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NEW YORK SCHOOL OF REGIONAL ANESTHESIA
Hadzic’s Peripheral Nerve

Blocks and Anatomy for
Ultrasound-Guided
Regional Anesthesia
Hadzic_FM_00i-xvi.indd 1 14/06/21 10:35 PM

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NEW YORK SCHOOL OF REGIONAL ANESTHESIA
Hadzic’s Peripheral Nerve

Blocks and Anatomy for
Ultrasound-Guided
Regional Anesthesia
THIRD EDITION
Editors
Ana M. Lopez, MD, PhD, DESA
Consultant Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
Angela Lucia Balocco, MD
Research Associate NYSORA, The New York School of Regional Anesthesia
Anesthesia Resident, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
Catherine Vandepitte, MD, PhD
Research Associate NYSORA, The New York School of Regional Anesthesia
Admir Hadzic, MD, PhD
Director NYSORA, The New York School of Regional Anesthesia
Visiting Professor, Department of Anesthesiology, Katholieke Universiteit Leuven (KUL), Belgium
Honorary Professor, University of Ljubljana, Slovenia
Doctor Honoris Causa, Karol Marcinkowski University of Medical Sciences, Poznan, Poland
New York Chicago San Francisco Lisbon London Madrid Mexico City
New Delhi San Juan Seoul Singapore Sydney Toronto

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DEDICATION
We dedicate this book to Jerry Vloka, MD, PhD

in recognition of his pioneering contributions to regional anesthesia
and immense inspiration for generations of students
and scholars of anesthesiology.

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9781260470055_PTCE_PASS3.indb 2
CONTENTS
Contributors ix 15. Infraclavicular Brachial Plexus Block 161

Foreword xiii 16. Costoclavicular Brachial Plexus Block 169
Acknowledgments xv 17. Axillary Brachial Plexus Block 177
18. Blocks for Analgesia of the Shoulder:
Phrenic Nerve Sparing Blocks 185
SECTION 1
19. Blocks About the Elbow 195
FOUNDATIONS 20. Wrist Block 205
1. Functional Regional Anesthesia Anatomy 3
2. Local Anesthetics: Clinical Pharmacology
and Selection 33 SECTION 4
3. Equipment for Peripheral Nerve Blocks 47 LOWER EXTREMITY BLOCKS
4. Electrical Nerve Stimulation 57 21. Lumbar Plexus Block 217
5. Optimizing Ultrasound Image 67 22. Fascia Iliaca Block 229
6. Monitoring and Documentation 23. Blocks for Hip Analgesia 239
in Regional Anesthesia 75
24. Femoral Nerve Block 247
7. Indications for Peripheral Nerve Blocks 89
25. Subsartorial Blocks: Saphenous Nerve,
8. Continuous Peripheral Nerve Blocks 101 Adductor Canal, and Femoral
9. Local Anesthetic Systemic Toxicity and Triangle Blocks 255
Allergy to Local Anesthetics 107 26. Lateral Femoral Cutaneous
10. Neurologic Complications of Nerve Block 265
Peripheral Nerve Blocks 117 27. Obturator Nerve Block 271
11. Preparation for Regional Anesthesia and 28. Proximal Sciatic Nerve Block 281
Perioperative Management 123
29. Popliteal Sciatic Block 291
30. Genicular Nerves Block 299
SECTION 2
31. iPACK Block 305
HEAD AND NECK BLOCKS 32. Ankle Block 313
12. Cervical Plexus Block 131
SECTION 5
SECTION 3
TRUNK AND ABDOMINAL
UPPER EXTREMITY BLOCKS WALL BLOCKS
13. Interscalene Brachial Plexus Block 143 33. Intercostal Nerve Block 325
14. Supraclavicular Brachial Plexus Block 153 34. Pectoral Nerves Block 333

viii Contents
35. Serratus Plane Block 341 39. Rectus Sheath Block 379
36. Paravertebral Block 349 40. Quadratus Lumborum Blocks 385
37. Erector Spinae Plane Block 359
38. Transversus Abdominis Plane Blocks 367 Index 395

CONTRIBUTORS
David Alvarez, MD Javier Domenech de la Lastra, MD, DESA

Department of Anesthesiology Department of Anesthesiology
Hospital Universitari de Bellvitge Hospital Clinic de Barcelona
Barcelona, Spain Barcelona, Spain
(Chapter 20) (Chapter 16)
Angela Lucia Balocco, MD Robin De Meirsman, MD

Ziekenhuis Oost-Limburg UZ Leuven
Genk, Belgium Leuven, Belgium
(Chapters 9, 11, 19, 31, 35, 37, 38, 39, and 40) (Chapter 34)
Jonas Bruggen, MD Dimitri Dylst, MD

UZ Leuven Ziekenhuis Oost-Limburg
Leuven, Belgium Genk, Belgium
Robbert Buck, MD Christopher J. Edwards, MD

UZ Antwerpen Wake Forest Baptist Medical Center
Antwerpen, Belgium Winston Salem, North Carolina
(Chapter 12) United States of America
(Chapter 36)
Eveline Claes, MD
Department of Anesthesiology Gert-Jan Eerdekens, MD
AZ Diest Department of Anesthesiology
Diest, Belgium UZ Leuven
(Chapter 10) Leuven, Belgium
(Chapters 17 and 40)
Tomás Cuñat, MD, DESA
Department of Anesthesiology Victor Frutos, MD
Hospital Clinic de Barcelona Department of Anesthesiology and Pain Clinics
Barcelona, Spain Hospital Universitari Germans Trias i Pujol
(Chapter 30) Badalona, Spain
(Chapter 1)
Lotte Cuyx, MD
Department of Anesthesiology Jeff Gadsden, MD
UZ Leuven Department of Anesthesiology
Leuven, Belgium Duke University Hospital
(Chapter 38) Durham, North Carolina
United States of America
Olivier De Fré, MD (Chapter 10)
Anesthesiology Department
AZ Herentals Levin Garip, MD
Herentals, Belgium Department of Anesthesiology
(Chapter 2) UZ Leuven
Leuven, Belgium
(Chapter 2)

x Contributors
Admir Hadzic, MD, PhD Leen Janssen, MD

Director, The New York School of Regional Anesthesia Department of Anesthesiology
New York, United States of America UZ Antwerpen
Department of Anesthesiology Antwerpen, Belgium
Ziekenhuis Oost-Limburg (Chapter 5)
Genk, Belgium
(Chapters 3, 4, 10, and 11) Manoj K. Karmakar, MD
Director of Pediatric Anesthesia
Rawad Hamzi, MD Chinese University of Hong Kong
Department of Anesthesia and Pain Management Prince of Wales Hospital
Wake Forest Baptist Medical Center Sha Tin, Hong Kong, China
Winston Salem, North Carolina, (Chapter 21)
(Chapter 33) Bram Keunen, MD
Department of Anesthesiology
Tyler Heijnen, MD Ziekenhuis Oost-Limburg
Department of Anesthesiology Genk, Belgium
Ziekenhuis Oost-Limburg (Chapter 15)
Genk, Belgium
(Chapter 18)
Samantha Kransingh, FCA, FANZCA
South Canterbury District Health Board
Jelena Heirbaut, MD
Timaru, New Zealand
(Chapters 5 and 22)
UZ Antwerpen
Antwerpen, Belgium
(Chapter 4) Queenayda A. D. Kroon, MD
Department of Anesthesia and Pain Management
Jore Hendrikx, MD University Medical Centre Maastricht
Department of Anesthesiology Maastricht, The Netherlands
UZ Leuven (Chapter 33)
Leuven, Belgium
(Chapter 31) Annelies Langenaeken, MD
Lotte Hendrix, MD UZ Leuven
Department of Anesthesiology Leuven, Belgium
UZ Leuven (Chapter 29)
Leuven, Belgium
(Chapter 13) Raphaël Lapré, MD
Daryl S. Henshaw, MD
AZ Rivierenland
Department of Anesthesiology and Pain Management
Reet, Belgium
Wake Forest Baptist Medical Center
(Chapter 2)
Winston Salem, North Carolina
(Chapter 36) Ana Lopez, MD, PhD
Peter Hulsbosch, MD Ziekenhuis Oost-Limburg
Department of Anesthesiology Genk, Belgium
Regionaal Ziekenhuis Heilig Hart (Chapters 1, 11, 12, 16, 18, 20, 21, and 32)
Leuven, Belgium
(Chapter 15) Sofie Louage, MD
J. Douglas Jaffe, MD AZ Glorieux
Department of Anesthesiology and Pain Management Ronse, Belgium
Wake Forest Baptist Medical Center (Chapters 27, 28, and 29)
Winston Salem, North Carolina
(Chapter 33)

