1.

SUPRASCAPULAR NERVE BLOCK:

I. Indications: (1)

 Joint pathologies-degenerative, inflammatory (rheumatoid, seronegative

arthropathies), and crystal arthropathies)
 Labral/rotator cuff pathology
 Impingement or adhesive capsulitis
 Regional anesthesia for minor procedures like hydrodilatation

II. Technique: (2)

Patient position: seated with patient’s back facing examiner. The first step is to identify the
landmark which is spine of scapula using palpation. The nerve can be targeted either in the
suprascapular or the spinoglenoid notch. 5ml of anesthetic agent mixed with 2ml of
ultrasound contrast agent(UCA) can be injected.

a).For suprascapular notch: place transducer over the supraspinous fossa with lateral end of
probe over the acromion. the notch is seen deep to the supraspinatus muscle (Figure 1).
Needle is directed from medial to lateral aspect (Fig 2).

b). For spinoglenoid notch: place transducer inferolateral to the spine over the infraspinatus
fossa, the posterior glenohumeral joint space is seen. On sliding the probe medially, the nerve
within the notch is seen deep to the infraspinatus muscle and tendon(Fig 3). Needle is
inserted from lateral to medial direction (Fig 4).

As these notches are located at a depth (deep to the supraspinatus and infraspinatus muscles,
respectively), there is significant attenuation of the USG waves, and it's difficult to assess the
accurate anesthetic distribution making the role of ultrasound contrast agent(UCA) imminent
(Fig 5). The most common complication seen with non-imaging guided nerve block in this
region was pneumothorax which can be easily evaded using ultrasound guidance. (3)

2. TAP (transversus abdominis plane) BLOCK:

I. Indications:

Pre-operative anaesthesia for various abdominal surgeries, cesarean section, hysterectomy,

cholecystectomy, colectomy, prostatectomy, and hernia repair.(4)

II. Technique:

Patient position: supine, transducer placed in a horizontal orientation in the mid-axillary line
at the level of the umbilicus (Fig 6).
Using the in-plane approach, the needle is inserted in anterior to posterior direction, and
advanced via the external and internal oblique to reach the target TAP plane. Anesthetic
agent is injected into the plane which causes splitting of the fascial planes (Fig 7). The needle
should be continually advanced within the dissected plane to separate the two
muscles(internal oblique and transversus abdominis) using hydraulic pressure. It is a volume
block and hence the best results are obtained when a larger volume of agent (~25-30ml on
each side) is injected with extensive spread of the injectate. (5)
Variant: QL(Quadratus Lumborum) block that only differs at the site of injection
however follows a similar principle. For the QL block, patient lies prone, probe is placed in
transverse orientation at a level above the iliac crest around the posterior axillary line. A
needle is inserted in medial to lateral direction and ~30ml of anesthetic agent is injected in
the between QL and the psoas muscle(Fig 8)(Fig 9). Accurate localization of agent in the
deep seated QL plane is enabled by contrast enhancement(Fig 10) (6)

3. PERIPROSTATIC NERVE BLOCK:

I. Indications: periprocedural anaesthesia for:

 Transrectal ultrasound (TRUS) guided prostate biopsy(most commonly)
 Minimally invasive surgical treatments (MIST) done for benign prostatic hyperplasia
(BPH). (7)

II. Technique:(8)
Patient positioning: left lateral decubitus with the left leg kept straight and the right leg
flexed to touch the abdomen.
A gel lubricant is applied intrarectally, and the TRUS probe with an attached biopsy guide is
inserted into the rectum. The probe is adjusted to the sagittal plane, and a spinal needle is
inserted through the biopsy guide channel into the target location under ultrasound guidance.
To effectively numb a large portion of the prostate gland, the anesthetic agent is injected at
the bibasal location, where significant neurovascular bundles of the prostate gland pass. This
location can be identified on ultrasound by an echogenic triangle of fat at the angle between
the seminal vesicle and the base of the prostate bilaterally. This area has a distinctive
appearance resembling the snow peak of a mountain and is called the "Mount Everest
sign"(Fig 11).
Injection can also be done at the apical location (between the apex of the prostate gland and
the puborectalis muscle) as it helps numb the most painful site during prostate biopsy. The
apical location can be identified on ultrasound by a smaller echogenic triangle on either side
of the apex of the prostate gland. The combination of apical and bibasal injections results in
the lowest pain score during the biopsy.
Anesthetic agent mixed with UCA (4:1) is injected into each site described above using a 23-
gauge, 15-cm long needle attached to biopsy guide channel. The needle placement is
confirmed on ultrasound imaging, and successful deposition is indicated by the appearance of
a hyperechoic cloud-like wheal at the needle tip that causes dissection and widening of the
plane between the rectal wall and the prostate. The biopsy is performed after waiting for 5-10
minutes for the anesthetic to take full effect.
The most dreaded complication of periprostatic nerve block is systemic lidocaine toxicity
which may result from inadvertent intravascular injection into the prostatic venous plexus,
this can be prevented by using UCA along with anesthetic agent(Fig 12). (9)

