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Challenges, Solutions, and Advances in Ultrasound-Guided Regional Anesthesia
Challenges, Solutions, and Advances in Ultrasound-Guided Regional Anesthesia
Challenges, Solutions, and Advances in Ultrasound-Guided Regional Anesthesia
doi: 10.1093/bjaed/mkw026
Advance Access Publication Date: 19 May 2016
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2G03, 3A09
© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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374
Challenges, solutions, and advances in USGRA
resolution.2 All US beams typically diverge at greater depth, while Challenges presented by the ultrasound image
wider beams diverge further in the far field. Therefore, lateral
Artifacts are presentations on the display which are added or
resolution is best at shallow depths and worse with deeper im-
omitted, or are of improper location, brightness, shape, and
aging. Lateral resolution is improved by positioning the focal
size compared with the true anatomical features. Some artifacts
zone, the narrowest part of the US beam, at the level of the target
are useful in interpretation, while others may cause confusion
object.
and error. A good understanding of artifacts, why they arise
Temporal resolution refers to the US machine frame rate
and how to deal with them when they occur, is important in
which is the speed at which an imaging device produces
the practice of USGRA. Failure to recognize imaging artifacts
consecutive images and is important in real-time imaging during
may lead to complications, including incorrect needle placement
USGRA.3 The rate at which consecutive image frames are gener-
or deposition of LA in the wrong location or hazardous areas. Ar-
ated and viewed affects the visualization of moving structures. A
tifacts are commonly observed during ultrasound-guided nerve
low frame rate may obscure motion during a procedure including
blocks and may be related either to the tissues, the block needle,
probe movement, needle insertion, and the placement of LA dur-
or both (Table 1). The most common artifacts observed during
ing USGRA. Temporal resolution is influenced by the speed of
USGRA are either acoustic or anatomic.
sound in tissue and may be improved by decreasing the imaging
depth to just below the target and minimizing tissue movement
by the slow injection of LA. Acoustic artifacts
Acoustic artifacts are usually the result of incorrect assumptions
during processing by the instrumentation. These assumptions
Table 1 Errors associated with ultrasound artifacts include sound travels in straight lines; the intensity of returning
echoes is directly related to scatter from the imaged object and
Artifact Error distance of structures on the image is directly proportional to
the time taken for the sound wave to return to the transducer.
Acoustic Presentation of ultrasound information
Some acoustic artifacts are also secondary to operator error, in-
Anatomic or pitfall Interpretation
Optical illusion Perception cluding improper transducer placement or scanning technique.
Other Electrical noise A common operator error is a suboptimal angle of insonation re-
sulting in a significant portion of the returning US beam being
transmitted away from the transducer producing a degraded
image (Fig. 1). As the incident angle of the US beam to the
nerve approaches 90°, the target image becomes optimal. This
artifact can be reduced by sweeping the transducer through an
arc to determine the position of the transducer which provides
the best available image of the target nerve. Classification of com-
mon acoustic artifacts together with their origins and imaging
errors are listed in Table 2.
Acoustic errors may also be subdivided into missing or falsely
perceived structures and are often due to errors in gain setting.
Gain refers to the degree of amplification applied to all US signals
returning to the transducer. Too high a gain will make the image
too bright and obscure structures, while too little gain will darken
the image and may make a structure appear absent. This artifact
is avoided by adjusting the gain setting to permit an optimal view
Fig 1 Angle of insonation. When the ultrasound beam is perpendicular to the
of the target nerve and surrounding tissues. Attenuation is the
reflector, the ultrasound beam is returned to the transducer. When the angle of progressive loss of acoustic energy and signal strength as the
insonation is reduced, the ultrasound beam is reflected away from the US wave passes through tissue. Attenuation can be reduced by in-
transducer and the view of the target is suboptimal. creasing the overall gain control and image brightness. Time gain
Attenuation Reduced amplitude of echoes by intervening structures with high attenuation Shadowing
Increased relative amplitude of echoes caused by an intervening structure of low attenuation Enhancement
Resolution Pulse frequency Axial resolution
Beam divergence Lateral resolution
Interference patterns from echoes generated by closely spaced reflectors Speckle
Propagation path Sound pulse reverberates back and forth between two strong parallel reflectors Reverberation
Change in direction of a sound pulse when it crosses a boundary and when a change of speed Refraction
of sound occurs
Reflection of the sound pulse from a highly reflective surface Mirror image
Side beams from the transducer cause objects to be viewed in a lateral location Side lobe
Miscellaneous Two closely spaced reflective surfaces and generated echoes with a conical shape Comet tail
Fig 4 Mirror artifact. BP, brachial plexus; FR, first rib; PL, pleura; MI, mirror image;
SA, subclavian artery.
Fig 2 Reverberation artifact and acoustic shadowing. AS, acoustic shadowing; PL,
peritoneal layer; PRS, posterior layer of rectus sheath; RA, reverberation artifact;
SI, small intestine.
Fig 3 Acoustic enhancement. AA, axillary artery; AE, acoustic enhancement; shows multiple linear and hyperechoic areas distal to the reflect-
AV, axillary vein; MCN, musculocutaneous nerve; MN, median nerve; UN, ulnar
ing surface (Fig. 2). The comet tail sign refers to the mergence of
nerve.
multiple reverberation artifacts in a tapered band adjacent to the
object.4 Increasing the pressure of the probe on the skin may
eliminate the reverberation artifact. The ‘double-barrelled sub-
compensation (TGC) is a setting applied in ultrasonography to ac- clavian artery’ is also an example of a reverberation artifact
count for tissue attenuation of the US beam. TGC independently (Fig. 4). This results from the US beam bouncing within the
increases the gain of reflected signals with increasing time from lumen of the subclavian artery and creating a mirror image of
the transmitted pulse and is equivalent to increasing the gain of a the subclavian artery deep to the first rib. It is important to recog-
reflected US signal with increasing tissue depth. nize that the image of the subclavian artery under the first rib is
Acoustic shadowing may also cause structures to appear less an artifact and attempted needle insertion towards this point
echogenic and occurs when a target lies below a structure which may lead to a pneumothorax.
strongly absorbs or reflects US waves. Air and bone are common
causes of acoustic shadowing during USGRA and may be avoided
Anatomic or pitfall error
by changing the transducer position (Fig. 2).