Contributors xi
Leander Mancel, MD Filiep Soetens, MD

UZ Leuven AZ Turnhout
Leuven, Belgium Turnhout, Belgium
(Chapter 6) (Chapters 2 and 9)
Berend Marcus, MD Sam Van Boxstael, MD

UZ Leuven Ziekenhuis Oost-Limburg
Leuven, Belgium Genk, Belgium
(Chapter 7) (Chapters 24, 25, and 26)
Evi Mellebeek, MD Imré Van Herreweghe, MD

Ziekenhuis Oost-Limburg AZ Turnhout
Genk, Belgium Turnhout, Belgium
(Chapter 24) (Chapters 2 and 7)
Felipe Muñoz-Leyva, MD Astrid Van Lantschoot, MD

Department of Anesthesia and Pain Management Department of Anesthesiology
University Health Network, University of Toronto, Ziekenhuis Oost-Limburg
Toronto Western Hospital Genk, Belgium
Toronto, Ontario, Canada (Chapters 34 and 35)
(Chapters 9 and 37)
Kathleen Van Loon, MD
Gwendolyne Peeters, MD Department of Anesthesiology
Department of Anesthesiology UZ Leuven
UZ Gent Leuven, Belgium
Gent, Belgium (Chapter 9)
(Chapter 9)
Jill Vanhaeren, MSc
Xavier Sala-Blanch, MD Research Associate
Department of Anesthesiology The New York School of Regional Anesthesia
Hospital Clinic de Barcelona New York, United States of America
Barcelona, Spain (Chapter 39)
(Chapters 1 and 23)
Catherine Vandepitte, MD, PhD
Amar Salti, MD, EDRA Department of Anesthesiology
Department of Anesthesia and Pain Medicine Ziekenhuis Oost-Limburg
Sheikh Khalifa Medical City Genk, Belgium
Abu Dhabi, United Arab Emirates (Chapters 6, 8, 11, 15, 17, 19, and 28)
(Chapter 22 and 27)
Stefanie Vanhoenacker, MD
Ruben Schreurs, MD Department of Anesthesiology
Department of Anesthesiology Sint-Jozefskliniek Izegem
Ziekenhuis Oost-Limburg Izegem, Belgium
Genk, Belgium (Chapter 14)
(Chapter 25)
Thibaut Vanneste, MD
Jeroen Smet, MD Department of Anesthesiology
Department of Anesthesiology Ziekenhuis Oost-Limburg
UZ Gent Genk, Belgium
Gent, Belgium (Chapters 13, 14, 23, and 30)
(Chapter 3)

xii Contributors
Rob Vervoort, MD Daquan Xu

Department of Anesthesiology Associate Researcher
UZ Leuven The New York School of Regional Anesthesia
Leuven, Belgium New York, United States of America

FOREWORD
The third edition of this standard textbook on ultrasound NYSORA’s Reverse Ultrasound Anatomy™ (RUA) images
nerve blocks is released during a unique period in human his- feature functional anatomy or block techniques with clear
tory. The COVID-19 pandemic and the threats that the disease instructions on the principles and goals of each given tech-
poses to both patients and healthcare workers have substan- nique. These cognitive aids entailed countless hours of work
tially changed perioperative practice. During the pandemic, and collaboration between NYSORA’s creative and edito-
regional anesthesia was established as the preferred method rial teams to develop highly didactic creatives that facilitate
over general anesthesia whenever possible. Nerve blocks pre- understanding of the anatomy, fascial planes, and principles
serve respiratory function and avoid aerosolization during of nerve blockade. RUA helps students memorize sono-
intubation and extubation and, hence, viral transmission to anatomy patterns, which is essential for ultrasound imaging.
other patients and healthcare workers. As an example, the use The knowledge of the sonoanatomy patterns substantially
of nerve blocks as the preferred surgical anesthesia method increases ultrasound proficiency and skills retention. Wher-
during the pandemic allowed many limb surgeries to be car- ever applicable, clinical images of the patient’s position,
ried out with decreased exposure to healthcare workers and ultrasound transducer placement, and anatomical detail are
less burden on post-anesthesia care units (PACUs) and utili- featured. Recent relevant literature was added to the “Sug-
zation of hospital beds. With regional anesthesia, patients can gested Reading” for readers who like to explore the original
leave acute postoperative care facilities faster and avoid admis- sources of the information presented. We chose this approach
sion to the limited hospitalization beds. In our center, using in an effort to provide the most practical, pragmatic informa-
regional anesthesia and nerve blocks as the main anesthetic tion and relieve the content from massive literature citations.
choice allowed elective orthopedic surgery in many patients. Readers should be advised that this book is not meant to be
The use of ultrasound-guided local regional anesthesia (LRA) an encyclopedic listing of all techniques and their variations.
has increased exponentially in the last few years. The traditional Rather, our textbook should be viewed as a compendium of
techniques have been refined and a number of new approaches well-established knowledge, didactically organized for learn-
have been devised to better suit the evolving clinical practice. ing, and transferring knowledge to students of anesthesiology.
Nerve blocks are an essential component of multimodal analge- With this approach, the textbook aims to help standardize, and
sia in enhanced recovery after surgery (ERAS) protocols. Their implement well-established techniques, indications, pharma-
use enhances analgesia and reduces or eliminates the use of opi- cology, monitoring, and the documentation of nerve blocks.
oids in the postoperative period. Some traditional nerve block Instead of burdening the reader with experimental block tech-
techniques have been substituted by more selective techniques niques with unproven clinical benefit, we aimed to include
to minimize motor block and facilitate early rehabilitation and the most clinically useful nerve block, fascial, and infiltration
recovery. New ultrasound-guided fascial plane techniques, dis- techniques with proven efficacy and clinical applicability.
tal nerve blocks, and selective periarticular injections also are Information about perioperative management and local anes-
increasingly being used to yield a better balance between effi- thetic toxicity treatment was also added, and/or fully revised.
cacy, simplicity, safety, and sensory-motor block ratio. Because patients commonly present with a vague history of
This third edition of NYSORA’s textbook is substantially allergy to local anesthetics, the new edition also features highly
updated and revised to include the many new developments practical algorithms to facilitate decision-making and manage-
in regional anesthesia and trends in clinical practice. The new ment of allergy to local anesthetics.
edition features entirely new artwork, new clinical images, We are confident that this textbook will continue to be one
and new fascial plane and infiltration techniques. All in all, of the primary resources on peripheral nerve blocks in medi-
some 500 new algorithms, illustrations, ultrasound images, cal practices worldwide.
clinical photographs, and cognitive aids were included to
Sincerely,
facilitate learning. In addition to anesthesiologists, the highly
didactic and organized technique descriptions and func- Drs Hadzic, Lopez, Balocco, and Vandepitte
tional anatomy principles will be valuable to all anesthesia
providers, acute and chronic pain specialists, as well as inter- Free access to online videos at www.accessanesthesiology.com.
ventional pain, musculoskeletal medicine, and emergency Search for this title in the library and select “View All Videos”
department physicians. in the Multimedia widget on the landing page of the book.