4. CELIAC PLEXUS NEUROLYSIS:

I. Indications: persistent and intractable abdominal pain as a result of primary pancreatic,

esophageal, gastric, and biliary neoplasm, metastatic disease associated with retroperitoneal
lymph node involvement as well as chronic pancreatitis. (10,11)

II. Technique: anterior approach.

Patient position: supine, transducer(curvilinear) placed in the epigastric region, trace origin
of celiac axis from the abdominal aorta. Transhepatic approach with a 15cm long, 20-21G
needle inserted from patient’s left side to reach the periaortic soft tissue(Fig 13, Fig 14).
Once tip is localized, injection of ~4ml anesthetic agent mixed with UCA(3:1) is carried out
under real-time ultrasound guidance. It appears as an echogenic cloud in CEUS mode. Once
dispersion in correct location is confirmed, ~10ml mixture of neurolytic agent and UCA
(10:1) is injected under CEUS guidance(Fig 15).
Since ultrasound guidance alone is not accurate in recognizing intravascular injection at this
depth, addition of CEUS component plays a pivotal role due to better localization and
accurate visualization of agent dispersion. (12)

5. UPPER LIMB BLOCKS:

I. Indications: preprocedural block and post-procedural analgesia in:
Hand and wrist surgery as a standalone technique
Incomplete or failed brachial plexus block as a rescue procedure(13)

Special tip: high injection pressure may cause intra-fascicular injection as these nerves are
small and superficial. This could be avoided by placing the needle tip adjacent to the nerve
and injecting a small volume (4-5ml) of the local anesthetic within the fascial sheath.
Intramuscular injection should also be avoided.
Out-of-plane approach can also be used

II. Technique: (13,14)

a). RADIAL NERVE:
Patient position: supine, elbow 90 degrees flexed with forearm resting on the abdomen.
Probe is placed transversely in the distal arm lateral aspect, ~3cm proximal to the elbow
crease(Fig 16).
Nerve is seen close to the humerus in the fascial plane between the brachialis and
brachioradialis muscles.
Needle is inserted in lateral to medial direction(Fig 17).

b). ULNAR NERVE:

Patient position: supine, elbow extended with palm facing up.
Probe placed transversely in the proximal forearm just distal to the elbow crease on the
medial aspect(Fig 18).
Nerve is located in the fascial plane between flexor digitorum superficialis and profundus.
Needle is inserted in lateral to medial direction carefully avoiding the ulnar artery which is
seen lateral to the nerve(Fig 19).

c). MEDIAN NERVE:

Patient position: supine, elbow extended with palm facing up.
Probe is placed transversely in the mid-forearm (Fig 20).
Nerve is located in the fascial plane between deep and superficial flexor muscles.
Needle is inserted in lateral to medial direction carefully avoiding the radial artery which is
seen lateral to the nerve in the same plane(Fig 21).

CONCLUSION:
US-guided nerve block provides advantages over traditional methods of regional anaesthesia
& pain relief as it avoids risks associated with general anaesthesia/sedation, & side effects
caused by opioid analgesia.
US prevails over other modalities (fluoroscopy/CT/MRI) as it allows visualisation of the
local anesthetic distribution in real-time. (15)
If injectate dispersion around the nerve is not seen, it implies that needle tip is not where it
was thought to be, and hence injection should immediately be halted and tip of the needle be
relocated. Lack of spread can be due to intravascular needle placement which appears as an
echogenic "blush" within the vessel lumen, allowing for rapid termination of the injection and
avoidance of systemic toxicity. (16)
CEUS has further improved procedural guidance by visualising spread of the injectate and
checking needle tip relation with important anatomical structures. Even coating the outer part
of needle with ultrasound contrast leads to better visualization of the needle(Fig 22, Fig 23).

