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NEW YORK SCHOOL OF REGIONAL ANESTHESIA
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
Consultant Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
Admir Hadzic, MD, PhD
Director NYSORA, The New York School of Regional Anesthesia
Consultant Anesthesiology, Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium
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
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DEDICATION
9781260470055_PTCE_PASS3.indb 2
CONTENTS
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
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
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
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
Warning for Mothers who throw away the key of their children’s
mothers. hearts in childhood sometimes have a sad retribution.
As the children never were considered when they were
little and helpless, so they do not consider when they are strong and
powerful.
Care The fact is that care and labor are as much correlated
inevitable to to human existence as shadow is to light; there is no
human nature. such thing as excluding them from any mortal lot. You
may make a canary-bird or a gold-fish live in absolute contentment
without a care or labor, but a human being you cannot. Human
beings are restless and active in their very nature, and will do
something, and that something will prove a care, a labor, and a
fatigue, arrange it how you will. As long as there is anything to be
desired and not yet attained, so long its attainment will be attempted;
so long as that attainment is doubtful or difficult, so long will there be
care and anxiety.
THE MAYFLOWER.
Genial and There are people who, wherever they move, freeze the
ungenial hearts of those they touch, and chill all demonstration
natures. of feeling; and there are warm natures, that unlock
every fountain, and bid every feeling gush forth.
Power of “Oh, nonsense! now, John, don’t talk humbug. I’d like to
beauty. see you following goodness when beauty is gone. I’ve
known lots of plain old maids that were perfect saints
and angels; yet men crowded and jostled by them to get at the pretty
sinners. I dare say now,” she added, with a bewitching look over her
shoulder at him, “you’d rather have me than Miss Almira Carraway,
—hadn’t you, now?”
Growing alike. “The thing with you men,” said Grace, “is that you want
your wives to see with your eyes, all in a minute, what
has got to come with years and intimacy, and the gradual growing
closer and closer together. The husband and wife, of themselves,
drop many friendships and associations that at first were mutually
distasteful, simply because their tastes have grown insensibly to be
the same.”
DEACON PITKIN’S FARM.
A New Diana Pitkin was like some of the fruits of her native
England hills, full of juices which tend to sweetness in maturity,
woman. but which, when not quite ripe, have a pretty decided
dash of sharpness. There are grapes that require a frost to ripen
them, and Diana was somewhat akin to these.
AGNES OF SORRENTO.
Dual nature. But, reviewing his interior world, and taking a survey of
the work before him, he felt that sense of a divided
personality which often becomes so vivid in the history of individuals
of strong will and passion. It seemed to him that there were two men
within him: the one turbulent, passionate, demented; the other vainly
endeavoring, by authority, reason, and conscience, to bring the rebel
to subjection. The discipline of conventual life, the extraordinary
austerities to which he had condemned himself, the monotonous
solitude of his existence, all tended to exalt the vivacity of the
nervous system, which in the Italian constitution is at all times
disproportionately developed; and when those weird harp-strings of
the nerves are once thoroughly unstrung, the fury and tempest of the
discord sometimes utterly bewilders the most practiced self-
government.
Power of an “Son, it is ever so,” replied the monk. “If there be a man
honest that cares neither for duke nor emperor, but for God
character. alone, then dukes and emperors will give more for his
good word than for a whole dozen of common priests.”
“We old folks are twisted and crabbed and full of knots
Relation of with disappointment and trouble, like the mulberry-trees
age to youth.
that they keep for vines to run on.”
Effect of The ear that has never heard anything but abuse is
harshness. strangely incredulous of anything so heavenly as
kindness.
DRED.
Use of a Every kind of creature has its uses, and there are times
chatterbox. when a lively, unthinking chatterbox is a perfect
godsend. Those unperceiving people who never notice
the embarrassment of others, and who walk with the greatest facility
into the gaps of conversation, simply because they have no
perception of any difficulty there, have their hour; and Nina felt
positively grateful to Mr. Carson for the continuous and cheerful rattle
which had so annoyed her the day before.
Good and evil It is our fatality that everything that does good must do
inseparable. harm. It is the condition of our poor, imperfect life here.
“Streaked
men.”
“But den, you see, honey, der’s some folks der’s two
men in ’em,—one is a good one, and t’oder is very bad. Wal, dis yer
was jest dat sort.... He was one of dese yer streaked men, dat has
drefful ugly streaks; and, some of dem times, de Lord only knows
what he won’t do.”
POGANUC PEOPLE.
Opinionated Miss Debby was one of those human beings who carry
people. with them the apology for their own existence. It took
but a glance to see that she was one of those forces of
nature which move always in straight lines, and which must be
turned out for if one wishes to avoid a collision. All Miss Debby’s
opinions had been made up, catalogued, and arranged at a very
early period of life, and she had no thought of change. She moved in
a region of certainties, and always took her own opinions for granted
with a calm supremacy altogether above reason. Yet there was all
the while about her a twinkle of humorous consciousness, a vein of
original drollery, which gave piquancy to the brusqueness of her
manner, and prevented people from taking offence.