9781260470055_PTCE_PASS3.indb 2
ACKNOWLEDGMENTS
This book would not be possible without the extraordinary football teams; innovators; and above all incredibly skilled
people who contributed their time and talent and undying and passionate surgeons. It has been an absolute pleasure
commitment to create an educational masterpiece. Many building the orthopedic anesthesia service with you. A short
thanks to Drs Ana Lopez (senior editor), Angela Lucia glimpse at the website of the department of orthopedic
Balocco, and Catherine Vandepitte, the third edition editors. surgery at ZOL is sufficient to get a sense that NYSORA-
Their combination of commitment, knowledge, research, EUROPE at ZOL is flanked by true giants of orthopedic sur-
and clinical expertise is apparent on every page of this book. gery (https://www.zol.be/raadplegingen/orthopedie).
Many thanks to the leadership at Ziekenhuis Oost-Limburg Thank you to the NYSORA International Team: Pat Pokorny
(ZOL; Genk, Belgium) for their support and for facilitating a (UK), Kusum Dubey (New Delhi), Katherine Hughey-Kubena
creative platform in the hospital’s clinical setting. In particu- (USA), Elvira Karovic, Medina Brajkovic, Ismar Ruznjic (B&H),
lar, many thanks to the medical director, Dr. Griet Vander Nenad Markovic (SER), Jill Vanhaeren, and Greet van Meir
Velpen, and the “can-solve-all” manager, Chantal Desticker. (BE). This is an incredible team of NYSORA’s go-getters.
Without your support, this book, and the creation of our cen- Thank you to NYSORA’s illustrator Ismar Ruznjic for
ter of excellence for regional anesthesia at ZOL, would not be the new-style illustrations and artwork he imparted to this
possible. Thank you to the leadership of the department, espe- edition. Ismar has grown with NYSORA to become one of
cially Rene Heylen, Jan Van Zundert, and Pieter De Vooght; the world’s very best anatomy illustrators.
their vision led to the creation of one of the best regional A big thank you to our designer and 3-D maestro, Nenad
anesthesia centers in the heart of Europe. Thank you to our Markovic, an ultimate perfectionist, whose eye has been con-
regional anesthesia team and block nurses Birgit Lohmar, structively critical to many artistic and stylistic aspects of this
Joelle Caretta, Ine Vanweert, Kristell Broux, Ilse Cardinaels, book, and NYSORA’s content at large.
Sydney Herfs, Elke Janssen, Hüda Erdem, Mohamed Rafiq, Finally, a huge thanks to all the contributors to this book,
Danny Baens, and all the operating nurses in the N-Block at as there have been quite a few. Such a volume, packed with so
the orthopedic surgery unit. much anatomical information, can always have hidden errors.
Many thanks to all top fellows in regional anesthesia. We have relied on our stellar contributors to detect and cor-
These young, bright doctors contribute immense value to rect them wherever possible. However, should the readers
our teaching mission, and carry on the mission of national find any that we have missed that require correction, please
ambassadors of regional anesthesia after graduation. Big forward them to info@nysora.com. We vouch to improve
gratitude to our anesthesia residents who rotate through our upon them and thank you immensely in advance for your
service from their mothership Universities: Leuven (KUL), feedback.
Gent, Antwerp, and others.
Many thanks to all,
Our orthopedic surgery department is by all means one
of the best in Europe and beyond. Made up of ultra high- Editors
achievers; physicians of national, Olympic, and professional

9781260470055_PTCE_PASS3.indb 2
1
SECTION
Foundations
Chapter 1 Functional Regional Anesthesia Anatomy 3

Chapter 2 Local Anesthetics: Clinical Pharmacology
and Rational Selection 33
Chapter 3 Equipment for Peripheral Nerve Blocks 47
Chapter 4 Electrical Nerve Stimulation 57
Chapter 5 Optimizing Ultrasound Image 67
Chapter 6 Monitoring and Documentation in Regional Anesthesia 75
Chapter 7 Indications for Peripheral Nerve Blocks 89
Chapter 8 Continuous Peripheral Nerve Blocks 101
Chapter 9 Local Anesthetic Systemic Toxicity
and Allergy to Local Anesthetics 107
Chapter 10 Neurologic Complications of Peripheral Nerve Blocks 117
Chapter 11 P
reparation for Regional Anesthesia
and Perioperative Management 123
Hadzic_Ch01_p001-032.indd 1 10/06/21 3:55 PM

9781260470055_PTCE_PASS3.indb 2
1 Functional Regional
Anesthesia Anatomy
Knowledge of anatomy is essential for the practice of regional biotechnology may eventually result in development of the
anesthesia and ultrasound-guided regional anesthesia proce- strategies to promote axonal growth and reduce neuronal death.
dures. This chapter provides a concise overview of the essential A typical neuron consists of a cell body (soma) with a
functional anatomy necessary for the implementation of tradi- large nucleus. The cell body is attached to several branching
tional and ultrasound-guided regional anesthesia techniques. processes, called dendrites, and a single axon (Figure 1-2).
Figure 1-1 demonstrates the anatomical planes and directions Dendrites receive incoming messages, whereas single axons per
used as a conventional approach throughout the book. neuron conduct outgoing messages. In peripheral nerves, axons
are long and slender; they are often referred to as nerve fibers.
Anatomy of Peripheral Nerves
The neuron is the basic functional unit responsible for nerve
conduction. Neurons are the longest cells in the body, often as
Connective Tissue
long as 1 meter. Most neurons have a limited ability to repair The peripheral nerve is composed of three types of fibers:
after injury. Advances in the understanding of the neurobi- (1) somatosensory or afferent nerves, (2) motor or effer-
ology of nerve regeneration and experimental advances in ent nerves, and (3) autonomic nerves. In a peripheral
FIGURE 1-1. Conventional body planes and directions. Red,

sagittal; orange, sagittal paramedian; green, transverse; and purple,
coronal or axial.

4 SEC TION 1 Foundations
FIGURE 1-2. Composition of the neuron.
nerve (Figure 1-3), individual axons are enveloped in a loose structures filling the space in between them, such as the
and delicate connective tissue, the endoneurium. Groups neurovascular bundles of intermuscular septae. This tissue
of axons are arranged within a bundle (nerve fascicle) sur- contributes to the functional mobility of nerves during joint
rounded by the perineurium. The perineurium imparts and muscular movement.
mechanical strength to the peripheral nerve and functions Of note, the fascicular bundles are not continuous through-
as a diffusion barrier to the fascicle, isolating the endo- out the peripheral nerve but divide and anastomose with one
neurial space and preserving the ionic milieu of the axon. another as frequently as every few millimeters (Figure 1-4).
At each branching point, the perineurium splits with the This arrangement of peripheral nerves helps to explain why
fascicle. The fascicles, in turn, are embedded in loose con- intraneural injections, which disrupt this organization, may
nective tissue called the interfascicular epineurium, which result in disastrous consequences as opposed to clean needle
contains adipose tissue, fibroblasts, mastocytes, blood ves- nerve cuts, which heal more readily. In the vicinity of joints,
sels, and lymphatics. The outer layer surrounding the nerve the fascicles are thinner, more numerous, and are likely sur-
is the epineurium, a denser collagenous tissue that protects rounded by a greater amount of connective tissue, which
the nerve. The paraneurium consists of loose connective reduces the vulnerability of the fascicles to pressure and
tissue that holds a stable relationship between adjacent stretching caused by movement.

