation or analgesia.
(From the American Society of Anesthesiologists,61 with permission of ASA.)
state of dentition, and family history. Occasionally it may shown to result in no significant difference in mean resid-
be necessary to convert a regional to a general anesthetic ual gastric volume or pH.60 As a consequence, a number
technique. Therefore all the information relevant to provi- of organizations have amended their fasting guidelines
sion of general anesthesia should be obtained. (Table 5.4).61
The patient interview allows one to obtain the relevant
information outlined above; it is also an opportunity to Equipment
prepare the patient psychologically for the procedure and In 1986, the Department of Anesthesia of Harvard Medical
the peri-operative experience in general and to obtain School published detailed, mandatory standards for
informed consent. Informed consent implies that the mate- minimal patient monitoring during anesthesia.62 For the
rial risks and benefits of the proposed procedure have been safe conduct of regional anesthesia, in addition to the pres-
explained, as well as those of the available alternatives. ence of an anesthesiologist or nurse anesthetist, the follow-
When one explains the reasons for choosing one technique ing equipment should be available and used:
over another, and when appropriate assurances as to the • pulse oximeter
standard of care are given, most patients will accept regional
• blood pressure monitor
anesthesia. Assurances as to the availability of block supple-
mentation and sedation up to the level of general anesthe- • ECG monitor
sia should be given, as well as a detailed description of the • peripheral nerve stimulator and/or ultrasound machine.
performance of the block(s). Patients may perceive sensa- The equipment included in Box 5.2 should also be available
tions of an unusual or bizarre nature under regional anes- for immediate use, and a checklist performed prior to anes-
thesia; therefore, explanation, reassurance, and appropriate thesia. In addition, the nerve stimulator to be used should
sedation should be provided. Most patients who have be checked according to the manufacturer’s instructions
benefited from a well-executed regional anesthetic will prior to each use.
choose the same technique for future interventions when
possible.59 Injection and safe practice
Pre-operative fasting Once the needle has been correctly located, slow, deliberate
Traditionally, adult patients scheduled for a surgical inter- injection should be made of no more than 5 mL at a time.
vention were required to abstain from both oral solids and The injection should be discontinued and the needle repo-
fluids for a minimum of 6h, and, more often, from mid- sitioned immediately if the patient complains of pain or
night the night before. However, unrestricted clear fluids paresthesia. Low pressure local anesthetic injections can be
(water and apple juice) up to 2 h before surgery have been made by using the compressed air injection technique.82
36
CHAPTER
Box 5.2
Pre-anesthetic checklist
A Gas pipelines 5. Functioning high-pressure relief valve.
Secure connections between terminal units (outlets) and anes- 6. Unidirectional valves and soda lime.
thetic machine. 7. Functioning adjustable pressure relief valve.
B Anesthetic machine D Vacuum system

1. • Suction adequate.
• Turn on machine master switch and all other necessary E Scavenging system
electrical equipment
• Correctly connected to patient circuit and functioning.
• Line oxygen (40–60 p.s.i., 275–415 kPa)
• Line nitrous oxide (40–60 p.s.i., 275–415 kPa) F Routine equipment
• Adequate reserve cylinder oxygen pressure 1. Airway
• Adequate reserve cylinder nitrous oxide content • Functioning laryngoscope (backup available)
• Check for leaks and turn off cylinders • Appropriate tracheal tubes: patency of lumen and
• Flow meter function of oxygen and nitrous oxide over integrity of cuff
the working range. • Appropriate oropharyngeal airways
2. • Stylet
• Vaporizer filled • Magill forceps.
• Filling ports pin-indexed and closed 2. IV supplies.
• Ensure ‘on/off’ function and turn off. 3. Blood pressure cuff of appropriate size.
3. Functioning oxygen bypass (flush). 4. Stethoscope.
4. Functioning oxygen failsafe device. 5. ECG monitor.
5. 6. Pulse oximeter.
• Oxygen analyzer calibrated and turned-on functioning 7. Capnograph.
mixer (where available) 8. Temperature monitor.
• Attempt to create a hypoxic O2/N2O mixture and verify 9. Functioning low- and high-pressure alarm.
correct changes in flow and/or alarm.
6. Functioning common fresh gas outlet. G Drugs
7. Ventilator function verified. 1. Adequate supply of frequently used drugs and i.v. solutions.
8. Backup ventilation equipment available and functioning. 2. Appropriate doses of drugs in labeled syringes.
Note: If an anesthetist uses the same machine in successive H Location of special equipment in each anesthetizing
cases, departmental policy may permit performing an abbrevi- location
ated checklist between cases.
1. Defibrillators.
C Breathing circuit 2. Emergency drugs.
1. Correct assembly of circuit to be used. 3. Difficult intubation kit.
2. Patient circuit connected to common fresh gas outlet.
3. Oxygen flow meter turned on. (From Ref. 63, McIntyre JWR. Regional Anesthesia Safety. In: Finucane BT
4. (ed). Complications of Regional Anesthesia. Philadelphia, Churchill
• Check for exit of fresh gas at face mask Livingstone, 1999, with permission from the American Society of
• Pressurize. Check for leaks and integrity at circuit (e.g. Regional Anesthesia and Pain Medicine.)
Pethick text for coaxial).
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PART I Principles
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disposable face masks. J Clin Pathol 1980;33:1086– 61. American Society of Anesthesiologists. Guidelines for
1091. sedation and analgesia by non-anesthesiologists. Park
47. Panikkar KK, Yentis SM. Wearing of masks for Ridge, IL: ASA; 1999:3–11.
obstetric regional anesthesia: a postal survey. 62. Eichhorn JH, Cooper JB, Cullen DJ. Standards for
Anaesthesia 1996;51:398–400. patient monitoring during anesthesia at Harvard
48. Sleth JC. Evaluation des mesures d’asepsie lors de la Medical School. JAMA 1986;256:1017–1020.
realisation d’un catheterisme epidural et perception 63. McIntyre JWR. Regional anesthesia safety. In:
de son risque infectieux. Resultats d’une enquête Finucane BT, editor. Complications of regional
en Languedoc-Roussillon. Ann Fr Anesth Reanim anesthesia. Philadelphia: Churchill Livingstone;
1998;17:408–414. 1999:1–30.
49. Handwashing Liaison Group. Hand washing: a 64. Bonica JJ, Moore DC, Orlov M. Brachial plexus block
modest measure – with big effects. Br Med J anesthesia. Am J Surg 1949;78:65.
1999;318:686. 65. Moberg E, Dhunér K-G. Brachial plexus block
50. Mimoz O, Karim A, Mercat A, et al. Chlorhexidine analgesia with xylocaine. J Bone Joint Surg 1951;
compared with povidone iodine as skin prep 33A:884.
before blood culture. Ann Int Med 1999;131:834– 66. Wooley EJ, Vandam LD. Neurological sequelae of
837. brachial plexus nerve block. Ann Surg 1959;149:
51. Rotter ML. Hand washing and hand disinfection. 53–60.
In: Mayhall CG, editor. Hospital epidemiology and 67. Brand L, Papper EM. A comparison of supraclavicular
infection control. 2nd edn. Philadelphia: Lippincott and axillary techniques for brachial plexus blocks.
Williams & Wilkins; 1999:1339–1355. Anesthesiology 1961;22:226–229.
39
PART I Principles
68. Schmidt E, Racenberg E, Hilderbrand G, et al. 76. Winchell SW, Wolfe R. The incidence of neuropathy
Komplikationen und gefahren der plexus-brachialis- following upper extremity nerve blocks. Reg Anesth
anästhesie unter besonderer Berücksichtiging von 1985;10:12–15.
Langzeitschaden. Anästh Intensivther Notfallmed 77. Tourtier Y, Rébillion M, Delort J, et al. Complications
1981;16:346–349. of axillary block using two techniques: experience
69. Brand L, Papper EM. A comparison of supraclavicular with 1400 cases. Anesthesiology 1989;71:A726.
and axillary techniques for brachial plexus blocks. 78. Davis WJ, Lennon RL, Wedel DJ. Brachial plexus
Anesthesiolog 1961;22:226–229. anesthesia for outpatient surgical procedures on an
70. De Jong RH. Axillary block of the brachial plexus. upper extremity. Mayo Clinic Proc 1991:66:544–
Anesthesiology 1961;22:215–225. 547.
71. Hamelberg W, Dysart R, Bosomworth P. Perivascular 79. Stan TC, Krantz MA, Solomon DL, et al. The
axillary versus supraclavicular brachial plexus block incidence of neurovascular complications following
and general anesthesia. Anesth Anal 1962;41;85–90. axillary brachial plexus block using a transarterial
72. Wall JJ. Axillary nerve blocks. Ann Sur 1959;149: approach. Reg Anesth 1995;20:486–492.
53. 80. Löfström B, Wennberg A, Widén L. Late disturbances
73. Moore DC, Bridenbaugh LD, Thompson GE, et al. in nerve function after block with local anesthetic
Bupivacaine: a review of 11,080 cases. Anesth Anal agents. Acta Anesth Scand 1966;10:111–122.
1978:57:42–53. 81. Mogensen BA, Mattsson HS. Posttraumatic instability
74. Selander D, Edshage S, Wolff T. Parasthesiae or no of the metacarpophalangeal joint of the thumb.
parasthesiae? Nerve lesions after axillary blocks. Acta Hand 1980;12:85–90.
Anaesth Scan 1979;23:27–33. 82. Tsui BC, Knezevich MP, Pillay J. Reduced injections
75. Plevak DJ, Linstromberg JW, Danielsson DR. pressures using a compressed air injection technique
Paresthesiae vs non-paresthesiae – the axillary block. (CAIT): an in vitro study. Reg Anesth Pain Med
Anesthesiology 1983;59:A216. 2008;33:168–173.
40
PART I Principles
CHAPTER
6
Peripheral nerve block materials
Frank Loughnane
intensity and duration of current in peripheral nerve stimu-

Nerve stimulators lation (Fig. 6.1).
The total charge applied to the nerve is a product of
In 1911, Stoffel demonstrated how a galvanic current could
the current intensity and the duration of the pulse. The
be applied to identify nerve fibers.1 A year later, Perthes
minimum in vitro quantity of current necessary to generate
described how the use of electrical stimulation could
an action potential can be calculated from the equation
improve the safety of neural block in the practice of
anesthesia.2 I = Ir (1+ C t ).
Nerve stimulation is a popular technique for the location
and identification of nerve fibers, particularly in Europe.3 It I is the current required, Ir the rheobase, C the chronaxie,
was introduced into contemporary practice in 1973 by and t the duration of stimulus. The rheobase is the minimum
Montgomery and Raj against considerable opposition, par- current required to depolarize a nerve when applied for a
ticularly in the USA, where many practitioners advocated long period. The chronaxie is the duration of impulse nec-
the dictum ‘no paresthesia, no anesthesia’.4,5 Nerve stimula- essary to stimulate at twice the rheobase.
tion, through the intentional avoidance of direct contact The chronaxie of a motor nerve is less than that of a
with the nerve fiber, aims to reduce the risk of neurologic sensory nerve. In the clinical setting, therefore, a motor
complications. However, the relations between stimulating response may be elicited without stimulating pain fibers if
current, motor and sensory responses, success rates, and the duration of impulse is short. Sensory nerves may also
needle–nerve distances are far from clear in the clinical be identified using a nerve stimulator if the pulse duration
setting.6–8 The nerve stimulation method produces periph- is greater than 400 µs (Table 6.1).
eral nerve injury in up to three cases in 10 000.9 In contrast, Coulomb’s law:
the transarterial approach to brachial plexus anesthesia pro- E = K ( Q r2)
duces nerve lesions in 0.8% of cases and the paresthesia
approach in 2.8%.10,11 The following is a discussion on the governs the relation between the stimulus intensity and the
theoretical as well as practical aspects of nerve stimulation distance from the nerve. E is the current required, K a con-
and the equipment commonly used to locate nerves. The stant, Q the minimal current, and r the distance. The sig-
reader should remain cognizant of the fact that no defini- nificance lies in the squaring of the distance. While one may
tive study outlining the exact nature of the relationship thus approach the nerve through the progressive diminu-
between the stimulating current and the observed responses tion of current, at distances greater than 0.5 cm from the
in clinical practice exists to date. nerve large currents are required; at greater than 2 cm, cur-
rents of up to 50 mA may be generated. These currents
produce pain locally and require that appropriate care be
Electrophysiology taken in patients with intracardiac electrodes (Table 6.2).
Ohm’s law describes the relation between potential dif-
The electrochemical nature of nerve fiber conduction ference (U), resistance (R), and intensity (I):
renders it amenable to electrical stimulation. The strength–
duration curve demonstrates the relation between the U = R × I.

DOI: 10.1016/B978-0-7020-3148-9.00014-1
PART I Principles
Distal anode
Stimulus (mA) 15
Needle as
cathode
10 Current flow + Charge

++++ - - - -
5
Resultant depolarization
A
Rheobase
0
0 100 200 300 400 500
Chronaxie Pulse duration (ms) Distal cathode
Figure 6.1 Strength–duration curve, cat sciatic nerve. The rheobase is Needle as
cathode
the smallest current to stimulate the nerve with a long pulse width. The
chronaxie is the pulse duration at a stimulus strength twice the rheo-
Current flow Charge
base. The curve was obtained from a cat sciatic nerve with the stimulat- -- - - - +++ - - -
ing needle touching the nerve. (From Pither C, Prithvi R, Ford D. The use
of peripheral nerve stimulators for regional anesthesia. A review of
experimental characteristics, techniques and clinical applications. Reg
Anesth 1985; 10; 49–58, with permission from the American Society of Resultant depolarization
Regional Anesthesia and Pain Medicine.)
B
Figure 6.2 Preferential cathodal stimulation. With the needle as the
cathode (A), electron flow is toward the needle, causing an area of
depolarization around the needle tip. With the needle as anode (B), the
Table 6.1 Chronaxies of mammalian peripheral nerves
area adjacent to the nerve is hypopolarized, with a zone of depolariza-
Nerve fiber type Chronaxie tion in a ring distant to the needle, an arrangement that requires more
current to stimulate the nerve. (From Pither C, Prithvi R, Ford D. The use
Cat sural nerve Aα 50–100 µs13 of peripheral nerve stimulators for regional anesthesia. A review of
experimental characteristics, techniques and clinical applications. Reg
Aδ 170 µs14 Anesth 1985; 10; 49–58, with permission from the American Society of
Cat saphenous nerve C 400 µs15 Regional Anesthesia and Pain Medicine.)
(From Pither C, Prithvi R, Ford D. The use of peripheral nerve stimulators for
regional anesthesia. A review of experimental characteristics, techniques
and clinical applications. Reg Anesth 1985; 10; 49–58, with permission from In practice, U corresponds to the potential difference
the American Society of Regional Anesthesia and Pain Medicine.) between the poles of the nerve stimulator; R corresponds
to the internal resistance of the patient and the resistance
of the cables. The negative electrode is connected to the
needle and the positive to the patient’s skin via a gel elec-
trode. Because the interior of a nerve at rest is negatively
Table 6.2 Calculated values for current required to charged relative to the exterior, if the poles are reversed
stimulate nerve at various distances from the nerve hyperpolarization of the nerve occurs; it is then necessary
to apply a current of greater intensity to achieve the same
Distance (cm) motor response. These currents may be uncomfortable for
the patient (Fig. 6.2, Table 6.3).
On nerve 0.5 1 2
Stimulus 0.1 2.5 10 40
Characteristics
Current* 0.5 12.5 50 200
mA 1.0 25.0 100 400 The characteristics considered desirable in a nerve stimula-
tor are constant current output; digital display; square-
*Current increases to unacceptable levels at distances greater than 2 cm.
(From12 Pither C, Prithvi R, Ford D. The use of peripheral nerve stimulators
shaped, monophasic, negative impulse; variable output
for regional anesthesia. A review of experimental characteristics, techniques control; linear output; clearly marked polarity; short pulse
and clinical applications. Reg Anesth 1985; 10; 49–58, with permission from width; variable stimulation frequency of 1 or 2 Hz; high-
the American Society of Regional Anesthesia and Pain Medicine.)
quality cables and connections; and indicators of power
42
CHAPTER
Peripheral nerve block materials 6
The nerve stimulator should have a variable output

Table 6.3 Polarity of stimulation
control that operates on a linear scale. This means that the
Anodal vs cathodal current output of the device alters in proportion to the movement
required to stimulate of the dial.
peripheral nerve Reference The negative lead must be attached to the needle for
reasons already outlined. By convention, the negative lead
∞ 4.57 BeMent & Ranck, 196916 is colored black and the positive red. To avoid confusion,
∞ 4.3 Ford et al, 198417 clear labeling or non-interchangeable connections are
required.
(From12 Pither C, Prithvi R, Ford D. The use of peripheral nerve stimulators
for regional anesthesia. A review of experimental characteristics, techniques
and clinical applications. Reg Anesth 1985; 10; 49–58, with permission from
the American Society of Regional Anesthesia and Pain Medicine.)
Needles used in peripheral nerve block
The needles used in nerve stimulation have been tradition-
ally classified depending on whether or not they possess an
failure, circuit closure, high circuit resistance, and device
insulating coat. Uninsulated needles are cheaper and may
malfunction.17,18
be less painful on insertion. However, the current emanates
The resistance of the human body, cables, connections,
from the whole of the needle shaft, with the maximum
etc., may vary between 1000 and 20 000 ohms. It is impor-
current density just proximal to the tip. The needle is there-
tant that the current should not vary with these changes in
fore still capable of eliciting a response when the tip has
resistance, i.e. the device should have a constant current
bypassed the nerve. Furthermore, as the current is widely
output. As U = R∞I (U being the potential difference
dispersed through the length of the needle, a greater current
between the poles of the device, R the impedance of the
intensity is required to generate the same electrical charge
external electrical circuit, and I the current intensity), the
at the nerve for any given duration of impulse.
nerve stimulator must be able to deliver a high output
Insulated needles have high precision in locating nerves.
load to avoid a possible 20-fold change in the current
The stimulating current is concentrated in, directed from,
delivered.
and forms a sphere around the needle tip. This is more
A digital display of the current intensity delivered is
likely to result in accurate delivery of local anesthetic solu-
important as one approaches the nerve with very small cur-
tion. These needles are relatively expensive and skin punc-
rents. Knowledge of the precise intensity is vital for accurate
ture tends to be more difficult and uncomfortable for the
nerve location. A final current intensity of 0.5 mA or less
patient. This group of needles may be further subdivided
is associated with a high success rate in brachial plexus
into those with a coated or an uncoated bevel. Needles with
anesthesia.19
a coated bevel have the stimulating current more densely
The current impulse needs to be square-shaped, mono-
concentrated at the needle tip, resulting in more precision
phasic, and negative. The amplitude corresponds to the
and the requirement for less current to stimulate the nerve
intensity of the electric current and is expressed in milliam-
(Figs 6.3 and 6.4).20,21 Figure 6.5 illustrates the basic materi-
peres (mA); the duration is measured in ms or µs. It is
als required for the performance of a peripheral nerve
important to have a short ascent and descent time to
block.
the impulse because the charge applied to the nerve is a
product of the current and the duration. Therefore the more
square-shaped the signal, the greater the precision of the Peripheral nerve catheters
instrument.
To be able to choose between several pulse widths is The first use of peripheral nerve catheters in the manage-
equally of value. A short pulse width of 50–100 µs is neces- ment of acute and chronic pain was described in 1946.22
sary because this corresponds to the chronaxies of mam- Initially, ureteral lacquered silk catheters were used. Devel-
malian Aα fibers (see Table 6.1). According to Coulomb’s opments in material technology have now provided us with
law, the electrical field produced for a current intensity of nylon, polyurethane, and Teflon catheters of high quality.
constant duration is inversely proportional to the square of These modern catheters are packaged with an appropriately
the distance: sized stimulating short bevel or Tuohy needle. For example,
an 18-G needle will accompany a 20-G catheter.
E = K ( Q r2)
Catheters used for continuous peripheral nerve block
(see previous section, Electrophysiology). Therefore one need to be relatively stiff and blunt. This is in contrast
may bring the needle tip closer to the nerve through the to those used for neuraxial block, which need to be
progressive diminution of current intensity. Conversely, as pliable and resistant to kinking and knotting. While
one moves away from the nerve, currents of high intensity nylon catheters may be degraded by phenol and ethanol,
are required to stimulate the nerve. this problem does not occur with Teflon catheters.
43
PART I Principles
A B
Figure 6.3 Computer-simulated models for zones of current density Figure 6.5 Materials required for the performance of peripheral nerve
around the tips of insulated and uninsulated needles. The center of B is block.
just proximal to the needle tip and most of the zone extends up the
needle shaft. (From Bashein et al 1984,20 with permission.)
Uncoated
needle
Stimulation 10
current
9
(mA)
8
7
6
5
4
Coated needle,
3
bevel uncoated
2
1
0
-10 0 +10
Time (min)
Figure 6.4 Comparison of current required to stimulate nerve against Figure 6.6 Device for continuous plexus block featuring auto delivery
distance from nerve for various needle types. (From B. Braun Medical large volume patient-controlled analgesia and flow-rate selection.
Inc. Technical aspects of peripheral electrical nerve stimulation. Online.
Available: http://www.bbraunusa.com/stimuplex/pens1.html)
Fortunately, local anesthetics appear to have no such tion between final catheter tip position and the stimulating
degrading effects.23 needle tip position is often far from clear. A variety of
Catheters capable of nerve stimulation have been mar- cost-effective devices are available that allow continuous
keted.24 These devices may result in higher success rates in infusions of local anesthetic agents. Those with a patient-
catheter placement; as with the current systems of advanc- controlled bolus facility and variable flow rate selectors,
ing the catheter through or over the block needle, the rela- such as in Fig. 6.6 allow great flexibility.
44
CHAPTER
Peripheral nerve block materials 6
Ultrasound in the practice of regional anesthesia guaranteed. Nevertheless, the reported success rates are
similar to those with other techniques.25 Furthermore, the
The first report on the use of ultrasound as an aid to nerve loss of resolution at greater depths renders the technology
location appeared in the anesthesiology literature in 1978.25 less accurate for blocks such as that of the psoas compart-
Since the mid 1990s, such reports have become more ment. Devices with the lower frequency of 3.5–5 MHz are
common as the standard of equipment has improved, costs required to penetrate these depths.
have decreased, and more portable equipment has become The value of this technology has been demonstrated in
available. Ultrasound has been used as an aid in the per- avoiding pneumothorax in infraclavicular blocks by allow-
formance of blocks of the celiac plexus, psoas compart- ing one to visualize the position of the needle tip in relation
ment, stellate ganglion, and others. However, it is in to vital structures.28,29 It has led to recommendations for the
brachial plexus anesthesia that interest has concentrated. modification of some approaches depending on patient
size, obesity, and sex.30 It may permit the use of smaller
anesthetic volumes and result in a higher success rate and
Fundamentals of ultrasonography the speedier performance of some blocks.31
Sound waves above a frequency of 20 000 Hz are ultra- Ultrasound-guided regional anesthesia (UGRA) has now
sound. An ultrasound device can convert electrical current moved into mainstream clinical practice. Miniaturization
into sound waves and sound waves into electrical current. and increases in processing power have resulted in extremely
It thus acts as both transmitter and receiver. The velocity of powerful machines being available at the point of patient
transmission of sound waves in a medium depends on the contact. The newer challenges are attainment and mainte-
acoustic impedance of that medium, which in turn depends nance of competence in UGRA, the facilitation of clinical,
on the density of the medium. When sound waves reach educational, and research interests, and the detection of
two materials of different acoustic impedance, they are sonopathology evident during ultrasound scanning.
reflected back to different degrees. The greater the imped-
ance, the greater the reflectivity of this signal and the
brighter the image seen on the screen. In contrast, fluids References
transmit sound perfectly and so generate no echoes.26
If the emitting source moves away from the receiver, the 1. Stoffel A. Eine neue Operation für spastische
detected frequency of the wave decreases, and similarly Lähmungen. Münch Med Woch 1911;47:2493–2498.
increases as the source moves toward the receiver. This is 2. Perthes G. Ueber Leitunganästhesie unter
known as the Doppler effect. In practice, the Doppler effect zuhilfenahme elektrischer reizung. Münch Med Woch
is used to measure the velocity of blood within a vessel. In 1912;47:2545–2548.
order to identify complex structures such as the brachial 3. Benhamou D. Axillary plexus block using multiple
plexus, high-resolution devices are required with perfor- nerve stimulation: a European view. Reg Anesth Pain
mance in the 7.5–10 MHz range. Availability of the Doppler Med 2001;26:495–498.
effect will permit the identification of vascular structures, 4. Montgomery SJ, Raj PP, Nettles D, et al. The use of
which may further aid in the location of nerve fibers. the nerve stimulator with standard unsheathed
needles in nerve blockade. Anesth Analg
1973;52:827–831.
Clinical application 5. Raj PP. Ancillary measures to ensure success. Reg
Anesth 1980;5:9–12.
To interpret the images obtained with ultrasound devices,
it is necessary in the first instance to have a thorough 6. Gold SJ, Duthie DJR. Nerve stimulator current
knowledge not only of the topographic anatomy of the and regional nerve block efficacy. Br J Anaesth
area of interest but also of the cross-sectional anatomy. 2001;86:321.
Ultrasound permits one to explore three-dimensional 7. Riegler FX. Brachial plexus block with the nerve
spaces non-invasively, but only two of these dimensions are stimulator: motor response characteristics at three
visible at any one time. A period of training is therefore sites. Reg Anesth 1992;176:295–299.
necessary to appreciate the benefits of this technology. 8. Urmey WF, Stanton J, O’Brien S, et al. Inability to
In regional anesthesia, ultrasound has been variously consistently elicit a motor response following sensory
used to identify and mark the skin over blood vessels, to paresthesia during interscalene block administration.
guide the needle or catheter to the nerve, to avoid vital Reg Anesth 1998;23:7–57.
structures, to visualize the spread of local anesthetics, and 9. Auroy Y, Benhamou D, Bargues L, et al. Major
to validate currently used landmarks.27 complications of regional anesthesia in France.
Despite confirmation of correct needle and catheter posi- The SOS regional anesthesia hotline service.
tion with ultrasound, a 100% clinical success rate is not Anesthesiology 2002;97:1274–1279.
45
PART I Principles
10. Plevak D, Linstromberg J, Danielsson D. Paresthesia 22. Ansboro F. Method of continuous brachial plexus
vs non-paresthesia – the axillary block. block. Am J Surg 1946;71:716–722.
Anesthesiology 1983;59:A216. 23. Gale DW, Ramamurthy S, Valley MA. Commonly
11. Selander D, Edshage S, Wolff T. Parasthesiae or no used neurolytic solutions significantly degrade nylon
parasthesiae? Nerve lesions after axillary blocks. Acta but not Teflon epidural catheters. Reg Anesth 1996;
Anaesth Scand 1979;23:27–33. 21:S51.
12. Pither C, Prithvi R, Ford D. The use of peripheral 24. Copeland SJ, Laxton MA. A new stimulating catheter
nerve stimulators for regional anesthesia. A review of for continuous peripheral nerve blocks. Reg Anesth
experimental characteristics, technique and clinical Pain Med 2001;26:589–590.
applications. Reg Anesth 1985;10:49–58. 25. La Grange P, Foster P, Pretorius L. Application of
13. Shaefer J. Elektrophysiologie I. Wein: Franz Deufficke; the Doppler ultrasound blood flow detector in
1940. supraclavicular brachial plexus block. Br J Anaesth
14. Casey K. Which elements are excited in electrical 1978;50:965–967.
stimulation of mammalian central nervous system: a 26. De Andres J, Sala-Blanch X. Ultrasound in the
review. Brain Res 1975;98:417–440. practice of brachial plexus anesthesia. Reg Anesth
15. Koslow M, Bak A, Li C. C fibre excitability in the cat. Pain Med 2002;27:77–89.
Exp Neurol 1973;41:745–753. 27. Peterson MK, Millar FA, Sheppard DG. Ultrasound-
16. BeMent SL, Ranck JB. A quantitative study of guided nerve blocks [editorial]. Br J Anaesth 2002;88:
electrical stimulation of central myelinated fibers. 621–624.
Expo Neurol 1969;24:147–170. 28. Kapral S, Krafft P, Eisenberger K, et al. Ultrasound-
17. Ford D, Pither C, Raj P. Electrical characteristics of guided supraclavicular approach for regional
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18. Galindo A. Electrical localization of peripheral nerves: 29. Ootaki C, Hyashi H, Amano M. Ultrasound-guided
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2001;26:478–483. assessment of topographic anatomy in volunteers
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1984;63:919–924. Ultrasonographic guidance improves sensory block
21. [Anonymous]. Technical aspects of peripheral and onset time of three-in-one blocks. Anesth Analg
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http://www.bbraunusa.com/stimuplex/pens1.html.
46
PART I Principles
CHAPTER
Principles of ultrasound-guided
7
regional anesthesia
Vladimir Alexiev · Dominic Harmon
The ability to use ultrasound guidance for regional anesthe- angle. When the ultrasound beam hits a needle at an
sia is achieved by systematic learning and maintained by inappropriate angle, the reflected wave will not reach
regular practice. Knowledge of anatomy is paramount for the transducer and there will be no image of the
the successful practice of regional anesthesia. In order to needle (Fig 7.2).
visualize this anatomy, one has to know how to use an Why cannot I see the deeper structures?
ultrasound machine. We hope this chapter will give the Tissues absorb ultrasound waves. The higher the
reader the knowledge and impetus to make better use of frequency, the higher the absorption. Thus high
their ultrasound equipment, but it takes learning from frequency transducers are less suitable for visualization
more experienced colleagues, practice, self-discipline and of deeper structures (Fig 7.3).
reflection to get one’s skills to an adequate level. Why is the artery blue?
The color Doppler allows us to visualize moving particles.
When the particles move towards the ultrasound
Introduction to ultrasound transducer by convention they are visualized in red,
when they move away from the ultrasound transducer,
Ultrasound is a mechanical wave with frequencies over in blue. Thus, if we orient the ultrasound transducer
20 000 Hz. Ultrasound used in medicine is generated and against the flow, we get red image of the respective
sensed by piezoelectric crystals. The ultrasound transducer vessel. The same vessel will visualize blue if we turn
incorporates a battery of piezoelectric crystals. When scan- the ultrasound transducer in the direction of the flow
ning, the transducer switches quickly between transmitter (Fig 7.4).
and receiver modes. When in transmitting mode, the piezo-
electric crystals are stimulated by electrical energy, vibrate
and emit ultrasound waves. In the receiver mode the crys-
tals are hit by the ultrasound waves reflected from the Ultrasound physics
tissues (Fig 7.1). The resultant mechanical stimulation of
the crystals is converted to electrical signals, which are pro- Imaging modes. There are multiple imaging modes (A, B
cessed and ultimately create the image we see on the screen. and M-mode, various Doppler modes – color, pulsed
wave, continuous wave, etc.). B-mode is the imaging
mode most commonly used in regional anesthesia.
Why understanding ultrasound physics and how to B-mode or ‘brightness’ imaging produces a two-
use an ultrasound machine is important dimensional image with a different grey scale between
black and white. Structures appear hypoechoic (dark)
Here are some examples: or hyperechoic (bright) and shades in between.
Why don’t I see my needle? Frequency. Ultrasound waves can be of different
When a sound wave hits a reflective surface, the resultant frequency. The higher frequency waves produce better
reflection is at an angle corresponding to the incidence spatial resolution and thus allow us to see anatomic

DOI: 10.1016/B978-0-7020-3148-9.00015-3
PART I Principles
Alternating electrical current stimulates

the crystals
Piezoelectric crystals
Emitted ultrasound waves
A Scanned area
Electrical signals from the crystals to

the processing unit A
Piezoelectric crystals
Reflected ultrasound waves
B Scanned area
Figure 7.1 (A) Stimulated by alternating electric current, the piezoelec-

tric crystals vibrate and emit ultrasound waves. (B) The reflected waves
hit back the crystals, which undergo conformational changes and gen-
erate electric current.
Figure 7.3 (A). High frequency transducer: deep structures do not

visualize due to the absorbtion of the ultrasound. Note the good resolu-
tion at superficial level. (B) Low frequency transducer: deep structures
visualized due to the better penetration of the ultrasound. Note the
image has lower resolution, compared with Fig. 7.3A.
Incidence angle 90° Incidence angle 80°
A B
structures in greater detail (Fig 7.3). As a downside,
the high frequency waves have low tissue penetration
due to their higher tissue absorption. Thus, when
visualising deeper structures, lower frequency waves
are more useful (Fig 7.3). Ultrasound transducers have
either fixed or adjustable frequencies. It is important
to use an ultrasound transducer appropriate for the
depth of the block.
The Doppler shift effect. When a sound wave hits a
Incidence angle 30°
stationary object, the reflected wave has the same
C frequency. When a sound wave hits an object that
Figure 7.2 (A) Impact angle 90°: the reflected beam reaches the trans-
is moving, the reflected wave changes its frequency.
ducer and generates good image. (B) Impact angle 80°: there is partial This is depicted in Figure 7.5. When the object (for
loss of signal and the image is degraded. (C) Impact angle 30°: the example, a red blood cell) is moving towards the
reflected signal does not reach the transducer and the image is lost. ultrasound transducer, the reflected waves will have
48
CHAPTER
Principles of ultrasound-guided regional anesthesia 7
Transducer Emitted wave
Reflected wave
Direction of
A moving object
Transducer Emitted wave
A Reflected wave
Direction of
B moving object
Figure 7.5 (A) When the object is moving towards the transducer, the
reflected waves have increased frequency. (B) When the object is
moving away from the transducer, the reflected waves have lower
frequency.
a higher frequency than the original. When using

Color Doppler mode imaging, this increase in
frequency is visualized on the screen by convention
in red. When the object is moving away from the
transducer, the reflected waves have a lower frequency
B than the original, and this change is depicted in blue.
If the ultrasound beam is perpendicular to the moving
object, the reflected waves will not show any shift in
frequency and there will be no color depicted on
the screen. Thus, depending on the orientation of the
transducer, the same blood vessel can appear red,
blue, or black (Fig 7.4).
Absorption and gain. Ultrasound waves are partially
absorbed by tissues and their energy converted to heat.
This results in a reduction of the signal subsequently
reflected and available for detection by the ultrasound
transducer. In order to compensate for the absorbed
waves, ultrasound machines amplify the reflected
signals (gain) (Fig. 7.6). The operator can control
gain. Gain can be adjusted at different depths of the
scanned area, optimizing the resultant image.
Reflection. When an ultrasound wave hits a tissue
C
interface, a proportion is reflected. The extent of
Figure 7.4 (A) Transducer tilted against the direction of the flow: the reflection depends on the extent of difference between
artery is visualized in red. (B) Transducer tilted in the direction of the the acoustic impedances at the interface. Tissue
flow: the artery is visualized in blue. (C) Transducer perpendicular to impedances are shown in Table 7.1. We want to
the flow: there is no Doppler shift and the artery is visualized in black. achieve minimal reflection at the transducer-skin
interface (thus the importance of using coupling gel
to eliminate the air under the ultrasound transducer)
49
PART I Principles
A
B
Figure 7.7 Scan of the axilla. L: fat tissue; B: bone; M: muscle; F: fascia;
V: vessel; N: nerve.
Table 7.1 The acoustic impedances of selected

body tissues
Tissue Acoustic impedance (g/cm2 sec × 100)
Air 0.0004
Fat 1.3
Water 1.5
Blood 1.6
B Muscle 1.7
Bone 7
and optimal reflection from the structures we are

interested in.
The angle of reflected waves depends on the angle of the
incident waves. Ideally, the incident wave will hit the
area of interest at a 90° angle and thus the reflected
waves will return to the transducer to be processed
and visualized. Any angle different from 90° will
result in a suboptimal image (Fig. 7.2).
Tissue echogenicity. Highly reflective tissues (e.g. bone,
fascias) produce bright images (hyperechoic);
moderately reflective tissues (e.g. muscle) produce
moderate intensity images (hypoechoic), while fluid
C
filled spaces (vessels) visualize as dark images
Figure 7.6 (A) Insufficient gain. Note the deep structures are not visual- (anechoic) (Fig. 7.7). When assessing tissue
ized well. (B) Optimal gain. Note the overall good resolution and the echogenicity one has to take into account depth. Due
improved visualization of the deeper structures. (C) Excessive gain. Note to absorption, the deeper the structure, the more
the blurred image resulting in poor resolution. hypoechoic it may appear (despite not being
hypoechoic strictly speaking) unless depth-adjusted
gain is used to compensate for the absorption.
50
CHAPTER
The control unit

The ultrasound machine
The control unit allows for adjusting the depth of the image,
The ultrasound machine consists of a transducer (acting as the gain, focus, to select different visualization modes etc.
transmitter and receiver), main unit (generating pulses for (Fig. 7.9).
the transmitter, processing the impulses from the receiver, Selecting the appropriate depth is the first step when
control unit, memory) and a display. scanning. The target structure should be in the center of the
imaging field where the best resolution is possible. Depth
The transducer should also accommodate other important anatomical
Transducers vary in size, shape, frequency range and number relations.
of piezoelectric crystals. For superficial blocks, a high fre- By manipulating the gain one can improve the image
quency transducer (7–15 MHz) will provide better axial quality. This may involve increasing as well as decreasing
resolution (i.e. better ability to distinguish as separate struc- the gain (Fig. 7.6).
tures dots lying along the path of the ultrasound beam) The focus refers to the depth at which best lateral resolu-
(Fig. 7.3). The more piezoelectric crystal elements, the better tion is achieved (lateral resolution refers to the ability to
the resolution. A lower frequency transducer (1–5 MHz) is visualize two dots lying side by side as separate). The trans-
more appropriate for deeper blocks as there is less absorp- ducers come with preset or adjustable focus depth. In either
tion and thus better signal from the deeper structures (Fig. case, the operator should try to match the focus depth with
7.3). Transducers with a small footprint (i.e. hockey stick the depth of the object of interest.
transducers) are useful in children or where space is limiting Ultrasound machines come with a selection of scanning
(Fig. 7.8). Wider (with large footprint) and curvilinear trans- modes optimized for different applications (nerve block
ducers (sector) allow for visualization of a bigger area and mode, vascular mode, echocardiography mode etc.).
thus may be helpful in visualizing landmark structures at Spatial compound imaging is based on combining
the same time as the nerves of interest (Fig. 7.8). images taken at different beam angles into one final
image. This technique allows for better visualization of the
scanned area.
Beam steering allows for adjustment of the angle of the
ultrasound beam leaving the transducer. This is helpful in
needle visualization.
Ultrasound tissue appearance

Fat tissue is usually located most superficially (appears on
top of the screen), is hypoechoic with interspersed irregular
brighter lines of connective tissue (Fig 7.7).
Depth
Gain
Imaging mode
B
Figure 7.9 The control unit. Note the controls for setting depth, gain,
Figure 7.8 (A) A hockey stick transducer. (B) A curvilinear transducer. imaging mode etc.
51
PART I Principles
Muscle is hypoechoic (though appears brighter than the the arteries). Doppler will visualize flow (usually continu-
fat tissue), with more granular texture, and is surrounded ous for veins and pulsatile for arteries) (Fig 7.4). One can
by a hyperechoic fascial sheath (Fig 7.7). distend a collapsed vein (for example when scanning in the
Vessels are anechoic (Fig. 7.10), compressible (veins cervical area) by asking the patient to perform a Valsalva
more than arteries) (Fig 7.10), and pulsatile (usually only maneuver (Fig 7.10).
Bone is highly reflective. It visualizes as a hyperechoic
band, behind which there is an acoustic shadow due to
poor penetration (Fig 7.7).
Nerve imaging varies with the location. The proximal
parts (i.e. nerve roots when scanning the interscalene area)
are rich in nerve tissue and appear black or hypoechoic
M
(similar to vessels) (Fig 7.10). As the brachial plexus runs
V
distally (i.e. supraclavicular area), the proportion of con-
nective tissue increases and the nerve has a grape-like
appearance (Fig. 7.11). Further distally in the upper limb,
R the connective tissue dominates and the nerves appear
C
more hyperechoic (Fig 7.7), or may display a honeycomb
pattern (Fig. 7.12). The fascicles are hypoechoic dots with
A
a surrounding hyperechoic rim (epineurium). Anisotropy
can affect the ultrasound appearance of nerves (Fig. 7.13).
The above comments relate to transverse imaging of nerves.
On longitudinal imaging, nerves have a fascicular pattern
unlike the fibrillar pattern of tendons (Fig. 7.14).
Tendons are hyperechoic and often look similar to
peripheral nerves (Fig 7.12). There are some tips that help
V
to differentiate them. When scanning dynamically, one can
follow the course of a tendon and observe it merging into
a muscle. Nerves are continuous, and can be demonstrated
C to change course or give divisions when scanned along
their course. If we ask the patient to activate the respective
N
V
V
C R
P
C
L
Figure 7.10 (A) Scan of the interscalene area. M: muscle; V: internal
jugular vein; C: carotid artery; R: nerve roots of the brachial plexus. Note
the nerve roots visualize as hypoechoic vessel-like structures. (B) Pres- Figure 7.11 Scan of the supraclavicular area. R: rib; P: pleura; L: lung
sure applied to the transducer. Note the vein (V) is compressed. tissue; V: vessel; N: nerve. Note the grape-like appearance of the brachial
C: carotid artery. (C) The patient is performing Valsalva maneuver. Note plexus (hyperechoic epineurium with large hypoechoic zones com-
the distended vein (V). C: carotid artery. prised of nerve tissue) as well as the drop-out of signal below the rib.
52
T
T A U
M M
A
U
T T
A B
Figure 7.12 (A) Scan of the wrist. T: tendon; M: median nerve; U: ulnar nerve; A: ulnar artery. Note the honeycomb appearance of the median
nerve. (B) Another scan of the wrist. Note the similarity of the median (M) and ulnar (U) nerves to the nearby tendons (T). A: ulnar artery.
N
N
A B
Figure 7.13 (A) Scan of the popliteal area. F: fat tissue; M: muscle; V: vessel; N: nerve. Note the nerve appears very similar to the surrounding
muscle tissue. (B) Demonstration of anisotropy. By slightly tilting the transducer, the nerve visualizes much more clearly.
A B
Figure 7.14 (A) Long axis scan of a nerve. Note the fascicular pattern: long fascicles of hypoechoic nerve tissue (arrows) with interspersed irregular
hyperechoic lines representing the epineurium. (B) Long axis scan of a tendon. Note the fibrillar pattern: multiple long hyperechoic lines (arrows),
representing the connective tissue.
53
PART I Principles
muscles, there is more obvious movement of the tendons Loss of image. There are many reasons why an anatomi-
compared to the nerves near them. cal structure is not seen with ultrasound. The following are
Fascias appear very bright (hyperechoic) (Fig 7.7). some examples. When the contact between the transducer
Pleura visualizes as a hyperechoic line, while the lung and the skin is incomplete (because of insufficient amount
tissue is hypoechoic (Fig 7.11). Occasionally, one can see of coupling agent with resultant air pockets, or when the
a comet-tail sign under the pleura caused by reverberation one side of the ultrasound transducer is lifted), there will
(see below) at the pleural interface. be drop-out areas (Fig. 7.15). Another reason for loss of
Lymph nodes are more likely to be detected in particular image is insufficient depth or gain (Fig. 7.6), or usage of a
anatomic regions (e.g. groin). They have a hypoechoic high frequency ultrasound transducer for imaging deep
centre, are non-compressible, color Doppler will not detect structures (Fig. 7.3). When the impact angle of the ultra-
flow, and when the ultrasound transducer is moved, they sound beam is different from 90°, the reflected waves may
disappear, unlike the vessels, which can be followed not reach the transducer (Fig 7.2). The ultrasound beam is
longitudinally. extremely thin. In order to visualize longitudinally another
thin structure (i.e. a needle or a nerve), the beam has to be
perfectly aligned to it. This skill is difficult to master and
Artifacts requires a lot of practice. Minimal rotation or tilting of the
transducer leads to loss of the image (Fig. 7.16).
Artifacts can be defined as absence of imaging of an existing
anatomical structure, distorted image, or visualization of a
non-existent anatomical structure.
Anisotropy refers to the variable echogenicity of tissues
when the incidence angle of the ultrasound beam is
changed. By angling the transducer more distally or proxi-
mally one can significantly improve the visualization of a N
scanned nerve (Fig 7.13).
Figure 7.16 (A) Transducer and needle not aligned. The needle (N)
Figure 7.15 Air pocket (A) between the transducer and the skin, does not visualize fully. (B) By rotating and/or sliding the transducer,
caused by lack of a coupling agent. Note the signal dropout (D) beneath. alignment is achieved and the needle tip (arrow) appears on the screen.
54
CHAPTER
Transducer
M
Figure 7.17 Bayonet artifact. Note the two adjacent tissue areas
conducting ultrasound at different speeds. This results in the needle
appearing to be deformed on the screen. A = artery, M = muscle.
Image resolution poor. Too much gain can cause all

the tissues to appear hyperechoic and blur the differences
between them (Fig. 7.6). Appropriate manipulation of the
gain control will improve the image quality. Using a higher
frequency ultrasound transducer may improve image reso-
lution further (Fig. 7.3).
Bayonet artifact. Sometimes a transducer may overlie
two adjacent areas that allow ultrasound to travel with dif- B
ferent speeds. A needle passing through these two areas
Figure 7.18 (A) Reverberation: ultrasound wave repeatedly reflected
may visualize as broken because the ultrasound waves between two surfaces generates secondary echoes. (B) One needle
passing through the ‘higher-velocity’ tissue will reach the visualizing as more than one due to reverberation (arrow).
transducer faster and will give the impression that they
come from a more shallow layer than the waves coming
from the ‘lower-velocity’ tissues (Fig. 7.17).
Reverberation. Reverberation occurs when repeated
reflection occurs between two strongly reflective surfaces
(Fig. 7.18). Instead of a single reflected wave there is a series
of waves reaching the receiver one after another, giving
the false impression of multiple hyperechoic layers in the
scanned area (Fig. 7.18). If this occurs, the operator should
try to reduce the gain.
Posterior enhancement occurs when scanning over a U
fluid filled space (i.e. a cyst). The tissue immediately under MCN M
this space may appear hyperechoic due to the significant
reflection at the tissue interface and the good conductance A
R
of the reflected waves through the fluid back towards the
transducer (Fig. 7.19). Care needs to be taken interpreting
sonoanatomy here.
Posterior shadowing can be seen as a dropout of signal
behind tissues that poorly conduct ultrasound (i.e. bone or Figure 7.19 Posterior enhancement artifact (arrow). A: axillary artery;
air filled spaces like bowels) (Fig. 7.11). M: median; U: ulnar; R: radial nerves; MCN: musculocutaneous nerves.
55
PART I Principles
A B
Figure 7.20 (A) Example of good orientation of operator, patient and ultrasound screen. (B) Example of poor orientation. Note the operator has
to turn his/her head in order to look at the screen.
A B
Figure 7.21 (A) Correct positioning of operator’s hands. The position shown ensures stability when manipulating the transducer and the needle.
(B) This is an example of poor position, as the way the hands hold the transducer and the needle does not provide stability.
Ergonomics Scanning technique and

When performing ultrasound-guided nerve blocks, the anatomical survey
operator, the needle transducer interface, and the ultra-
sound screen should be in one line if possible. The angle General considerations
of the display should be adjusted for optimal visibility (Fig.
7.20). The configuration has to provide maximal comfort Transverse (short axis, cross-sectional) scanning involves
and stability for the patient as well as the operator. Both orientating the transducer perpendicular to the long axis of
hands of the operator (the scanning and the needling hand) the anatomical structure of interest (Fig. 7.7). When using
should rest on the patient to ensure stability and thus short axis views, the identification of nerves and the confir-
optimal control (Fig. 7.21). The necessary procedural mation of the spread of local anesthetic is facilitated (Fig.
equipment needs to be within easy reach and an assistant 7.22). Tilting the ultrasound transducer can dramatically
is desirable. improve the image (Fig. 7.13), while slight tilting or sliding
56
CHAPTER
Figure 7.22 The donut sign (arrows) – local anesthetic spreading in a

circle around the nerve (N).
usually does not cause loss of the target (unlike when using
longitudinal scanning).
Orientating the transducer parallel to the long axis of the
anatomical structure of interest gives a longitudinal (long
axis) view. This sometimes can be helpful to confirm that
a structure is a nerve (Fig 7.14). This scanning orientation
is more difficult as the ultrasound transducer and anatomi-
cal structure have to be perfectly aligned in order to produce B
an image of the structure.
Scanning technique
Set up an ergonomic configuration as mentioned above.
Select an ultrasound transducer appropriate for the depth
of the scanned area. Obey the principles of asepsis. Apply
coupling gel. The transducer has to be in sufficient contact
with the skin. Avoid excessive pressure, as this may cause
image distortion, compress vessels or push structures of
interest out of the visualized field. It may also hurt the
patient.
The basic movements when manipulating the transducer
are sliding, rotation and tilting.
Sliding allows one to position the transducer over the
area of interest. It encompasses moving the transducer on
C
the proximal/distal or medial/lateral axis (Fig. 7.23).
Following this, the depth of imaging should be adjusted, Figure 7.23 (A) Sliding. (B) Rotation. (C) Tilting.
thus enlarging the target while keeping the necessary
landmark structures in view. Consider adjusting the gain
and focus. Next, one can rotate the transducer to achieve
optimal orientation (short or long axis) against the object
of interest (Fig 7.23). The latter should be in the centre of
57
PART I Principles
the screen. The last step is tilting (Fig 7.23). These maneu-
vers are important in needle identification.
Anatomical survey and target identification

How do we interpret what we see? There is no substitute
for sound anatomical knowledge. The first step in image
S
interpretation is to orient yourself, for example by lifting S
S
either side of the transducer and observing the screen.
Pattern recognition is the key skill. Look for landmarks such
as bone, blood vessels and muscles. At this stage, usually
the nerve structures will be apparent. Physical adjustment
of the transducer is often helpful. Optimization of the ultra-
sound image using depth, gain and focus are used. The
use of Doppler facilitates identification of blood vessels.
Dynamic scanning helps structure identification.
It is recognized that there are inter-individual variations
in sonoanatomy. Operator experience is thus essential. A
practiced routine of anatomical survey increases operator Figure 7.24 Longitudinal midline scan at L3/4 level. Processus spino-
experience and facilitates structure identification. sus (S), epidural space (arrow). Note the depth of the epidural space can
be determined.
CLINICAL PEARLS
Once you have done some theoretical study you should practice
scanning in logical steps.
• Get instruction from experienced colleagues.
• Familiarize yourself with the equipment. Learn how to adjust the
depth, gain, focus, and practice the basic transducer moves of
sliding, rotation and tilting.
• Practice needling technique on phantom (aligning the
ultrasound beam with the needle, maintaining the needle tip in
view at all times, observing injectate spread in real time, improve
your ability to reach different targets with the needle).
• Hand–eye coordination is a vital skill, and you should repeatedly
look down to the patient to verify that the needle and the
transducer are properly aligned.
• Practice scanning different anatomical areas under supervision
(interscalene, supraclavicular, axillary, inguinal, popliteal area).
• Practice pattern recognition and survey scans.
• It is mandatory to attend repeatedly courses combining
cadaveric and ultrasound workshops. Repeat attendance at such Figure 7.25 Mechanical needle guide.
courses helps to learn and refresh relevant anatomy, reflect on
previous practice and deepen our understanding of what we do.
It is also an opportunity to meet experts and learn new technique of needle intervention. Ultrasound can also be
techniques, as the practice of ultrasound guided regional
anesthesia is rapidly evolving.
used to facilitate blocks without guidance. Here ultrasound
is used to identify anatomy and provide valuable informa-
tion, such as depth of target structures. For example, one
can visualize the position of the spinous and transverse
processes and measure the depth of the epidural and the
Practicalities of ultrasound-guided paravertebral spaces (Fig. 7.24).
regional anesthesia Needle visualization. The key to visualizing needles in
long axis is perfect alignment of ultrasound beam and
Point of entry and depth. Ultrasound helps selection of needle. The ultrasound beam is narrow and thus practice
needle entry and outlines depth required. The point of cannot be replaced. Never advance the needle without visu-
needle entry should be a distance of 1 cm from the ultra- alization. Adjust the transducer (sliding, tilting, rotation,
sound transducer. This facilitates asepsis and the free hand pressure) rather than the needle, as this is safer and causes
58
CHAPTER
Suggested reading
Wind K, Smith H, Jacob A, et al. Ultrasound machine
comparison: an evaluation of ergonomic design, data
management, ease of use, and image quality. Reg
Anesth Pain Med 2009;34:349–356.
Sites B, Brull R, Chan V, et al. Artifacts and pitfall errors
associated with ultrasound-guided regional
anesthesia. Part I: Understanding the basic principles
of ultrasound physics and machine operations. Reg
Anesth Pain Med 2007;32:412–418.
Sites B, Brull R, Chan V, et al. Artifacts and pitfall errors
associated with ultrasound-guided regional
anesthesia. Part II: A pictorial approach to
understanding and avoidance. Reg Anesth Pain Med
Figure 7.26 Acoustic shadow degrading the image after air bubbles 2007;32:419–433.
were injected (arrow). Manickam B, Perlas A, Chan V, Brull R. The role of a
preprocedure systematic sonographic survey in
ultrasound-guided regional anesthesia. Reg Anesth
less discomfort for the patient. The more parallel the needle
Pain Med 2008;33:566–570.
is to the ultrasound beam, the easier it is to see. Beam steer-
ing and compound imaging may be of help. Large bore Hopkins R, Bradley M. In-vitro visualization of biopsy
needles visualize better. The industry is working on solu- needles with ultrasound: a comparative study of
tions to improve needle shaft and needle tip visibility standard and echogenic needles using an ultrasound
(e.g. echogenic coating). Mechanical needle guides help to phantom. Clinical Radiology 2001;56:499–502.
maintain the transducer – needle alignment (Fig. 7.25). A Chin K, Perlas A, Chan V, Brull R. Needle visualization
free hand technique rather than the use of needle guides is in ultrasound-guided regional anesthesia: challenges
favored, due to the greater flexibility it allows. and solutions. Reg Anesth Pain Med 2008;33:
Local anesthetic spread. Proper placement of local anes- 532–544.
thetic is paramount to achieve fast and sufficient nerve Cheung S, Rohling R. Enhancement of needle visibility in
block. The solution should encircle the nerve, thus outlin- ultrasound-guided percutaneous procedures.
ing it (the donut sign) (Fig. 7.22). Avoid injecting air Ultrasound in Med & Biol 2004;30:617–624.
bubbles, as these cause acoustic shadowing and deteriorate Sites B, Chan V, Neal J, et al. The American Society of
the image (Fig. 7.26). Regional Anesthesia and Pain Medicine and the
Catheter placement. While it is impractical to try to visu- European Society of Regional Anaesthesia and Pain
alize the catheter tip movement as it is advanced, with Therapy Joint Committee recommendations for
ultrasound one can demonstrate the spread of local anes- education and training in ultrasound-guided regional
thetic close to the nerves of interest. anesthesia. Reg Anesth Pain Med 2009;34:40–46.
59
PART I Principles
CHAPTER
8
Peripheral nerve blockade for
ambulatory surgery
Stephen Mannion · Xavier Capdevila
discuss specific points in relation to what blocks to use

Introduction for what type of surgery for the upper and lower limbs
respectively.
Over the last 15–20 years there has been a rapid increase
worldwide in the numbers of surgical patients being
treated in the ambulatory setting. While the main driving
force has been a financial one, there are many benefits for
patients including faster return home, greater access to Scope of the chapter and definition of
treatment, and innovations in both anesthetic and surgical the terms
techniques to facilitate the rapid discharge of patients from
hospital.1 The definition of ‘ambulatory setting’ is important, as
Anesthesia provided in the ambulatory setting must be ambulatory may mean patients staying in a healthcare facil-
such that the patient is rapidly awake, has minimal post- ity for up to 23 hours. This distinction is more appropriate
operative cognitive dysfunction, mild or no pain, a very low for the USA, where ambulatory is defined as a healthcare
risk (<15%) of postoperative nausea and/or vomiting facility stay of up to 23 hours. Surgery where the patient is
(PONV), is able to commence oral diet within a few hours discharged home on the same day and does not stay over-
and is able to ambulate with minimal support (apart from night is termed same-day or outpatient surgery.
an aid such as a crutch). The ability to void urine is not a In Europe, most models of ambulatory surgery are
requirement unless neuraxial anesthesia has been per- based on the patient not staying overnight. In the rest of
formed or the patient has undergone a surgical procedure the English-speaking world (including the UK, Ireland,
likely to lead to urinary retention. These parameters are Australia and New Zealand), the term day surgery is used
necessary in order to avoid unplanned hospital admissions for ambulatory surgery when patients do not stay
(Box 8.1). overnight.
These post-anesthesia attributes will already be familiar For the purpose of this chapter, the term ambulatory will
to anesthesiologists who practice regional anesthesia and describe all patients admitted for up to 23 hours, but it will
therefore it is logical that there is a significant role for the be specified if an overnight stay is necessary.
use of peripheral nerve blocks (PNB) for ambulatory The chapter’s scope does not include the following tech-
surgery. This chapter will provide the reader with a com- niques, which may be described as peripheral nerve blocks:
prehensive overview of the use of PNB for ambulatory eye blocks, paravertebral blocks and truncal blocks (ilioin-
surgery. guinal, transversus abdominis blocks). These block tech-
There are four main sections to the chapter. The first niques are described elsewhere in this book and the basic
section will detail the practical matters of setting up and principles of using PNB for ambulatory surgery can be
running an ambulatory PNB service; the final section will applied to them. The use of neuraxial blocks will also not
expand on the role and management of catheters and be discussed. Readers are directed to the articles in the
continuous infusions; the second and third sections will Suggested Reading section for more information.

DOI: 10.1016/B978-0-7020-3148-9.00016-5
CHAPTER
Peripheral nerve blockade for ambulatory surgery 8
Box 8.1 Box 8.2

Anesthesia postoperative criteria necessary in the Factors required for successful peripheral nerve blockade
ambulatory setting in an ambulatory setting
• No respiratory compromise • Communication
• Minimal cognitive dysfunction • Consent
• Mild or no pain • Working environment
• No PONV • Performance of techniques
• Rapidly alert • Choice of local anesthetic
• Minimal cardiovasular changes • Multi-modal analgesia
• No respiratory compromise • Postoperative care
• Minimal cognitive dysfunction • Patient acceptance
• Can eat and drink early • Catheters and continuous infusions.
• Can walk early.
Consent
Patients should give their informed consent for a proce-
dure. The relative benefits and risks of the block should be
Setting up and running a peripheral discussed with each patient so they can make their own
nerve blockade service in risk/benefit analysis. Benefits include improved pain relief
an ambulatory setting compared to opioids, less PONV, quicker recovery and
earlier discharge from hospital compared with GA. Risks
The starting up and running of a successful PNB service in include those of local anesthetic (LA) toxicity and neural
an ambulatory setting requires consideration of a number damage, which has a 1 : 10 000 chance of nerve injury per-
of areas,2 which are described in the following paragraphs sisting beyond 3 months. Minor, short-lived and expected
(Box 8.2). side-effects such as paresthesia and numbness should be
explained to the patient. A written record of this discussion
Communication and the patient’s agreement or not to have PNB should be
recorded.
The decision to perform PNB for ambulatory surgery
patients will impact directly on a number of people in your Working environment
healthcare facility. Good communication prior to com-
mencing a PNB service is vital to ensure all members of the Compared with GA, the performance of PNB takes longer
healthcare team are supportive of the concept. to achieve anesthesia, as the time to onset includes both
Many surgeons are unfamiliar with PNB for anesthesia or the time to perform the block and for the LA to act. However,
analgesia and may feel initially uncomfortable operating a number of studies3,4 have shown that less time is spent in
on patients who are awake. They may also have experienced the operating theatre (20 mins), the PACU (40 mins) and
poor regional anesthesia practice with failed or partial the hospital (40–100 mins), resulting in an overall time
blocks and apparent delays to the operating schedule. gain with PNB compared to GA (Fig. 8.1). There is a 20
Patients may be less inclined to accept a PNB if their surgeon minute increase in the amount of time the anesthesiologist
is unconvinced of the benefits. In our experience, a well run spends with the patient.
PNB service will result in the surgeon recommending PNB An effective schedule is required to ensure these time
to their patients. benefits are realized. Some suggestions are to have a second
Nursing staff need to be familiarized with the techniques anesthesia provider (nurse anesthetist or another anesthe-
and their expected outcomes, as well as the type of assis- siologist) available who can monitor one patient while
tance required. Nurses in the recovery or post-anesthesia another is having a PNB placed, starting either earlier to
care unit (PACU) must be aware that many patients under- place the PNB or commencing the operating schedule with
going PNB for anesthesia can bypass the PACU (79% vs a GA case.
25% for general anesthesia (GA) patients), going directly The use of a dedicated block room has been advocated
to the ward. Ward nurses have to be made aware that but this may not be cost effective unless it serves a number
patients can usually be discharged faster compared to of operating theatres and has a regular patient load.4 A
patients post GA. more practical solution is to perform the blocks in the
61
PART I Principles
Preparation Procedure Recovery PACU SDCU Figure 8.1 Differences in time between
220
GA and PNB in an ambulatory setting for
GA Discharged directly upper limb surgery; SDCU: Surgical Day
to SDCU Care Unit. From Armstrong KP, Cherry RA.
200 Can J Anaesth 2004;51(1):41–4.
180
160
Reg
GA
140
Reg GA
120
Reg Reg*
GA Reg
100 GA
80 Reg
60
40
No difference No difference Difference = 1.5h Difference = 26min Difference = 15min*
Difference = 25min
PACU, hence utilizing the nursing staff and facilities already

available.5
Box 8.3
Equipment and drugs
Performance of techniques • Sterile dressing packs, gloves and gowns
• Nerve block needles and luer-lock syringes
Proper preparation is vital for the safe provision of regional
• Nerve stimulator or ultrasound machine
anesthesia and this is discussed in greater detail in another
• Choice of local anesthetic e.g. mepivacaine, ropivacaine
chapter of this book. Briefly, the following equipment and
• Catheter sets
drugs are required (Box 8.3) and we would recommend
• Oxygen
that a dedicated regional anesthesia trolley be organized.
• IV cannulas and giving sets
Importantly, Intralipid must be stored as part of the emer-
• Adrenaline
gency drugs.
• Atropine
Although the successful use of Intralipid for LA toxicity
• Propofol
in humans has only been documented in case reports, the
• Midazolam
results have been so dramatic that its use is recommended.
• Intralipid
Intralipid has been effective in LA toxicity resulting
• IV fluids.
from the long-acting amides bupivacaine, ropivacaine and
levobupivacaine. While successful use has been described
for the short-acting LA, mepivacaine, to date the only use
for lidocaine has been in a pediatric patient who received minutes), higher success rates (3–10% greater when com-
both lidocaine and ropivacaine for psoas compartment pared to multi-stimulation techniques) and possibly lower
block.6 LA volumes compared to NST.7,8 However, whether these
The individual nerve block techniques are described in differences will result in benefit in the average ambulatory
detail in their respective chapters. The type of block to setting is debatable. The advantage of USG may be offset
choose for a particular surgical procedure is discussed in the by its significantly increased capital cost.
relevant upper or lower limb section. Sedation has potential advantages and disadvantages.
Modern peripheral nerve blockade is performed using Disadvantages are mainly related to excessive sedation or
either a nerve-stimulation technique (NST) or ultrasound loss of the airway. Advantages of sedation include a reduc-
guidance (USG) to locate the relevant nerves. USG for PNB tion in patient anxiety, increased comfort during prolonged
is generally accepted to result in a faster onset (about 5 (>1 hour) surgery and improved patient cooperation during
62
CHAPTER
block performance. The choice of sedation is one for each inflammatories (NSAIDs), both prior to and regularly post
anesthesiologist, but in our experience in the ambulatory block resolution, is effective in clinical practice. Oral opioids
setting intravenous midazolam often negates the benefits may be required, depending on the type and extent of
of a PNB technique, and either low doses of fentanyl, alfen- surgery.
tanil or propofol result in patient comfort and controlled
sedation. For longer surgery, a low dose target-controlled
infusion of propofol (1–2 µg/mL) is an alternative. Postoperative care
However, continuous monitoring of respiratory effort and
oxygen saturation is necessary. The postoperative management of patients who receive a
PNB in an ambulatory setting is particularly important, as
they will be discharged relatively earlier from the healthcare
Choice of local anesthetic facility.
Although there has been some debate regarding the fea-
The main determinant of the type of LA to use is the dura-
sibility and safety of discharging a patient home with an
tion of surgery. In reality, the duration of the shorter acting
insensate limb, general consensus is that patients can be
LAs such as the ester prilocaine (3–4 mg/kg), or amides
discharged if some basic principles are followed.
lidocaine (4.5 mg/kg) and mepivacaine (5–6 mg/kg) is suf-
Firstly, the anesthesiologist has to be prepared to accept
ficient for most ambulatory surgery. The addition of epi-
the clinical situation. Even with short-acting LAs, 50% of
nephrine (1 : 200 000) prolongs the duration of action of
patients will have residual block present when they are
lidocaine from 1–1.5 hours to 3.5–4 hours, which is equiv-
otherwise fit for discharge home.10 The discharge criteria
alent to mepivacaine. Adding epinephrine also increases
normally used for patients undergoing GA, such as the
the permitted dose of lidocaine to 7 mg/kg.
modified Aldrete score, are inappropriate because they
Other adjuncts can be added – tramadol prolongs mepiva-
require the patient to move all four limbs.11 A scoring
caine and clonidine increases block duration for both lido-
system not requiring limb movement, such as the Postan-
caine and mepivacaine. Unfortunately, the doses of clonidine
esthesia discharge scoring system (PADSS), may have to be
(2 µg/kg) required often result in sedation, which may be
incorporated into your practice12 (Table 8.1).
undesirable in a day surgery setting and delay discharge.
Secondly, discharging a patient home with a long-acting
Long-acting LAs such as levobupivacaine and ropivacaine
LA block is safe. A study of 1791 patients who underwent
are generally not used because of the prolonged motor
a total of 2382 blocks of both the upper and lower limb,
blockade. The use of a continuous technique allows lower
with ropivacaine 0.5% in a day surgery setting, found an
doses to be used, providing a motor sparing effect, and is
incidence of paresthesia of 0.25% at 7 days. All had resolved
useful for more major ambulatory surgery such as shoulder
by 3 months. One patient fell getting out of a car following
arthroplasty.9 There are no studies in the ambulatory setting
combined femoral and sciatic nerve blocks, with no
comparing the duration of analgesia of long- versus short-
sequelae.13 Another study found no difference in the inci-
acting LAs, but it is reasonable to assume that the benefits
dence of paresthesia at 1 year when comparing axillary
seen with long-acting LAs for in patients would be similar.
block with GA for hand surgery.14
Performing selective analgesic blocks with a long-acting
Finally, the patient must be given both verbal and written
LA while using a short-acting LA for the main block
instructions in the care of the insensate limb. An example
and anesthesia, is an effective technique (for example, for
information sheet is included (Box 8.4). It should be
a Dupuytren’s contracture, performing an axillary block
explained that the limb is numb and must be cared for
with mepivacaine and an ulnar block at the elbow with
and protected from injury and temperature extremes until
levobupivacaine).
the limb returns to the patient’s own normal sensation
and motor function. The use of a sling (upper limb) or
Multi-modal analgesia crutch (lower limb) is a useful visual reminder. Patients
should also be given details of how long the block is
The duration of analgesia provided by PNB is usually longer expected to last, as well as a contact telephone number
than the duration of anesthesia, but, depending on the should the block persist outside defined parameters, which
choice of LA or if a single shot technique is performed, this will depend on the type of LA and/or continuous tech-
may be limited to 6–8 hours post-block. Importantly, nique used.
patients’ perception of pain post block resolution is often Follow-up is required after discharge and must continue
much higher than would otherwise be anticipated. This is until there is complete resolution of the block. In practice,
most likely as a result of the loss of profound analgesia this usually consists of a telephone contact after 24 hours
following block resolution. and on a daily basis thereafter if necessary, although some
Therefore a multi-modal approach to analgesia is required. centers have nurses who visit patients with continuous infu-
The use of acetaminophen and non-steroidal anti- sions. Occasionally, the patient will have to re-attend with
63
PART I Principles
Table 8.1 Post-anesthesia discharge scoring system (PADSS) for determining home readiness
Discharge criteria Score
Vital signs:
Vital signs must be stable and consistent with age and pre-operative baseline
Blood pressure and pulse within 20% of pre-operative baseline 2
Blood pressure and pulse 20–40% of pre-operative baseline 1
Blood pressure and pulse >40% of pre-operative baseline 0
Activity level:
Patient must be able to ambulate at pre-operative level
Steady gait, no dizziness, or meets pre-operative level 2
Requires assistance 1
Unable to ambulate 0
Nausea and vomiting:
Patient should have minimal nausea and vomiting before discharge
Minimal: successfully treated 2
Moderate: successfully treated with intravenous medication 1
Severe: continues after repeated treatment 0
Pain:
Patient should have minimal or no pain before discharge
The level of pain that the patient has should be acceptable to the patient
Pain should be controllable by oral analgesics
The location, type and intensity of pain should be consistent with anticipated postoperative discomfort
Pain acceptable 2
Pain controllable with oral analgesics 1
Pain not acceptable 0
Surgical bleeding:
Postoperative bleeding should be consistent with expected blood loss for the procedure
Minimal: does not require dressing change 2
Moderate: up to two dressing changes required 1
Severe: more than three dressing changes required 0
TOTAL
Maximum score = 10.
Patients scoring ≥ 9 are fit for discharge.
Modified after Chung F, Chan VW, Ong D. J Clin Anesth 1995;7(6):500–6.
the anesthesiologist if there is persistence of the block or Patient acceptance and satisfaction
evidence of neural injury. Any suspicion of neural injury
should be rapidly followed-up and confirmed. The guide- Studies have demonstrated that patients’ acceptance of PNB
lines from the Consensus Statement of the American Society in the ambulatory setting is very high, with 98% of patients
of Regional Anesthesia on Neurologic Complications of reporting that they would have the same anesthesia tech-
Regional Anesthesia and Pain Medicine, 2005 are useful in nique again.16,13 Patients’ overall satisfaction of a PNB as
this circumstance.15 the principal method of anesthesia is also very high. Using
64
CHAPTER
The most appropriate block for shoulder surgery is an