Difficulty ofIt is curious that men are not generally ashamed of any
confession. form of anger, wrath, or malice; but of the first step
towards a nobler nature,—the confession of a wrong,—
they are ashamed.
First false Boys, and men too, sometimes, by a single step, and
step. that step taken in a sudden hurry of inconsideration,
get into a network of false positions, in which they are very uneasy
and unhappy, but live along from day to day seeing no way out.
A DOG’S MISSION.
MY WIFE AND I.
Unsuspected The man who has begun to live and work by artificial
danger. stimulant never knows where he stands, and can never
count upon himself with any certainty. He lets into his
castle a servant who becomes the most tyrannical of masters. He
may resolve to turn him out, but will find himself reduced to the
condition in which he can neither do with nor without him.
In short, the use of stimulant to the brain power brings on a disease
in whose paroxysms a man is no more his own master than in the
ravings of fever, a disease that few have the knowledge to
understand, and for whose manifestations the world has no pity.
Heredity. Out of every ten young men who begin the use of
stimulants as a social exhilaration, there are perhaps
five in whose breast lies coiled up and sleeping this serpent,
destined in after years to be the deadly tyrant of their life—this curse,
unappeasable by tears, or prayers, or agonies—with whom the
struggle is like that of Laocoön with the hideous python, yet songs
and garlands and poetry encircle the wine-cup, and ridicule and
contumely are reserved for him who fears to touch it.
Personality. We are all familiar with the fact that there are some
people who, let them sit still as they may, and conduct
themselves never so quietly, nevertheless impress their personality
on those around them, and make their presence felt.
Persistency. If you will have your own way, and persist in it, people
have to make up with you.
Flaws in Ideal heroes are not plentiful, and there are few gems
gems. that don’t need rich setting.
Impossibility People who hate trouble generally get a good deal of it.
of evading It’s all very well for a gentle, acquiescent spirit to be
trouble. carried through life by one bearer. But when half a
dozen bearers quarrel and insist on carrying one opposite ways, the
more facile the spirit, the greater the trouble.
Woman as a “You girls and women don’t know your power. Why,
Gospel. Mary, you are a living Gospel. You have always had a
strange power over us boys. You never talked religion
much, but I have seen high fellows come away from being with you
as still and quiet as one feels when he goes into a church. I can’t
understand all the hang of predestination and moral ability, and
natural ability, and God’s efficiency, and man’s agency, which Dr.
Hopkins is so engaged about; but I can understand you,— you can
do me good.”
Holiness of “But do you remember you told me once that, when the
woman. snow first fell, and lay so dazzling and pure and soft all
about, you always felt as if the spreads and window
curtains, that seemed white before, were not clean? Well, it’s just like
that with me. Your presence makes me feel that I am not pure,—that
I am low and unworthy,—not worthy to touch the hem of your
garment. Your good Dr. Hopkins spent a whole half day, the other
Sunday, trying to tell us about the beauty of holiness; and he cut,
and pared, and peeled, and sliced, and told us what it wasn’t; and
what was like it, and wasn’t; and then he built up an exact definition,
and fortified and bricked it up all round; and I thought to myself that
he’d better tell ’em to look at Mary Scudder, and they’d understand
all about it.”
Repression. Her large brown eyes had an eager joy in them when
Mary entered; but they seemed to calm down again,
and she received her only with that placid, sincere air which was her
habit. Everything about this woman showed an ardent soul,
repressed by timidity and by a certain dumbness in the faculties of
outward expression; but her eyes had, at times, that earnest,
appealing language which is so pathetic in the silence of inferior
animals. One sometimes sees such eyes, and wonders whether the
story they intimate will ever be spoken in mortal language.
OLDTOWN FOLKS
Individuality.
Tina had one of those rebellious heads of curls that every breeze
takes liberties with, and that have to be looked after, and watched,
and restrained. Esther’s satin bands of hair could pass through a
whirlwind and not lose their gloss. It is curious how character runs
even to the minutest thing,—the very hairs of our head are
numbered by it,—Esther, always and in everything self-poised,
thoughtful, reflective; Tina, the child of every wandering influence,
tremulously alive to every new excitement, a wind-harp for every air
of heaven to breathe upon.
A woman’s “The fact is, a man never sees a subject thoroughly till
view. he sees what a woman will think of it, for there is a
woman’s view of every subject, which has a different
shade from a man’s view, and that is what you and I have insensibly
been absorbing in all our course hitherto.”
Reserve. But it was not the little maiden’s way to speak when
anything thwarted or hurt her, but rather to fold all her
feelings and thoughts inward, as some insects, with fine gauzy
wings, draw them under a coat of horny concealment.