Functional Regional Anesthesia Anatomy CHAPTER 1 5
Blood vessels
Axon Perineurium
Schwann cell
Epifascicular epineurium
Endoneurium
Mesoneurium
Spinal nerve
Dorsal root ganglion
Ventral root
FIGURE 1-3. Organization of the peripheral nerve.
Peripheral nerves receive blood supply from the adjacent group of longitudinal capillaries that run within the fascicles
blood vessels running along their course. There are two inde- and endoneurium. Neuronal injury after nerve blockade may
pendent interconnected vascular systems. The extrinsic sys- be due, at least partly, to the pressure or stretch within con-
tem consists of arteries, arterioles, and veins that lie within nective sheaths and the consequent interference with the vas-
the epineurium. The intrinsic vascular system comprises a cular supply to the nerve.

FIGURE 1-4. Diagram of fascicular arrangement in a peripheral nerve.
the dorsal root ganglia and enter the dorsolateral aspect of the
Communication Between the spinal cord to form the dorsal root. The motor fibers arise from
Central Nervous System and neurons in the ventral horn of the spinal cord and pass through
Peripheral Nervous Systems the ventrolateral aspect of the spinal cord to form the ventral
The central nervous system (CNS) communicates with the body root. The dorsal and ventral roots converge in the interverte-
through spinal nerves, which have sensory and motor compo- bral foramen to form the spinal nerves, which then divide into
nents (Figure 1-5). The sensory fibers arise from neurons in dorsal and ventral rami. The dorsal rami innervate muscles,
FIGURE 1-5. Schematic transverse section of thoracic vertebra showing the spine and the origin of
spinal nerves.

FIGURE 1-6. Anatomy of a typical spinal intercostal nerve.
bones, joints, and the skin of the back along the posterior mid- is no C8 vertebra, the C8 nerve passes between the C7 and
line. The ventral rami innervate muscles, bones, joints, and the T1 vertebrae.
skin of the antero-lateral aspect of the neck, thorax, abdomen, In the thoracic region, the T1 nerve passes between the T1
pelvis, and the extremities (Figure 1-6). and T2 vertebrae. This pattern continues down through the
remainder of the spine. The vertebral arch of the fifth sacral
and first coccygeal vertebrae is rudimentary. Because of
this, the vertebral canal opens inferiorly at the sacral hiatus,
Spinal Nerves where the fifth sacral and first coccygeal nerves pass. Roots of
There are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, spinal nerves must descend through the vertebral canal before
5 lumbar, 5 sacral, and 1 coccygeal. Spinal nerves pass exiting the vertebral column through the appropriate inter-
through the vertebral column at the intervertebral foramina vertebral foramen since the inferior end of the spinal cord
(Figure 1-7). The first cervical nerve (C1) passes superior to (conus medullaris) is located at the L1-L2 vertebral level in
the C1 vertebra (atlas). The second cervical nerve (C2) passes adults. Collectively, these roots are called the cauda equina.
between the C1 (atlas) and C2 (axis) vertebrae. This pattern Outside the vertebral column, ventral rami from cervi-
continues down the cervical spine; however, because there cal and lumbosacral spinal levels coalesce to form intricate

Thoracic and Abdominal Wall

1 C1
Thoracic Wall
2 C2
3
C3 The intercostal nerves originate from the ventral rami of
Cervical 4
5
C4
C5
the first 11 thoracic spinal nerves (T1-T11). Each intercostal
6 C6 nerve becomes part of the neurovascular bundle of the rib
7
and provides sensory and motor innervations (Figure 1-9).
C7
8 T1
1
2
T2
T3
Except for the first, each intercostal nerve gives off a lateral
3 T4 cutaneous branch that pierces the overlying muscle near the
T5
4
5 T6 midaxillary line. This cutaneous nerve divides into anterior
Thoracic
6 T7
and posterior branches, which supply the adjacent skin. The
7 T8
8 T9 intercostal nerves from the second to the sixth space reach
9 T10 the anterior thoracic wall and pierce the superficial fascia
10
11
T11
near the lateral border of the sternum and divide into medial
T12
12 and lateral cutaneous branches.
L1
1 Most fibers of the anterior ramus of the first thoracic spinal
L2
2
nerve join the brachial plexus for distribution to the upper
L3
limb. The small first intercostal nerve is the lateral branch
Lumbar 3 L4
and supplies only the muscles of the intercostal space, not the
4 L5 overlying skin. In contrast, the lower five intercostal nerves
5 S1
S2
abandon the intercostal space at the costal margin to supply
1
2
S3
S4 the muscles and skin of the abdominal wall.
Sacral 3 S5
4
5
Coccygeal
Anterior Abdominal Wall
The lower six thoracic nerves and the first lumbar nerve
FIGURE 1-7. Spinal nerves. innervate the skin, muscles, and parietal peritoneum of the
anterior abdominal wall. At the costal margin, the seventh
to eleventh thoracic nerves (T7-T11) leave their intercostal
networks called plexuses from which nerves extend into the
spaces and enter the abdominal wall in a fascial plane between
neck, the arms, and the legs.
the transversus abdominis and internal oblique muscles. The
seventh and eighth intercostal nerves slope upward following
Dermatomes, Myotomes, the contour of the costal margin, ninth runs horizontally, and
the tenth and eleventh have a downward trajectory. Anteri-
and Osteotomes orly, the nerves pierce the rectus abdominis muscle and the
A dermatome is the area of the skin supplied by the dor- anterior layer of the rectus sheath to emerge as anterior cuta-
sal (sensory) root of a specific spinal nerve (Figure 1-8). In neous branches that supply the overlying skin (Figure 1-9).
the trunk, each segment is horizontally disposed, except C1, The subcostal nerve (T12) takes the line of the twelfth rib
which does not have a sensory component. The dermatomes across the posterior abdominal wall. It continues around the
of the limbs from the fifth cervical to the first thoracic nerve flank and terminates similarly to the lower intercostal nerves.
(C5-T1) and from the third lumbar to the second sacral ver- The seventh to twelfth thoracic nerves (T7-T12) give off lat-
tebrae (L3-S2) extend like a series of bands from the midline eral cutaneous nerves, which further divide into anterior and
of the trunk posteriorly into the limbs. Of note, there is con- posterior branches. The anterior branches supply the skin as
siderable overlapping between adjacent dermatomes. far forward as the lateral edge of the rectus abdominis. The
A myotome is the segmental innervation of skeletal mus- posterior branches supply the skin overlying the latissimus
cle by a ventral root of a specific spinal nerve (Figure 1-8). dorsi. The lateral cutaneous branch of the subcostal nerve is
An osteotome is the area of the bone supplied by the sensory distributed to the skin on the side of the buttock.
root of the specific spinal nerve. The iliohypogastric and ilioinguinal nerves, both branches
Distribution of dermatomes, myotomes, and osteotomes of L1, supply the inferior part of the abdominal wall. The ilio-
does not follow the same pattern in some areas, where dif- hypogastric nerve runs above the iliac crest and splits into
ferent nerves supply the innervation of deep and superfi- two terminal branches. The lateral cutaneous branch supplies
cial structures (Figure 1-8). Regardless, the knowledge of the side of the buttock; the anterior cutaneous branch sup-
their distribution is relevant for the application of regional plies the suprapubic region.
anesthesia as a guide to decide which block techniques are The ilioinguinal nerve leaves the intermuscular plane by
appropriate to provide adequate analgesia and anesthesia piercing the internal oblique muscle above the iliac crest.
for specific surgical procedures. It continues between the two oblique muscles to enter the

FIGURE 1-8. Distribution of dermatomes, myotomes, and osteotomes: (A) anterior view and (B) posterior view.