Box 8.4 interscalene block (ISB) because of the consistent blockade
Patient information sheet post upper limb block of the suprascapular, dorsal scapular and axillary nerves
compared with more distal blocks.17
Name of your Hospital
Hadzic et al. demonstrated that for outpatient rotator cuff
Day Surgical Unit surgery, single shot ISB resulted in patients having less pain,
Department of Anesthesiology earlier ambulation and discharge, with no unplanned hos-
pital admissions, compared with patients who received
Instructions to patients discharged home after upper
general anesthesia.18
limb regional anesthesia
For more extensive surgery such as TSA, severe pain is
Dear Patient, common and pain control following TSA is important to
You have received a nerve block of your hand and arm as allow early rehabilitation and discharge from hospital. The
anesthesia for surgery. use of continuous ISB allows TSA to be performed as a
This results in you having a numb (’dead’) hand/arm for a 23-hour ambulatory procedure, with patients discharged
number of hours and because of this you will have difficulty home with portable LA pumps and catheters that are
using your hand (motor function) and feeling whether some- either removed by a community nurse or by the patient
thing is hot or cold (sensation). or their carer.19
The numbness of your hand/arm will normally last for Patients undergoing TSA who were randomized to a con-
between 4 and 8 hours but can last for longer in some patients. tinuous ISB infusion with ropivacaine 0.2% were suitable
If your hand/arm remains numb after 24 hours please tele- for discharge a median of 30 hours (21 vs 51 hours) earlier
phone the Peri-operative Assessment Unit on xxx–xxxxxxx than patients who received the saline control. They required
and ask for bleeper xxx for advice. less intravenous morphine, had less pain and had greater
Patients normally experience return of some movement of external shoulder rotation.20
the hand followed by ‘pins and needles’. Patients undergoing TSA will still require GA and convert-
The following instructions must be followed until sensation ing this type of surgery into a successful ambulatory proce-
and motor function of your hand and arm return to normal. dure requires a well-organized system in place to follow up
This is to avoid injury. patients and their continuous catheters at home.21
• Keep your arm in the sling provided The effects of ISB on pulmonary function are well known;
• Avoid touching any hot surfaces e.g. radiators or cups of however, there were no differences found in pulmonary
tea/coffee function between a group of patients receiving a continu-
• Do not try to lift or move anything with your hand/arm. ous ISB infusion and a patient-controlled morphine group.22
Using USG, it is possible to perform an ISB with 5 mL
of LA, which reduces the incidence of diaphragmatic paraly-
a Likert scale of 1–5, Klein and colleagues found that in a sis from 100% with 20 mL of LA to 45% with the lower
study of over 1700 patients, the mean (± SD) for satisfac- volume.23
tion with the PNB technique was 4.88 ± 0.44 at 24 hours The clinical significance of these changes in pulmonary
and 4.77 ± 0.69 on day 7 post surgery.13 function in patients without pulmonary disease is debat-
able and respiratory problems have not been reported
Catheters in patients discharged home following ambulatory
The placement of catheters for PNB allows for continuous overnight TSA.22 This clinical pathway may not be appropri-
infusions of low dose LA, hence facilitating prolonged post- ate for patients suffering from pre-existing pulmonary
operative analgesia. This permits more major surgery to be compromise.
performed in the ambulatory setting, as the patient’s pain
can be managed at home. These techniques are discussed Elbow, forearm and hand surgery
in greater detail elsewhere in this chapter.
Supraclavicular, infraclavicular and axillary brachial plexus
blocks are all suitable blocks for elbow, forearm and hand
Which upper limb blocks to use for surgery. Mid-humeral and specific nerve blocks at the
which surgical procedure elbow, wrist and fingers may also have a role, especially in
providing selective anesthesia to a particular nerve(s).24
Shoulder surgery In the ambulatory setting, axillary brachial plexus
blockade is often regarded as the most appropriate block
Common ambulatory surgical procedures on the shoulder because of its high success rate (>95% with USG or multi-
are arthroscopy, rotator cuff repair and total shoulder stimulation NST) and very low complication rate.7 Con-
arthroplasty (TSA). cerns regarding the risk of pneumothorax as a complication
65
PART I Principles
of the infraclavicular and, in particular, the supraclavicular are discharged home sooner that patients undergoing GA.
blocks have been raised, with some anesthesiologists Patients also report greater satisfaction with PNB compared
uncomfortable in performing these blocks in an ambula- to GA (81 vs 50%).25
tory setting. These concerns are largely unfounded, espe-
cially if USG is applied, which may improve safety by
permitting visualization of the needle relative to the pleura Which lower limb blocks to use for
and lung. It should be noted that the supraclavicular block, which surgical procedure
even with the use of USG, is only 85% effective for forearm
or hand surgical anesthesia, compared with 95–98% with Regional anesthesia in outpatients is common but restricted
infraclavicular or axillary blocks.8 to a few techniques. In Klein et al.’s survey among 1078
A number of randomized studies have compared PNB anesthesiologists affiliated to the SAMBA, respondents indi-
with GA for ambulatory hand surgery. McCartney et al. cated that they were most likely to perform axillary (77%),
compared transarterial axillary block to GA in 100 patients interscalene (67%), and ankle blocks (68%) on ambulatory
undergoing ambulatory hand surgery.10 Patients who patients but less likely to perform the other lower extremity
received axillary block reported a longer duration to first conduction blocks29 (Fig. 8.2). Discharge with an insensate
analgesic, had lower pain scores and opioid consumption, upper extremity is widely accepted but discharge with an
less nausea/vomiting and spent less time in the hospital insensate lower extremity or with motor blockade is not
than patients receiving general anesthesia. There was no common, and seems controversial. Injury from falls may
difference in pain scores or opioid consumption on post- occur without protective reflexes, mainly if a combined
operative days 1, 7, and 14, however, and the axillary block block has been used.13 However, the low incidence of such
had a 10% failure rate, necessitating GA in these patients. complications is probably related to appropriate patient
USG or multi-stimulation techniques have a failure rate of selection and detailed discharge instructions.
3–5% and are recommended instead of the trans-arterial
approach.
Hip surgery
Hadzic et al. randomized 52 patients undergoing hand
and wrist surgery in the ambulatory setting to receive either Hip surgery is one of the most common and classical
infraclavicular block with chloroprocaine plus epinephrine orthopedic surgical procedures but at present, total hip
and bicarbonate or GA with propofol induction, desflurane arthroplasty (THA) is not considered an ambulatory pro-
maintenance and wound infiltration with bupivacaine. cedure. THA results in relatively severe postoperative pain
Infraclavicular block led to faster recovery times, lower pain requiring hospitalization to provide potent analgesia (PCA
scores (3% vs 48% with pain scores >3), four times less IV morphine or regional blocks). The average duration of
nausea/vomiting and earlier discharge from hospital.25 hospitalization after THA is classically 4 to 5 days. Femoral
For surgery on the fingers, a number of techniques for or lumbar plexus block (with sciatic block when indicated)
digital anesthesia have been described, including the digital
or ‘ring’ block, the intrathecal digital block (injection of
local anesthetic into the flexor sheath) and the metacarpal
Ankle 68.1
block (local anesthetic injected between and at the level of
the metacarpal bones).26 Digital blocks are useful if a tour- Popliteal 20.8
niquet is not required or as selective long-acting analgesia. Sciatic 11.6
These are simple to perform and provide a mean duration Lumbar plexus 10.9
of anesthesia of 24.9 hours with bupivacaine 0.5%, 10.4 Femoral 39.6
hours for lidocaine 2% with epinephrine (1 : 100 000) and
4.9 hours for plain lidocaine 2%.26 Epinephrine results in
Wrist 23.1
a temporary reduction in digital blood flow but with pres-
ervation of digital perfusion.27 An advantage of the intrathe- Infraclavicular 5.7
cal block is that it involves only a single injection, has a Supraclavicular 11.9
faster onset time (3.91 vs 7.16 min) and better proximal Interscalene 66.5
and radial digital anesthesia than metacarpal block.28 Axillary 76.9
Similar findings have been reported for digital block com-
0 10 20 30 40 50 60 70 80 90
pared to the metacarpal block. Percentage
Summary Figure 8.2 Frequency of peripheral nerve blockade performed by

members of the Society for Ambulatory Anesthesia. Horizontal bars
Upper limb ambulatory surgery performed under PNB represent percentages of respondents who indicated that they perform
results in patients who have less pain, need fewer opioids, the indicated techniques on ambulatory patients. From Klein et al
have less PONV, resume oral diet and ambulate earlier, and Anesth Analg 2002;94:71–6.
66
CHAPTER
can provide not only excellent anesthesia but also superb charge. Femoral nerve block is also used for knee arthros-
analgesia, facilitating timely discharge after THA. Using copy. Better anesthesia resulted from the addition of the
long acting local anesthetics or placing catheters in the lateral femoral cutaneous nerve block or an obturator nerve
vicinity of the nerves or plexus can achieve longer duration block when compared with the femoral nerve block alone,
of analgesia. Ilfeld and colleagues reported the feasibility and this provided improved intra-operative conditions.36
in five patients of converting THA into an overnight-stay An intra-articular injection of LA alone, a femoral nerve
procedure using a continuous psoas compartment nerve block alone, or a combined intra-articular and femoral
block provided at home with a portable infusion pump nerve block provided acceptable intra-operative anesthesia,
with a continuous infusion of ropivacaine 0.2%.30 All but excellent surgical conditions, and similar postoperative
one patient met the discharge criteria on postoperative day analgesia in the study by Goranson et al.37 A combination
(POD) 1 and three patients were discharged directly home of femoral-sciatic blocks can provide more stable intra-
on POD 1. Postoperative pain was well-controlled, opioid operative hemodynamics with less hypotension, compared
requirements and sleep disturbances were minimal, and with GA.38 In addition, this PNB combination permitted a
patient satisfaction was high. Furthermore, the same group PACU bypass compared with GA, as well as a shorter length
evaluated if a 4-day ambulatory continuous lumbar plexus of PACU stay. Furthermore, the femoral-sciatic block had
block (LPB) could maximize ambulation distance and less total anesthesia cost compared with GA. The analgesic
decrease the time required to reach three specific potential of femoral nerve blocks can be demonstrated in
readiness-for-discharge criteria after hip arthroplasty, com- more painful surgical procedures, such as anterior cruciate
pared with an overnight continuous LPB only. They ligament (ACL) reconstruction. Mulroy et al. in a prospec-
reported a 38% decrease in the time to reach the three tive study examined 55 patients having ACL repair under
predefined discharge criteria but not an increase in ambu- epidural block.39 Postoperatively they received a femoral
lation distance. This technique combined with multi- nerve block with 0.5% bupivacaine or saline. There was
modal anesthetic and analgesic regimens with associated superior postoperative analgesia in the block group,
minimally invasive surgical approaches and rapid rehabili- whereas 50% of the patients in the sham group reported
tation protocols, has been incorporated into the manage- visual analog scale (VAS) pain scores of greater than 5 out
ment of total joint arthroplasty surgical programs.31,32 In a of 10. Iskandar et al. compared a femoral nerve with intra-
study of 665 patients utilizing this clinical pathway, Mears articular regional analgesia for patients having ACL repair
and colleagues reported that 38.9% of patients were dis- with a hamstring graft.40 They reported better postoperative
charged home with indwelling peripheral nerve catheters. pain relief in the femoral nerve block group. Nevertheless,
Hospital discharge in less than 24 hours was achieved in when a hamstring graft is used for ACL repair, a significant
44.4%. After discharge, 73.5% of patients required no component of postoperative pain can arise from the sciatic
home or outpatient nursing care.33 nerve distribution. Williams et al. strongly supported the
addition of a sciatic nerve block to a femoral nerve block
Knee surgery for more extensive knee surgery.41 In 1200 consecutive out-
patients having knee surgery, they reported that single
Knee arthroscopy is well suited as an ambulatory proce- shot/continuous femoral nerve blocks alone provided little
dure. Analgesia can be provided by intra-articular regional benefit for simple arthroscopy but improved analgesia
anesthesia and analgesia, as well as from peripheral nerve and reduced unanticipated hospital admissions in liga-
blockade. Authors evaluated the use of psoas compartment ment repairs or more complex arthroscopic knee surgery.
or femoral blocks for knee arthroscopy. Hadzic et al. com- In these patients, the addition of a single-shot sciatic nerve
pared patients scheduled for knee arthroscopies receiving block conferred even better postoperative analgesia and
combined psoas compartment block and sciatic nerve fewer hospital admissions. For total knee arthroplasty the
block or a GA.34 They reported an incidence of moderate to use of a continuous 4-day ambulatory femoral block dem-
severe PONV in 12% of patients with combined psoas onstrates improved analgesic, maximizes ambulation dis-
compartment and sciatic blocks versus 62% with fast-track tance and decreases the time required to reach three specific
GA that included prophylactic dolasetron. Peri-operative readiness-for-discharge criteria, compared to an overnight
nerve blocks reduced sore throat, increased ability to bypass infusion only.42
phase 1 PACU, and reduced time to meet discharge criteria.
Jankowski et al. found that supplemental analgesics were Foot and ankle surgery
required in 45% of patients receiving a GA compared with
only 21% receiving psoas compartment block.35 In addi- Popliteal block provides analgesia advantages over both
tion, the GA group had higher pain scores at 30, 60, 90, ankle blocks and wound infiltration after foot surgery.43
and 120 min. However, there is a risk of epidural spread Randomized studies demonstrated that duration of postop-
attributed to the paravertebral needle insertion site and erative analgesia after popliteal block was 1080 mins, com-
high injection pressure that can potentially impede dis- pared with 690 mins after ankle block and 709 min after
67
PART I Principles
there are limited data on which to base recommendations

Box 8.5 on the optimal basal rate, bolus volume, and lockout
Benefits of PNB compared to GA period, the majority of studies indicate that a lower basal
infusion in conjunction with a patient controlled bolus
• Reduces pain scores
dose provides the optimal method of delivery, as it provides
• Reduced opioid consumption
equivalent analgesia but with a lower total LA dose com-
• Less PONV
pared to continuous infusions with higher basal rates. The
• Less drowsiness
technique of continuous block or specifically patient-
• Faster return to pre-operative cognitive function
controlled regional anesthesia (PCRA) has been used for
• Eat and drink earlier
brachial plexus, interscalene block, and femoral nerve
• Ambulate earlier
block. After total hip or knee arthroplasty, PCRA techniques
• Better patient satisfaction and acceptance
reduce the LA consumption without compromise in patient
• Faster discharge
satisfaction or pain scores in comparison with continuous
• Fewer unplanned admissions
infusions. Recent randomized double-blinded, placebo-
• Fewer cardiac and respiratory effects.
controlled trials provided data involving patients discharged
at home with CPNB. These studies included patients sched-
uled for procedures that had had an infraclavicular,47 inter-
scalene,48 or posterior sciatic popliteal perineural catheter.49
subcutaneous wound infiltration.44 The popliteal block also Patients receiving perineural LA infusions achieved clini-
provided better analgesia and higher patient satisfaction. In cally lower resting and breakthrough pain scores while
painful foot or ankle surgery, White et al. compared pro- requiring fewer oral analgesics. Patients who received peri-
spectively a postoperative continuous popliteal block with neural LA, and specifically those receiving PCRA, experi-
0.25% bupivacaine versus saline.45 The bupivacaine group enced additional benefits related to improved analgesia.
had lower VAS pain scores for 48 h, 70% less morphine Between 0 and 30% of patients with perineural ropivacaine
consumption and a shorter length of hospital stay. Simi- reported insomnia due to pain as compared with 60–70%
larly, Ilfeld et al. randomized patients to receive a continu- of patients using only oral opioids. Patients receiving peri-
ous popliteal block with 0.2% ropivacaine or saline, after neural ropivacaine infusion woke up from sleep because
an induction block with mepivacaine 2%.46 They reported of breakthrough pain episodes an average of zero times on
a decrease in postoperative pain, opioid requirements, the first postoperative night compared with two times
opioid-related side-effects, and better sleep with fewer for patients receiving perineural saline. Obviously, lower
awakenings. opioid consumption in patients receiving perineural LA
resulted in fewer opioid-related side-effects. Patients receiv-
Summary ing perineural LA also reported greater satisfaction with
Benefits such as long-lasting analgesia, rapid rehabilitation, their postoperative analgesia, with scores of 8.8–9.8 com-
better sleep, fewer opioid-related side-effects, and preserved pared with 5.5–7.7 for patients receiving placebo.47–49 The
hamstring function support the applicability of PNB for benefits of such analgesia appear to be substantiated by
painful hip, knee, and foot and ankle surgery. More fre- fewer hospital readmissions in the continuous PNB group.
quent use of single-shot injections and, especially, continu- Capdevila et al. compared CPNB infusions of ropivacaine
ous nerve blocks in the ambulatory setting seems warranted (0.2%), either as a continuous infusion or PCRA, with PCA
(Box 8.5). intravenous morphine in 83 patients scheduled for ambu-
latory orthopedic surgery for functional recovery and post-
operative analgesia.50 Basal–bolus ropivacaine infusion
Catheters and continuous local (PCRA) decreased the time to commencing a 10 min walk,
anesthesia infusions optimized all daily activities, and decreased the amount of
ropivacaine used. The PCA morphine group had greater
The advantages of single-injection PNB are limited because pain scores and consumption of breakthrough morphine
of the relative short duration of long-acting local anesthet- and ketoprofen as compared with the ropivacaine group.
ics (usually 10–24 h). After resolution of PNB, postopera- The incidence of nausea/vomiting, sleep disturbance, and
tive pain management is often difficult. The method of dizziness increased, and the patient satisfaction score
continuous PNB infusions is variable, based on institu- decreased in the PCA morphine group. After ambulatory
tional practice and the cost and availability of infusions orthopedic surgery, ropivacaine (0.2%) delivered as a PCRA
devices in both the inpatient and outpatient settings. Infu- infusion optimizes functional recovery and pain relief.
sion regimens can include a basal infusion only, an inter- Recently in postoperative popliteal sciatic nerve block
mittent bolus dosing only, and a combination of a basal patients, Taboada and colleagues reported that LA admini-
infusion with a patient-controlled bolus dosing. Although stered as a new automated regular bolus in conjunction
68
CHAPTER
with PCRA provided similar pain relief as a continuous 3. Gebhard RE. Outpatient regional anesthesia for upper
infusion technique combined with PCRA.49 Furthermore, extremity surgery. International Anesthesiology
the new dosing regimen reduced the need for additional Clinics. Regional Anesthesia for Ambulatory Surgery
PCRA and the overall consumption of local anesthetic. 2005;43(3):177–183.
Electronic infusion pumps provide highly accurate and 4. Armstrong KP, Cherry RA. Brachial plexus anesthesia
consistent basal rates over the entire infusion duration but compared to general anesthesia when a block
are costly and need to be returned to the healthcare unit if room is available. Can J Anaesth 2004;51(1):
used in the ambulatory setting. Elastomeric devices can 41–44.
provide a higher or lower-than-expected basal rate with an 5. Sandberg WS, Daily B, Egan M, et al. Deliberate
error rate of ± 20%.51 There are insufficient published data perioperative systems design improves operating
to determine the clinical situations in which the typical room throughput. Anesthesiology 2005;103(2):
basal rate variation of elastomeric pumps would be clini- 406–418.
cally relevant. Elastomeric pumps are cheaper per unit price
6. Felice K, Schumann H. Intravenous lipid emulsion
but are disposable. These pumps are also less technically
for local anesthetic toxicity: a review of the literature.
challenging than electronic pumps, with no alarms or
J Med Toxicol 2008;4(3):184–191.
complex programming. In some trials, patients prefer elas-
tomeric pumps due to this simplicity despite the fact that 7. Casati A, Danelli G, Baciarello M, et al. A prospective,
there is no warning if a catheter occlusion or pump mal- randomized comparison between ultrasound and
function occurs.52 Investigators have utilized elastomeric nerve stimulation guidance for multiple injection
pumps for multiple catheter locations and surgical proce- axillary brachial plexus block. Anesthesiology
dures. Pumps allow for both PCRA boluses and a basal 2007;106(5):992–996.
infusion, while others allow a basal rate only. Without the 8. Williams SR, Chouinard P, Arcand G, et al.
option for a bolus dose, higher doses of oral opiates are Ultrasound guidance speeds execution and improves
often required for break through pain. The infusion can the quality of supraclavicular block. Anesth Analg
be tailored to provide a minimum basal rate allowing 2003;97(5):1518–1523.
maximum infusion duration and minimal motor block, yet 9. Boezaart AP. Continuous interscalene block for
allow bolus dosing for physical therapy. ambulatory shoulder surgery. Best Pract Res Clin
While the use of USG in regional anesthesia has prompted Anaesthesiol 2002;16(2):295–310.
a revolution in how we approach single-shot PNB, data 10. McCartney CJ, Brull R, Chan VW, et al. Early but no
concerning its use for ambulatory CPNB are sparse. In long-term benefit of regional compared with general
theory, USG has the potential to confirm catheter tip loca- anesthesia for ambulatory surgery. Anesthesiology
tion (direct visualization of the catheter tip or indirectly by 2004;101:461–467.
visualizing LA spread). Only two large prospective observa- 11. Aldrete JA. The post anesthesia recovery score
tional studies in ambulatory patients demonstrated the revisited. J Clin Anesth 1995;7:89–91.
effectiveness of USG as the primary modality (with or 12. Chung F, Chan VW, Ong D. A post-anesthetic
without needle nerve stimulation) to place peripheral nerve discharge scoring system for home readiness after
catheters.53,54 Both studies reported that 98% of catheters ambulatory surgery. J Clin Anesth 1995;7(6):500–
provided optimal postoperative analgesia with a low inci- 506.
dence of minor side-effects (complications rate was 0.4%).
13. Klein SM, Nielsen KC, Greengrass RA, et al.
The first attempt catheter success rate was 96%. There were
Ambulatory discharge after long-acting peripheral
few interventions requiring an anesthesiologist or a dedi-
nerve blockade: 2382 blocks with ropivacaine. Anesth
cated nurse, as patients had access to 24-hour telephone
Analg 2002;94(1):65–70.
advice via a contact person for any questions or problems
they might have had. 14. Brull R, McCartney CJ, Chan VW, et al. Effect of
transarterial axillary block versus general anesthesia
on paresthesiae 1 year after hand surgery.
Anesthesiology 2005;103(5):1104–1105.
References 15. Neal JM, Bernards CM, Hadzic A, et al. ASRA Practice
Advisory on Neurologic Complications in Regional
1. Pavlin JD, Kent CD. Recovery after ambulatory Anesthesia and Pain Medicine. Reg Anesth Pain Med
anesthesia. Curr Opin Anaesthesiol 2008;21(6): 2008;33(5):404–415.
729–735. 16. Koscielniak-Nielsen ZJ, Rasmussen H, Nielsen PT.
2. Williams BA, Kentor ML. Making an ambulatory Patients’ perception of pain during axillary and
surgery centre suitable for regional anaesthesia. Best humeral blocks using multiple nerve stimulations.
Pract Res Clin Anaesthesiol 2002;16(2):175–194. Reg Anesth Pain Med 2004;29(4):328–332.
69
PART I Principles
17. Julien RE, Williams BA. Regional anesthesia survey of the Society for Ambulatory Anesthesia.
procedures for outpatient shoulder surgery. Int Anesth Analg 2002;94:71–76.
Anesthesiol Clin 2005;43(3):167–175. 30. Ilfeld BM, Gearen PF, Enneking FK, et al. Total hip
18. Hadzic A, Williams BA, Karaca PE, et al. For arthroplasty as an overnight-stay procedure using an
outpatient rotator cuff surgery, nerve block anesthesia ambulatory continuous psoas compartment nerve
provides superior same-day recovery over general block: a prospective feasibility study. Reg Anesth Pain
anesthesia. Anesthesiology 2005;102(5):1001–1007. Med 2006;31:113–118.
19. Ilfeld BM, Morey TE, Wright TW, et al. Continuous 31. Ilfeld BM, Ball ST, Gearen PF, et al. Ambulatory
interscalene brachial plexus block for postoperative continuous posterior lumbar plexus nerve blocks after
pain control at home: a randomized, double-blinded, hip arthroplasty: a dual-center, randomized, triple-
placebo-controlled study. Anesth Analg 2003;96(4): masked, placebo-controlled trial. Anesthesiology
1089–1095. 2008;109:491–501.
20. Ilfeld BM, Vandenborne K, Duncan PW, et al. 32. Chelly JE, Ben-David B, Joshi RM, et al. Minimally
Ambulatory continuous interscalene nerve blocks invasive total hip replacement as an ambulatory
decrease the time to discharge readiness after total procedure. Int Anesthesiol Clin 2005;43:161–
shoulder arthroplasty: a randomized, triple-masked, 165.
placebo-controlled study. Anesthesiology 2006; 33. Mears DC, Mears SC, Chelly JE, et al. THA with a
105(5):999–1007. minimally invasive technique, multi-modal
21. Mayfield JB, Carter C, Wang C, Warner JJ. anesthesia, and home rehabilitation: factors
Arthroscopic shoulder reconstruction: fast-track associated with early discharge? Clin Orthop Relat
recovery and outpatient treatment. Clin Orthop Relat Res 2009;467(6):1412–1417.
Res 2001;(390):10–16. 34. Hadzic A, Karaca PE, Hobeika P, et al. Peripheral
22. Borgeat A, Perschak H, Bird P, et al. Patient- nerve blocks result in superior recovery profile
controlled interscalene analgesia with ropivacaine compared with general anesthesia in outpatient knee
0.2% versus patient-controlled intravenous analgesia arthroscopy. Anesth Analg 2005;100:976–981.
after major shoulder surgery: effects on diaphragmatic 35. Jankowski CJ, Hebl JR, Stuart MJ, et al. A comparison
and respiratory function. Anesthesiology 2000;92(1): of psoas compartment block and spinal and general
102–108. anesthesia for outpatient knee arthroscopy. Anesth
23. Riazi S, Carmichael N, Awad I, et al. Effect of local Analg 2003;97:1003–1009.
anaesthetic volume (20 vs 5 ml) on the efficacy and 36. Bonicalzi V, Gallino M. Comparison of two regional
respiratory consequences of ultrasound-guided anesthetic techniques for knee arthroscopy.
interscalene brachial plexus block. Br J Anaesth Arthroscopy 1995;11(2):207–212.
2008;101(4):549–556. Epub 2008 Aug 4. 37. Goranson BD, Lang S, Cassidy JD, et al. A
24. Brown AR. Anaesthesia for procedures of the hand comparison of three regional anaesthesia techniques
and elbow. Best Pract Res Clin Anaesthesiol for outpatient knee arthroscopy. Can J Anaesth
2002;16(2):227–246. 1997;44(4):371–376.
25. Hadzic A, Arliss J, Kerimoglu B, et al. A comparison 38. Casati A, Cappelleri G, Berti M, et al. Randomized
of infraclavicular nerve block versus general comparison of remifentanil-propofol with a sciatic-
anesthesia for hand and wrist day-case surgeries. femoral nerve block for out-patient knee arthroscopy.
Anesthesiology 2004;101:127–132. Eur J Anaesthesiol 2002;19(2):109–114.
26. Thomson CJ, Lalonde DH. Randomized double-blind 39. Mulroy MF, Larkin KL, Batra MS, et al. Femoral nerve
comparison of duration of anesthesia among three block with 0.25% or 0.5% bupivacaine improves
commonly used agents in digital nerve block. Plast postoperative analgesia following outpatient
Reconstr Surg 2006;118:429–432. arthroscopic anterior cruciate ligament repair. Reg
27. Wilhelmi BJ, Blackwell SJ, Miller JH, et al. Do not use Anesth Pain Med 2001;26:24–29.
epinephrine in digital blocks: myth or truth? Plast 40. Iskandar H, Benard A, Ruel-Raymond J, et al. Femoral
Reconstr Surg 2001;107:393–397. block provides superior analgesia compared with
28. Cummings AJ, Tisol WB, Meyer LE. Modified intra-articular ropivacaine after anterior cruciate
transthecal digital block versus traditional digital ligament reconstruction. Reg Anesth Pain Med
block for anesthesia of the finger. J Hand Surg [Am] 2003;28:29–32.
2004;29:44–48. 41. Williams BA, Kentor ML, Vogt MT, et al. Femoral-
29. Klein SM, Pietrobon R, Nielsen KC, et al. Peripheral sciatic nerve blocks for complex outpatient knee
nerve blockade with long-acting local anesthetics: a surgery are associated with less postoperative pain
70
CHAPTER
before same-day discharge: a review of 1,200 51. Ilfeld BM, Morey TE, Enneking FK. Portable infusion
consecutive cases from the period 1996–1999. pumps used for continuous regional analgesia:
Anesthesiology 2003;98:1206–1213. delivery rate accuracy and consistency. Reg Anesth
42. Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory Pain Med 2003;28:424–432.
continuous femoral nerve blocks decrease time to 52. Capdevila X, Macaire P, Aknin P, et al. Patient-
discharge readiness after tricompartment total knee controlled perineural analgesia after ambulatory
arthroplasty: a randomized, triple-masked, placebo- orthopedic surgery: a comparison of electronic versus
controlled study. Anesthesiology 2008;108:703–713. elastomeric pumps. Anesth Analg 2003;96:414–417.
43. McLeod DH, Wong DH, Vaghadia H, et al. Lateral 53. Fredrickson MJ, Ball CM, Dalgleish AJ. Successful
popliteal sciatic nerve block compared with ankle continuous interscalene analgesia for ambulatory
block for analgesia following foot surgery. Can J shoulder surgery in a private practice setting. Reg
Anaesth 1995;42:765–769. Anesth Pain Med 2008;33:122–128.
44. McLeod DH, Wong DH, Claridge RJ, Merrick PM. 54. Swenson JD, Bay N, Loose E, et al. Outpatient
Lateral popliteal sciatic nerve block compared with management of continuous peripheral nerve catheters
subcutaneous infiltration for analgesia following foot placed using ultrasound guidance: an experience in
surgery. Can J Anaesth 1994;41:673–676. 620 patients. Anesth Analg 2006;103:1436–1443.
45. White PF, Issioui T, Skrivanek GD, Early JS, et al. The
use of a continuous popliteal sciatic nerve block after
surgery involving the foot and ankle: does it improve
the quality of recovery? Anesth Analg 2003;97:
Suggested reading
1303–1309. Mulroy MF, McDonald SB. Regional anesthesia for
46. Ilfeld BM, Thannikary LJ, Morey TE, et al. Popliteal outpatient surgery. Anesthesiol Clin North America
sciatic perineural local anesthetic infusion: 2003;21(2):289–303.
a comparison of three dosing regimens for O’Donnell BD, Iohom G. Regional anesthesia techniques
postoperative analgesia. Anesthesiology 2004; for ambulatory orthopedic surgery. Curr Opin
101:970–977. Anaesthesiol 2008;21(6):723–728.
47. Ilfeld BM, Morey TE, Enneking FK. Infraclavicular Liu SS, Strodtbeck WM, Richman JM, Wu CL. A
perineural local anesthetic infusion: a comparison of comparison of regional versus general anesthesia
three dosing regimens for postoperative analgesia. for ambulatory anesthesia: a meta-analysis of
Anesthesiology 2004;100:395–402. randomized controlled trials. Anesth Analg
48. Ilfeld BM, Morey TE, Wright TW, et al. Continuous 2005;101(6):1634–1642.
interscalene brachial plexus block for postoperative Arakawa M. Central neuraxial blockade in ambulatory
pain control at home: a randomized, double-blinded, surgery. J Anesth 2003;17(2):149.
placebo-controlled study. Anesth Analg 2003;96:
Mulroy MF, Salinas FV. Neuraxial techniques for
1089–1095.
ambulatory anesthesia. Int Anesthesiol Clin
49. Taboada M, Rodríguez J, Bermudez M, et al. 2005;43(3):129–141.
Comparison of continuous infusion versus
automated bolus for postoperative patient-controlled
analgesia with popliteal sciatic nerve catheters.
Anesthesiology 2009;110:150–154. Useful websites
50. Capdevila X, Dadure C, Bringuier S, et al. Effect
of patient-controlled perineural analgesia on American Society of Regional Anesthesia and Pain
rehabilitation and pain after ambulatory orthopedic Medicine www.asra.com
surgery: a multicenter randomized trial. British Association of Day Surgery www.daysurgeryuk.org
Anesthesiology 2006;105:566–573. Society for Ambulatory Anesthesia www.sambahq.org
71
PART I Principles
CHAPTER
9
Which block for which surgery?
Dora Breslin · Stewart Grant
eral nerve blocks is desirable for successful regional anes-

Introduction thesia, the majority of regional anesthesiologists use only a
limited number of blocks regularly. In addition, their block
A recent editorial highlighted that ‘Regional anesthesia
choice may also depend on the nerve location technique
always works, provided we put the right dose of the right
they use. For example, when performing brachial plexus
drug in the right place’.1 Locating the right place is key to
anesthesia above the clavicle using nerve stimulation, many
providing a successful block. With recent developments in
regional anesthesiologists will use an interscalene approach,
peripheral nerve blockade this has become easier. We now
while if they use ultrasound they may opt for an ultrasound
have high quality peripheral nerve stimulators in addition
guided supraclavicular approach. With experience, the
to portable ultrasound technology to aid us in nerve loca-
anesthetist will be able to select the most appropriate
tion.2–4 While accurate nerve location is key to successful
technique (or combination of techniques) in addition to
peripheral nerve blockade, equally important is choosing
making the regional anesthesia technique work.
an appropriate block for the planned surgery. This can only
be obtained by discussing and understanding the planned
surgery with the surgeon. With central neuraxial blockade Applied anatomy
we are aware that a low lumbar epidural would be of limited
benefit for upper abdominal surgery, a thoracic epidural A thorough understanding of anatomy relevant to regional
being of more benefit. Similarly, for wrist surgery, accepting anesthesia is essential if it is to be performed with precision
ulnar nerve stimulation for an axillary block may be of and accuracy and to avoid complications. While the exact
limited benefit, if the surgical incision is on the dorsum of location of nerves is important, the surrounding tissues and
the wrist, where it would have been better to identify the fascial planes are equally important, as the local anesthetic
radial nerve either with nerve stimulation or ultrasound, in is placed in close proximity to the nerves. Traditionally,
addition to blocking other branches of the brachial plexus. doctors have focused particularly on dermatomes, in
Hence, it is not only important to block the correct plexus, addition to osteotomes and myotomes, when performing
but equally important to consider and ensure we block the regional anesthetic techniques (Ch. 4). However, with
necessary nerve branches for the surgical procedure. It is peripheral nerve blocks it is more useful to think what
therefore essential that anesthetists have a comprehensive nerve branches supply the surgical site and to ensure that
knowledge of applied anatomy for regional anesthesia. we block these nerves.
Utilization of regional anesthesia has increased hugely
over the last 20 years, with a recent study suggesting that it Upper limb peripheral nerve blocks
is now used in 37% of surgical cases amenable to a regional
technique.5 This is likely to increase further in coming years. The upper limb is supplied by nerves of the brachial plexus.
In recent years, we have seen a large number of peripheral The brachial plexus is formed by the anterior primary rami
nerve blocks described in the literature, with several descrip- of the lower four cervical nerves (C5–C8) and the first tho-
tions for each approach for a given nerve block. Thankfully, racic nerve (T1).6,7 In some individuals there may also be
the introduction of ultrasound has somewhat simplified contributions from the C4 and T2 nerve roots. The plexus
this. While the ability to perform a wide variety of periph- supplies motor innervation to all the muscles of the upper
DOI: 10.1016/B978-0-7020-3148-9.00017-7
CHAPTER
Which block for which surgery? 9
patients with severe respiratory co-morbidities. In addition,

Table 9.1 Innervations of the major joints of
patients may develop hoarseness and ptosis. This is a super-
the upper limb
ficial block and complications are rare. However, serious
Acromioclavicular Suprascapular, axillary and lateral complications have been reported with this block, including
joint pectoral nerves spinal cord injury, vascular injection and pneumothorax.8
Shoulder joint Suprascapular, axillary and lateral The supraclavicular approach is suitable for surgeries of
pectoral nerves the upper arm, elbow and hand, and is performed at the
level of the trunks of the brachial plexus. It is frequently
Elbow joint Musculocutaneous, radial, ulnar referred to as the spinal anesthetic of the upper limb as it
and median nerves can provide complete anesthesia of the limb below the
Wrist joint Radial, ulnar and median nerves shoulder in a consistent time-efficient manner. In the past,
some anesthetists were cautious about performing this
Notes: Median, ulnar, radial, musculocutaneous and axillary nerves are five block because of the rare complication of pneumothorax,
terminal branches of the brachial plexus. The suprascapular nerve is a
branch from the upper trunk while the lateral pectoral nerve is a branch and the fact that the landmarks were not easy to ascertain,
from the lateral cord of the brachial plexus. particularly in obese patients. However, the advent of ultra-
sound has resulted in a huge increase in the utilization of
this block, where the plexus can be seen lying posterior and
lateral to the subclavian artery on the first rib (Fig. 9.1).
limb with the exception of the trapezius and levator scapula Local anesthetic can be preferentially injected around the
muscles. It supplies cutaneous innervation to the upper lower trunk (C8, T1) of the plexus, particularly when used
limb with the exception of the area of the axilla (upper for hand surgery. Use of this block may still result in phrenic
inner arm), which is supplied by the intercostobrachial nerve paralysis (50%) and Horner’s syndrome.6 Placement
nerve. Above the shoulder is supplied by the supraclavicular of a continuous catheter at this site (supraclavicular fossa)
nerve (cervical plexus), and the dorsal scapular area is sup- for post operative analgesia is easy to secure and less likely
plied by cutaneous branches of spinal nerves. The plexus to become dislodged (Fig. 9.2).
has five terminal branches (median, ulnar, radial, muscu- The infraclavicular approach to the brachial plexus is
locutaneous and axillary nerves) in addition to a number ideal for surgeries from the elbow to the hand. The block
of smaller branches. The innervations of the major joints is performed at the level of the cords of the brachial plexus,
of the upper limb are highlighted in Table 9.1. A more as they lie in close proximity to the subclavian (axillary)
detailed description of upper limb anatomy can be found artery deep to the pectoralis major muscle. The block can
in Chapter 14. It is possible to block the brachial plexus be performed with the arm in any position, whereas with
at various levels as it leaves the intervertebral foramina the axillary approach the arm is abducted. Blocking the
and traverses towards the periphery. The most proximal plexus at this level typically results in satisfactory anesthesia
approach at the level of the nerve roots is the interscalene of the musculocutaneous nerve. Because the nerves lie deep
approach; the supraclavicular block is performed at the to the muscle, this block is particularly suited to a continu-
level of the trunks, while the infraclavicular block is per- ous catheter technique where the catheter can be secured to
formed at the level of the cords, with axillary approach at the anterior chest wall.
the level of the terminal branches. All of these blocks can The axillary approach to the brachial plexus anesthetizes
be successfully performed with either nerve stimulation or the terminal branches of the plexus, as they lie in close
with ultrasound guided techniques (Ch. 7).2–4 proximity to the axillary artery.6 It is ideal for surgeries
The interscalene approach is suitable for surgeries of the below the elbow, particularly hand surgery. This block is
shoulder and upper arm, and can be performed with the safe and easy to perform and is therefore widely used. The
arm in almost any position. It blocks the plexus close to anesthetist needs to be aware that there are multiple vessels
the nerve roots at about the level of the cricoids cartilage (arteries and veins) in close proximity to the nerves and
(C6).6 This may help explain why there is less spread to the care should be taken to avoid intravascular injection. A
lower roots, resulting in poor block of the ulnar nerve (C8, single injection technique is associated with a significant
T1). The posterior shoulder will not be anesthetized, requir- failure, therefore a multiple injection technique should be
ing wound infiltration for the port site for shoulder arthros- used or the block performed under ultrasound guidance to
copies. Equally, the anterior port for arthroscopy may also ensure adequate spread of local anesthetic9 (Fig. 9.3). The
be missed because the skin is supplied by T2. A supplemen- musculocutaneous nerve lies between the biceps and cora-
tal skin infiltration needs to be made over the distribution cobrachialis muscle and may be some distance away from
of T2 to ensure the anterior port or the lower end of a total the other branches of the plexus which lie close to the
shoulder incision is adequately anesthetized. The phrenic artery. It is critical to block the musculocutaneous nerve, as
nerve is paralyzed with this approach as it lies on the ante- it supplies the flexor muscles of the arm and the skin over
rior scalene muscle, so caution should be exercised in the lateral surface of the forearm.
73
PART I Principles
Skin
Art
Rib
A
A
Skin
LA Needle
Art
Rib
B
B
Figure 9.2 Supraclavicular continuous catheter. Placed for intra-
Figure 9.1 Ultrasound-guided supraclavicular block. (A) The nerve operative anesthesia and postoperative analgesia in a patient with
plexus (arrows) is seen lying lateral to the subclavian artery (Art). (B) The severe hand trauma (4-finger amputation).
tip and shaft of the needle is seen lateral to the artery after injection of
local anesthetic.
The utilization of elbow and forearm blocks is discussed

in Chapters 21 and 22. These blocks are easy to perform,
particularly when ultrasound guidance is used (Fig. 9.4).
These techniques are useful both as the primary anesthetic,
and also for postoperative analgesia. Consideration should
be given as to whether the surgeon is using a tourniquet
and in what location. Upper arm tourniquets can be used
for short periods of time, but longer use will require anes-
thesia of the tourniquet location. In such cases, a distal
forearm or elbow block performed with a long acting local
anesthetic (to provide postoperative analgesia) can be used
in combination with a more proximal block such as infra-
clavicular or axillary block, using a shorter-acting local
anesthetic (lignocaine). The more distal block should be
performed first to minimize the risk of unrecognized intra- Figure 9.3 Ultrasound-guided axillary block. The plaster cast is left in
neural injection. These blocks are also frequently used as situ, as there is no need to utilize nerve stimulation.
74
CHAPTER
Skin
v
lN
BR
dia
Ra
B Figure 9.5 The intercostobrachial nerve (T2) is blocked using subcuta-

neous infiltration of local anesthetic around the medial aspect of the
Bone upper arm (along the red line).
Figure 9.4 An ultrasound scan of the radial nerve (arrow) at the elbow,
lying above the bone, between the brachioradialis (BR) and the brachia-
lis muscles (B).
Lower limb peripheral nerve blocks
The lower limb has a dual nerve supply consisting of the
lumbar plexus and the sacral plexus.7 The lumbar plexus is
‘rescue’ blocks, where following a more proximal block formed by the anterior rami of L1 to L4 with contributions
there is incomplete anesthesia in a branch of the plexus. from T12 in some individuals. The three main branches of
This branch can then be blocked at the elbow or forearm. the lumbar plexus related to lower limb peripheral nerve
Again, caution should be exercised, as rescue blocks may be blocks are the femoral (L2,3,4), obturator (L2,3,4), and
associated with a higher incidence of nerve injury. lateral femoral cutaneous nerves (L2,3); other branches
The intercostobrachial nerve (T2) supplies the area of the include the iliohypogastric, ilioinguinal and the genitofem-
axilla (upper inner arm) which is important for certain oral nerves. The sacral plexus is formed by the anterior rami
upper arm procedures. In addition, this is where an upper of L4 to S4. The major nerve branches of the sacral plexus
arm tourniquet is typically located. While tourniquet pain are the sciatic nerve, the posterior cutaneous nerve of the
is largely related to muscle ischemia, anesthetizing the skin thigh and the pudendal nerve.7 The sciatic nerve splits into
in this area will improve patient comfort. This is easily its 2 branches, the common peroneal and the tibial nerve,
achieved using subcutaneous infiltration of local anesthetic typically about 7–10 cm above the popliteal fossa. The
around the medial aspect of the upper arm (Fig. 9.5). The sciatic nerve has numerous articular (hip and knee) and
supraclavicular nerve block (cervical plexus) can be per- muscular branches. The innervations of the major joints of
formed by injecting local anesthetic along the posterior the lower limb are highlighted in Table 9.2. A more detailed
border of the sternocleidomastoid muscle (Ch. 11). description of lower limb anatomy can be found in Chapter
The surgical location, as stated at the start of the chapter, 23. Blockade of peripheral nerves of the lower limb has
will dictate where the nerve block is placed. A reasonable been shown to provide comparable analgesia and func-
guide is that the higher up the arm the surgery is performed, tional recovery in the postoperative period to epidural
the more proximal the nerve block should be performed, analgesia, and superior analgesia and recovery to PCA
but this is not always the case. If, for example, vascular opioids.10,11 To provide complete anesthesia of the lower
access surgery is being performed on the medial part of the limb using peripheral nerve blocks, we need to block both
upper arm, then performing an interscalene nerve block the lumbar and the sacral plexus. There is no single periph-
will not be advantageous. With interscalene nerve block, eral nerve block injection that can reliably block both of
the nerve roots that are commonly missed are C8 and T1. these together. Thus we need to consider which plexus
C8 and T1 are the nerve roots that supply the ulnar nerve provides the majority of the innervation and block this
and the skin of the medial aspect of the upper arm (along plexus first to allow time for the major block to setup. We
with a variable distribution from T2). A more appropriate also need to block either the other plexus or the significant
nerve block here would be a supraclavicular or infraclavicu- branches. For above knee surgery, the major innervation is
lar nerve block that will block C8, T1 distribution, along the lumbar plexus. In below knee surgery, the sciatic nerve
with supplementation of T2 by subcutaneous infiltration. (sacral plexus) is the dominant nerve supply (and should
75
PART I Principles
Table 9.2 Innervations of the major joints of

the lower limb
Hip joint Femoral, obturator and sciatic nerves
Knee joint Femoral, obturator and sciatic (tibial,
common peroneal) nerves
Ankle joint Femoral (saphenous) and sciatic (tibial,
superficial & deep peroneal) nerves
be anesthetized first), with only a small cutaneous distribu- LFCN

tion from the saphenous nerve (femoral) on the anterior FEM
medial surface of the leg to the medial malleolus. The
OBT
saphenous nerve can then be blocked at the groin with a
low volume femoral nerve block, in the thigh area, where
it lies in the adductor canal behind the sartorius muscle or
at the level of the tibial tuberosity. Sciatic
A
Lumbar plexus
The most proximal approach to the lumbar plexus is the
posterior approach (also called the psoas compartment
block, Ch. 27). This block results in the most reliable anes-
thesia of the three important branches (femoral, obturator
and lateral femoral cutaneous nerves) of the lumbar plexus.
The branches of the lumbar plexus are spread out, and
hence this block typically requires a large volume of local
anesthetic (30 mL; Fig. 9.6). This block is ideal for provid-
ing both anesthesia and analgesia for hip surgery, surgery
above the knee and knee surgery. It must be combined with
blockade of the sacral plexus, or is frequently used in com-
bination with spinal anesthesia to provide analgesia in the
postoperative period for major joint surgery. This posterior
approach is frequently used to place a continuous periph-
eral nerve catheter system, as it is a clean area and easy to
fix the continuous catheter in the lumbar area. It is a deep
block12 (6–10 cm, or greater in the obese) and more B
complex to perform, so it should not be used in people at
risk of bleeding. As the plexus lies in a vascular area, it may Figure 9.6 (A, B) Anterior and posterior anatomical model of the
lumbar plexus. The lumbar plexus as it arises from the lumbar spinal
be associated with a higher risk of inadvertent intravascular
column. Note that the nerves are spread over several centimeters,
injection and local anesthetic toxicity.13 Because of the which is why a larger volume of local anesthetic is required to produce
close proximity of the plexus to the spinal cord with this complete anesthesia.
approach, and the volumes of local anesthetic used, it is
not surprising that neuraxial spread of local anesthetic is
well described. This can result in bilateral lower limb The femoral nerve block (Ch. 26) is indicated for patients
sensory and motor block, in addition to hypotension and undergoing hip surgery, surgery above the knee and knee
cardiovascular compromise. Ultrasound facilitates the per- surgery. It reliably results in blockade of the femoral nerve
formance of many blocks, particularly the more superficial but less frequently results in blockade of the lateral femoral
blocks. However, the lumbar plexus is difficult to accurately cutaneous nerve or obturator nerve.15 For this reason, it
visualize with ultrasound. So while the posterior approach does not provide reliable anesthesia for knee replacement
provides the most reliable blockade of the lumbar plexus, surgery even when combined with proximal sciatic nerve
providing excellent anesthesia for hip and knee surgery, blockade. If the surgery is to be performed with peripheral
many anesthetists prefer the safer and easier anterior nerve blocks alone, a psoas compartment block combined
approach (femoral nerve block) to the lumbar plexus.14 with a proximal sciatic nerve block would have the highest
76
CHAPTER
success rate. Alternately, the lateral femoral cutaneous and both in the pre-operative hip fracture and postoperative
the obturator nerves can also be blocked. The femoral, patient.16–18
lateral femoral cutaneous nerve, and obturator nerves can The saphenous nerve is the continuation of the femoral
all be blocked with ultrasound guidance. A continuous nerve and supplies cutaneous sensation on the anterior
peripheral nerve catheter is frequently placed to provide medial surface of the leg to the medial malleolus. The
postoperative analgesia following lower limb joint replace- saphenous nerve can be blocked with a low volume femoral
ment (Fig. 9.7). An alternative block to the femoral block nerve block, or in the thigh area where it lies in the adduc-
is the fascia iliaca block (Ch. 28). This block is extremely tor canal behind the sartorius muscle. Probably the easiest
easy and quick to perform and is ideal for analgesia for hip place to block the saphenous nerve is with subcutaneous
and knee surgery. Similar to the femoral nerve block, it local anesthetic infiltration medial to the tibial tuberosity,
provides reliable anesthesia to the femoral nerve, but vari- but because of the variable anatomy of the saphenous nerve
able anesthesia to the lateral femoral cutaneous and the in this position, this technique is not universally successful.
obturator nerves. It is frequently used to provide analgesia Blockade of the saphenous nerve is used in combination
with sciatic nerve block to provide complete anesthesia and
analgesia below the knee.
Sacral plexus
The main branch of the sacral plexus is the sciatic nerve,
the most proximal approach being the parasacral approach,
a posterior approach blocking the nerve as it exits the
greater sciatic foramen. The classic approach to the sciatic
nerve (Fig. 9.8) anesthetizes the nerve as it lies beneath the
gluteal muscle, medial to the greater trochanter of the
femur (Ch. 24). Sciatic nerve block is used for surgery on
the knee, calf, ankle, and foot, when combined with block
of the femoral or saphenous nerve. With these proximal
approaches, the posterior cutaneous nerve of the thigh lies
in close proximity to the sciatic nerve. These blocks are deep
blocks and require adequate sedation, particularly when
A
performed with nerve stimulation. Placement and securing
continuous peripheral nerve catheters is ideal in these
GT
PSIS SH
B
Figure 9.7 (A, B) Placement of a continuous femoral nerve catheter for Figure 9.8 The classic approach of Labat to the sciatic nerve. Land-
postoperative analgesia following revision of total knee replacement. marks are the posterior superior iliac spine, greater trochanter and sacral
Note the large abdominal pannus (A) taped up (white tape) to allow hiatus. This nerve block is used for surgery on the knee, calf, ankle
access to the femoral crease. and foot.
77
PART I Principles
locations. As the patient is typically on their side for these

procedures, they are frequently combined with a posterior Making regional anesthesia work
approach to the lumbar plexus or spinal anesthetic. Ultra-
Choosing the appropriate peripheral nerve block for the
sound guidance can be used for these proximal approaches,
surgery is the key to making regional anesthetic techniques
but it is easier to visualize the sciatic nerve with the subglu-
work. This is particularly true when peripheral nerve block
teal and popliteal approaches. An anterior approach to the
techniques are used for both surgical anesthesia and post-
sciatic nerve (Ch. 25), when combined with a femoral and
operative analgesia. However, success using peripheral
obturator block, also results in complete anesthesia of the
nerve blocks starts long before the placement of the block
knee and below. The anterior approach is a deeper block,
needle. At the pre-anesthetic visit following full assessment
which may be more difficult to perform and is associated
of the patient (History, Examination and Investigations),
with a higher incidence of complications.
the anesthetist informs the patient that the surgical proce-
A frequently used approach to the sciatic nerve is the
dure can be performed using a regional anesthetic tech-
popliteal block, performed proximal to the popliteal fossa
nique, or a regional anesthetic may form part of the
before the sciatic nerve splits into its two branches, the
anesthetic plan (Box 9.1). Indications and contraindica-
common peroneal and the tibial nerve.19,20 This block can
tions to block placement are discussed in Chapter 4 of this
be performed with nerve stimulation or with ultrasound
book. They may also inform the patient of the potential
guidance, where it can be easily seen lying above the vas-
benefits of a regional technique, including improved anal-
cular structures (Fig. 9.9). It results in anesthesia below the
gesia and decreased side-effects in the postoperative period.
knee, and can be combined with saphenous nerve block. It
Early patient education is important to the acceptability
is ideal for ankle and foot surgery, although consideration
and success of these techniques. Many surgeons now also
has to be given to the location of the tourniquet. Again, this
inform their patients that the proposed surgery can be per-
is an appropriate site to place a continuous catheter for
formed while using a regional anesthetic. Experienced sur-
postoperative analgesia after appropriate surgery.
geons may also caution the anesthetist when a peripheral
The ankle block (Ch.31) provides excellent anesthesia
nerve block technique may not be ideal (e.g. risk of com-
and analgesia for surgery on the foot and toes. It is a com-
partment syndrome (Fig. 9.10) or when additional blocks
bination of blocking four terminal branches of the sciatic
may be necessary; for example, harvesting bone graft from
nerve (posterior tibial, deep and superficial peroneal, sural)
the iliac crest.
and the saphenous nerve. It is easy to perform and has a
An important factor in making regional anesthesia work
low risk of complications.
is maintaining operating theatre efficiency.21,22 This can
A discussion on the utilization of paravertebral, inter-
largely be facilitated by being organized. The use of regional
costal and transversus abdominis plane (TAP) blocks is
anesthesia block carts helps keep the necessary equipment
included in Chapters 32–34.
Skin
NV
Vein
Art
Figure 9.10 Lower limb compartment syndrome. Intracompartmental

pressure monitor being performed in a patient with a tibial shaft frac-
Figure 9.9 Ultrasound popliteal block. The sciatic nerve above the ture and considerable associated swelling. A peripheral nerve block
popliteal fossa. The nerve (NV) can be easily seen lying on the popliteal using a long-acting local anesthetic may delay the detection of com-
artery (Art) and vein (V). partment syndrome in long bone fractures (Tibia).
78
CHAPTER
Box 9.1
Making regional anesthesia work
Pre-operative management
• Appropriate history/exam/investigation
• Know proposed surgical procedure/site
• Patient education
• Decide optimal regional technique
Block performance
• Standard monitoring/emergency equipment available
• Sedation
• Appropriate block for surgery
• Correct procedure/side
• Consider continuous catheter system A
• Appropriate local anesthetic / concentration (%)
• Block early to allow adequate time for local anesthetic to
work
• Assess adequacy of the block
• Consider rescue blocks if necessary
• Consider use of arterial tourniquet
Intra-operative management
• Patient education
• What to expect
• Standard monitoring
• Assess adequacy of the block
• Appropriate sedation as necessary
• Background music
• Patient comfort-blankets and pillows
• Supplemental oxygen
• Plan postoperative analgesia B
Postoperative management Figure 9.11 Regional anesthesia block rooms or areas can improve
• Patient education operating room efficiency. (A) The ‘block area’ with full monitoring
• Block duration/resolution and emergency resuscitation equipment. (B) The ‘Regional Anesthesia
Supply Cart’ contains the necessary supplies to perform regional
• Protecting anesthetised extremity
anesthetics.
• Preventing falls
• Postoperative analgesia
• Multi-modal analgesia plan
equally effective when used purely for postoperative anal-
gesia, improving safety by decreasing the total dose of local
anesthetic used. Mepivacaine and lignocaine have a faster
onset but shorter duration of anesthesia and may be appro-
together and improves efficiency. The use of induction priate for shorter cases (Ch. 3). In addition, when regional
rooms or ‘block areas’ allows peripheral nerve blockade to anesthesia is performed prior to entering the operating
be performed ahead of entering the operating room, there- room, the peripheral nerve block can be assessed and a
fore saving time.21,22 (Fig. 9.11). This is especially important rescue block performed, or alternate anesthetic planned if
when using longer-acting local anesthetics (bupivacaine, necessary. Regional anesthetic techniques also have advan-
levobupivacaine and ropivacaine), where it may take 30–45 tages on completion of surgery where emergence and extu-
minutes to achieve complete surgical anesthesia. Typically, bation are not required, thus improving operating room
higher concentrations of local anesthetics are used for anes- efficiency.21,22 Patients receiving these techniques may also
thesia compared to postoperative analgesia. Bupivacaine have a shorter stay in the post-anesthetic care unit.
0.5% may be required for anesthesia, but it has been shown Performance of some peripheral nerve block techni-
that the lower concentrations (i.e. bupivacaine 0.25%) are ques can be painful and may require sedation for block
79
PART I Principles
2. Pither C, Raj PP, Ford D. The use of peripheral nerve

stimulators for regional anesthesia. A review of
experimental characteristics, technique and clinical
applications. Reg Anesth 1985;10:49–58.
3. Soeding P, Eizenberg N. Review article: anatomical
considerations for ultrasound guidance for regional
anesthesia of the neck and upper limb. Can J Anaesth
2009;56(7):518–533.
4. Chin KJ, Chan V. Ultrasound-guided peripheral nerve
blockade. Curr Opin Anaesthesiol 2008;21(5):624–
631.
5. Hanna MN, Jeffries MA, Hamzehzadeh S, et al.
Survey of the utilization of regional and general
anesthesia in a tertiary teaching hospital. Reg Anesth
Figure 9.12 Intra-operative care of the patient is important. Intra- Pain Med 2009;34(3):224–228.
operative sedation in combination with background music and warming 6. Neal JM, Gerancher JC, Hebl JR, et al. Upper
blankets facilitate patient comfort while undergoing a total knee extremity regional anesthesia: essentials of our
replacement with combined psoas compartment and sciatic nerve current understanding, 2008. Reg Anesth Pain Med
block.
2009;34(2):134–170. Review.
7. Moore KL. In: Moore KL, Dalley AF, editors.
performance. This is particularly true for deeper peripheral Clinically orientated anatomy, 4th edn. Philadelphia:
nerve blocks such as infraclavicular blocks in muscular indi- Lippincott, Williams & Wilkins; 1999.
viduals, and the posterior approach to the lumbar plexus 8. Benumof JL. Permanent loss of cervical spinal cord
or some approaches to the sciatic nerve. In addition, the function associated with interscalene block performed
use of nerve stimulation is associated with increased dis- under general anesthesia. Anesthesiology 2000;
comfort compared with ultrasound-guided techniques. 93(6):1541–1544.
Appropriate use of sedation is associated with improved 9. O’Donnell BD, Ryan H, O’Sullivan O, Iohom G.
patient satisfaction. The use of low doses of opioid analge- Ultrasound-guided axillary brachial plexus block with
sics, such as alfentanil or fentanyl combined with mid- 20 milliliters local anesthetic mixture versus general
azolam, may facilitate the performance of the procedure. anesthesia for upper limb trauma surgery: an
The aim is to provide analgesia and anxiolosis but maintain observer-blinded, prospective, randomized, controlled
patient cooperation to try and minimize complications. trial. Anesth Analg 2009;109(1):279–283.
The intra-operative care of patients who have received 10. Singelyn FJ, Deyaert M, Joris D, et al. Effects of
regional anesthetic techniques can be challenging and is intravenous patient-controlled analgesia with
important to the success of the block (Box 9.1). Depending morphine, continuous epidural analgesia, and
on the patient, they may wish to be sedated during the continuous three-in-one block on postoperative pain
surgery, or may prefer to listen to music rather than the and knee rehabilitation after unilateral total knee
noisy theatre environment. In addition they should be kept arthroplasty. Anesth Analg 1998;87(1):88–92.
warm and comfortable (Fig. 9.12).
11. Capdevila X, Barthelet Y, Biboulet P, et al. Effects of
In summary, we have a variety of peripheral nerve block
perioperative analgesic technique on the surgical
techniques to provide complete anesthesia and analgesia of
outcome and duration of rehabilitation after
the upper and lower limbs. It is important that we choose
major knee surgery. Anesthesiology 1999;91(1):
an appropriate block resulting in anesthesia in the distribu-
8–15.
tion of the proposed surgery. We also need to consider the
use of additional blocks. The peripheral nerve block is the 12. Capdevila X, Macaire P, Dadure C, et al. Continuous
key factor, but there are many other considerations to psoas compartment block for postoperative analgesia
making regional anesthesia work. after total hip arthroplasty: new landmarks, technical
guidelines, and clinical evaluation. Anesth Analg
2002;94(6):1606–1613.
References 13. Breslin DS, Martin G, Macleod DB, et al. Central
nervous system toxicity following the administration
1. Denny NM, Harrop-Griffiths W. Location, location, of levobupivacaine for lumbar plexus block: a report
location! Ultrasound imaging in regional anesthesia. of two cases. Reg Anesth Pain Med 2003;28(2):144–
British Journal of Anesthesia 2005;94(1):1–3. 147.
80
CHAPTER
14. Tran D, Clemente A, Finlayson RJ. A review of 18. Ganapathy S, Wasserman RA, Watson JT, et al.
approaches and techniques for lower extremity nerve Modified continuous femoral three-in-one block
blocks. Can J Anaesth 2007;54(11):922–934. for postoperative pain after total knee arthroplasty.
15. Morau D, Lopez S, Biboulet P, et al. Comparison of Anesth Analg 1999;89(5):1197–1202.
continuous 3-in-1 and fascia iliaca compartment 19. Hadzić A, Vloka JD. A comparison of the posterior
blocks for postoperative analgesia: feasibility, catheter versus lateral approaches to the block of the sciatic
migration, distribution of sensory block, and nerve in the popliteal fossa. Anesthesiology 1998;
analgesic efficacy. Reg Anesth Pain Med 2003; 88(6):1480–1486.
28(4):309–314. 20. Perlas A, Brull R, Chan VW, et al. Ultrasound
16. Foss NB, Kristensen BB, Bundgaard M, et al. Fascia guidance improves the success of sciatic nerve block
iliaca compartment blockade for acute pain control at the popliteal fossa. Reg Anesth Pain Med 2008;
in hip fracture patients: a randomized, placebo- 33(3):259–265.
controlled trial. Anesthesiology 2007;106(4): 21. Williams BA, Kentor ML, Williams JP, et al. Process
773–778. analysis in outpatient knee surgery: effects of regional
17. Cuignet O, Mbuyamba J, Pirson J. The long-term and general anesthesia on anesthesia-controlled time.
analgesic efficacy of a single-shot fascia iliaca Anesthesiology 2001;94(5):937–938.
compartment block in burn patients undergoing 22. Armstrong KP, Cherry RA. Brachial plexus anesthesia
skin-grafting procedures. J Burn Care Rehabil compared to general anesthesia when a block room is
2005;26(5):409–415. available. Can J Anaesth 2004;51(1):41–44.
81
PART I Principles
CHAPTER
10
Training in peripheral nerve blockade
Frank Loughnane
In 1979–1980, anesthesia residents in the USA reported • program director and faculty
using regional anesthesia techniques in approximately 21% • facilities and resources
of cases.1 While over the following decade this improved • the educational program
to 29.8%, large differences remained between individual • scholarly activity
training programs in their ability to deliver training in
• consultant skills
peripheral nerve blockade techniques.2 A follow-up study
in the year 2000 showed a disappointingly small increase • evaluation
in use to 30.2% of cases; an insignificant change.3 More- • board certification (or equivalent).
over, the vast majority of cases revolve around central neur- Some of the ‘critical determinants of learning’ have been
axial blockade, with most residents gaining their exposure identified and include:
to peripheral nerve blocks through chronic pain modules.
1. the existence of a formal structured training program
Thus, upwards of 40% of United States residents (registrars)
2. time constraints/theater efficiency
are likely to have received inadequate training in peripheral
nerve block techniques. Although there is little supporting 3. trainer–trainee interaction
published evidence, this picture is likely to be replicated in 4. patient safety/trainer/trainee stressors.6
many other countries. In order to meet this need, there are Programs such as that endorsed by ASRA are required to
data to suggest that in the United States alone there is a ensure residents obtain such formal structured training and
requirement in the order of 250 trained regional anesthesia to minimize factors such as in points (2), (3) and (4). It
experts.4 In order to redress such deficiencies in training, it sets out a template that any institution may adopt and
is apparent that residency programs will need to reappraise adapt in developing a comprehensive fellowship program
not only their core curricula but also their faculty and their (Box 10.1). The remainder of this chapter will, for the most
core competencies. part, deal with the practicalities of imparting skills and the
assessment of competencies in these skills.
Institutional organization
In an effort to move the subspecialty forward in this regard,
the American Society of Regional Anesthesia has endorsed
Skills and competencies
a set of guidelines for regional anesthesia fellowship train-
For many years, training programs have tended to con-
ing.5 These guidelines have been developed by a group
centrate on exposing their residents to a subspecialty for
of regional anesthesiology fellowship directors and other
a predetermined period of time in order for them to
interested parties from across the United States over a
attain competence. While this method has worked in the
number of years. They suggest a method for addressing:
imparting of certain skills, it is clearly flawed. Therefore,
• scope and duration of training efforts have been directed towards a variety of alternative
• institutional organization techniques.
DOI: 10.1016/B978-0-7020-3148-9.00018-9
CHAPTER
Training in peripheral nerve blockade 10
Box 10.1
Guidelines for Regional Anesthesia Fellowships
A consensus document from the directors of regional anesthe- B) Institutional policy and resources: the fellowship must
sia fellowship programs. be recognized and approved by the institution’s
division of Medical Education.
Mission statement:
III. Program Director and Faculty:
• The purpose of this endeavor is to develop a set of A) Program Director: the director of the fellowship
standards for subspecialty training in regional anesthesia. training program must be an ABA Board-Certified
• These fellowship programs will ensure the ongoing anesthesiologist (or equivalent, e.g. FRCPC, FRCA)
development of regional anesthesia as a defined who has completed 1 year of fellowship training in
subspecialty. regional anesthesia, or is a dedicated and skilled
• Research activities, educational curricula, and, most practitioner of regional anesthesia. The Program
importantly, clinical care will be emphasized. Director must also have an academic and/or clinical
Program requirements for Fellowship Training in affiliation with an ACGME (or recognized equivalent)
Regional Anesthesia: accredited institution.
Outline: B) Faculty: the majority of the faculty in the training
program must be Board-Certified (or equivalent) in
I. Scope and duration of training
Anesthesiology. A division of the faculty in the
II. Institutional organization
training program must also demonstrate an expertise
III. Program Director and Faculty
in regional anesthesiology and/or related disciplines
IV. Facilities and resources
such as acute pain medicine. The number of faculty in
V. The educational program
a program may vary based on the number of fellows
VI. Scholarly activity
in training; however a minimum of two regional
VII. Consultant skills
anesthesia faculty must be maintained.
VIII. Evaluation
IV. Facilities and resources:
IX. Board Certification.
A) Equipment: suitable equipment for the performance of
I. Scope and duration of training: a wide variety of regional anesthetic techniques must
A) Scope of training: regional anesthesia training is a be available. Such equipment must include nerve
subspecialty focused on the peri-operative simulators, neuraxial and peripheral block supplies,
management of patients receiving neuraxial or catheter systems, and the basic requirements for
peripheral neural blockade for anesthesia or analgesia. conducting general anesthesia, according to the ASA
Fellowship training should be concerned with the standards. Dedicated and acceptable on-call facilities
development of expertise in the practice and theory must also be maintained if fellows are expected to
of regional anesthesiology. take in-house calls.
B) Duration of training: the time required for subspecialty B) Support services: appropriate support services, which
training in regional anesthesia shall be 12 months. may include, but are not limited to, anesthesia
There should be enough flexibility to allow the technical and pharmacy support should be available
Program Director to tailor the program to meet the as needed by the program.
individual needs of their fellows. Specialized clinical C) Library: a departmental library, or portion of the
rotations of less than 12 months may be made institutional library, dedicated to anesthesiology with
available but the minimum amount of training literature specific to the practice of regional
necessary to use fellowship in the diploma language anesthesia must be maintained.
is 1 year. V. The Educational Program:
II. Institutional organization: A) Clinical education: the clinical program will serve
A) Relationship to a core program: institutions with as the cornerstone of the fellowship training in
subspecialty training in regional anesthesia must have regional anesthesia. In order to achieve the
a direct affiliation with an ACGME (or similar, e.g., necessary level of expertise, fellows should be
RCPC or RCA) accredited residency in anesthesiology. familiar with the indications, contraindications,
If the institution in which the fellowship is based is techniques, and complications of the techniques
other than the primary institution of an accredited listed, below.
residency, a written agreement linking the two, and
an evaluation protocol consistent with ACGME (or Basic techniques:
equivalent) approved standards for residency • Superficial cervical plexus block
programs must be prerequisites. • Axillary brachial plexus block
83
PART I Principles
Box 10.1 (continued)
• Intravenous regional anesthesia (Bier block) should be reviewed regularly with the appropriate
• Wrist block faculty advisor.
• Digital nerve block Fellows must be able to show competency in the
• Intercostobrachial nerve block following areas:
• Saphenous nerve block • demonstrate rational selection of regional
• Ankle block anesthesia for specific clinical situations
• Spinal anesthesia • demonstrate effective anxiolysis of patients by
• Lumbar epidural anesthesia both pharmacological and interpersonal
• Combined spinal-epidural anesthesia techniques
• Femoral nerve block • demonstrate cost-effective management decision
Intermediate techniques: • demonstrate ability to rescue failed regional
anesthesia techniques
• Deep cervical plexus block
• demonstrate effective management of isolated
• Interscalene block
peripheral nerve and central neuraxial blocks with
• Supraclavicular block
respect to the physiologic consequences both
• Infraclavicular block
intra-operatively and postoperatively
• Sciatic nerve block: posterior approach
• demonstrate successful use of a peripheral nerve
• Genitofemoral nerve block
stimulator for neuronal blocks
• Popliteal block: all approaches
• demonstrate effective management of regional
• Suprascapular nerve block
anesthesia in critically ill patients
• Intercostal nerve block
• demonstrate knowledge of practice management
• Thoracic epidural anesthesia
principles as they relate to regional anesthesia.
Advanced techniques: Exposure to regional anesthetic techniques
• Continuous interscalene block involving pediatric and ambulatory surgery patients is
• Continuous infraclavicular block strongly encouraged. Access to cadavers and/or
• Continuous axillary block electronic models would greatly enhance the
• Thoracolumbar paravertebral block: single injection educational program experience, as would exposure to
or continuous advanced localization techniques for block placement
• Lumbar plexus block (e.g. ultrasound), where feasible. Physiologic and
• Combined lumbar plexus/sciatic block pharmacologic consequences of regional anesthesia
• Continuous femoral nerve block must be stressed. Particular attention should be
• Sciatic nerve block: anterior approach and focused on the potential respiratory and hemodynamic
parafemoral technique perturbations, which accompany performance of
• Obturator nerve block neuraxial and peripheral nerve blocks.
• Continuous sciatic nerve block B) Didactic Educational Program: a didactic and
• Continuous popliteal block: all approaches educational program specifically dedicated to regional
• Cervical epidural anesthesia anesthesia practice must also be a part of fellowship
• Cervical paravertebral block training.
• Maxillary nerve block i) A lecture series or Grand Rounds, which covers
• Mandibular nerve block topics relevant to, but not limited to, regional
• Retrobulbar and peribulbar nerve block. anesthesia, shall be held no fewer than 12 times
Fellows will be required to complete a formal per year. A ‘Journal Club’ (current literature review)
rotation in acute pain management. This rotation will should be held at least once monthly. Fellows
include multimodal analgesic techniques such as should present articles at least twice in 12 months
neuraxial and peripheral nerve catheters local under the supervision of an attending
anesthetics and narcotic infusions, and non-narcotic anesthesiologist. A case conference specifically
analgesic adjuvants. Indications, contraindications, designed for fellows and supervised, or given, by a
side-effects, potential complications, and daily qualified faculty member shall occur at least once
management of patients on the acute pain service per month.
should be stressed. Fellows should complete daily ii) Fellows shall be expected to deliver a Grand
case logs to track their clinical experience. These logs Rounds lecture including a relevant literature
84
CHAPTER
review at least once during the course of the integrated institutions is of paramount importance to
fellowship. the program. Adequate documentation of scholarly
iii) Fellows should appreciate the practice of regional activity on the part of the program director and
anesthesia from a multidisciplinary approach the teaching faculty at the parent and integrated
including joint conferences with surgical or institutions must be submitted at the time of the
medical colleagues. program review. Scholarly activity at affiliated
iv) Fellows should have the opportunity to learn institutions cannot account for or substitute for the
teaching techniques by educating junior residents educational environment of the parent and integrated
during the academic year. institutions.
By completion of the accredited program, the fellow Documentation of scholarly activities is based on:
is expected to have a working knowledge base 1. Active participation of the faculty in clinical
consisting of the following: discussions, rounds, and conferences in a manner
• understands general attributes of local anesthetic that promotes a spirit of inquiry and scholarship.
pharmacology Scholarship implies an in-depth understanding of
• understands specific clinical attributes of various basic mechanisms of normal and abnormal states and
local anesthetics, including onset, duration, the application of current knowledge to practice.
motor/sensory differentiation, toxicity, and 2. Participation in journal clubs and research
treatment conferences.
• understands principles and indications for various 3. Participation in research, particularly in projects
local anesthetic adjuvants, including epinephrine, funded following peer review that result in
phenylephrine, opioids, sodium bicarbonate, and publications or presentations at regional and national
clonidine scientific meetings.
• understands principles of, and options for, regional 4. Active participation in regional or national professional
anesthetic procedures and scientific societies, particularly through
• understands complications of regional anesthetic presentations at organizations’ meetings and
techniques publications in their journals.
• understands principles of regional anesthesia as 5. Offering of guidance and technical support (e.g.
they apply to pain management research design, institutional committee protocol
• understands outcome studies related to the approval, statistical analysis) for fellows involved in
influence of regional anesthesia on perioperative scholarly activities.
outcome While not all members of a teaching faculty can be
• develops familiarity with major scientific studies investigators, clinical and/or basic science research
related to regional anesthesia. must be ongoing in the department of anesthesiology
VI. Scholarly activity: of the parent and integrated institution(s). The faculty,
A) Expectations for Fellows: Fellows shall have the as a whole, must document active involvement in all
opportunity to participate in clinical and/or laboratory phases of scholarly activity as defined above in order
research and be given appropriate nonclinical time to to be considered adequate to conduct a program of
fulfill these goals. There will be opportunities for the graduate education in anesthesiology.
fellow to become involved in research already in VII. Consultant skills:
progress, or to develop an original project. In either A) Communication skills: fellows should possess
case, an appropriate attending anesthesiologist will communication skills sufficient to solicit and
be appointed to mentor and assist the fellow to imparting formation. The fellow must be able to
facilitate these goals. The types of activities that clearly delineate options available to the patient
would suffice as academic projects include a research regarding regional anesthesia as well as the risks and
paper and/or case report submitted to a peer-review benefits in a manner that is understandable to the
journal and presented; a clinical chart review or a patient.
review article submitted to, and accepted by a B) Collaboration skills: fellows must be able to work in a
peer-reviewed journal; a book chapter; or other team environment, communicating and cooperating
endeavor. with surgeons, nurses, pharmacists, physical
B) Expectations for Faculty: The quality of the therapists, and all members of the peri-operative
educational environment of the parent and team.
85
PART I Principles
By the end of the fellowship, successful graduates will be VIII. Evaluation:

able to: A) As per ACGME Residency Guidelines, the attending
• appreciate the roles of other members of the team faculty will be evaluated by the fellows twice
• communicate clearly in a collegial manner that annually.
facilitates the achievement of care goals B) Written evaluations of fellows by all faculty with
• help other members of the team to enhance the whom they have worked shall occur quarterly.
sharing of important information The results of these evaluations shall be recorded and
• formulate care plans that utilize the multidisciplinary reviewed with the fellows by the program director no
team skills, such as a plan for facilitated recovery. less often than every 6 months.
Recommended case numbers Cumulative learning curves
There is broad agreement as to the minimum recommended

number of times a resident should perform a procedure in 0.8
order to reach the requisite standard.7–9 The learning curves
for a variety of procedures show a marked improvement of Relative success (in %)
skill after the initial 20 attempts and inter-individual scat-
tering decreases over time (Figs 10.1–10.6).
0.4
This method of prescribing a minimum case load for
trainees can be limited by the case mix, staff to resident
ratios in teaching manual skills, and physician preferences
for special procedures. These factors in turn may contribute
0.0
to the variation amongst institutions which has led to 0 20 40 60 80 100
the lamentable situation as outlined in the opening para- No. of performed procedures
graph of this chapter. In addition, recommending minimum
numbers is likely to do both the resident who quickly
reaches competence and whose further efforts would be Arterial line
better expended elsewhere, and the poorly performing resi- Intubation
dent who requires further exposure to the procedure, a Spinal anesth.
disservice. Epidural anesth.
Brachial plex block
Figure 10.1 A summary of mean learning curves. (Konrad C, Schüpfer
Simulation-based training G, Wietlisbach, Gerber H. Learning manual skills in anesthesiology: is
there a recommended number of cases for anesthetic procedures?
A variety of simulator models for peripheral nerve blockade
Anesth Analg 1998; 86: 635–639.)
have been proposed. These include gel phantoms and
turkey leg and pig models.10 Workshop delegates report
these to be well suited for training purposes and highly
relevant for clinical practice. Workshop delegates, however, arrived at by expert consensus, have been used to assess
are in large part a self-selecting group and simulation-based technical proficiency in the performance of interscalene
assessment is still in its infancy. In order to use simulation block.12 Both assessment modalities are capable of reliably
for high-stakes assessments, such as accreditation, more discriminating between different levels of training. As
research and development is required to refine and stan- objective measures of technical skills, they are feasible and
dardize scenario content, scoring methods, evaluator train- capable of improving the validity and reliability of compe-
ing, and assessment protocols.11 tency-based assessments (Tables 10.1 and 10.2).
Checklist and global rating scale Cusum method