Acoustic enhancement occurs when an area behind a weakly Anatomic artifacts are tissue structures which resemble the
attenuating structure produces stronger echoes than the sur- target nerve. These errors are also referred to as ‘pitfall errors’.
rounding structures. This artifact commonly occurs behind Tendons and nerves may be difficult to distinguish by ultrason-
blood vessels and may lead to confusion with neural structures ography (Fig. 5). This is a particular problem in the wrist, but
lying posterior to arteries and veins. This is particularly import- tracking structures proximally often assist in differentiating the
ant when scanning the axilla where the radial nerve lies behind two structures since tendons will integrate within their respect-
the axillary artery and may be confused with acoustic enhance- ive muscles. Blood vessels are not normally mistaken for nerves.
ment artifact (Fig. 3). In such instances, the use of a nerve stimu- Arteries are anechoic and pulsatile, while veins are compressible.
lator may be helpful to confirm the presence or absence of the Nerves are usually hyperechoic (echo bright) or hypoechoic (echo
radial nerve. dark) and non-compressible. However, the roots of the brachial
Image degradation is often the result of reverberation which plexus may sometimes appear similar to a small diameter ves-
results from US waves reflecting off two strong reflectors, for ex- sels. Colour Doppler is useful in identifying vascular structures
ample, the pleura, peritoneum, or a fascial plane. The image but may be misleading if the transducer is placed perpendicular
Fig 8 Fusion of the median and musculocutaneous nerves. The median and
musculocutaneous nerves are fused proximally in the axilla and separate
Fig 7 Degradation of the ultrasound image by injected air. Air within reflects the
distally in the arm. AA, axillary artery; MCN, musculocutaneous nerve; MN,
ultrasound beam and degrades the view of the median nerve and needle tip. FDP,
median nerve; UN, ulnar nerve.
flexor digitorum profundus; FDS, flexor digitorum superficialis; MN, median
nerve. The small unlabelled arrows indicate the block needle.
Video 2 If reading the pdf online, click on the image to view the video.
Video 1 If reading the pdf online, click on the image to view the video.
important to note that the true needle image is the one nearest
the transducer. Such artifacts most commonly occur when the
needle is completely perpendicular to the US beam and can
therefore be reduced by decreasing the angle of the US beam to Fig 10 An echogenic needle. The arrow indicates cornerstone technology. Image
<90°. In addition, a reduction in far gain will darken the distal reproduced with permission from Pajunk GmbH Medizintechnologie.
artifacts.
A mirror artifact is a type of reverberation artifact and is pro-
duced when an object is located in front of a strong US reflector, beam while keeping the needle tip at 0 or 180° to the US beam.
e.g. needles and bone. A second representation of the needle is Priming the needle with air or fluid does not improve needle
observed in an incorrect location behind the strong reflector echogenicity.
and may cause confusion. It is important to note that the true
needle image is the one nearest the transducer.
Combined neurostimulation and ultrasound guidance
Another common needle artifact is the bayonet artifact in
which the needle appears broken or bent (Fig. 9). This artifact oc- The parallel contribution of US guidance and peripheral nerve
curs because of differences in the speed of sound in different stimulation (PNS) or ‘dual guidance’ may offer versatility and re-
tissues which are adjacent to the needle. The speed of sound is assurance when localizing nerves. Although ultrasonography
reduced in adipose tissue compared with muscle and takes long- has the advantages of real-time imaging of nerves and monitor-
er to return to the transducer. Therefore, a needle placed in ing the spread of LA, it also encourages multiple injections and
adipose tissue will appear to be deeper than that part of the needle realignments during ultrasound-guided nerve block.
needle which is in muscle. However, PNS also has some disadvantages including a reliance
The side lobe artifact is often seen during USGRA and may on eliciting a motor response which may be affected by numer-
cause confusion in image interpretation.15 Several low-intensity ous factors, including disease processes. Failed nerve block in
beams, side lobes, are often located peripheral to the main axis of the presence of an adequate motor response is not uncommon
an US beam. Although they are of a much lower intensity than and may be due to the presence of fascial planes inhibiting the
the main beam, these peripheral beams are sufficiently high to spread of LA and delivery of asymmetric current from the needle
create significant artifacts when they interact with highly reflect- tip. PNS combined with ultrasonography is useful for identifying
ive acoustic surfaces, including a metallic needle path. In con- neural structures when there is doubt about the sonoanatomy
trast, other US artifacts, the side lobe artifact is visible anterior and as a warning system when there is uncertainty about the
to the true needle path. The artifact is divergent and diffuse position of the needle tip. Dual guidance may also be useful as
while the needle tip projected beyond the true needle pathway. an aid when learning USGRA. However, it is sometimes difficult
The side lobe artifact is a particular problem with but not unique to distinguish between intra- and extra-fascicular injection by
to linear transducers and can be observed with both static current resolution. Triple monitoring (US, PNS, and measure-
and real-time equipment. The artifact is minimized by careful ment of injection pressure) has been proposed as the standard
repositioning of the US transducer. to minimize nerve injury.16
have also been designed. Other approaches to improving needle 3. Fiegenbaum H. Echocardiography, 5th Edn. Philadelphia: Lea
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