Dorsal root
(sensory root)
Ventral root
(motor root)
Spinal ganglion
Meningeal ramus
Spinal nerve
Dorsal ramus (posterior)

with medial ramus and Sympathetic ganglion
lateral ramus Lateral cutaneous ramus
Ventral cutaneous ramus
Ramus communicans
Ventral ramus
FIGURE 1-9. Course and distribution of an intercostal nerve.
inguinal canal through the spermatic cord. Emerging from periphery of the diaphragm. Inflammation of the peritoneum
the superficial inguinal ring, it gives cutaneous branches to gives rise to pain in the lower thoracic and abdominal wall. In
the skin on the medial side of the root of the thigh, the proxi- contrast, the peritoneum on the central part of the diaphragm
mal part of the penis, and the front of the scrotum in males receives sensory branches from the phrenic nerves (C3, C4,
and the mons pubis and the anterior part of the labium majus and C5), and irritation in this area may produce pain in the
in females. region of the shoulder (the fourth cervical dermatome).
Nerve Supply to the Peritoneum Nerve Plexuses

The lower thoracic and first lumbar nerves innervate the The ventral rami of the cervical, lumbar, and sacral spinal
parietal peritoneum of the abdominal wall. The lower tho- nerves form a neural network known as plexuses. The nerve
racic nerves also innervate the peritoneum that covers the fibers from these spinal segments distribute in different

FIGURE 1-10. Organization of the cervical plexus from roots to terminal nerves.
terminal nerves. The four major nerve plexuses are the cervi- anterior scalene muscle, passes through the superior tho-
cal, brachial, lumbar, and sacral plexus. racic aperture, and descends on the walls of the mediasti-
num to innervate the diaphragm (phrenic nerve). Thus, the
cervical plexus has a relevant role in maintaining the respira-
The Cervical Plexus tory function. Superficial branches from the cervical plexus
The cervical plexus originates from the ventral rami of C1 pass around the posterior margin of the sternocleidomas-
to C5, which form three loops (Figure 1-10). Deep motor toid muscle and provide sensory innervation to the skin of
branches originating from these loops innervate the infra- the lateral scalp, neck, clavicle, shoulder, and upper thorax
hyoid and scalene muscles. Fibers from C3 to C5 form the (Figure 1-11). Table 1-1 describes the origin and innerva-
phrenic nerve, which descends on the anterior surface of the tion of each nerve of the cervical plexus.

FIGURE 1-11. Dissection of the superficial branches of the cervical plexus.
TABLE 1-1 Organization and Distribution of the Cervical Plexus

NERVES SPINAL SEGMENTS DISTRIBUTION
Ansa cervicalis (superior and inferior C1-C3 Five of the extrinsic laryngeal muscles (sternothyroid,
branches) sternohyoid, omohyoid, geniohyoid, and thyrohyoid)
by way of cranial nerve XII
Lesser occipital, transverse cervical, C2-C4 Skin of upper chest, shoulder, neck, and ear
supraclavicular, and greater auricular
nerves
Phrenic nerve C3-C5 Diaphragm
Cervical nerves C1-C5 Levator scapulae, scalene muscles, sternocleidomastoid
muscles, and trapezius muscles (with cranial nerve XI)

FIGURE 1-12. Organization of the brachial plexus from roots to terminal nerves.
The Brachial Plexus (C8-T1) trunks (Figure 1-12). At the level of the clavicle,
every trunk gives off an anterior and a posterior division.
The ventral rami of spinal nerves C5-T1 form the brachial These divisions rearrange their fibers to form the lateral,
plexus, which innervates bones, joints, muscles, and the medial, and posterior cords, which in turn give off the
skin of the upper extremity and shoulder girdle. Between peripheral nerves for the upper extremity (Figure 1-13).
the anterior and middle scalene muscles, the roots converge Table 1-2 describes the origin and innervation of each nerve
to form the superior (C5-C6), middle (C7), and inferior of the brachial plexus.

FIGURE 1-13. Dissection of the brachial plexus from the roots in the neck to the axillary fossa.
TABLE 1-2 Anatomy of the Brachial Plexus C5-T1

MYOTOMES
NERVE
(TERMINAL SPINAL MOTOR
BRANCH) NERVES TRUNK CORD MUSCLES RESPONSE SCLEROTOMES DERMATOMES
Long thoracic C5-C7 Serratus Forward
anterior flexion of
the arm and
contraction of
the serratus
anterior
Dorsal C5 Levator scap- Elevation of
scapular ulae, rhom- the scapula
boid muscles
Nerves to C4-C6 Upper Subclavius Sternoclavicular
subclavius joint

TABLE 1-2 Anatomy of the Brachial Plexus C5-T1 (Continued)

MYOTOMES
NERVE
Suprascapular C5-C6 Upper Supra- Abduction Glenohumeral
spinatus, and lateral and acromiocla-
infraspinatus rotation of vicular joints, sub-
the shoulder acromial bursa
Subscapular C5-C6 Upper Posterior Subscapularis, Adduction Deep surface of
(upper and teres major and medial the scapula
lower) rotation of
the shoulder
Thoracodorsal C6-C8 Upper, Posterior Latissimus Extension,
middle, dorsi adduction,
lower and medial
rotation of
the shoulder
Axillary C5-C6 Upper Posterior Deltoid, teres Abduction Glenohumeral Anterior and
minor and lateral anterior and posterior
rotation of acromioclavicular shoulder
the shoulder joints
Radial C5-T1 Upper, Posterior Triceps, Extension of 1st/3rd superior Posterior arm
middle, anconeus, the elbow, humerus, elbow and forearm,
lower brachioradia- wrist, and joint, radius, ulna, dorsal aspect of
lis, extensor fingers, supi- carpus, 1st-3rd the hand (1st-4th
carpi radialis nation of metacarpus and fingers)
longus and the forearm, phalanges
brevis, supina- abduction of
tor, extensor the wrist and
digitorum thumb
communis,
extensor
digiti minimi,
extensor carpi
ulnaris, exten-
sor indicis,
extensor pol-
licis longus
and brevis,
abductor
pollicis
Lateral C5-C7 Upper, Lateral Pectoralis Glenohumeral
pectoral middle minor, pecto- and acromiocla-
ralis major vicular joints
Musculocuta- C5-C6 Upper Lateral Coracobra- Flexion of the Humerus elbow Lateral forearm
neous chialis, biceps elbow and and proximal rim
brachii, supination of radioulnar joints
brachialis the forearm

TABLE 1-2 Anatomy of the Brachial Plexus C5-T1 (Continued)

MYOTOMES
NERVE
Median C6-T1 Upper, Lateral, Elbow: Pro- Flexion of Elbow joint Palmar aspect of
middle, medial nator teres, the wrist (anterior), radius, the hand (1st-4th
lower flexor carpi and 2nd-3rd ulna, 1st-4th fingers) and dor-
radialis, pal- fingers, pro- metacarpus and sal aspect of the
maris longus nation of the phalanges distal half of the
Forearm: forearm 2nd-4th fingers
Flexor
digitorum
superficialis/
profundus,
flexor pol-
licis longus,
pronator
quadratus
Hand: Thenar
muscles, 1st-
2nd lumbrical
muscles
Medial C8-T1 Lower Medial Pectoralis Clavicle
pectoral minor, pecto-
ralis major
Medial T1 Lower Medial Medial aspect of
brachial the arm
cutaneous
Medial C8-T1 Lower Medial Medial aspect of
antebrachial the forearm
cutaneous
Ulnar C8-T1 Middle Medial Flexor carpi Flexion of the Elbow joint, ulna Medial aspect of
ulnaris, flexor wrist and 4th- and medial aspect the hand, 4th-5th
digitorum 5th fingers, of the wrist, hand finger
profundus adduction of and 4th-5th
and interos- the thumb fingers
seous (4th-
5th fingers),
muscles of
the hypothe-
nar eminence,
adductor
pollicis, flexor
pollicis brevis