Validated global rating systems and a checklist created Cumulative sum (cusum) analysis is a statistical method of
using a Delphi technique, whereby content validity is distinguishing deviations from an acceptable failure rate. It
86
CHAPTER
Learning curve intubation Learning curve brachial plexus anesthesia

1.0 1.0
Rate of success (in %)

0.8 0.8
0.6 0.6
0.4 0.4
0.2 0.2
0.0 0.0
0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90
No. of performed procedures No. of performed procedures
Figure 10.2 The intubation learning curve. (Konrad C, Schüpfer G, Figure 10.5 The brachial plexus anesthesia learning curve. (Konrad C,
Wietlisbach, Gerber H. Learning manual skills in anesthesiology: is there Schüpfer G, Wietlisbach, Gerber H. Learning manual skills in anesthesiol-
a recommended number of cases for anesthetic procedures? Anesth ogy: is there a recommended number of cases for anesthetic proce-
Analg 1998; 86: 635–639.) dures? Anesth Analg 1998; 86: 635–639.)
Learning curve arterial line

1.0
Learning curve spinal anesthesia
Relative success (in %)

0.8
1.0
0.6
0.8
0.6 0.4
0.4 0.2
0.2 0.0
0 10 20 30 40 50 60 70 80 90
0.0 No. of performed procedures
0 10 20 30 40 50 60 70 80 90 Figure 10.6 The arterial line learning curve. (Konrad C, Schüpfer G,
No. of performed procedures
Wietlisbach, Gerber H. Learning manual skills in anesthesiology: is there
Figure 10.3 The spinal anesthesia learning curve. (Konrad C, Schüpfer a recommended number of cases for anesthetic procedures? Anesth
G, Wietlisbach, Gerber H. Learning manual skills in anesthesiology: is Analg 1998; 86: 635–639.)
there a recommended number of cases for anesthetic procedures?
Anesth Analg 1998; 86: 635–639.)
has been used in industry as a method of quality control

and more latterly in healthcare, where it has the potential
to determine when a resident is proficient in a new tech-
Learning curve epidural anesthesia nique and as a continuous audit of quality of practice for
1.0 more experienced clinicians.13–15
Prior to commencement, suitable acceptable and unac-
Relative success (in %)
0.8
ceptable failure rates for the procedure must be chosen (p0
0.6
and p1), examples of which are given in Table 10.3. The
desired magnitude of the type 1 and type 2 errors (α andβ)
0.4 must also be chosen and the two boundary limits to
the cusum, h0 and h1 are calculated, as is the variable s
0.2 (Fig. 10.7). The cusum increases by 1−s for a failure and
decreases by s for a success. When the cusum breaks through
0.0 the lower boundary limit (h0) from above then the true
0 10 20 30 40 50 60 70 80 90
No. of performed procedures failure rate does not differ significantly from the acceptable
Figure 10.4 The epidural anesthesia learning curve. (Konrad C,
failure rate (the null hypothesis) with the probability of
Schüpfer G, Wietlisbach, Gerber H. Learning manual skills in anesthesiol- a type II error equal to β. If the cusum breaks through
ogy: is there a recommended number of cases for anesthetic proce- the upper boundary limit (h1) from below then the
dures? Anesth Analg 1998; 86: 635–639.) true failure rate is significantly greater than the acceptable
87
PART I Principles
Table 10.1 Generic technical skills global rating scale

Respect for tissue 1 2 3 4 5
Frequently used unnecessary Careful handling of tissue 4 Consistently handled tissues
force on tissue or caused But occasionally caused with minimal damage
damage inadvertent damage
Time and motion 1 2 3 4 5
Many unnecessary moves Efficient time/motion but Clear economy of
some unnecessary moves movement and maximum
effieciency
Instrument handling 1 2 3 4 5
Repeatedly makes tentative Competent use of Fluid moves with
or awkward moves with instruments but instruments and no
instruments by occasionally appeared awkwardness
inappropriate use of stiff or awkward
instruments
Knowledge of 1 2 3 4 5
instruments
Frequently asked for wrong Knew names of most Obviously familiar with the
instrument or used instruments and used instruments and knew
inappropriate instrument appropriate instrument their names
Flow of procedure 1 2 3 4 5
Frequently stopped Demonstrated some Obviously planned course
procedure and seemed forward planning with of procedure with
unsure of next move reasonable progression effortless flow from one
of procedure move to the next
Use of assistants 1 2 3 4 5
Consistently placed Appropriate use of Strategically used assistants
assistants poorly or failed assistants most of the to the best advantage at
to use assistants time all times
Knowledge of 1 2 3 4 5
procedure
Deficient knowledge Knew all important steps of Demonstrated familiarity
the operation with all aspects of
operation
OVERALL 1 3 5
PERFORMANCE
Very poor Competent Clearly superior
Reproduced from Naik V, Perlas A, Chandra D, Chung D, Chan V. An assessment tool for brachial plexus regional anesthesia performance: establishing construct
validity and reliability. Reg Anesth Pain Med 2007; 32: 41–45.
failure rate with a probability of a type I error equal to α. extradural from two anesthesiology residents is shown in
Further lines are drawn on the graph at 2h1, 3h1 and 4h1 as Figure 10.8.
required, allowing the null hypothesis to be accepted or The advantages of this method are that poor performance
rejected on further attempts. If the cusum stays between h0 can be detected early, i.e. as soon as an upper boundary line
and h1 the observations must be continued, as no statistical is crossed, and remedial action taken. It also allows practi-
inference can be made. A sample cusum chart for obstetric tioners to continually audit their own practice. The data are
88
CHAPTER
easy to obtain and comparisons are made with reference to

Table 10.2 Task-specific interscalene nerve block
minimum acceptable standards. The disadvantages are that
checklist
the standards of success and failure need to be defined; the
1 Positions patient supine and head up system relies on the honesty of the individual and their
2 Turns head slightly to contralateral side consistent interpretations of success and failure. The method
3 Identifies interscalene groove by palpation doesn’t allow weighting of the score according to expected
4 Infiltrates skin by local anesthetic difficulty and doesn’t assess other important components
5 Betadine skin prep × 2 of the learning process or personal characteristics seen to
6 Landmarks site of injection parallel to level of cricoid be important to the practice of anesthesiology.
cartilage
7 Asks for nerve stimulator to be turned to level >1.0
and <1.5 ‘A specialty in transition?’
8 Advances atraumatic needle no more than 1 inch
Peripheral nerve blockade is now a well-accepted method
relative to skin
for realizing the clinical and economic benefits of better
9 Remains perpendicular to all planes
pain control, ‘fast-tracking’ of patients, improved discharge
10 Needle advanced slightly caudal
11 Recognizes appropriate muscle group stimulation
12 Asks for voltage on nerve stimulator to be turned
The formulae to calculate the variables for the cusum are:
down
13 Readjusts needle to obtain maximal twitch response 1–
a = 1n
for lesser voltage
14 Upon accepting twitch asks for aspiration for blood/ b = 1n
1–
CSF
15 Asks for injection of 1–2 cc of local to r/o P = 1n
P1
intervertebral injection P0
16 Asks for injection of 5 cc incremental dose of local Q = 1n
1 – P1
anesthetic 1 – P
17 Mentions observation of tachycardia –b
h0, the lower boundary limit, = P + Q
18 Mentions observation of level of consciousness
19 Re-aspiration after each 5 cc dose to r/o blood and a
h1, the upper boundary limit, =
CSF P+Q
20 Removes needle and applies pressure and massage to Q
s=
injection site P+Q
Reproduced from Naik V, Perlas A, Chandra D, Chung D, Chan V. An Figure 10.7 The formulae to calculate the variables for the cusum.
assessment tool for brachial plexus regional anesthesia performance: (Kestin I. A statistical approach to measuring the competence of
establishing construct validity and reliability. Reg Anesth Pain Med 2007; 32: anaesthetic trainees at practical procedures. Br J Anaesth 1995; 75:
41–45.
805–809.)
Table 10.3 Acceptable and unacceptable failure rates for four procedures (as defined by a consensus of consultants),
the values of s and the boundary limits for the cusum
Acceptable failure rate % Unacceptable failure rate % s h0h1
Obstetric extradurals 5 10 0.07 2.94
Spinal anesthesia 10 20 0.14 2.71
Central venous cannulation 5 15 0.09 1.81
Arterial cannulation 20 40 0.29 2.24
Reproduced from Kestin I. A statistical approach to measuring the competence of anaesthetic trainees at practical procedures. BJA 1995; 75: 805–809.
89
PART I Principles
210 can be identified when novices undertake to learn these

180 techniques.18 The incorporation of transesophageal echo
(TEE) into mainstream clinical practice has led to a formal
150 process of accreditation and documentation, and so it may
120 be with USGRA.
Cusum
Registrar A The American Society of Regional Anesthesia and Pain

90
Medicine and the European Society of Regional Anesthesia
60 and Pain Therapy Joint Committee has now issued recom-
30 mendations for education and training in USGRA (Box
10.2).19 The document aims to define the scope of practice
0
20 40 60 80 100 120 140 160 180 of USGRA under the following headings:
-30
Registrar B • define the structure and common tasks used when per-
No. of attempts forming an ultrasound-guided nerve block
Figure 10.8 The cusum for obstetric extradurals from two anesthetic • articulate the core competencies and skill sets associated
registrars. For registrar A, the cusum increases through six successive with USGRA
boundary lines in the first 99 attempts; the true failure rate for this series
is 27%. From attempt 100 onwards, the cusum is stable and then
• suggest a training process for both established practitio-
declines through two boundary lines; the failure rate for this series ners and residents
(6.7%) is not significantly different from the acceptable failure rate (5%). • recommend the establishment of a quality improve-
For registrar B, a lower boundary line is crossed after 47 attempts; ment process for USGRA.
the true failure rate is not significantly different from the acceptable
rate. (Kestin I. A statistical approach to measuring the competence
of anaesthetic trainees at practical procedures. Br J Anaesth 1995; 75:
805–809.) Acquiring and maintaining expertise
The practical implications of training large numbers of
times, improved physical therapy and improved postopera- anesthesiology residents and their seniors in USGRA is for-
tive cognitive dysfunction scores. Unfortunately, the inher- midable and it will likely be a number of years before every
ent failure rate it has carried to date, combined with other residency program has the in-house expertise to be able to
impediments to its performance in theater, has meant it has do this. Advice on training is available from a number of
been held in lower esteem than generally simple, safe and sources (Table 10.4) and there are many workshops that
efficacious general anesthesia.16 The traditional methods can be currently availed of. However, there is usually no
used to perform peripheral nerve blockade (transarterial formal accreditation of attained skills.
and paresthesia techniques, nerve stimulation) have relied As the range of procedures likely to be performed by
on a sound knowledge of anatomy and surface anatomy. anesthesiologists using ultrasound increases (Table 10.5),
Inherent weaknesses in these approaches are obvious when it is likely that so too will there be a demand for more
one considers the range of anatomical variation present in comprehensive training to a high standard. Such training
the human population and the limitations in the sensitivity will have to enable the practitioner to recognize common
and specificity of nerve stimulation. pathology and when a referral for further investigation is
The advent of ultrasound has been described as a signifi- required (Table 10.6).20
cant step-change in regional anesthesia.17 As ultrasound- Motivation to improve, focus on clearly defined tasks,
guided regional anesthesia (USGRA) has the potential to immediate useful feedback and repetitive deliberate prac-
produce successful nerve block in all cases, failures will be tice strategically guided by an expert instructor are the keys
due to poor operator technique rather than inherent defi- to forming and maintaining expertise.21 Simulation-based
ciencies of the technique per se. This is an important point training may form an important component in this and
to consider, as the requirement to deliver suitably trained USGRA may be particularly suited to this type of training
practitioners will come with the realization of regional and the on going assessment of expertise.22 It is also likely
anesthesia’s potential. that the public, government and other regulators will insist
While experienced practitioners will learn the techniques on some form of assessment and accreditation. Anesthesi-
from their peers, it behoves the profession as a whole to ologists have been to the forefront in this type of training
ensure training in USGRA becomes a core part of all future and are well placed to affect both the pace and direction of
anesthesiology training. The teaching of these new, yet the changes that are required. Funding of simulator-based
essential, skills should be included as part of residency research to establish valid training content, structure, and
training. The proverb ‘see one, do one, teach one’ should scoring metrics is required. Collaboration is necessary with
not be applied to a core competency such as USGRA, and educators, psychometricians, and other specialties. Training
a number of quality-compromising patterns of behavior of a large cadre of skilled instructors/evaluators and a
90
CHAPTER
Box 10.2
I. The Ultrasound-guided Regional Anesthesia • Establish familiarity with the major scientific literature
Coordinator related to UGRA
Each department of anesthesiology at which UGRA is being • Learn techniques for UGRA
performed or is sought to be performed may choose to identify • Understand the applications of color Doppler interrogation
a staff member, an UGRA coordinator, who will help facilitate • Understand equipment specifications
the safe and skilled implementation of UGRA. The UGRA coor- • Infection control and equipment cleaning.
dinator should be the designee of the anesthesiology depart-
Interpersonal/communication skills
ment and will support the education and supervision of
anesthesiologists practicing UGRA. The UGRA coordinator in a • Communicate sensitively and effectively with patients and
training institution would likely be responsible for developing their families regarding ultrasound findings
and coordinating the educational process for residents learning • Explain any complexities of UGRA in terms that the patient
and achieving core competencies in UGRA. The Joint Com- can understand
mittee suggests that the UGRA coordinator designation be • Demonstrate team leadership/management skills for
granted to an individual following a review by the departmental the management of an effective regional anesthesia
leadership. service.
The Joint Committee recommends that the candidate obtain
Professionalism
the following:
1. Letter of recommendation from department leadership Be open to constructive criticism regarding ultrasound
2. A written description of clinical experience including skills.
case volume, length of experience, and safety; System-based practice
and
• Recognize costs associated with UGRA practice
3. Participation in at least one accredited ultrasound
• Collaborate with other members of the health care team to
workshop (as described in the Training section).
ensure quality patient care
II. Core competencies for residency training in UGRA • Use evidence-based, cost-conscious strategies in caring for
The following list overlaps with the skills defined in the profi- all patients.
ciency section of the Practice Pathway:
Practice-based learning and improvement
Patient care
• Identify and acknowledge gaps in personal knowledge and
• Perform gentle ultrasound examinations, providing skills in the care of patients presenting for UGRA
appropriate sedation • Use textbook and online and computer-based resources to
• Demonstrate proper patient selection broaden knowledge base regarding UGRA techniques
• Use appropriate monitoring during UGRA • Perform electronic searches of the medical literature to
• Demonstrate proper nerve localization techniques identify articles that address the medical issues
• Perform effective and safe nerve blocks. surrounding UGRA
Ultrasound knowledge • Understand and critically evaluate outcome studies
related to the influence of UGRA on peri-operative
• Understand the general principles of ultrasound physics
outcome
• Understand benefits and limitations of UGRA techniques
• Attend the department’s required teaching conferences
• Understand differences between in-plane vs out-of-plane
• Develop time management skills to perform the required
techniques and their indications
tasks in a reasonable amount of time with satisfactory
• Understand key artifacts and pitfall errors associated with
quality.
UGRA
• Develop an intimate knowledge of 2-dimensional
ultrasound anatomy of the major neurovascular structures III. Recommended ultrasound curriculum
of the upper and lower extremities Equipment specifications
• Appreciate common non-neural pathological states that Minimal specifications include a machine with a linear trans-
are diagnosed by ultrasound: atherosclerotic disease and ducer that has a frequency of 8 MHz or higher, color Doppler
venous thrombosis technology, and image storage capabilities.
91
PART I Principles
Curriculum content: scanning techniques 6. Initiate the BPART (maneuvers to optimize image quality):
• The role of physics for UGRA; understand terminology (e.g. a. Pressure: varying degrees of transducer pressure on
piezoelectric effect, frequency, resolution, attenuation, skin
echogenicity, color Doppler) b. Alignment: sliding movement of the transducer to
• The role of instrumentation in image acquisition (e.g. define the lengthwise course of the nerve
image mode, gain, time gain compensation, transducer c. Rotation: the transducer is turned in either a clockwise
types) or counterclockwise direction to optimize the image
• Equipment requirements: types of transducers (linear, d. Tilting: the transducer is tilted in both directions to
curved and phased array for different indications and maximize the angle of incidence of the ultrasound beam
scanning at different depths), footprint length, frequency with the target nerve
(range, 2Y15 MHz) 7. Scan anticipated needle trajectory with color Doppler to
• Ultrasound acoustic artifacts and imaging artifacts (pitfalls). identify any unsuspected vascularity.
These include reverberation artifacts, acoustic V. Recommended terminology to distinguish in-plane
enhancement, acoustic shadowing, gain-related artifacts, technique from out-of-plane technique
resolution-related artifacts, mistaking tendon or muscle for
Most peripheral nerves described in the anesthesia literature
nerve11,12
have been imaged in short axis (transverse or cross section).
• Techniques to perform effective ultrasound examinations;
Alternatively, if the transducer is rotated 90° from the short-axis
appreciate the Joint Committee recommended BPART
view, the long-axis view (longitudinal scan) is generated. The
(maneuvers for generating optimal imaging: Pressure,
short-axis view is generally preferred, because it allows the
Alignment, Rotation, and Tilting; see IV below).
operator to assess the lateral-medial perspective of the target
Curriculum content: UGRA procedures nerve, which is lost in the long-axis view. In the literature, two
• Define indications and contraindications techniques have emerged regarding the orientation of the
• Practice procedural technique on available organic and needle with respect to the ultrasound beam. The in-plane
inorganic simulators approach generates a long-axis view of the needle, allowing full
• Define relevant anatomy in each region including the visualization of the shaft and tip of the needle. The in-plane
ability to identify muscle, pleura, nerve, approach has the disadvantage that, because the ultrasound
• tendon, and bone beam is very thin, it can be challenging to maintain continuous
• Define needle insertion technique using the Joint needle imaging. The out-of-plane view has the limitation that a
Committee recommended terminology (in-plane vs small block needle imaged in short axis can be hard to visualize.
out-of-plane: see V below) Furthermore, with the out-of-plane view, distinguishing the
• Understand potential difficulties and pitfalls needle tip from the shaft may be challenging. Regardless of the
• Describe ultrasound appearance of common anatomical technique chosen, the goal is to steer the needle away from
variations seen during upper and lower extremity block neighboring structures such as vessels and pleura and to
• Recognize correct and incorrect distributions of local confirm the spread of local anesthetic within correct fascial
anesthetic compartments and around the target nerves.
• Appreciate Joint Committee recommended standardization
VI. Recommended procedure for correlating ultrasound
of patient-screen relationships (see VI below).
screen with patient sidedness for patients in prone,
IV. Recommended technique for ultrasound scanning supine, and lateral decubitus positions
1. Find landmark vascular structure (possibly assisted by color Before needle insertion, each neural structure should be refer-
Doppler), bone, or muscle enced to key landmark structures in the anterior–posterior and
2. Find nerve or plexus on short-axis imaging (transverse lateral–medial planes. However, because of the bilateral nature
scan) of the peripheral nervous system, variations in patient position-
3. Place machine focus on target structures ing, differing presets of various ultrasound systems, and the
3. Place depth setting at 1 cm deep to target structures nuances of individual techniques, it would be difficult to
5. Adjust gain, time gain compensation, and frequency as standardize the correlation of sidedness of the screen with
necessary an anatomical location. This is in contrast to transesophageal
92
CHAPTER
echocardiography where, in the transgastric short-axis view of applies pressure with a finger at this defined site. A
Therefore, the Joint Committee recommends this simple proce- corresponding indentation should be visualized on the left
dure for correlation of the ultrasound screen with patient sided- aspect of the ultrasound screen. If indentation occurs on
ness in any patient position. screen right, then the operator must turn the transducer
1. After the application of the transducer onto the patient’s 180°. After such a correction, the operator should returnto
skin, the landmark structure or peripheral nerve is step 1 until correct imaging has been obtained and
identified. The primary operator states that the top of the confirmed.
ultrasound screen correlates with the patient’s skin. To
confirm this, pressure is applied with a finger onto the skin.
This area should be visualized being compressed on the Adapted from Sites B, Chan V, Neal J, et al. The American Society of
ultrasound screen. Regional Anesthesia and Pain Medicine and the European Society of
2. For patients in any position, the operator states that screen Regional Anaesthesia and Pain Therapy Joint Committee
left represents a defined anatomical aspect of the patient recommendations for education and training in ultrasound-guided
(e.g. cephalad). To confirm this, the primary operator again regional anesthesia. Reg Anesth Pain Med 2009; 34: 40–46.
Table 10.4 Websites for information Table 10.5 Ultrasound procedures likely to be conducted
UK Royal College of Publications www.rcr.ac.uk by anesthetists
BFCR(05)1 Standards for Arterial and venous imaging and access
Ultrasound Equipment + Avoidance of vessels during other procedures (e.g.
BFCR(05)2 Ultrasound Training percutaneous tracheostomy). Diagnosis of deep vein
Recommendations thrombosis
British Medical Ultrasound Society www.bmus.org Nerve blockade
+ Other musculoskeletal imaging in pain management
European Federation of Ultrasound www.efsumb.org echocardiography
Australian Society Ultrasound in www.asum.com.au Varying from basic to complex examinations using
Medicine transthoracic and TOE probes
Association of Cardiothoracic www.acta.org.uk Diagnosis of pleural and pulmonary pathology
Anaesthetists Limited trauma; abdominal and chest examinations (e.g.
Focused Abdominal Sonogram for Trauma [FAST] type
British Society of Echocardiography www.bsecho.org scans) for assessment of bleeding.
American Institute of Ultrasound in www.aium.org Abdominal scanning for: kidney size, bladder volume, IVC
Medicine diameter – as an indicator of volume status
Royal College of Obstetricians and www.rcog.org.uk Reproduced from Bodenham A. Ultrasound imaging by anaesthetists:
Gynaecologists training and accreditation issues. Br J Anesth 2006; 96: 414–417.
Reproduced from Bodenham A. Ultrasound imaging by anaesthetists:

training and accreditation issues. Br J Anesth 2006; 96: 414–417.
93
PART I Principles
Table 10.6 Levels of competence for ultrasound, shortened from Royal College of Radiologists’ guidelines
Level 1
Practice at this level should usually require the following abilities:
To perform common examinations safely and accurately
To recognize and differentiate normal anatomy and pathology
To diagnose common abnormalities within certain organ systems
To recognize when a referral for a second opinion is indicated
Within most medical specialties the training would be gained during parent specialist training programs
Level 2
Practice at this level would usually require most or all of the following abilities:
To manage referrals from Level 1 practitioners
To recognize and diagnose almost all abnormalities in the relevant organ system
To perform common non-complex ultrasound-guided invasive procedures
To teach ultrasound to trainees and Level 1 practitioners
To conduct some research in ultrasound
The training to this level would be gained during a period of subspecialty training either within or after completion of the
parent specialist training
Level 3
This is an advanced level of practice which includes some or all of the following abilities:
To accept tertiary referrals from Level 1 and Level 2 practitioners
To perform specialized examination and guided invasive procedures
To conduct substantial research and development in ultrasound
To teach ultrasound at all levels
In the UK this would equate to a consultant radiologist with a subspecialty practice which includes a significant
commitment to ultrasound
Note: The boundaries between levels should only be regarded as a guide.
Reproduced from Bodenham A. Ultrasound imaging by anaesthetists: training and accreditation issues. Br J Anaesth 2006; 96: 414–417
Reproduced from Hargett M, Beckman J, Liguori G, Neal J. Guidelines for regional anesthesia fellowship training. Reg Anesth Pain Med 2005; 30: 218–225.
commitment to large-scale standardized training and assess- 6. Kulcsar Z, Aboulafia A, Hall T, Shorten G.
ment of medical students, residents, and experienced Determinants of learning to perform spinal
anesthesiologists is also necessary.11 anaesthesia: a pilot study. Eur J Anaesthesiol
2008;25:1026–1031.
7. Kopacz D, Neal J, Pollock J. The regional anesthesia
References ‘learning curve’: what is the minimum number of
epidural and spinal blocks to reach consistency? Reg
1. Bridenbaugh L. Are anesthesia resident programs
Anesth 1996;21:182–190.
failing regional anesthesia? Reg Anesth 1982;7:26–28.
2. Kopacz D, Bridenbaugh L. Are anesthesia residency 8. Kopacz D, Neal J, Pollock J. Residency training in
programs failing regional anesthesia? The past, regional anesthetic techniques: is experience with
present and future. Reg Anesth 1993;18:84–87. more than 40 attempts necessary? Reg Anesth 1997;
22:205–211.
3. Kopacz D, Neal J. Regional anesthesia and pain
medicine: Residency training – the year 2000. Reg 9. Konrad C, Schüpfer G, Wietlisbach M, Gerber H.
Anesth Pain Med 2002;27:9–14. Learning manual skills in anesthesiology: is there
4. Brown D. Fellowship training in regional anesthesia. a recommended number of cases for anesthetic
Reg Anesth Pain Med 2005;30:215–217. procedures? Anesth Analg 1998;86:635–639.
5. Hargett M, Beckman J, Liguori G, Neal J. Guidelines 10. Raimer C, Birnbaum J, Wauer H, Volk T. A training
for regional anesthesia fellowship training. Reg model for peripheral regional anesthesia techniques.
Anesth Pain Med 2005;30:218–225. Reg Anesth Pain Med 2004;29:65.
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11. Weinger M. Experience not equal expertise: can 17. Hopkins P. Ultrasound guidance as a gold standard
simulation be used to tell the difference? Anesthesiol in regional anaesthesia. BJA 2007;98:299–301.
2007;107:691–694. 18. Sites B, Spence B, Gallagher J, et al. Characterizing
12. Naik V, Perlas A, Chandra D, et al. An assessment novice behavior associated with learning ultrasound-
tool for brachial plexus regional anesthesia guided peripheral regional anesthesia. Reg Anesth
performance: establishing construct validity Pain Med 2007;32:105–117.
and reliability. Reg Anesth Pain Med 2007;32: 19. Sites B, Chan V, Neal J, et al. The American Society of
41–45. Regional Anesthesia and Pain Medicine and the
13. Kestin I. A statistical approach to measuring the European Society of Regional Anaesthesia and Pain
competence of anaesthetic trainees at practical Therapy Joint Committee recommendations for
procedures. BJA 1995;75:805–809. education and training in ultrasound-guided regional
anesthesia. Reg Anesth Pain Med 2009;34:40–46.
14. de Oliveira Filho G. The construction of learning 20. Bodenham A. Ultrasound imaging by anaesthetists:
curves for basic skills in anesthetic procedures: an training and accreditation issues. Br J Anaesth
application of the cumulative sum method. Anesth 2006;96:414–417.
Analg 2002;95:411–416.
21. Ericsson K. Deliberate practice and the acquisition
15. de Oliveira Filho G. Learning curves and and maintenance of expert performance in medicine
mathematical models for interventional ultrasound and related domains. Academic Med 2004;79:
basic skills. Anesth Analg 2008;106:568–573. 870–881.
16. Sites B, Spence B, Gallagher J, et al. Regional 22. Reznick P, MacRae H. Teaching surgical skills:
anesthesia meets ultrasound: a specialty in transition. changes in the wind. N Engl J Med 2006;355:
Acta Anaesthesiol Scand 2008;52:456–466. 2664–2669.
95
PART II
Peripheral nerve blocks
PART II Peripheral nerve blocks
CHAPTER
11
Cervical plexus block
The branches of the superficial cervical plexus supply the

Indications skin and superficial structures of the head, neck, and shoul-
der. There are four cutaneous branches, which become sub-
Surgical Superficial neck procedures; excision of thyro-
cutaneous at the posterior border of the sternocleidomastoid
glossal and branchial cysts; excision of neck lymph nodes;
muscle (Fig. 11.1). The lesser occipital and great auricular
thyroid and parathyroid surgery; carotid endarterectomy;
are derived from the C2 and C3 roots and run in a cephalad
central venous cannulation; shoulder surgery in combina-
direction. The lesser occipital nerve supplies sensation to
tion with interscalene block.
the upper side of the neck, the upper part of the auricle,
Therapeutic Complex regional pain syndrome; posther-
and the adjoining skin of the scalp. The great auricular
petic neuralgia; postoperative pain.
nerve is the largest cutaneous branch and divides into an
anterior and a posterior branch. The posterior branch sup-
plies the skin lying behind the ear and the medial and
Contraindications lateral surfaces of the lower part of the auricle. The anterior
branch supplies the skin in the lower posterior part of the
Absolute face and the concave surface of the auricle. The transverse
See Chapter 4. cervical nerve, also from C2 and C3 roots, runs horizontally
across the neck and provides sensory innervation to the
Relative anterolateral aspect of the neck from the mandible to the
Hemorrhagic diathesis; anticoagulation treatment; local sternum. The supraclavicular branch, from the C3 and C4
neural injury; respiratory compromise; and anatomic dis- roots, runs caudally over the clavicle and divides into three
tortion (due to previous surgery or trauma). branches: medial, intermediate, and lateral. It provides
sensory innervation to the lower aspect of the neck, acro-
mial region of the neck, and as far as the second intercostal
Clinical anatomy space on the chest.
The deep branches of the cervical plexus innervate the
The cervical plexus is formed from the ventral rami of the deeper structures of the neck, including the muscles of the
upper four cervical nerves. The dorsal and ventral roots anterior neck and the diaphragm (phrenic nerve).
combine to form spinal nerves as they exit through the
intervertebral foramina. The cervical nerves exit from the
cervical spine through gutters in the transverse processes Surface anatomy
that run in an anterolateral direction, immediately poste-
rior to the vertebral artery. The cervical plexus lies behind The main landmarks for the superficial cervical plexus block
the sternocleidomastoid muscle, giving off both superficial (Fig. 11.2) include the mastoid process, suprasternal notch,
(superficial cervical plexus) and deep (deep cervical plexus) and posterior border of the sternocleidomastoid muscle at
branches. the level of the cricoid cartilage. The sternocleidomastoid
DOI: 10.1016/B978-0-7020-3148-9.00019-0
3
1
6
5
2 5
Figure 11.1 Cadaver structures illustrating branches of the superficial Figure 11.3 Landmarks for the deep cervical plexus block. The mastoid
cervical plexus. 1: sternocleidomastoid muscle; 2: clavicle; 3: transverse process, suprasternal notch, and transverse process of C6 are identified
cervical nerve; 4: lesser occipital nerve; 5: great auricular nerve (anterior and marked. A line is drawn along the posterior border of the sterno-
and posterior branches); 6: supraclavicular branches (medial, intermedi- cleidomastoid muscle. A second line is drawn 1 cm posterior to the first
ate, and lateral branches). line. The C4 transverse process is identified in relation to the transverse
process of C6 or at the level of the superior aspect of the thyroid
cartilage. Transverse processes of C3 and C2 are located 1.5 and 3 cm
proximal from C4.
Sonoanatomy
The cervical plexus is found at the level of the first four
cervical vertebrae deep to the sternocleidomastoid, in the
layer superficial to the scalenus medius and levator scapu-
lae. The cervical plexus can be further divided into a super-
ficial and deep portion. The superficial branches perforate
the cervical fascia to supply skin and other integumental
structures whilst the deep branches predominantly supply
muscle. The patient is positioned supine with the head
slightly turned to the opposite side. Perform a systematic
Figure 11.2 Landmarks for the superficial cervical plexus block. The
survey from superficial to deep, medial to lateral and crani-
mastoid and suprasternal notch are marked with a pen and the poste-
rior border of the sternocleidomastoid is outlined. The needle insertion ally. A high frequency ultrasound transducer is placed in a
point is at the midpoint of this line, which corresponds to the level of coronal plane anterolateral to the neck to identify the
the cricoid cartilage. respective vertebral level The transverse process of C7
usually does not have an anterior tubercle, but only one
prominent posterior tubercle (Fig 11.4). Additionally, the
muscle and its posterior border can be accentuated by C6 transverse process is sonographically verified by tracing
asking the patient to perform a head lift. The external the course of the vertebral artery, which usually enters the
jugular vein crosses the posterior border of the sterno- foramen at that vertebra. After achieving a coronal echo-
cleidomastoid muscle close to the injection site. It can be plane with the depiction of the transverse processes of C6
accentuated by asking the patient to perform a Valsalva and C7, the transducer is shifted cranially and the fourth
maneuver. The carotid artery can be palpated medial to the cervical vertebra (C4) is identified by counting the respec-
sternocleidomastoid muscle and indicates the vascular tive vertebral levels upwards. Parts of the superficial plexus
nature of the territory. can be identified in the double fascial layer in all patients
The main landmarks for the deep cervical plexus block at the level of C4. This double fascial layer is formed by the
(Fig. 11.3) include the mastoid process; the posterior border fascia of the sternocleidomastoid muscle and the deep cer-
of the sternocleidomastoid muscle at the level of the cricoid vical fascia (Fig. 11.5). Here the C4 nerve root can also
cartilage; C6 transverse process (the most prominent cervi- be seen arising between the anterior and posterior tubercles
cal transverse process); and the thyroid cartilage. of the fourth transverse process (Fig. 11.5). This level
100
CHAPTER
Cervical plexus block 11
PT R
Lateral Medial
Figure 11.4 The transverse process of C7 usually does not have an

anterior tubercle, but only one prominent posterior tubercle (PT). R =
nerve root.
Figure 11.6 Superficial cervical plexus block technique. The needle is

first inserted in a perpendicular plane to the skin and behind the pos-
terior border of the sternocleidomastoid muscle. A loss of resistance is
SCM felt as the fascia surrounding the sternocleidomastoid is penetrated.
Also, subcutaneous injections are made superiorly and inferiorly along
DCF the border of the sternocleidomastoid from this point.
Lateral ECA Medial
ICA
LCM nocleidomastoid muscle between these two landmarks. The
needle insertion site is marked at the midpoint of the pos-
terior border of the sternocleidomastoid adjacent to the
cricoid cartilage (Fig. 11.2).
The needle insertion site is infiltrated with local anes-
thetic using a 25-G needle. A 23-G needle is then inserted
in a perpendicular fashion just behind the posterior border
of the sternocleidomastoid muscle (Fig. 11.6). A ‘pop’ is
Figure 11.5 The cervical plexus is seen as hypoechoic structures often felt as the cervical fascia is penetrated. Incremental
(arrows) in a double fascial layer between the sternocleidomastoid injection of local anesthetic (5 mL) is made with repeated
and deep cervical fascia using a high frequency transducer. SCM: sterno- aspiration. This is the preferred block site due to the tight
cleidomastoid muscle; DCF: deep cervical fascia; LCM: longus coli arrangement of the plexus here. Local anesthetic injection
muscle; ICA: internal carotid artery; ECA: external carotid artery. should form a contour corresponding to the sternocleido-
mastoid muscle. The needle is then redirected both superi-
orly and inferiorly along the posterior border of the
correlates with the carotid bifurcation in most patients sternocleidomastoid while making subcutaneous injections
(Fig. 11.5). (5-mL injections are made in each direction).
Deep cervical plexus

Technique The mastoid process and transverse process of C6 are iden-
tified and marked with a pen (Fig. 11.3). A line is drawn
Landmark based approach connecting these two points. A second line is drawn parallel
and 1 cm posterior to the first line (Fig. 11.3). The trans-
verse process of the fourth cervical vertebrae can be located,
Superficial cervical plexus having previously located the transverse process of the sixth
As for all regional anesthetic procedures, after checking that cervical vertebrae in relation to the cricoid cartilage. The
emergency equipment is complete and in working order, transverse process of the fourth cervical vertebrae can also
intravenous access, ECG, pulse oximetry, and blood pres- be located by drawing a horizontal line from the superior
sure monitoring are established. Asepsis is observed. aspect of the thyroid cartilage. Although a single-injection
The patient is placed in the supine position, with the head technique at C4 can be used, block at C3 is also possible.
facing away from the side to be blocked. The mastoid C3 can be located 1.5 cm cephalad from C4.
process and suprasternal notch are identified and marked. Needle (23-G) orientation is perpendicular to the skin
The next step is to identify the posterior border of the ster- and slightly caudad (Fig. 11.7) until bony contact at 1–2 cm
101
Figure 11.7 Deep cervical plexus block technique. The needle is ori-
ented perpendicular to the skin and slightly caudad until bony contact Figure 11.8 Global view of ultrasound-guided cervical plexus block.
at 1–2 cm. The needle is withdrawn 1–2 mm and 3–5 mL of local anes-
thetic is injected.
from the skin. A paresthesia in the distribution of the cervi- be made to look like the scanning field. That is, the right
cal plexus may be found. At this point the needle is gently side of the screen represents the right side of the field.
withdrawn 1 mm and incremental injections of local anes- Adjustable ultrasound variables such as scanning mode,
thetic (3–5 mL) are made with repeated aspiration. The depth of field, and gain are optimized.
fingers of the palpating hand should be used to fix the skin Developing and maintaining a predetermined basic scan-
at the transverse process of the level to be blocked. This ning routine is of enormous help in improving operator
decreases the depth of the needle insertion and makes the confidence and success. A transverse image of the superficial
block both easier and safer to perform. cervical plexus is obtained (Fig. 11.5). The superficial cervi-
cal plexus is kept in the center of the field of view. The
needle entry site is at the lateral-most end of the linear
Ultrasound-guided approach transducer. A free hand technique, rather than the use of a
needle guide, is preferred. A 21-GA × 50-mm needle (B.
Intravenous access, electrocardiogram (ECG), pulse oxim- Braun, Bethlehem PA) is inserted parallel to the axis of the
etry and blood pressure monitoring are established. Maxi- beam of the ultrasound transducer with the bevel facing the
mized comfort for the operator and patient is an important transducer (Fig 11.9). The needle is attached to sterile
step in pre-procedure preparation. For the ultrasound- extension tubing, which is connected to a 10-mL syringe
guided cervical plexus block, the patient is placed in the and flushed with local anesthetic solution to remove all air
supine position, with the head turned slightly to the side from the system. It is then introduced at the lateral-most
opposite that to be blocked. The operator stands or sits end of the transducer and visualized along its entire path
adjacent to the side to be blocked. The ultrasound screen, to the superficial cervical plexus (Fig 11.10). It is important
transducer, needle, and plane of imaging should all be not to advance the needle without good visualization. This
placed in one view for the operator. For the cervical plexus may require needle or ultrasound transducer adjustment.
block, the ultrasound screen is placed above the shoulder Once the needle has approached the superficial cervical
on the side to be blocked (Fig 11.8). Room lights may be plexus, 1–2 mL of local anesthetic may be injected to
turned down to enhance image viewing. The operating confirm correct needle placement. Local anesthetic appears
lights can be used to maintain some working lighting in the as a hypoechoic image. Correct needle placement is con-
background. The patient is asked to raise their head to firmed by observing solution surrounding the superficial
identify the interscalene groove. cervical plexus (Fig 11.11). For a superficial cervical plexus
The skin is disinfected with antiseptic solution and block, local anesthetic should be injected between the
draped. A sterile sheath (CIVCO Medical Instruments, double layer of the fascia rather than deep to it. Penetrat-
Kalona, IA, USA) is applied over the ultrasound transducer ing the fascia will lead to a deep cervical plexus block
with sterile ultrasound gel (Aquasonic, Parker Laboratories, rather than a superficial cervical plexus block. Local anes-
Fairfield, NJ, USA). Another layer of sterile gel is placed thetic injected deep to the fascia does not consistently
between the sterile sheath and the skin. The cervical plexus reach all relevant superficial parts of the cervical plexus.
is scanned in transverse plane. The ultrasound screen should Following confirmation of correct needle placement,
102
CHAPTER
Cervical plexus block 11
SCM
N CB
LA
ECA
LCM ICA
Figure 11.9 Ultrasound transducer and needle positioning during

ultrasound-guided cervical plexus block. Note the needle orientation in
the same plane as the ultrasound beam. Figure 11.11 Transverse ultrasound image of the cervical plexus
showing local anesthetic spread using a a 8–14 MHz linear ultrasound
transducer. LA: local anesthetic; N: needle tip; SCM: sternocleidomastoid
muscle; SMM: scaleus medius muscle; CB: cervical plexus; ICA: Internal
carotid artery; ECA: external carotid artery.
SCM
N
DCF CB the brachial plexus is possible, resulting in upper limb
ECA anesthesia.
LCM ICA • Neural injuries are extremely rare. Injury to neuroaxial
Lateral Medial structures due to proximity is possible; using the needle
orientation described decreases this risk.
CLINICAL PEARLS
• Light premedication with midazolam or fentanyl facilitates block
Figure 11.10 Real time imaging of needle insertion for the cervical
placement and significantly decreases patient discomfort during
plexus block. Notice the needle shaft marked with arrows and the block performance.
needle tip (N) in close proximity to the cervical plexus. N = needle
• A number of vascular structures are close to this location, so
tip; SCM = sternocleidomastoid muscle; DCF: deep cervical fascia;
careful and repeated aspirations should be made to avoid
LCM: longus coli muscle; CB: cervical plexus; ICA: Internal carotid artery; accidental intravascular injection of local anesthetic during
ECA: external carotid artery. landmark based cervical plexus blocks.
Deep blocks are more likely to fail than superficial cervical plexus
blocks. Cervical plexus blocks provide good analgesia for incision and
10 mL of local anesthetic solution can be injected to preparation down to the carotids. However, during preparation of the
achieve blockade. carotid sheath many patients experience pain because the carotid
artery has additional afferent autonomic nerve supply which is not con-
sistently blocked by classical cervical plexus blocks. Ultrasound can be
used to direct perivascular local anesthetic injection.
Adverse effects No serious complications occur with superficial cervical plexus blocks
as opposed to deep cervical plexus blocks.
• Hematoma formation due to puncture of the external Since the cervical plexus has anastomoses with cranial nerves (e.g.
XI, XII) and the sympathetic chain, a block of the superficial parts is
jugular vein. more likely to produce complete analgesia.
• Phrenic nerve block due to its location on the anterior A high interscalene ultrasound-guided block has been reported. The
scalene muscle; also hoarseness, dysphagia, and a authors report injection at this point resulting in spread of local anes-
Horner’s syndrome due to block of the recurrent laryn- thetic to the proximal cervical plexus roots.
geal nerve and the sympathetic chain. Partial block of
103
• Local anesthetic toxicity due to injection into the exter- Roessel T, Wiessner D, Heller AR, et al. High-resolution
nal or internal jugular arteries or vertebral artery leads ultrasound-guided high interscalene plexus block for
rapidly to toxic reactions. carotid endarterectomy. Reg Anesth Pain Med
2007;32(3):247–253.
Soeding P, Eizenberg N. Review article: anatomical
Suggested reading considerations for ultrasound guidance for regional
anesthesia of the neck and upper limb. Can J Anesth
Merle JC, Mazoit JX, Desgranges P, et al. A comparison of 2009:56:518–533.
two techniques for cervical plexus blockade: Martinoli C, Bianchi S, Santacroce E, et al. Brachial plexus
evaluation of efficacy and systemic toxicity. Anesth sonography: a technique for assessing the root level.
Analg 1999;89:1366–1370. AJR Am J Roentgenol 2002;179:699–702.
Stoneham MD, Knighton JD. Regional anaesthesia for Pandit JJ, Satya-Krishna R, Gration P. Superficial or deep
carotid endarterectomy. Br J Anaesth 1999;82: cervical plexus block for carotid endarterectomy: a
910–919. systematic review of complications. Br J Anaesth
Sandeman DJ, Griffiths MJ, Lennox AF. Ultrasound 2007;99:159–169.
guided deep cervical plexus block. Anaesth Intensive
Care 2006;34(2):240–244.
104
CHAPTER
12
Orbital blocks
John McAdoo
orbital lamina of the ethmoid bone. The superior orbital

Indications fissure lies between the greater and lesser wings of the sphe-
noid bones, and the inferior orbital fissure lies between the
Surgical Cataract extraction; trabeculectomy; vitrectomy;
maxilla and the superior wing of the sphenoid.
cryotherapy; panphotocoagulation.
The medial walls of each orbit are parallel to each other
Therapeutic Postoperative pain relief.
(Fig. 12.2). The lateral or temporal wall of each orbit forms
an angle of 90° to the contralateral lateral wall. The medial
and lateral walls of the orbit make a 45° angle to each
Contraindications other. The floor of the orbit inclines at an angle of 10°
anteriorly to posteriorly.
The A–P length of the orbit is 40–45 mm (Fig. 12.3) and
Absolute the orbital volume is approximately 30 mL. The A–P diam-
See Chapter 4. eter of a normal globe is 24 mm and the horizontal diam-
Relative eter is 23.5 mm. The globe lies eccentrically in the orbit,
Myopia; anatomic or pathologic abnormalities, which may being displaced medially and superiorly.
pose surgical difficulties; raised intraocular pressure; and
previous scleral buckling procedures. Motor nerve supply
The motor nerve supply to the eye (Fig. 12.4) and surround-
ing structures comes from the cranial nerves. The third,
Anatomy fourth, and sixth cranial nerves supply the motor innerva-
tion to the recti muscles and partial motor innervation to
Orbital cavity the levator palpebrae superioris muscle. The seventh cranial
nerve supplies motor function to the orbicularis oculi
The superior orbital margin is formed by the frontal bone muscles. The parasympathetic nervous system supplies the
and contains the supraorbital foramen or notch, through circular muscle of the iris, while the sympathetic nervous
which the superior orbital nerve emerges (Fig. 12.1). The system supplies the radial muscles of the iris and partial
inferior orbital margin is formed laterally by the zygomatic innervation to the levator palpebrae superioris muscle. The
bone and medially by the maxilla. The roof of the orbit is third, fourth, and sixth cranial nerves enter the orbit via the
formed by the frontal bone, the lateral or temporal wall by superior orbital fissure. The third cranial nerve (oculomo-
the zygomatic bone. The posterior wall of the orbit consists tor) supplies all recti muscles with the exception of the
of the greater and lesser wings of the sphenoid bone. The lateral rectus muscle. The superior oblique muscle is
orbital floor is formed by the maxilla, and the medial supplied by the fourth cranial nerve (trochlear) and the
(nasal) wall of the orbit by the lacrimal bone and the lateral rectus muscle is supplied by the sixth cranial nerve
DOI: 10.1016/B978-0-7020-3148-9.00020-7
6
7
8 6 1
8
3
2
1 2
5 4
Figure 12.1 Bony structures of the orbital cavity. 1: Maxillary bone; 2:

zygomatic bone; 3: frontal bone; 4: supraorbital notch; 5: infraorbital
foramen; 6: lesser and greater wings of sphenoid bone; 7: optic canal;
8: superior and inferior orbital fissures.
23°
45°
1
90° 2
4 3
Figure 12.2 Globe and orbit. The medial walls of each orbit are parallel
to each other. The lateral (temporal) walls of the orbits form an angle
of 90° to each other. The medial and lateral walls of the orbit make a 6
45° angle with each other. 5
(abducent). With the exception of the trochlear nerve, the B

motor nerves lie within the muscle cone formed by the four
Figure 12.3 An MR image of globe and orbit. The A–P length of the
recti muscles. The nerves enter the muscle cone surround- orbit is 40–45 mm. The horizontal diameter of a normal globe is 23.5 mm
ing the optic nerve via the tendinous ring (annulus of and the A–P diameter is 24 mm. The globe lies eccentrically in the orbit,
Zinn). being displaced medially and superiorly. View A: 1, horizontal and AP
diameters of eye; 2, optic nerve; 3, medial rectus muscle; 4, lateral rectus
Sensory nerve supply muscle; 5, optic canal and nerve. View B: 1, superior rectus muscle and
levator palpebrae superioris muscles; 2, superior oblique muscle; 3,
Sensory supply to the eye (Figs 12.4A and 12.5) and sur- lateral rectus muscle; 4, medial rectus muscle; 5, orbital margin
(J-shaped); 6, interior rectus muscle.
rounding tissues is via the ophthalmic nerve, which is the
first division of the trigeminal nerve. It supplies sensation
to the eye, lacrimal gland, conjunctiva, part of the mucous
membrane of the nose, skin of the nose, eyelids, forehead,
106
CHAPTER
Orbital blocks 12
Abducent Trochlear Ciliary Short ciliary

Supratrochlear
nerve nerve ganglion nerves
Superior Supraorbital
ethmoidal
Lacrimal
Inferior
ethmoidal Zygomaticotemporal
Zygomaticofacial
Long ciliary Ciliary ganglion
Zygomatic
Trigeminal Sensory root
ganglion Nasociliary Frontal
Ophthalmic
nerve
Figure 12.5 Sensory supply to the orbit. See text for details.
Maxillary Pterygopalatine Maxillary Infraorbital
A nerve ganglion sinus nerve
Frontal nerve Trochlear nerve Oculomotor nerve
(superior division)
Lacrimal gland Supratrochlear
nerve through the supraorbital foramen or notch and gives
Lacrimal nerve
Trochlea branches to the conjunctiva and eyelid. It then continues
Abducent nerve and supplies the skin of the scalp almost to the lambdoid
Trochlear nerve
Lateral rectus suture. The supratrochlear nerve emerges from the orbit
Anterior
ethmoidal nerve between the trochlea and the supraorbital foramen. It sup-
Infraochlear
plies sensation to the conjunctiva and skin of the upper
Oculomotor nerve nerve eyelid and the skin of the lower forehead.
(inferior division) The nasociliary nerve enters the orbit via the superior
Nasociliary nerve
Inferior orbital orbital fissure within the tendinous ring close to the oculo-
fissure Medial rectus
Zygomaticofacial
motor nerve and ophthalmic artery. It gives off the long
nerve posterior ciliary nerves and branches to the ciliary ganglion.
Inferior oblique Optic nerve It also gives off the anterior and posterior ethmoid nerves.
The optic nerve enters the orbit via the optic canal. It
Inferior rectus Infraorbital Ciliary Ophthalmic artery enters the muscle cone via the tendinous ring surrounded
B nerve ganglion
by the dura mater. It contains the central retinal artery and
Figure 12.4 Motor supply to the orbit. Lateral (A) and frontal (B) views. vein. The ophthalmic artery lies lateral to the optic nerve
initially, and then crosses superiorly to lie medial to the
optic nerve within the muscle cone. The ophthalmic venous
plexus also lies in close proximity.
and scalp. The ophthalmic nerve enters the orbit via the
superior orbital fissure. It is the smallest division of the Arterial supply
trigeminal nerve and arises from the anteromedial part of
the trigeminal ganglion. Just before entering the superior The ophthalmic artery is a branch of the internal carotid
orbital fissure it divides into three branches: the lacrimal, artery as it emerges from the cavernous sinus. It enters the
frontal, and nasociliary nerves. orbital cavity through the optic canal below and lateral to
The lacrimal nerve is the smallest branch of the ophthal- the optic nerve. It enters the muscle cone via the tendinous
mic nerve. It enters the orbit via the superior orbital fissure ring and runs lateral to the optic nerve and medial to the
and runs along the upper border of the lateral rectus muscle. oculomotor and abducent nerves, ciliary ganglion, and
It enters the lacrimal gland and gives branches to the lacri- lateral rectus muscle. It crosses above the optic nerve to
mal gland and conjunctiva. Finally it pierces the orbital reach the medial wall of the muscle cone and runs anterior
septum and ends in the skin of the upper eyelid. between the superior oblique and the medial rectus
The frontal nerve is the largest of the branches of the muscles. It divides into two branches: the supratrochlear
ophthalmic nerve. It enters the orbit via the superior orbital and dorsal nasal. Other branches are the central retinal
fissure outside the muscle cone. It runs superiorly to the artery, lacrimal artery, and the long and short posterior
levator palpebrae superioris. It divides into the supraorbital ciliary arteries. Branches also supply the muscles, eyelids,
and supratrochlear nerves. The supraorbital nerve passes and meninges.
107
Venous drainage sclera by the episcleral space. Tenon’s capsule is penetrated

posteriorly by the ciliary vessels and nerves and fuses with
Venous drainage of the orbit is via the ophthalmic veins, the sheath of the optic nerve. Anteriorly, it fuses with the
of which there are two. The superior ophthalmic vein runs sclera just behind the corneoscleral junction. The tendons of
with the ophthalmic artery and has corresponding tributar- the recti muscles penetrate the capsule anteriorly.
ies. It passes through the superior fissure and ends in the
cavernous sinus. The inferior orbital vein begins in a venous
complex on the floor and medial wall of the orbit. It may Surface anatomy
join the superior ophthalmic vein or may empty directly
into the cavernous sinus via the inferior orbital sinus. The
central retinal vein traverses the optic nerve to end in either
Extraconal retrobulbar and lateral peribulbar blocks
the superior ophthalmic vein or the cavernous sinus. The needle insertion points for the extraconal retrobular
(Fig. 12.7) and lateral peribulbar blocks are at the lowest
Ocular muscles margin of the inferior rim of the orbit. This approximates
to the junction of the medial two-thirds and the lateral
The muscles of the eyelids (Fig. 12.4B) include the levator one-third of the lower lid. This will give the greatest dis-
palpebrae superioris and the orbicularis oculi muscles. The tance from the globe and avoids the inferior rectus muscle.
orbital muscles are the four recti muscles and the superior
and inferior oblique muscles. The recti muscles arise from
the semitendinous ring, which surrounds the optic canal.
The muscles penetrate the fascial sheath of the eyeball
(Tenon’s capsule) and are inserted in the sclera 5–6 mm
posterior to the corneoscleral junction. The superior oblique
muscle arises from the body of the sphenoid and, having
traversed the trochlea, passes backward and is inserted into
the sclera posterior to the equator. The inferior oblique
muscle arises from the orbital surface of the maxilla medi-
ally and is inserted into the lateral part of the sclera behind
the equator.
Tenon’s capsule (fascial sheath of the eyeball)

Tenon’s capsule (Fig. 12.6) is a thin membrane that envelops A
the eyeball from the optic nerve to the corneoscleral junc-
tion. It separates the eye from the orbital fat and forms a
capsule within which the eye moves. It is separated from the
Superior
rectus
Superior
oblique
Ciliary
nerves Optic nerve
surrounded
Lateral by meninges
rectus and extension of
subarachnoid space
Inferior
oblique Medial rectus
Fascial sheath of
eyeball (tenons
capsule)
B
Inferior rectus
Figure 12.7 Extraconal retrobulbar block. Landmarks (A) and needle
insertion at the lowest margin of the inferior rim of the orbit (B). The
needle passes backward in a sagittal plane and parallel to the orbital
Figure 12.6 Tenon’s capsule with orbit removed. floor and lateral wall.
108
CHAPTER
Orbital blocks 12
Figure 12.9 Landmarks for sub-Tenon block. The point of needle inser-
tion is halfway between the inferior and medial recti muscles, 4 mm
from the corneoscleral junction.
X
Technique
As for all regional anesthetic procedures, after checking
that the emergency equipment is complete and in working
order, intravenous access, ECG, pulse oximetry, and
blood pressure monitoring are established. Asepsis is
observed.
B Extraconal retrobulbar block

Figure 12.8 Medial peribulbar block. Landmarks (A) and needle inser-
tion at the medial side of the caruncle (B). The needle passes backward The side to be anesthetized and the axial length of the globe
in a sagittal plane and parallel to the medial orbital wall. Depth of inser- are verified. The axial length dictates which block will be
tion can range from 12 mm to a maximal needle insertion of 25 mm, as used, because an axial length greater than 26 mm is a rela-
measured by observing the needle or hub junction reach the plane of tive contraindication to retrobulbar block. The patient lies
the iris, as shown. in the supine position.
The operator stands on the side to be blocked, below the
patient’s shoulder. The local anesthetic cream, which is
applied 1 h before surgery to the skin of the lower lid on
the side to be anesthetized, is removed in the operating
Medial peribulbar block theater when the skin is prepared with antiseptic solution.
The inferior orbital margin is identified at the junction of
The plica semilunaris, which lies temporal to the caruncle, the medial two-thirds and lateral one-third of the lower
is the landmark for the medial peribulbar block (Fig. 12.8). eyelid. With the eye in the primary or neutral position, the
inferior lid is indented, gently displacing the eye upward
Sub-Tenon block and medially within the orbit. A 32-mm 27-G Atkinson
tipped needle on a 5-mL syringe is inserted between the
The point of insertion for the sub-Tenon block (Fig. 12.9) indenting finger and the inferior orbital margin. The needle
is the point on the conjunctiva halfway between the inferior is directed initially vertically in the sagittal and coronal
and medial recti muscles, 4 mm from the corneoscleral planes, using the indenting finger to maintain the direction
junction. of the needle. The needle is inserted to a depth of 16 mm,
109
which ensures that the tip of the needle is past the greater lidocaine 2% with 1 : 200 000 adrenaline is injected beneath
diameter of the eye. the Tenon capsule. A slight resistance to the injection
The needle is now angled parallel to the orbital floor should be felt but resistance should not be excessive. The
and the lateral wall of the orbit, and is inserted to its full onset of complete block will take approximately 15 min.
depth, or 25 mm for a lateral peribulbar technique. This Assessing lateral and vertical eye movement verifies the
technique reduces significantly the risk of the needle efficacy of the block. The eye is assessed for the presence of
entering the muscle cone. Following aspiration, 4 mL of chemosis and hemorrhage.
lidocaine 2% and 1 : 200 000 adrenaline (epinephrine)
plus 75 IU/mL hyaluronidase (Hyalase) is injected slowly.
The needle is removed and gentle pressure is applied to
the closed eye. Assessing lateral and vertical eye move- Adverse effects
ment verifies the efficacy of the block. Finally the eye is
assessed for the presence of chemosis and hemorrhage. A • Globe perforation has been reported with all techniques
Honan balloon is applied to the eye and inflated to described. At particular risk are myopic eyes with
35 mmHg. This reduces the intraocular pressure prior to an axial length greater than 26 mm and eyes that
surgery. have undergone scleral buckling operations. This is
due to a thin sclera, staphylomas, and the increased
diameters of the eye. This is a serious sight-threatening
Medial peribulbar block complication.
The patient lies in the supine position. The operator stands • Central spread of local anesthetic to the brain, leading
on the side to be blocked, at the patient’s shoulder. With to cardiovascular system instability and respiratory
the eye in the primary position, the lids are separated to depression, may occur. This is a life-threatening
identify the plica semilunaris medially adjacent to the car- complication.
uncle. Local anesthetic drops are applied topically to the • Retrobulbar hemorrhage may be due to arterial or venous
conjunctiva of the eye. A 32-mm 27-G Atkinson tipped hemorrhage and is potentially sight-threatening.
needle on a syringe is angled tangentially to the globe, • Optic nerve trauma is a very rare, sight-threatening
piercing the conjunctiva at the plica semilunaris. When complication.
the tip of the needle touches the medial wall of the orbit, • Central retinal artery or vein occlusion is associated with
the direction of the needle is changed to the vertical in the patients with atherosclerotic vascular disease. Avoid
sagittal and coronal planes. The needle is inserted until its local anesthetics containing adrenaline.
tip meets the lacrimal crest – usually at a depth of 12 mm. • Ocular muscle dysfunction may be transient or perma-
Following aspiration, 2–4 mL of bupivacaine 0.5% is nent. This complication is attributed to either direct
injected. Assessing lateral and vertical eye movement veri- myotoxicity of local anesthetic agents or hemorrhage
fies the efficacy of the block. Finally, the eye is assessed for into muscles due to trauma.
the presence of chemosis and hemorrhage. • Subconjunctival chemosis and subconjunctival hemor-
rhage, which resolve spontaneously.
Sub-tenon block • Subcutaneous hemorrhage at the site of transcutaneous
injections; this resolves spontaneously.
The patient lies in the supine position. The operator stands • Corneal abrasion due to trauma of speculum insertion
on the side to be blocked, at the patient’s shoulder. Local may decrease operative view for the surgeon.
anesthetic drops are applied topically to the conjunctiva of
the eye. Antiseptic drops are also applied. An appropriate
left- or right-eye speculum is carefully placed, separating the
eyelids. CLINICAL PEARLS
The conjunctiva midway between the medial and inferior
recti muscles is gently picked up with Moorfield forceps
• Check axial length before any orbital local anesthetic procedure.
3–4 mm from the limbus. Blunt-tipped curved Westcott If measurement is not available (e.g. for a patient undergoing a
spring scissors, with the tips pointing away from the globe, trabeculectomy), ask the patient about wearing corrective lenses
are used to open the conjunctiva. The conjunctiva and or glasses for distance vision.
Tenon capsule are separated from the sclera with the tips • Always ask patients to maintain their eye in the primary or
of the scissors. A curved blunt 19-G sub-Tenon cannula is neutral position during local anesthetic procedures.
inserted gently under the conjunctiva, following the curve • For cataract extraction, absolute eye akinesia is not necessary.
of the globe until a slight resistance is felt. Then 4 mL of
110
CHAPTER
Orbital blocks 12
Wong DHW. Regional anaesthesia for intraocular surgery.