REFERENCES:

1.Shanahan EM. Suprascapular nerve block (using bupivacaine and methylprednisolone

acetate) in chronic shoulder pain. Ann Rheum Dis. 2003 May 1;62(5):400–6.

2. Harmon D. Ultrasound-guided SuprascapularNerve Block Technique. Pain Physician.

2007 Nov 14;6;10(6;11):746–746.

3. Mardani-Kivi M, Nabi BN, Mousavi MH, Shirangi A, Leili EK, Ghadim-Limudahi ZH.
Role of suprascapular nerve block in idiopathic frozen shoulder treatment: a clinical trial
survey. Clin Shoulder Elb. 2022 May 16;25(2):129–39.

4. Venkatraman R, Ranganathan Jothi A, Sakthivel A, Sivarajan G. Efficacy of ultrasound-

guided transversus abdominis plane block for postoperative analgesia in patients
undergoing inguinal hernia repair. Local Reg Anesth. 2016 Jan;7.

5. Tsai HC, Yoshida T, Chuang TY, Yang SF, Chang CC, Yao HY, et al. Transversus
Abdominis Plane Block: An Updated Review of Anatomy and Techniques. BioMed Res
Int. 2017;2017:8284363.

6. El-Dawlatly AA, Turkistani A, Kettner SC, Machata AM, Delvi MB, Thallaj A, et al.
Ultrasound-guided transversus abdominis plane block: description of a new technique and
comparison with conventional systemic analgesia during laparoscopic cholecystectomy. Br
J Anaesth. 2009 Jun;102(6):763–7.

7. Rai A, Gonzalez RR. Local Anesthesia for Minimally Invasive Treatment of the Prostate
in the Office Setting. In: Smith AD, Preminger GM, Kavoussi LR, Badlani GH,
Rastinehad AR, editors. Smith’s Textbook of Endourology [Internet]. Chichester, UK:
John Wiley & Sons, Ltd; 2018 [cited 2022 Dec 7]. p. 1661–71. Available from:
https://onlinelibrary.wiley.com/doi/10.1002/9781119245193.ch143

8. Nazir B. Pain during Transrectal Ultrasound-Guided Prostate Biopsy and the Role of
Periprostatic Nerve Block: What Radiologists Should Know. Korean J Radiol.
2014;15(5):543–53.
9. Hetta WM, Niazi G, Elfawy D. Local anesthesia by periprostatic block in transrectal
ultrasound guided prostatic biopsy. Egypt J Radiol Nucl Med. 2014 Mar;45(1):137–42.

10. Kambadakone A, Thabet A, Gervais DA, Mueller PR, Arellano RS. CT-guided Celiac
Plexus Neurolysis: A Review of Anatomy, Indications, Technique, and Tips for Successful
Treatment. RadioGraphics. 2011 Oct;31(6):1599–621.

11. Yan BM, Myers RP. Neurolytic celiac plexus block for pain control in unresectable
pancreatic cancer. Am J Gastroenterol. 2007 Feb;102(2):430–8.

12. Wang L, Lu M, Wu X, Cheng X, Li T, Jiang Z, et al. Contrast-enhanced ultrasound–

guided celiac plexus neurolysis in patients with upper abdominal cancer pain: initial
experience. Eur Radiol. 2020 Aug;30(8):4514–23.

13. Sehmbi H, Madjdpour C, Shah UJ, Chin KJ. Ultrasound guided distal peripheral
nerve block of the upper limb: A technical review. J Anaesthesiol Clin Pharmacol. 2015
Sep;31(3):296.

14. Ince I, Aksoy M, Celik M. Can We Perform Distal Nerve Block Instead of Brachial
Plexus Nerve Block Under Ultrasound Guidance for Hand Surgery? Eurasian J Med. 2016
Oct;48(3):167–71.

15. Gray AT. Ultrasound-guided regional anesthesia: current state of the art.
Anesthesiology. 2006 Feb;104(2):368–73, discussion 5A.

16. Huang DY, Yusuf GT, Daneshi M, Husainy MA, Ramnarine R, Sellars MEK, et al.
Contrast-enhanced US–guided Interventions: Improving Success Rate and Avoiding
Complications Using US Contrast Agents. RadioGraphics. 2017 Mar;37(2):652–64.