FIGURE 1-14. Organization of the lumbar plexus from roots to terminal nerves.
The Lumbar Plexus in the posterior abdominal wall between the psoas major
and quadratus lumborum muscles. The main branches
The ventral rami of spinal nerves L1-L4 form the lumbar of the lumbar plexus are the iliohypogastric, ilioinguinal,
plexus. They divide into anterior and posterior divisions genitofemoral, lateral femoral cutaneous, obturator, and
that coalesce to form the terminal nerves (Figure 1-14). femoral nerves (Figure 1-15 and Figure 1-16). Table 1-3
The lumbar plexus innervates the skin, muscles, peritoneal describes the origin and innervation of each nerve of the
lining of the lower abdominal wall, and the anteromedial lumbar plexus.
aspect of the lower extremities. The plexus runs caudally

FIGURE 1-15. Dissection of the lumbar plexus in the pelvic cavity.
Lateral femoral cutaneous

nerve
Inguinal ligament
Iliopsoas muscle
Femoral nerve
Tensor fasciae latae
Sartorius muscle
Pectineus muscle
Femoral artery
Femoral vein
Adductor longus muscle
Great saphenous vein
Gracilis muscle
FIGURE 1-16. Dissection of the femoral nerve below the inguinal ligament.

TABLE 1-3 Anatomy of the Lumbar Plexus L1-L4

MYOTOMES
NERVE
BRANCH) NERVES MUSCLES RESPONSE SCLEROTOMES DERMATOMES
Iliohypogastric T12-L1 Abdominal muscles Contraction of the Skin over inferior
(external and internal abdominal wall abdomen and
oblique, transverse (inguinal area) buttocks
abdominis)
Ilioinguinal L1 Internal oblique Contraction of the Skin over superior,
abdominal wall medial thigh, and
(inguinal area) portions of external
genitalia
Genitofemoral L1-L2 Cremaster Elevates the scrotum Anteromedial surface
of thigh and portions
over genitalia
Lateral femoral L2-L3 Anterolateral aspect
cutaneous of thigh
Femoral (anterior/ L2-L4 Sartorius, pectineus Flexion, aduction, Anteromedial aspect
superficial branches): and external rotation of thigh
anterolateral cutane- of the hip
ous, anteromedial
cutaneous
Femoral (posterior L2-L4 Quadriceps Extension of the Ilium, anterior and Anterior surface of
branch): saphe- knee, patellar lateral aspect of thigh, medial surface
nous, nerves to the femur, superior artic- of leg, and foot
quadriceps ular aspect of tibia;
hip and knee joints
Obturator L2-L4 Adductors of thigh Adduction of the Ischium, pubis, medial Medial surface of
(adductors magnus, thigh, external rota- aspect of femur; hip thigh
brevis, and longus); tion of the hip and knee joints
gracilis, obturator
externus
The Sacral Plexus between the greater trochanter and ischial tuberosity in the
gluteal area (Figure 1-18). In the proximal thigh, the nerve
The ventral rami of spinal nerves L4-L5 and S1-S4 form lies behind the lesser trochanter of the femur and is covered
the sacral plexus, which innervates the buttocks, perineum, superficially by the long head of the biceps femoris muscle.
posterior aspect of the thigh, and the whole leg below the The two components of the sciatic nerve diverge into two
knee, except the sensory territory of the saphenous nerve recognizable nerves as it approaches the popliteal fossa: the
(Figure 1-17). The main nerve is the sciatic nerve that leaves common peroneal and the tibial nerves. Table 1-4 describes
the pelvis through the greater sciatic foramen and travels the origin and innervation of each nerve of the sacral plexus.

FIGURE 1-17. Organization of the sacral plexus from roots to terminal nerves.
better understanding of the neuronal components that need

Innervation of the Major Joints to be anesthetized to achieve anesthesia for or analgesia after
Much of the practice of peripheral nerve blocks involves joint surgery. Table 1-5 summarizes the innervation and
orthopedic and joint surgery. Consequently, knowledge of kinetic function of the major muscle groups of the upper
the sensory innervation of major joints is important for a and lower extremities.

Gluteus maximus muscle
Superior gluteal
artery and nerve
Tendon of piriform muscle
Sacrotuberous ligament
Pudendal nerve
Sciatic nerve
Inferior gluteal nerve
Posterior femoral
cutaneous nerve
Ischial tuberosity
FIGURE 1-18. Dissection of the sciatic nerve at the pelvic outlet.
TABLE 1-4 Anatomy of the Sacral Plexus L4-S4

NERVE
(TERMINAL SPINAL MOTOR MOTOR RESPONSE TO
BRANCH) NERVES INNERVATION NEUROSTIMULATION DERMATOMES SCLEROTOMES
Gluteal (superior/ L4-S2 Abductors of thigh Contraction of the Medial and supe-
inferior) (gluteus minimus, buttocks and external rior aspect of the
gluteus medius, and rotation of the hip buttocks
tensor fasciae latae) and
extensor of thigh
(gluteus maximus)
Posterior femoral S1-S3 Skin of perineum
cutaneous and posterior
surface of thigh
and leg

TABLE 1-4 Anatomy of the Sacral Plexus L4-S4 (Continued)

NERVE
(TERMINAL SPINAL MOTOR MOTOR RESPONSE TO
BRANCH) NERVES INNERVATION NEUROSTIMULATION DERMATOMES SCLEROTOMES
Sciatic Gluteal Three of the hamstrings Extension of hip, flexion Hip joint; ischium,
level (semitendinosus and of knee posterior aspect
semimembranosus long of the femur
head of biceps femoris);
adductor magnus (with
obturator nerve)
Tibial L4-S3 Flexor of knee and Flexion of the knee, plan- Posterior aspect Knee, ankle, and
plantar flexors of ankle tar flexion of the foot and of leg, plantar all foot joints;
(popliteus, gastrocne- toes, inversion of the foot aspect of foot tibia, fibula, and
mius, soleus plantaris, plantar aspect of
and tibialis posterior the foot
muscles and long head
of biceps femoris mus-
cle); flexors of toes
Common L4-S2 Biceps femoris muscle Flexion of the knee, dorsi Anterior surface Knee, ankle, and
peroneal (short head); fibularis flexion of the foot and aspect of leg and all foot joints;
(brevis and longus) and toes, eversion of the foot dorsal aspect of proximal tibia and
tibialis anterior muscles; foot; skin over fibula and dorsal
extensors of toes lateral portion aspect of the foot
of foot (through
the sural nerve)
Pudendal S2-S4 Muscles of perineum, Motor contraction of the External genitalia,
including urogenital dia- muscles involved lower third of
phragm and external anal the urethra and
and urethral sphincter vagina, skin of the
muscles; skeletal muscles anal circumfer-
(bulbospongiosus, ischio- ence, caudal third
cavernosus muscles) of the rectum
Nerve to the qua- L4-L5 Quadratus femoris, infe- Adduction and external Hip joint
dratus femoris and rior gemellus rotation of the hip
inferior gemellus
Nerve to obtura- L5-S1 Superior gemellus, Abduction of the hip
tori and superior obturator internus
gemellus
Nerve to piriformis S1-S2 Piriformis Abduction and lateral
rotation of the hip
Nerves to coccyg- S3-S4 Coccygeus, levator ani Motor contraction of the
eus and levator ani muscles involved