Suggested reading Can J Anaesth 1993;40:635–657.
Fichman RA, Hoffman J. Anaesthesia for cataract surgery
and its complications. Curr Opin Ophthalmol
1994;5:21–27.
111
CHAPTER
13
Wound local anesthetic infusions
Jack Barrett
Placing local anesthetic in or close to the surgical wound

has become a popular method of providing intra- and post- Rationale for using local
operative analgesia. The technique is applied by a single anesthetic infusion
injection or by continuous infusion using an indwelling
catheter. Wound infusions can be an important component Postoperative pain arises from the interaction of three
of the multi-modal approach to postoperative pain relief. factors:
They have been shown to have a significant opioid-sparing 1. Impulses generated from injured nerve fibers innervat-
effect. For more minor surgical incisions, such as those used ing the site of surgery.
for arthroscopic surgery, local anesthetic infusions alone 2. Inflammatory mediators, such as prostaglandins and
may provide adequate analgesia. cytokines are at increased concentrations at the surgical
Local anesthetic infusions are more practical now with the site and sensitize nerve fibers.
development of portable infusion devices. Catheters with 3. Sensitization of pain-transmitting pathways in the spinal
multiple holes or permeable membranes disperse local anes- cord that elevates their responsiveness to non-painful
thetic over a wider area. These techniques have the advantage stimuli such as pressure or touch. Prolonged peripheral
of simplicity of performance and, to date, are considered to sensitization as a result of surgery can result in central
be safe. The equipment needed, of course, adds to the cost sensitization. This is thought to be a significant cause of
of the procedure but these costs may be offset by a shorter chronic postoperative pain.3
stay in hospital and increased patient satisfaction.
Crile, a surgeon from Cleveland, USA, was the first to Local anesthetics can be used peri-operatively to affect all
describe, in 1913, the benefit of local anesthesia application three of the above.4 In addition, because these systems are
to the surgical wound in providing analgesia and decreasing relatively simple to use they can and have been used in the
morbidity and mortality. Capelle, in 1935, described the home setting postoperatively.5
use of an infusion apparatus to deliver local anesthesia to
the wound.1 In 1950, Blades and Ford used a fine catheter
to deliver local anesthetic to thoracotomy wounds. Mechanisms of action
Over the past 20 years, numerous papers have reported
the use of local anesthesia in wounds of major abdominal Local anesthetics are known to block impulse transmission
incisions, gynecological and obstetric procedures, ortho- in all peripheral nerves by virtue of their ability to block
pedic operations, plastics procedures and mastectomy, sodium channels and thus inhibit conduction in the nerve
among others. These studies have confirmed a decrease axon. Infiltration of local anesthetic around the site of
in pain scores at rest and during activity. They have, in surgery can suppress the generation and propagation of
addition, been associated with a decreased incidence of injury-induced discharge from ectopic foci in injured
side-effects.2 nerves. Continuous infusion of slow release formulations
DOI: 10.1016/B978-0-7020-3148-9.00021-9
CHAPTER
Wound local anesthetic infusions 13
of local anesthetic may extend such inhibition for days after catheter is obviously essential and great care regarding
surgery. asepsis must be taken when recharging the infusion
In addition, it is now apparent that systemic concentra- system.
tions of local anesthetic i.e. lignocaine 2–4 µg per mL for The fact that surgeons place catheters has the added
only a few hours peri-operatively can have an analgesic advantage of making them more aware of postoperative
effect postoperatively for a number of days. The mechanism pain and empowering them to assist its palliation. Postop-
for this is unknown at present. erative pain has up to recently not been seen as a complica-
Local anesthetics have an anti-inflammatory action also, tion in surgical terms. The incidence of post-surgical chronic
through their effects on cells of the immune system, as well pain is higher than many surgeons appear to realize.6
as on other cells, e.g. microorganisms, thrombocytes and Catheters can be placed in the wound itself or at some
erythrocytes. distance from the incision. Because of fear of infection, it
is advocated by some that it is better to place the catheter
outside the wound. The optimal positioning will depend
Potential problems on the direction of the nerve supply to the area. It may
require the use of two catheters if there is a nerve supply
Initial fears regarding the potential risks of infection and from both sides, as in the chest for example.
effects on wound healing would appear to be unfounded, In the abdomen, catheters should be placed in the muscle
as studies have not shown any adverse effects on wound plane in which the nerve supply runs. These will be dealt
healing or increased rates of infection. with in more detail in the individual sites below.
Local anesthetics are known to have myotoxic properties,
but in concentrations used for infusion these have not been Orthopedic procedures
observed to date.
It would appear that local anesthetic infusions have very Shoulder surgery
few side-effects and as a result their risk–benefit ratio is
positive.2 Arthroscopic surgery
Wound catheter techniques decrease opioid requirements
Positioning without significant side-effects.
Subacromial catheter placement is recommended (Fig.
To date most catheters are placed in position by the operat- 13.1) but intra-articular catheters have also been used. A
ing surgeon under aseptic conditions. Aseptic placing of the flow rate of 2–5 mL/hr is adequate.
Figure 13.1 Subacromial

Coracoacromial ligament Acromion placement of catheter.
Subdeltoid bursa Coracoid process
Pectoralis minor tendon (cut)
Greater tubercle
Lesser tubercle Subscapularis muscle
of humerous Musculocutaneous muscle
Intertubercular Coracobrachialis muscle
tendon sheath
Circumflex scapular artery (cut)
Deltoid muscle Teres major muscle
(reflected)
Latissimus dorsi muscle
Pectoralis major
muscle (reflected)
Anterior circumflex
humeral artery
Long head
Biceps
brachii Short head
muscle
Medium nerve (cut)

Brachial artery (cut)
113
Aponeurosis of Anterior layer of External oblique Figure 13.2 Catheter placement for
external oblique muscle rectus sheath muscle mid-line incisions.
Internal oblique
Aponeurosis of Rectus abdominis muscle
muscle
Internal oblique muscle
Linea alba Skin Transversus
Aponeurosis of abdominis muscle
transversus abdominis muscle
Posterior layer Falciform Subcutaneous

Peritoneum of rectus sheath ligament tissue
Extra peritoneal fascia Transversalis fascia Placement of catheter (fatty layer)
between fascia and
peritoneum
Open shoulder surgery Injection of 20 mL of local anesthetic to the peri-capsular

There are fewer reports on the use of local anesthetic infu- area combined with a catheter on the tensor fascia lata has
sions in open shoulder surgery than on arthroscopic proce- produced excellent results, in the author’s experience.
dures; however, it appears that continuous wound infusions
do have an opioid-sparing effect. A preclosure bolus of local Abdominal surgery
anesthetic is also recommended. Flow rate of 5 mL/hr is Laparotomy with mid-line incision8
sufficient in most cases. A higher concentration of local
This is a common surgery and is associated with severe
anesthetic (0.375%) may be required compared with
postoperative pain, especially if the wound is above the
arthroscopic surgery (0.25%).
umbilicus. Incisions below the umbilicus tend to be less
Joint surgery painful. Nevertheless, the incisions for open laparotomy
can be long, and therefore a fenestrated catheter is recom-
Anterior cruciate ligament reconstuction (ACLR) mended. It would appear that subfascial placement is more
A bolus injection into the joint of 20–25 mL followed effective than subcutaneous (Fig. 13.2).9 The length of cath-
by a continuous infusion at both the donor site and intra- eter can be adjusted for the size of the incision. A bolus is
articularly appears to give the best result. Pain control is suggested prior to infusion.
enhanced by the addition of morphine 5 mg and /or ketor- Flow rates depend on the size of the wound. Flow rates
olac 30 mg. Infusion for 48 hours is recommended at a of up to 10 mL/hr maybe necessary for longer incisions.
flow rate of 10 mL/hr intra-articularly and 2 mL/hr in the
wound. Sub-costal incisions
Again, a subfascial placement is recommended, with flow
Total knee replacement rates of at least 4 mL/hr using a fenestrated catheter.
As in the ACLR above, both intra-articular and subcutane-
ous parapatellar catheters are recommended. A fenestrated Laparoscopic cholecystectomy
catheter is suggested because of the length of the wound, The current recommended technique for this surgery is the
with a flow rate of 5 mL/hr, preceded by a bolus dose into use of a 20-mL bolus in the gallbladder bed and in the
the wound layers. trocar sites, followed by intermittent 10-mL boluses intra-
More recently, a high dose local infiltration technique has peritoneally. An epidural catheter is sufficient here. Infu-
been described. This combines the use of local anesthetics sions do not appear to add any benefit.10
together with an anti-inflammatory agent and adrenaline Note, this technique does not relieve shoulder pain.
in the tissues around the wound and also the use of an
intra-articular catheter.7 Appendicectomy via McBurney’s incision
The technique for open laparotomy, i.e. subfascial place-
Total hip arthroplasty ment of the catheter, is also recommended here.
Here also, postoperative continuous wound infusions have
been shown to be effective. If the wound is especially long, Nephrectomy
2 fenestrated catheters may be necessary; again, preceded Studies are scarce here, but placement of a fenestrated cath-
by a bolus injection to the layers of the wound. The eter between the oblique muscles has been shown to be
optimum technique has yet to be determined, however. effective.
114
CHAPTER
Wound local anesthetic infusions 13
Inguinal herniotomy
A subfascial placement of the catheter has demonstrated
efficacy. Low flow rates, i.e. 2 mL/hr are sufficient, if pre-
ceded by a bolus injection to the incision or by the use of
an ilioinguinal block.
Breast surgery
Postoperative use of continuous indwelling catheters has
been shown to be of benefit in many types of breast surgery,
including mastectomy, plastic/cosmetic procedures and
axillary clearance.11 Figure 13.3 Elastometric pump empty.
Multi-holed catheters are recommended, and placed in
the superior aspect of the wound to allow for gravity to aid
distribution of the local anesthetic. The use of drains may
negate the benefit of the infusion.
A study placing the catheter parallel and inferior to the
axillary vein has been shown to be effective for axillary
surgery.12
The catheter has been placed behind the breast implant
in augmentation surgery and has been found to be
effective.
The use of a bolus injection prior to infusion of c.4 mL/
hr for 48 hours is also recommended.
Cardiothoracic surgery
Current evidence suggests that the use of two fenestrated Figure 13.4 Elastometric pump filled.
catheters, one placed in the subfascial plane above the
sternum and the other subcutaneous in the wound, is effec-
tive in reducing pain at rest, and opioid consumption.13 the catheter has been more effective. Further studies will
Flow rates of 2 mL/hr in each catheter are recommended confirm the optimal catheter position.
for at least 48 hours.
Gynecological/obstetrical surgery Equipment

Cesarian section The basic system is a pump (Figs 13.3 and 13.4) and a
Cesarian section through a Pfannenstiel incision is associ- catheter. Sterile equipment and aseptic technique are essen-
ated with less postoperative pain when local anesthetic is tial to minimize the risk of infection.
perfused via a fenestrated catheter placed either above or Pumps include elastomeric and battery driven types.
below the fascia.14 The optimal position is as yet undeter- Some elastomeric pumps are fitted with flow restrictors and
mined. Diclofenac alone infused to the wound was found clamps to prevent overdose. Nevertheless, these do not
to be superior to intravenous diclofenac.15 always prevent accidental emptying of the pump and do
As with other incisions, it is probably best to have a pre- not alert personnel to changes in flow rate. Pumps housed
closure bolus before commencing the infusion. in a protective rigid plastic cover are less prone to external
Infusion rates of 4–6 mL/hr should suffice unless the pressure that may result in an increase in flow rate.
wound is very wide. Catheters should be available in different lengths to
This technique is especially beneficial in these patients, provide for wounds of varying length. They should be
as early mobilization is preferable. multi-holed and facilitate uniform flow and even distribu-
tion of drug over the length of the wound.
Abdominal hysterectomy
This procedure has also been shown to be associated with
less postoperative pain and decreased opioid consumption Drugs
when a wound infusion of local anesthesia has been used.16
Placement of the catheter above the fascia has been more Robivicaine and levobupivicaine are the most commonly
effective than below the fascia, which is at variance with studied local anesthetics for continuous infusions. These
other abdominal surgeries when subfascial placement of are associated with less toxicity and are the recommended
115
drugs. Levobupivicaine is most commonly used in a con- colorectal surgery. A randomised double-blind,
centration of 0.25%, while robivicaine has been used in placebo-controlled study. Anaesthesiology
similar concentrations, but some authors have recom- 2007;107:155–159.
mended 0.375%. 9. Fredman B, Zohar E, Tarabyk A, et al. Bupivicaine
There is some concern over possible cytotoxic effects of wound installation via an electronic patient-
local anesthetics on articular chondrocytes or osteoblasts; controlled device and a double catheter system
however, this needs further evaluation.17 does not decrease postoperative pain or opioid
Diclofenac given by continuous infusion to the wound requirement after major abdominal surgery. Anaesth
has been shown to give more effective pain relief and have Analg 2001;92:189–193.
a greater opioid-sparing effect than giving the same dose 10. Gupta A, Thöm S, Axelsson K, et al. Postoperative
intravenously. However, this needs further study and is not pain relief using intermittent injections of 0.5%
recommended until more is known about its use in this ropivacaine through a catheter after laparoscopic
situation. cholecystectomy. Anaesth Analg 2002;95:450–456.
11. Rawal N, Gupta A, Helsing M, et al. Pain relief
following breast augmentation surgery: a comparison
References between incisional patient-controlled regional
analgesia and traditional oral analgesia. Eur J
1. Capelle W. Die Bedentung des Wundschmerzes und Anaesthesiol 2006;23:1010–1017.
seiner Ausschaltung fur dan Ablauf der Atmung bei 12. Schell SR. Patient outcomes after axillary node
Laparotomierte. Dtsch Z Chir 1935;246:466. dissection for breast cancer: use of postoperative
2. Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous local anaesthesia infusion. J Surg Res
continuous wound catheters delivering local 2006;134:124–132.
anaesthetic for post operative analgesia: a quantitative 13. Dowling R, Theilmeier K, Ghaly A, et al. Improved
and qualitative systematic review of randomised pain control after cardiac surgery: Results of a
controlled trials. J Am Coll Surg 2006;203:914–932. randomised double blind clinical trial. J Thorac
3. Kehlet H, Jensen TS, Woolf CJ. Persistent post surgical Cardiovasc Surg 2003;26:127–128.
pain: risk factors and prevention. Lancet 2006;367: 14. Ranta PO, Ala-Koko TI, Kukkonen JE, et al. Incisional
1618–1625. and epidural analgesia after caesarian delivery: a
4. Strichartz GR. Novel ideas of local anaesthetic actions prospective, placebo-controlled, randomised clinical
on various ion channels to ameliorate post operative study: Int J Obstetric Analgesia 2006;15:189–194.
pain. BJA 2008;101(1):45–47. 15. Lavand’homme PM, Roelants F, Waterloos H, de
5. Rawal N, Axellson K, Hylander J, et al. Postoperative Kock MF. Postoperative pain analgesic effects of
patient-controlled local anaesthetic administration at continuous wound infiltration with diclofenac after
home. Anaesth Analg 1998;86:86–89. elective Caesarian delivery. Anaesthesiology
6. McRae WA. British Journal of Anaesthesia 2007;106:220–225.
2001;87(1):88–98. 16. Gupta S, Maheshwari R, Dulara SC. Wound
7. Röstlund T, Kehlet H. High dose local infiltration instillation of 0.25% bupivacaine as continuous
analgesia after hip and knee replacement-what is it, infusion following hysterectomy. Middle East J
why does it work and what are the future challenges? Anaesth 2005;18:595–610.
Acta Orthop 2007;78:159–161. 17. Karpi JC, Chu CR. Lidocaine exhibits dose-and
8. Beaussier M, E’Ayoubi H, Schiffer E, et al. Continuous time-dependent cytotoxic effects on bovine articular
preperitoneal infusion of robivicaine provides chondrocyes in vitro. Am J Sports Med 2007;35:
effective analgesia and accelerates recovery after 1621–1634.
116
CHAPTER
14
Brachial plexus anatomy
Dominic Harmon
Before selection of technique, it is important to have a lower (C8, T1) pairs of roots merge to form the upper and
thorough understanding of brachial plexus anatomy. The lower trunks of the brachial plexus, while the middle root
plexus is composed of roots, trunks, divisions, cords, and (C7) continues as the middle trunk. The lower trunk is
branches (Fig. 14.1). The brachial plexus stems from the smaller than the others, and is frequently derived entirely
ventral rami of the C5 to T1 nerve roots in the majority of from the eighth cervical nerve. The nerve to subclavius
individuals. Approximately 15% of patients may have con- arises from the roots of C5 and C6, where they join to form
tributions to the brachial plexus from the C4 or T2 nerve the upper trunk, which also gives off the suprascapular
roots, creating a ‘prefixed’ or ‘postfixed’ plexus (see Fig. nerve (to supra- and infraspinatus muscles and the shoul-
15.9). The cervical roots emerge from the intervertebral der joint). The trunks are formed in the lower part of the
foramina and lie on a sulcus on the vertebral transverse posterior triangle of the neck, between the sternocleidomas-
processes between the anterior and posterior tubercles to toid and trapezius muscles and above the middle third of
which the scalene muscles are attached. Immediately lateral the clavicle. The trunks travel to the margin of the first rib
to the transverse processes of the cervical vertebrae, the and divide into anterior and posterior divisions.
nerve roots are sheathed in the prevertebral fascia. The
nerve roots then travel between the scalene muscles and
form three trunks (upper, middle, and lower). The intersca- Relations
lene groove is a palpable surface anatomy depression
between the anterior and middle scalene muscles; it allows In the neck, the brachial plexus lies in the posterior triangle,
clinicians easy and reliable access to the roots and trunks being covered by the skin, platysma, and deep fascia; it is
of the plexus. The roots are posterior to the vertebral artery crossed by the supraclavicular nerves, the inferior belly of
– an important anatomic relation for the interscalene block. the omohyoid, the external jugular vein, and the transverse
The nerve roots of the plexus, as they exit the interverte- cervical artery. It emerges between the anterior and medial
bral foramina, typically comprise a single large fascicle, scalene muscles; its upper part lies above the third part of
surrounded by a scant amount of epineurium. These then the subclavian artery, while the trunk formed by the union
divide and recombine along the length of the plexus until, of the eighth cervical and first thoracic is placed behind the
eventually, most fascicles have been segregated into largely artery. The plexus next passes behind the clavicle.
motor or sensory axons, bound for a particular area or Each trunk divides into an anterior and a posterior divi-
structure. The number of fascicles increases and their cross- sion behind the clavicle. Divisions then form three cords as
sectional area decreases, from proximal to distal in the they pass under the clavicle and around the humeral head,
plexus. At the same time, the amount of connective tissue where they are joined by the axillary artery. The cords are
of the epineurium progressively increases from proximal to labeled as the lateral, medial, and posterior cords; they are
distal. named as such based on the relative anatomic position to
The dorsal scapular nerve (to rhomboids) and the long the axillary artery. At the outer border of the first rib, the
thoracic nerve (to serratus anterior) arise from the C5 and upper two anterior divisions unite to form the lateral cord,
C5, 6, and 7 roots, respectively. The upper (C5, 6) and the anterior division of the lower trunk runs on as the
DOI: 10.1016/B978-0-7020-3148-9.00022-0
down the medial aspect of the arm to lie behind the base
Roots C4
of the medial epicondyle at the elbow. The radial nerve
Trunks C5
from the posterior cord passes posteriorly through an inter-
C6
Divisions
muscular space to spiral round the back of the humerus and
C7 enter the cubital fossa, where it lies in a deep plane between
Cords
T1 the brachioradialis and brachialis. The radial nerve gives
T2 off the posterior cutaneous nerve of the arm in the axilla,
and the lower lateral cutaneous nerve of the arm and pos-
Terminal nerves Upper
terior cutaneous nerve of the forearm at the back of the
Musculocutaneous Mid humerus. The posterior cord also gives off two subscapular
Axillary
Median
Lower nerves (to subscapularis and teres major), the thoracodorsal
Radial Pectoralis Clavicle nerve (to latissimus dorsi), and the axillary (circumflex
Ulnar minor muscle humeral) nerve; the latter winds round the back of the
Figure 14.1 Brachial plexus anatomy. humerus to supply the deltoid and a small area of skin at
the upper lateral part of the arm.
medial cord, while all three posterior divisions unite to

form the posterior cord. The lateral and medial cords Branches of the brachial plexus
provide ventral innervation to the upper limb, with the
posterior cord providing dorsal innervation. The cords The branches of the brachial plexus may be arranged into
enter the axilla from above the axillary artery and lie lateral, two groups: those given off above and those below the
medial, and posterior to the middle part of the artery, clavicle.
behind the pectoralis minor muscle. The cords divide at the
border of the pectoralis minor muscle into five major Supraclavicular branches (from roots or trunks)
peripheral nerves, which provide innervation to the upper
extremity. The five nerves of the brachial plexus are the • Dorsal scapular C5
axillary, musculocutaneous, radial, median, and ulnar • Suprascapular C5, 6
nerves. • Nerve to subclavius C5, 6
The cords and the artery are surrounded by a thin fascial • Long thoracic C5, 6, 7
sheath called the axillary sheath. The sheath is a collection • To longus colli and scaleni C5, 6, 7, 8.
of connective tissue surrounding the neurovascular struc-
tures of the brachial plexus. It is a continuum of the pre-
vertebral fascia, which invests the scalene muscles in the Infraclavicular branches
neck. The sheath is a multicompartmental structure formed The infraclavicular branches are derived from the three
by thin layers of fibrous tissue surrounding the plexus in cords of the brachial plexus.
thin membranes and extending inward to create discrete
fascial septae. Nerves are thus enmeshed in this tissue rather Lateral cord
than lying separate and distinct. These compartments may • Musculocutaneous C5, 6, 7
limit the circumferential spread of injected solutions, • Lateral pectoral C5, 6, 7
thereby requiring separate injections into each com- • Lateral head of median nerve C6, 7.
partment for optimal nerve block. However, proximal
connections between compartments have been identified, Medial cord
which may account for the success of single-injection • Medial pectoral C8, T1
techniques. • Medial cutaneous nerve of forearm C8, T1
Lateral and medial pectoral nerves from their respective
• Medial cutaneous nerve of arm C8, T1
cords supply the pectoralis major and minor. The muscu-
• Ulnar C8, T1
locutaneous nerve from the lateral cord enters the coraco-
brachialis, supplying it and going on to supply the biceps • Medial head of median nerve C8, T1.
and brachialis; it becomes the lateral cutaneous nerve of the Posterior cord
forearm at the lateral side of the biceps tendon at the elbow.
• Upper subscapular C5, 6
Lateral and medial roots from their respective cords unite
to form the median nerve, which crosses in front of the • Lower subscapular C5, 6
brachial artery at the middle of the arm and lies medial to • Thoracodorsal C5, 6 .
the artery at the elbow. The ulnar nerve arises from the • Axillary C5, 6
medial cord between the axillary artery and vein, and passes • Radial C6, 7, 8, T1.
118
CHAPTER
Brachial plexus anatomy 14
The median nerve winds around from the medial to the lateral side of the
humerus in a groove between the medial and lateral heads
The median nerve (C6 to T1) extends along the middle of the triceps. It pierces the lateral intermuscular septum
of the arm and forearm to the hand. As it descends through and passes between the brachialis and brachioradialis to
the arm, it lies at first lateral to the brachial artery; the front of the lateral epicondyle, where it divides into a
about the level of the insertion of the coracobrachialis, it superficial and a deep branch.
crosses the artery – usually in front of, but occasionally
behind it – and lies on its medial side at the elbow, where
The superficial branch of the radial nerve
it is situated behind the bicipital fascia and is separated
from the elbow joint by the brachialis. In the forearm, it The superficial branch of the radial nerve passes along the
passes between the two heads of the pronator teres and front of the radial side of the forearm to the commence-
crosses the ulnar artery, but is separated from this vessel by ment of its lower third. It lies at first slightly lateral to the
the deep head of the pronator teres muscle. It descends radial artery, concealed beneath the brachioradialis. In the
beneath the flexor digitorum superficialis, and lies on the middle third of the forearm, it lies behind the same muscle,
flexor digitorum profundus, to within 5 cm of the wrist close to the lateral side of the artery. It leaves the artery
flexor retinaculum; here it becomes more superficial and is about 7 cm above the wrist, passes beneath the tendon of
situated between the tendons of the flexor digitorum super- brachioradialis, and, piercing the deep fascia, divides into
ficialis and flexor carpi radialis. Here it lies behind, and two branches. The lateral branch, the smaller, supplies the
rather to the radial side of, the tendon of the palmaris skin of the radial side and ball of the thumb, joining with
longus, and is covered by the skin and fascia. It then passes the ventral branch of the lateral cutaneous nerve of the
deep to the wrist flexor retinaculum. The palmar cutaneous forearm. The medial branch communicates, above the
branch of the median nerve passes over the flexor retinacu- wrist, with the dorsal branch of the lateral cutaneous nerve
lum and provides sensory innervation to the central palm of the forearm, and on the back of the hand with the dorsal
and, variably, the radial proximal palm / thenar area, central branch of the ulnar nerve.
palm and thenar eminence.
The deep branch of the radial nerve
The ulnar nerve The deep branch of the radial nerve winds to the back
of the forearm around the lateral side of the radius between
The ulnar nerve (C8 to T1) is smaller than the median nerve the two planes of fibers of the supinator, and continues
and lies at first behind it, but diverges from it in its course downward between the superficial and deep layers of
down the arm. At its origin, it lies medial to the axillary muscles to the middle of the forearm. Diminished in size,
artery, and bears the same relation to the brachial artery as it descends as the dorsal interosseous nerve on the interos-
far as the middle of the arm. Here it pierces the medial seous membrane, in front of the extensor pollicis longus,
intermuscular septum, runs obliquely across the medial to the back of the wrist, where it presents a gangliform
head of the triceps muscle, and descends to the groove enlargement from which filaments are distributed to the
between the medial epicondyle and the olecranon, accom- ligaments and articulations of the wrist.
panied by the superior ulnar collateral artery. At the elbow, The sensory (Figs 14.2 and 14.3) and motor innervation
it rests on the back of the medial epicondyle, and enters the of the upper limb is clinically important. Knowledge of
forearm between the two heads of the flexor carpi ulnaris. sensory innervation helps determine which cutaneous nerve
In the forearm, it descends along the ulnar side, lying on distributions within a surgical field require blockade. Motor
the flexor digitorum profundus; its upper half is covered by innervation is clinically relevant as a means of matching a
the flexor carpi ulnaris, its lower half lies on the lateral side peripheral nerve stimulation response to a particular nerve
of the muscle, and is covered by fascia, and skin. In the upper being stimulated. As the arm has multiple innervation,
third of the forearm, it is separated from the ulnar artery by assessment of block efficacy is best achieved by assessing
a considerable interval, but in the rest of its extent lies close function unique to each nerve. It is important to remember
to the medial side of the artery. About 5 cm above the wrist that significant variation in the structure of the brachial
it ends by dividing into a dorsal and a ventral branch. plexus occurs, with seven major configurations described.
The approaches to the brachial plexus include the inter-
The radial nerve scalene, supraclavicular, infraclavicular, axillary, and mid-
humeral approaches. In relation to the brachial plexus
The radial nerve (C5 to T1), the largest branch of the bra- anatomy, the interscalene block is performed at the level of
chial plexus, is the continuation of the posterior cord of the the trunks, whereas the supraclavicular block is performed
plexus. It descends behind the first part of the axillary artery where the divisions are transitioning into cords. The infra-
and the upper part of the brachial artery, and in front of clavicular block is performed at the proximal cord level and
the tendons of the latissimus dorsi and teres major. It then the axillary block is performed where the terminal nerves
119
Supra- Upper lateral

clavicular cutaneous
nerve of arm
Anterior Posterior
Upper lateral Lower lateral
cutaneous cutaneous
nerve of arm nerve of arm
Posterior
Intercosto-
cutaneous
brachial
nerve of arm
Lower lateral Medial Posterior

cutaneous cutaneous cutaneous
nerve of arm nerve of arm nerve of
forearm
Medial cutaneous
Lateral
nerve of forearm Lateral
cutaneous
nerve of cutaneous
forearm nerve of
Ulnar forearm
Median Radial
Figure 14.2 Cutaneous innervation of the upper limb.
Anterior Posterior plexus anesthesia include abnormalities of muscles, vessels,

and nerves. Newer imaging modalities have allowed
C4 C4 improved characterization of anatomic relationships for
successful nerve blockade in various positions along the
T3 brachial plexus and its terminal nerves. Real-time ultraso-
C5 C5
nography is particularly useful in characterizing local
anatomy, demonstrating nerve positions, and detecting
anatomic variation that may affect block success or com-
T1 T1
promise patient safety.
C6 C6
C8 C8
Suggested reading
C7 C7
Bonnel F. Microscopic anatomy of the adult human
Figure 14.3 Sensory dermatomes of the upper limb. brachial plexus: an anatomical and histological
basis for microsurgery. Microsurgery 1984;5:107–
118.
Williams PL, Warwick R, Dyson M, et al. Gray’s anatomy.
emerge. The midhumeral approach occurs well after the 37th ed. Edinburgh: Churchill Livingstone; 1989.
peripheral nerves have been formed.
Knowledge of anatomy remains the cornerstone of
regional anesthesia. Variations and anomalies of the upper
extremity that may impact on the performance of brachial
120
CHAPTER
15
Interscalene block
cricoid cartilage (C6). Important anatomic relations (Fig.

Indications 15.2) include the external jugular vein, which crosses the
posterior border of the sternocleidomastoid muscle at this
Surgical Surgical procedures of the clavicle, shoulder,
point, the phrenic nerve on the anterior scalene muscle,
upper arm, and forearm (exception being the medial
and the vertebral artery.
aspect).
Therapeutic Shoulder and upper arm pain (‘frozen
shoulder’); humeroscapular periarthritis; poststroke pain;
postherpetic neuralgia; lymphedema after breast surgery;
Surface anatomy
vascular diseases and injuries; complex regional pain
The main landmarks for the interscalene block (Fig. 15.3)
syndrome; postamputation pain; tumor-related pain; pain
include clavicle; sternal notch; cricoid cartilage; sternal and
management for shoulder rehabilitation therapy; pro-
clavicular heads of the sternocleidomastoid muscle – these
longed postoperative analgesia (continuous technique).
can be accentuated by asking the patient to perform a head
lift; interscalene groove – both scalene muscles descend to
Contraindications the first rib and can be identified by asking the patient to
inhale deeply, because they contract before the sterno-
cleidomastoid muscle; and the external jugular vein –which
Absolute can be accentuated by asking the patient to perform a
See Chapter 4. Valsalva maneuver. A skin marker should routinely be used
Relative to delineate the anatomic structures before performing
Hemorrhagic diathesis; anticoagulation treatment; chronic the block.
obstructive airways disease; contralateral paresis of the
phrenic or recurrent laryngeal nerves; and distorted anatomy
(due to previous surgery or trauma). Sonoanatomy
Perform a systematic anatomical survey from medial to
Clinical anatomy lateral and superficial to deep. The carotid artery and inter-
nal jugular vein are seen medially. Medial to the vessels, the
The cervical nerves exit from the cervical spine through thyroid and trachea are identified. The ultrasound-guided
gutters in the transverse processes that run in an anterolat- intrascalene block is performed at the lateral border of the
eral direction, immediately posterior to the vertebral artery. clavicular head of the sternocleidomastoid at the level of
The cervical nerves enter a facial space in the posterior tri- the cricoid cartilage. Here the brachial plexus is a superficial
angle of the neck between the anterior and middle scalene structure and a high frequency ultrasound transducer (6 to
muscles called the interscalene compartment (Fig. 15.1). 13 MHz) is used. A high frequency transducer allows good
The interscalene block is performed at the level of the visualization of structures to a depth of 4–5 cm. The ultra-

DOI: 10.1016/B978-0-7020-3148-9.00023-2
4
2
5 3
1
1
Figure 15.3 Landmarks for the interscalene block. Further accentua-

3 tion of the anatomy can be achieved by asking patients to lift their head
up against resistance (with the head turned to the side). Additionally,
5 when palpating the interscalene groove, the groove can be better
5
appreciated by asking the patient to sniff. 1, Clavicle; 2, cricoid cartilage;
4 3, clavicular head of the sternocleidomastoid muscle; 4, sternal head of
the sternocleidomastoid muscle; 5, posterior border of the sternocleido-
mastoid muscle.
Figure 15.1 Coronal T1-weighted MR image showing the anatomy of

the cervical region relevant to interscalene block (post contrast). Note
relation of anterior and medial scalene muscles on the side contralateral
to the injected contrast. 1, Sternocleidomastoid muscle; 2, common
carotid artery; 3, middle scalene muscle; 4, clavicle; 5, anterior scalene
muscle.
2
Figure 15.4 The patient is positioned supine with the head turned 45°
to the contralateral side. The ultrasound transducer is then positioned
in the posterior triangle of the neck at the level of the cricoid cartilage
with an axial oblique orientation.
8
7 4 sound transducer is placed in an axial oblique plain (Fig.
5 6 1 15.4) and the most superficial structure consistently
encountered is the sternocleidomastoid muscle. This
appears as a triangular structure with the apex pointing
3 laterally. Immediately deep to the sternocleidomastoid
muscle are the anterior and middle scalene muscles. These
Figure 15.2 Neck dissection of cadaver structures illustrating the bra-
can be accentuated by asking the patient to sniff. The roots
chial plexus. 1, Clavicle; 2, cricoid cartilage; 3, retracted sternocleidomas- of the brachial plexus appear between these two muscles in
toid muscle; 4, anterior scalene muscle; 5, middle scalene muscle; 6, the interscalene groove. At this level it is common to iden-
brachial plexus; 7, phrenic nerve; 8, internal jugular vein. tify between one and five hypoechoic structures (roots or
122
CHAPTER
Interscalene block 15
SCM ASM
Carotid
artery
MSM
Medial Lateral
Figure 15.6 Locating the interscalene groove. The palpating fingers

are placed deep to the sternocleidomastoid muscle.
Figure 15.5 Transverse view of the brachial plexus at the lateral border
of the sternocleidomastoid muscle, at the level of the cricoid cartilage
between the anterior and middle scalene muscles, using a high fre-
quency linear ultrasound transducer. The arrows indicate the roots of
the brachial plexus, which are reflected as hypoechoic structures. ASM:
anterior scalene muscle; MSM: middle scalene muscle; SCM: sterno-
cleidomastoid muscle.
trunks) and, depending on the position of the ultrasound

transducer, these may appear oval or round. The brachial
plexus at this level lies at a depth of around 1 cm from the
skin (Fig. 15.5).
Technique
Figure 15.7 Locating the interscalene groove. The fingers are rolled
Landmark-based approach laterally until a groove behind the posterior border of the sternocleido-
mastoid is identified.
As for all regional anesthetic procedures, after checking that
emergency equipment is complete and in working order,
intravenous access, ECG, pulse oximetry, and blood pres- ing hand should be firmly seated in the interscalene groove.
sure monitoring are established. Asepsis is observed. To assure stability of both hands, all fingers not in use
The patient is placed in the supine position with the head should be resting on the neighboring structures. The direc-
facing away from the side to be blocked. The patient is tion of needle insertion runs inward, slightly dorsally, and
asked to elevate the head slightly to bring the clavicular 30–40° caudally (backward, inward, and downward; Fig.
head of the sternocleidomastoid muscle into prominence. 15.8). This needle direction takes into account the orienta-
The palpating finger is placed behind the sternocleidomas- tion of the gutter of the transverse processes of the cervical
toid muscle and the patient is instructed to end the head vertebrae, on which the cervical roots lie. It also acts as a
lift (Fig. 15.6). The finger now lies on the belly of the ante- safety technique to decrease the risk of intervertebral needle
rior scalene muscle, and with lateral movement of the insertion. The stimulating current is set at 1.0 mA, 2 Hz,
finger to the lateral edge of this muscle, the groove between and 0.1 ms. The needle is advanced slowly until the appro-
the anterior and middle scalene muscles (interscalene priate muscle response is obtained: shoulder, elbow, index
groove) is encountered (Fig. 15.7). The injection site in the finger, or thumb movement. The needle position is adjusted
interscalene groove lies at the level of the cricoid opposite while decreasing the current to 0.35 mA with maintenance
the transverse process of C6 (Chassaignac tubercle). of the muscle response.
The needle insertion point is infiltrated with local anes- Muscle responses that indicate a less than optimal final
thetic using a 25-G needle. A 35–50-mm 21-G insulated needle location include diaphragmatic contraction. The
needle is used. The index and middle fingers of the palpat- phrenic nerve lies on the anterior scalene muscle and is thus
123
1
2
3
4
Figure 15.8 Interscalene block technique. The needle is inserted into 5
the interscalene groove at the level of the cricoid cartilage and advanced 5
into the groove with an inward, downward, and backward orientation.
The index and middle finger of the palpating hand are placed over the
interscalene groove and the skin over the groove is stretched. 6
a needle location that is too anterior to the plexus. Muscle

contraction of the posterior compartment muscles of the
shoulder indicates suprascapular nerve stimulation, a final
needle position that is too posterior. Failure to obtain
motor response to nerve stimulation should prompt with-
Figure 15.9 Coronal fat-saturated MR image after injection of 30 mL
drawal of the needle and reinsertion in a 5–10% angle
of contrast. Note C4 nerve root joining C5 nerve root, creating a ‘pre-
anterior or posterior to the initial insertion plane. fixed’ brachial plexus. Spread of contrast reaches the level of the upper
Incremental injections of local anesthetic (40 mL) are border of C4 and caudad to the level of the clavicle. 1, Vertebral artery;
made with repeated aspiration. This volume is sufficient for 2, C4 root; 3, C5 root; 4, posterior and middle scalene muscles; 5, brachial
an adequate block of the brachial plexus and the caudal plexus elements; 6, brachial plexus.
part of the cervical plexus (Fig. 15.9). Digital pressure is
applied proximal to injection (Fig. 15.10) to promote distal
spread of local anesthetic; this is to facilitate reaching the
lower roots of the plexus. The lower roots of the plexus may
not be anesthetized due to the proximal injection site with
this technique.
Ultrasound-guided approach
Intravenous access, electrocardiogram (ECG), pulse oxim-
etry and blood pressure monitoring are established. Maxi-
mized comfort for the operator and patient is an important
step in pre-procedure preparation. For the ultrasound-
guided interscalene block, the patient is placed in the
supine position with the head turned to the side opposite
that to be blocked. The operator stands or sits adjacent to Figure 15.10 Interscalene block technique. Proximal digital pressure
the side to be blocked. The ultrasound screen, transducer, promotes distal spread of local anesthetic.
needle, and plane of imaging should all be placed in one
view for the operator. For the interscalene block, the ultra- patient is asked to raise their head to identify the intersca-
sound screen is placed below the shoulder on the side to lene groove.
be blocked (Fig. 15.11). Room lights may be turned down The skin is disinfected with antiseptic solution and
to enhance image viewing. The operating lights can be used draped. A sterile sheath (CIVCO Medical Instruments,
to maintain some working lighting in the background. The Kalona, IA, USA) is applied over the ultrasound transducer
124
CHAPTER
Figure 15.11 Global view of the block field for the ultrasound-guided Figure 15.12 Ultrasound transducer and needle positioning during
interscalene block. If the needle is to approach from the medial aspect ultrasound-guided interscalene block. Note the needle orientation in
of the transducer, then the ultrasound screen is placed on the side to the same plane as the ultrasound beam.
be blocked below the patient’s shoulder.
SCM ASM
with sterile ultrasound gel (Aquasonic, Parker Laboratories,
Fairfield, NJ, USA). Another layer of sterile gel is placed
between the sterile sheath and the skin. The brachial plexus
Carotid
at the interscalene level is scanned in the axial oblique
artery
plain. The ultrasound screen should be made to look like MSM
the scanning field. That is, the right side of the screen rep-
resents the right side of the field. Adjustable ultrasound
variables such as scanning mode, depth of field, and gain
Medial Lateral
are optimized.
Developing and maintaining a predetermined basic scan- N
ning routine is of enormous help in improving operator
confidence and success. The trachea, common carotid and
internal jugular veins and sternocleidomastoid muscle are
identified. The ultrasound transducer is moved laterally to
identify the lateral edge of the sternocleidomastoid muscle. Nerve roots of the brachial plexus
Beneath this muscle edge, the anterior and middle scalene Figure 15.13 Real time imaging of needle insertion for the intersca-
muscles lie with the roots of the brachial plexus between lene block. Needle insertion is on the lateral aspect of the transducer.
(Fig. 15.5). The patient can be asked to sniff to identify the Notice the needle shaft marked with arrows and the needle tip (N) in
close proximity to the nerve roots. N: needle tip; SCM: sternocleidomas-
scalene muscles. Moving the transducer down the neck toid; ASM: anterior scalene muscle; MSM: middle scalene muscle.
facilitates identification of the brachial plexus roots. The
roots will appear as large hypoechoic (dark) structures.
A skin wheal of local anesthetic is raised at the lateral tip is slowly advanced under ‘real-time’ imaging until the
aspect of the ultrasound transducer. The needle bevel needle reaches the side of the target neural structures (Fig.
should face the active face of the transducer to improve 15.13). The operator can slide and tilt the transducer to
visibility of the needle tip. A free-hand technique rather maintain the needle tip within the plane of imaging as
than the use of a needle guide is preferred. A 21-GA × much as possible. Manipulation of the transducer or redi-
50-mm insulated needle (Pajunk, Geisingen, Germany; or rection of the block needle may be necessary to bring the
B. Braun, Bethlehem PA) is inserted parallel to the axis of needle tip into the plane of imaging.
the beam of the ultrasound transducer (Fig. 15.12). The The final needle position can be further confirmed with
needle is attached to sterile extension tubing, which is con- the use of a nerve stimulator (Stimplex; B. Braun, Bethle-
nected to a 20-mL syringe and flushed with local anesthetic hem, PA). Characteristic motor activity in the forearm and
solution to remove all air from the system. The operator hand is seen. An alternate method of needle insertion for
can slide and tilt the transducer to maintain the needle tip the interscalene block can be from the medial aspect of the
within the plane of imaging as much as possible. The needle ultrasound transducer (Fig. 15.14). During the slow serial
125
SCM N ASM SCM N
Carotid
MSM
artery
MSM
Medial Lateral
Medial Lateral
LA
Carotid
artery
ASM Nerve roots of the
brachial plexus
Figure 15.14 Real time imaging of needle insertion for the intersca- Nerve roots of the brachial plexus
lene block. Needle insertion is on the medial aspect of the transducer. Figure 15.15 View of the interscalene space after administration of
Notice the needle shaft marked with arrows and the needle tip (N) in 20 mL of local anesthetic solution, using a high frequency linear trans-
close proximity to the nerve roots. N: needle tip; SCM: sternocleidomas- ducer. The arrows indicate the nerve roots of the brachial plexus sur-
toid; ASM: anterior scalene muscle; MSM: middle scalene muscle. rounded by local anesthetic. LA: local anesthetic; ASM: anterior scalene
muscle; MSM: middle scalene muscle; SCM: sternocleidomastoid
muscle.
injection of the local anesthetic solution, the spread of the
solution can be indirectly confirmed by interscalene space
distention and enhanced nerve borders (Fig. 15.15).
However, if appropriate local anesthetic is not visualized
after a small volume of solution (0.5 to 2 mL) has been
injected, the needle tip should be repositioned. Typically,
smaller volumes of local anesthetic solution are required
for ultrasound-guided interscalene blocks compared to
non-guided techniques. The volume of solution injected is
determined by the spread pattern observed. The needle is
readjusted to allow complete encirclement of the nerve
roots with local anesthetic. Typically in adults, 20 mL of
local anesthetic solution is used. Local anesthetic appears
as a hypoechoic image.
Continuous technique
Continuous interscalene block requires modification of the
single-shot technique in order to facilitate insertion of the
catheter into the brachial plexus sheath. As with other con-
tinuous nerve block techniques, the initial dose of local Figure 15.16 The final needle location on the C6 vertebra and the
foramen that contains the vertebral artery. The cervical roots are poste-
anesthetic is usually injected and only then is the infusion
rior to the vertebral artery.
of a more dilute local anesthetic initiated.
Once the local anesthetic is injected, the catheter is care-
fully inserted some 5 cm beyond the tip of the needle while cal current or 1–2 mL of air, which appears as a white flash
keeping the needle immobile. When the catheter meets on the ultrasound screen.
resistance at the tip of the needle, the needle may be repo- Once the catheter is inserted, the needle is withdrawn
sitioned at a different angle or rotated to facilitate advance- while simultaneously advancing the catheter to prevent its
ment of the catheter. The position of the tip can be dislodgment from the brachial plexus sheath. The catheter
confirmed with ultrasound by either injecting dextrose is secured with a transparent dressing. Ultrasound-guided
water, which does not interfere with conduction of electri- versus neurostimulation-assisted catheter placement is
126
CHAPTER
associated with similar postoperative analgesia but the foramen of the C6 cervical transverse process, not
decreased procedure-related pain and performance time. far from the final needle location with the interscalene
Ultrasound can be used postoperatively to assess continued block. This relation can be seen on the C6 cervical ver-
correct positioning of the catheter. tebra (Fig. 15.16).
• Epidural or subarachnoid injection: high epidural block
or total spinal block, both requiring immediate treat-
Adverse effects ment. Injection in a caudal direction (avoiding horizon-
tal orientation) with short needles reduces this risk. The
• Hoarseness due to block of the recurrent laryngeal nerve. distance from skin to the spinal canal can be as short as
• Unilateral paralysis of the diaphragm due to proximity 0.5 cm.
of phrenic nerve on anterior scalene muscle. • Pneumothorax is unlikely with correct technique.
• Horner syndrome due to stellate ganglion block. • Pressure on the carotid artery is rare and transient due
• Neural injuries are extremely rare. to volume of injectate.
• Local anesthetic toxicity due to intravascular injection
into the vertebral artery or other cervical vessels, leading
rapidly to toxic reactions. The vertebral artery runs in Suggested reading
Borgeat A, Ekatodramis G, Kalberer F, et al. Acute and
nonacute complications associated with interscalene
CLINICAL PEARLS block and shoulder surgery: a prospective study.
Anesthesiology 2001;95:875–880.
• If an upper arm tourniquet is to be used then the interscalene Chan VWS. Applying ultrasound imaging to interscalene
block must be combined with block of the intercostobrachial brachial plexus block. Reg Anesth Pain Med
nerve by subcutaneous injection in the axilla. 2003;28(4):340–343.
• The twitches of the deltoid muscle are sufficient. There does Kapral S, Greher M, Huber G, et al. Ultrasonographic
not seem to be any increase in success rate after obtaining
guidance improves the success rate of interscalene
more distal twitch responses with the landmark-based
neurostimulation approach. brachial plexus blockade. Reg Anesth Pain Med
• In non-ultrasound-guided interscalene blocks, the ulnar nerve is 2008;33(3):253–258.
spared in 50% of cases, therefore it is not an ideal block for Lehtipalo S, Koskinen LO, Johansson G, et al. Continuous
medial elbow, forearm and hand surgery. interscalene brachial plexus block for postoperative
• The brachial plexus roots appear as 1–5 hypoechoic structures. analgesia following shoulder surgery. Acta
• If there is difficulty in visualizing the brachial plexus roots, a Anaesthesiol Scand 1999;43:258–264.
useful tip is to scan inferiorly in the supraclavicular area, where
the brachial plexus can be seen as a bunch of ‘grapes’ lateral to Long TR, Wass CT, Burkle CM. Perioperative interscalene
the subclavian artery. The brachial plexus can then be traced blockade: an overview of its history and current
superiorly to the interscalene region. clinical use. J Clin Anesth 2002;14:546–556.
• Needle placement in the interscalene space is indicated by fluid Perlas A, Chan VWS, Simons M. Brachial plexus
expansion in the space bounded by the hyperechoic fascial
sheath of the anterior and middle scalene muscles
examination and localization using ultrasound and
(hydrodissect). The hypoechoic nerve roots move apart. Incorrect electrical stimulation: A volunteer study.
needle placement will result in intramuscular fluid during Anesthesiology 2003;99:429–435.
hydrodissection and the absence of the above. Winnie AP. Interscalene brachial plexus block. Anesth
Analg 1970;49:455–466.
127
CHAPTER
16
Supraclavicular block
Indications Surface anatomy

Surgical Surgical procedures of the proximal humerus, Important landmarks for the supraclavicular block include
elbow, forearm, and hand. the interscalene groove behind the posterior border of the
Therapeutic Complex regional pain syndrome; postam- sternocleidomastoid muscle, the clavicle, and the subcla-
putation pain; postherpetic neuralgia; tumor-related pain; vian pulse (Fig. 16.2). The interscalene groove can be iden-
vascular diseases and injuries; prolonged postoperative tified by placing a finger behind the sternocleidomastoid
analgesia (continuous technique). muscle and then rolling laterally. Maneuvers to help
identify landmarks include asking the patient to flex their
neck against resistance to identify the sternocleidomastoid
Contraindications muscle. Sniffing accentuates the scalene muscles. The
groove can be followed toward the clavicle. The belly of
Absolute the omohyoid muscle crosses the groove, and 1 cm above
See Chapter 4. the clavicle the subclavian pulse is usually palpated. The
external jugular vein crosses the interscalene groove and
Relative posterior border of the sternocleidomastoid muscle at the
Hemorrhagic diathesis; anticoagulation therapy; local level of the cricoid cartilage. The needle insertion site is
neural injury; contralateral paresis of the phrenic or recur- immediately posterior to the subclavian pulse.
rent laryngeal nerves; and contralateral pneumothorax or If the subclavian pulse is not palpable, needle insertion
pneumonectomy. is 2 cm lateral to the clavicular head of the sternocleido-
mastoid muscle and 2 cm proximal from the clavicle.
Needle insertion should be closer to the palpable middle
Clinical anatomy scalene muscle than to the anterior scalene muscle because
the brachial plexus lies in closer proximity to this muscle.
In the neck, the brachial plexus lies in the posterior triangle
(Fig. 16.1), covered by the investing layer of deep cervical
fascia, platysma, and skin. It is crossed by the supraclavicu-
lar nerves, the inferior belly of the omohyoid muscle, the Sonoanatomy
external jugular vein, and the transverse cervical artery and
vein. It emerges between the anterior scalene and middle The ultrasound transducer should be held between the
scalene muscles; its upper part lies above the third part of thumb, index and ring fingers of the non-dominant hand.
the subclavian artery, while the lower trunk formed by the Placing the little finger and ulnar aspect of the hand on the
union of the eighth cervical and first thoracic nerve roots is patient will stabilize the transducer. Firm even surface pres-
placed behind the artery; the plexus next passes behind the sure with the ultrasound transducer usually produces the
clavicle. best images. Above the clavicle, the ultrasound transducer
DOI: 10.1016/B978-0-7020-3148-9.00024-4
CHAPTER
Supraclavicular block 16
7 5 6
7
4 3
9
2
8 Figure 16.3 The patient is positioned supine with the head turned 45°
to the contralateral side. The ultrasound transducer is positioned in the
posterior triangle of the neck just above the clavicle, with a coronal
oblique orientation.
Figure 16.1 Cadaver structures illustrating anatomy pertinent to the
supraclavicular subclavian perivascular technique. 1: Clavicle; 2: sterno-
cleidomastoid muscle; 3: anterior scalene muscle; 4: middle scalene
muscle; 5: brachial plexus; 6: subclavian artery; 7: transverse cervical
artery and vein; 8: branches of cervical plexus; 9: omohyoid muscle
retracted upward.
SCM
MS
Medial Lateral
AS
R
A
P
Figure 16.4 Supraclavicular sagittal cross-section, at the level of the

first rib, showing the subclavian artery of the supraclavicular region and
identifying hypodense nodular structures in the superoposterior portion
of the subclavian artery, corresponding to the divisions of the brachial
plexus (arrows). (R): first rib; (P): pleura; (A): subclavian artery; (SCM):
sternocleidomatoid muscle; (AS): anterior scalene muscle; (MS): middle
scalene muscle.
Figure 16.2 Landmarks for the supraclavicular block. The posterior
border of the sternocleidomastoid muscle and interscalene groove are
identified. The interscalene groove is followed toward the clavicle. The
subclavian pulse is palpable above the clavicle in the interscalene and inferior primary trunks divide into their anterior and
groove.
posterior branches. The plexus runs superficially at this
level, and high-frequency transducers are thus needed
(10 MHz) to identify the relevant structures (Fig. 16.4).
(38-mm linear array high frequency transducer) is oriented Technical difficulties are encountered in studying the
in a coronal oblique axis to the neck (Fig. 16.3). This is the supraclavicular region due to the presence of the supracla-
transverse ultrasound transducer orientation. Such trans- vicular depression, which complicates both manipulation
verse imaging facilitates identification of nerves and associ- of the ultrasound transducer and needle puncture. First
ated relations. It also allows verification of circumferential locate the subclavian artery. Identify the hyperechoic first
spread of local anesthetic around nerves. A curvilinear rib deep to the subclavian artery and its shadow beneath.
transducer can also be used for this block. Perform a Identify the pleura and air artifact beneath. This is different
systematic anatomical survey from medial to lateral and from the shadow beneath the first rib. The brachial plexus
superficial to deep. is found lateral and posterior to the subclavian artery. The
The supraclavicular ultrasound-guided technique focuses subclavian artery and brachial plexus lie between the
on the supraclavicular fossa, where the superior, middle, scalene muscles.
129
Technique successful block. If the artery is entered initially, the needle

is withdrawn and oriented dorsolaterally.
Incremental injection of local anesthetic is made with
Landmark-based approach
repeated aspiration. For this block, 40 mL of local anes-
As for all regional anesthetic procedures, after checking that thetic is adequate (Fig. 16.7).
intravenous access, ECG, pulse oximetry, and blood pres- Ultrasound-guided approach
sure monitoring are established. Asepsis is observed.
The patient is placed in the supine position with the head Intravenous access, ECG, pulse oximetry and blood pres-
turned away from the side to be blocked. The arm is placed sure monitoring are established. Maximized comfort for the
in view resting on the abdomen. The skin and subcutane- operator and patient is an important step in pre-procedure
ous tissue are infiltrated with local anesthetic. Light seda-
tion may aid patient comfort. The subclavian artery is
palpated above the medial third of the clavicle.
A 35-mm 21-G insulated needle is used. The stimulating
current is set at 1 mA, 2 Hz, and 0.1 ms. Needle orientation
is caudad and parallel to the neck (Fig. 16.5). It is important
to avoid any dorsomedial orientation. At a depth of 1–2 cm
a fascial sheath is entered. The superior trunk of the bra-
chial plexus is usually located first. The needle position is
adjusted while decreasing the current to 0.35 mA with
maintenance of the muscle response.
The response that results in the greatest block success is
muscle contraction below the shoulder. Responses indicat-
ing incorrect needle locations include diaphragmatic con-
traction (the phrenic nerve lies on the anterior scalene – too
anterior a position) and contraction of the posterior com-
partment muscles of the shoulder (suprascapular nerve
Figure 16.6 Supraclavicular block technique: deep insertion. The first
stimulation – too posterior a needle position). Contact rib may be contacted on deep insertion.
with the first rib may occur on deep needle insertion (Fig.
16.6). The subclavian artery lies within the brachial plexus
fascial sheath and injection in its proximity will produce
1 4
4
5
3
Figure 16.5 Supraclavicular block technique: needle orientation. The Figure 16.7 Coronal oblique T1-weighted MR image showing relevant
needle is first inserted immediately posterior to the palpable subclavian anatomy and spread of 40 mL of contrast. Note predominantly caudad
pulse. The needle is held between the thumb and index finger and spread of contrast below the clavicle. 1: sternocleidomastoid muscle; 2:
oriented parallel to the neck and caudally. It is important to avoid any posterior and middle scalene muscles; 3: contrast spread; 4: vertebral
dorsomedial needle orientation. arteries; 5: subclavian artery and brachial plexus divisions.
130
CHAPTER
artery lying on top of the hyperechoic first rib. The pleura

is identified as a hyperechoic fine line outlining the anechoic
lung tissue.
The skin is disinfected with antiseptic solution and
draped. A sterile sheath (CIVCO Medical Instruments,
Kalona, IA, USA) is applied over the ultrasound transducer
between the sterile sheath and the skin. A skin wheal of
local anesthetic is raised at a distance from the lateral aspect
of the transducer to facilitate sterility and allow a shallow
angle of approach to improve needle visualization. An
alternate method of needle insertion for the supraclavicular
block can be from the medial aspect of the ultrasound
transducer. The needle bevel should face the active face of
the transducer to improve visibility of the needle tip. A
Figure 16.8 Global view of the block field for the ultrasound-guided free-hand technique rather than the use of a needle guide
supraclavicular block.
is preferred. A 21-GA × 50-mm insulated needle (B. Braun,
Bethlehem PA) is inserted parallel to the axis of the beam
of the ultrasound transducer (Fig 16.9). For this approach,
preparation. For the ultrasound-guided supraclavicular the operator can slide and tilt the transducer to maintain
block, the patient is placed in the supine position with the needle tip within the plane of imaging as much as pos-
the head turned to the side opposite that to be blocked. The sible. The needle tip is slowly advanced under ‘real-time’
operator stands or sits at the patient’s head, adjacent to the imaging until the needle reaches the side of the target
side to be blocked. The ultrasound screen, transducer, neural structures (Fig 16.10). Manipulation of the trans-
needle, and plane of imaging should all be placed in one ducer or redirection of the block needle may be necessary
view for the operator. For the supraclavicular block, the to bring the needle tip into the plane of imaging. Patients
ultrasound screen is placed below the shoulder on the side tolerate transducer manipulation better than needle redi-
to be blocked (Fig. 16.8). Room lights may be turned down rection. The placement of the needle tip should be very
to enhance image viewing. The operating lights can be used superficial.
to maintain some working lighting in the background. The Once the needle tip has been confirmed by ultrasonogra-
patient is asked to raise their head to identify the inter- phy to lie in close proximity to the brachial plexus, this can
scalene groove. The pulsation of the subclavian artery is be further confirmed by using a nerve stimulator (Stimu-
palpated above the clavicle. plex; B. Braun, Bethlehem PA). Characteristic motor activity
The ultrasound screen should be made to look like the in the forearm and hand is seen. Test injections for assess-
scanning field. That is, the right side of the screen represents ment of local anesthetic spread should be small (0.5 to
the right side of the field. Adjustable ultrasound variables 2 mL). If the local anesthetic spread is not seen on the
such as scanning mode, depth of field, and gain are ultrasound screen, the injection should be stopped. The
optimized. needle is readjusted to allow complete encirclement of
Developing and maintaining a predetermined basic scan- the brachial plexus with local anesthetic (Fig 16.10). Local
ning routine is of enormous help in improving operator anesthetic solution appears as a hypoechoic image. Typi-
confidence and success. Scanning should proceed from a cally, a decreased volume of local anesthetic is required
cephalad to caudad neck position. The trachea, common compared to non-ultrasound-guided supraclavicular blocks.
carotid and internal jugular veins and sternocleidomastoid
muscle are identified. The transducer is moved laterally to Continuous technique
identify the lateral edge of the sternocleidomastoid muscle.
Beneath this muscle edge, the anterior and middle scalene Continuous supraclavicular block is similar to the single-
muscles lie with the roots of the brachial plexus between. shot technique. As with other continuous nerve block tech-
The patient can be asked to sniff to identify the scalene niques, the initial dose of local anesthetic is usually injected
muscles. Moving the transducer in this position down the and only then the infusion of a more dilute local anesthetic
neck facilitates identification of the brachial plexus roots. is initiated. Once the local anesthetic is injected, the catheter
The brachial plexus roots will appear as large hypoechoic is carefully inserted some 5 cm beyond the tip of the cannula
(dark) structures. The brachial plexus roots can be scanned while keeping the cannula immobile. Once the catheter is
to just above the clavicle. Here the brachial plexus is a inserted, the cannula is withdrawn while simultaneously
cluster of hypoechoic nodules lateral to the subclavian advancing the catheter to prevent its dislodgment. The
131
catheter is secured with a transparent dressing. With this

approach, a 2–3-cm tunnel can also help to optimize cath-
eter fixation. The position of the catheter tip is confirmed
by injecting 1–2 mL of air and observing its echodense
spread. Compared to the interscalene approach, this part of
the body is minimally exposed to movement, which
decreases the risk of catheter displacement.
Adverse effects
• Pneumothorax risk is decreased by avoiding any dorso-
medial needle orientation when not using ultrasound
A and mainting the needle in view at all times when using
ultrasound.
• Local anesthetic toxicity due to intravascular injection;
risk decreased by careful aspiration.
CLINICAL PEARLS
• The plexus is closer to the middle scalene than to the anterior
scalene.
• Phrenic nerve block is less likely than with the interscalene
technique because here it is further away on the anterior scalene
muscle.
• Infiltration of the skin and subcutaneous tissue should not be too
deep because the plexus may be quite superficial.
• Provides analgesia and anesthesia for the arm and forearm.
B • Although color Doppler pulsing is not required to identify the
subclavian artery, it greatly facilitates identification of the
Figure 16.9 Ultrasound transducer and needle positioning during the brachial plexus by allowing the differentiation of nerves
ultrasound-guided supraclavicular block. Note the needle orientation in (hypoechogenic in the absence of Doppler effect) from the
the same plane as the ultrasound beam, (A) lateral to medial approach; arterial and venous branches found in the zone (hypoechogenic
(B) medial to lateral approach. with Doppler effect).
• Ultrasound-guided techniques allow visualization of the pleura
and a probable decreased risk of pneumothorax with
supraclavicular blocks.
• Developing and maintaining a predetermined basic scanning
routine is of enormous help in improving operator confidence
and success.
• An alternate method of needle insertion for the supraclavicular
block can be from the medial aspect of the ultrasound
transducer.
• Lymph nodes are hypoechoic, similar to nerves. These may be
N seen in the neck region.
ASM LA • Hypoechoic vessels may be seen in among the brachial plexus in
Medial Lateral the supraclavicular region. Most common is the suprascapular
artery or the transverse cervical artery. Because of similarity in
appearance (both hypoechoic), it is important to differentiate
A the vascular structures from the nerve structures by using color
Doppler.
Figure 16.10 Real-time imaging of needle insertion for the supracla-

Suggested reading
vicular block. Notice the needle shaft marked with arrows and the
needle tip (N) in close proximity to the nerve roots. N: needle tip; ASM: Chan VW, Perlas A, Rawson R, Odukoya O. Ultrasound-
anterior scalene muscle; (A): subclavian artery; LA: local anesthetic. The guided supraclavicular brachial plexus block. Anesth
needle approach here is from medial to lateral. Analg 2003;97(5):1514–1517.
132
CHAPTER
Kapral S, Krafft P, Eibenberger K, et al. Ultrasound-guided anesthesia: a simulation study using magnetic
supraclavicular approach for regional anesthesia of resonance imaging. Anesth Analg 2001;93:442–
the brachial plexus. Anesth Analg 1994;78(3): 446.
507–513. Winnie AP. Plexus anesthesia, Vol. 1. Perivascular
Klaastad O, Smedby O. The supraclavicular lateral para techniques of brachial plexus block. Copenhagen:
vascular approach for brachial plexus regional Schultz; 1983.
133
CHAPTER
17
Suprascapular block
medial aspect of the scapula and followed laterally and

Indications superiorly to the acromion. Two centimeters superior to the
midpoint of the spine of the scapula is the needle insertion
Surgical Surgical procedures on the shoulder as a supple-
point.
mentary analgesic technique.
Therapeutic Shoulder pain; frozen shoulder (to facilitate
physiotherapy).
Sonoanatomy
Contraindications An initial scan is performed in the sagittal orientation at
the superior medial border of the scapula to identify the
Absolute pleura. Scanning proceeds laterally with this transducer ori-
See Chapter 4. entation. Where the scapula moves beyond the lung field
is noted. The ultrasound transducer is now placed parallel
Relative to the scapular spine (Fig. 17.2) such that the scapular spine
Hemorrhagic diathesis; anticoagulation treatment; and is visualized as a superficial hyperechoic line (Fig. 17.3). By
contralateral pneumothorax or pneumonectomy. moving the transducer cephalad the suprascapular fossa is
identified (Fig. 17.4). While imaging the supraspinatus
muscle and the bony fossa underneath, the ultrasound
Clinical anatomy transducer is slowly moved laterally (maintaining a trans-
verse transducer orientation) to locate the suprascapular
The suprascapular nerve receives fibers from the fifth and notch (Fig. 17.5). The suprascapular nerve is seen as
sixth cervical nerve roots. It branches from the superior a round hyperechoic structure at 4–6 cm depth beneath
trunk of the brachial plexus and courses posteriorly or deep the transverse scapular ligament in the scapular notch
towards the scapula. It passes through the suprascapular (Fig. 17.5).
notch under the transverse scapular ligament to enter the
supraspinatus fossa. It then passes around the lateral aspect
of the neck of the scapula into the infraspinous fossa. It
provides sensation to the shoulder and acromioclavicular Technique
joint.
Surface anatomy As for all regional anesthetic procedures, after checking that
the emergency equipment is complete and functional,
The spine of the scapula is the main bony landmark for the intravenous access, ECG, pulse oximetry, and blood pres-
suprascapular block (Fig. 17.1). It can be palpated from the sure monitoring are established. Asepsis is observed.

DOI: 10.1016/B978-0-7020-3148-9.00025-6
CHAPTER
Suprascapular block 17
TM
SM
Figure 17.1 Landmarks for the suprascapular block. The patient is

placed in the sitting or standing position with the hand of the side to SF
be blocked placed on the opposite shoulder. This draws the scapula off
the chest wall and decreases the risk of pneumothorax. The spine and
medial border of the scapula are identified and marked. The midpoint
of the spine of the scapula is located; 2 cm superiorly is the needle
insertion point. Figure 17.4 Transverse view of suprascapular fossa with a 6–13 MHz
linear transducer. TM: trapezius muscle; SM: supraspinatus, SF: scapular
fossa.
Subcutaneous tissue
Trapezius
Figure 17.2 Ultrasound transducer placed along the scapular spine.

Supraspinatus
Transverse
scapular ligament
SS Coracoid
process
Suprascapular nerve
Figure 17.5 Transverse view of suprascapular notch with a 6–

13 MHz linear transducer.
The block is performed with the patient in the sitting or

standing position, with the hand of the side to be blocked
resting on the contralateral shoulder (Fig. 17.6). The opera-
tor stands behind the patient. To reduce the risk of pneu-
mothorax, as short a needle as practical is used. Needle
Figure 17.3 Superficial hyperechoic line representing the scapular orientation is caudad and posterior. The needle is advanced
spine (SS). until bony contact is made, withdrawn slightly, and 10 mL
135
Figure 17.6 Suprascapular block technique. The needle is inserted

caudally and slightly posteriorly. Figure 17.8 Global view of the ultrasound-guided suprascapular block.
Figure 17.7 Suprascapular block technique. On bony contact, the

needle is withdrawn 1–2 mm and 6–8 mL of local anesthetic is injected.
Note the needle does not enter the suprascapular notch. Figure 17.9 Ultrasound transducer and needle orientation for the
ultrasound-guided suprascapular block.
of local anesthetic injected after careful aspiration (Fig.

17.7). It is not necessary to locate the scapular notch nor Room lights may be turned down to enhance image viewing.
to elicit paresthesia because these increase the risk of pneu- The operating lights can be used to maintain some working
mothorax and nerve injury. lighting in the background.
The ultrasound screen should be made to look like the
Ultrasound-guided approach scanning field. That is, the right side of the screen represents
the right side of the field. Adjustable ultrasound variables
Intravenous access, ECG, pulse oximetry and blood such as scanning mode, depth of field, and gain are
pressure monitoring are established. Maximized comfort optimized.
for the operator and patient is an important step in pre- Developing and maintaining a predetermined basic scan-
procedure preparation. For the ultrasound-guided supra- ning routine is of enormous help in improving operator
scapular block, the patient is placed in the sitting position. confidence and success. A 21-gauge, 50-mm b-bevel needle
The operator stands adjacent to the side to be blocked. The (Stimuplex; B. Braun, Bethlehem, PA) is inserted along the
ultrasound screen, transducer, needle, and plane of imaging longitudinal axis of the ultrasound beam (Fig. 17.9). This
should all be placed in one view for the operator. For the needle was chosen due to its good ultrasound visibility. The
suprascapular block, the ultrasound screen is placed in needle is visualized in its full course. The endpoint for
front of the shoulder on the side to be blocked (Fig. 17.8). injection was an ultrasound image demonstrating the
136
CHAPTER
Suprascapular block 17
taneously advancing the catheter to prevent its dislodg-

Subcutaneous tissue ment. The catheter is secured with a transparent dressing.
The catheter can be tunneled superiorly to a non-mobile
site on the back to prevent dislodgment. Patient and staff
Trapezius
should be warned that the shoulder will be asensate during
infusion. Attention should be paid to same during mobili-
zation and physiotherapy.
LA spread
at needle tip Adverse effects
Hematoma due to suprascapular artery or vein puncture is
Supraspinatus rare. Pneumothorax is rare, especially if the suprascapular
notch is not entered.
CLINICAL PEARLS
Transverse
• Excellent block for analgesia of the shoulder.
scapular ligament
• Easy to learn.
• The suprascapular nerve can be blocked where it leaves the
Figure 17.10 Real-time imaging of needle insertion for the ultrasound- brachial plexus in the neck. A good focus to identify the nerve
guided suprascapular block. Local anesthetic is injected deep to the here is the inferior belly of the omohyoid muscle.
scapular ligament. • The suprasacapular nerve can be identified with ultrasound in
the suprascapular fossa after it has passed through the
suprascapular notch. The transducer is oriented perpendicular to
the course of the nerve. The nerve will be seen in the floor of the
needle tip in proximity to the suprascapular nerve in the suprascapular fossa.
suprascapular notch (Fig. 17.10). The injection and spread
of local anesthetic (4–6 mL) is visualized.
Suggested reading
A continuous anesthesia technique is possible. A technique
similar to the single-injection technique described can be Harman D, Hearty C. Ultrasound-guided suprascapular
used. An 18-G Tuohy needle is inserted caudally and pos- nerve block technique. Pain Physician 2007;10(6):
teriorly from a puncture site 2 cm cephalad from the mid- 743–746.
point of the spine of the scapula. On bony contact, the Wasseff MR. Suprascapular nerve block. A new approach
needle is withdrawn slightly and a catheter threaded for the management of frozen shoulder. Anesthesia
through the needle. The needle is withdrawn while simul- 1992;47:120–123.
137
CHAPTER
18
Vertical infraclavicular block

Surgical Surgical procedures at the elbow, forearm, and Important bony landmarks are the clavicle, anterior aspect
hand. of the acromion, the suprasternal notch, and the spine of
Therapeutic Complex regional pain syndrome; postam- the scapula. The distance between the suprasternal notch
putation pain; vascular disease and injuries; tumor-related and anterior aspect of the acromion is measured and
pain; prolonged postoperative analgesia (continuous divided equally to find the needle insertion point, inferior
technique). to the clavicle (Fig. 18.2). Recent studies have shown that
the optimal site in females may be 0.8 cm lateral to the
midpoint. In adults, this distance is usually greater than
Contraindications 17 cm. A healed fractured clavicle will change the relations
of this insertion point and is thus a relative contraindica-
Absolute tion for performing this block without ultrasound.
See Chapter 4. It may be difficult to locate the anterior aspect of the
acromion. This can be facilitated by locating the spine of
Relative the scapula and tracing its border forward to the most ante-
Hemorrhagic diathesis; anticoagulant therapy; local neural rior bony prominence. This point can be confirmed as the
injury; risk of compartment syndrome; and distorted anterior prominence of the acromion by asking the patient
anatomy (due to previous surgery or trauma, e.g. fractured to raise the arm. The bony prominence of the acromion will
clavicle). not move, unlike the head of the humerus.
The needle insertion point is lateral to the apex of
the lung (Fig. 18.3). This can be confirmed by palpating the
Clinical anatomy subclavian artery both above the clavicle and medial to the
needle insertion point.
The brachial plexus passes behind the clavicle to enter the
axilla. Here it lies laterally to the subclavian vessels and
dome of the lung (Fig. 18.1). Above the clavicle, the trunks
have formed divisions that continue to form the cords of Sonoanatomy
the plexus in the axilla.
The plexus lies deep to skin, pectoralis major, and the The ultrasound-guided infraclavicular technique is per-
clavipectoral fascia. The origin of the lateral cord lies most formed over the pectoral region. In view of the increased
superficially. Deeper and slightly laterally, the plexus forms depth at which the brachial plexus is found at this level
a tight arrangement, making this site a good one for achiev- with respect to other techniques, the ultrasound transducer
ing a comprehensive block of the plexus. The plexus lies should be of lower frequency (4–7 MHz). Scanning is
approximately 2–4 cm from the skin in adults. performed laterally in proximity to the coracoid process
DOI: 10.1016/B978-0-7020-3148-9.00026-8
CHAPTER
Vertical infraclavicular block 18
2 1
3
6 5
4 1
2
3
5
vertical infraclavicular block technique. 1: Sternal notch; 2: clavicle; 6
3: anterior aspect of the acromion; 4: pleural cavity; 5: subclavian artery; 4
6: brachial plexus.
Figure 18.3 Axial oblique T1-weighted MR image showing anatomy

relevant to the vertical infraclavicular block. 1: Injection point; 2: clavicle;
3: superomedial; 4: inferolateral; 5: brachial plexus; 6: apex of lung.
Figure 18.2 Landmarks for the vertical infraclavicular block. The supra-
sternal notch and anterior aspect of the acromion are marked. The
measured distance between these points is divided equally to find the
needle insertion point. The subclavian artery can be palpated above
the clavicle and medial to the needle insertion point.
(Fig 18.4). The ultrasound transducer (curvilinear, held in

a sagittal orientation) is placed near the lower edge of the
clavicle, and a transverse view (parasagittal plane) of the Figure 18.4 Orientation of the ultrasound transducer when perform-
ing the infraclavicular block. It is orientated in a sagittal plane.
axillary artery and vein is obtained (Fig 18.5). A good alter-
native is to use a small curved transducer for infraclavicular
scanning since it provides a wider field of view and more
space for needle insertion. However, phased array or linear (tilt) the transducer slightly in the parasagittal plane to
transducers can also be used. Care should be used not to check if this hyperechoic structure stays in the same loca-
apply too much downward pressure on the transducer, tion. If it does not, this is not likely to be a nerve structure.
which may occlude the axillary vein. The Doppler options The pleura or chest wall is identified as a hyperechoic fine
facilitate identification of the vascular structures. line outlining the anechoic lung tissue if the transducer is
Perform a systematic anatomical survey from superficial moved medially. It can be seen to move with respiration.
to deep. The pectoralis major and minor muscles are most The plexus is usually found at a depth of 2–6 cm. The cords
superficial and easily identified. Identify the axillary artery of the plexus are located adjacent to the artery in medial,
and vein deep to the pectoralis minor muscle. The vein is lateral and posterior positions (Fig 18.5). Upper limb posi-
almost always caudad to the artery. Look for hyperechoic tion does influence these relationships. Arm abduction to
nerve structures around the axillary artery. Hyperechoic 90° will bring the three cords closer together and will
density posterior to the axillary artery can be due to ‘acous- enhance nerve visualization. The pectoralis major, pectora-
tic enhancement’, an artifact generated when the ultrasound lis minor muscles and clavipectoral fascia are visualized
beam crosses a vessel with little acoustic impedance. Angle and further identified by appropriate resisted movements.
139
Res
Anterior
PMJ
PMN
AA
CP
Caudad
M P
5.1
Figure 18.5 Transverse view of the infraclavicular (IFC) part of the Figure 18.6 Vertical infraclavicular block technique. The needle
brachial plexus (lateral approach), using a 4–7 MHz curvilinear trans- (50 mm) is first inserted perpendicular to the patient trolley with no
ducer. PMN: pectoralis minor muscle; PMJ: pectoralis major muscle; CP: medial orientation.
clavipectoral fascia; AA: axillary artery, V: axillary vein. M: medial cord;
L: lateral cord; P: posterior cord.
1
Technique 2
3
4
Landmark-based approach 6
4 7
As for all regional anesthetic procedures, after checking that 5
intravenous access, ECG, pulse oximetry, and blood pres-
The patient is placed supine, with the upper arm at
the side of the body and the hand resting on the abdomen;
the head is rotated slightly to the opposite side. The
needle insertion site is anesthetized. A 50-mm 21-G insu-
lated needle is used. The stimulating current is set at 1 mA, Figure 18.7 Coronal oblique T1-weighted MR image after injection of
2 Hz, and 0.1 ms. The needle is advanced vertically, per- 30 mL of contrast, showing spread of contrast predominantly inferolat-
pendicular to the patient trolley rather than to the chest erally toward the axilla. Little contrast spreads superomedially.
wall (Fig. 18.6), until the appropriate muscle response is No contrast is seen above the clavicle. 1: Acromion; 2: coracoid;
obtained. The needle position is adjusted while reducing 3: clavicle; 4: contrast spread; 5: axillary artery; 6: brachial plexus cords;
7: subclavian artery.
the current to 0.35 mA with maintenance of the muscle
response.
Elbow flexion (musculocutaneous nerve) is often seen Ultrasound-guided approach
first. Advancing the needle deeper and slightly laterally
results in distal muscle responses; movement of the wrist Intravenous access, ECG, pulse oximetry and blood pres-
or fingers indicates an optimum needle position. Pectoralis sure monitoring are established. The patient lies supine,
contraction indicates too medial a needle position. Deltoid with the upper limb abducted at 90° to the body. This
contraction is not acceptable because it is due to stimula- moves the plexus away from the chest wall and the needle
tion of the axillary nerve, which runs outside the plexus advanced in the sagittal plane is unlikely to encounter the
sheath. rib cage. It also makes the plexus more compact. The head
The plexus is usually found at a depth of 2–4 cm. Incre- is rotated slightly to the opposite side. The operator stands
mental injection of local anesthetic is made with repeated on the side to be blocked, at the head of the patient
aspiration. For this block, 40 mL of local anesthetic is suf- (Fig 18.8). The ultrasound screen should be placed on the
ficient (Fig. 18.7). side of the block below the shoulder.
140
CHAPTER
Figure 18.8 Global view of the block field for the ultrasound-guided Figure 18.10 Ultrasound transducer and needle positioning during
infraclavicular block. ultrasound-guided infraclavicular block. Note: the needle orientation is
in the same plane as the ultrasound beam.
USA) is applied over the ultrasound transducer with sterile

ultrasound gel (Aquasonic, Parker Laboratories, Fairfield,
NJ, USA). Another layer of sterile gel is placed between the
sterile sheath and the skin. A skin wheal of local anesthetic
is raised at a distance from the transducer to facilitate steril-
ity and allow a shallow angle of approach to improve needle
visualization. The needle entry site is 1–2 cm cephalad to
the final curvilinear transducer position (Fig 18.10). A
25-gauge needle is advanced under real-time ultrasound
guidance and local anesthetic is deposited along the needle
entry path. A 17-G Tuohy needle is used in a free-hand
technique. This needle is chosen as it gives good tissue feel
and has advantages for ultrasound visualization. The needle
without stylet is connected to sterile extension tubing
attached to a stopcock and two 20-mL syringes, and flushed
with local anesthetic to remove all air from the system.
Figure 18.9 After obtaining best image of the cords the footprint of
The Tuohy needle is introduced and not advanced until
the transducer is marked with a skin marker. Outline of transducer
marked as T. A line marked through middle of footprint, a cross on line visualized. This may require needle or transducer adjust-
marked N = needle entry site. C: coracoid process; CL: clavicle. ment. Advance the needle at a 45–60° angle from the cepha-
lad end of the ultrasound transducer along its long axis in
the caudad direction. The goal is to deposit local anesthetic
The deltopectoral region is scanned with a 4–7 MHz around all three cords of the brachial plexus. Local anes-
ultrasound transducer. Developing and maintaining a pre- thetic injected posterior to the axillary artery resulting in a
determined basic scanning routine is of enormous help in U shape spread around the artery is associated with com-
improving operator confidence and success. Start scanning plete blockade of the arm, forearm and hand (Fig. 18.11).
on a line drawn from the mid-clavicular point to the axil- Consistent success is associated with local anesthetic spread
lary pulse to obtain an image of the axillary artery and vein. posterior to the axillary artery and a radial nerve type stimu-
Adjustable ultrasound variables such as scanning mode, lation, while inconsistent block is associated with spread
depth of field, and gain are optimized. Move the transducer anterior to the axillary artery and a median nerve type stimu-
cephalad or caudad to bring the axillary artery to the centre lation. In practice, it is best to inject the first 10–15 mL of
of the image. Then start sliding the transducer laterally local anesthetic posterior to the artery in the 6 o’clock posi-
while maintaining the axillary artery in the centre of the tion (posterior cord). Then inject further as the needle is
image to a point when the three cords wrap around the withdrawn to the 9 o’clock position (lateral cord). If spread
artery on three sides. If you go further laterally, two branches to the 3 o’clock position it is deemed inadequate; it may be
from the medial and lateral cords are seen lying anterior to necessary to separately place the block needle between the
the axillary artery, and further laterally, they join to form axillary artery and vein to access the medial cord.
the median nerve. The outline of the ultrasound transducer A more medial approach to the one described above can
is marked on the skin (Fig 18.9). also be used. In this approach, the plexus is arranged above
The skin is disinfected with antiseptic solution and draped. the subclavian artery as it passes beneath the clavicle (Fig
A sterile sheath (CIVCO Medical Instruments, Kalona, IA, 18.12). The pleura will be in the scanning field and the
141
Res
PMN Anterior PMJ
CPF
AV
Caudad

ultrasound-guided infraclavicular block (medial approach). Note the
needle orientation perpendicular to the ultrasound beam.
M
NT AA
Figure 18.11 Transverse view of the infraclavicular part of the brachial

plexus, using a 4–7 MHz curvilinear transducer. PMN: pectoralis minor
muscle; PMJ: pectoralis major muscle; CPF: clavipectoral fascia; AA: axil- AxA
lary artery; AV: axillary vein; M: medial cord; NT: needle tip; LA: local
anesthetic is injected posterior to the axillary artery. Arrows indicate
needle shaft. AxV
PMJ
CPF
M
AV AA BP
Caudad Cephalad
P
P
L
Figure 18.14 Transverse view of the infraclavicular part of the brachial

plexus. Catheter tip is placed between posterior cord and axillary artery.
AxA: axillary artery; AxV: axillary vein; M: medial cord; L: lateral cord;
Figure 18.12 Transverse view of the infraclavicular (IFC) part of the P: posterior cord. Arrows outline the catheter.
brachial plexus at the median IFC level, using an 8–12 MHz linear trans-
ducer. PMJ: pectoralis major muscle; CPF: clavipectoral fascia; AA: axillary
artery; AV: axillary vein; BP: brachial plexus; P: pleura. catheter is secured with a transparent dressing. With this
approach, a 2–3-cm tunnel medially can also help to opti-
pectoralis minor muscle will not be seen. A short axis mize catheter fixation. This part of the body is minimally
approach can be used here (Fig 18.13). Aiming in a medial exposed to movement, which makes this block ideal for a
to lateral orientation is probably safer in trying to avoid continuous technique. Although the approach to this block
the pleura. is perpendicular to the plexus, catheter placement in prac-
tice is not a problem, especially if a stimulating Tuohy
needle is used.
The position of the catheter tip is confirmed by injecting
Continuous infraclavicular block is similar to the single- 1–2 mL of air and observing its echodense spread around
shot technique. As with other continuous nerve block the posterior cord (Fig 18.14). A multi-orifice catheter
techniques, the initial dose of local anesthetic is injected should not be used, as the local anesthetic will flow prefer-
and only then is the infusion of a more dilute local anes- entially from an orifice located in low resistance tissue.
thetic initiated. This facilitates block onset and catheter
placement.
After the local anesthetic is injected, the catheter is care- Adverse effects
fully inserted some 5 cm beyond the tip of the cannula
while keeping the cannula immobile. Once the catheter is • Unilateral paralysis of the diaphragm due to phrenic
inserted, the cannula is withdrawn while simultaneously nerve block (less likely than with the supraclavicular
advancing the catheter to prevent its dislodgment. The approach).
142
CHAPTER
• Horner syndrome due to stellate ganglion block. These • Local anesthetic toxicity due to intravascular injection;
are unusual because local anesthetic rarely passes above risk decreased by avoiding medial orientation of the
the clavicle. needle.
• Neural injury is extremely rare. • Pneumothorax is more likely in smaller, overweight
patients. Particular attention must be paid to avoiding
medial needle deviation and not using a needle greater
than 50 mm in length.
CLINICAL PEARLS Suggested reading