CAPTIONS:

[fig]1 Patient position for suprascapular nerve block in the suprascapular notch. The red
circle represents the site of needle insertion.
[fig]2 Ultrasound image showing the needle direction (red arrow)for the suprascapular nerve
block in the suprascapular notch. Note that the needle traverses the supraspinatus and the
trapezius muscle bulk
[fig]3 Patient position for suprascapular nerve block in the spinoglenoid notch. The red circle
represents the site of needle insertion.
[fig]4 Ultrasound image showing the needle direction (red arrow)for the suprascapular nerve
block in the spinoglenoid notch. Note that the needle traverses the infraspinatus and the
deltoid muscle bulk.
[fig]5 Contrast-enhanced ultrasound(CEUS) image color box with corresponding B-mode
image at the spinoglenoid notch showing Ultrasound contrast agent (UCA)-local
anesthetic(LA) agent mixture as an echogenic blush within the notch showing accurate
dispersion relative to the grayscale image
[fig]6 Patient position for TAP block. The red circle represents the site of needle insertion
which is directed from the anterior to the posterior aspect.
[fig]7 Ultrasound image showing the needle direction (red arrow) for the TAP block. Note
that the needle traverses the external oblique(EO)and the internal oblique(IO) muscle to reach
the TAP plane which is between the IO and the transversus abdominis(TA)
[fig]8 Schematic diagram showing the QL(quadratus lumborum) plane(blue line) between the
QL muscle and the psoas muscle which continues laterally as the TAP plane. With the patient
in the prone position, the transducer is placed in the posterolateral aspect of the flank. Note
the needle direction(black line) is from medial to lateral aspect
[fig]9 Ultrasound image showing the QL plane(green line) between the QL muscle and the
psoas muscle. The needle direction(red line) is from the medial to the lateral aspect. The
transverse process(TP) at the same level can be used as a landmark to identify the QL muscle
deep to the erector spinae.
[fig]10 Contrast-enhanced ultrasound(CEUS) image color box with a corresponding B-mode
grayscale image showing Ultrasound contrast agent (UCA)-local anesthetic(LA) agent
mixture dispersion within the QL plane (yellow arrow) which is otherwise inconspicuous on
grayscale by virtue of the depth of the plane.
[fig]11 Schematic diagram and the corresponding TRUS(transrectal ultrasound) image
depicting the desired site of LA injection for periprostatic nerve block(yellow arrow) in
parasagittal location also known as the 'Mount Everest sign'-echogenic triangular area
between prostate and seminal vesicle
[fig]12 CEUS image with a corresponding B-mode grayscale image showing UCA-LA agent
mixture dispersion at the prostate base for bibasal periprostatic nerve block(yellow arrow).
Inadvertent injection into vascular structures can be immediately terminated using real-time
assessment with CEUS
[fig]13 Schematic diagram showing the probe position for celiac plexus neurolysis. The
needle can be inserted (black line) from either side using the transhepatic approach to reach
the periaortic location.
[fig]14 Preliminary transabdominal USG for celiac plexus neurolysis planning with a color
box showing celiac trunk bifurcation
[fig]15 CEUS image with a corresponding B-mode grayscale image showing UCA-neurolytic
agent solution seen as an echogenic cloud in CEUS mode. The Spread of drugs around the
aorta can be well visualized
[fig]16 Patient and probe position for radial nerve block in the elbow region. The red circle
represents the site of needle insertion.
[fig]17 Ultrasound image showing the needle direction (red arrow)for the radial nerve block.
Note that the needle is directed from the lateral to medial aspect targeting the nerve within the
fascia
[fig]18 Patient and probe position for ulnar nerve block just below the elbow on the medial
aspect. The red circle represents the site of needle insertion.
[fig]19 Ultrasound image showing the needle direction (red arrow)for the ulnar nerve block.
The needle is directed from the lateral to medial aspect and carefully avoids the ulnar artery
which is medial to the nerve
[fig]20 Patient and probe position for median nerve block in the mid-forearm on the volar
aspect. The red circle represents the site of needle insertion.
[fig]21 Ultrasound image showing the needle direction (red arrow)for the median nerve
block. The needle is directed from the lateral to medial aspect and carefully avoids the radial
artery which is medial to the nerve
[fig]22 CEUS image with a corresponding B-mode grayscale image showing better
visualization of the needle on the CEUS mode after coating the needle outer surface with
UCA