TABLE 1-5 Summary of Movement by Joint

UPPER EXTREMITY
Shoulder (Glenohumeral) Joint
Flexion Biceps brachii—long head Musculocutaneous nerve
Coracobrachialis
Deltoid Axillary nerve
Pectoralis major Medial and lateral pectoral nerve
Extension Triceps brachii—long head Radial nerve
Latissimus dorsi Thoracodorsal nerve
Adduction Latissimus dorsi Thoracodorsal nerve
Pectoralis major Medial and lateral pectoral nerves
Teres major Lower subscapular nerve
Subscapularis Upper and lower subscapular nerve
Abduction Supraspinatus Suprascapular nerve
Medial rotation Pectoralis major Medial and lateral pectoral nerve
Latissimus dorsi Thoracodorsal nerve
Teres major Lower subscapular nerve
Subscapularis Upper and lower subscapular nerves
Lateral rotation Teres minor Axillary nerve
Infraspinatus Suprascapular nerve
Elbow (Humeroulnar, Humeroradial) Joint
Flexion Brachialis Musculocutaneous
Biceps brachii—long and short heads
Flexor carpi radialis Median nerve
Extension Triceps brachii—long lateral, medial head Radial nerve
Anconeus
Radioulnar Joints
Supination Biceps brachii—long and short head Musculocutaneous
Supinator Radial nerve
Pronation Pronator teres Median nerve
Pronator quadratus
Wrist (Radiocarpal, Ulnocarpal) Joint
Flexion Flexor carpi radialis Median nerve
Palmaris longus
Flexors of fingers listed below
Flexor carpi ulnaris Ulnar nerve
Extension Extensor carpi radialis longus and brevis Radial nerve
Extensors of fingers listed below
Extensor carpi ulnaris
Carpometacarpal Joints
Opposition Opponen pollicis Median nerve
Opponens digiti minimi Ulnar nerve

TABLE 1-5 Summary of Movement by Joint (Continued)

UPPER EXTREMITY
Metacarpophalangeal Joints
Flexion Flexor digitorum superficialis Median nerve
Flexor digitorum profundus Median and ulnar nerves
Flexor pollicis longus and brevis Median nerve
Interosseus Ulnar nerve
Lumbricals Median and ulnar nerves
Extension Extensor digitorum communis Radial nerve
Extensor indicis
Extensor digiti minimi
Adduction Palmar interosseous Ulnar nerve
Abductor pollicis
Abduction Dorsal interosseous Ulnar nerve
Abductor digiti minimi
Abductor pollicis longus Radial nerve
Abductor pollicis brevis Median nerve
Interphalangeal Joints
Flexion Flexor digitorum superficialis Median nerve
Flexor digitorum profundus Median and ulnar nerves
Flexor pollicis longus and brevis Median nerve
Extension Extensor digitorum communis Radial nerve
Extensor indicis
Extensor digiti minimi
Lumbricals (index, middle fingers) Median nerve
Lumbricals (ring, little fingers) Ulnar nerve
Interosseous muscles
LOWER EXTREMITY
Hip (Acetabulofemoral) Joint
Flexion Iliacus/psoas major Femoral nerve
Pectineus
Rectus femoris
Sartorius
Adductor magnus Obturator nerve
Adductor longus and brevis
Tensor fascia lata Superior gluteal nerve
Extension Biceps femoris—long head Sciatic nerve
Semimembranosus
Semitendinosus
Gluteus maximus Inferior gluteal nerve
Adductor magnus Obturator nerve

TABLE 1-5 Summary of Movement by Joint (Continued)

LOWER EXTREMITY
Hip (Acetabulofemoral) Joint
Adduction Adduct magnus, longus, brevis Obturator nerve
Gracilis
Pectineus Femoral nerve
Abduction Gluteus minimus Superior gluteal nerve
Gluteus medius
Tensor fascia lata
Medial rotation Gluteus minimus Superior gluteal nerve
Gluteus medius
Tensor fascia lata
Lateral rotation Piriformis Nerve to piriformis
Obturator internus Nerve to obturator internus
Superior gemilli Nerve to obturator internus
Inferior gemelli Nerve to quadratus femoris
Quadratus femoris Nerve to quadratus femoris
Sartorius Femoral nerve
Knee (Tibiofemoral) Joint
Flexion Bicep femoris—long and short heads Sciatic nerve
Semitendinosus
Semimembranosus
Popliteus Tibial nerve
Gastrocnemius
Sartorius Femoral nerve
Extension Rectus femoris Femoral nerve
Vastus lateralis
Vastus intermedius
Vastus medialis
Medial rotation Popliteus Tibial nerve
Semimembranosus Sciatic nerve
Semitendinosus
Lateral rotation Biceps femoris Sciatic nerve
Ankle (Talocrural) Joint
Plantar flexion Soleus Tibial nerve
Gastrocnemius
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Peroneus longus and brevis Superficial peroneal nerve
Dorsiflexion Tibialis anterior Deep peroneal nerve
Extensor digitorum
Extensor hallucis longus

Shoulder Joint Elbow Joint

Innervation to the shoulder joints originates from the supe- Branches of all major nerves of the brachial plexus
rior and middle trunks of the brachial plexus that can be that cross the joint, including the musculocutaneous,
blocked at the interscalene level. Most of the shoulder capsule radial, median, and ulnar nerves, supply the elbow joint
is supplied by the axillary and suprascapular nerves, which (Figure 1-20).
can be selectively blocked more distally. (Figure 1-19).
FIGURE 1-19. Innervation of the shoulder joint.
FIGURE 1-20. Innervation of the elbow joint.

Hip Joint Wrist and Hand

Branches from the femoral and obturator nerves from the Most of the terminal branches of the brachial plexus, includ-
lumbar plexus and from the sciatic nerve and the nerve to the ing the radial, median, and ulnar nerves, innervate the wrist
quadratus femoris from the sacral plexus innervate the hip and hand joints (Figure 1-23).
joint (Figure 1-21).
Ankle and Foot
Knee Joint The innervation of the ankle and foot joints is complex and
Branches from the femoral nerve innervate the knee joint ante- involves the terminal branches of the common peroneal (deep
riorly. On its medial side, the nerve receives branches from the and superficial peroneal nerves), tibial (tibial nerve), and fem-
posterior division of the obturator nerve, while both divisions oral nerves (saphenous nerve). An easier view is that the entire
of the sciatic nerve supply its posterior side (Figure 1-22). innervation of the ankle joint originates from the sciatic nerve,
FIGURE 1-21. Innervation of the hip joint.

FIGURE 1-22. Innervation of the knee joint. The origin of the superomedial and superolateral genicular
nerves (from the sciatic nerve or femoral nerve) is controversial.
FIGURE 1-23. Innervation of the wrist.