Landmark- based approach
Arcand G, Williams SR, Chouinard P, et al. Ultrasound-
• Correct identification of the anterior aspect of the acromion
is important. It is useful to follow the spine of the scapula
guided infraclavicular versus supraclavicular block.
anteriorly to the acromion. A finger resting on the acromion Anesth Analg 2005;101(3):886–890.
will not move as the patient flexes his or her shoulder. Bigeleisen P, Wilson M. A comparison of two techniques
• Practice locating this important landmark. for ultrasound-guided infraclavicular block. BJA
• If the musculocutaneous nerve is stimulated, moving the 2006;96(4):502–507.
needle a little more laterally will enter the main part of the
plexus.
Greher M, Retzel G, Niel P, et al. Ultrasonographic
• If the plexus is not located by 4 cm, the block should be assessment of topographic anatomy in volunteers
reattempted a little more laterally (0.5–1 cm); do not move suggests a modification of infraclavicular vertical
medially because this will increase the risk of vessel brachial plexus block. BJA 2002;88(5):632–636.
puncture and pneumothorax. Kilka HG, Geiger P, Mehrkens HH. Die vertikale
• This approach is excellent for a continuous technique. infraklavikulare Blockade des Plexus brachialis.
Ultrasound-guided approach Anaesthesist 1995;44:339–344.
• Advantages of ultrasound- guided infraclavicular block include:
Klaastad O, Lilleas FG, Rotnes JS, et al. A magnetic
• Decreased risk of pneumothorax
resonance imaging study of modifications to the
• Successful block can be achieved with a decreased volume infraclavicular brachial plexus block. Anesth Analg
of local anesthetic solution. 2000;91:929–933.
• The block can be repeated in the same area, unlike the Sandhu NS, Manne JS, Medabalmi PK, et al.
unguided nerve stimulation technique Sonographically guided infraclavicular brachial plexus
• Vascular puncture less likely. block in adults: a retrospective analysis of 1146 cases.
J Ultrasound Med 2006;25(12):1555–1561.
143
CHAPTER
19
Axillary block

Surgical Surgical procedures on the forearm and hand; For all blind techniques of axillary brachial plexus block,
lower arm surgery may also require block of the musculo- palpation of the axillary pulse is paramount. The needle
cutaneous nerve. insertion point is located proximally along the line of the
Therapeutic Complex regional pain syndrome; posther- axillary pulse. Abduction and external rotation of the shoul-
petic neuralgia; postamputation pain; vascular diseases and der and flexion of the elbow bring the axilla into view. The
injuries; prolonged postoperative analgesia (continuous anterior axillary fold is formed by the pectoralis major
technique). muscle, with the posterior axillary fold by latissimus dorsi
and teres major muscles. The pulsation of the lower part of
the axillary artery can be felt by palpating the medial side
Contraindications of the arm just in front of the posterior axillary fold. In very
muscular individuals, it may be necessary to decrease the
Absolute degree of abduction to palpate the artery. The pulsation is
See Chapter 4. followed proximally and marked.
With single-injection techniques, it is important to iden-
Relative tify the axillary pulse as far proximal in the axilla as pos-
Hemorrhagic diathesis; anticoagulation treatment; and sible. This will increase the success rate for musculocutaneous
upper arm fractures or other conditions preventing abduc- nerve block with the single-injection technique. The belly
tion of the arm, such as frozen shoulder. of the coracobrachialis muscle should be identified because
its infiltration will block the musculocutaneous nerve.
Clinical anatomy
Sonoanatomy
At the site of axillary block the terminal nerves of the bra-
chial plexus form a particular pattern with the axillary artery In ultrasound scanning of the axillary brachial plexus, the
(Fig. 19.1). Around the second part of the artery – the divi- patient is positioned supine with the arm abducted 90° on
sions being produced by the pectoralis minor muscle – the an arm board. A linear 6–13 MHz ultrasound transducer is
median nerve lies anteriorly, the radial nerve posteriorly, used. Begin the examination by scanning the upper arm in
and the ulnar nerve posteromedially (Fig. 19.2). The axil- the axilla just distal to the border of the pectoralis muscle.
lary vein lies more medial. The musculocutaneous nerve A transverse or short-axis view is used. Perform a systematic
has left the fascial sheath at the level of the coracoid and is anatomical survey from superficial to deep and above and
thus unlikely to be anesthetized with single-injection axil- below the axillary artery. Identify the humerus and the
lary technique. The medial cutaneous nerve of arm and the triceps, biceps and coracobrachialis muscles. Identify the
intercostobrachial nerve lie subcutaneously. pulsatile axillary artery. Decrease transducer pressure to
DOI: 10.1016/B978-0-7020-3148-9.00027-X
CHAPTER
Axillary block 19
M
AxV
U
AxA
5
3 1
R
4 2
Figure 19.1 Cadaver structures illustrating characteristic location of

nerves to axillary artery. 1: axillary artery; 2: radial nerve; 3: median nerve;
4: ulnar nerve; 5: musculocutaneous nerve; 6: axillary vein.
Figure 19.3 Transverse view of the axillary part of the brachial plexus
using a 6–13 MHz linear transducer. The arrows indicate the brachial
plexus reflected as hypoechoic structures. AxA: axillary artery; AxV: axil-
HLA
lary vein; R: radial nerve; M: median nerve; U: ulnar nerve.
BiM BM
Artery
MN AxA
Radial Superior Inferior

AR
PL
Median
H
Ulnar
Figure 19.4 Transverse view of the musculocutaneous nerve using
a 6–13 MHz linear transducer. AxA: axillary artery; BiM: biceps muscle;
BM: brachialis muscle; H:humerus; MN: musculocutaneous nerve.
FRP towards the apex of the axilla, the musculocutanous nerve

can be traced to its origin from the lateral cord (Fig. 19.4).
Figure 19.2 Sagittal T1-weighted MR image of the axilla after injection
of 10 mL of contrast, highlighting the arrangement of the nerves around Distally, it diverges from the axillary artery to travel in the
the axillary artery. coracobrachialis muscle. The axillary nerve also originates
from the posterior cord and can be seen going cephalad
towards the surgical neck of the humerus. By moving the
allow axillary veins to expand and be identified. The ultrasound transducer distally, the radial nerve can be
Doppler options facilitate identification of the vascular traced winding around the humerus.
structures, thereby contributing to minimizing vascular
puncture. The nerves lie in a close relationship to the axil-
lary artery near the apex of the axilla, before they start Technique
diverging. There is considerable variation in their relation-
ship to the artery and they are very mobile; slight pressure Landmark-based approach
of the transducer can displace the nerves. The nerves appear
as hypoechoic structures with a hyperechoic circumference As for all regional anesthetic procedures, after checking that
(Fig. 19.3). By sliding the ultrasound transducer proximally the emergency equipment is complete and functional,
145
Figure 19.6 Axillary block technique. The needle is first inserted ante-
rior to the palpable axillary pulse. The needle is oriented to follow the
course of the neurovascular bundle.
Figure 19.5 The axillary block. The patient is placed in the supine posi-
tion, with the arm abducted and forearm flexed to 80° and parallel to
the long axis of the body.

The patient lies supine with the arm abducted (80°) and
the elbow flexed (90°; Fig. 19.5). Hyperabduction should
be avoided because it can make palpation of the artery dif-
ficult and distort the distribution of local anesthetic. The
axillary artery is palpated as far proximally as possible
under the lateral edge of the pectoralis major muscle, and 1
fixed with the index and middle fingers. A 35-mm 21-G 2
insulated stimulating needle is used. The stimulating current
is set at 1.0 mA, 2 Hz, and 0.1 ms. The needle is advanced
proximally at an angle of 30° in the direction (Fig. 19.6)
of the neurovascular sheath. Entry of the needle into the 3
neurovascular sheath is confirmed by a ‘fascial click’. The
needle is advanced slowly until the appropriate muscle
response is obtained. 3
Stimulation of the median nerve produces flexion of the
middle and index fingers, thumb, and pronation and Figure 19.7 Axial oblique T1-weighted MR image showing spread of
flexion of the wrist. Stimulation of the ulnar nerve produces contrast outside and away from the axillary sheath. This followed excel-
flexion of the ring and little fingers with ulnar deviation of lent median nerve stimulation down to 0.5 mA and insertion of cathe-
ter. This suggests that perhaps 0.5 mA is too high a current to be sure
the wrist, while stimulation of the radial nerve will produce that the needle is inside the axillary sheath. 1: brachial plexus and axillary
dorsiflexion of the fingers and wrist. Finger flexion alone in vessels; 2: nerve sheath; 3: contrast spread.
the case of the ring and little fingers could represent either
ulnar or median stimulation. The needle position is adjusted
while decreasing the current to 0.30 mA with maintenance injection technique is used, 10 mL at each site is adequate.
of the muscle response (Fig. 19.7). A muscle response in The stimulating current needs to be increased for the second
the upper arm should not be accepted. Individual nerves and subsequent nerves because the previously injected local
can be targeted and located with ease. Ideally, the nerve(s) anesthetic will increase the electrical resistance in the area.
supplying the area of surgery should be sought. To increase the likelihood of blocking the musculocutane-
Incremental injection of the local anesthetic is made with ous nerve, digital pressure is maintained distal to the site
repeated aspiration. To block terminal nerves of the plexus, of injection to encourage proximal spread of the local anes-
40 mL of local anesthetic is sufficient. If a multiple- thetic within the axillary sheath; a tourniquet may be used
146
CHAPTER
Axillary block 19
2 1
3
Figure 19.10 Intercostobrachial block technique. A subcutaneous

injection (5–6 ml) in the axilla will anesthetize the intercostobrachial
and medial cutaneous nerve of arm.
from the medial cord of the brachial plexus. Block of both

Figure 19.8 Coronal T1-weighted MR image after injection of 40 mL nerves can be achieved with a subcutaneous injection of
of contrast. Injection was made without distal pressure being applied.
local anesthetic in the medial aspect of the upper arm (Fig.
1: profunda brachii artery; 2: radial nerve; 3: median nerve.
19.10). Injection should be made from the biceps muscle
to the triceps muscle.
Musculocutaneous nerve block

The musculocutaneous nerve (C5, 6) is a branch of the
2
lateral cord of the brachial plexus. It leaves the brachial
plexus fascial sheath at the level of the coracoid process,
1 pierces the coracobrachialis muscle, and then runs between
the biceps and brachialis muscles in the arm. It passes
through the antecubital fossa deep to the biceps tendon and
continues as the lateral cutaneous nerve of the forearm. It
supplies motor fibers to the coracobrachialis muscle, the
biceps muscle, and brachialis muscles. It is the sensory
supply of the skin covering the radial aspect of the lower
two-thirds of the forearm.
The musculocutaneous nerve can be blocked as part of
an infraclavicular technique using the vertical infraclavicu-
lar or coracoid approaches (see Ch. 18). An injection into
the body of the coracobrachialis will also anesthetize it
Figure 19.9 Coronal T1-weighted MR image 30 min post injection of
40 mL of contrast. Note the spread is almost entirely away from the
without the need to elicit paresthesia or a motor response.
axilla, two-thirds of the length of the upper arm. 1: biceps muscle; 2: It can be blocked as part of the midhumeral approach (see
deltoid muscle. Ch. 20). The lateral cutaneous nerve of the arm can be
blocked at the elbow by an injection just lateral to the
tendon of the biceps at the elbow crease. A 23-G needle is
for a similar effect (Figs 19.8 and 19.9). The arm is then inserted to a depth of 2–3 cm and injection of 4 mL of local
placed across the chest. anesthetic is made.
If an upper arm tourniquet is to be used, additional block
of the intercostobrachial nerve and medial cutaneous nerve Ultrasound-guided approach
of the arm is of value to reduce the cutaneous element of
the pain due to the tourniquet. The intercostobrachial nerve Intravenous access, ECG, pulse oximetry and blood pressure
is the lateral cutaneous branch of the second intercostal monitoring are established. For the ultrasound-guided axil-
nerve. The medial cutaneous nerve of the arm originates lary block, the patient is placed in the supine position with
147

the ultrasound-guided axillary block. Note the needle orientation paral-
lel to the plane of the ultrasound beam.
Figure 19.11 Global view of the block field for the ultrasound guided The skin is disinfected with antiseptic solution and
axillary block.
between the sterile sheath and the skin. A skin wheal of
local anesthetic is raised at a distance from the transducer
to facilitate sterility and allow a shallow angle of approach
to improve needle visualization.
Long axis approach

A 21-GA × 50-mm insulated needle or 2-inch Tuohy needle
(18-G) is inserted parallel to the axis of the beam of the
ultrasound transducer (Fig. 19.13). The needle is intro-
Figure 19.12 Orientation of the ultrasound transducer when perform-
duced vertically down, either through the lateral part of the
ing the ultrasound-guided axillary block.
pectoralis major, or biceps brachii, or coracobrachialis
muscles. The operator can slide and tilt the transducer to
the upper limb to be blocked abducted to 90° and flexed maintain the needle tip within the plane of imaging as
at the elbow, with the hand resting adjacent to the head. much as possible. The needle tip is slowly advanced under
The operator stands or sits adjacent to the side to be blocked. ‘real-time’ imaging to bring the needle tip to rest just deep
For the axillary block, the ultrasound screen is placed below to the axillary artery and adjacent to the radial nerve. A dual
the shoulder on the side to be blocked (Fig. 19.11). injection technique in which local anesthetic solution is
The ultrasound transducer is placed on the skin perpen- injected both deep (radial nerve) and superficial (median
dicular to the long axis of the axillary artery, vein, and the and ulnar nerves) to the axillary artery should be employed.
elements of the brachial plexus (transverse plane) (Fig. Once the needle tip has been confirmed by ultrasonogra-
19.12). The round, pulsatile axillary artery is identified, and phy to lie in close proximity to the median, ulnar or radial
then minor adjustments are made to obtain a view of nerves, this can be confirmed by using a nerve stimulator
accompanying neuronal structures. The axillary vein will be (Fig 19.14). Characteristic motor activity in the hand is
more compressible than the axillary artery and generally seen. Test injections for assessment of local anesthetic
possesses a thinner vessel wall. Minimal pressure should be spread should be small (0.5 to 2 mL). If the local anesthetic
exerted on the ultrasound tranducer to identify veins. spread is not seen on the ultrasound screen, the injection
Typically, only one or sometimes two branches of the should be stopped. The needle is readjusted to allow com-
axillary brachial plexus may be seen on any particular view. plete encirclement of the nerves with local anesthetic. Local
However, a systematic examination of the entire axillary anesthetic appears as a hypoechoic image (Fig 19.15). Typi-
brachial plexus may be made by sliding the transducer cally, a decreased volume of local anesthetic is required
slowly from medial to lateral, and up and down the arm, compared to non-ultrasound-guided axillary blocks. Lido-
while the ultrasound transducer is oriented perpendicular caine, 2%, with epinephrine 1 : 200 000 and sodium bicar-
to the axillary artery, and as a result, sequentially viewing bonate 8.5% solution (1/10 mL of solution) 5–10 mL per
the median, radial, ulnar and musculocutaneous nerves. nerve to a maximum of 40 mL may be used. Other longer
148
CHAPTER
Axillary block 19
N
MN LA AxA
Superior Inferior
AxA
Figure 19.16 Transverse ultrasound image in the axillary location

showing the circumferential local anesthetic and the musculocutane-
ous nerve using a 6–13 MHz linear transducer. LA: local anesthetic;
AxA: axillary artery; MN: musculocutaneous nerve.
Figure 19.14 Real-time imaging of needle insertion for the long axis
approach of ultrasound-guided axillary block. Notice the needle shaft
marked with arrows and the needle tip (N) in close proximity to the
brachial plexus. N: needle tip; AxA = axillary artery.
N
UN
MN AxV
LA AxA Figure 19.17 Ultrasound transducer and needle positioning during
Superior Inferior
ultrasound-guided axillary block. Note the needle orientation perpen-
dicular to the plane of the ultrasound beam.
subcutaneous wheal is raised on the medial side of the arm

to block the intercostobrachial nerve.
Short axis approach

Figure 19.15 Axillary brachial plexus with surrounding local anesthetic A transverse image of axillary brachial plexus is obtained
(LA). N: needle; AxA: axillary artery; AxV: axillary vein; MN: median nerve; and then the needle is introduced in short axis of beam to
UN: ulnar nerve. reach the nerves individually (Figs 19.17 and 19.18). The
disadvantage is that the needle is not clearly seen at all
times and the needle tip position is indirectly ascertained
acting local anesthetic agents may be substituted for longer by tissue motion and spread of local anesthetic. Between 4
lasting blocks if a catheter technique is not used. and 10 mL of 2% lidocaine is deposited around each of the
The needle is withdrawn and the musculocutaneous identified nerves.
nerve is identified in the corocobrachialis muscle or between
the biceps and brachoradialis. Once the needle tip has been Continuous technique
confirmed by ultrasonography to lie in close proximity to
the musculocutaneous nerve, this can be confirmed by Generally, catheters placed by the axillary route are easily
using a nerve stimulator. Characteristic motor activity is displaced. Nevertheless, the axillary brachial plexus block
seen. A deposit of local anesthetic is made around the mus- is the most widely-used continuous technique. With this
culocutaneous nerve (Fig. 19.16). If the musculocutaneous block, the approach is parallel to the neurovascular bundle,
nerve is not seen clearly, 10 mL of local anesthetic may be which facilitates catheter placement. Tunneling is recom-
injected into the belly of the coracobrachialis muscle. A mended. As with the single-injection technique, the
149
musculocutaneous nerve is frequently not anesthetized. A

N catheter may be placed deep to the axillary artery or near
the nerve which supplies the incision.
AxA
Adverse effects
Superior Inferior
• Hematoma formation due to puncture of the axillary

artery
• Neural injuries are extremely rare
• Local anesthetic toxicity is a particular risk because intra-
vascular injection into the axillary vessels is possible
• Traumatic pseudoaneurysm may be accompanied by
postoperative paresthesia and plexus paralysis.
Figure 19.18 Real-time imaging of needle insertion for the short axis
approach of ultrasound-guided axillary block. Notice the needle tip (N)
as hyperechoic dot with loss of ultrasound image beneath. N: needle
tip; AxA: axillary artery.
Suggested reading
Bouaziz H, Narchi P, Mercier FJ, et al. The use of a
selective axillary nerve block for outpatient hand
surgery. Anesth Analg 1998;86:746–748.
Chan VW, Perlas A, McCartney CJ, et al. Ultrasound
guidance improves success rate of axillary brachial
plexus block. Can J Anesth 2007;54:176-182.
CLINICAL PEARLS Finucane BT, Yilling F. Safety of supplementing axillary
brachial plexus blocks. Anesthesiology 1989;70:
Landmark-based approach 401–403.
• Palpate the axillary artery as high in the axilla as possible Klaastad O, Smedby O, Thompson GE, et al. Distribution
• Check site of surgery and target the relevant nerve of local anesthetic in axillary brachial plexus block: a
• Distal pressure increases chance of blocking musculocutaneous clinical and magnetic resonance imaging study.
nerve Anesthesiology 2002;96:1315–1324.
• To confirm median nerve stimulation, palpate flexor carpi
radialis tendon
Lavoie J, Martin R, Tetrault JP, et al. Axillary plexus block
• Be prepared to do ‘escape blocks’ at elbow or wrist or using a peripheral nerve stimulator: single or multiple
midhumeral. injections. Can J Anaesth 1992;39:583–586.
Ultrasound-guided approach Patridge BL, Katz J, Benirshoke K. Functional anatomy of
• Do not press hard with the ultrasound transducer as this leads to the brachial plexus sheath: implications for
compression of veins anesthesia. Anesthesiology 1987;66:743–747.
• Inject local anesthetic around each nerve to increase success Retzl G, Kapral S, Greher M, et al. Ultrasonographic
• When the needle is introduced anteriorly, the local anesthetic findings of the axillary part of the brachial plexus.
should be injected around deeper branches first Reg Anesth Pain Med 2001;92:1271–1275.
• Advantages of ultrasound-guided axillary block include:
Sites BS, Beach ML, Spence BC, et al. Ultrasound guidance
• No sparing of musculocutaneous or intercostobrachial
nerves
improves the success rate of a perivascular axillary
• Successful block can be achieved with a decreased volume brachial plexus block. Acta Anaesthesiol Scand
of local anesthetic solution 2006;50:678–684.
• The block can be repeated in the same area, unlike the Vester-Andersen T, Christiansen C, Sorensen M, et al.
unguided nerve stimulation technique Perivascular axillary block II: influence of volume of
• Vascular puncture less likely. local anesthetic on neural blockade. Acta Anaesthesiol
Scand 1983;27:95–98.
150
CHAPTER
20
Midhumeral block
insertion site, the four major nerves of the upper limb have
Indications a characteristic location in relation to the brachial artery.
The median nerve lies anterior to the artery, the ulnar nerve
Surgical Surgical procedures in the innervated area; sup-
posteromedially, and the radial nerve posteriorly, adjacent
plementation of incomplete anesthesia of the brachial
to the humerus. The musculocutaneous nerve lies superior
plexus.
to the artery and under the biceps at this point. The medial
Therapeutic Complex regional pain syndrome; posther-
cutaneous nerve of the arm lies medial to the artery within
petic neuralgia; postamputation pain; prolonged postop-
the canal.
erative analgesia (continuous technique).
Contraindications Surface anatomy

The main landmarks for the midhumeral block include the
Absolute junction between the upper one-third and lower two-thirds
See Chapter 4. of the humerus and the brachial artery. This can be approxi-
Relative mated as three fingers’ breadth below the anterior axillary
Hemorrhagic diathesis; anticoagulation treatment; and fold (Fig. 20.1).
local neural injury.
Sonoanatomy
Clinical anatomy
At the humeral canal level, the four main branches of the
The humeral canal, containing the terminal nerves of the brachial plexus, the radial, the ulnar, the median, and the
brachial plexus and the brachial artery, lies on the medial musculocutaneous nerves, are anatomically separated from
aspect of the arm. At this location it is possible to anesthe- each other. The relation to blood vessels is less variable
tize the four major nerves of the upper limb separately. The than at the axillary level. These characteristics favor nerve
humeral canal is bounded superiorly by the biceps muscle, identification and selective injection under ultrasound
inferiorly by triceps, laterally by coracobrachialis, and guidance. The nerves of the brachial plexus do not appear
medially by skin and subcutaneous tissue. The needle inser- together on the same ultrasound screen at the level of the
tion site is at the junction between the upper one-third and humeral canal. Consequently, blockade of these nerves
the lower two-thirds of the humerus, in proximity to the with the classical single point of puncture is technically
brachial artery. A common mistake is to choose a needle difficult.
insertion site at the midpoint of the humerus. Here the Ultrasound examinations of the brachial plexus through
radial nerve is inaccessible because it lies in the radial the humeral canal show that ulnar and median nerves are
groove on the posterior aspect of the humerus. At the needle located superficially under the skin. The radial nerve,

DOI: 10.1016/B978-0-7020-3148-9.00028-1
located beside the humerus, is the most dorsally located and can be divided into two compartments (Fig. 20.2). A
nerve of the plexus. The musculocutaneous nerve is situated superficial and a dorsal nerve can be found within each
midway between these two nerves. Images obtained from compartment. Median and musculocutaneous nerves are
ultrasound examinations of the brachial plexus through the located inside the cephalic compartment, whereas the mus-
humeral canal can be illustrated on a graphical synthesis culocutaneous nerve is located dorsally. Ulnar and radial
nerves are located inside the caudal compartment; the
radial nerve is located dorsally.
Nerves in the midhumeral region have mixed echo-
genicity (honeycomb appearance with a mixture of
hypoechoic nerve fascicles and hyperechoic connective
tissues). The nerves are round or oval. Move the transducer
towards the axilla and distally towards the elbow to appre-
ciate the course of each nerve.
Technique
Figure 20.1 Landmarks for the midhumeral block. The needle inser-
tion point for the midhumeral block is located at the junction between sure monitoring are established. Asepsis is observed.
the upper third and lower two-thirds of the humerus. This can be The patient is placed supine and the arm abducted at 90°.
approximated as three fingers’ breadth below the anterior axillary fold. At the junction between the upper and middle thirds of the
Cephalic compartment Caudal compartment
In plane In plane
MN
In plane Out of plane

HA BV
UN
MN
MCN
66%
RN
12h 12h
HB
13 42 3 46
UN
4a 1a 4v 1v
9h 3h 9h 3h
3a 2a 3v 2v
46%
3 3 3 9
6h 6h
Figure 20.2 Graphical synthesis of the brachial plexus at the level of the humeral canal under ultrasound description. RN: radial nerve; UN: ulnar
nerve: MCN: musculocutaneous nerve: MN: median nerve: HA: humeral artery: BV: basilic vein: HB: humerus. The dotted line separates the caudal
compartment from the cephalic compartment. The underlined numbers correspond to volunteers. The MN is between 12 and 1 o’clock in 66% of
the cases. The UN is situated at the 3 o’clock position in 46% of the cases. The UN and the RN cannot be blocked from a single point of puncture
located on the cephalic side of the probe (long line arrows). The 2 points of puncture inside the 2 compartments are mandatory (broken line
arrows).1
152
CHAPTER
Midhumeral block 20
Figure 20.3 Midhumeral block technique: locating the median nerve. Figure 20.4 Midhumeral block technique: locating the ulnar nerve.
The needle is inserted anterior and parallel to the brachial pulse to The needle is inserted medial and perpendicular to the brachial pulse
locate the median nerve. to locate the ulnar nerve.
arm, a line is drawn over the brachial artery. The needle

insertion point is infiltrated with local anesthetic using a
25-G needle. A 50-mm 22-G insulated needle connected to
a peripheral nerve stimulator is inserted almost tangentially
to the skin, between the brachial artery and the palpating
finger, in the direction of the axilla, in order to locate the
median nerve (Fig. 20.3). The stimulating current is set at
1.0 mA, 2 Hz, and 0.1 ms. The needle is advanced slowly
until the appropriate muscle response is obtained. The
needle position is adjusted while decreasing the current to
0.35 mA with maintenance of the muscle response. Stimu-
lation of the median nerve will produce contraction of the
flexor carpi radialis and flexor digitorum superficialis of the
fingers. Incremental injections of local anesthetic (6–8 mL)
are made with repeated aspiration.
After blocking the median nerve, the current is increased Figure 20.5 Midhumeral block technique: locating the radial nerve.
to 2 mA, and the needle withdrawn and redirected beneath The skin is retracted inferior to the brachial pulse and oriented perpen-
and medial to the artery (Fig. 20.4). Stimulation of the dicular to the artery and toward the humerus to locate the radial nerve.
ulnar nerve induces contraction of the flexor carpi ulnaris
muscle. Incremental injection of local anesthetic (6–8 mL)
is made with repeated aspiration. Ultrasound-guided approach
The needle is now withdrawn and, with a high level of
stimulation in the subcutaneous position, redirected toward The ultrasound machine and block tray should be placed
the radial nerve. This nerve is posterior to the artery, close in positions which allow the operator to simultaneously
to the humerus (Fig. 20.5). Stimulation of the radial nerve scan the patient and take items from the block tray with
causes contraction of the extensor muscles of the forearm. minimal movement. This setup may take some forethought
Incremental injections of local anesthetic (6–8 mL) are but is a worthwhile exercise, and will facilitate successful
made with repeated aspiration. regional anesthesia.
To block the musculocutaneous nerve, the needle is The operator stands on the side to be blocked, and with
directed from its initial subcutaneous position beneath the the patient supine and the arm abducted at 90 ° (Fig. 20.7).
biceps muscle (Fig. 20.6). Stimulation of this nerve induces The skin is disinfected with antiseptic solution and draped.
contraction of the biceps muscle and flexion of the elbow. A sterile sheath (CIVCO Medical Instruments, Kalona, IA,
Incremental injections of local anesthetic (6 mL) are made USA) is applied over the ultrasound transducer with sterile
with repeated aspiration. A final 3 mL is injected medial to ultrasound gel (Aquasonic, Parker Laboratories, Fairfield,
the artery to block the medial cutaneous nerves of the arm NJ, USA). Another layer of sterile gel is placed between the
and the forearm. sterile sheath and the skin. The humeral canal region is
153
Figure 20.6 Midhumeral block technique: locating the musculocuta-

neous nerve. The needle is inserted superior to the brachial pulse and
under the biceps to locate the musculocutaneous nerve.
Figure 20.8 (A) Position of the patient, the ultrasound transducer,

and the needle during block of the radial nerve. (B) Position of the
Figure 20.7 Global view of the block field for the ultrasound-guided patient, the ultrasound transducer, and the needle during block of the
humeral block. ulnar, the median, and the musculocutaneous nerves. The ultrasound
transducer is repositioned more cephalad and slightly laterally com-
pared to the position of the transducer described in A; for the block of
scanned with a 7–13 MHz linear transducer. The ultra- the ulnar nerve, the needle is re-orientated in an in-plane position. (C)
sound screen should be made to look like the scanning A second point of puncture is performed on the cephalad side of the
field. Adjustable ultrasound variables such as scanning ultrasound transducer in order to block the musculocutaneous nerve
mode, depth of field, and gain are optimized. and the median nerve through an in-plane approach.
With transverse imaging of the humeral canal, in half of
the cases, when the point of puncture is situated cephalic culocutaneous and median nerves. This technique allows a
to the ultrasound transducer the needle crosses the basilic reduction of the skin-to-radial nerve distance to facilitate
vein in order to reach the ulnar nerve. Similarly, the radial visualization of the radial nerve otherwise hidden by the
nerve cannot be blocked through this pathway because the humerus.
humerus is situated on the pathway of the needle in 58% In this configuration, the radial nerve is initially blocked
of cases (Fig. 20.2). It would be possible to introduce the through an out-of-plane approach. After the transducer has
needle on the caudal side of the probe, but in this configu- been re-directed anterior to the vessels, the ulnar nerve is
ration, movements of the needle are impeded by the upper blocked within the same point of puncture through an in-
limb layout. plane approach (Fig. 20.8). Nerves from the cephalic com-
Two points of puncture are thus used for the ultrasound- partment are both blocked through an in-plane approach.
guided humeral block: the first is dedicated to the blockade The deepest nerve is always blocked first; otherwise the
of radial and ulnar nerves (moving the transducer cau- injected local anesthetic impedes location of the deepest
dally); and the second is dedicated to the blockade of mus- structures.
154
CHAPTER
Midhumeral block 20
Once the needle has approached each individual nerve,

1–2 mL of local anesthetic may be injected to confirm
correct needle placement. Local anesthetic appears as a
hypoechoic image. Correct needle placement is confirmed
HA by observing solution surrounding each individual nerve
Superior (Fig 20.9). Should this not occur, the needle may need to
Inferior
be repositioned, and the procedure repeated. Following
confirmation of correct needle placement, 4–6 mL of local
anesthetic solution can be injected to achieve blockade of
RN each nerve.
HB
A Continuous midhumeral techniques have not been
described, but it may be possible to provide continuous
anesthesia of an individual upper arm nerve at this loca-
BV
UN
tion. Ultrasound can be used to assist catheter placement.
MN HA
Superior Inferior
Adverse effects
• Hematoma formation due to puncture of the brachial
HB
artery.
• Neural injuries are extremely rare.
B
into the brachial vessels leading rapidly to toxic reac-
tions. Overdosage or intravascular diffusion can also
cause symptoms of local anesthetic toxicity. Slow injec-
BB
HA tion of local anesthetics will decrease the incidence of
Superior Inferior this complication.
MCN • Pseudoaneurysm may be accompanied by postoperative
paresthesia.
CBM
HB CLINICAL PEARLS
C • Sedation is paramount with this multi-injection technique.
• Palpation of the brachial artery must be performed with care.
Figure 20.9 (A) Sonoanatomy of the radial nerve at the humeral canal. The palpating finger may approximate the needle tip to the
RN: radial nerve; HB: humerus; HA: humeral artery. (B) Sonoanatomy of nerve while in fact it is further away. Thus, final needle location
the median and ulnar nerves. UN: ulnar nerve; MN: median nerve; HA: and injection must be performed without digital palpation of
humeral artery; BV: basilic vein; HB: humerus. (C) Sonoanatomy of the the artery.
musculocutaneous nerve. MCN: musculocutaneous nerve; CBM: cora- • Often differentiation between median and ulnar nerve on
cobrachialis muscle; BB: biceps brachialis muscle; HB: humerus; HA: muscular contraction is difficult. By resting the hand on the
humeral artery. forearm it is easy to distinguish between contraction of flexor
carpi radialis (median) and flexor carpi ulnaris (ulnar). This may
be due to Martin–Gruber anastomosis – communication of the
median and ulnar nerves in the arm and forearm.
A 22-GA × 50-mm insulated needle (B. Braun, Bethlehem • A multi-injection technique can be performed with different local
anesthetics. For instance, short-acting local anesthetics can be
PA) is attached to sterile extension tubing, which is con-
injected on the musculocutaneous nerve, whereas long-acting
nected to a 20 mL syringe and flushed with local anesthetic local anesthetics can be injected on the other nerves. In the case
solution to remove all air from the system. It is then intro- of hand and wrist surgery, this technique allows the patient to
duced as indicated above. It is important not to advance recover the flexion of the forearm while providing effective
the needle without good visualization. This may require postoperative analgesia.
needle or transducer adjustment.
155
Frizelle HP. Technical note: the humeral canal approach

Reference to the brachial plexus. Yale J Biol Med 1998;71:
585–589.
1. Guntz E, Van den Broeck V, Dereeper E, et al.
Hickey RM, Hoffman J, Tingle LJ, et al. Comparison of
Ultrasound-guided block of the brachial plexus at the
the clinical efficacy of three perivascular techniques
humeral canal. Can J Anesth 2009;56:109–114.
for axillary brachial plexus block. Reg Anesth
1993;18:335–338.
Suggested reading Perlas A, Chan VW, Simons M, et al. Brachial plexus
examination and localization using ultrasound and
Bouaziz H, Narchi P, Mercier FJ, et al. Comparison electrical stimulation: a volunteer study. Anesthesiol
between conventional axillary block and a new 2003;99(2):429–435.
approach at the midhumeral level. Anesth Analg
1997;84:1058–1067.
156
CHAPTER
21
Elbow blocks
the anterior aspect of the arm above the brachioradialis. It

Indications passes deep to the brachioradialis over the lateral epicon-
dyle, where it divides into a deep and a superficial branch
Surgical Surgical procedures in the innervated area; sup-
(Fig. 21.2). The radial nerve provides sensation for the
plementation of incomplete anesthesia of the brachial
radial half of the dorsum of the hand, the back of the
plexus.
thumb, and part of the dorsum of the index finger.
Therapeutic Peripheral nerve injury pain.
The ulnar nerve leaves the brachial artery halfway down
the arm and passes behind the medial epicondyle in a
Contraindications fibrous tunnel. It passes between the two heads of flexor
carpi ulnaris to enter the forearm (Fig. 21.3). The ulnar
nerve provides sensation for the ulnar half of the dorsum
Absolute of the hand, little finger, and ulnar side of the ring finger.
See Chapter 4.
Relative
Hemorrhagic diathesis; anticoagulation treatment; local Surface anatomy
neural injury; and distorted anatomy (due to previous
surgery or trauma). Important structures include the medial and lateral epicon-
dyles of the humerus, olecranon process, intercondylar skin
crease, biceps tendon, brachioradialis muscle, and brachial
Clinical anatomy artery (Fig. 21.4). The biceps tendon can be palpated with
elbow flexion beneath the intercondylar crease, and it runs
The three major nerves of the forearm can be blocked at the laterally to the head of the radius. The brachioradialis
elbow (Fig. 21.1), and also the three cutaneous nerves of muscle can be palpated lateral to the biceps tendon. The
the forearm. brachial artery is palpated medial to the biceps muscle.
The median nerve, which lies anteromedially to the bra-
chial artery near the axilla, crosses medial to the artery in
the arm. At the elbow it lies between the tendons of bra- Sonoanatomy
chialis and pronator teres, and deep to the bicipital apo-
neurosis. It passes between both heads of pronator teres to The examination begins with the patient supine, the arm
enter the forearm (Fig. 21.2). The median nerve provides abducted, the forearm supinated, and the wrist halfway
sensory innervation to the lateral half of the palm, flexor between pronation and supination (Fig. 21.5). A systematic
aspect of the thumb, index finger, middle finger, and radial survey should be performed from superficial to deep and
side of the ring finger. medial to lateral. A high frequency ultrasound transducer
The radial nerve passes between the long and medial head is used. With a transverse orientation, the median nerve
of the triceps to travel around the humerus and emerges on is found medial to the brachial artery at the elbow as a

DOI: 10.1016/B978-0-7020-3148-9.00029-3
3 5
4 2
1
1
2
4
6
3
1
7
Figure 21.3 Cadaver structures illustrating anatomy pertinent to ulnar
nerve block at the elbow. 1: Olecranon process; 2: medial epicondyle;
3: triceps muscle; 4: ulnar nerve.
Figure 21.1 Axial T1-weighted MR image showing anatomy of rele-

vant structures at the elbow. 1: radial nerve with profunda brachii artery
and vein; 2: biceps tendon; 3: brachial artery; 4: brachioradialis; 5: site of
median nerve; 6: extensor carpi radialis longus; 7: ulnar nerve.
5
2
4 3
1
6 7
10
8
9 Figure 21.4 Landmarks for nerve blocks at the elbow. Landmarks
include the medial and lateral epicondyles of the humerus, intercondy-
lar skin crease, biceps tendon, brachioradialis muscle, and brachial pulse.
The biceps tendon can be palpated with elbow flexion beneath the
intercondylar crease and it runs laterally to the head of the radius.
The brachioradialis muscle can be palpated lateral to the biceps tendon.
The brachial artery is palpated medial to the biceps muscle.
Figure 21.2 Cadaver structures illustrating anatomy pertinent to
median and radial nerve block at the elbow. 1: biceps muscle and apo-
neurosis; 2: brachioradialis; 3: brachialis; 4: radial nerve; 5: lateral cutane-
ous nerve of forearm; 6: brachial artery; 7: median nerve; 8: brachial vein; structures to identify include the hypoechoic brachioradia-
9: pronator teres; 10: medial cutaneous nerve of forearm. lis and brachialis muscles. The radial nerve lies in the fascial
thickening between these (Fig. 21.7). The ulnar nerve is
seen posterior to the medial epicondyle at the elbow level
hyperechoic structure (Fig. 21.6). This is on the medial side in the condylar groove (Fig. 21.8).
of the antecubital fossa. The radial nerve, after winding
around the humerus, descends in the intermuscular septum
between the brachialis and brachoradialis initially, and Technique
then the extensor carpi radialis. The radial nerve is easily
seen with ultrasound, as the deep and superficial branches Landmark-based approach
between the brachioradialis and brachialis muscles at the
elbow. This nerve appears as a hyperechoic oval structure As for all regional anesthetic procedures, after checking that
on the radial side of the antecubital fossa. The two key the emergency equipment is complete and in working
158
CHAPTER
Elbow blocks 21
BRM
Lateral RN Medial
BM
Figure 21.7 Sonosatomy relevant to radial nerve block at the elbow.

RN: radial nerve; BM: brachialis muscle; BRM: brachoradialis muscle.
Figure 21.5 Arm position for ultrasound-guided nerve blocks at the

elbow.
UN
MN
BA
B
Medial Lateral
B
Figure 21.8 Sonosatomy relevant to ulnar nerve block at the elbow.
UN: ulnar nerve, B: bone.
Figure 21.6 Sonosatomy relevant to median nerve block at the elbow. (Fig. 21.9). Needle orientation is cephalad and toward the
MN: median nerve; BA: brachial artery; B: bone. humerus. The stimulating current is set at 1.0 mA, 2 Hz,
and 0.1 ms. The needle is advanced slowly until the appro-
priate muscle response is obtained: finger rather than wrist
order, intravenous access, ECG, pulse oximetry, and blood flexion. A loss of resistance is felt as the bicipital aponeu-
pressure monitoring are established. Asepsis is observed. rosis is punctured. The needle position is adjusted while
The patient is placed in the supine position, with the arm decreasing the current to 0.35 mA with maintenance of the
to be blocked abducted 30° with the elbow extended on muscle response. Wrist flexion may be due to direct muscle
an arm board. The operator sits at the side to be blocked stimulation. Incremental injections of local anesthetic
below the patient’s elbow. The needle insertion point is (4–6 mL) are made with repeated aspiration. If no twitch
infiltrated with local anesthetic using a 25-G needle. For is found, ‘walk’ the needle in a medial to lateral plane.
block at the elbow, a 25-mm insulated needle is used.
Radial nerve block
Median nerve block Needle insertion for radial nerve block is halfway between
Needle insertion for median nerve block is medial to the biceps tendon and lateral border of the arm (or 1 cm
the brachial pulse at the level of the intercondylar crease lateral to the biceps tendon), in the gutter between the
159
Figure 21.9 Median nerve block technique. Needle insertion for

median nerve block is medial to the brachial pulse at the level of the
intercondylar crease. Needle orientation is cephalad and toward the Figure 21.11 Ulnar nerve block technique. The elbow is flexed 90° and
humerus. the arm internally rotated across the upper body for ulnar nerve block.
Needle orientation is 45° to the skin in a cephalad direction.
Ulnar nerve block

The elbow is flexed 90° and the arm internally rotated
across the upper body for ulnar nerve block. Needle orien-
tation is 45° to the skin in a cephalad direction (Fig. 21.11).
The ulnar nerve is very superficial and contacted within
0.5–1 cm. Little finger flexion and ulnar deviation of the
hand, rather than wrist flexion due to possible direct flexor
carpi ulnaris stimulation, results in greatest block success.
Incremental injections of local anesthetic (4 mL) are made
with repeated aspiration. The needle is walked in a medial
to lateral direction if the ulnar nerve is not stimulated. With
elbow flexion, the ulnar nerve may slip over the medial
epicondyle.
Figure 21.10 Radial nerve block technique. Needle insertion for radial
Cutaneous nerves of forearm blocks
nerve block is halfway between the biceps tendon and lateral border of
the arm (or 1 cm lateral to the biceps tendon), in the gutter between Because the branches of the sensory nerves of the forearm
the biceps tendon and brachioradialis at the level of the intercondylar have already ramified extensively and cross the joint super-
skin crease. Needle orientation is cephalad and toward the humerus. ficially in a diffuse subcutaneous network, good anesthesia
of the forearm itself is difficult to obtain. The lateral cuta-
neous nerve of the forearm can be blocked by injection
deep to the fascia in the muscular groove between the
biceps tendon and brachioradialis at the level of the inter- biceps and brachioradialis. The medial cutaneous nerve of
condylar skin crease (Fig. 21.10). Needle orientation is the forearm can be blocked by subcutaneous injection in
cephalad and aimed toward the humerus (toward the the intermuscular groove between the biceps and pronator
lateral epicondyle). At a depth of 2–3 cm, the radial nerve teres. The posterior cutaneous nerve of the forearm can be
will be encountered. Finger and thumb extension, rather blocked by subcutaneous injection from the lateral epicon-
than wrist extension due to possible direct stimulation of dyle to the olecranon.
extensor carpi radialis, results in greatest block success.
Incremental injections of local anesthetic (4–6 mL) are Ultrasound-guided approach
made with repeated aspiration.
If direct brachioradialis contraction is elicited, move the Intravenous access, electrocardiogram (ECG), pulse oxim-
needle slightly more medially. Failure to elicit an appropri- etry and blood pressure monitoring are established. Maxi-
ate muscle response should be followed by walking the mized comfort for the operator and patient is an important
needle in a medial to lateral orientation. step in pre-procedure preparation. For ultrasound-guided
160
CHAPTER
Elbow blocks 21
Figure 21.12 Global view of the block field for ultrasound-guided Figure 21.13 Ultrasound transducer and needle positioning during
nerve blocks at the elbow. ultrasound-guided median nerve block at the elbow. Note the needle
orientation in the same plane as the ultrasound beam.
nerve blocks at the elbow, the patient is placed in the

supine position, the arm abducted, the forearm supinated,
and the wrist halfway between pronation and supination. LA MN BA
The operator sits adjacent to the side to be blocked. The
ultrasound screen, transducer, needle, and plane of imaging Medial N Lateral
should all be placed in one view for the operator. For
ultrasound-guided nerve blocks at the elbow, the ultra-
sound screen is placed above the elbow on the side to be
blocked (Fig. 21.12). Room lights may be turned down to
enhance image viewing. The operating lights can be used B
to maintain some working lighting in the background.
draped. A sterile sheath (CIVCO Medical Instruments, Figure 21.14 Real-time imaging of needle insertion for ultrasound-
Kalona, IA, USA) is applied over the ultrasound transducer guided median nerve block at the elbow. Needle insertion is on the
with sterile ultrasound gel (Aquasonic, Parker Laboratories, medial aspect of the transducer. Notice the needle shaft and the needle
Fairfield, NJ, USA). Another layer of sterile gel is placed tip (N) in close proximity to the median nerve. N: needle tip; MN: median
between the sterile sheath and the skin. The ultrasound nerve; LA: local anesthetic; BA: brachial artery; B: bone.
screen should be made to look like the scanning field. That
is, the right side of the screen represents the right side of
the field. Adjustable ultrasound variables such as scanning is seen. Test injections for assessment of local anesthetic
mode, depth of field, and gain are optimized. spread should be small (0.5–2 mL). If the local anesthetic
Developing and maintaining a predetermined basic scan- spread is not seen on the ultrasound screen, the injection
ning routine is of enormous help in improving operator should be stopped. The needle is readjusted to allow com-
confidence and success. On the medial side of the antecu- plete encirclement of the nerve with local anesthetic (5 mL).
bital fossa, the median nerve is identified on the medial Local anesthetic appears as a hypoechoic image (Fig 21.14).
side of the brachial artery. A 21-GA × 50-mm insulated On the lateral side of the antecubital fossa, the radial
needle is inserted parallel to the axis of the beam of the nerve is identified as deep and superficial branches between
ultrasound transducer (Fig. 21.13). The operator can slide the brachioradialis and brachialis muscles. A 21-GA ×
and tilt the transducer to maintain the needle tip within the 50-mm insulated needle is inserted parallel to the axis of
plane of imaging as much as possible. The needle is slowly the beam of the ultrasound transducer (Fig. 21.15). The
advanced under ‘real-time’ imaging to bring the needle tip needle is slowly advanced under ‘real-time’ imaging to
to rest adjacent to the median nerve. Once the needle tip bring the needle tip to rest adjacent to the radial nerve. The
has been confirmed by ultrasonography to lie in close prox- needle is readjusted to allow complete encirclement of the
imity to the median nerve, this can be confirmed by using nerve with local anesthetic (5 mL). Local anesthetic appears
a nerve stimulator. Characteristic motor activity in the hand as a hypoechoic image (Fig. 21.16).
161

ultrasound-guided radial block at the elbow. Note the needle orienta-
tion in the same plane as the ultrasound beam.

BM ultrasound-guided ulnar nerve block at the elbow. Note the needle
Lateral Medial orientation in the same plane as the ultrasound beam.
RN
LA
BRM N
LA N
Figure 21.16 Real-time imaging of needle insertion for ultrasound-
guided radial nerve block at the elbow. Needle insertion is on the medial
aspect of the transducer. Notice the needle shaft and the needle tip (N) UN
in close proximity to the radial nerve. N: needle tip; RN: radial nerve; LA:
local anesthetic; BM: brachialis muscle; BRM: brachoradialis muscle,
B: bone.
The ulnar nerve is seen posterior to the medial epicondyle

at the elbow level in the condylar groove (Fig. 21.8). A
21-GA × 50-mm insulated needle is inserted parallel to the
axis of the beam of the ultrasound transducer (Fig. 21.17).
The needle is slowly advanced under ‘real-time’ imaging to
bring the needle tip to rest adjacent to the ulnar nerve. The
needle is readjusted to allow complete encirclement of the Figure 21.18 Real-time imaging of needle insertion during ultrasound-
nerve with local anesthetic (5 mL). Local anesthetic appears guided ulnar nerve block at the elbow. Notice the needle shaft marked
as a hypoechoic image (Fig. 21.18). with arrows and the needle tip (N) in close proximity to the ulnar nerve.
N: needle tip; UN: ulnar nerve; LA: local anesthetic.
Adverse effects
• Hematoma.
CLINICAL PEARLS
• Local anesthetic toxicity due to intravascular injection, • If a tourniquet is used, then the medial cutaneous nerve of the
diffusion, or overdosage can cause symptoms of arm needs to be blocked
CNS toxicity. Slow injection of local anesthetic and • Unlike wrist blocks, blockade at the elbow will provide good
repeated aspiration will decrease the incidence of this motor block in the wrist and fingers
complication.
162
CHAPTER
Elbow blocks 21
Loewy J. Sonoanatomy of the median, ulnar and radial

Suggested reading nerves. Can Assoc Radiol J 2002;53(1):33–38.
McCartney CJ, Xu D, Constantinescu C, et al. Ultrasound
Amoiridis G, Vlachonikolis IG. Verification of the
examination of peripheral nerves in the forearm. Reg
median-to-ulnar and ulnar-to-median nerve
Anesth Pain Med 2007;32(5):434–439.
motor fiber anastomosis in the forearm: an
electrophysiological study. Clin Neurophysiol
2003;114:94–98.
163
CHAPTER
22
Wrist blocks
nerve provides sensation for the ulnar half of the back

Indications and front of the hand, little finger, and ulnar side of the
ring finger.
Surgical Hand or finger surgery not requiring a tourniquet;
The radial nerve at the wrist lies between the flexor carpi
supplementation of incomplete brachial plexus block.
radialis and the radial artery (Fig. 22.3). The radial nerve
Therapeutic Differentiation of finger or hand pain.
provides sensation for the radial half of the dorsum of the
hand, back of the thumb, and part of the dorsum of the
Contraindications index finger.
Absolute Surface anatomy

See Chapter 4.
Relative Bony landmarks include the ulnar styloid and the radial
Local neural injury and distorted anatomy (due to previous styloid carpal bones. Other landmarks include the wrist
surgery or trauma). crease, flexor carpi radialis, palmaris longus, and flexor
carpi ulnaris tendons (Fig. 22.4). These tendons can be
accentuated by having the patient flex the wrist while
Clinical anatomy making a fist. The radial artery can be palpated lateral to
the tendon of the flexor carpi radialis, and the ulnar artery
The hand is innervated by the three nerves that pass through lateral to the flexor carpi ulnaris tendon.
the wrist (Fig. 22.1).
The median nerve approaches the wrist between the pal-
maris longus (if present) and the flexor carpi radialis. It can Sonoanatomy
also lie beneath the palmaris longus (Fig. 22.2). The median
nerve provides sensation to the lateral half of the palm, The examination begins with the patient supine, the arm
flexor aspect of the thumb, index finger, middle finger, and abducted, the forearm and wrist in supination (Fig. 22.5).
radial side of the ring finger. A systematic survey should be performed from superficial
The ulnar nerve, in the middle of the forearm between to deep and medial to lateral. A high frequency ultrasound
the flexor digitorum profundus and the flexor carpi ulnaris, transducer is used with a transverse orientation.
gives off a dorsal and a ventral cutaneous branch. At the The median nerve passes distally in the volar aspect of
wrist, the ulnar nerve lies between the ulnar artery and the the forearm between the flexor digitorum superficialis
lateral border of the flexor carpi ulnaris (Fig. 22.2), which and the flexor digitorum profundus muscles (Fig. 22.6A).
inserts on the pisiform bone. Near the pisiform bone, it Approximately 5 cm proximal to the flexor retinaculum,
passes superficial to the flexor retinaculum and ends by the median nerve courses around the radial or lateral edge
dividing into superficial and deep branches. The ulnar of the flexor digitorum superficialis, where its position

DOI: 10.1016/B978-0-7020-3148-9.00030-X
CHAPTER
Wrist blocks 22
2
1
2
1 3
4
3 5
4
6
8
7
5 7
6 7
Figure 22.2 Cadaver structures illustrating anatomy pertinent to nerve

blocks at the wrist. 1; Flexor carpi ulnaris; 2; ulnar nerve and artery; 3;
flexor digitorum superficialis; 4; palmaris longus; 5; median nerve; 6;
flexor carpi radialis; 7; superficial branches of the radial nerve; 8; radial
artery.
Figure 22.1 Axial MR image showing anatomy of relevant structures

at the wrist. 1; Median nerve; 2; palmaris longus tendon; 3; ulnar artery;
4; ulnar nerve; 5; radial artery; 6; radial nerve; 7; radius.
5 3
4
1
2
4
4
Figure 22.4 Landmarks for the nerve blocks at the wrist. Landmarks
include radial and ulnar styloids; flexor carpi radialis and ulnaris; palmaris
longus; radial and ulnar arteries; and the wrist skin crease.
Figure 22.3 Cadaver structures illustrating anatomy pertinent to radial
nerve block at the wrist. 1; Cephalic vein; 2; extensor pollicis longus;
3; flexor carpi radialis; 4; superficial branches of the radial nerve; 5; radial
artery.
Figure 22.5 Arm position for ultrasound-guided blocks at the wrist.
165
UA
MN UN
Lateral Medial
Figure 22.7 Ultrasound image of the ulnar nerve at the wrist. UN: ulnar
nerve; UA: ulnar artery.
RA APL EPB
MN
Lateral Medial Radius
Figure 22.8 Ultrasound image of the superficial radial nerve at the

wrist. RA: radial artery; APL: abductor pollicis longus tendon; arrow: radial
nerve; EPB: extensor pollicis brevis tendon.
B echoic fat surrounding the median nerve accentuates the

contrast between the hyperechoic nerve and hypoechoic
Figure 22.6 (A) Ultrasound image of the median nerve (MN) in the
forearm. (B) Ultrasound image of the median nerve proximal to the muscle proximally. Once the median nerve is identified
carpal tunnel. proximally, it can then be followed distally in the
transverse-axial plane to the carpal tunnel. The echogenic
surface of the pisiform at the ulnar aspect of the wrist
becomes more superficial. Just proximal to the carpus, the defines the proximal carpal tunnel.
nerve lies between the tendons of the flexor digitorum The ulnar nerve at the wrist lies within the Guyon canal,
superficialis and the flexor carpi radialis, partially deep an oblique fibro-osseous tunnel, formed by the flexor reti-
to the tendon of palmaris longus (if it is present; Fig. 22.6B). naculum and palmar carpal ligaments, that lies within the
The nerve then passes deep to the flexor retinaculum into proximal part of the hypothenar eminence. The canal con-
the carpal tunnel of the wrist. tains the ulnar nerve, the ulnar artery with its venae comi-
When scanning in the axial plane, at the level of the tantes, and loose fibrofatty tissue. On transverse sonograms,
carpal tunnel, it is often difficult to differentiate hyper- the ulnar nerve appears as a rounded structure with a loca-
echoic tendons from the normal median nerve. However, tion medial to the artery (Fig. 22.7).
when the transducer is moved proximally in the axial plane, Keeping the patient’s wrist halfway between pronation
several findings on sonography allow identification of the and supination, place the ultrasound transducer over the
median nerve. First, the median nerve courses around the lateral aspect of the radial styloid to examine the first com-
radial aspect of the flexor digitorum superficialis to ulti- partment of the extensor tendons – abductor pollicis longus
mately lie between the flexor digitorum superficialis and (ventral) and extensor pollicis brevis (dorsal). Look at the
the flexor digitorum profundus. Second, the hyperechoic radial artery and the sensory branch of the radial nerve, the
tendons of the flexor digitorum superficialis and the flexor first encroaching deep, the second superficial to the first
digitorum profundus are contiguous with hypoechoic compartment (Fig. 22.8). Scanning from proximal to distal,
muscle at the musculotendinous junctions, whereas the note the radial nerve and its branches snapping from ventral
median nerve remains relatively hyperechoic. The hyper- to dorsal over these tendons.
166
CHAPTER
Wrist blocks 22
medial to the artery. For ulnar nerve block, ventral and

Technique medial approaches can be used. The needle and syringe are
held like a pencil between the thumb and index fingers;
Landmark-based approach needle orientation is cephalad for the ventral approach
(Fig. 22.10).
The patient is instructed to indicate when they feel a
paresthesia in the palm and fingers. On obtaining a pares-
thesia, the needle is withdrawn slightly. Absence of pares-
thesia is checked prior to injecting 3 mL of local anesthetic.
The patient is placed in the supine position, with the arm
The ulnar nerve at the wrist may also be blocked by injec-
abducted and extended at the elbow and wrist joints, and
tion medial and deep to flexor carpi ulnaris (Fig. 22.11).
placed on an arm board or on the operator’s knee, with the
The medial approach is preferable because ulnar artery
wrist slightly dorsiflexed. The operator sits facing the
damage is less likely, and both dorsal and palmar cutane-
patient’s hand. A paresthesia technique is the technique
ous branches may be blocked from the same needle inser-
described here. A 15-mm 25-G needle is used.
tion point.
Median nerve block
Needle insertion for median nerve block is 2 cm cephalad
from the wrist crease between the tendons of the flexor carpi
radialis and palmaris longus, if present (Fig. 22.9). The
needle and syringe are held like a pencil between the thumb
and index fingers, with a cephalad needle orientation.
The patient is instructed to indicate when they feel a
paresthesia in the palm and fingers. On obtaining a pares-
thesia, the needle is withdrawn slightly. Absence of pares-
thesia is checked prior to injecting 3 mL of local anesthetic.
A subcutaneous injection is also made on withdrawal, to
block the palmar cutaneous branch of the median nerve.
The median nerve may also be blocked by injection deep
in the flexor retinaculum in the wrist.
Ulnar nerve block

Needle insertion for ulnar nerve block is 2 cm cephalad Figure 22.10 Ulnar nerve block technique at the wrist: ventral
from the wrist crease lateral to the flexor carpi ulnaris or approach. Needle insertion is 2 cm cephalad from the wrist crease
lateral to the flexor carpi ulnaris. The needle and syringe are held like a
pencil between the thumb and index fingers; needle orientation is
cephalad.
Figure 22.9 Median nerve block technique at the wrist. Needle inser-
tion is 2 cm cephalad from the wrist crease between the tendons of
flexor carpi radialis and palmaris longus (if present). The needle and Figure 22.11 Ulnar nerve block technique at the wrist: medial
syringe are held like a pencil between the thumb and index fingers; with approach. Needle insertion is 2 cm cephalad from the wrist crease;
a cephalad needle orientation. medial; and deep to the flexor carpi ulnaris.
167
The ulnar nerve can also be blocked 6 cm cephalad from paresthesia is not sought because the radial nerve is now
the proximal wrist crease by injection of 4 mL of local superficial fibers only. Local anesthetic solution is massaged
anesthetic beneath the tendon of the flexor carpi ulnaris. in to improve the subcutaneous spread. Local anesthetic
This method will block the dorsal and ventral branches of (8–10 mL) is injected.
the ulnar nerve, and is the method of choice if anesthesia
is required on the dorsal aspect of the little finger. Ultrasound-guided approach
Intravenous access, electrocardiogram (ECG), pulse oxim-
Radial nerve block etry and blood pressure monitoring are established. Maxi-
Needle insertion for radial nerve block is at the level of the mized comfort for the operator and patient is an important
wrist crease (Fig. 22.12). For radial nerve block at the wrist, step in pre-procedure preparation. For ultrasound-guided
a 30-mm 22-G needle is used. A subcutaneous injection is nerve blocks at the wrist, the patient is placed in the supine
made from the radial styloid across the tendon of the exten- position, the arm abducted, the forearm and wrist in supi-
sor pollicis brevis to the middle of the dorsal surface of the nation (Fig. 21.5). The operator sits adjacent to the side to
wrist (Fig. 22.13). The needle is redirected, infiltrating now be blocked. The ultrasound screen, transducer, needle, and
across the tendon of the extensor pollicis brevis to the plane of imaging should all be placed in one view for the
ventral surface of the wrist and over the radial artery. A operator. For ultrasound-guided nerve blocks at the wrist
the ultrasound screen is placed at the elbow level on the
side to be blocked (Fig. 22.14). Room lights may be turned
down to enhance image viewing. The operating lights
can be used to maintain some working lighting in the
background.
between the sterile sheath and the skin. The wrist is scanned
in the transverse plane using a high frequency transducer.
The ultrasound screen should be made to look like the
scanning field. That is, the right side of the screen represents
the right side of the field. Adjustable ultrasound variables
such as scanning mode, depth of field, and gain are
Figure 22.12 Radial nerve block technique at the wrist: needle inser- optimized. Developing and maintaining a predetermined
tion. Needle insertion is at the level of the wrist crease. A subcutaneous basic scanning routine is of enormous help in improving
injection is made from the radial styloid across the tendon of the exten- operator confidence and success.
sor pollicis longus. The median nerve is identified just proximal to the wrist
crease. A 15-mm 25-G needle is inserted parallel to the axis
Figure 22.13 Radial nerve block technique at the wrist: subcutaneous

injection. The subcutaneous injection is continued to the dorsal surface Figure 22.14 Global view of the block field for ultrasound-guided
of the wrist. nerve blocks at the wrist.
168
CHAPTER
Wrist blocks 22
of the beam of the ultrasound transducer (Fig. 22.15). The

needle is slowly advanced under ‘real-time’ imaging to
bring the needle tip to rest adjacent to the median nerve.
The needle is readjusted to allow complete encirclement of
the nerve with local anesthetic (5 mL). Local anesthetic
appears as a hypoechoic image (Fig. 22.16).
The ulnar nerve is identified adjacent to the pisiform
bone in the wrist. A 15-mm 25-G needle is inserted parallel
to the axis of the beam of the ultrasound transducer (Fig.
22.17). The needle is slowly advanced under ‘real-time’
imaging to bring the needle tip to rest adjacent to the ulnar
nerve. The needle is readjusted to allow complete encircle-
ment of the nerve with local anesthetic (5 mL). Local anes-
thetic appears as a hypoechoic image (Fig 22.18). A

ultrasound-guided ulnar nerve block at the wrist. Note the needle ori-
entation in the same plane as the ultrasound beam.
ultrasound-guided median nerve block at the wrist. Note the needle
orientation in the same plane as the ultrasound beam.
MN
LA N
LA
N
UN
Figure 22.16 Real-time imaging of needle insertion during ultrasound- Figure 22.18 Real-time imaging of needle insertion during ultrasound-
guided median nerve block at the wrist. Needle insertion is on the guided ulnar nerve block at the wrist. Needle insertion is on the medial
medial aspect of the transducer. Notice the needle shaft marked with aspect of the transducer. Notice the needle shaft marked with arrows,
arrows, and the needle tip (N) in close proximity to the median nerve. and the needle tip (N) in close proximity to the ulnar nerve. N: needle
N: needle tip; MN: median nerve; LA: local anesthetic. tip; UN: ulnar nerve; LA: local anesthetic.
169
Adverse effects
• Hematoma
CLINICAL PEARLS
• The injection should be immediately stopped if the patient
reports pain on injection or if resistance to injection is met.
• Block of radial nerve is the least consistent because this is a
sensory nerve with a variable subcutaneous course; thus larger
volumes (10 mL) of local anesthetic are required to ensure its
blockade.
Figure 22.19 Ultrasound transducer and needle positioning during • The intensity of the sensory blocks can be tested by using ice. The
ultrasound-guided superficial radial nerve block at the wrist. Note the ulnar territory is tested on the medial aspect of the hand; the
needle orientation in the same plane as the ultrasound beam. median territory on the lateral aspect of the palm at the level of
the index finger; and the musculocutaneous territory on the
lateral aspect of the wrist.
• Ultrasound-guided median nerve block can be performed in the
forearm and here the palmar cutaneous branch will also be
LA N
SRN blocked in a single injection.
• Ultrasound-guided ulnar nerve block can be performed in the
forearm in a single injection before the nerve divides into ventral
and dorsal branches.
A
• Ultrasound-guided radial nerve block at the elbow can reliably
block all branches of the superficial radial nerve.
Suggested reading
Gebhard RE, Al-Samsam T, Greger J, et al. Distal nerve
blocks at the wrist for outpatient carpal tunnel
surgery offer intraoperative cardiovascular stability
Figure 22.20 Real-time imaging of needle insertion during ultrasound-
guided superficial radial nerve block at the wrist. Needle insertion is and reduce discharge time. Anesth Analg
on the medial aspect of the transducer. Notice the needle shaft 2002;95:351–355.
marked with arrows, and the needle tip (N) in close proximity to the Klezl Z, Krejca M, Simcik J. Role of sensory innervation
superficial radial nerve. N: needle tip; SRN: superficial radial nerve; variations for wrist block anesthesia. Arch Med Res
LA: local anesthetic; A: radial artery; R: radius. 2001;32:155–158.
Loewy J. Sonoanatomy of the median, ulnar and radial
Branches of the superficial radial nerve are identified in nerves. Can Assoc Radiol J 2002;53(1):33–38.
the subcutaneous tissue in proximity to the radial artery at Macaire P, Singelyn F, Narchi P, Paqueron X. Ultrasound-
the wrist. A 15-mm 25-G needle is inserted parallel to the or nerve stimulation-guided wrist blocks for carpal
axis of the beam of the ultrasound transducer (Fig 22.19). tunnel release: a randomized prospective comparative
The needle is slowly advanced under ‘real-time’ imaging to study. Reg Anesth Pain Med 2008;33(4):363–368.
bring the needle tip to rest adjacent to the nerve. Local Thompson WL, Malchow RJ. Peripheral nerve blocks and
anesthetic appears as a hypoechoic image (Fig. 22.20). anesthesia of the hand. Mil Med 2002;167:478–482.
170
CHAPTER
23
Lumbar and sacral plexus anatomy
Dominic Harmon
The anterior divisions of the lumbar, sacral, and coccygeal the psoas major muscle, initially together or separate
nerves form the lumbosacral plexus. The plexus is usually throughout, with the former above the latter. They both
divided into three parts: the lumbar, sacral, and pudendal pass laterally in front of the quadratus lumborum to enter
plexuses, for ease of description. The lumbar plexus primar- the neurovascular plane between the transverse abdominis
ily innervates the ventral aspect, whereas the sacral plexus and internal oblique muscles.
innervates the dorsal aspect of the lower limb. The iliohypogastric nerve pierces the internal oblique
about 2 cm medial to the anterior superior iliac spine and
goes on to pierce the external oblique about 3 cm above
Lumbar plexus the superficial inguinal ring (anterior cutaneous branch). It
supplies sensation to suprapubic skin; a lateral cutaneous
The lumbar plexus (Fig. 23.1) lies deep within the psoas branch supplies posterolateral gluteal skin.
major muscle in front of the transverse processes of the The ilioinguinal nerve pierces the lower border of the
lumbar vertebrae. It is formed by the ventral rami of the internal oblique to enter the inguinal canal, which it leaves
first three lumbar nerves and the greater part of the ventral through the superficial ring to supply the skin of the ante-
ramus of the fourth nerve. All the branches of the plexus rior scrotum (mons pubis and labium majus), root of penis
emerge from the substance of the psoas major. (clitoris), and upper medial thigh.
The first lumbar nerve, frequently supplemented by the
12th thoracic, splits into an upper and a lower branch; the
upper and larger branch divides into the iliohypogastric The genitofemoral nerve
and ilioinguinal nerves, the lower and smaller branch
The genitofemoral nerve (L1, 2) emerges from the anterior
unites with a branch of the second lumbar to form the
surface of the psoas major. Its genital branch enters the
genitofemoral nerve.
inguinal canal through the deep ring, and runs in the sper-
The remainder of the second nerve, and the third and
matic cord, supplying cremaster and a small area of scrotal
fourth nerves, divide into ventral and dorsal divisions. The
skin in males. In females, it accompanies the round liga-
ventral division of the second unites with the ventral divi-
ment. The femoral branch passes down behind the inguinal
sions of the third and fourth nerves to form the obturator
ligament with the femoral artery (superficial and lateral to
nerve. The dorsal divisions of the second and third nerves
it), and pierces the femoral sheath and fascia lata to supply
divide into two branches, a smaller branch from each
the skin over the femoral triangle.
uniting to form the lateral cutaneous nerve of the thigh,
and a larger branch from each joining with the dorsal divi-
sion of the fourth nerve to form the femoral nerve. The lateral cutaneous nerve of thigh
The iliohypogastric and ilioinguinal nerves The lateral cutaneous nerve of the thigh (lateral femoral
cutaneous nerve) arises from the dorsal divisions of the
The iliohypogastric (L1) and ilioinguinal (L1) nerves second and third lumbar nerves. It emerges from the lateral
emerge from the upper part of the lateral border of border of the psoas major about its middle, and crosses the

DOI: 10.1016/B978-0-7020-3148-9.00031-1
T12 The medial cutaneous nerve passes obliquely across the

Iliohypogastric L1 upper part of the sheath of the femoral artery, and divides
nerve in front or at the medial side of that vessel into two branches:
L2
Ilioinguinal an anterior and a posterior. The anterior branch runs down-
nerve L3 ward on the sartorius, perforates the fascia lata at the lower
L4 third of the thigh, and divides into two branches. The pos-
Femoral L5
terior branch descends along the medial border of the sar-
nerve torius muscle to the knee, where it pierces the fascia lata,
Deep communicates with the saphenous nerve, and gives off
Lateral ring Obturator
cutaneous nerve several cutaneous branches.
Lumbosacral
nerve of The posterior division of the femoral nerve gives off the
trunk
thigh Superficial ring saphenous nerve, and muscular and articular branches.
Inguinal ligament
Ilioguinal nerve The saphenous nerve
The saphenous nerve is the largest cutaneous branch of the
Genitofemoral Genitofemoral
femoral nerve. It approaches the femoral artery where this
nerve (femoral nerve (genital
branch L1) branch L2) vessel passes beneath the sartorius, and lies in front of it,
behind the aponeurotic covering of the adductor canal, as
Figure 23.1 Lumbar plexus anatomy.
far as the opening in the lower part of the adductor magnus.
Here it leaves the artery and emerges from behind the lower
edge of the aponeurotic covering of the canal; it descends
vertically along the medial side of the knee behind the
sartorius, pierces the fascia lata between the tendons of the
iliacus muscle obliquely toward the anterior superior iliac
sartorius and gracilis, and becomes subcutaneous.
spine. It passes under the inguinal ligament and over the
The nerve then passes along the tibial side of the leg,
sartorius muscle into the thigh, where it divides into two
accompanied by the great saphenous vein, descends behind
branches.
the medial border of the tibia, and at the lower third of the
The anterior branch becomes superficial about 10 cm
leg divides into two branches; one continues its course
below the inguinal ligament and divides into branches,
along the margin of the tibia and ends at the ankle, the
which are distributed to the skin of the anterior and lateral
other passes in front of the ankle and is distributed to the
parts of the thigh as far as the knee. The posterior branch
skin on the medial side of the foot, as far as the ball of
pierces the fascia lata and subdivides into branches, which
the great toe.
pass backward across the lateral and posterior surfaces of
the thigh, supplying the skin from the level of the greater
trochanter to the middle of the thigh. The obturator nerve
The femoral nerve The obturator nerve (L2, 3, 4) emerges from the medial
border of the psoas major, crosses the pelvic brim medial
The femoral nerve, the largest branch of the lumbar plexus, to the sacroiliac joint, and runs along the wall of the pelvis
arises from the dorsal divisions of the second, third, and to the obturator foramen, through which it passes above
fourth lumbar nerves. It descends through the fibers of the the obturator vessels. In the thigh, it divides into an anterior
psoas major, emerging from the muscle at the lower part and posterior branch. The anterior branch descends lying
of its lateral border, and passes down between it and on the adductor brevis deep to the pectineus and adductor
the iliacus muscle, behind the iliac fascia; it then runs longus. The posterior branch descends into the thigh
beneath the inguinal ligament into the thigh, and splits between the adductor longus and adductor magnus.
into an anterior and a posterior division. In the thigh, the The obturator nerve supplies the adductor muscles and
anterior division of the femoral nerve gives off anterior gracilis, and skin over the medial side of the thigh. Up to
cutaneous and muscular branches. The anterior cutaneous 57% of the population has no cutaneous branch of the
branches comprise the intermediate and medial cutaneous obturator nerve. For this reason, blockade of this nerve can
nerves. only be confirmed by motor testing.
The intermediate cutaneous nerve pierces the fascia lata An accessory obturator nerve is present in 29% of the
(and generally the sartorius) about 7.5 cm below the ingui- population. It descends along the medial border of the
nal ligament, and divides into two branches that descend psoas major, crosses the superior pubic ramus of the pelvis,
in immediate proximity along the forepart of the thigh to and passes under the pectineus, where it divides into several
supply the skin as low as the front of the knee. branches.
172
CHAPTER
Lumbar and sacral plexus anatomy 23
L4 between the lumbosacral trunk and the first sacral nerve.

Piriformis muscle The inferior gluteal vessels run between the second and
L5 Superior
Lumbosacral third sacral nerves. Collateral and terminal branches of the
gluteal
Superior trunk sacral plexus include:
artery
gluteal • Ventral collateral branches of the sacral plexus, which
S1
nerve Inferior are the nerve to the obturator internus muscle, the hem-
gluteal
Inferior
artery orrhoidal nerve, the pudendal nerve, and nerves to the
gluteal S2
various pelvic structures. All these nerves form the
nerve
S3 pudendal plexus (ventral branch of S4, anastomized
with the S2 and S3 branches of the sacral plexus). These
Sciatic nerve Perforating S4 nerves supply pelvic and perineal organs.
cutaneous nerve
• Dorsal collateral branches: the inferior and superior
Posterior femoral S5 gluteal nerves, the nerves to the piriformis, gemelli, and
cutaneous nerve Anococcygeal quadratus femoris muscles.
nerve
• The sacral plexus, which innervates the skin of the
Pudendal nerve medial part of the gluteal and posterior aspects of the
C1
thigh. It also innervates the hip joint and proximal
Figure 23.2 Sacral plexus anatomy. muscles of the thigh. More caudally, the plexus extends
as the sciatic nerve.
From the lower margin of the periformis, the sciatic nerve
passes into the buttock on the posterior surface of the
ischium. From midway between the greater trochanter and
Sacral plexus the ischial tuberosity, deep to the gluteus maximus, the
nerve passes vertically downward into the hamstring com-
The sacral plexus (Fig. 23.2) is formed by the lumbosacral partment. It lies posterior to the obturator internus, gemelli,
trunk (L4,L5) and the ventral rami of the first, second, and quadratus femoris, and adductor magnus, but it is crossed
third sacral nerves. The nerves forming the sacral plexus posteriorly by the long head of biceps femoris. The sciatic
appear at the medial margin of the psoas major, converge nerve usually divides into the tibial and common peroneal
toward the greater sciatic notch, and unite to form a large nerves at the upper angle of the popliteal fossa. It occasion-
band located on the posterior wall of the pelvic cavity, in ally divides into these components within the pelvis, and
front of the piriformis muscle. From the anterior and pos- the common peroneal part pierces the piriformis as it leaves
terior surfaces of the band several branches arise. The band the pelvis.
itself is continued as the sciatic nerve, which splits on the From the apex of the popliteal fossa, the tibial nerve (L4,
back of the thigh into the tibial and common peroneal 5, S1, 2, 3) passes vertically down deep to the heads of
nerves; these two nerves sometimes arise separately in gastrocnemius but superficial and lateral to the popliteal
the plexus. vein and artery. In the popliteal fossa it supplies skin, the
knee joint, calf muscles, and popliteus; it gives the sural
nerve, which descends between the two heads of gastrocne-
Relations mius, accompanied by the small saphenous vein to the
back of the lateral malleolus and the lateral border of the
The sacral plexus lies on the posterior aspect of the pelvis foot, supplying the overlying skin. The tibial nerve passes
between the piriformis and the pelvic fascia. In front of it down the leg deep to the soleus, supplying the deep muscles,
are the hypogastric vessels, the ureter, and the sigmoid and reaches the medial side of the ankle, between the mal-
colon. The gluteal vessels follow the same course as the leolus and the heel; here it divides into lateral and medial
sacral nerves but in a more anterior plane. The pelvic fascia plantar nerves.
is fixed medially on the anterior sacral foramina, where the From the apex of the popliteal fossa, the common pero-
sacral nerves emerge. Through this fascia, the sacral plexus neal nerve (L4, 5, S1, 2) passes downward and laterally,
lies near the rectum. Laterally, the sacral plexus lies close to medial to the biceps tendon, and turns round the neck of
the greater sciatic foramen, sandwiched by the obturator the fibula in the substance of the peroneus longus, where
internus muscle. The sacral plexus runs in a fascial plane it divides into superficial and deep peroneal nerves. The
limited by the pelvic fascia ventrally, the piriformis dor- superficial peroneal nerve supplies the peroneus longus and
sally, and medially and laterally by the obturator internus brevis, and emerges between them to supply the skin of the
muscle. Hypogastric vessels are located near the sacral lower leg and much of the dorsum of the foot. The deep
plexus as well as the superior gluteal artery, which passes peroneal nerve passes into the anterior compartment of the
173

Ilioinguinal Iliohypogastric
Subcostal Subcostal
T12
Femoral (of Posterior S4
genitofemoral) femoral
S5 S3
cutaneous L1
Lateral
femoral Cutaneous
cutaneous branch of
obturator L2 L2
Cutaneous
branch of Lateral
obturator femoral
cutaneous L3 L3
Intermediate
femoral Medial
cutaneous femoral L3
cutaneous
Medial
femoral Lateral sural L4 L4
cutaneous L5
L5
Superficial
Lateral sural peroneal
Saphenous Saphenous
Sural Sural S1 S1
Superficial Medial
peroneal calcaneal
Deep Medial
peroneal and lateral
plantar
Figure 23.4 Sensory dermatomes of the lower limb.
Figure 23.3 Cutaneous innervation of the lower limb.
leg to supply the muscles here, and proceeds to the foot matching a peripheral nerve stimulation response to the
between the two malleoli to supply the skin of the first particular nerve being stimulated.
web space.
The sensory and motor innervation of the lower limb
(Figs 23.3 and 23.4) is clinically important. Knowledge of Suggested reading
sensory innervation helps determine which cutaneous
nerve distributions within a surgical field require blockade. Williams PL, Warwick R, Dyson M, et al. Gray’s anatomy.
Motor innervation is clinically relevant as a means of 37th ed. London: Churchill Livingstone; 1989.
174
CHAPTER
24
Posterior sciatic block
pelvis into the gluteal region through the greater sciatic

Indications foramen below the piriformis muscle, and descends
between the greater trochanter of the femur and the ischial
Surgery Surgical procedures on the lower limb from the
tuberosity (Figs 24.1 and 24.2). Once it emerges from under
knee distally, including Achilles’ tendon repair and most
cover of the gluteus maximus, it becomes superficial as it
foot surgery (excluding the area supplied by the saphenous
passes down the posterior thigh.
nerve); in combination with a lumbar plexus block for knee
It divides at a variable distance, often two-thirds of the
surgery, including total knee replacement and cruciate liga-
way down the posterior thigh, into the common peroneal
ment repair.
and tibial nerves.
Therapeutic Prolonged postoperative analgesia (continu-
The sciatic nerve provides sensory innervation to the pos-
ous technique); neuralgia; postamputation pain.
terior thigh, the lateral portion of the leg below the knee
(the medial aspect being supplied by the saphenous nerve,
a branch of the femoral nerve), and most of the foot. It also
Contraindications supplies innervation to the head of the femur and partially
to the capsule of the hip joint. It supplies motor innerva-
Absolute tion to the hamstrings and all muscle groups distal to
See Chapter 4. the knee.
Relative
Hemorrhagic diathesis; anticoagulation therapy; local Surface anatomy
neural injury; patient difficulty turning into lateral decubi-
tus position; and risk of lower extremity compartment Important bony structures for the posterior sciatic block
syndrome (e.g. fresh fractures of the tibia and fibula, or include the greater trochanter of the femur, the posterior
especially, traumatic and extensive elective orthopedic pro- superior iliac spine, and the sacral hiatus. The greater tro-
cedures of the tibia and fibula). chanter can be difficult to identify exactly. It can be identi-
fied by palpating the lateral aspect of the proximal femur;
‘walking’ upward, one’s finger tends to ‘fall off’ the bone
Clinical anatomy when the apex of the greater trochanter is reached. The apex
of the greater trochanter lies approximately a hand’s breadth
The sciatic nerve originates from the lumbar and sacral below the lateral aspect of the iliac crest. It is easier to
plexes and is the largest nerve in the body. The ventral rami palpate when the patient’s hip is passively abducted to relax
of L4 and L5 join with those of S1, 2, and 3 to form the the gluteus medius and maximus. The posterior superior
sciatic nerve. It is made up of two major nerves: the common iliac spine is the bony prominence at the posterior end of
peroneal and the tibial. The sciatic nerve arises on the pelvic the iliac crest. It is directly below the ‘sacral dimple’ (dimple
surface of the piriformis muscle. It then passes out of the of Venus), a depression in the skin visible above the buttock,
DOI: 10.1016/B978-0-7020-3148-9.00032-3
7 1
8
6 9 2
3
5 4
3
4
1

sciatic block technique. 1: retracted gluteus maximus; 2: gluteus medius;
3: piriformis; 4: superior and inferior gemelli; 5: quadratus femoris; Figure 24.3 Landmarks for the posterior sciatic block. The greater tro-
6: sciatic nerve; 7: posterior cutaneous nerve of thigh; 8: inferior gluteal chanter (1) and posterior superior iliac spine (2) are marked. The mea-
nerve and artery; 9: superior gluteal artery. sured distance between these points is divided equally. A perpendicular
line is drawn extending into the thigh; 5 cm down this line is the needle
insertion point (3). A line drawn from the greater trochanter to the sacral
hiatus (4) should intersect this point.
2
4 3
Figure 24.4 Patient position for the ultrasound-guided posterior
sciatic nerve block.
5
Figure 24.2 Axial T1-weighted MR image showing anatomy of sciatic

nerve at site of block using the classical posterior approach of Labat.
Sonoanatomy
1: greater trochanter; 2: quadratus femoris muscle; 3: ischial tuberosity;
4: sciatic nerve; 5: gluteus maximus muscle.
The patient is positioned laterally, with the side to be anes-
thetized uppermost and with the hip and knee flexed (Fig.
24.4). Perform a systematic anatomical survey from cepha-
close to the midline. Palpation from the iliac crest can help lad to caudad and from superficial to deep using a low-
to correctly identify the posterior superior iliac spine. frequency, 5–2 MHz, curved array ultrasound transducer.
A consistent method of outlining the greater trochanter The prominence of the greater trochanter and the ischial
is needed because this is a large structure and variations can tuberosity are identified. These are seen as hyperechoic lines
affect further marking. It is suggested that the outer perim- with shadowing beneath. On a sonogram, the ‘subgluteal
eter of the greater trochanter is used for line drawings. A space’ is seen as a hypoechoic area between the hyperechoic
line is drawn between the posterior superior iliac spine and perimysium of the gluteus maximus and the quadratus
the greater trochanter (Fig. 24.3). This line is bisected and femoris muscles (Fig. 24.5). It extends from the greater
a perpendicular line is drawn passing downward from its trochanter laterally to the ischial tuberosity medially. At
midpoint. A further line is drawn from the sacral hiatus to this level, the sciatic nerve is seen as an oval hyperechoic
the greater trochanter. The point at which this line intersects nodule approximately 1.5–2 cm in diameter within the
with the perpendicular line marks the point for needle subgluteal space. It is often difficult to see the sciatic
insertion. The intersection is usually 5 cm along the per- nerve due to tissue depth and reflections of muscles and
pendicular line. fascial coverings. Follow the nerve by scanning proximally
176
CHAPTER
Posterior sciatic block 24
Medial SN GM Lateral
GT
IT
QF
Figure 24.5 Transverse sonogram between the greater trochanter

(GT) and ischial tuberosity (IT) showing the hypoechoic subgluteal Figure 24.7 Posterior landmark-based sciatic block technique.
space between the hyperechoic perimysium of the gluteus maximus The needle is inserted in a 90° orientation to all planes.
(GM) and the quadratus femoris muscle (QF). The sciatic nerve
(SN) is seen as a hyperechoic nodule in the medial aspect of the
subgluteal space.
1
2
Figure 24.6 Patient position for the posterior landmark-based 3 4

approach to sciatic nerve block. The patient is placed in the lateral posi-
tion with a slight forward tilt. The upper hip is flexed, with the foot
resting on the extended knee of the lowermost limb.
Figure 24.8 Axial T1-weighted MR image after injection of 20 mL of
contrast, showing spread of contrast. Note spread toward the sacral
(cephalad) and distally (caudad) to follow the course of the roots and lateral wall of the pelvis. 1: ischium; 2: sciatic nerve roots;
nerve. It may be necessary to first identify the nerve in the 3: gluteus maximus muscle; 4: sacrum.
posterior thigh region and then trace the nerve proximally,
should visualization be difficult.
slowly until the appropriate muscle response is obtained:

Technique tibial nerve component produces plantar flexion and inver-
sion of the foot, while common peroneal stimulation pro-
Landmark-based approach duces dorsiflexion and eversion of the foot. Hamstring
contraction should not be accepted as a suitable response
As for all regional anesthetic procedures, after checking that because it can be due to direct gluteal muscle stimulation.
emergency equipment is complete and in working order, The nerve is usually 7–9 cm deep to the skin. If bone is
intravenous access, ECG, pulse oximetry, and blood pres- contacted, the needle is redirected medially or laterally. The
sure monitoring are established. Asepsis is observed. initial stimulating current should be kept at 0.75 mA or less
The patient is placed in the lateral decubitus (Sims) posi- because direct stimulation of the gluteus maximus muscle
tion (Fig. 24.6). A 100-mm insulated needle is used. The (Fig. 24.2) with higher currents can mimic sciatic nerve
stimulating current is set at 0.75 mA, 2 Hz, and 0.1 ms. The stimulation. The needle may stimulate the inferior gluteal
needle is oriented 90° to all planes (Fig. 24.7) and advanced nerve (a branch from the sacral plexus). This results in
177
rhythmic contractions of gluteus maximus; in this circum- of the needle tip. A free hand technique rather than the use
stance, the sciatic nerve is a few centimeters deeper and of a needle guide is preferred. A 21-GA × 120-mm insulated
possibly 1 cm laterally. It is best to reattempt the block with regional block needle (Pajunk, Geisingen, Germany; or B.
needle insertion 1 cm lateral to the original site. The needle Braun, Bethlehem PA) is inserted within the plane of
position is adjusted while reducing the current to 0.35 mA imaging to visualize the entire shaft and bevel along the
with maintenance of the muscle response. path of the ultrasonic beam (Fig. 24.10). The needle is
Incremental injections of local anesthetic are made with attached to sterile extension tubing, which is connected to
repeated aspiration. For this block, 20 mL of local anes- a 20-mL syringe and flushed with local anesthetic solution
thetic is adequate. to remove all air from the system. The operator can slide
and tilt the transducer to maintain the needle tip within the
Ultrasound-guided approach plane of imaging as much as possible. The needle tip should
be clearly identified within the plane of imaging before
Intravenous access, electrocardiogram (ECG), pulse oxim- advancing the needle. The needle is advanced until it reaches
etry and blood pressure monitoring are established. Maxi- the side of the target sciatic nerve (Fig 24.11).
mized comfort for the operator and patient is an important Once the needle tip has been confirmed by ultrasonogra-
step in pre-procedure preparation. For the ultrasound- phy to lie adjacent to the sciatic nerve, this can be con-
guided sub-gluteal sciatic block, the patient is placed in the firmed by using a nerve stimulator (Stimplex; B. Braun,
prone or lateral position. The operator stands on the side Bethlehem PA). If an electrical nerve stimulation technique
to be blocked with the ultrasound screen on the opposite is used, characteristic motor activity of either dorsi- or plantar-
side (Fig. 24.9). Room lights may be turned down to flexion is elicited in the foot. Test injections for assessment
enhance image viewing. The operating lights can be used of local anesthetic spread should be small (0.5–2 mL). If
to maintain some working lighting in the background. local anesthetic spread is not seen on the ultrasound screen,
The skin is disinfected with antiseptic solution and injection should be stopped. Local anesthetic is deposited
draped. A sterile sheath (CIVCO Medical Instruments, on four sides by manipulating the needle tip position. Local
Kalona, IA, USA) is applied over the ultrasound transducer anesthetic: 20 mL of lidocaine 2% with epinephrine
between the sterile sheath and the skin. The sub-gluteal
region is scanned in the transverse plain using a linear or
curvilinear transducer. The ultrasound screen should be
made to look like the scanning field. That is, the right side
of the screen represents the right side of the field. Adjustable
ultrasound variables such as scanning mode, depth of field,
and gain are optimized.
A skin wheal of local anesthetic is raised at the medial
aspect of the ultrasound transducer. The needle bevel should
face the active face of the transducer to improve visibility
ultrasound-guided posterior sciatic block. Note the needle orientation
LA
SN
Medial Lateral
Figure 24.11 Ultrasound image of the ultrasound-guided posterior

Figure 24.9 Global view of the block field for the ultrasound-guided sciatic block after administration of 20 mL of local anesthetic solution.
posterior sciatic nerve block. N: needle; LA: local anesthetic; SN: sciatic nerve.
178
CHAPTER
Posterior sciatic block 24
1 : 200 000. If the block is used for postoperative analgesia

bupivacaine 0.5% with epinephrine (1 : 200 000) or ropiva- CLINICAL PEARLS
caine 1% with epinephrine (1 : 200 000) can be used, which
• Sciatic nerve block in combination with femoral nerve block
give nearly 24 hours of analgesia. provides complete anesthesia to the lower limb
• Excellent block for Achilles’ tendon repair
Continuous technique • Observe the foot when nerve stimulation is used as the needle is
advanced
Continuous posterior sciatic block is similar to the single- • Can be used for continuous analgesia; however, there are better
shot technique, although it can be difficult to thread the approaches (e.g. parasacral)
catheter due to the perpendicular approach to the nerve. An • With ultrasound-guided techniques, various patient positions
can be used
alternate technique is to use the same needle insertion site
but to aim the needle caudally toward the midpoint between
the greater trochanter and the ischial tuberosity. An
insulated Tuohy needle, oriented appropriately, may be
useful to assist catheter placement with the classic posterior Suggested reading
landmark-based approach.
As with other continuous nerve block techniques, the di Benedetto P, Bertini L, Casati A, et al. A new posterior
initial dose of local anesthetic is usually injected and only approach to the sciatic nerve block: a prospective,
then is the infusion of a more dilute local anesthetic initi- randomized comparison with the classic posterior
ated. Once the local anesthetic is injected, the catheter is approach. Anesth Analg 2001;93:1040–1044.
carefully inserted some 5 cm beyond the tip of the needle Chan VW, Nova H, et al. Ultrasound examination and
while keeping the needle immobile. Other approaches to localization of the sciatic nerve: a volunteer sudy.
the sciatic nerve (including parasacral, subgluteal, and pop- Anesthesiology 2006;104(2):309–314.
liteal) are favored for continuous sciatic block. The catheter Chantzi C, Alevizou A, Saranteas T, et al. Usefulness of
should be accessible with the patient supine and thus the two to 5 MHz ultrasound probe in examination
secured in a lateral direction. Administer a continuous and block of the sciatic nerve in orthopedic trauma
infusion of ropivacaine 0.2% at 5–12 mL per hour, achiev- patients: a preliminary study. J Clin Anesth 2007;
ing postoperative analgesia without significant motor 19:486–488.
weakness. Labat G. Regional anesthesia: techniques and clinical
applications. Philadelphia: WB Saunders; 1924.
Oberndorfer U, Marhofer P, Bösenberg A, et al.
Adverse effects Ultrasonographic guidance for sciatic and femoral
nerve blocks in children. Br J Anaesth 2007;98(6):
• Neural injury is rare with the use of a nerve stimulator, 797–801.
but possible. Saranteas T, Chantzi C, Paraskeuopoulos T, et al. Imaging
• Local anesthetic toxicity due to intravascular injection; in anesthesia: the role of 4 MHz to 7 MHz sector
slow injection and careful aspiration after each 5 mL array ultrasound probe in the identification of the
should ensure safety. sciatic nerve at different anatomic locations. Reg
• Hematoma due to puncture of inferior gluteal vessels. Anesth Pain Med 2007;32:537–538.
179
CHAPTER
25
Anterior sciatic block
ischial tuberosity. It passes posterior to the lesser trochanter

Indications of the femur and here it is blocked by this approach. Once
it emerges from under cover of the gluteus maximus muscle,
Surgery Surgical procedures on the lower limb from the
it becomes superficial as it passes down the posterior thigh.
knee distally, including Achilles’ tendon repair and most
The site of division into the common peroneal and tibial
foot surgery (excluding the area supplied by the saphenous
nerves is highly variable, often two-thirds the way from the
nerve); in combination with a lumbar plexus block for knee
gluteal region to the popliteal fossa.
surgery, including total knee replacement and cruciate liga-
The sciatic nerve provides sensory innervation to the pos-
ment repair.
terior thigh, the lateral portion of the leg below the knee
(the medial aspect being supplied by the saphenous nerve),
ous technique); neuralgia; postamputation pain.
and most of the foot. It also supplies sensory innervation
to the head of the femur and partially to the capsule of the
Contraindications hip joint. It supplies motor innervation to the hamstring
muscles, and through its branches it supplies all muscle
groups distal to the knee.
Absolute
See Chapter 4.
Relative Surface anatomy
Hemorrhagic diathesis; anticoagulation therapy; local
neural injury; risk of lower extremity compartment syn- Important bony structures for the anterior landmark-based
drome (e.g. fresh fractures of the tibia and fibula, or sciatic block include the anterior superior iliac spine, the
especially traumatic and extensive elective orthopedic pubic tubercle, and the greater trochanter of the femur
procedures of the tibia and fibula); and distorted anatomy (Fig. 25.1). A line is drawn between the anterior superior
due to fractured femur. iliac spine and the pubic tubercle (along the inguinal liga-
ment). This line is divided into equal thirds. At the junction
between the medial one-third and the lateral two-thirds, a
Clinical anatomy perpendicular line is drawn extending into the thigh. A
further line is drawn from the greater trochanter, parallel to
The sciatic nerve originates from the lumbar and sacral the inguinal ligament. Where the perpendicular line crosses
plexus and is the largest nerve in the body. The ventral rami this line is the needle insertion point. Rotation of the hip
of L4 and L5 join with those of S1, 2, and 3 to form the due to leg position or pathology can change anatomic rela-
sciatic nerve. It is made up of two major nerves: the common tions; this must be remembered when the needle insertion
peroneal and the tibial. The sciatic nerve leaves the pelvis point is chosen. Important anatomic details include the
via the sciatic foramen below the piriformis, and then close proximity of the femoral nerve at the site of needle
passes between the greater trochanter of the femur and the insertion.
DOI: 10.1016/B978-0-7020-3148-9.00033-5
CHAPTER
Anterior sciatic block 25
3
1 4
Figure 25.2 Transverse transducer orientation for the ultrasound-

Figure 25.1 Landmarks for the anterior sciatic block. The anterior guided anterior sciatic nerve block.
superior iliac spine and pubic tubercle are marked. The measured dis-
tance between these points is divided into equal thirds. At the junction
between the medial one-third and lateral two-thirds, a perpendicular
line is drawn extending into the thigh. A second line is drawn, parallel
to the inguinal ligament from the greater trochanter. Where this
line intersects with the vertical line is the needle insertion point.
1: anterior superior iliac spine; 2: pubic tubercle; 3: inguinal ligament QM
AM
divided into equal thirds; 4: vertical line; 5: greater trochanter; 6: needle
insertion point.
SN
Lateral Medial
GMM
Sonoanatomy
F
The sciatic nerve may be difficult to visualize in this region
because of the required depth of beam penetration and the
use of a lower frequency transducer. A transverse transducer
orientation is used (Fig. 25.2). Visualization of the sciatic Figure 25.3 Transverse ultrasound image of the anterior thigh region
nerve may be obstructed by the lesser trochanter of the (approximately 8 cm from inguinal crease in adult). F: femur; QM: quad-
femur. Perform a systematic anatomical survey from proxi- riceps muscle; AM: adductor muscles; GMM: gluteus maximus muscle;
mal to distal and from lateral to medial. First identify the SN: sciatic nerve.
femur, a curved hyperechoic line with an underlying bone
shadow. Move the transducer proximally and distally to
identify the lesser trochanter. Identify the anterior muscular allow the transducer to capture the best possible transverse
layers: quadriceps muscles laterally and the adductor view of the sciatic nerve behind (posterior to) the lesser
muscles medially (approximately 8 cm from inguinal crease trochanter. Angle the transducer slightly cephalad or caudad
in adults; Fig. 25.2). Identify the gluteus maximus muscle to optimize the angle of incidence (90°) to capture the best
posteriorly. The gluteus maximus muscle bulk gets smaller possible nerve image. Scan the nerve proximally (cephalad)
as the transducer is moved more distally away from the and distally (caudad) to follow the course of the nerve and
inguinal crease. Locate the hyperechoic sciatic nerve deep to confirm nerve identity. A longitudinal scanning approach
to the adductor muscles and posterior to the femur (Fig. can also be used to identify the sciatic nerve at the lesser
25.3). The ultrasound image of the sciatic nerve in cross trochanter (Fig. 25.4).
section is typically seen as an oval-to-circular hyperechoic
structure. It is often vaguely delineated or appears isoechoic
to the surrounding muscles, the latter particularly if using Technique
a tangential ultrasound beam plane.
If the lesser trochanter obstructs visualization of the Landmark-based approach
sciatic nerve, move the transducer further on the medial
aspect of the anterior thigh and orient the transducer in a As for all regional anesthetic procedures, after checking
slightly anterior–posterior direction. This orientation will that emergency equipment is complete and functional,
181
AM
1
1
QM
SN
2
3
F GMM 4
Figure 25.4 Longitudinal ultrasound image of the anterior thigh

region. F: femur; QM: quadriceps muscle; AM: adductor muscles; GMM: Figure 25.6 Axial T1-weighted MR image showing anatomy of proxi-
gluteus maximus muscle; SN: sciatic nerve. mal thigh at site of injection for anterior approach to sciatic nerve block.
Note proximity of femoral nerve and vessels to track of needle.
1: Femoral nerve and vessels; 2: sciatic nerve; 3: gluteal vessels; 4: gluteus
maximus.
the sciatic nerve is usually stimulated 3–4 cm deeper (Fig.

25.6). Total needle depth to the sciatic nerve is approxi-
mately 70% of thigh thickness; usually 8–12 cm. The needle
is advanced slowly until the appropriate muscle response
is obtained: tibial nerve component produces plantar
flexion and inversion of the foot, while common peroneal
stimulation produces dorsiflexion and eversion of the foot.
The needle position is adjusted while reducing the current
to 0.35 mA with maintenance of the muscle response.
Hamstring contraction response is not accepted. On its path
to the sciatic nerve, femoral nerve stimulation may be ini-
tially found. To ensure safe practice, the femoral nerve
Figure 25.5 Anterior sciatic block technique. The needle is inserted
with a slightly lateral orientation. If the lesser trochanter is contacted, should not be blocked before sciatic nerve block.
the needle is withdrawn and aimed more medially. The sciatic nerve is Incremental injection of 20–30 mL of local anesthetic is
usually contacted at 8–12 cm from the skin, depending on thigh made with repeated aspiration.
thickness.
intravenous access, ECG, pulse oximetry, and blood pres- Intravenous access, electrocardiogram (ECG), pulse oxim-
sure monitoring are established. Asepsis is observed. etry and blood pressure monitoring are established.
The patient is placed in the supine position with the leg Maximized comfort for the operator and patient is an
in the neutral position. The operator stands on the side to important step in pre-procedure preparation. For the ultra-
be blocked, at the level of the patient’s thigh. The area of sound-guided anterior sciatic block, the patient is placed in
the needle track is anesthetized with local anesthetic. Anal- the supine position with the knee flexed and the ipsilateral
gesia or sedation is very desirable for this block. A 150-mm hip externally rotated. The operator stands on the side to
insulated needle is inserted perpendicularly with some be blocked with the ultrasound screen on the same side
lateral angulation in line with the lesser trochanter of the above the hip (Fig. 25.7).
femur (Fig. 25.5). The stimulating current is set at 1.2 mA, The skin is disinfected with antiseptic solution and
2 Hz, and 0.1 ms. draped. A sterile sheath (CIVCO Medical Instruments,
On contact with the lesser trochanter, the needle is with- Kalona, IA, USA) is applied over the ultrasound transducer
drawn, angulated in a less lateral orientation, and advanced; with sterile ultrasound gel (Aquasonic, Parker Laboratories,
182
CHAPTER
Anterior sciatic block 25
AM
QM
Lateral SN Medial
GMM
Figure 25.9 Needle end point for ultrasound-guided anterior sciatic

Figure 25.7 Global view of the block field for the ultrasound-guided block before injection. F: femur; QM: quadriceps muscle; AM: adductor
anterior sciatic nerve block. muscles; GMM: gluteus maximus muscle; SN: sciatic nerve.
as an anterior to posterior direction when the thigh is exter-

nally rotated.
The needle is attached to sterile extension tubing, which
is connected to a 20-mL syringe and flushed with local
anesthetic solution to remove all air from the system. The
operator can slide and tilt the transducer to maintain the
needle tip within the plane of imaging as much as possible.
The needle tip should be clearly identified within the plane
of imaging before advancing the needle. Because of the
steep angle of needle advancement, it may be difficult to
clearly visualize the block needle. Often, needle and tissue
(muscle) movements are observed without a clear view of
Figure 25.8 Ultrasound transducer and needle positioning during the the needle shaft and tip. Also adjustment in needle direc-
ultrasound-guided anterior sciatic block. Note the needle orientation in tion can be technically challenging. Change in needle angle
the same plane as the ultrasound beam. often requires needle withdrawal and a second needle
attempt through the adductor muscles.
The needle is brought in contact with the nerve, taking
care not to puncture it. If an electrical nerve stimulation
Fairfield, NJ, USA). Another layer of sterile gel is placed technique is used (recommended here) characteristic motor
between the sterile sheath and the skin. The anterior thigh activity of either dorsi- or plantar-flexion is elicited in the
region is scanned in the transverse plain with a low fre- foot. After negative aspiration, 1 mL of local anesthetic is
quency transducer. The ultrasound screen should be made injected. If spread of local anesthetic is satisfactory, then a
to look like the scanning field. That is, the right side of the further 3–4 mL of local anesthetic is injected. The needle
screen represents the right side of the field. Adjustable ultra- tip is readjusted posterior to the nerve and another aliquot
sound variables such as scanning mode, depth of field, and of local anesthetic is deposited around it. The needle tip is
gain are optimized. manipulated if required to deposit anesthetic on all sides
A skin wheal of local anesthetic is raised at a distance of the sciatic nerve.
from the medial aspect of the ultrasound transducer to A hypoechoic (fluid) expansion can be seen during local
facilitate sterility and allow a shallow angle of approach to anesthetic injection (Fig. 25.10). Fluid expansion in the
improve needle visualization. The needle bevel should face adductor muscles indicates intramuscular injection. Appro-
the active face of the transducer to improve visibility of the priate needle advancement is required. Inject 15–20 mL of
needle tip. A free hand technique rather than the use of a local anesthetic for postoperative analgesia.
needle guide is preferred. A 22-GA × 120-mm insulated
regional block needle (B. Braun, Bethlehem PA) is inserted Continuous technique
within the plane of imaging to visualize the entire shaft and
bevel along the path of the ultrasonic beam (Fig. 25.8). Continuous anterior sciatic block is similar to the single-
Advance the needle in a medial to lateral direction as well shot technique. As this approach is perpendicular to the
183
CLINICAL PEARLS
• This block is useful if patients cannot turn on their side.
AM • Fracture of the femur significantly distorts the anatomy.
QM • Sedation is appropriate.
Lateral SN Medial • This block does not always block the posterior cutaneous nerve
of the thigh, which is required if a thigh tourniquet is to be used.
GMM • Ultrasound-guided sciatic nerve block in the anterior thigh is
F considered an intermediate to advanced skill level block. Both
In Plane (IP) and Out of Plane (OOP) approaches are challenging
to perform.
Figure 25.10 Needle end point for ultrasound-guided anterior sciatic

block after injection. F: femur; QM: quadriceps muscle; AM: adductor
muscles; GMM: gluteus maximus muscle; SN: sciatic nerve, LA: local
anesthetic.
Suggested reading
Beck GP. Anterior approach to the sciatic nerve.
nerve, an insulated Tuohy needle oriented appropriately Anesthesiology 1963;24:222–224.
may be useful to assist catheter placement. Chan VW, Nova H, Abbas S, et al. Ultrasound examination
As with other continuous nerve block techniques, the and localization of the sciatic nerve: a volunteer study.
initial dose of local anesthetic is usually injected and only Anesthesiology 2006;104(2):309–314.
then is the infusion of a more dilute local anesthetic initi- Chantzi C, Saranteas T, Zogogiannis J, et al. Ultrasound
ated. Once the local anesthetic is injected, the catheter is examination of the sciatic nerve at the anterior thigh
carefully inserted some 5 cm beyond the tip of the needle in obese patients. Acta Anaesthesiol Scand
while keeping the needle immobile. Other approaches to 2007;51(1):132.
the sciatic nerve (including parasacral, subgluteal, and pop- Elsraete V, Poey C, et al. New landmarks for the anterior
liteal) are favored for continuous sciatic block. approach to the sciatic nerve block: imaging and
clinical study. Anesth Analg 2002;95:214–218.
Ota J, Sakura S, Hara K, Saito Y. Ultrasound-guided
Adverse effects anterior approach to sciatic nerve block: a
comparison with the posterior approach. Anesth
• Hematoma is possible, especially if the patient is receiv- Analg 2009;108(2):660–665.
ing anticoagulants Tsui BC, Ozelsel TJ. Ultrasound-guided anterior sciatic
• Neural injury to sciatic nerve and possibly femoral nerve block using a longitudinal approach:
nerve, especially if the femoral nerve is blocked ‘expanding the view’. Reg Anesth Pain Med
initially. 2008;33(3):275–276.
184
CHAPTER
26
Femoral nerve block
the muscle at the lower part of its lateral border, and passes
Indications down between it and the iliacus muscle, deep to the fascia
iliaca (Fig. 26.1). It then passes behind the inguinal liga-
Surgical Muscle biopsy; skin-graft donor site; patellar frac-
ment to enter the thigh. The nerve lies deep to the fascia
ture fixation or wiring; combined with other techniques for
lata and fascia iliaca. The fascia iliacus separates it from the
saphenofemoral vein ligation; hip fracture repair and hip
vascular bundle containing the femoral artery and vein (Fig.
and knee replacement; above- and below-knee amputation;
26.2). It divides into two major branches (anterior and
knee arthroscopy; repair of fractured shaft of femur; ankle
posterior) early in the proximal anterior thigh (Fig. 26.1).
and foot surgery.
The anterior branch provides cutaneous innervation to
Therapeutic Postoperative analgesia (continuous tech-
the skin overlying the anterior surface of the thigh and
nique) and rehabilitation in cruciate ligament reconstruc-
provides motor innervation to the sartorius muscle. The
tion and knee replacement; postherpetic neuralgia; complex
posterior branch provides innervation to the quadriceps
regional pain syndrome; postamputation pain; tumor-
muscle and the knee joint and gives rise to the saphenous
related pain.
nerve, which innervates the medial side of the leg below
the knee.
Contraindications
Absolute
Surface anatomy
See Chapter 4. The main landmarks for femoral nerve block are the ante-
Relative rior superior iliac spine, the pubic tubercle, inguinal liga-
Hemorrhagic diathesis; anticoagulation treatment; local ment, inguinal crease, and femoral artery (Fig. 26.3). The
neural injury; situations where a dense sensory block could pubic tubercle can be palpated three fingers’ breadth from
mask the onset of lower extremity compartment syndrome the midline, along the upper border of the pubis. The ingui-
(e.g. fresh fractures of the tibia and fibula, or especially nal ligament is outlined by a line connecting the anterior
traumatic and extensive elective orthopedic procedures of superior iliac spine and the pubic tubercle.
the tibia and fibula); and distorted anatomy due to previ- The femoral artery lies approximately at the intersection
ous surgery or trauma (e.g. prosthetic femoral artery graft). of the medial third and lateral two-thirds of the inguinal
ligament (the midinguinal point). The femoral nerve is
found lateral to the femoral artery (NAVL: nerve, artery,
Clinical anatomy vein, and ligament as you go toward the midline). The
inguinal crease is a skin fold 3–6 cm below and parallel to
The femoral nerve arises from the ventral rami of the the inguinal ligament. Here the artery lies at its most super-
second, third, and fourth lumbar nerves. It descends ficial and where relations are usually constant. Below this
through the substance of the psoas major, emerging from point, the nerve begins to disappear behind the artery.
DOI: 10.1016/B978-0-7020-3148-9.00034-7
Figure 26.3 Landmarks for the femoral nerve block. The anterior supe-
rior iliac spine, pubic tubercle, and inguinal ligament are outlined. The
femoral artery is identified at the level of the inguinal crease.
1
3
5
4 Lateral Medial
2 FN
FA
6 FV
7
8
Figure 26.4 Transverse ultrasound image of the femoral nerve lateral

Figure 26.1 Cadaver structures illustrating anatomy relevant to to the femoral artery and femoral vein, using an 8-14 MHz linear ultra-
femoral nerve block technique. 1: Anterior superior iliac spine; 2: pubic sound transducer. FA: femoral artery; FV: femoral vein; FN: femoral nerve.
tubercle; 3: inguinal ligament with sectioned abdominal muscles;
4: sartorius muscle; 5: iliopsoas muscle; 6: femoral nerve; 7: femoral
artery; 8: femoral vein.
Sonoanatomy
The femoral nerve is found lateral to the femoral artery in
the groin, lying outside the femoral sheath and beneath the
1 fascia lata and iliaca. These fascial layers are seen as hyper-
1 2 3
echoic lines. Its appearance on ultrasound (Fig. 26.4) is
similar to many peripheral nerves, and described as mul-
tiple round or oval hypoechoic (dark) areas encircled by
hyperechoic (bright) rims. The hypoechoic structures are
the nerve fascicles. The femoral nerve may be identified on
ultrasound as an oval (95% oval beneath the inguinal liga-
ment) or triangular-shaped structure measuring approxi-
mately 3 mm in anteroposterior diameter and 10 mm in
mediolateral diameter. Correct transducer angulation is
essential for adequate nerve visualization. Femoral nerve
Figure 26.2 Axial T1-weighted MR image of anatomy relevant to anisotropy occurs with transducer angulation of as little
femoral nerve block. 1: Femoral vein and artery; 2: femoral nerve; as 10° from the vertical. Anisotropy is a property of
3: iliopsoas muscle. muscles, nerves, and tendons which relates to the change
186
CHAPTER
Femoral nerve block 26
Figure 26.5 Orientation of the ultrasound transducer when perform- Figure 26.7 Femoral nerve block technique. The needle is inserted
ing the femoral nerve block. It is directed in a transverse plane to the adjacent to the femoral artery at the level of the inguinal crease. The
femoral artery. needle is oriented in a 45° cephalad orientation.
Technique
FN FA emergency equipment is complete and in working order,
FV intravenous access, ECG, pulse oximetry, and blood pres-
The patient is placed in the supine position with the
operator standing on the side to be blocked, at the level of
the patient’s thigh. The needle insertion point is infiltrated
with local anesthetic using a 25-G needle. A 50-mm 21-G
insulated needle is oriented in a 45° cephalad and posterior
orientation lateral to the palpated femoral artery at the
inguinal crease (Fig. 26.7). The stimulating current is set at
1.0 mA, 2 Hz, and 0.1 ms.
The needle is advanced slowly until the appropriate
Figure 26.6 Ultrasound identification of femoral vessels with colorflow
muscle response is obtained: quadriceps contraction with
Doppler. FN: femoral nerve; FA: femoral artery; FV: femoral vein. resultant rhythmic patellar movement. The needle position
is adjusted while decreasing the current to 0.35 mA with
maintenance of the muscle response. Initial stimulation
currents should be less than 1.0 mA if the patient has a
in ultrasound appearance of the target structure with the fractured shaft of femur, as muscle twitches can be painful.
scanning angle used. Nerves are best visualized when the Frequently a ‘pop’ can be felt as the needle penetrates the
ultrasound beam hits them at 90°. In this case, the femoral fascia (usually at 2–3 cm), although this is often less
nerve becomes isoechoic with surrounding structures, and obvious in elderly patients.
disappears from view, when the transducer is angled 10– Incremental injections of local anesthetic are made with
13° from the vertical. repeated aspiration. Fifteen milliliters of local anesthetic
To identify the femoral nerve, the transducer is placed will adequately block the femoral nerve, but if a three-in-
over the femoral vessels on the anterior thigh at 90° to the one block is required then use 30 mL in an adult (Figs 26.8
expected orientation of the nerve and vessels (Fig. 26.5). and 26.9). If a quadriceps contraction is not elicited, the
The vessels may be identified as large round hypoechoic needle is aimed 10° laterally. Contraction of the sartorius
structures, and blood flow may be demonstrated using muscle is not appropriate; the needle should be oriented
colorflow Doppler (Fig. 26.6). The femoral nerve is then 10° laterally from this point and inserted slightly deeper.
visualized a variable distance lateral to the femoral artery. Multi-injection techniques have been described.
187
1 4
3
3
24
Figure 26.8 Axial T1-weighted MR image showing the spread of con-

trast to the obturator nerve and vessels inferomedial to the psoas
muscle. This perhaps would account for the three-in-one block that can
occur with this technique. It appears that the contrast spreads in a
fascial plane between the psoas and iliacus muscles and ‘spills over’ the
psoas on to its inferomedial border where the obturator nerves run. 5
1; Psoas muscle; 2; contrast; 3; iliacus muscle; 4; obturator nerve.
The ultrasound machine and block tray should be placed
in positions which allow the operator to simultaneously
scan the patient and take items from the block tray with
minimal movement. This setup may take some forethought
but is a worthwhile exercise, and will facilitate successful
regional anesthesia.
The operator stands or sits on the side to be blocked,
and with the patient in a supine position (Fig. 26.10). The
skin is disinfected with antiseptic solution and draped. A Figure 26.9 Sagittal T1-weighted MR image of spread after injection
of 30 mL of contrast. Note similarity of spread in Figure 26.8. Note that
sterile sheath (CIVCO Medical Instruments, Kalona, IA, contrast covers the femoral nerve and spreads laterally toward the ante-
USA) is applied over the ultrasound transducer with sterile rior superior iliac spine, where the lateral cutaneous nerve of the thigh
ultrasound gel (Aquasonic, Parker Laboratories, Fairfield, lies. The contrast did not reach the roots of the lumbar plexus. 1: Ante-
NJ, USA). Another layer of sterile gel is placed between rior superior iliac spine; 2: psoas muscle; 3: iliacus muscle; 4: contrast
the sterile sheath and the skin. The infrainguinal region is spread; 5: injection site.
scanned with a 6–13 MHz linear transducer. The ultra-
sound screen should be made to look like the scanning
field. That is, the right side of the screen represents the
right side of the field. Adjustable ultrasound variables extension tubing, which is connected to a 20 mL syringe
such as scanning mode, depth of field, and gain are and flushed with local anesthetic solution to remove all air
optimized. from the system. It is then introduced at the lateral-most
A transverse image of the femoral nerve, artery, and vein end of the transducer and visualized along its entire path
is obtained (Fig. 26.4). The femoral nerve is kept in the to the femoral nerve (Fig. 26.12). It is important not to
centre of the field of view. The needle entry site is at the advance the needle without good visualization. This may
lateral-most end of the linear transducer. A 23-gauge needle require needle or ultrasound transducer adjustment.
is advanced under real-time ultrasound guidance and local Once the needle has approached the femoral nerve,
anesthetic is deposited along the needle entry path. A free 1–2 mL of local anesthetic may be injected to confirm correct
hand technique rather than the use of a needle guide is needle placement. Local anesthetic appears as a hypoechoic
preferred. A 21-GA × 50-mm insulated needle (B. Braun, image. Correct needle placement is confirmed by observing
Bethlehem PA) is inserted parallel to the axis of the beam solution surrounding the femoral nerve (Fig. 26.13). Should
of the ultrasound transducer, with the bevel facing the this not occur, the needle may need to be repositioned, and
transducer (Fig. 26.11). The needle is attached to sterile the procedure repeated. Following confirmation of correct
188
CHAPTER
FV
LA
Lateral FA Medial
FN
Figure 26.13 Transverse ultrasound image at the level of the inguinal

crease showing local anesthetic spread using an 8–14 MHz linear ultra-
sound transducer. LA: local anesthetic; FA: femoral artery; FV: femoral
vein; FN: femoral nerve.
inguinal crease to avoid the catheter kinking at the femoral

Figure 26.10 Global view of the block field for the ultrasound-guided crease. As with other continuous nerve block techniques,
femoral nerve block. the initial dose of local anesthetic is usually injected and
only then is the infusion of a more dilute local anesthetic
initiated. Once the local anesthetic is injected, the catheter
is carefully inserted some 5 cm beyond the tip of the needle
while keeping the needle immobile. When the catheter
meets resistance at the tip of the needle, the needle may be
repositioned at a different angle, or rotated to facilitate
advancement of the catheter. Once the catheter is inserted,
the needle is withdrawn while simultaneously advancing
the catheter to prevent its dislodgment. The catheter is
secured with a transparent dressing. Ultrasound-guided
versus neurostimulation-assisted catheter placement is
associated with similar postoperative analgesia but
Figure 26.11 Ultrasound transducer and needle positioning during decreased procedure-related pain and performance time.
ultrasound-guided femoral nerve block. Note the needle orientation in
the same plane as the ultrasound beam.
Ultrasound can be used postoperatively to assess continued
correct positioning of the catheter.
Saphenous nerve block landmark-based approach

The saphenous nerve is a branch of the femoral nerve and
N
FV provides cutaneous sensation to the medial aspect of the
Lateral Medial
FA ankle and a variable portion of the medial foot. It is prob-
FN
ably most consistently blocked by femoral block; however,
it can be blocked separately at the level of the knee.
The saphenous nerve passes within the adductor canal
beneath the sartorius muscle, and then curves around the
Figure 26.12 Real-time imaging of needle insertion for the ultrasound- posteriomedial aspect of the knee to divide into branches
guided femoral nerve block. Notice the needle shaft marked with arrows along the anteriomedial aspect of the proximal tibia
and the needle tip (N) in close proximity to the femoral nerve. N: needle (Fig. 26.14).
tip; FA: femoral artery; FV: femoral vein; FN: femoral nerve. Several techniques for block of the saphenous nerve have
been described. The tibial tuberosity can be felt as a bony
needle placement, 10–20 mL of local anesthetic solution prominence inferior to the patella. The gastrocnemius
can be injected to achieve blockade. muscle can be palpated medially from the tibial tuberosity
and is a relevant anatomic landmark for saphenous nerve
Continuous technique block. The saphenous nerve is blocked by subcutaneous
injection from the tibial tuberosity to the gastrocnemius
Continuous femoral block is similar to the single-shot tech- muscle. An ellipse of local anesthetic is injected with
nique. The insertion point, however, is slightly above the 4–6 mL of solution.
189
2
1
3
4
4
5
3
Figure 26.14 Cadaver structures illustrating anatomy relevant to

saphenous nerve block at the knee. 1: Tibial tuberosity; 2: patella; Figure 26.15 Global view of the block field for the ultrasound-guided
3: semi-tendinosus and semi-membranosus muscles; 4: saphenous saphenous nerve block.
nerve branches; 5: long saphenous vein.
Saphenous nerve block ultrasound-guided approach

The ultrasound machine and block tray should be placed SV SN
minimal movement.
The operator stands on the side to be blocked, with the
patient in a supine position, the knee flexed to 45° and the
hip externally rotated (Fig. 26.15). The skin is disinfected
with antiseptic solution and draped. A sterile sheath (CIVCO T
Medical Instruments, Kalona, IA, USA) is applied over the
ultrasound transducer with sterile ultrasound gel (Aqua-
sonic, Parker Laboratories, Fairfield, NJ, USA). Another
layer of sterile gel is placed between the sterile sheath and Figure 26.16 Ultrasound identification of saphenous nerve and vein.
the skin. The infrainguinal region is scanned with a SN : saphenous nerve; SV : saphenous vein; T: tibia.
6–13 MHz linear transducer. The ultrasound screen should
be made to look like the scanning field. That is, the right
side of the screen represents the right side of the field.
Adjustable ultrasound variables such as scanning mode,
depth of field, and gain are optimized.
A transverse image of the great saphenous vein is obtained
(Fig. 26.16). A thigh tourniquet can facilitate this. The
saphenous vein is kept in the centre of the field of view.
The saphenous nerve lies in its proximity. The needle entry
site is at the lateral-most end of the linear transducer. A
23-gauge needle is advanced under real-time ultrasound
guidance and local anesthetic is deposited along the needle
entry path. A free hand technique rather than the use of a
needle guide is preferred. A 21-GA × 50-mm insulated
needle (B. Braun, Bethlehem PA) is inserted parallel to the
axis of the beam of the ultrasound transducer (Fig. 26.17).
The needle is attached to sterile extension tubing, which is
connected to a 10 mL syringe and flushed with local anes- Figure 26.17 Ultrasound transducer and needle positioning during
thetic solution to remove all air from the system. It is then ultrasound-guided saphenous nerve block. Note the needle orientation
introduced at the lateral-most end of the transducer and in the same plane as the ultrasound beam.
190
CHAPTER
ment, 5–10 mL of local anesthetic solution can be injected

to achieve blockade. A trans-sartorial peri-femoral tech-
SV nique has also been described.
LA
Adverse effects
• Hematoma is unusual, even if the artery is perforated;
pressure should be applied to the needle insertion site
T • Neural injuries are extremely rare
• Local anesthetic toxicity due to injection into the femoral
artery; slow injection and careful aspiration after each
Figure 26.18 Transverse ultrasound image at medial aspect of the 5 mL should ensure safety.
knee showing local anesthetic spread around saphenous nerve using a
linear high frequency transducer. LA: local anesthetic; SV: saphenous
vein; T: tibia.
Suggested reading
visualized along its entire path to the saphenous nerve. It Casati A, Fanelli G, Beccaria P, et al. The effects of the
is important not to advance the needle without good visu- single or multiple injection technique on the onset
alization. This may require needle or ultrasound transducer time of femoral nerve blocks with 0.75% ropivacaine.
adjustment. Anesth Analg 2000;91:181–184.
Once the needle has approached the saphenous nerve, Fredrickson MJ, Ball CM, Dalgleish AJ, et al. A prospective
1–2 mL of local anesthetic may be injected. Local anes- randomized comparison of ultrasound and
thetic appears as a hypoechoic image. Correct needle place- neurostimulation as needle end points for
ment is confirmed by observing solution surrounding the interscalene catheter placement. Anesth Analg
saphenous nerve (Fig. 26.18). Should this not occur, the 2009;108(5):1695–1700.
needle may need to be repositioned, and the procedure Gray AT, Collins AB. Ultrasound-guided saphenous nerve
repeated. Following confirmation of correct needle place- block. Reg Anesth Pain Med 2003;28(2):148.
Gray AT, Collins AB, Schafhalter-Zoppoth I. An
introduction to femoral nerve and associated lumbar
CLINICAL PEARLS plexus nerve blocks under ultrasonic guidance.
Techniques in Regional Anesthesia and Pain
• Femoral block is more difficult to perform in patients with a Management 2004;8:155–163.
fractured femur, because the anatomy is frequently altered due Gruber H, Peer S, Kovacs P, et al. The ultrasonographic
to hematoma formation and external rotation of the lower limb. appearance of the femoral nerve and cases of
• The three-in-one block is similar to the classical femoral nerve iatrogenic impairment. J Ultrasound Med 2003;
block; larger volumes of local anesthetic and distal digital
pressure are technique modifications. Obturator anesthesia
22(2):163–172.
tends to be less reliable with the three-in-one than with the Marhofer P, Nasel C, Sitzwohl C, et al. Magnetic
lumbar plexus approach. Lateral cutaneous nerve of thigh resonance imaging of the distribution of local
anesthesia tends to be less reliable with the three-in-one than anesthetic during the three-in-one block. Anesth
with the iliacus compartment block.
Analg 2000;90:119–124.
• Femoral block is a superficial block and does not result in
significant patient discomfort; thus light premedication usually Tsui BC, Ozelsel T. Ultrasound-guided transsartorial
suffices. perifemoral artery approach for saphenous nerve
• Ultrasound guidance has been shown to: improve the quality of block. Reg Anesth Pain Med 2009;34(2):177–178.
femoral nerve block; increase the success rate of femoral nerve Vloka JD, Hadzic A, Drobnik L, et al. Anatomical
block; decrease the onset time of femoral nerve block and
decrease the volume of local anesthetic solution required to
landmarks for femoral nerve block: a comparison of
perform femoral nerve block. four needle insertion sites. Anesth Analg 1999;89:
• Occasionally, an artery can be seen within the fibers of the 1467–1470.
femoral nerve; this occurs with a low take off of the deep Winnie AP, Ramamurthy S, Durrani Z. The inguinal
circumflex iliac artery, a branch of the profunda femoris artery. paravascular technique of lumbar plexus anesthesia:
the ‘3-in-1 block’. Anesth Analg 1973;52:989–996.
191
CHAPTER
27
Psoas block
the fascia iliaca. The erector spinae (medial) and quadratus

Indications lumborum (lateral) muscles are superficial to and posterior
to the psoas muscle.
Surgical Surgical procedures on the upper leg; combined
Anatomically, the psoas muscle is regarded as one mass
with a sciatic nerve block when necessary; skin grafting
and there is no ‘compartment’ as such within the muscle.
from anterior, lateral, and medial thigh; surgery on the
Nevertheless, injectate does infiltrate the muscle (Fig. 27.3)
anterior knee and patella
and covers the lumbar roots and nerves running within the
muscle. The roots join and form the lumbar plexus within
ous technique); amputation pain; postherpetic neuralgia;
the psoas muscle. Branches of the plexus include the femoral,
hip pain.
obturator, and lateral cutaneous nerves of the thigh.
Contraindications
Surface anatomy
Absolute Important landmarks for the psoas block include the iliac
See Chapter 4. crests, the posterior superior iliac spine, and the vertebral
Relative column (Fig. 27.4). The posterior superior iliac spine is the
Bleeding diathesis; anticoagulation therapy; lumbar scolio- bony prominence at the posterior end of the iliac crest. It
sis in non-ultrasound-guided approaches; and local neural is directly below the ‘sacral dimple’ (dimple of Venus), a
injury. dimple in the skin visible above the buttock, close to the
midline.
A vertical line is drawn between the highest points of the
Clinical anatomy iliac crests. This is called the Tuffier line and passes through
the disc space of L3 and L4. A second line is drawn parallel
The lumbar plexus is formed by the ventral rami of the first to the spinous processes and passes through the posterior
three lumbar nerves and the greater part of the ventral superior iliac spine on the side to be blocked. Where these
ramus of the fourth, with a contribution from the twelfth two lines intersect is the needle insertion point (usually
thoracic nerve root in 50% of cases. It lies in front of the 4–5 cm from the midline).
transverse processes of the lumbar vertebrae, deep within
the psoas major muscle (Fig. 27.1). The nerve roots of the
lumbar plexus lie in a ‘cleavable’ space in the psoas major Sonoanatomy
muscle (Fig. 27.2). The space is limited superiorly by the
insertion of psoas major on the body of the vertebrae; pos- Ultrasonographic visualization of the psoas muscle in
teriorly by the lumbar transverse processes and peridural adults requires a low frequency transducer (5–8 MHz)
space; and anteriorly by the aponeurotic continuation of due to the depth of the lumbar plexus (5–8 cm). A high

DOI: 10.1016/B978-0-7020-3148-9.00035-9
CHAPTER
Psoas block 27
1
8 2
7 2
6
3 4
3
5
4
1
Figure 27.3 Axial T1-weighted view after injection of 40 mL of con-

trast. Note spread through the psoas muscle. This demonstrates well
the cleavable nature of the psoas muscle. 1: Psoas muscle; 2: potential
Figure 27.1 Lumbar (L2) sagittal section illustrating anatomy relevant space created by contrast spread; 3: iliacus muscle; 4: obturator nerve.
to the psoas block.1, Spinous process; 2, vertebral body; 3, transverse
process; 4, erector spinae muscle; 5, quadratus lumborum muscle;
6, psoas muscle; 7, lumbar nerve; 8, kidney.
1
1
2 3 2 4
3
5 4
Figure 27.4 Landmarks for the psoas block. The iliac crest and poste-
rior superior iliac spine are marked. A line is drawn joining both iliac
crests. A line is drawn, parallel to the spine, which passes through the
Figure 27.2 Coronal T1-weighted MR image of anatomy relevant to posterior superior iliac spine. Where both lines intersect is the needle
psoas block. 1: right kidney; 2: retroperitoneal space; 3: psoas muscle; insertion point. 1: iliac crest; 2: posterior superior iliac spine; 3: spinous
4: anterior superior iliac spine; 5: lumbar nerve roots; 6: iliacus muscle. processes; 4: needle insertion point.
frequency transducer can also be used, particularly in chil- demonstrates a hypoechoic background interspersed with
dren. For longitudinal sonograms, the transducer is placed hyperechoic bands (dots on transverse view) representing
3 cm lateral to the spinous processes (Fig. 27.5). This allows fibrous structures within the muscle. Unlike the sonoanat-
for identification of the transverse processes. The transverse omy in children, visualization of the lumbar plexus in
processes produce bright hyperechoic signals, with signal adults is substantially impaired by these structures, and
loss distally. The psoas muscle is seen deep to these struc- often is impossible to identify. The kidneys are visualized
tures (Fig. 27.6). The transducer is advanced caudally and as oval shaped structures usually at the level of L2 or L3,
then cranially to identify the respective lumbar interspaces. and therefore can be avoided during ultrasound-guided
The sacrum is identified as a continuous hyperechoic line. psoas compartment block. The kidneys can also be
The longitudinal sonographic pattern of the psoas muscle seen to move with respiration. The more hyperechoic,
193
Figure 27.5 Orientation of the ultrasound transducer when perform- Figure 27.7 Orientation of the ultrasound transducer when perform-
ing the ultrasound-guided psoas block. It is initially in a longitudinal ing the psoas block in the transverse plane.
plane to identify the vertebral level.
ES
QL
PM
K
TP
VB
PM
Lateral Medial
Figure 27.8 Transverse ultrasound image of the sonoanatomy rele-
Figure 27.6 Longitudinal ultrasound image of lumbar paravertebral
vant to the psoas block. PM: psoas; ES: erector spinae; QL: quadratus
region. The transverse processes (TP) produce bright signals with signal
lumborum; VB: vertebral body; K: kidney.
loss distally. The psoas muscle (PM) is seen deep to these structures.
wedge-shaped, psoas muscle lies medial and deeper to the Technique

kidneys. At the interspace of L4–L5, the transducer is rotated
90° into the transverse plane (Fig. 27.7). Landmark-based approach
The use of the transverse plane at this level minimizes
bony interference. The erector spinae and quadratus lum- As for all regional anesthetic procedures, after checking that
borum muscles are identified superficial to the articular emergency equipment is complete and functional, intrave-
processes of the vertebral bodies. The psoas muscle is seen nous access, ECG, pulse oximetry, and blood pressure mon-
deep to the articular process as a hyperechoic structure itoring are established. Asepsis is observed.
interspersed with hypoechoic dots or speckles. The signal The lumbar plexus can be blocked with a single injection
‘drop-out’ from the vertebral body of L4 is seen distal to as it passes through the psoas muscle. As this is a deep
the psoas muscle (Fig. 27.8). block, sedation is indicated for patient comfort and the
194
CHAPTER
Psoas block 27
Figure 27.9 Patient position for the psoas block. The patient is placed
in the lateral position, with both hips flexed.
Figure 27.11 Lumbar (L2) sagittal section illustrating needle orienta-

tion and endpoint for the psoas block.
Correct needle position is indicated by quadriceps muscle

contraction. After eliciting the appropriate muscle contrac-
tion, the current is then decreased to 0.35 mA while main-
taining the response. Hip flexion (direct muscle stimulation
of the psoas major) indicates a needle position that is too
deep; intraperitoneal, aortic, or caval puncture also indicate
too deep a position. Adductor muscle contraction or venous
puncture (ascending lumbar vein) indicates a too medial
orientation. Medial puncture should also be avoided to
reduce risk of intrathecal or epidural injection. Stimulation
of the sciatic nerve indicates needle puncture that is too
Figure 27.10 Psoas block technique. The needle is oriented perpen- caudad. Renal puncture indicates needle insertion that is
dicular to the skin. too lateral and too cephalad.
When the needle position is satisfactory, incremental
injection of local anesthetic is made, with repeated aspira-
needle track should be anesthetized with local anesthetic. tion for blood and cerebrospinal fluid (40 mL total
The patient is placed in the lateral position, with the side volume).Intravenous access, electrocardiogram (ECG),
to be blocked uppermost and the hips flexed (Fig. 27.9). pulse oximetry and blood pressure monitoring are estab-
This block is commonly performed combined with a sciatic lished. Maximized comfort for the operator and patient is
nerve block. The two blocks can be performed with the an important step in pre-procedure preparation. Sedation
patient in the same position if the classical Labat posterior is required for patient comfort as a result of the depth of
sciatic approach is used. the block. For the ultrasound-guided psoas block, the
A 100-mm insulated stimulating needle is used. The stim- patient is placed in the prone or lateral position, with the
ulating current is set at 1.0 mA, 2 Hz, and 0.1 ms. The side to be blocked uppermost and the hips flexed (Fig.
needle is inserted perpendicular to the skin (Fig. 27.10), 27.12). A pillow is placed under the abdomen to straighten
using the needle insertion point as described previously the lumbar lordosis if the prone position is used. The opera-
and traverses the following structures: skin, fat, erector tor stands or sits on the side to be blocked (Fig. 27.12). For
spinae, and quadratus lumborum muscles (Fig. 27.11). the psoas block, the ultrasound screen is placed at the same
Contact with the transverse process is an important refer- level opposite the side to be blocked. The patient may also
ence point. The plexus lies 2–3 cm deep to the transverse be placed in the lateral position.
process, 7–9 cm from the skin. If the transverse process (L4) The lumbar region at the L4–L5 is scanned with a 5 MHz
is contacted, the needle should be redirected below, because curvilinear or 13 MHZ linear transducer in the longitudinal
passing above increases the risk of renal puncture. Normal and transverse planes, as described earlier, to image the
kidney extends down to the L3 level. relevant sonoanatomy. The ultrasound screen should be
195
ES
QL
N
PM
N
VB
LA
Figure 27.12 Global view of the block field for the ultrasound-guided
psoas block.
Lateral Medial
Figure 27.14 Real-time imaging of needle insertion for the ultrasound-
guided psoas block. N: needle tip; LA: local anesthetic; ES: erector spinae;
QL: quadratus lumborum; PM: psoas muscle; VB: vertebral body.
syringe connected to extension tubing that is flushed to

expel any air is attached to the needle.
The needle is then advanced under real-time ultrasound
guidance between the transverse processes towards the pos-
terior part of the psoas muscle (Fig 27.14). Close proximity
to the lumbar plexus is demonstrated by quadriceps twitches
at 0.5 mA. Following negative aspiration for blood or cere-
brospinal fluid, 1–2 mL of local anesthetic solution is then
injected and traced sonographically. Verification of final
needle position, spread of solution within the psoas com-
Figure 27.13 Ultrasound transducer and needle positioning during partment, or fine adjustments to needle position, can be
the ultrasound-guided psoas block. Note the needle orientation in the achieved by imaging in the longitudinal plane.
same plane as the ultrasound beam.
made to look like the scanning field. That is, the right side Continuous technique
of the screen represents the right side of the field. Adjustable
ultrasound variables such as scanning mode, depth of field, The approaches described above are suitable for continuous
and gain are optimized. The optimum transverse transducer techniques. Continuous psoas block is similar to the single-
position is marked. The skin is disinfected with antiseptic shot technique. As this approach is perpendicular to the
solution and draped. A sterile sheath (CIVCO Medical plexus, an insulated Tuohy needle, oriented appropriately,
Instruments, Kalona, IA, USA) is applied over the ultra- may be useful to assist catheter placement. However, it is
sound transducer with sterile ultrasound gel (Aquasonic, possible using an uninsulated Tuohy needle and a loss of
Parker Laboratories, Fairfield, NJ, USA), and placed over the resistance technique. The position of the catheter tip can be
previously marked area that is covered by another layer of confirmed by injecting 1–2 mL of air and observing its echo-
sterile gel. A skin wheal of local anesthetic is raised at the dense spread within the psoas muscle with ultrasound.
medial edge of the ultrasound transducer. The subcutane- As with other continuous nerve block techniques, the
ous tissues are also infiltrated with local anesthetic. A 22-GA initial dose of local anesthetic is usually injected and only
× 120-mm insulated regional block needle (B. Braun then is the infusion of a more dilute local anesthetic initi-
Medical, Bethlehem, PA, USA) is inserted perpendicular to ated. Once the local anesthetic is injected, the catheter is
the skin in line with the transducer (Fig. 27.13). A 20-mL carefully inserted some 5 cm beyond the tip of the needle
196
CHAPTER
Psoas block 27
while keeping the needle immobile. As there is a risk of • Spinal or epidural anesthesia due to intrathecal or epi-
epidural spread with the psoas block, large volumes of local dural injection; it is thus imperative to monitor these
anesthetic should be injected slowly, with appropriate patients carefully during and after injection of local
patient observation. anesthetic
Continuous lumbar plexus block is a safe alternative to • Renal or ureteric injury is a particular risk with tech-
continuous epidural analgesia, especially when anticoagu- niques above L4
lants are administered peri-operatively. The catheter should • Neural injury is rare
be accessible with the patient supine and thus secured in a • Local anesthetic toxicity is possible due to the multiplic-
lateral direction. The catheter is secured with a clear trans- ity of vessels in the area.
parent dressing.
Adverse effects Suggested reading

Capdevila X, Macaire P, Dodure C, et al. Continuous
• Hematoma: the aorta, vena cava, or lumbar vessels can psoas compartment block for postoperative analgesia
be punctured after total hip arthroplasty: new landmarks, technical
guidelines, and clinical evaluation. Anesth Analg
2002;94:1606–1613.
CLINICAL PEARLS Chayen D, Nathan H, Chayen M. The psoas compartment
block. Anesthesiology 1976;45:95–99.
• Quadriceps contraction on stimulation is an excellent indicator Kirchmair L, Enna B, Mitterschiffthaler G, et al. Lumbar
of correct needle position.
plexus in children. A sonographic study and its
• Combined with sciatic nerve block, this block gives excellent
anesthesia of the leg and is especially useful for knee surgery. relevance to pediatric regional anesthesia.
• For hip surgery, the T12 nerve needs to be anesthetized Anesthesiology 2004;101:445–450.
separately. Kirchmair L, Entner T, Kapral S, Mitterschiffhaler G.
• Suitable for continuous techniques for prolonged pain relief in Ultrasound guidance for the psoas compartment
hip and knee surgery. block: an imaging study. Anesth Analg 2002;94:
• The psoas compartment block is the only true ‘3-in-1’ block 706–710.
– anesthetizing the femoral, lateral femoral cutaneous, and
obturator nerves. Mannion S, O’Callaghan S, Walsh M, et al. ‘In with the
• The psoas compartment block should only be performed by an new, out with the old?’ – comparison of two
experienced anesthesiologist approaches for psoas compartment block. Anesth
• Hemodynamic monitoring and assessment of bilateral Analg 2005;101:259–264.
anesthesia are mandatory following the block. Turker G, Uckunkaya N, Yavascaoglu B, et al. Comparison
• Ultrasonographic visualization of the lumbar plexus is rare of the catheter-technique psoas compartment block
except in children.
and the epidural block for analgesia in partial hip
• The position of the kidney is verified during an ultrasound-
guided technique. surgery. Acta Anaesthesiol Scand 2003;47:30–36.
• It is easier to scan the psoas muscle in the prone position
compared with the lateral position. The disadvantage is
impaired visualization of the quadriceps muscle contraction to
nerve stimulation.
197
CHAPTER
28
Iliacus block
medial. At the inguinal ligament, the femoral nerve lies in

Indications a gutter between the psoas and iliacus muscles. These nerves
thus lie beneath the iliacus fascia (Fig. 28.1). Spread of local
Surgical Muscle biopsy; skin-graft donor site; patellar frac-
anesthetic (Figs 28.2 and 28.3) beneath the iliacus fascia
ture fixation or wiring; combined with other techniques for
produces a higher success rate of anesthesia of the femoral
saphenofemoral vein ligation; hip fracture repair and hip
nerve, lateral cutaneous nerve of the thigh, and obturator
and knee replacement; above- and below-knee amputation;
nerves than the femoral nerve block technique.
knee arthroscopy; repair of fractured shaft of femur; ankle
and foot surgery.
Therapeutic Postoperative analgesia (continuous tech-
nique) and rehabilitation in cruciate ligament reconstruc-
Surface anatomy
tion and knee replacement; postherpetic neuralgia; complex
The main landmarks for iliacus block are the anterior supe-
regional pain syndrome; postamputation pain; tumor-
rior iliac spine, pubic tubercle, and inguinal ligament. The
related pain.
pubic tubercle can be palpated three fingers’ breadth from
the midline, along the upper border of the pubis.
Contraindications The inguinal ligament is outlined by a line connecting the
anterior superior iliac spine and the pubic tubercle. The
inguinal ligament is divided into equal thirds. At the junc-
Absolute tion between the outer one-third and inner two-thirds, a
See Chapter 4. perpendicular line is drawn; 1 cm along this line is the
Relative needle insertion point (Fig. 28.4). The femoral artery can
Hemorrhagic diathesis; anticoagulation treatment; local be palpated 2–3 cm more medially in the groin.
neural injury; and risk of lower extremity compartment It is important to remember that with a fractured neck of
syndrome (e.g. fresh fractures of the tibia and fibula, or femur these relations may change.
especially traumatic and extensive elective orthopedic pro-
cedures of the tibia and fibula).
Sonoanatomy
Clinical anatomy The iliacus muscle is found lateral to the femoral artery in
the groin, lying outside the femoral sheath and beneath the
The iliacus fascia covers the iliacus and psoas muscles in fascia lata and iliaca. A transverse ultrasound transducer
the pelvis and descends into the thigh with these muscles orientation is used (Fig. 28.5). The fascia lata and iliaca are
(Fig. 28.1). The femoral nerve lies anterior to the psoas seen as hyperechoic lines. The appearance of the iliacus
muscle initially, with the lateral cutaneous nerve of the muscle on ultrasound is hypoechoic with hyperechoic
thigh lateral to the psoas muscle and obturator nerve fascial boundaries (Fig. 28.6).