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He sat disconsolately down on the ground several feet from one of
the landing jacks. Sonya sat down beside him. "We won't be able to
go back at all now," she said. "Neither your ship nor mine can carry
us both, and there's no way we can occupy more than one of them at
a time."
Gordon sighed. "I suppose we could radio for help," he said presently.
"But if we did we'd have to tell them everything that happened. I'm
afraid they'd be sort of skeptical about the rain. Of course, we could
leave that part out—but I'm afraid they'd be skeptical about the collars
too. In fact, I don't think they'd even believe us. They'd simply jump to
the conclusion that we've fal—that we don't want to return and would
order us back on the double the minute maximum juxtaposition
occurred. No, if we radio for help, we've got to have a good concrete
reason for doing so—one that they'll be able to understand and
believe."
Sonya managed a wan smile. "I—I can just see myself standing
before the Council of Ministers, blaming what happened on the rain,"
she said.
Gordon laughed, "And I can just see myself standing before a
congressional investigating committee, explaining about the collars."
He began to feel better. A situation that could lend itself to humor
could not be wholly hopeless. "Here's what we'll do for now," he went
on. "We'll radio back the report we agreed upon, and then we'll go on
with our work as though nothing is wrong. Sometimes problems solve
themselves; but just in case this one shouldn't, and we can't go back,
we'll build a cabin so we'll have some place to live."
Sonya's eyes sparked like a little girl's. "Let's build it by that little
brook," she said. "Where—where we first met."
"Fine," Gordon said.
During the ensuing weeks, they spent their mornings gathering data
and their afternoons working on the cabin. They took time out to
analyze a sample of rain water, but it evinced no unusual qualities.
Gordon was not surprised. Shortly after landing, he had tested a
sample of Venusian water for drinking purposes, and with the same
result. Clearly, the quality that had undermined their inhibitions
originated in the cloud-cover, and evaporated soon after it reached
the ground.
After the cabin was finished, they began going on afternoon-hikes
into the hills, tramping through idyllic woods, talking and laughing,
exclaiming now and then at unexpected patterns of flowers, starting
at sudden rainbow-flights of birds. They saw but few Venusians, and
the few they did see ignored them. One afternoon they found a fern-
bordered pool beneath a white-skirted waterfall, and after that they
came there every day to swim. Sonya's skin darkened to a deep gold,
and looking at her, Gordon sometimes found it hard to breathe. Every
so often the sky darkened, and rain fell; but the rain was superfluous
now. And as for the invisible magnetic chain that bound them
together, that had been supplanted by another invisible chain that
was ten times as strong.
And yet the original one still remained, and the problem it represented
grew more and more acute as their scheduled departure-times
approached. They desperately needed a good practical reason to
give their respective governments for not returning to Earth—and
quite providentially at the very last moment (though it seemed
anything but providential at the time) they discovered that they had
one. Or rather, Sonya did. On the morning of the day she was
scheduled to undergo the rigors of acceleration, she regarded
Gordon shyly across the little breakfast table he had built. "I—I am
going to have a baby," she said.
The news, when it arrived in Moscow, had something of the impact of
a hydrogen bomb, and when it leaked through a hitherto unsuspected
crevice in the Kremlin, there was a sort of chain-reaction throughout
the entire Soviet Union. It was at this point in his political career that
the Soviet premier discovered a universal truth: people the world
over, whether they be communistic or capitalistic, have a very large
soft spot in their hearts when it comes to babies.
That spring, Venus outshone herself, and hung in the evening sky
over Moscow somewhat in the manner of the star over Bethlehem.
The premier had a haunted look on his face when he appeared
before the Council of Ministers. He was not alone. The Ministers had
haunted looks on their faces too. What did you do when you had to
cope with a forthcoming space baby who would be half capitalist and
half communist and who was already adored by the whole world?
The premier did not know. But there was one thing he did know: in
the last analysis, any party is the people, and while you can con the
people into believing that black bread is white bread and that caraway
seeds are caviar, you cannot con them into believing that a child
conceived on the Planet of Love by a Russian girl and an American
boy is anything other than a harbinger of peace.
So in the long run, what the premier did was the only thing he could
have done. He arranged a summit meeting with the president of the
United States and the prime minister of Great Britain, and for the first
time in history, the East and the West really got together. The threat
of war could not, of course, be totally eliminated at such short notice;
but a number of aggravations that could precipitate a war could be
eliminated—and were. This accomplished, the three leaders drew up
plans for a super three-man spaceship to be built posthaste by the
best engineers the three nations could supply, and unanimously
agreed that the pilot would be English, the obstetrician, Russian, and
the nurse, American.
It has been said that after the meeting the Soviet premier and the
president of the United States got together and began thinking up
names. This is extremely doubtful. Anyway, if they did, they were
wasting their time, for Sonya Mikhailovna and Gordon Andrews had
already taken care of the matter. The name they chose is well-known
today—except, perhaps, by those for whom this history has been
recorded. Which brings us back to the aforementioned news bulletin.
In common with most news bulletins, it has about as much poetry in it
as an old shoe, but its message shines forth with a radiance that
excels even the radiance cast by the star over Moscow.
Geneva, Switzerland, September 11, 1996—The young Russo-
American ambassador-at-large, Pëtr Gordonovitch Andrews,
announced this morning that his peace plan has been accepted by all
major and minor powers, and that the war that has threatened
mankind for the past half century can no longer occur.
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Anatomy for Ultrasound-Guided

Regional Nerve Blocks in Anesthesia and Pain Therapy

Atlas of Peripheral Nerve Ultrasound With Anatomic and

Military Advanced Regional Anesthesia and Analgesia

Ultrasound Guided Procedures and Radiologic Imaging for

Imaging Anatomy. Ultrasound 2nd Edition Paula J.

Applications of Ultrasound in Anesthesia A Handbook 1st

Color Atlas of Ultrasound Anatomy 2nd edition Berthold

Atlas of Interventional Orthopedics Procedures:

Hadzic’s Peripheral Nerve

Hadzic_FM_00i-xvi.indd 1 14/06/21 10:35 PM

Hadzic_FM_00i-xvi.indd 2 14/06/21 10:35 PM

Hadzic’s Peripheral Nerve

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We dedicate this book to Jerry Vloka, MD, PhD

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Contributors ix 15. Infraclavicular Brachial Plexus Block 161

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Hadzic_FM_00i-xvi.indd 8 14/06/21 10:35 PM

David Alvarez, MD Javier Domenech de la Lastra, MD, DESA

Angela Lucia Balocco, MD Robin De Meirsman, MD

Jonas Bruggen, MD Dimitri Dylst, MD

Robbert Buck, MD Christopher J. Edwards, MD

Hadzic_FM_00i-xvi.indd 9 14/06/21 10:35 PM

Admir Hadzic, MD, PhD Leen Janssen, MD

Hadzic_FM_00i-xvi.indd 10 14/06/21 10:35 PM

Leander Mancel, MD Filiep Soetens, MD

Berend Marcus, MD Sam Van Boxstael, MD

Evi Mellebeek, MD Imré Van Herreweghe, MD

Felipe Muñoz-Leyva, MD Astrid Van Lantschoot, MD

Hadzic_FM_00i-xvi.indd 11 14/06/21 10:35 PM

Rob Vervoort, MD Daquan Xu

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Chapter 1 Functional Regional Anesthesia Anatomy 3

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FIGURE 1-1. Conventional body planes and directions. Red,

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FIGURE 1-2. Composition of the neuron.

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FIGURE 1-3. Organization of the peripheral nerve.

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FIGURE 1-4. Diagram of fascicular arrangement in a peripheral nerve.

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FIGURE 1-6. Anatomy of a typical spinal intercostal nerve.

Hadzic_Ch01_p001-032.indd 7 10/06/21 3:55 PM

Thoracic and Abdominal Wall

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Hadzic_Ch01_p001-032.indd 9 10/06/21 3:55 PM

Dorsal ramus (posterior)

FIGURE 1-9. Course and distribution of an intercostal nerve.

Nerve Supply to the Peritoneum Nerve Plexuses

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FIGURE 1-11. Dissection of the superficial branches of the cervical plexus.