DOI: 10.1016/B978-0-7020-3148-9.00036-0
CHAPTER
Iliacus block 28
4
4 3 2
Figure 28.2 Axial T1-weighted MR image after injection of 40 mL of

6 8 1
3 contrast, showing spread of injectate. Compare with Figure 21.5. Note
contrast surrounding femoral and obturator nerves. Spread is via the
plane between the iliacus and psoas muscles. 1: psoas muscle; 2: iliacus
muscle; 3: femoral nerve; 4: obturator nerve.

The patient is placed in the supine position, with the
2 operator standing on the side to be blocked, at the level of
the patient’s thigh. Having outlined landmarks, the needle
insertion point is infiltrated with local anesthetic using a
25-G needle. An 18-G Tuohy needle is inserted perpendicu-
lar to the skin (Fig. 28.7). An initial loss of resistance is
identified on penetrating the fascia lata. A second loss of
Figure 28.1 Cadaver structures illustrating anatomy relevant to the resistance indicates penetration of the fascia iliaca. No
iliacus block technique. 1: anterior superior iliac spine; 2: pubic tubercle; muscle response is sought. Incremental injection of local
3: inguinal ligament with abdominal muscles sectioned and removed; anesthetic (30–40 mL) is made with repeated aspiration.
4: iliacus muscle; 5: iliacus fascia; 6: femoral nerve; 7: lateral cutaneous No resistance to injection should be present.
nerve of thigh; 8: genitofemoral nerve. The obturator nerve is not visible As this is a compartment block, volume of local anes-
on the medial aspect of the psoas muscle. thetic is important. The compartment is highly vascular,
suggesting that inclusion of vasoconstrictor agents, such as
adrenaline (epinephrine) and clonidine, with local anes-
A scanning routine is used. To identify the iliacus muscle, thetic, may be useful.
the transducer is placed over the femoral vessels on the
anterior thigh at 90° to the expected orientation of the Ultrasound-guided approach
nerve and vessels (Fig. 28.5). Identify the fascia lata. Move
the tranducer laterally. Identify the fascia iliaca as a hyper- The ultrasound machine and block tray should be placed
echoic line deep to the fascia lata. The iliacus muscle lies in positions which allow the operator to simultaneously
beneath. scan the patient and take items from the block tray with
Technique regional anesthesia.
The operator stands on the side to be blocked, and with
Landmark-based approach the patient in a supine position (Fig. 28.5). The skin is
disinfected with antiseptic solution and draped. A sterile
As for all regional anesthetic procedures, after checking that sheath (CIVCO Medical Instruments, Kalona, IA, USA) is
emergency equipment is complete and in working order, applied over the ultrasound transducer with sterile ultra-
199
Figure 28.4 Landmarks for the iliacus block. The anterior superior iliac
spine, pubic tubercle, and inguinal ligament are outlined. The inguinal
ligament is divided into equal thirds. At the junction between the outer
one-third and inner two-thirds, a perpendicular line is drawn extending
into the thigh; 1 cm down this line is the needle insertion point.
3
2
2
4
Figure 28.3 (Right) Sagittal T1-weighted MR image demonstrating

spread of contrast toward the anterior superior iliac spine, where the
lateral cutaneous nerve of the thigh lies. Compare with Figure 21.6. 1:
psoas muscle; 2: contrast spread; 3: anterior superior iliac spine; 4: iliacus
muscle. Figure 28.5 Global view of the block field for the ultrasound-guided
iliacus block.
sound gel (Aquasonic, Parker Laboratories, Fairfield, NJ,

USA). Another layer of sterile gel is placed between the
sterile sheath and the skin. The infrainguinal region is FL
scanned with a 6–13 MHz linear transducer. The ultra- FI
sound screen should be made to look like the scanning
field. That is, the right side of the screen represents the right FA
FN IM
side of the field. Adjustable ultrasound variables such as
scanning mode, depth of field, and gain are optimized. Medial Lateral
A transverse image of the iliacus muscle is obtained (Fig.
28.6). The iliacus muscle is kept in the center of the field
of view. The needle entry site is at the lateral-most end of
the linear transducer. A 23-gauge needle is advanced under
real-time ultrasound guidance and local anesthetic is depos-
ited along the needle entry path. A free hand technique Figure 28.6 Transverse ultrasound image at the level of the inguinal
rather than the use of a needle guide is preferred. An 18-GA crease showing sonoanatomy relevant to the iliacus block using a
21-Tuohy needle is inserted parallel to the axis of the beam 2-5 MHz curvilinear ultrasound transducer. FL: fascia lata; FI: fascia iliaca;
of the ultrasound transducer, with the bevel facing the IM: iliacus muscle; FA: femoral artery; FN: femoral nerve.
200
CHAPTER
Iliacus block 28
FL N
FA FN FI
Medial IM Lateral
Figure 28.9 Real-time imaging of needle insertion for the iliacus block.
Notice the needle shaft marked with arrows. N: needle tip; FL: fascia lata;
FI: fascia iliaca; IM: iliacus muscle; FA: femoral artery; FN: femoral nerve.
Figure 28.7 Iliacus block technique. The epidural needle is inserted

perpendicular to the skin. A loss of resistance technique is used to
identify the iliacus fascia.
FN
FA
Medial FV Lateral
LA
Figure 28.10 Transverse ultrasound image at the level of the inguinal

crease showing local anesthetic spread deep to fascia iliaca using a
2–5 MHz curvilinear ultrasound transducer. LA: local anesthetic;
FA: femoral artery; FV: femoral vein; FN: femoral nerve.
Figure 28.8 Ultrasound transducer and needle positioning for the 40 mL of local anesthetic solution can be injected to achieve
ultrasound-guided iliacus block. Note the needle orientation in the blockade.
same plane as the ultrasound beam.
transducer (Fig. 28.8). The needle is attached to sterile Continuous iliacus block is similar to the single-shot tech-
extension tubing, which is connected to a 20-mL syringe nique. The needle bevel should be directed in a cephalad
and flushed with local anesthetic solution to remove all air direction. As with other continuous nerve block techniques,
from the system. It is then introduced at the lateral-most the initial dose of local anesthetic is usually injected and
end of the transducer and visualized along its entire path only then is the infusion of a more dilute local anesthetic
to the iliacus muscle (Fig. 28.9). It is important not to initiated. Once the local anesthetic is injected, the catheter
advance the needle without good visualization. This may is carefully inserted some 5 cm beyond the tip of the needle
require needle or ultrasound transducer adjustment. while keeping the needle immobile. Once the catheter is
Once the needle has advanced deeper than the iliacus inserted, the needle is withdrawn while simultaneously
fascia, 1–2 mL of local anesthetic may be injected to confirm advancing the catheter to prevent its dislodgment. The cath-
correct needle placement. Local anesthetic appears as a eter is secured with a transparent dressing. Ultrasound can
hypoechoic image. Correct needle placement is confirmed be used to facilitate catheter placement. The catheter may
by observing solution surrounding beneath the iliacus not be seen. Deposition of local anesthetic in the correct
fascia (Fig. 28.10). Should this not occur, the needle may plane following injection through the catheter confirms
need to be repositioned, and the procedure repeated. correct placement. Ultrasound can be used postoperatively
Following confirmation of correct needle placement, 30– to assess continued correct positioning of the catheter.
201

• Hematoma: note that needle insertion is more lateral Capdevila X, Biboulet P, Bouregba M, et al. Comparison
than with the femoral nerve block technique, which of the three-in-one and fascia iliaca compartment
decreases the risk of intravascular injection. blocks in adults: clinical and radiographic analysis.
Anesth Analg 1998;86:1039–1044.
• Neural injuries are extremely rare; the technique is easy
to perform on a conscious patient, which increases Dolan J, Williams A, Murney E, et al. Ultrasound guided
safety. fascia iliaca block: a comparison with the loss of
resistance technique. Reg Anesth Pain Med
• Local anesthetic toxicity due to overdosage or intravas-
2008;33(6):526–531.
cular diffusion can cause symptoms of CNS toxicity.
Slow injection of local anesthetics and repeated aspira- Kizelshteyn G, Crevecoeur E. Anatomic consideration of
tion decrease the incidence of this complication. the fascia iliaca compartment block. Anesth Analg
1990;71:210–212.
Paut O, Sallabery M, Schreiber-Deturmeny E, et al.
Continuous fascia iliaca compartment block in
CLINICAL PEARLS children: a prospective evaluation of plasma
bupivacaine concentrations, pain scores, and side
• The alteration in tissue resistance is often better appreciated by
advancing a blunt needle (e.g. a Tuohy needle), held like a pen, effects. Anesth Analg 2001;92:1159–1163.
with small side-to-side or vertical oscillations
• The distance from the femoral artery provides this margin of
safety
• Asking the patient to cough increases intra-abdominal pressure
and results in forced expulsion of local anesthetic through a
needle placed beneath the iliacus fascia.
202
CHAPTER
29
Lateral cutaneous nerve of thigh block
eral thigh as far as the knee; the posterior branch innervates

Indications the lateral aspect of the thigh to mid-thigh level.
Surgical Surgical procedures involving the lateral side of
thigh and knee, including skin-graft harvesting from the
lateral thigh, or removal of skin lesions from the lateral
Surface anatomy
thigh.
Important anatomic landmarks for block of the lateral cuta-
Therapeutic (Diagnosis and) treatment of meralgia par-
neous nerve of thigh include the anterior superior iliac
esthetica; differential diagnosis of thigh pain; postoperative
spine and the inguinal ligament. The needle insertion site
pain relief.
is located 2 cm medial and 2 cm inferior to the anterior
superior iliac spine (Fig. 29.2). This should be below the
Contraindications inguinal ligament, unlike the needle insertion site for the
ilioinguinal nerve block.
Absolute
See Chapter 4. Sonoanatomy
Relative
Bleeding diathesis; anticoagulation therapy; and obesity, The LCNT nerve is found below the ASIS between the fascia
making palpation of the anterior superior iliac spine diffi- lata and iliaca. These fascial layers are seen as hyperechoic
cult in the landmark-based approach. lines. The appearance of the LCNT on ultrasound is as a
round or oval hypoechoic (dark) area. Both branches of the
LCNT cross the sartorius superficially. Due to the small size
Clinical anatomy of the nerve and anatomical variability, a scanning routine
is paramount. Scan initially with a transverse orientation in
The lateral cutaneous nerve of the thigh (L2, 3) (LCNT) is the medial thigh to identify the femoral vessels and nerve.
a purely sensory nerve. It emerges from the psoas muscle With continued transverse scanning, move the transducer
along its lateral border. It runs deep to the iliac fascia on lateral and cephalad to identify the sartorius (triangular
the iliacus muscle, emerging immediately inferior and shape on transverse scan) insertion to the ASIS. Move the
medial to the anterior superior iliac spine. After crossing transducer caudally from here to the proximal third of the
under the inguinal ligament, it passes through the origin of thigh (Fig. 29.3). The LCNT can be seen crossing the sarto-
the sartorius muscle and travels beneath the fascia lata, rius superficially or, alternatively, locate both fascial layers
before dividing into a large descending branch and a smaller (fascia lata and iliaca) medial or lateral to the sartorius (Fig.
posterior branch, a variable distance below the inguinal 29.4). Injection of 5% dextrose between both fascial layers
ligament (Fig. 29.1). The branches pierce the fascia lata will help nerve visualization (Fig. 29.5). If the nerve is dif-
separately. The descending branch innervates the anterolat- ficult to identify initially, a good focus point is the space

DOI: 10.1016/B978-0-7020-3148-9.00037-2
LCNT FL F1
3 5 4
5
5
Medial Lateral
Figure 29.4 Sonoanatomy relevant to the lateral cutaneous nerve of

thigh block using a high frequency ultrasound transducer. S: sartorius;
Figure 29.1 Cadaver structures illustrating anatomy pertinent to FL: fascia lata; FI: fascia iliaca, LCNT = lateral cutaneous nerve of thigh.
lateral cutaneous nerve of thigh block technique. 1: anterior superior
iliac spine; 2: inguinal ligament; 3: fascia lata; 4: sartorius muscle; 5: divi-
sions of the lateral cutaneous nerve of thigh.
FL
F1 LCNT
S TFL
Medial Lateral
Figure 29.5 Injection of 5% dextrose between fascial layers helps iden-

tify the LCNT. S: sartorius; TFL: tensor fascia lata; FL: fascia lata; FI: fascia
iliaca, LCNT: lateral cutaneous nerve of thigh.
Figure 29.2 Lateral cutaneous nerve of thigh block technique. The between the sartorius and the more lateral tensor fascia
needle insertion point is 2 cm medial and 2 cm inferior from the anterior lata. A sagittal oblique transducer orientation obtained by
superior iliac spine (below the inguinal ligament). The needle is inserted
moving the medial aspect of the transducer to a slightly
perpendicular to the skin.
caudal position, parallel to the course of the nerve, can help
identify the deep circumflex iliac artery (Fig. 29.6). This can
be further identified with Doppler. This artery is crossed by
the nerve, and can facilitate its identification (Fig. 29.6).
Technique
emergency equipment is complete and functional, intrave-
nous access, ECG, pulse oximetry, and blood pressure mon-
itoring are established. Asepsis is observed.
The patient is placed in the supine position. A 30-mm
23-G hypodermic needle is inserted perpendicular to the
Figure 29.3 Ultrasound transducer positioning for the lateral cutane- skin. The needle is advanced in a controlled, intermittent
ous nerve of thigh block. fashion. Penetration of the fascia lata is indicated by a ‘pop’
204
CHAPTER
Lateral cutaneous nerve of thigh block 29
Figure 29.6 A sagittal oblique transducer orientation parallel to

the course of the nerve can help identify the deep circumflex iliac Figure 29.7 Global view of the block field for the lateral cutaneous
artery. This artery is crossed by the nerve and can facilitate its nerve of thigh block.
identification.
sensation. Injection is performed above and below the

fascia lata, in a medial to lateral direction. For this block,
10 mL of local anesthetic is adequate.
The ultrasound machine and block tray should be placed
regional anesthesia.
The operator stands on the side to be blocked, and with
the patient in a supine position and the ipsilateral hip
neutrally rotated (Fig. 29.7). The skin is disinfected with
antiseptic solution and draped. A sterile sheath (CIVCO
Medical Instruments, Kalona, IA, USA) is applied over the Figure 29.8 Ultrasound transducer and needle positioning during
ultrasound transducer with sterile ultrasound gel (Aqua- ultrasound-guided lateral cutaneous nerve of thigh block. Note the
needle orientation in the same plane as the ultrasound beam.
sonic, Parker Laboratories, Fairfield, NJ, USA). Another
layer of sterile gel is placed between the sterile sheath and
the skin. The infrainguinal region is scanned with a
6–13 MHz linear transducer SonoSite MicroMaxx unit
(SonoSite, Micromaxx, Bothwell, WA, USA). The ultra-
sound screen should be made to look like the scanning FL
field. That is, the right side of the screen represents the right LCNT
side of the field. Adjustable ultrasound variables such as F1
scanning mode, depth of field, and gain are optimized. TFL
Medial S Lateral
A transverse image of the LCNT is obtained (Fig. 29.4).
The LCNT nerve is kept in the center of the field of view.
The needle entry site is at the lateral-most end of the trans-
ducer. A 23-gauge needle is inserted parallel to the axis
of the beam of the ultrasound transducer, with the bevel
facing the transducer (Fig. 29.8). It is important not to Figure 29.9 Real-time imaging of needle insertion for the lateral cuta-
advance the needle without good visualization (Fig. 29.9). neous nerve of thigh nerve block. S: sartorius; TFL: tensor fascia lata;
This may require needle or ultrasound adjustment. FL: fascia lata; FI: fascia iliaca, LCNT: lateral cutaneous nerve of thigh.
205
Once the needle has approached the LCNT nerve, 1–2 mL

of local anesthetic may be injected to confirm correct needle Suggested reading
placement. Local anesthetic appears as a hypoechoic image.
Brown TCK, Dickens DRV. A new approach to lateral
Correct needle placement is confirmed by observing
cutaneous nerve of thigh block. Anaesth Intensive
solution surrounding the LFCN nerve. 5 mL of local anes-
Care 1986;14:126–127.
thetic is injected.
Damarey B, Demondion X, Boutry N, et al. Sonographic
assessment of the lateral femoral cutaneous nerve.
Continuous technique J Clin Ultrasound 2009;37(2):89–95.
A continuous technique has not been described. Dias Filho LC, Valença MM, Guimarães Filho FA, et al.
Lateral femoral cutaneous neuralgia: an anatomical
insight. Clin Anat 2003;16(4):309–316.
Adverse effects Hurdle MF, Weingarten TN, Crisostomo RA, et al.
Ultrasound-guided blockade of the lateral femoral
• Hematoma can occur cutaneous nerve: technical description and review
of 10 cases. Arch Phys Med Rehabil 2007;88(10):
• Unwanted anesthesia due to spread of local anesthetic
1362–1364.
to femoral, ilioinguinal, or iliohypogastric nerves can
occur if larger than necessary volumes of local anesthetic Hopkins PM, Ellis FR, Halsall PJ. Evaluation of local
are used. anesthetic blockade of the lateral femoral cutaneous
nerve. Anesthesia 1991;46:95–96.
Ng I, Vaghadia H, Choi PT, Helmy N. Ultrasound
imaging accurately identifies the lateral femoral
CLINICAL PEARLS cutaneous nerve. Anesth Analg 2008;107(3):
• Landmark-based technique is associated with high failure rates
1070–1074.
(40%) secondary to variable LFCN anatomy Shannon J, Lang SA, Yip RW, Gerard M. Lateral femoral
• Ultrasound identification of the LFCN is technically feasible and cutaneous nerve block revisited. A nerve stimulator
more accurate than anatomical landmarks technique. Reg Anesth 1995;20(2):100–104.
• An ultrasound scanning routine is important to help identify this
small nerve on ultrasound.
206
CHAPTER
30
Popliteal block
common epineural sheath from their origin to the popliteal

Indications fossa. The two nerves innervate the entire leg below the
knee except for the anteromedial leg and foot, which are
Surgical Foot surgery; below-knee amputations; Achilles’
innervated by the saphenous nerve (L2, 3, 4).
tendon surgery; in conjunction with a femoral or saphe-
The sciatic nerve branches in the region of the distal thigh
nous block for short saphenous vein surgery and fixation
(Fig. 30.3), anywhere between 4 and 13 cm above the pop-
of ankle fractures.
liteal crease, although occasionally they can run as two
Therapeutic Mobilization of the ankle; complex regional
separate nerves from the sciatic foramen. The tibial nerve is
pain syndrome; postamputation pain; tumor-related pain.
the larger of the two branches and runs parallel and slightly
lateral to the midline. Inferiorly, it passes between the
Contraindications heads of the gastrocnemius muscle. The common peroneal
nerve runs laterally along the medial aspect of the biceps
femoris muscle. After bifurcation, the tibial nerve immedi-
Absolute ately gives off the sural nerve, which innervates the lateral
See Chapter 4. aspect of the foot. The common peroneal nerve also gives
Relative off a sural communicating nerve (Fig. 30.4), and once it
Hemorrhagic diathesis; anticoagulation treatment; dis- is below the head of the fibula it divides into superficial
torted anatomy (due to previous surgery or trauma); and and deep peroneal nerves. The nerves lie more superficial
risk of lower extremity compartment syndrome (e.g. fresh and lateral to the popliteal vessels in the popliteal fossa and
fractures of the tibia and fibula, or especially traumatic and about midway between the skin and the posterior aspect of
extensive elective orthopedic procedures of the tibia and the femur.
fibula).
Surface anatomy
Clinical anatomy
The main landmarks for the lateral popliteal block include
The popliteal fossa is defined as the space between the skin, the superior aspect of the patella and a muscular groove
the femur anteriorly and the biceps femoris muscle later- between the biceps femoris and vastus lateralis muscles
ally, the semitendinosus and semimembranosus muscles (Fig. 30.5). Identification of this groove is difficult in obese
medially, and inferiorly by both heads of the gastrocnemius patients and should be mastered prior to procedure. This is
(Figs 30.1 and 30.2). The space is mostly filled with fat and easily felt when patients flex their leg against resistance.
contains in its anterolateral aspect the popliteal vessels The main landmarks for the posterior popliteal block
and nerves. The sciatic nerve is formed from roots L4 to S2 include skin crease of the knee joint and biceps femoris
(and occasionally S3) and consists of two distinct divisions muscle laterally, and semimembranosus muscle medially
– the tibial and common peroneal nerves – which share a (Fig. 30.6). The patient can be asked to flex the leg to
DOI: 10.1016/B978-0-7020-3148-9.00038-4
1
6
4
5
77 1
4 2
2
6 4 3
5
8 7
9
Figure 30.1 Cadaver structures illustrating anatomy relevant to the
posterior popliteal block technique. 1: biceps femoris; 2: semimembra-
nosus; 3: semitendinosus; 4: gastrocnemius; 5: tibial nerve; 6: common
peroneal nerve; 7: popliteal vessels. Figure 30.3 Axial T1-weighted MR image of thigh 5 cm superior to
popliteal crease. Note separate tibial and common peroneal compo-
nents of sciatic nerve lateral to midline. 1: Femur; 2: profunda femoris
artery; 3: tibial nerve; 4: common peroneal nerve; 5: sural communicat-
ing nerve; 6: biceps femoris muscle; 7: gracilis muscle; 8: semimembra-
nosus muscle; 9: semitendinosus muscle.
3
1
4 1 2
3
6
4
5
lateral popliteal block technique. 1: biceps femoris; 2: vastus lateralis; 3:
10 9 8
intermuscular groove; 4: common peroneal nerve.
7
identify the margins of the popliteal fossa. Absence of bony

landmarks with the posterior approach increases the learn-
ing curve with this approach.
Figure 30.4 Axial T1-weighted MR image showing anatomy at the
level of the superior border of the patella. Note relations of the common
peroneal 10. and tibial nerves 9. to popliteal vessels. The common pero-
Sononatomy neal and tibial components are 7 mm apart in this patient. The sural
communicating nerve is marked. 1: quadriceps tendon: 2: patella; 3:
Using a transverse transducer orientation, perform a sys- vastus medialis muscle; 4: popliteal artery; 5: popliteal vein; 6: sartorius
tematic anatomical survey of structures from superficial muscle; 7: semimembranosus muscle; 8: gracilis muscle.
208
CHAPTER
Popliteal block 30
Figure 30.7 The ultrasound transducer is positioned in the popliteal

fossa with a transverse orientation.
SN
Lateral Medial
Figure 30.5 Landmarks for the lateral popliteal block. A vertical line is STM/
drawn from the superior aspect of the patella. A second line is drawn SMM
BFM
that outlines the groove between vastus lateralis and biceps femoris. PA
Where both lines intersect is the needle insertion point.
PV F
Figure 30.8 Ultrasound image of the block field for the popliteal sciatic
nerve block. Transverse ultrasound image using a low frequency curvi-
linear ultrasound transducer. SN: sciatic nerve branches; BFM: biceps
femoris muscle; STM/SMM: semitendinosus and semimembranosus
muscles; PA: popliteal artery; PV: popliteal vein; F: femur.
location is always superficial to the femur and lateral to the

popliteal artery (Fig. 30.8). If the sciatic nerve is not easily
visible, angle the transducer and aim the beam caudally
towards the foot (Fig. 30.9). This will bring the nerve into
view once the angle of incidence is approximately 90° to
the nerve. Scan the region proximally and distally to assess
nerve anatomy. Position the transducer in a location where
the sciatic nerve is clearly visualized as a single nerve before
Figure 30.6 Landmarks for the posterior popliteal block. A line is its bifurcation. Nerve visualization is significantly improved
drawn that outlines the knee crease. Muscular boundaries formed by once local anesthetic is injected, due to enhanced contrast
semimembranosus and semitendinosus medially and biceps femoris between the hyperechoic nerve and the hypoechoic fluid
laterally are outlined. At the midpoint of the knee crease, a perpendicu- collection.
lar line is drawn into the thigh. The needle insertion point is 5 cm along
this line and 1 cm laterally.
Technique
(skin) to deep and from medial to lateral in the popliteal Landmark-based approach
fossa (Fig. 30.7). First identify the femur, which is deep and
casts a bony shadow. Next, identify the pulsatile popliteal As for all regional anesthetic procedures, after checking that
artery that is superficial to the femur (Fig. 30.8). If it is not emergency equipment is complete and in working order,
visible, scan distally towards the popliteal crease where the intravenous access, ECG, pulse oximetry, and blood pres-
popliteal artery is more superficial. The popliteal vein may sure monitoring are established. Asepsis is observed.
or may not be visible (collapsed by transducer pressure).
Note the muscle groups medially (semitendinosus and Lateral approach
semimembranosus muscles) and laterally (biceps femoris The patient is placed supine, with the lower limb in the
muscle; Fig. 30.8). The hyperechoic sciatic nerve in this neutral position. The feet should be extended beyond the
209
Figure 30.9 If the sciatic nerve is not easily visible, angle the transducer
and aim the beam caudally towards the foot.
Figure 30.11 Lateral popliteal block technique. The needle is inserted

at 30° to the horizontal plane.
Figure 30.10 Patient position for the lateral popliteal block. The
patient is placed in the supine position with the feet visible beyond the
edge of the patient trolley. Note the sandbag beneath the knee, and
tape maintaining neutral leg position.
edge of the table in order to better discern the response to

nerve stimulation (Fig. 30.10). A small sandbag underneath
the knee or a pillow under the thigh facilitates the tech-
nique. The upper border of the patella is identified and a
line is drawn vertically downward to the patient trolley. The
groove between the lateral border of vastus lateralis and the
biceps femoris tendon is identified. The intersection of
the two lines is the needle insertion point.
Having outlined landmarks, the needle insertion point is
infiltrated with local anesthetic using a 25-G needle. A 50–
Figure 30.12 Lateral popliteal block technique. The needle passes
100-mm 21-G insulated needle is inserted at 30° to the through the intermuscular groove and is most likely to encounter the
horizontal plane, ensuring that the needle is directed away common peroneal nerve initially.
from the popliteal vessels (Fig. 30.11). The stimulating
current is set at 1.0 mA, 2 Hz, and 0.1 ms. The needle is
advanced slowly until the appropriate muscle response is The common peroneal nerve is usually found first because
obtained. The needle position is adjusted while decreasing it is located more laterally (Fig. 30.12). After the first nerve
the current to 0.35 mA with maintenance of the muscle is stimulated, at less than 0.5 mA, 10 mL of local anesthetic
response. is injected slowly after careful aspiration. Then the ampli-
The common peroneal and tibial nerves are identified by tude of the nerve stimulator is increased to 2 mA and the
their muscular responses: plantar flexion or inversion of the needle is advanced slightly. The tibial nerve is located
foot for the tibial nerve, and dorsiflexion or eversion of the approximately 1–3 cm more medially, and a further 10 mL
foot for the common peroneal nerve. With failure to elicit of local anesthetic is injected. With prior injection of
nerve stimulation, needle insertion is moved in an antero- local anesthetic, the second nerve should be found in a
posterior direction within the groove. short time if possible, because there is a theoretical risk
210
CHAPTER
Popliteal block 30
Figure 30.13 Patient position for the posterior popliteal block. The Figure 30.14 Posterior popliteal block technique. The needle is
patient is placed in the prone position with the feet visible beyond the inserted in a 45° cephalad orientation.
edge of the table.
of nerve damage when the surrounding area becomes

anesthetized.
A muscular twitch may be elicited in the biceps femoris
muscle. This is direct muscle stimulation and indicates that
the needle trajectory is correct. Inversion is a muscular
movement, which is common to both nerves, caused by the
action of the tibialis posterior muscle innervated by the
tibial nerve, and the tibialis anterior muscle innervated by
the common peroneal nerve. Strong inversion motion is an
3
indicator of blockade of both nerves in 60% of cases. 1
Posterior approach
The patient is placed in the prone or lateral position. The 2
5 4
feet should be extended beyond the edge of the table in
order to better discern the response to nerve stimulation
(Fig. 30.13). The patient is asked to flex the leg to identify
the margins of the popliteal fossa. The fossa is divided into
lateral and medial triangles, with the crease at the base of
these triangles. The site of needle insertion is 5 cm above
the popliteal crease and 1 cm lateral to the midline of the Figure 30.15 Axial T1-weighted MR image showing spread of 20 mL
triangle. of contrast injected at same level as in Figure 30.3. The common pero-
neal nerve was stimulated prior to injection. Note the wide spread of
After raising a skin wheal of local anesthetic, a 50– contrast in the intermuscular plane, which is significantly widened by
100-mm 21-G insulated needle is inserted in a 45° cepha- the volume of contrast. Note also the apparent movement of the nerves
lad orientation (Fig. 30.14). The stimulating current is set medially and also that contrast does not completely surround the tibial
at 1.0 mA, 2 Hz, and 0.1 ms. The needle is advanced slowly nerve but spreads to areas unnecessary for sciatic nerve block. 1: pro-
until the appropriate muscle response is obtained. The funda femoris artery; 2: femoral vessels; 3: common peroneal nerve; 4:
needle position is adjusted while decreasing the current to tibial nerve; 5: sural communicating nerve.
0.35 mA with maintenance of the muscle response.
Usually the nerves are located at a depth of 1.5–2 cm, with the posterior approach, because the nerves lie in close
resulting in either plantar flexion and inversion (tibial proximity.
nerve) or dorsiflexion and eversion (common peroneal
nerve) of the foot. When the described responses are not Ultrasound-guided approach
obtained on the first needle pass, the needle is withdrawn
and redirected slightly laterally using the same insertion Intravenous access, electrocardiogram (ECG), pulse oxim-
site. Then 30–40 mL of local anesthetic is injected (Fig. etry and blood pressure monitoring are established. Maxi-
30.15). A single injection technique is usually sufficient mized comfort for the operator and patient is an important
211
Figure 30.17 Transducer and needle positioning during ultrasound-

guided popliteal sciatic block. Note the needle orientation in the same
plane as the ultrasound beam.
N
Figure 30.16 Global view of the block field for the ultrasound-guided LA
popliteal sciatic nerve block (prone patient position).
SN
step in pre-procedure preparation. For the ultrasound-
guided popliteal sciatic block, the patient is placed in the
prone, lateral or supine positions. The operator stands on
the side to be blocked, with the ultrasound screen on the
opposite side (Fig. 30.16). F
In the prone position, the patient is asked to flex their
knee to identify the upper border of the popliteal fossa by
defining the biceps femoris, and semitendinosus and semi-
membranosus muscles. Maintaining the knee in a fixed Figure 30.18 Ultrasound image of the politeal fossa (prone patient
semi-flexed position facilitates block placement. At the apex position) after administration of 20 mL of local anesthetic solution,
of the popliteal triangle, the ultrasound transducer is ori- using a high frequency linear transducer. N: needle; LA: local anesthetic;
ented perpendicular to the long axis of the leg, with the SN: sciatic nerve; F: femur.
ultrasound beam perpendicular to the nerve (Fig. 30.7).
The bodies of the semimembranosus and biceps femoris,
as well the popliteal artery, vein, and the sciatic nerve, alization. The needle bevel should face the active face of the
should be identified. The sciatic nerve will appear as a large transducer to improve visibility of the needle tip. A free-
hyperechoic structure surrounded by a white (hyperechoic) hand technique rather than the use of a needle guide is
ring and it will lie lateral and superficial to the pulsatile preferred. A 21-GA × 50–100-mm insulated regional block
popliteal artery (Fig. 30.8). The target sciatic nerve is placed needle (B. Braun, Bethlehem PA) or 17-GA Tuohy needle
within the centre of the imaging field of view. (Arrow Intl. reading PA, USA) is inserted within the plane
The skin is disinfected with antiseptic solution and of imaging to visualize the entire shaft and bevel along the
draped. A sterile sheath (CIVCO Medical Instruments, path of the ultrasonic beam (Fig. 30.17). The needle is
Kalona, IA, USA) is applied over the ultrasound transducer attached to sterile extension tubing, which is connected to
with sterile ultrasound gel (Aquasonic, Parker Laboratories, a 20-mL syringe and flushed with local anesthetic solution
Fairfield, NJ, USA). Another layer of sterile gel is placed to remove all air from the system. The operator can slide
between the sterile sheath and the skin. The popliteal region and tilt the transducer to maintain the needle tip within the
is scanned in the transverse plane. The ultrasound screen plane of imaging as much as possible. The needle tip should
should be made to look like the scanning field, i.e. the right be clearly identified within the plane of imaging before
side of the screen represents the right side of the field. advancing the needle.
Adjustable ultrasound variables such as scanning mode, The needle is brought in contact with the nerve, taking
depth of field, and gain are optimized. care not to puncture it (Fig. 30.18). If an electrical nerve
A skin wheal of local anesthetic is raised at a distance stimulation technique is used, characteristic motor activity
from the ultrasound transducer to facilitate sterility and of either dorsi- or plantar-flexion is elicited in the foot. After
allow a shallow angle of approach to improve needle visu- negative aspiration, one mL local anesthetic is injected. If
212
CHAPTER
Popliteal block 30
N
SN
LA
Figure 30.19 The ultrasound transducer is positioned on the lateral

aspect of the lower limb proximal to the knee joint with a transverse
orientation.
Figure 30.21 View of the politeal fossa (supine patient position) after
SN
administration of 20 mL of local anesthetic solution. N: needle; LA: local
Lateral Medial anesthetic; SN: sciatic nerve; F: femur.
BFM
PA
PV F
Figure 30.20 Ultrasound image of the block field for the popliteal
sciatic nerve block (supine patient position). Transverse ultrasound
image using a 4 MHz curvilinear ultrasound transducer. SN: sciatic nerve
branches; BFM: biceps femoris muscle; PA: popliteal artery; PV: popliteal
vein; F: femur. Figure 30.22 Needle insertion for the popliteal sciatic nerve block with
a supine patient and ultrasound transducer in the popliteal fossa.
Needle insertion is different to the patient prone position as needle
insertion is on the lateral aspect of the lower limb.
spread of local anesthetic is satisfactory, then a further
3–4 mL of local anesthetic is injected. The needle tip is
readjusted posterior to the nerve and another aliquot of
local anesthetic is deposited around it. The needle tip is (avoiding the tendon, as tendon injuries heal slowly; Fig.
manipulated to deposit anesthetic on all sides of the sciatic 30.21). The larger bulk of the muscle minimizes peri-
nerve. A total of 20 mL of local anesthetic is sufficient to catheter leaks. The needle is followed under real-time
block the sciatic nerve or its terminal branches. The two imaging and the local anesthetic is deposited on all sides
large branches, posterior tibial nerve and common pero- of the nerve by repositioning the needle tip as previously
neal nerve, can be individually blocked just below the bifur- described. In the posterior transducer position, a transverse
cation of the sciatic nerve. A larger surface area available for image is obtained proximal to the knee joint (Fig. 30.8).
diffusion, and a shorter distance for local anesthetic to This ultrasound image will be the same as the transverse
reach core fibers hasten the onset of surgical anesthesia. ultrasound image produced in the prone patient position.
When a lateral patient position is used, the leg to be The difference in this technique is the needle entry site,
blocked is uppermost, with the knee flexed at 60–70°. A which here is from the lateral aspect of the lower limb
17- or 18-gauge 2–4-inch long Tuohy needle is used for (Fig. 30.22).
administering the block. Alternately, a 22-G insulated
needle may be used for the single injection technique. Continuous technique
With the supine patient, a lateral or posterior transducer
position can be used. In the lateral transducer position (Fig. Continuous lateral popliteal block is similar to the single-
30.19), a transverse image is obtained proximal to the knee shot technique. As with other continuous nerve block tech-
joint (Fig. 30.20). A 17-G 3.5-inch needle is used. The niques, the initial dose of local anesthetic is usually injected
needle is introduced through the fleshy part of biceps and only then is the infusion of a more dilute local anes-
femoris muscle between its tendon and the iliotibial tract thetic initiated. Once the local anesthetic is injected, the
213
catheter is carefully inserted some 5 cm beyond the tip of second nerve, because there is a considerable amount of
the needle while keeping the needle immobile. When the local anesthetic in the area after the first injection.
catheter meets resistance at the tip of the needle, the needle • Local anesthetic toxicity due to intravascular injection
may be repositioned at a different angle or rotated to facili- into the popliteal vessels. Appropriate technique and
tate advancement of the catheter. Once the catheter is careful aspiration will decrease this risk.
inserted, the needle is withdrawn while simultaneously • Overdosage or intravascular diffusion can also cause
advancing the catheter to prevent its dislodgment. The posi- symptoms of local anesthetic toxicity. Slow injection
tion of the tip can be confirmed with ultrasound by either of local anesthetics decreases the incidence of this
injecting dextrose water, which does not interfere with con- complication.
duction of electrical current, or 1–2 mL of air, which • Pressure on the popliteal artery is rare and due to pop-
appears as a white flash on the ultrasound screen. About liteal hematoma associated with arterial puncture and
3–4 cm of the catheter is left in the popliteal fossa and the anticoagulant therapy.
catheter is then secured with a clear transparent dressing.

• Hematoma. Chan VW, Nova H, Abbas S, et al. Ultrasound
• Neural injuries are extremely rare. When using the lateral examination and localization of the sciatic nerve:
approach, be mindful of the time taken to find the a volunteer study. Anesthesiology 2006;104(2):
309–314.
Hadzic A, Vloka JD. A comparison of the posterior versus
lateral approaches to the block of the sciatic nerve in
CLINICAL PEARLS the popliteal fossa. Anesthesiology 1998;88:
1480–1486.
• Remember to block the saphenous nerve if the surgery includes
the medial aspect of the lower limb. Hadzic A, Vloka JD, Singson R, et al. A comparison of
• Use a large volume of local anesthetic for the posterior intertendinous and classical approaches to popliteal
landmark-based approach; this results in better blockade due to nerve block using magnetic resonance imaging
the quantity of adipose tissue in the popliteal fossa. simulation. Anesth Analg 2002;94:1321–1324.
• Stimulation of the biceps femoris muscle indicates a needle Schwemmer U, Markus CK, Greim CA, et al. Sonographic
position that is too lateral with the posterior landmark-based
approach. imaging of the sciatic nerve and its division in the
• A double-injection technique when using the lateral landmark- popliteal fossa in children. Pediatric Anesthesia
based approach results in more consistent block than assuming 2004;14:1005–1008.
the presence of a single nerve sheath, whereupon both nerves Singelyn FJ, Aye F, Gouverneur JM. Continuous popliteal
will be blocked if one is located. sciatic nerve block: an original technique to provide
• With ultrasound-guided techniques, various patient positions
postoperative analgesia after foot surgery. Anesth
can be used.
• With ultrasound imaging, variants in sciatic nerve anatomy (e.g.
Analg 1997;84:383–386.
division of terminal branches) can be appreciated and used to Sinha A, Chan VW. Ultrasound imaging for popliteal
advantage. sciatic nerve block. Reg Anesth Pain Med 2004;29:
• The ultrasound-guided popliteal sciatic nerve block has several 130–134.
described approaches
Vloka JD, Hadzic A, April E, et al. The division of the
• If the sciatic nerve is not readily visible, angle the transducer and
aim the beam caudally towards the foot.
sciatic nerve in the popliteal fossa: anatomical
• If nerve visualization is difficult, ask the patient to plantar flex
implications for popliteal nerve blockade. Anesth
and dorsiflex the foot. One may see the ‘seesaw’ sign as the tibial Analg 2001;92:215–217.
and peroneal components slide up and down during foot Zetlaoui PJ, Bouaziz H. Lateral approach to the sciatic
movement. nerve in the popliteal fossa. Anesth Analg
1998;87:79–82.
214
CHAPTER
31
Ankle block
The deep peroneal nerve runs deep to the extensor reti-

Indications naculum and superficial to the tibia, lateral to the anterior
tibial artery. It is bounded medially by the anterior tibial
Surgical Surgical procedures on the forefoot, particularly
artery and tendon of the extensor hallucis longus muscle,
the toes.
and laterally by the extensors of the second toe. It provides
Therapeutic Postamputation pain; diagnostic and thera-
sensory innervation to the tarsal and metatarsal joints and
peutic blocks for foot pain; postoperative pain relief.
the first interdigital space.
The superficial peroneal nerve travels distally with the
peroneus brevis muscle, becoming superficial above the
Contraindications lateral malleolus, and runs over the dorsum of the foot, to
which it provides sensory innervation (Figs 31.2 and 31.3).
Absolute The saphenous nerve runs superficially with the great
See Chapter 4. saphenous vein. It divides into terminal branches at the
ankle. It provides sensory innervation to the medial aspect
Relative of the ankle and dorsum of the foot in a wedge shape
Swollen ankle and leg tourniquet (necessitates higher toward the great toe.
blockade). The sural nerve runs superficially with the small saphe-
nous vein and lies subcutaneously between the lateral mal-
leolus and Achilles, tendon (Figs 31.2 and 31.4). It provides
Clinical anatomy sensory innervation to the lateral aspect of the ankle and
foot.
The ankle and foot are innervated by five nerves. One, the
saphenous nerve, is the terminal branch of the femoral
nerve, whereas the remaining four are branches of the Surface anatomy
sciatic nerve. These are the tibial nerve, the sural nerve, and
the superficial and deep peroneal nerves. Important bony structures for the ankle block include the
The tibial nerve runs deep to the flexor retinaculum and medial and lateral malleoli and the calcaneum. Other land-
posterior to the posterior tibial vein and artery, between the marks include the Achilles’ tendon, and on the ventral
Achilles’ tendon and medial malleolus (Figs 31.1 and 31.2). aspect of the ankle, the anterior tibial artery pulse and
It divides into medial and lateral plantar nerves providing extensor hallucis longus tendon (Fig. 31.5). These tendons
sensory innervation to the medial side of the sole of the can be accentuated if the patient dorsiflexes the foot against
foot and heel. The tibial nerve provides motor supply to resistance. A single needle insertion site at the midpoint of
the intrinsic muscles of the foot. It is the largest nerve at the intermalleolar line on the ventral aspect of the ankle is
the ankle, requiring the longest block onset, and thus used for block of the superficial and deep peroneal nerves
should be blocked first. and saphenous nerve. Needle insertion for sural and tibial
DOI: 10.1016/B978-0-7020-3148-9.00039-6
1 1
3 4
55
6
2 2 3
4
Figure 31.1 Cadaver structures of the medial aspect of the ankle illus-
trating anatomy pertinent to the ankle block. 1: medial malleolus;
2: Achilles’ tendon; 3: tendon of tibialis posterior; 4: tendon of flexor
5
digitorum longus; 5: posterior tibial artery and vein; 6: tibial nerve. 6
5
Figure 31.2 Axial T1-weighted MR image showing relevant anatomy
of ankle. 1: site of deep peroneal nerve; 2: superficial peroneal nerve;
1 3: tibia; 4: fibula; 5: posterior tibial artery; 6: tibial nerve; 7: sural nerve;
2 8: Achilles’ tendon.
3 4
6
6
4
1
3
2
Figure 31.3 Cadaver structures of the ventral aspect of the ankle illus-
trating anatomy pertinent to the ankle block. 1: medial malleolus;
2: tendon of tibialis anterior; 3: tendon of extensor hallucis longus;
4: tendon of extensor digitorum longus; 5: anterior tibial artery; 6: super- Figure 31.4 Cadaver structures of the lateral aspect of the ankle illus-
ficial peroneal nerve branches. The deep peroneal nerve is deep to the trating anatomy pertinent to the ankle block. 1: Lateral malleolus;
fascia and cannot be seen here. 2: Achilles’ tendon; 3: sural nerve; 4: short saphenous vein.
216
CHAPTER
Ankle block 31
TP PTA
FDL
TN
Anterior
MM FHL
Figure 31.5 Landmarks for the ankle block include medial and lateral Figure 31.7 Transverse ultrasound image of the sonoanatomy rele-
malleoli: intermalleolar line: dorsalis pedis pulse: and Achilles’ tendon. vant to the tibial nerve block using a 10–15 MHz linear transducer.
TP: tibialis posterior; FDL: flexor digitorum longus; PTA: posterior tibial
artery; TN: tibial nerve; FHL: flexor hallucis longus; MM: medial
malleolus.
and are often hyperechoic. Then identify the pulsatile pos-

terior tibial artery (Doppler use is optional). The tibial
nerve at the ankle is often round to oval with a honeycomb
appearance (Fig. 31.7). It is expected to lie posterior to the
posterior tibial artery. Trace the tibial nerve proximally. The
nerve is larger and is easier to identify more cephalad in the
leg. It is also easy to image the nerve longitudinally by
Figure 31.6 A high frequency ultrasound transducer placed immedi- rotating the transducer 90°.
ately above and behind the medial malleolus to locate the tibial nerve
in the transverse (short axis) view. Deep peroneal nerve
Position the patient supine and bolster the foot with a
block is adjacent to the Achilles tendon, at the level of pillow to expose the anterior and medial portion of the
the superior aspect of the medial and lateral malleoli, lower leg and foot. The lower limb is in the neutral posi-
respectively. tion. The small deep peroneal nerve may be difficult to
locate. This nerve lies adjacent to the anterior tibial vessels
(above the ankle) and the dorsalis pedis at the ankle region.
Sonoanatomy A 10–15 MHz transducer is placed on the dorsum of the
foot along the intermalleolar line to locate the dorsalis
Tibial nerve pedis artery in the transverse view (Fig. 31.8) The predomi-
nantly hypoechoic deep peroneal nerve is found lateral to
Position the patient supine and bolster the foot with a the dorsalis pedis artery and the extensor hallucis longus
pillow to expose the anterior and medial portion of the tendon (Fig. 31.9).
lower leg and foot.. The lower limb is externally rotated.
Place a 10–15 MHz transducer immediately above the Superficial peroneal nerve
medial malleolus to locate the tibial nerve in the transverse
(short axis) view (Fig. 31.6). Perform a systematic anatomi- Position the patient supine and bolster the foot with a
cal survey in the medial aspect of the ankle. The bony pillow to expose the anterior and lateral portion of the
medial malleolus is easily identified (bony shadow). Move lower leg and foot. The lower limb is internally rotated for
the transducer slightly posteriorly to identify the tibialis examination (Fig. 31.10). The superficial peroneal nerve
posterior and flexor digitorum longus tendons. Both can be identified sonographically between the peroneus
tendons are found within the flexor retinaculum of the longus and extensor digitorum longus muscles separated
ankle. They display a sliding movement with ankle flexion by the anterior crural intermuscular septum, using a 10–
217
SPN
Medial EDL Lateral
PL
Figure 31.8 A high frequency ultrasound transducer is placed on the

dorsum of the foot along the intermalleolar line to locate the dorsalis
pedis artery in the transverse view.
DPN Figure 31.11 Transverse ultrasound image of the sonoanatomy rele-

DPA vant to the superficial peroneal nerve block using a 10 MHz linear trans-
ducer. SPN: superficial peroneal nerve; PL: peroneus longus; EDL:
extensor digitorum longus.
Lateral T Medial
Figure 31.9 Transverse ultrasound image of the sonoanatomy rele-

vant to the deep peroneal nerve block using a 10–15 MHz linear trans-
ducer. DPN: deep peroneal nerve; T: tibia; DPA: dorsalis pedis artery.
Figure 31.12 A high frequency ultrasound transducer is placed in the
transverse orientation above and behind the lateral malleolus for sural
nerve identification.
Sural nerve
Position the patient supine and bolster the foot with a
pillow to expose the anterior and lateral portion of the
lower leg and foot. The lower limb is internally rotated for
examination. A tourniquet is placed around the proximal
tibia to distend the lesser saphenous vein. A transverse
image of the lesser saphenous vein with a 10–15 MHz
transducer above the lateral malleolus is obtained (Fig.
Figure 31.10 Lower limb and transducer positioning for superficial 31.12). The sural nerve is usually only identified after injec-
peroneal nerve identification. tion of local anesthetic around the lesser saphenous vein
(Fig. 31.13).
15 MHz transducer (Fig. 31.11). Distal to this, the nerve is Saphenous nerve
superficial. The nerve pierces the fascia at a variable distance
above the intermalleolar line (6–16 cm). The nerve typi- Position the patient supine and bolster the foot with a
cally divides below the level it pierces the fascia. Its detec- pillow to expose the anterior and medial portion of the
tion is facilitated by the presence of fat around it. lower leg and foot. The lower limb is externally rotated for
218
CHAPTER
Ankle block 31
LSV SN
LSV SN GSV
AT
Figure 31.13 The sural nerve is identified in proximity to the lesser

saphenous vein. SN: sural nerve; AT: Achilles’ tendon; LSV: lesser saphe- Figure 31.15 The saphenous nerve is identified in proximity to the
nous vein. greater saphenous vein. SN: saphenous nerve; GSV: greater saphenous
vein: T: tibia.
Figure 31.14 A high frequency ultrasound transducer is placed in the

transverse orientation above the medial malleolus for saphenous nerve
identification.
examination. A tourniquet is placed around the proximal

tibia to distend the greater saphenous vein. A transverse
image of the greater saphenous vein with a 10–15 MHz Figure 31.16 Tibial nerve block technique. The needle is inserted adja-
transducer above the medial malleolus is obtained (Fig. cent to the Achilles’ tendon and toward the superior aspect of the
31.14). The saphenous nerve is usually only identified after medial malleolus. On bony contact, the needle is withdrawn and injec-
injection of local anesthetic around the greater saphenous tion is made.
vein (Fig. 31.15).
31.16), just posterior to the tibial artery. If paresthesia is

Technique elicited, the needle should be withdrawn slightly and 5 mL
of local anesthetic be injected. If paresthesia is not reported,
Landmark-based approach the needle is advanced to the bone and withdrawn slightly,
and 10 mL of local anesthetic injected.
emergency equipment is complete and in working order, Deep peroneal nerve block
intravenous access, ECG, pulse oximetry, and blood pres- To block the deep peroneal nerve, a needle is inserted
sure monitoring are established. Asepsis is observed. lateral to the extensor hallucis longus tendon and artery at
the level of the intermalleolar line (Fig. 31.17). The needle
Tibial nerve block is introduced perpendicular to the skin until bony contact
The block is performed by needle insertion on a line is made, withdrawn slightly, and 4–5 mL of local anesthetic
between the medial malleolus and Achilles’ tendon (Fig. injected.
219
Figure 31.17 Deep peroneal nerve block technique. At the midpoint Figure 31.19 Superficial peroneal nerve block technique. At the mid-
of the intermalleolar line and lateral to the dorsalis pedis pulse: the point of the intermalleolar line a subcutaneous injection is made to the
needle is oriented perpendicular to the skin. On bony contact, the lateral malleolus.
needle is withdrawn slightly and injection is made.
Figure 31.20 Sural nerve block technique. The needle is inserted adja-
cent to the Achilles’ tendon and toward the superior aspect of the
Figure 31.18 Saphenous nerve block technique. At the midpoint of lateral malleolus. On bony contact, the needle is withdrawn and injec-
the intermalleolar line a subcutaneous injection is made to the medial tion is made.
malleolus. The lateral malleolus is lowermost.
Sural nerve block

The sural nerve block is performed by needle insertion on
Saphenous nerve block a line between the lateral malleolus and the Achilles’ tendon
Saphenous nerve is blocked by subcutaneous injection (Fig. 31.20). If paresthesia is reported, the needle is with-
passing medially from the insertion point of the deep pero- drawn slightly and injection made. Otherwise, the needle
neal nerve block toward the medial malleolus (Fig. 31.18), is advanced until bony contact is made, withdrawn slightly,
avoiding the saphenous vein. For this block, 4–5 mL of and the injection made.
local anesthetic is adequate. The ankle block using the above technique uses three
injection points. Alternately, all five nerves can be blocked
Superficial peroneal nerve block individually.
The superficial peroneal nerve is blocked by a subcutaneous
injection passing laterally from the insertion point of the Ultrasound-guided approach
deep peroneal nerve block toward the lateral malleolus
(Fig. 31.19). For this block, 4–5 mL of local anesthetic is The ultrasound machine and block tray should be placed
sufficient. in positions which allow the operator to simultaneously
220
CHAPTER
Ankle block 31
TN
MM
Anterior
LA
Figure 31.21 Global view of the block field for the ultrasound-guided FHL
ankle block.
Figure 31.23 Local anesthetic surrounding the tibial nerve at the

ankle. TN: tibial nerve; FHL: flexor hallucis longus; MM: medial malleolus;
LA: local anesthetic.

guided tibial nerve block. Note the needle orientation is perpendicular Figure 31.24 Transducer and needle positioning during ultrasound-
to the ultrasound beam. guided deep peroneal nerve block. Note the needle orientation is per-
pendicular to the ultrasound beam.
minimal movement. This setup may take some forethought tip on each side of the tibial nerve without puncturing the
but is a worthwhile exercise, and will facilitate successful posterior tibial artery. Once satisfied with the needle posi-
regional anesthesia. tion, inject 5–8 mL of local anesthetic. Observe local anes-
The operator stands at the patient’s feet, with the ultra- thetic injection in real time to judge adequacy of spread.
sound machine on the side to be blocked, (Fig 31.21). The Aim to see circumferential spread of hypoechoic local anes-
skin is disinfected with antiseptic solution and draped. A thetic solution around the nerve ‘donut sign’ (Fig. 31.23).
sterile sheath (CIVCO Medical Instruments, Kalona, IA,
USA) is applied over the ultrasound transducer with sterile Deep peroneal nerve block
ultrasound gel (Aquasonic, Parker Laboratories, Fairfield, A 25-G 2.5-cm needle can be inserted using the OOP
NJ, USA). Another layer of sterile gel is placed between the approach (Fig. 31.24). If the deep peroneal nerve is clearly
sterile sheath and the skin. The ultrasound screen should visualized, inject 2–3 mL of local anesthetic on each side
be made to look like the scanning field. That is, the right of the nerve. If the nerve is not clearly visualized, inject
side of the screen represents the right side of the field. 2–3 mL of local anesthetic on each side of the artery in the
Adjustable ultrasound variables such as scanning mode, subcutaneous plane. Observe local anesthetic spread around
depth of field, and gain are optimized. the nerve circumferentially in the subcutaneous plane
above bone and at approximately the same level as the
Tibial nerve block artery (Fig. 31.25).
Both In Plane (IP) and Out of Plane (OOP) approaches can
be used. The IP approach is commonly used for single-shot Superficial peroneal nerve block
injection. Insert a 4–5 cm 22–25 G needle in-line with the The superficial peroneal nerve can be identified sonograph-
ultrasound transducer (Fig. 31.22). Aim to place the needle ically between the peroneus longus and extensor digitorum
221
SPN LA
LA
Lateral Medial EDL
Medial Lateral
Artery
PL
Deep Peroneal Nerve
Figure 31.25 Local anesthetic surrounding the deep peroneal nerve

at the ankle. LA: local anesthetic.
Figure 31.27 Local anesthetic surrounding the superficial peroneal

nerve. SPN: superficial peroneal nerve; LA: local anesthetic. PL: peroneus
longus; EDL: extensor digitorum longus.

guided superficial peroneal nerve block. Note the needle orientation is
perpendicular to the ultrasound beam.
guided saphenous nerve block at the ankle. Note the needle orientation
is perpendicular to the ultrasound beam.
longus muscles, separated by the anterior crural intermus-
cular septum proximal to the intermalleolar line. A 25-G
2.5-mm needle can be inserted using the OOP approach
(Fig. 31.26). Inject 2–3 mL of local anesthetic on each side
of the nerve. Observe local anesthetic spread around the
nerve circumferentially (Fig. 31.27).
GSV
LA
Saphenous nerve block
A transverse image of the greater saphenous vein above the T
medial malleolus is obtained. A 25-G 2.5-cm needle can be
inserted using the OOP approach (Fig. 31.28). Inject local
anesthetic (2–3 mL) on either side of the greater saphenous
vein (Fig. 31.29).
Sural nerve block

A transverse image of the lesser saphenous vein above the
lateral malleolus is obtained. A 25-G 2.5-cm needle can be
inserted using the OOP approach (Fig. 31.30). Inject local Figure 31.29 Inject local anesthetic (2–3 mL) on either side of the
anesthetic (2–3 mL) on either side of the lesser saphenous greater saphenous vein for the saphenous nerve block. T: tibia; GSV:
vein (Fig. 31.31). greater saphenous vein; LA: local anesthetic.
222
CHAPTER
Ankle block 31
correct plane following injection through the catheter con-

firms correct placement. Ultrasound can be used post-
operatively to assess continued correct positioning of the
catheter.
CLINICAL PEARLS
• This block is relatively painful for the patient. It is worthwhile
Figure 31.30 Transducer and needle positioning during ultrasound- anesthetizing the skin with local anesthetic cream before
guided sural nerve block. Note the needle orientation is perpendicular injecting.
to the ultrasound beam. • For the tibial nerve block, it is best to place the foot to be injected
over the opposite foot, with the medial malleolus uppermost.
This gives good access to the nerve.
• This block is especially appropriate for the diabetic patient, who
may also have multiple organ disease, requiring amputation of
forefoot or toe(s).
• The tibial nerve can be located with a peripheral nerve
LSV stimulation technique; it is possible to place a catheter to
LA
provide continuous analgesia in its area of sensory innervation.
AT • Ultrasound has been shown to improve the success of tibial and
sural nerve blocks at the ankle.
Suggested reading
Fredrickson MJ. Ultrasound-guided ankle block. Anaesth
Intensive Care 2009;37(1):143–144.
Macaire P, Gaertner E, Capdevila X. Continuous post-
Figure 31.31 Inject local anesthetic (2–3 mL) on either side of the operative regional analgesia at home. Minerva
lesser saphenous vein for the sural nerve block. AT: Achilles’ tendon; LSV: Anestesiol 2001;67(9 Suppl. 1):109–116.
lesser saphenous vein; LA: local anesthetic. Redborg KE, Antonakakis JG, Beach ML, et al. Ultrasound
improves the success rate of a tibial nerve block at
the ankle. Reg Anesth Pain Med 2009;34(3):256–260.
Redborg KE, Sites BD, Chinn CD, et al. Ultrasound
A continuous tibial nerve block can be performed. The improves the success rate of a sural nerve block at the
catheter is secured with a transparent dressing. Ultrasound ankle. Reg Anesth Pain Med 2009;34(1):24–28.
can be used to facilitate catheter placement. The catheter Schurman DJ. Ankle-block anesthesia for foot surgery.
may not be seen. Deposition of local anesthetic in the Anesthesiology 1976;4:348–352.
223
CHAPTER
32
Paravertebral block
spinal (intercostal) nerve, dorsal ramus, rami communican-

Indications tes, and sympathetic chain (anteriorly). The paravertebral
space is continuous medially with the epidural space and
Surgical Thoracic; breast; cholecystectomy; renal and ure-
laterally with the intercostal space. The inferior limit of this
teric; herniorrhaphy; appendicectomy; video-assisted tho-
space occurs at the origins of the psoas major muscle. The
racoscopic surgery; minimally invasive cardiac surgery.
superior limit extends into the cervical region.
Therapeutic Acute pain management for fractured ribs
and flail chest; intercostal neuralgia associated with osteo-
porotic vertebral fractures; liver capsular pain after blunt
abdominal trauma; acute and chronic postherpetic neural- Surface anatomy
gia; postamputation pain; chronic benign and tumor-
related pain; prolonged postoperative analgesia (continuous The main landmarks for the paravertebral block are the
technique). spinous and transverse processes. Identification of the
appropriate vertebral level for blockade is facilitated by
knowledge of dermatomes and anatomic landmarks that
Contraindications suggest vertebral level (Fig. 32.3). The spinous process of
C7 (vertebrae prominens) is prominent and does not move
Absolute with neck flexion. The spine and inferior angle of the
See Chapter 4. scapula lie at the T3 and T7 vertebral levels, respectively.
Relative
Hemorrhagic diathesis; anticoagulation treatment; dis-
torted anatomy (e.g. kyphoscoliosis or previous thoracic Sonoanatomy
surgery).
A linear array transducer is placed initially at a point 2.5 cm
lateral to the tip of the spinous process in a vertical orienta-
Clinical anatomy tion, obtaining a sagittal paramedian view of the transverse
processes (TP), superior costotransverse ligament (SCTL)
The paravertebral space is a wedge-shaped area on both and underlying pleura (Fig. 32.4). The transverse processes
sides of the vertebral column (Fig. 32.1). The boundaries are seen as interrupted hyperechoic lines with loss of image
of the space are: posteriorly, the superior costotransverse beneath. The parietal pleura is identified as a bright struc-
ligament; laterally, the posterior intercostal membrane; and ture running deep to the adjacent TPs and can be seen to
anteriorly, the parietal pleura. At the base of the triangle slide with patient respirations. The superior costotransverse
(medially) is the posterolateral aspect of the vertebra, disc, ligament, though less distinct, is seen as a collection of
and intervertebral foramen (Fig. 32.2). Contents of the homogeneous linear echogenic bands alternating with
paravertebral space include fatty tissue, intercostal vessels, echo-poor areas running from one TP to the next (Fig. 32.4).

DOI: 10.1016/B978-0-7020-3148-9.00040-2
CHAPTER
Paravertebral block 32
4
5 3

paravertebral block. 1: spinous process; 2: vertebral body; 3: transverse
process; 4: paravertebral space; 5: spinal canal. Figure 32.3 Landmarks for the paravertebral block. The needle inser-
tion point is 2.5 cm lateral to the spinous process. Approximate verte-
bral levels can be obtained by determining the positioning of the spine
and inferior angle of the scapula and the vertebrae prominens (C7).
Pleura
Sympathetic
chain
Dorsal root
ganglion
Intercostal
nerve TP SCTL
Superior
costo- PP TP
transverse
ligament
LT
Rib
Figure 32.4 Ultrasound anatomy of a paravertebral space. Two bright

lines demonstrate contiguous transverse processes, with the paraverte-
bral space found between the superior costotransverse ligament and
Figure 32.2 Anatomy of the paravertebral space.
the underlying parietal pleura. LT: lung; PP: parietal pleura; SCTL: supe-
rior costotransverse ligament; TP: transverse process.
Technique The needle insertion point is infiltrated with local anes-

thetic using a 25-G needle. An 18-G Tuohy needle is inserted
Landmark-based approach perpendicular to the skin until contact is made with the
transverse process (Fig. 32.5). This usually occurs 2–4 cm
As for all regional anesthetic procedures, after checking that from the skin. The location of the transverse process is criti-
emergency equipment is complete and in working order, cal in the performance of this block. If this contact is not
intravenous access, ECG, pulse oximetry, and blood pres- made, it is likely that the needle lies between the transverse
sure monitoring are established. Asepsis is observed. processes. The needle should be withdrawn and redirected
The patient is placed in the sitting or lateral position, with in a caudal or cephalic direction (Fig. 32.6). Once the trans-
the head in the flexed position and the back arched. Choose verse process is identified, the needle is withdrawn and
which dermatomes will be involved in the operative field. redirected in a cephalic/caudad direction to ‘walk’ over/
The spinous processes are palpated and marked with a skin under the transverse process.
marker. A point 2.5 cm lateral to the spinous processes is The paravertebral space is usually found 1–1.5 cm deep
marked. to the transverse process. It is imperative that the needle
225
Figure 32.5 Paravertebral block technique. The epidural needle is

inserted perpendicular to the skin until contact with the transverse
1
process.
Figure 32.6 Paravertebral block technique. The needle is ‘walked’ over

the transverse process and advanced until a loss of resistance is
identified.
Figure 32.7 Coronal T1-weighted MR image showing cephalad and

should not be advanced beyond this point because there is caudad spread of 20 mL of contrast injected below transverse process
a risk of pleural puncture. A subtle ‘click’ or loss of resis- of T10. 1; contrast spread; 2: psoas muscle.
tance is usually felt as the needle passes through the costo-
transverse ligament. somatic block of five dermatomes, and a sympathetic block
Incremental injections of local anesthetic (5 mL) are over eight dermatomes. Little is known regarding the factors
made with repeated aspiration. For a single-injection multi- that influence spread.
segment block, the volume used should be 15–25 mL.
While the onset of analgesia is within minutes after injec- Ultrasound-guided approach
tion of local anesthetic, up to 20 min is typically required
for surgical anesthesia. Intravenous access, ECG, pulse oximetry and blood pres-
Local anesthetic solution injected into the paravertebral sure monitoring are established. The block tray is set up as
space may remain localized, spread to the ipsilateral previously outlined. The ultrasound machine and block
paravertebral spaces above and below the injection site tray should be placed in positions which allow the operator
(Fig. 32.7), pass laterally through the intercostal space to simultaneously scan the patient and take items from the
(Fig. 32.8), or spread medially through the epidural space block tray with minimal movement. This setup may take
or across the vertebral bodies. Thermographic studies have some forethought but is a worthwhile exercise, and will
demonstrated that 15 mL of bupivacaine 0.5% produces a facilitate successful regional anesthesia. The operator stands
226
CHAPTER
Paravertebral block 32
3
4 2
Figure 32.8 Axial T1-weighted MR image showing spread of contrast Figure 32.10 Ultrasound transducer and needle positioning during
laterally below the ninth rib. 1: aorta; 2: intracostal contrast spread; 3: ultrasound-guided thoracic paravertebral block. Note the needle orien-
ninth rib; 4: T9 transverse process. tation in the same plane as the ultrasound beam.
chest wall is obtained and the transverse processes, superior

costotransverse ligament and parietal pleura identified (Fig.
32.4). The midpoint of the transducer is aligned midway
between the two adjacent TPs, local anesthesia is infiltrated
at its lower border and an 18-G Tuohy needle introduced
in a needle-in-plane approach in a cephalad orientation
(Fig. 32.10). The paravertebral space is entered midway
between the two TPs, avoiding bony contact. The tip of the
needle is advanced under direct vision to puncture the
superior costotransverse ligament. Saline (3 mL) is then
injected deep to the SCTL to demonstrate the position of
the injectate. Following a negative aspiration test, 15–20 mL
of local anesthetic agent is injected and visualized filling
Figure 32.9 Global view of block field for ultrasound-guided thoracic the paravertebral space (Fig. 32.11).
paravertebral block. An ultrasound-guided paravertebral technique has been
described where the needle is advanced in-plane with the
transducer, in a lateral-to-medial direction.1 An assisted
on the side to be blocked, with the patient in the sitting technique may also be used where the relevant structures
position (Fig. 32.9). The relevant spinous processes are are identified and measurements are used to facilitate block
palpated and marked. A line is drawn 2.5 cm lateral to the performance.
spinous process. The needle insertion point is 2.5 cm lateral
to the relevant spinous process. Continuous techniques
The skin is disinfected with antiseptic solution and draped.
A sterile sheath (CIVCO Medical Instruments, Kalona, IA, A catheter may be placed through the Tuohy needle and
USA) is applied over the ultrasound transducer with sterile secured in place. Leave 3 cm of the catheter within the
ultrasound gel (Aquasonic, Parker Laboratories, Fairfield, space.
NJ, USA). Another layer of sterile gel is placed between the
sterile sheath and the skin. The posterior chest wall is
scanned with a 6–13 MHz linear transducer. The ultrasound Adverse effects
screen should be made to look like the scanning field. That
is, the right side of the screen represents the cephalad side • Hematoma.
of the field. Adjustable ultrasound variables such as scan- • Hypotension due to sympathetic block is decreased
ning mode, depth of field, and gain are optimized. compared with centroneuroaxial techniques.
The transverse processes are generally found at a depth of • Local anesthetic toxicity is rare; avoid by frequent
2–3 cm from the skin. A sagittal image of the posterior aspiration.
227
• Epidural or subarachnoid injection: bilateral anesthesia

suggests an epidural or intrathecal injection; avoid by
preventing any medial orientation of the needle. Bilat-
eral anesthesia may also occur by spread of local anes-
thetic across the vertebral bodies.
• Pneumothorax is unlikely with correct technique (0.5%
incidence).
TP
SCTL
Reference
PP
1. Luyet C, Eichenberger U, Greif R, et al. Ultrasound-
guided paravertebral puncture and placement of
PP
catheters in human cadavers: an imaging study. Br J
LT Anaesth 2009;102(4):534–539.
Suggested reading
Davies RG, Myles PS, Graham JM. A comparison of the
analgesic efficacy and side-effects of paravertebral vs
Figure 32.11 Ultrasound image of a paravertebral space after injection
of saline-local anesthetic. The arrow highlights the displacement of the epidural blockade for thoracotomy – a systematic
parietal pleura as the paravertebral space is filled with fluid. LT: lung; PP: review and meta-analysis of randomized trials. Br J
parietal pleura; SCTL: superior costotransverse ligament; TP: transverse Anaesth 2006;96(4):418–426.
process. Exadakatylos AK, Buggy DJ, Moriarty DC, et al. Can
anesthetic technique for primary breast cancer surgery
affect recurrence or metastasis? Anesthesiology
2006;28:727–731.
Hara K, Sakura S, Nomura T, Saito Y. Ultrasound guided
thoracic paravertebral block in breast surgery.
Anaesthesia 2009;64(2):223–225.
CLINICAL PEARLS Karmakar MK. Thoracic paravertebral block.
Anesthesiology 2001;95:771–780.
• Simple and easy to learn, with a low incidence of complications.
• Compared with thoracic epidural techniques, it maintains Naja MZ, Gustafsson AC, Ziade MF, et al. Distance
hemodynamic stability, bladder sensation, and lower limb motor between the skin and the thoracic paravertebral
power. Promotes early mobilization. space. Anaesthesia 2005;60(7):680–684.
• Reliably blocks the posterior primary ramus, unlike the Naja Z, Lönnqvist PA. Somatic paravertebral blockade.
intercostal technique. Incidence of failed block and complications.
• A catheter may be left in situ for extended analgesia.
Anaesthesia 2001;56:1184–1188.
• Equivalent analgesia to thoracic epidurals for major thoracic
surgery, with fewer adverse effects. Pusch F, Wildling E, Klimscha W, Weinstabl C.
• The benefit of ultrasound guidance in improving the quality or Sonographic measurement of needle insertion depth
safety of paravertebral blockade has not been studied. in paravertebral blocks in women. Br J Anaesth
• Injecting under high pressure may increase the risk of epidural 2000;85(6):841–843.
spread and/or contralateral spread. Richardson J, Lönnqvist PA. Thoracic paravertebral block.
Br J Anaesth 1998;81:230–238.
228
CHAPTER
33
Intercostal block
branch arise. The collateral branch follows the lower border

Indications of the space in the same intermuscular interval as the main
trunk, which it may or may not rejoin before it is distrib-
Surgical Upper abdominal and thoracic superficial proce-
uted as an additional anterior cutaneous branch. The lateral
dures; insertion of thoracostomy and gastrostomy tubes.
branch accompanies the main trunk for a time before pierc-
Therapeutic Postoperative pain therapy after upper
ing the intercostal muscles obliquely. The main trunk con-
abdominal and thoracic procedures; intercostal neuralgia;
tinues anteriorly as the anterior cutaneous branch.
painful conditions after rib fractures or contusions of chest
The interior lower edge of the ribs provides a channel for
wall; pleuritic pain; postherpetic neuralgia; tumor-related
the intercostal nerve and its companion artery and vein.
pain.
The nerve lies just behind the lower border of the rib. Near
the midaxillary line, the groove becomes less well defined,
Contraindications and the nerve migrates away from the rib (Fig. 33.2). The
structures between skin and intercostal nerve vary, depend-
ing on body wall location on the nerve’s path. At the back
Absolute of the chest, the nerve lies between the pleura and the pos-
See Chapter 4. terior intercostal membrane (extension of internal intercos-
Relative tal muscle), but in most of its course it runs between the
Hemorrhagic diathesis; anticoagulation treatment; and internal intercostal muscles and the intercostalis intimi.
chronic obstructive lung disease. Where the latter muscles are absent, the nerve lies in contact
with the parietal pleura. In the intercostal groove, the vein
lies superior, with the artery and nerve more inferiorly. This
Clinical anatomy relation is not consistent, particularly in the paravertebral
region.
The intercostal nerves comprise the ventral rami of T1 to
T11. The 12th thoracic nerve is called the subcostal nerve.
They pass forward in the intercostal spaces below the inter- Surface anatomy
costal vessels. At the posterior aspect of the chest they lie
between the pleura and the posterior intercostal mem- Important bony structures relevant to the intercostal nerve
branes, but soon pierce the latter and run between the two block include the thoracic spinous processes, paraspinal
planes of intercostal muscles as far as the middle of the rib. muscles, posterior angulation of ribs, spine, and inferior tip
The intercostal nerves contribute and receive sympathetic of scapula. The lateral edge of the paraspinal muscles is
fibers. Shortly after exit from the intervertebral foramina, identified and marked. This is at the posterior angle of the
the dorsal rami become a posterior cutaneous branch to ribs. These lines angle medially in the upper thoracic region
skin and muscles in the paravertebral region (Fig. 33.1). At so as to parallel the medial edge of the scapula. The midline
the angle of the ribs, a lateral cutaneous and a collateral spinous processes are also marked. The inferior edges of the
DOI: 10.1016/B978-0-7020-3148-9.00041-4
External Rectus sheath Anterior cutaneous nerve

oblique
muscle
Internal
oblique
muscle
Transversus Rectus
abdominus muscle
muscle
Lateral Anterior
cutaneous primary
nerve ramus Vertebra
External
intercostal
muscle
Figure 33.3 Landmarks for the intercostal block. The patient lies in the
Internal prone position with the arms abducted above the head. The spinal
intercostal musculature is identified and marked laterally. The inferior borders of
muscle
the ribs are marked where they cross this muscle mass.
Innermost
intercostal
muscle Erector spinae Posterior
muscle primary ramus
Figure 33.1 Typical intercostal nerve.
Figure 33.4 Ultrasound appearance of the intercostal space. R: rib;

M: intercostal muscle; P: pleura.
Figure 33.2 The interior lower edge of the ribs provides a channel for
the intercostal nerve and its companion artery and vein. The nerve lies structures with a bright surface (periosteum; Fig. 33.4). A
just behind the lower border of the rib. Near the midaxillary line, the dark shadow is cast deep to the rib on ultrasound, illustrat-
groove becomes less well-defined, and the nerve migrates away from ing the phenomenon of echo shadowing. Echo shadowing
the rib. is an echo-free zone immediately behind a structure of high
absorbance or reflectivity, such as bone, calculi or metal
prosthesis. The pleura and lungs are visualized deep to the
ribs are palpated and marked. At the intersection of lines intercostal space between the echo shadows (Fig. 33.4).
are the needle insertion points (Fig. 33.3).
Technique
Sonoanatomy
The chest wall is best imaged in a coronal (vertical) plane.
Using a 6–13 MHz linear transducer, the relevant intercos- As for all regional anesthetic procedures, after checking that
tal space is visualized. The ribs appear as dense dark oval emergency equipment is complete and in working order,
230
CHAPTER
Intercostal block 33
Figure 33.5 Intercostal block technique: introducing the needle. The Figure 33.6 Intercostal block technique: injection of local anesthetic.
index and third finger retract skin up and over the rib. The needle is The left hand now holds the needle hub and shaft between the thumb,
introduced in a 20° cephalad orientation and advanced until it contacts index finger, and middle finger. The left-hand hypothenar eminence is
the rib. firmly placed against the patient’s back. The needle and syringe move
as a whole. This allows maximal control of needle depth as the left hand
‘walks’ the needle off the inferior margin of the rib and into the inter-
intravenous access, ECG, pulse oximetry, and blood pres- costal groove. At a distance of 2–4 mm past the edge of the rib, 3–5 mL
sure monitoring are established. Asepsis is observed. of local anesthetic is injected.
In the posterior approach, the patient lies in a prone or
lateral position. The prone position is particularly favored
if bilateral blocks are to be performed. The operator stands to simultaneously scan the patient and take items from the
behind the patient. A pillow is placed under the abdomen block tray with minimal movement. This setup may take
to reduce the lumbar lordosis and to accentuate the inter- some forethought but is a worthwhile exercise, and will
costal spaces posteriorly. The arms should be allowed to facilitate successful regional anesthesia.
hang down from the edge of the block table to permit the The patient is placed in the lateral position with the side
scapula to rotate as far laterally as possible. to be blocked uppermost (Fig. 33.7). The operator stands
The needle insertion point is infiltrated with local anes- or sits behind the patient. The relevant intercostal space(s)
thetic using a 25-G needle. The index and third finger of are palpated and marked at the lateral edge of the paraspi-
the left hand retract skin up and over the rib. A 30-mm nal muscles. This landmark corresponds to the posterior
23-G needle is introduced in a 20° cephalad orientation angle of the ribs. Blockade at this point ensures the lateral
through the skin between the tips of the retracting fingers, cutaneous branch is included in the block.
and advanced until it contacts the rib (Fig. 33.5). The left The skin is disinfected with antiseptic solution and
hand now holds the needle hub and shaft between the draped. A sterile sheath (CIVCO Medical Instruments,
thumb, index finger, and middle finger. The left-hand hypo- Kalona, IA, USA) is applied over the ultrasound transducer
thenar eminence is firmly placed against the patient’s back. with sterile ultrasound gel (Aquasonic, Parker Laboratories,
The needle and syringe move as a whole. This allows Fairfield, NJ, USA). Another layer of sterile gel is placed
maximal control of needle depth as the left hand ‘walks’ between the sterile sheath and the skin. The lateral chest
the needle off the inferior margin of the rib and into the wall is scanned with a 6–13 MHz linear transducer. The
intercostal groove. At a distance of 2–4 mm past the edge ultrasound screen should be made to look like the scanning
of the rib, 3–5 mL of local anesthetic is injected after aspira- field. That is, the right side of the screen represents the right
tion (Fig. 33.6). The intercostal block may also be per- side of the field. Adjustable ultrasound variables such as
formed in the midaxillary line, but there is risk of not scanning mode, depth of field, and gain are optimized.
blocking the lateral cutaneous branch. The intercostal space is generally found at a depth of
Continuous intercostal techniques have been described. 2–3 cm from the skin. A coronal image of the chest wall is
obtained and the ribs, pleura, and lungs identified (Fig.
Ultrasound-guided approach 33.4). The uppermost rib is kept in the centre of the field
of view. The needle entry site is at the caudad edge of the
Intravenous access, ECG, pulse oximetry and blood pres- linear transducer. A 23-gauge needle is advanced under
sure monitoring are established. The block tray is set up as real-time ultrasound guidance and local anesthetic is depos-
previously outlined. The ultrasound machine and block ited along the needle entry path. A free hand technique
tray should be placed in positions which allow the operator rather than the use of a needle guide is preferred. A 21-GA
231
N R
Figure 33.7 Global view of the block field for the ultrasound-guided
intercostal nerve block. Figure 33.9 Real-time imaging of needle insertion for the ultrasound-
guided intercostal nerve block. Notice the needle shaft marked with
arrows and the needle tip (N) position with local anesthetic injected into
the intercostal space. R: rib; M: intercostal.
M
R IN

guided intercostal nerve block. Note the needle orientation in the same Figure 33.10. Ultrasound appearance of the intercostal space with
plane as the ultrasound beam. intercostal nerve visualized. R: rib; M: intercostal muscle; IN: intercostal
nerve.
× 50-mm insulated needle (B. Braun, Bethlehem PA) is

inserted parallel to the axis of the beam of the ultrasound With the technique described above, the intercostal nerve
transducer (Fig. 33.8). The needle is attached to sterile is not seen with ultrasound. It can be seen, however, after
extension tubing, which is connected to a 20-mL syringe leaving the intervertebral foramen (Fig. 33.10).
and flushed with local anesthetic solution to remove all air
from the system. It is then introduced at the caudad edge Continuous techniques
of the transducer and visualized along its entire path to the
intercostal space. It is important not to advance the needle A continuous intercostal technique is possible. Catheters
without good visualization. This may require needle or that have a metal component are more easily visualized
transducer adjustment. with ultrasound.
The needle is advanced toward the inferior border of the
rib (Fig. 33.9). On contacting the rib, the needle is redi-
rected inferiorly to pass no more than 0.5 cm beyond the Adverse effects
inferior rib margin. Following a negative aspiration test,
2–5 mL of local anesthetic agent is injected and visualized • Bruising.
filling the intercostal space. • Neural injuries are extremely rare.
232
CHAPTER
Intercostal block 33

into the intercostal vessels is decreased by careful aspira- Suggested reading
tion. Overdosage or intravascular diffusion can cause
Murphy DF. Continuous intercostal nerve block.
symptoms of local anesthetic toxicity. Slow injection
Anesthesiology 1986;64(5):669–670.
will decrease the incidence of this complication.
Rendina EA, Ciccone AM. The intercostal space. Thorac
• Pneumothorax, which occurs in less than 1% of blocks,
Surg Clin 2007;17(4):491–501.
can be minimized by appropriate technique.
Rozen WM, Tran TM, Ashton MW, et al. Refining the
course of the thoracolumbar nerves: a new
understanding of the innervation of the anterior
CLINICAL PEARLS abdominal wall. Clin Anat 2008;21(4):325–333.
Shanti CM, Carlin AM, Tyburski JG. Incidence of
• Physicians should develop a consistent technique of hand and
needle control for this block. pneumothorax from intercostal nerve block for
• Patient positioning improves success in obese patients. analgesia in rib fractures. J Trauma 2001;51:536–539.
• If multiple levels are to be blocked, then sedation is mandatory.
• The intercostal block is performed behind the angle of the rib to
ensure blockade of the lateral cutaneous branch.
• Pneumothorax occurs in approximately 1% of unguided cases.
The benefit of ultrasound guidance in decreasing this risk has
not been studied.
• Vertical ultrasound scanning plane at 90° to the ribs is used.
• Intercostal nerves can be visualized posteriorly and close to the
intervertebral foramen.
233
CHAPTER
34
Transversus abdominis plane block
John McDonnell · Brian O’Donnell
abdominis plane of the anterior abdominal wall and sup-

Indications plies the skin, muscles and parietal peritoneum in the
abdomen (Fig. 34.2). The transversus abdominis plane
Surgical Analgesia for abdominal surgery with incision at
(TAP) lies between the internal oblique and transversus
or below the level of the T8 dermatome: bilateral block for
abdominis muscles, and forms a connective tissue conduit
midline abdominal incision (e.g. open/radical prostatec-
through which the ventral rami of T6 to L1 travel. Deposi-
tomy, colectomy, total abdominal hysterectomy); or unilat-
tion of local anesthetic solution in the TAP permits abdom-
eral block on side of surgical incision (inguinal hernia
inal wall sensory blockade.
repair, appendicectomy, orchidopexy, nephrectomy).
Therapeutic Analgesia following abdominal surgery,
management of abdominal wall pain syndromes. Surface anatomy
The surface anatomical landmarks for this block are: the
Contraindications iliac crest, the mid-axillary line and the costal margin. The
needle insertion point is at the apex of the Lumbar Triangle
Absolute of Petit, which is formed by the external oblique muscle
See Chapter 4. anteriorly, the latissimus dorsi muscle posteriorly, and the
iliac crest inferiorly (Fig. 34.3).
Relative
Hemorrhagic diathesis; anticoagulation treatment; abdomi-
nal wall herniae (particularly lumbar hernia through the Sonoanatomy
‘Triangle of Petit’ or ‘Grynfeltt’s lumbar orifice’).
The muscles of the anterior abdominal wall are readily
visible as three distinct layers (external oblique, internal
Clinical anatomy oblique, transversus abdominis) (Fig. 34.4). The muscle
layers are seen as marbled transverse structures surrounded
The sensory innervation of the abdominal wall is derived by bright hyperechoic fascial coverings. The target for this
from the sixth thoracic nerve to the first lumbar nerve (Fig. block is the space between the internal oblique muscle and
34.1). The nerves arise from the ventral rami of their respec- the transversus abdominis muscle at the level of the apex
tive nerve roots and travel anteriorly in a groove beneath of the Lumbar Triangle of Petit.
the respective ribs to lie between the internal intercostal
muscle and the innermost intercostal muscle. The intercos-
tal nerve gives a sensory branch at the mid-axillary line, Technique
which provides variable innervation from the posterior axil-
lary line anteriorly. The nerve continues forward as the The TAP block is usually performed following induction of
anterior cutaneous branch, which enters the transversus general anesthesia with the patient in a supine position.
DOI: 10.1016/B978-0-7020-3148-9.00042-6
CHAPTER
Transversus abdominis plane block 34
T4 T4
T6
Figure 34.3 The surface anatomical landmarks for the transversus
abdominis plane block.
T8
T10
T12/L1
Figure 34.1 The dermatomal levels and corresponding relevant ana-

EO
tomical surface landmarks are illustrated. From Harmon D, et al. Periop-
erative diagnostic and interventional ultrasound with DVD. Elsevier,
Saunders; 2008.
IO
External Rectus sheath Anterior cutaneous nerve

oblique
muscle TA
Internal
oblique P
muscle
Figure 34.4 Ultrasound appearance of the lateral abdominal wall.
Transversus Rectus EO: external oblique muscle; IO: internal oblique muscle; TA: transversus
abdominus muscle abdominis muscle; P: peritoneum.
muscle
Lateral Anterior
cutaneous primary
nerve
The technique may also be performed on conscious patients
ramus Vertebra
after cutaneous local anesthetic infiltration. Intravenous
External access, ECG, pulse oximetry and blood pressure monitoring
intercostal are established.
muscle
Internal
intercostal
muscle
The block tray is set up with antibacterial solution and
Innermost swabs, block needle and local anesthetic injectate. With the
intercostal patient in a supine position, the operator stands opposite
muscle Erector spinae Posterior
muscle primary ramus the side to be blocked and the iliac crest is palpated from
anterior to posterior. The needle insertion point is at the
Figure 34.2 The mixed motor sensory nerve travels anteriorly between
internal oblique and transversus abdominis muscles, as shown here,
apex of the Lumbar Triangle of Petit cephalad to the iliac
branching in the midaxillary line. From Harmon D, et al. Perioperative crest, behind the mid-axillary line. The skin is disinfected
diagnostic and interventional ultrasound with DVD. Elsevier, Saunders; with antiseptic solution and draped. The skin is pierced
2008. by the regional anesthesia needle (18-G Tuohy needle
235
Figure 34.5 Needle insertion for the landmark-based transversus

abdominis plane block.
Figure 34.7 The transducer is oriented transversely over the lateral

abdominal wall between the iliac crest and the costal margin.
of the table is optimal. The skin is disinfected with antiseptic

solution and draped. A sterile sheath is applied over the
ultrasound transducer with sterile ultrasound gel. Another
layer of sterile gel is placed between the sterile sheath and
the skin. The lateral abdominal wall is scanned in a trans-
verse plane with a high frequency linear array transducer in
the 10–13 MHz range. A low frequency transducer in the
2–5 MHz range is used in larger patients. The transducer
is oriented transversely over the lateral abdominal wall
between the iliac crest and the costal margin (Fig. 34.7). The
Figure 34.6 Global view of the block field for the ultrasound-guided ultrasound screen should be made to look like the scanning
transversus abdominis plane block. field. That is, the right side of the screen represents the right
side of the field. Adjustable ultrasound variables such as
scanning mode, depth of field, and gain are optimized.
connected to sterile extension tubing). The needle is The image of the abdominal wall at this level reveals the
advanced at right angles to the skin, and a ’pop’ sensation three muscle layers with their surrounding connective tissue
is appreciated as the external oblique muscle is traversed sheaths. The peritoneum and intestine are seen deep to
(Fig. 34.5). Further advancement results in a second ‘pop,’ the abdominal muscles (Fig. 34.4). The target is kept in the
which signals entry to the transversus abdominis fascial centre of the field of view, and the needle entry site is at the
plane. After aspiration to exclude vascular puncture, 0.3 mL/ superior border of the linear transducer. An 18-G Tuohy
kg of local anesthetic (usually 0.25% levobupivacaine to a needle is attached to sterile extension tubing, which is con-
maximum dose of 2 mg/kg) is injected into the space nected to a 20-mL syringe and flushed with local anesthetic
(repeated on the other side, if indicated). solution to remove all air from the system. It is then intro-
duced superior to the transducer and visualized along
Ultrasound-guided approach its entire path to the space between the internal oblique
muscle and the transversus abdominis muscle (Fig. 34.8).
The block tray is set up as previously outlined. The ultra- It is important not to advance the needle without proper
sound machine and block tray should be placed in posi- visualization; this may require ultrasound transducer
tions which allow the operator to simultaneously scan the adjustment.
patient and take items from the block tray with minimal Two distinct ‘pops’ are appreciated as the needle traverses
movement. This set-up may take some forethought but is a the external oblique and internal oblique muscles. The
worthwhile exercise, and will facilitate successful regional second pop heralds entry to the transversus abdominis
anesthesia. plane. Needle placement in the correct plane is indicated
The operator stands on the side to be blocked with the by fluid expansion in a space bounded by the hyperechoic
patient in a supine position and the ultrasound machine fascial sheath of the internal oblique and transverse
located on the contralateral side (Fig. 34.6). If both sides abdominis muscle layers (hydro dissect; Fig. 34.9). Incor-
are to be blocked, placing the ultrasound machine at the top rect needle placement will result in intramuscular fluid
236
CHAPTER
Transversus abdominis plane block 34
anesthetic is usually injected and only then is the infusion

of a more dilute local anesthetic initiated. Once the local
anesthetic is injected, the catheter is carefully inserted some
5 cm beyond the tip of the needle while keeping the needle
immobile. Ultrasound can be used to facilitate catheter
placement. The catheter may not be seen. Deposition of
local anesthetic in the correct plane following injection
through the catheter confirms correct placement. Once the
catheter is inserted, the needle is withdrawn while simulta-
neously advancing the catheter to prevent its dislodgment.
The catheter is secured with a transparent dressing.
Adverse effects
guided transversus abdominis plane block. Note the needle orientation Systemic toxicity
As this block relies on the administration of relatively
large volumes of injectate, there is potential for systemic
toxicity. Little is known as to the pharmacokinetics of local
anesthetic agents injected into the TAP. Care should be
taken not to exceed safe maximal doses of agents used (e.g.
levobupivacaine 2 mg/kg total dose).
EO
Abdominal organ injury
There has been one report of abdominal organ injury
IO with TAP block in a patient with undiagnosed hepatomeg-
aly. Careful attention to technique and the use of ultra-
LA
sound guidance may help avoid this potentially serious
TA complication.
Localized swelling
A flank bulge has been described following TAP block,
which may simply reflect motor block and relaxation of the
abdominal wall muscles.
Figure 34.9 Ultrasound appearance of 5 mL of local anesthetic solu-
tion filling the transversus abdominis plane. LA: local anesthetic; Femoral nerve block
EO: external oblique muscle; IO: internal oblique muscle; TA: transversus
abdominis muscle. Transient femoral nerve block is possible and is associated
with local anesthetic agent tracking between the transversus
during hydrodissection. Following confirmation of correct
needle placement, 2–30 mL of solution may then be
injected and observed to fill the plane. For a surgical inci- CLINICAL PEARLS
sion that does not involve the midline, a unilateral block
• Simple and easy to perform
on the side of the surgical incision will suffice. For a midline
• Provides excellent analgesia following many types of abdominal
incision, the procedure must be repeated on the opposite surgery
side, as blockade of the contralateral sensory afferents is • Midline incisions require bilateral blocks
necessary to obtain midline analgesia. • May be used for rescue analgesia
• An ultrasound- guided transversalis fascia plane block has been
Continuous technique described that blocks the lateral cutaneous branches of the
subcostal (T12) and iliohypogastric nerves (L1) more successfully
A continuous technique has been reported. As with other than the TAP block.
continuous nerve block techniques, the initial dose of local
237
abdominis muscle and the transversalis fascia. This space is On-Q pain relief system for postoperative pain
continuous, with a tissue plane deep to the iliacus fascia management after open nephrectomy. Br J Anaesth
which contains the femoral nerve. Ambulatory patients 2008;101(6):841–847.
should be examined for femoral nerve block prior to ambu- Grady MV, Cummings KC, 3rd. The ‘flank bulge’ sign of
lation and home discharge. a successful transversus abdominis plane block. Reg
Anesth Pain Med 2008;33(4):387.
Suggested reading Hebbard P. Transversalis fascia plane block, a novel
ultrasound-guided abdominal wall nerve block. Can J
Armstrong O, Hamel A, Grignon B, et al. Lumbar hernia: Anesth 2009;56(8):618–620.
anatomical basis and clinical aspects. Surg Radiol McDonnell JG, O’Donnell BD, Heffernan A, et al. The
Anat 2008;30:533–537. analgesic efficacy of transversus abdominis plane
Carney J, McDonnell JG, Ochana A, et al. The transversus block after abdominal surgery: a randomized
abdominis plane block provides effective controlled trial. Anesth Analg 2007;104(1):193–
postoperative analgesia in patients undergoing total 197.
abdominal hysterectomy. Anesth Analg 2008;107(6): McDonnell JG, O’Donnell BD, Farrell T, et al. Transversus
2056–2060. abdominis plane block: a cadaveric and radiological
Farooq M, Carey M. A case of liver trauma with a blunt evaluation. Reg Anesth Pain Med 2007;32(5):
regional anesthesia needle while performing 399–404.
transversus abdominis plane block. Reg Anesth Pain Rosario DJ, Jacob S, Luntkey J, et al. Mechanism of
Med 2008;33(3):274–275. femoral nerve palsy complicating percutaneous
Forastiere E, Sofra M, Giannarelli D, et al. Effectiveness of ilioinguinal field block. Br J Anaesth 1997;78:
continuous wound infusion of 0.5% ropivacaine by 314–316.
238
CHAPTER
35
Inguinal field block
Jack Barrett · Dominic Harmon
The inguinal region includes the inguinal canal, spermatic The ilioinguinal and iliohypogastric nerves are branches
cord, surrounding skin and subcutaneous tissue. It receives of the primary ventral ramus of L1, which stems from the
sensory innervation from the 11th and 12th thoracic nerves lumbar plexus and immediately receives a branch from the
and the ventral divisions of the first and second lumbar 12th spinal nerve. They run parallel to the intercostal (T1–
spinal nerves. The cutaneous branches of the lumbar plexus T11) and subcostal (T12) nerves, which are located in the
include the iliohypogastric, ilioinguinal, genitofemoral, intercostal spaces and below the 12th rib respectively. The
lateral femoral cutaneous nerves, and the obturator nerves. L1 primary ventral ramus enters the upper part of psoas
Local anesthesia is used frequently for inguinal hernia major where it commonly branches into the ilioinguinal
repair. This surgery is more commonly being performed as and iliohypogastric nerves which emerge at the lateral
an ambulatory procedure, and regional anesthesia may border of the psoas major, anterior to the quadratus lum-
offer advantages for this; it may also be the technique of borum and posterior to the kidneys. At the lateral border
choice in patients with intercurrent diseases. The technique of the quadratus lumborum, the two nerves pierce the
involves the blocking of the ilioinguinal, iliohypogastric, lumbar fascia to reach the plane between the internal
and genitofemoral nerves in combination with subcutane- oblique and transversus abdominis. They then slope down
ous injection. and around the abdominal wall.
This chapter describes techniques for blocking these The iliohypogastric nerve is situated cephalad to the ilio-
nerves, which can also be used individually for postopera- inguinal nerve. At the level of the iliac crest, the iliohypo-
tive pain relief and diagnostic or therapeutic blocks for gastric nerve divides into two terminal branches, the lateral
groin pain, as well as for superficial surgery. cutaneous branch and medial cutaneous branches. The
lateral cutaneous branch perforates the internal and exter-
nal oblique and supplies the skin over the ventral part of
the buttocks. This innervated area is behind that innervated
Clinical anatomy by the subcostal nerve. The medial cutaneous branch con-
tinues ventrally until it pierces the internal oblique muscle
The anterolateral abdominal wall comprises three muscu- above the anterior superior iliac spine, slopes downward
loaponeurotic layers. From deep to superficial these are between the internal oblique and external oblique muscles
the tranversus abdominis, internal oblique, and external (Fig. 35.1), then pierces the external oblique aponeurosis
oblique muscles. The subcostal (T12) nerve is the ventral 3 cm above the superficial inguinal ring, and ends by inner-
primary ramus of the T12 spinal nerve. It follows a similar vating skin over the lower part of the rectus abdominis and
course to other intercostal nerves in the subcostal groove front of the pubis.
of the rib. The subcostal nerve ends by innervating the The ilioinguinal nerve runs ventrally, caudad to, and in a
upper part of the rectus abdominis muscle and the skin deeper plane than the iliohypogastric nerve. It perforates the
overlying it. Its lateral cutaneous branch innervates the skin transversus abdominis at the level of the anterior superior
of the anterior buttock between the iliac crest and greater iliac spine and continues ventrally deep to the internal
trochanter. oblique (Fig. 35.2). Gradually, it pierces both internal and
DOI: 10.1016/B978-0-7020-3148-9.00043-8
Figure 35.1 Cadaver structures illustrating anatomy pertinent to the Figure 35.2 The external oblique close to the inguinal ligament is now
inguinal block technique. 1: anterior superior iliac spine; 2: pubic tuber- retracted, illustrating the ilioinguinal nerve. 1: ilioinguinal nerve.
cle; 3: inguinal ligament; 4: external oblique aponeurosis (retracted); 5:
internal oblique muscle; 6: iliohypogastric nerve.
to the femoral triangle. Branches of the femoral branch
external oblique to reach the lower border of either the descend laterally to the external iliac artery, behind the
spermatic cord (in males) or the round ligament of the inguinal ligament, and through the fascia lata into the
uterus (in females), where it finally reaches the inguinal femoral sheath. The femoral branch supplies the skin over
canal. It contributes fibers to the internal oblique, the skin the upper part of the femoral triangle and communicates
of the upper medial part of the thigh, and either the skin of with the intermediate cutaneous nerve of the thigh. The
the upper part of the scrotum and the root of the penis or genital branch (external spermatic) crosses the lower end
the skin covering the labium majus and the mons pubis. of the external iliac artery and enters the inguinal canal
The genitofemoral nerve arises from the first and second through the internal (deep) inguinal ring. It passes through
lumbar nerves and consists mainly of sensory fibers with a the superficial inguinal canal close to the pubic tubercle. It
motor component to the cremaster muscle (cremasteric supplies the cremaster muscle and traverses the inguinal
reflex). It lies within the fascial lining of the abdomen by canal in the spermatic cord to the end of the skin of the
piercing the psoas muscles and psoas fascia near its medial scrotum (anterolateral aspect). In women, the genital
border opposite the third or fourth lumbar vertebra. It branch accompanies the round ligament of the uterus and
descends under the peritoneum on the surface of the psoas ends in the skin of the mons pubis and labium majus.
major and crosses obliquely behind the ureter. At a variable Great variation of the sensory nerves to the inguinal
distance above the inguinal ligament, the nerve divides into region is not uncommon, there being communication
the genital (external spermatic) and femoral (lumboingui- between branches of the genitofemoral, ilioinguinal, or
nal) branches. The femoral branch is the cutaneous nerve iliohypogastric nerves.
240
CHAPTER
Inguinal field block 35
orientation (Fig. 35.5). The peritoneum and bowel are

Ilioinguinal/iliohypogastric nerve block seen deeper to these (Fig. 35.5). The nerves appear as
hypoechoic fascicular structures with hyperechoic rims
Surface anatomy sandwiched between the layers of muscle (Fig. 35.6). Trace
the course of the nerves from above ASIS and distally
The important bony structure for the ilioinguinal/iliohypo-
towards the inguinal region. The iliohypogastric and ilio-
gastric nerve block is the anterior superior iliac spine. The
inguinal nerves consistently lie between the internal
needle insertion site for ilioinguinal and iliohypogastric
oblique and transversus abdominis muscles here. The rec-
nerve blocks is 1 cm medial and 1 cm inferior to the ante-
ommended injection site for landmark-based approaches
rior superior iliac spine (i.e. above the inguinal ligament)
is situated medial to the anterior superior iliac spine. At
(Fig. 35.3).
this site, both nerves are often penetrating the internal
oblique muscle. Performing a ‘blind’ technique here may
Sonoanatomy result in difficulty for the injected local anesthetic to reach
both nerves if they are not lying in the same compartment.
Perform a systematic anatomical survey from the iliac crest This is a possible explanation for the high failure rates of
to the lower abdomen. The abdominal wall is scanned 20–30%. It is more likely to reach both nerves with local
about 5 cm cranial to the anterior superior iliac spine. A anesthetic using the landmark-based approach where the
sagittal oblique transducer orientation is used (Fig. 35.4). nerves are lying in the same layer of the abdominal wall.
At this point, all three muscle layers of the abdominal Small vessels are frequently seen to accompany nerves
wall can easily be identified by ultrasound and facilitate within the plane.
IO
ASIS IN/IH
Lateral Medial
TA
P
Figure 35.5 Sonoanatomy relevant to ilioinguinal and iliohypogastric

nerve block. IO: internal oblique; TA: transversus abdominis; IN/IH: ilio-
Figure 35.3 Inguinal block technique: ilioinguinal and iliohypogastric inguinal and iliohypogastric nerves; P: peritoneum, ASIS: anterior supe-
nerves. The needle insertion point is 1 cm medial and 1 cm inferior from rior iliac spine.
the anterior superior iliac spine (above the inguinal ligament). The
needle is inserted perpendicular to the skin.
IO
IN
Lateral IH Medial
TA
ASIS
Figure 35.6 Ultrasound appearance of the ilioinguinal/iliohypogastric

Figure 35.4 A sagittal oblique transducer orientation is used for the nerves. IO: internal oblique; TA: transversus abdominis; IN: ilioinguinal
ultrasound-guided ilioinguinal/iliyohypogastric nerve block. nerve; IH: iliohypogastric nerve; ASIS: anterior superior iliac spine.
241
The advantage of performing an ultrasound-guided

injection cranial and posterior of the anterior superior iliac
spine is the better visibility of the nerves at this point. Both
nerves are usually not yet divided and therefore greater in
diameter.
Technique
As for all regional anesthetic procedures, after checking that guided ilioinguinal/iliohypogastric nerve block. Note the needle orien-
emergency equipment is complete and in working order, tation is perpendicular to the ultrasound beam.
The patient lies supine. The operator stands at the side to the skin. The abdominal wall is scanned with a 6–13 MHz
be anesthetized. The ilioinguinal and iliohypogastric nerves linear transducer. The ultrasound screen should be made to
are anesthetized at a single injection site (Fig. 35.3). A look like the scanning field, i.e. the right side of the screen
35-mm 21-G needle is inserted through the skin 1 cm represents the right side of the field. Adjustable ultrasound
medial and 1 cm inferior to the anterior superior iliac variables such as scanning mode, depth of field, and gain
spine. The needle is held lightly between the fingers and are optimized.
slowly advanced in an incremental fashion; the ‘clicks’ of Injection point is 5 cm cranial and posterior to the ante-
the abdominal wall are best appreciated with this tech- rior superior iliac spine. The nerves are kept in the center
nique. Resting the ulnar border of the injecting hand on the of the field of view, and the needle entry site is at the center
patient can help steady it, to prevent overshooting the of the linear transducer (out-of-plane) (Fig. 35.7).
target. A 23-gauge needle is advanced under real-time ultra-
On piercing the external oblique muscle, 6–8 mL of local sound guidance and local anesthetic is deposited along the
anesthetic are injected to anesthetize the iliohypogastric needle entry path. A freehand technique rather than the use
nerve. Advancing the needle further pierces the internal of a needle guide is preferred. A 21-GA × 50-mm insulated
oblique muscle. Local anesthetic (increments of 2–5 mL needle (B. Braun, Bethlehem PA) is inserted perpendicular
within the calculated maximum allowable) is injected here to the axis of the beam of the ultrasound transducer. The
to anesthetize the ilioinguinal nerve. needle is attached to sterile extension tubing, which is con-
Injection is also made subcutaneously toward the ilium nected to a 20-mL syringe and flushed with local anesthetic
until bony contact is made, to anesthetize the lateral cuta- solution to remove all air from the system. It is important
neous branch of the subcostal nerve. A transverse subcuta- not to advance the needle without good visualization. This
neous injection toward the midline is also made to block may require needle or transducer adjustment.
further branches from the subcostal nerve. Once the needle has been placed within the correct mus-
cular plane adjacent to the nerves, 3–5 mL of local anes-
Ultrasound-guided approach thetic solution is injected. Needle placement in the correct
plane is indicated by fluid expansion in a space bounded
Intravenous access, ECG, pulse oximetry and blood pres- by the hyperechoic fascial sheath of the internal oblique
sure monitoring are established. The block tray is set up as and transverse abdominis muscle layers (hydro dissect)
previously outlined. The ultrasound machine and block (Fig. 35.8). Incorrect needle placement will result in intra-
tray should be placed in positions which allow the operator muscular fluid during hydrodissection (Fig. 35.9).
to simultaneously scan the patient and take items from the
block tray with minimal movement. This setup may take
some forethought but is a worthwhile exercise, and will Genitofemoral nerve block
facilitate successful regional anesthesia.
The operator stands on the side to be blocked with the Surface anatomy
patient in a supine position. The skin is disinfected with
antiseptic solution and draped. A sterile sheath (CIVCO The important bony structure for genitofemoral nerve block
Medical Instruments, Kalona, IA, USA) is applied over the is the pubic tubercle. The pubic tubercle can be palpated
ultrasound transducer with sterile ultrasound gel (Aqua- 3 cm from the midline. The needle insertion site for block
sonic, Parker Laboratories, Fairfield, NJ, USA). Another of the genital branch of genitofemoral nerve is 2 cm later-
layer of sterile gel is placed between the sterile sheath and ally and 2 cm cephalad from the pubic tubercle (Fig. 35.10).
242
CHAPTER
Inguinal field block 35
Lateral IO Medial
R
LA
IN/IH
TA
Figure 35.8 Needle placement in the correct plane is indicated by

fluid expansion in a space bounded by the hyperechoic fascial sheath
of the internal oblique and transverse abdominis muscle layers (hydro
dissect). IO: internal oblique; TA: transversus abdominis; IN/IH: ilioingui-
nal/iliohypogastric nerves; LA: local anesthetic.
Figure 35.11 Sonoanatomy relevant to genitofemoral nerve block
(genital branch). R: round ligament (female).
also to start scanning with the transducer at the internal

Lateral Medial inguinal ring, at which the femoral artery can be visualized
IO
IN/IH LA in the longitudinal scan (along the length of the femoral
artery). By moving the ultrasound transducer in the cepha-
TA lad direction, the artery is seen diving deep toward the
inguinal ligament. At this point, an oval or circular structure
can easily be seen superficial to the femoral artery. The
Figure 35.9 Incorrect needle placement will result in intramuscular transducer is then moved slightly in the medial direction
fluid during hydrodissection. IO: internal oblique; TA: transversus away from the femoral artery. The genital branch of the
abdominis; LA: local anesthetic. IN/IH: ilioinguinal/iliohypogastric nerves. genitofemoral nerve is not easily identified.
Technique
The genital branch is blocked by inserting a 35-mm 23-G
needle 2 cm lateral and 2 cm superior to the pubic tubercle
(Fig. 35.10). The needle is passed medially until the pubic
tubercle is contacted, withdrawn slightly, and injection of
4–5 mL of local anesthetic made in a fan-shaped manner.
A vertical injection in the midline at the pubis is made to
Figure 35.10 Genitofemoral nerve block technique. The needle inser- block overlapping innervation from the contralateral side.
tion point is 2 cm lateral and 2 cm superior from the pubic tubercle. The
Inguinal hernia repair requires, in addition to these nerve
needle is inserted toward the pubic tubercle. On bony contactt, the
needle is withdrawn and injection is made. blocks, a subcutaneous injection of local anesthetic at the
incision site (5–6 mL) and intra-operative block of the neck
of the hernial sac (3–4 mL), because intestine has a separate
Sonoanatomy sensory (sympathetic) nerve supply.
Inguinal hernia repair can also be performed using an
A high frequency linear transducer is used. The orientation infiltration technique (normally by the surgeon).
of the transducer is perpendicular to the inguinal ligament.
The final position of the transducer is 2 cm lateral to the Ultrasound-guided approach
pubic tubercle. The spermatic cord, which is oval or circular
in shape with 1 or 2 arteries within it (the testicular artery An out-of-plane technique is also used, with the needle
and the artery to vas deferens), is identifed. In the female, approaching the skin from the lateral aspect of the trans-
the round ligament is identified (Fig. 35.11). It is possible ducer (Fig. 35.12). Local anesthetic without epinephrine
243
• Local anesthetic toxicity: take care with total dose of

drug because large volumes of local anesthetic may be
needed, especially in obese patients.
CLINICAL PEARLS
• Gives excellent conditions for hernia repair
• Less useful for very large and recurrent hernias
• Calculate total safe dose of local anesthetic and do not exceed it
Figure 35.12 Transducer and needle positioning during ultrasound • Ideal for surgery in the ambulatory setting
guided genital branch of the genitofemoral nerve block. Note the • Up to 25% failure rate reported with landmark-based approach.
needle orientation is perpendicular to the ultrasound beam. • Bowel perforation and pelvic hematoma reported with
landmark-based approach
• Femoral nerve block an infrequent yet bothersome complication
• Ultrasound has been shown to improve the quality of analgesia
obtained and improve the success rate of ilioinguinal/
iliohypogastric block compared to landmark-based approaches.
S
LA
Suggested reading
Amid PK, Shulman AG, Lichtenstein IL. Local anesthesia
for inguinal hernia repair: step-by-step procedure.
Ann Surg 1994;220:735–737.
Amory C, Mariscal A, Guyot E, et al. Is ilioinguinal/
iliohypogastric nerve block always totally safe in
children? Paediatr Anaesth 2003;13(2):164–166.
Figure 35.13 Local anesthetic deposition inside and outside the sper- Ghani KR, McMillan R, Paterson-Brown S. Transient
matic cord for genitofemoral nerve block (genital branch). S: spermatic femoral nerve palsy following ilio-inguinal nerve
cord; LA: local anesthetic. blockade for day case inguinal hernia repair. J R Coll
Surg Edinb 2002 Aug;47(4):626–629.
is used to avoid the possible vasoconstriction effect on Gucev G, Yasui GM, Chang TY, Lee J. Bilateral ultrasound-
the testicular artery. Because of the anatomical anomalies guided continuous ilioinguinal-iliohypogastric block
found with the location of the genital branch in the geni- for pain relief after cesarean delivery. Anesth Analg
tofemoral nerve, 5 mL of local anesthetic is injected inside 2008;106(4):1220–1222.
and another 5 mL outside the spermatic cord (Fig. 35.13). Vaisman J. Pelvic hematoma after an ilioinguinal nerve
block for orchialgia. Anesth Analg 2001;92:
1048–1049.
Continuous techniques
Van Schoor AN, Boon JM, Bosenberg AT, et al.
A continuous technique has been described for the ilioin- Anatomical considerations of the pediatric
guinal and iliohypogsatric nerves but not for the genito- ilioinguinal/iliohypogastric nerve block. Paediatr
femoral nerve. A wound infusion catheter may be used Anaesth 2005;15(5):371–377.
(see Ch.13). Willschke H, Marhofer P, Bosenberg A, et al.
Ultrasonography for ilioinguinal/iliohypogastric
nerve blocks in children. Br J Anaesth 2005;95(2):
Adverse effects 226–230.
• Hematoma
• Block of the lateral cutaneous nerve of the thigh (close
to needle insertion site)
244
Index
A ultrasound-guided approach 220–222, surface anatomy 144

221f technique 145–150
Abdominal hysterectomy 115 deep peroneal nerve block 221, ultrasound-guided approach 74f,
Abdominal surgery 114–115 221f–222f 147–149, 148f–150f
appendicectomy via McBurney’s incision saphenous nerve block 222, 222f long axis approach 148–149,
114 superficial peroneal nerve block 148f–149f
inguinal herniotomy 115 221–222, 222f short axis approach 149, 149f–150f
laparoscopic cholecystectomy 114 sural nerve block 222, 223f Axillary brachial plexus block 65–66
laparotomy with mid-line incision 114, tibial nerve block 221, 221f Axon 11, 12f
114f Ankle block 78
nephrectomy 114 Ankle joint 76t B
sub-costal incisions 114 Ankle surgey 67–68
Abdominal wall see Transversus abdominis Anterior cruciate ligament reconstruction Bayonet artifact 55, 55f
plane block (ACLR) 114 B-mode 47–50
Absorption 49, 50f Anterior sciatic block 180–184 Bone, ultrasound appearance 50f, 52
Acoustic impedances 50t adverse effects 184 Brachial plexus 20f, 72–73
Acoustic shadowing 59, 59f clinical anatomy 180 anatomy 118f
Acromioclavicular joint, innervation 73t continuous technique 183–184 axillary approach 73
Acute pain management 19–22 contraindications 180 branches of 118–120
Alfentanil 62–63, 79–80 absolute 180 infraclavicular 118
Allergic reactions 33–34 relative 180 supraclavicular 118
Ambulatory surgery, peripheral nerve indications 180 infraclavicular approach 73
blockade 60–71 surgical 180 relations 117–118
American Board of Anesthesiology 8 therapeutic 180 supraclavicular approach 73
American Society of Regional Anesthesia 7, landmark-based approach 181–182, Breast surgery 115
82 182f Bupivacaine 14t, 62, 78–79
Regional Anesthesia Fellowships sonoanatomy 181, 181f–182f toxicity 32t
83b–86b surface anatomy 180, 181f
Amyotrophic lateral sclerosis 27 technique 181–184 C
Anatomical survey 58 ultrasound-guided approach 182–183,
Anatomy, applied 72–75 183f–184f Cardiothoracic surgery 115
Anechoicity 50, 50f Anticoagulant medication 23–26 Cardiovascular system toxicity 32–33
Anesthesia postoperative criteria 61b coumarin derivatives 23–26 Catheters 65
Anesthetic, choice of 63 heparin 23 continuous local anesthesia infusions
Anesthetic plan 79b NSAIDs 23 and 68–69
Anisotropy 53f, 54 Appendicectomy via McBurney’s incision placement 59
Ankle block 215–223 114 Central nervous system toxicity 31
clinical anatomy 215, 216f Applied anatomy 72–75 Central retinal artery/vein occlusion 110
continuous technique 223 Arthroscopy 65, 113, 113f Central sensitization 20
contraindications 215 Artifacts, ultrasound 54–56 Cervical plexus 72–73
absolute 215 anisotropy 53f, 54 Cervical plexus block 99–104
relative 215 bayonet artifact 55, 55f adverse effects 103–104
indications 215 image resolution poor 55 clinical anatomy 99, 100f
surgical 215 loss of image 54, 54f contraindications 99
therapeutic 215 posterior enhancement 55, 55f absolute 99
landmark approach 219–220 posterior shadowing 55 relative 99
deep peroneal nerve block 219, 220f reverberation 55, 55f indications 99
saphenous nerve block 220, 220f Axillary block 144–150 surgical 99
superficial peroneal nerve block 220, adverse effects 150 therapeutic 99
220f clinical anatomy 144, 145f landmark-based approach 101–102
sural nerve block 220, 220f continuous technique 149–150 deep cervical plexus 100f, 101–102,
tibial nerve block 219, 219f contraindications 144 102f
sonoanatomy 217–219 absolute 144 superficial cervical plexus 100f–101f,
deep peroneal nerve 218f relative 144 101
saphenous nerve 218–219, 219f indications 144 sonoanatomy 100–101, 101f
superficial peroneal nerve 217–218, surgical 144 surface anatomy 99–100, 100f
218f therapeutic 144 technique 101–102
sural nerve 218f–219f landmark-based approach 146f–147f, ultrasound-guided approach 102–103,
tibial nerve 217, 217f 150 102f–103f
surface anatomy 215–217, 217f musculocutaneous nerve block 147 Cesarian section 115
technique 219–223 sonoanatomy 144–145, 145f Chloroprocaine 14t
245
Index
Cholecystectomy, laparoscopic 114 surface anatomy 157, 158f H

Chronic pain management 22 technique 158–162
Clonidine 63 ultrasound-guided approach 160–162, Halsted, William Stewart 7
Colour Doppler 47–49 161f–162f Hand surgery 65–66
Common peroneal nerve 173 Elbow joint, innervation 73t Hematoma, as adverse effect see individual
Communication 61 Elbow surgery 65–66 procedures
Compartment syndrome 78, 78f Electronic infusion pumps 69 Henderson-Hasselbach equation 13
Complications 31–35 Electrophysiology 41–42, 42f, 42t–43t Heparin 23
Consent 61 Epidural anesthesia 197, 228 Hip joint, innervation 76t
Continuous local anesthesia infusions Epidural injection 127 Hip surgery 66–67
68–69 Epinephrine 63 Hirudin derivatives 26
Continuous nerve block 22–23 Equipment 36 Historical aspects 7–10
see also individual procedures Ergonomics, ultrasound 56, 56f Hoarseness 103, 127
Contrast agents 5 Etidocaine 14t Horner’s syndrome 73, 103, 127,
Control unit, ultrasound 51, 51f Extraconal retrobulbar block 108–110, 143
beam steering 51 108f Hyperechoicity 50
depth 51 Hypodermic injection, history of 8b
focus 51 F Hypoechoicity 50
gain 51 Hypotension 227
scanning modes 51 Fascias, ultrasound appearance 50f, 54 Hysterectomy, abdominal 115
spatial compound imaging 51 Fat tissue, ultrasound appearance 50f, 51
Coulomb’s law 41 Femoral nerve 75–76, 172 I
Coumarin derivatives 23–26 Femoral nerve block 67, 76–77, 185–191
Cremasteric reflex 240 adverse effects 191 Iliacus block 198–202
Cumulative sum (Cusum) analysis 86–89, clinical anatomy 185, 186f adverse effects 202
89f–90f, 89t continuous technique 189 clinical anatomy 198, 199f–200f
Cutaneous nerve 75–76 contraindications 185 continuous technique 201
Cutaneous nerves of forearm blocks 160 absolute 185 contraindications 198
Cyclo-oxygenase 20 relative 185 absolute 198
indications 185 relative 198
D surgical 185 indications 198
therapeutic 185 surgical 198
Deep peroneal nerve 218f landmark-based approach 187, therapeutic 198
Deep peroneal nerve block 219, 220f–222f, 187f–188f landmark-based approach 199, 201f
221 saphenous nerve block 189, 190f sonoanatomy 198–199, 200f
Dermatomes sonoanatomy 186–187, 186f–187f surface anatomy 198, 200f
lower limb 21f, 174f surface anatomy 185, 186f technique 199–201
upper limb 19, 20f technique 187–191 ultrasound-guided approach 199–201,
Diabetes mellitus 28 transient 237–238 200f–201f
Diaphragm, unilateral paralysis 127, ultrasound-guided approach 188–189, Iliohypogastric nerve 75–76, 171, 239
142–143 189f Iliohypogastric nerve block 112–113
Diclofenac 116 saphenous nerve block 190–191, Ilioinguinal nerve 75–76, 171, 239–
Differential nerve block 16 190f–191f 240
Digital block 66 Femoral-sciatic block 67 Ilioinguinal/Iliohypogastric nerve block
Dimple of Venus 192 Fentanyl 62–63, 79–80 241, 241f
Direct thrombin inhibitors 26 Fick’s law 15 continuous techniques 244
Doppler shift effect 48–49, 49f Fondaparinux 26 landmark-based approach 242
Dupuytren’s contracture 63 Foot surgery 67–68 sonoanatomy 241–242, 241f
Dysphagia 103 Forearm surgery 65–66 surface anatomy 241
Frequency 47–48, 48f technique 242
E Frequency transducers 47 ultrasound-guided approach 242,
Frontal nerve 107 242f–243f
Elastometric pump 115, 115f Image resolution, poor 55
Elbow blocks 157–163 G Image, loss of image 54, 54f
adverse effects 162 Imaging modes 47–50
clinical anatomy 157, 158f Gain 49, 50f Infection 34–35
contraindications 157 Genitofemoral nerve block 242–243 Infraclavicular block 65–66
absolute 157 landmark-based approach 243 ultrasound-guided 141f–142f
relative 157 sonoanatomy 243, 243f Inguinal field block 239–244
indications 157 surface anatomy 242, 243f adverse effects 244
surgical 157 technique 243–244 clinical anatomy 239–240, 240f
therapeutic 157 ultrasound-guided approach 243–244, see also individual procedures
landmark-based approach 158–160 244f Inguinal herniotomy 115
cutaneous nerves of forearm blocks Genitofemoral nerve 75–76, 171, 240 Injection and safe practice 36
160 Globe perforation 110 Intercostal block 229–233
median nerve block 159, 160f Goldan, Sydney Ormond 7 adverse effects 232–233
radial nerve block 159–160, 160f Guillain-Barré syndrome 28 clinical anatomy 229, 230f
ulnar nerve block 160, 160f Gynecological/obstetrical surgery continuous techiques 232
sonoanatomy 157–158, 159f 115 contraindications 229
246
Index
indications 229 Lignocaine 78–79 M

surgical 229 Lipid solubility 13, 14t
therapeutic 229 Local anesthetic infusions 112–116 Magnetic resonance imaging 4–5
landmark-based approach 230–231, drugs 115–116 contrast agent 5
231f equipment 115, 115f equipment 4
sonoanatomy 230, 230f mechanisms of action 112–113 image characteristics 5
surface anatomy 229–230, 230f positioning 113 physical principles 5
technique 230–232 potential problems 113–115 McBurney’s incision 114
ultrasound-guided approach 231–232, orthopaedic procedures 113–115 Mechanical needle guide 58–59, 58f
232f abdominal surgery 114–115 Medial peribulbar block 109–110, 109f
Intercostobrachial nerve 75 breast surgery 115 Median nerve 119
International normalized ratio 23–26 cardiothoracic surgery 115 Median nerve block 159, 160f, 167, 167f
Interscalene block (ISB) 65, 121–127 gynecological/obstetrical surgery Mepivacaine 14t, 15f, 62–63, 78–79
adverse effects 127 115 toxicity 32t
clinical anatomy 121, 122f joint surgery 114 Midazolam 62–63, 79–80
continuous techiques 126–127 shoulder surgery 113–114 Midhumeral block 151–156
contraindications 121 total hip arthroplasty 114 adverse effects 155
absolute 114 rationale 112 clinical anatomy 151
relative 121 Local anesthetic spread 59 continuous technique 155
indications 121 Local anesthetics 11–18 contraindications 151
surgical 121 nerve block 16–17 absolute 151
therapeutic 121 peripheral nerve 11 relative 151
landmark-based approach 123–124, pharmacodynamics 12–15 indications 151
123f–124f pharmacokinetics 15–16 surgical 151
sonoanatomy 121–123, 122f local distribution 15 therapeutic 151
surface anatomy 121, 122f metabolism and excretion 15–16 landmark-based approach 152–153,
technique 123–124 physicochemical properties 13–15 153f–154f
ultrasound-guided approach 124–127, ionization 13 surface anatomy 151, 152f
125f–126f lipid solubility 13 sonoanatomy 151–152, 152f
Intralipid 62 protein binding 13–15 technique 152–155
Intraspinal cocainization 7 structure and function 12 ultrasound-guided approach 153–155,
toxicity 31–35 154f–155f
J allergic reactions 33–34 Minimum blocking concentration 16
cardiovascular system 32–33 Mueller, Johannes P 7
Joint surgery 114 central nervous system 31 Multi-modal analgesia 63
infection 34–35 Multiple sclerosis 27
K myotoxicity 35 Muscle, ultrasound appearance 50f, 52
nerve injury 33 Musculocutaneous nerve block 147
Knee joint 76t neural 35 Myasthenia gravis 27–28
Knee surgery 67 peripheral vasculature 33 Myotomes of upper limb 19, 21f
Koller,Carl 7 systemic 31 Myotoxicity 35
see also individual procedures
L Longitudinal (long axis) view 57 N
Lower limb
Labat, Gaston 7 cutaneous innervation 22f, 174f Nasociliary nerve 107
Lacrimal nerve 107 dermatomes 21f, 174f Needle visualization 58–59
Laparoscopic cholecystectomy 114 muscular innervation 22f Needles 43
Lateral cutaneous nerve of thigh block nerves of 23f Nephrectomy 114
203–206 Lower limb blocks 66–68 Nerve block 16–17
adverse effects 206 foot and ankle surgery 67–68 differential 16
clinical anatomy 203, 204f hip surgery 66–67 minimum blocking concentration 16
continuous technnique 206 knee surgery 67 see also individual procedures
contraindications 203 Lower limb peripheral nerve blocks 75–78 Nerve cell 12f
absolute 203 Lumbar plexus 76–77, 76f, 171–172, 172f Nerve cell membrane 11
relative 203 femoral nerve 172 Nerve conduction 11
indications 203 genitofemoral nerve 171 Nerve fibers 16, 16t
surgical 203 iliohypogastric nerve 171 Nerve injury 33
therapeutic 203 ilioinguinal nerve 171 Nerve penetration 16–17
landmark-based approach 204–205 lateral cutaneous nerve of thigh Nerve stimulators 41
sonoanatomy 203–204, 204f–205f 171–172 characteristics 42–43
surface anatomy 203, 204f obturator nerve 172 Nerves, ultrasound appearance 52, 52f–53f
technique 204–206 posterior approach (psoas compartment Neural injury, as adverse effect see individual
ultrasound-guided approach 205f block) 76 procedures
Lateral cutaneous nerve of thigh 171– relations 173–174, 174f Neural toxicity 35
172 saphenous nerve 172 Neuromuscular disease 27
Lateral peribulbar blocks 108, 108f Lundy, John 7 Non-steroidal anti-inflammatory drugs 20,
Levobupivacaine 62–63, 115–116 Lung tissue, ultrasound appearance 52f, 23
Lidocaine 14t, 15, 62–63 54 NSAIDs see Non-steroidal anti-inflammatory
toxicity 32t Lymph nodes, ultrasound appearance 54 drugs
247
Index
Performance of techniques 62–63 landmark-based approach 209–

O Peripheral nerve 11 211
Obstetrical surgery 115 applied anatomy 11 lateral approach 209–211, 210f
Obturator nerve 75–76, 172 ionic basis of conduction 11 posterior approach 211, 211f
Ocular muscles 107f, 108 Peripheral nerve block sonoanatomy 209f–210f
dysfunction 110 continuous 22–23 surface anatomy 207–208, 209f
Ohm’s law 41 contraindications 23–28 technique 209–214
Open shoulder surgery 114 amyotrophic lateral sclerosis 27 ultrasound-guided approach 211–213,
Opioid drugs 20 anticoagulant medication 23–26 212f–213f
Optic nerve 107 diabetes mellitus 28 Postanesthesia care unit (PACU) 61
trauma 110 Guillain-Barré syndrome 28 Postanesthesia discharge scoring system
Orbital blocks 105–111 multiple sclerosis 27 (PADSS) 63, 64t
adverse effects 110 myasthenia gravis 27–28 Posterior enhancement 55, 55f
anatomy 105–108 neuromuscular disease 27 Posterior sciatic block 175–179
arterial supply 107 respiratory disease 26–27 adverse effects 179
motor nerve supply 105–106, 107f indications 19–22 clinical anatomy 175, 176f
ocular muscles 107f, 108 acute pain management 19–22 continuous technique 179
optic nerve 107 chronic pain management 22 contraindications 175
ophthalmic nerve 106–107 surgery 19 absolute 175
orbital cavity 105, 106f training in 82–95 relative 175
sensory nerve supply 106–107 Peripheral nerve block (PNB) for indications 175
Tenon’s capsule (fascial sheath of the ambulatory surgery 60–71 surgical 175
eyeball) 108, 108f anesthesia postoperative criteria 61b therapeutic 175
venous drainage 108 catheters and continuous local landmark-based approach 177–178,
contraindications 105 anesthesia infusions 68–69 177f
absolute 105 lower limb blocks 66–68 sonoanatomy 176–177, 176f–177f
relative 105 foot and ankle 67–68 surface anatomy 175–176, 176f
indications 105 hip surgery 66–67 technique 177–179
surgical 105 knee surgery 67 ultrasound-guided approach 178–179,
therapeutic 105 setting up and running a service 61–65 178f
surface anatomy 108–109 advantages and disadvantages of Posterior shadowing 55
extraconal retrobulbar and lateral sedation 62–63 Postoperative care 63–64
peribulbar blocks 108, 108f catheters 65 Preanesthetic checklist 37b
medial peribulbar block 109, 109f choice of anesthetic 63 Preoperative fasting 36
sub-Tenon block 109, 109f communication 61 Prilocaine 14t, 63
technique 109–110 consent 61 toxicity 32t
extraconal retrobulbar block 109– equipment and drugs 62b Procaine 14t
110 multi-modal analgesia 63 toxicity 32t
medial peribulbar block 110 patient acceptance and satisfaction Propofol 62–63
sub-Tenon block 110 64–65 Protein binding 13–15
Orbital cavity 105, 106f patient information sheet 63, 65b Pseudoaneurysm 155
performance of techniques 62–63 traumatic 150
postoperative care 63–64 Psoas block 192–197
P working environment 61–62 adverse effects 197
Paravertebral block 224–228 upper limb blocks 65–66 clinical anatomy 192, 193f
adverse effects 227–228 elbow, forearm and hand surgery continuous technique 196–197
clinical anatomy 224, 225f 65–66 contraindications 192
continuous techniques 227 shoulder surgery 65 absolute 192
contraindications 224 Peripheral nerve catheters 43–45 relative 192
absolute 224 Peripheral sensitization 19 indications 192
relative 224 Peripheral vasculature 33 surgical 192
indications 224 Phrenic nerve block 103 therapeutic 192
surgical 224 Phrenic nerve paralysis 73 landmark-based approach 194–196,
therapeutic 224 Physics of ultrasound 47–50 195f–196f
landmark-based approach 225–226, Pleura, ultrasound appearance 52f, 54 sonoanatomy 192–194, 194f
226f–227f Pneumothorax 73, 127, 132, 134–137, surface anatomy 192, 193f
sonoanatomy 224, 225f 135f, 228, 233 technique 194–197
surface anatomy 224, 225f Popliteal artery, pressure on 214 ultrasound-guided approach 196
technique 225–227 Popliteal block 67–68, 78, 78f, 207–214 Pudendal nerve 75–76
ultrasound-guided approach 226–227, adverse effects 214
227f–228f clinical anatomy 207, 208f R
Patient acceptance and satisfaction 64– continuous technique 213–214
65 contraindications 207 Radial nerve 119–120
Patient controlled regional anesthesia absolute 207 deep branch 119–120, 120f
(PCRA) 68–69 relative 207 superficial branch 119
Patient information sheet 63, 65b indications 207 Radial nerve block 159–160, 160f, 168,
Patient selection 35–36 surgical 207 168f
Pauchet, Victor 7 therapeutic 207 Reflection 49–50, 50t
248
Index
Regional anesthesia 78–80, 79b contraindications 134 peripheral vasculature 33

history 7–10 absolute 134 systemic 31
safe conduct of 35–36 relative 134 Training in peripheral nerve blockade
ultrasound-guided 47–59 indications 134 82–95
Renal injury 197 surgical 134 acquiring and maintaining expertise
Respiratory disease 26–27 therapeutic 134 90–94, 94t
Retrobulbar hemorrhage 110 landmark-based approach 134–136, checklist and global rating scale 86, 88t
Reverberation 55, 55f 136f cumulative sum (Cusum) analysis
Ropivacaine 14t, 62–63, 115–116 sonoanatomy 134, 135f 86–89, 89f–90f, 89t
Rotation 57–58, 57f surface anatomy 134, 135f institutional organization 82
Rotator cuff repair 65 technique 134–137 recommended case numbers 86,
Rovenstine, Emory 7 ultrasound-guided approach 136–137, 86f–87f
Rynd, Sir Francis 7 136f–137f simulation-based training 86
Sural nerve 218f–219f skills and competencies 82–89
S Sural nerve block 220, 220f, 222, 223f task-specific interscalene nerve block
Systemic toxicity 31 checklist 89t
Sacral dimple 192 Tramadol 63
Sacral plexus 75–78, 173, 173f T Transducer 51, 51f
relations 173–174, 174f curvilear 51, 51f
Saphenous nerve block 220, 220f, 222, Target identification 58 frequency 47
222f absorption and gain 49, 50f hockey stick 51, 51f
landmark-based approach 189, 190f acoustic impedances 50t Transverse (short axis, cross-section) view
ultrasound-guided approach 190–191, catheter placement 59 56–57
190f–191f Doppler shift effect 48–49, 49f Traumatic pseudoaneurysm 150
Saphenous nerve 77, 172, 189, 218–219, frequency 47–48, 48f Traversus abdominis plane (TAP) block
219f imaging modes 47–50 234–238
Schiff, Moritz S. 7 local anesthetic spread 59 adverse effects 237–238
Schleich, Carl Ludwig 7 needle visualization 58–59 abdominal organ injury 237
Schwann cells 11 practicalities 58–59, 58f femoral nerve block 237–238
Sciatic nerve 75–76, 173 reflection 49–50, 50t localized swelling 237
Sciatic nerve block 77–78, 77f tissue echogenicity 50 systemic toxicity 237
Sedation, advantages and disadvantages of anechoic 50, 50f clinical anatomy 234, 235f
62–63 hyperechoic 50 continuous technique 237
Shoulder joint, innervation 73t hypoechoic 50 contraindications 234
Shoulder surgery 65, 113–114 Tendons, ultrasound appearance 52–54, absolute 234
Simulation-based training 86 53f relative 234
Sliding 57, 57f Tenon’s capsule (fascial sheath of the dermatomal levels 235f
Spinal anesthesia 197 eyeball) 108, 108f indications 234
Subarachnoid injection 127, 228 Tetracaine 14t surgical 234
Subconjunctival chemosis 110 Tibial nerve 173, 217, 217f therapeutic 234
Subconjunctival hemorrhage 110 Tibial nerve block 219, 219f, 221, 221f landmark-based approach 235–237,
Subcostal nerve 239 Tilting 57–58, 57f 236f
Sub-Tenon block 109–110, 109f Tissue appearance, ultrasound 51–54 sonoanatomy 234, 235f
Superficial peroneal nerve 217–218, 218f bone 50f, 52 surface anatomy 234
Superficial peroneal nerve block 220–222, fascias 50f, 54 technique 234–235
220f, 222f fat tissue 50f, 51 ultrasound-guided approach 236–237,
Supraclavicular block 65–66, 128–133 lung tissue 52f, 54 236f–237f
adverse effects 132 lymph nodes 54 Tuffier line 192
clinical anatomy 128, 129f muscle 50f, 52
continuous technique 131–132 nerve 52, 52f–53f U
contraindications 128 pleura 52f, 54
absolute 128 tendons 52–54, 53f Ulnar nerve 119
relative 128 vessels 52, 52f Ulnar nerve block 160, 160f, 167–168,
indications 128 Tissue echogenicity 50 167f
surgical 128 hyperechoic 50 Ultrasound 45
therapeutic 128 hypoechoic 50 clinical application 45
landmark-based approach 130, 130f anechoic 50, 50f fundamentals 45
sonoanatomy 128–129, 129f Total hip arthroplasty (THA) 66–67, 114 introduction 47, 48f
surface anatomy 128, 129f Total knee replacement 114 physics 47–50
technique 130–132 Total shoulder arthroplasty (TSA) 65 tissue appearance 51–54
ultrasound-guided approach 130–131, Toxicity 31–35 Ultrasound-guided regional anesthesia
131f–132f allergic reactions 33–34 (USGRA) 47–59, 90
Supraclavicular continuous catheter cardiovascular system 32–33 Ultrasound-guided Regional Anesthesia
74f central nervous system 31 Coordinator 91b–93b
Suprascapular block 134–137 infection 34–35 Ultrasound machine 51
adverse effects 137 myotoxicity 35 control unit 51, 51f
clinical anatomy 134 nerve injury 33 beam steering 51
continuous technique 137 neural 35 depth 51
249
Index
focus 51 continuous technique 142, 142f contraindications 164

gain 51 contraindications 138 absolute 164
scanning modes 51 absolute 138 relative 164
spatial compound imaging 51 relative 138 indications 164
operation 47, 48f–49f indications 138 surgical 164
transducer 51, 51f surgical 138 therapeutic 164
Ultrasound scanning technique 57–58, 57f therapeutic 138 landmark-based approach 165f,
anatomical survey and 56–58 landmark-based approach 140, 167–170
rotation 57–58, 57f 140f median nerve block 167, 167f
sliding 57, 57f sonoanatomy 138–139, 139f–140f radial nerve block 168, 168f
tilting 57–58, 57f surface anatomy 138, 139f ulnar nerve block 167–168, 167f
Upper limb technique 140–142 sonoanatomy 164–166, 165f–166f
dermatomes 19, 20f ultrasound-guided approach 140– surface anatomy 164, 165f
myotomes 19, 21f 142 technique 167–170
osseous innervation 21f infraclavicular block 141f–142f ultrasound-guided approach 165f,
Upper limb blocks 65–66 Vessels, ultrasound appearance 52, 52f 168–170, 168f–170f
elbow, forearm and hand surgery Wrist joint, innervation 73t
65–66 W
peripheral nerve blocks 72–75
shoulder surgery 65 Warfarin 23–26
Waters, Ralph 7
V Wood, Alexander 7
Working environment 61–62
Vertical infraclavicular block 138–143 Wrist blocks 164–170
adverse effects 142–143 adverse effects 170
clinical anatomy 138, 139f clinical anatomy 164, 165f
250

Peripheral Nerve Blocks and Peri Operative Pain Relief 2nd Ed

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Peripheral Nerve Blocks and Peri Operative Pain Relief 2nd Ed

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Peripheral Nerve Blocks & Peri-Operative Pain Relief

Commissioning Editor: Michael Houston

Jack Barrett FFARCS(I) Dip. Pain Medicine

Frank Loughnane FCA(RCSI)

Brendan Finucane FRCA FRCP(C)

George Shorten FFARCS(I) FRCA MD PhD

First edition 2004

Peripheral nerve blocks and peri-operative pain relief.—

Library of Congress Cataloging in Publication Data

Working together to grow

Part II: PERIPHERAL NERVE BLOCKS

16 Supraclavicular block 128

Clip No Clip Title Video contributor(s) Length

Clip No Clip Title Video contributor(s) Length

Dora Breslin MD John McAdoo MD

Xavier Capdevila MD PhD John McDonnell MB MD FCARCSI

Physical principles Image characteristics

Regional anesthesia in perspective

Box 2.1 Box 2.2

The peripheral nerve Ionic basis of conduction

Applied anatomy A special membrane protein, the Na+–K+ ATPase pump, is

Interneuron Dorsal root Schwann cell Schwann Node of

Sensory neuron (unipolar)

Postganglionic Myelinated axon Schwann cell nucleus

Integral protein Peripheral protein Integral protein Cytoplasm

Their ratio is given by the Henderson–Hasselbach

Both the ionized and non-ionized forms can inhibit Na+

Lipid solubility in general, high lipid solubility is associated with increased

Table 3.1 Comparative pharmacology of local anesthetics

a functional reservoir that is released as the free drug is

the volume, mass, and concentration injected; and the pres-

Table 3.2 Characteristics of different categories of nerve ﬁber

successful regional anesthetic practice and the avoidance of

Anterior Posterior Anterior Posterior

Figure 4.6 Dermatomes of the lower limb.

Anterior Posterior Anterior Posterior

Lateral cutaneous Medial cutaneous Common

NSAIDs, opioids, and a regional anesthetic technique (with

Anterior Posterior tance. However, it can produce significant patient discom-

Table 4.1 Neuraxial* Anesthesia in the Patient Receiving Thromboprophylaxis

Normal INR (before Single injection, Insufﬁcient Absolute No evidence for

Table 4.1 Neuraxial* Anesthesia in the Patient Receiving Thromboprophylaxis—cont’d

have anti-acetylcholine receptor antibodies, and the disease

Systemic toxicity of local anesthetic drugs

©2011 Elsevier Ltd, Inc, BV

Plasma 24 CVS depression

been explained as being due to stimulation of spontaneous

Peripheral vasculature Allergic reactions

Table 5.3 Survey of reported neuropathies after upper extremity block*

Myotoxicity of local anesthetics

B Anesthetic machine D Vacuum system

References 3. Gaba DM. Human error in anesthetic mishaps.

36. Incaudo G, Schatz M, Patterson R, et al. 52. American Society of Anesthesiologists.

intensity and duration of current in peripheral nerve stimu-

©2011 Elsevier Ltd, Inc, BV

10 Current flow + Charge

The nerve stimulator should have a variable output

©2011 Elsevier Ltd, Inc, BV

Alternating electrical current stimulates

Emitted ultrasound waves

Electrical signals from the crystals to

Reflected ultrasound waves

Figure 7.1 (A) Stimulated by alternating electric current, the piezoelec-

Figure 7.3 (A). High frequency transducer: deep structures do not