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whatsoever whether such claim or cause arises in contract, tort or otherwise.

5
 CONTENTS
Preface
Acknowledgments

1. Basics of Musculoskeletal and Doppler Ultrasound Imaging for Regional

Anesthesia and Pain Medicine
2. Sonoanatomy Relevant for Ultrasound-Guided Upper Extremity Nerve Blocks
3. Sonoanatomy Relevant for Ultrasound-Guided Lower Extremity Nerve Blocks
4. Sonoanatomy Relevant for Ultrasound-Guided Abdominal Wall Nerve Blocks
5. Ultrasound Imaging of the Spine: Basic Considerations
6. Sonoanatomy Relevant for Ultrasound-Guided Injections of the Cervical Spine
7. Ultrasound of the Thoracic Spine for Thoracic Epidural Injections
8. Ultrasound Imaging of the Lumbar Spine for Central Neuraxial Blocks
9. Ultrasound Imaging of Sacrum and Lumbosacral Junction for Central Neuraxial
Blocks
10. Sonoanatomy Relevant for Thoracic Interfascial Nerve Blocks: Pectoral Nerve
Block and Serratus Plane Block
11. Sonoanatomy Relevant for Ultrasound-Guided Thoracic Paravertebral Block
12. Sonoanatomy Relevant for Ultrasound-Guided Lumbar Plexus Block

Index

6
 PREFACE

This Atlas is intended to illustrate the aspects of sonoanatomy that are important in the
performance of ultrasound guided nerve blocks for acute and chronic pain medicine. The use
of ultrasound has increased exponentially in the area of regional anesthesia and pain medicine
in the last decade. During this time of evolution, learning sonoanatomy was hampered with
the need to refer to various resources for the technical aspects of machine optimization,
correlating sonoanatomy with gross anatomy and other imaging modalities and discovering
the ergonomic aspects of imaging and intervention.
For regional anesthesia, transitioning from landmark based techniques for nerve blocks to
real time ultrasound image guided nerve blocks required the development of the ability to
visualize and understand the cross sectional anatomy of the area of interest outside the
traditional transverse, sagittal and coronal axis views presented by current modalities such as
computed tomography and magnetic resonance imaging.
For pain medicine, transitioning from fluoroscopy guided interventions to real time
ultrasound image guided or assisted interventions required the development of new points of
reference for interventions and a move away from traditional fluoroscopic guided endpoints
for intervention.
This book is divided into chapters that present the sonoanatomy specific for interventions
in the area of interest. With a total of 768 illustrations this book is designed to be the
complete resource for gross anatomy, CT, MR and sonoanatomy of the specific area of
interest for easy cross-reference between gross anatomy and the various modalities allowing
users to better understand the sonoanatomy. These cross-referenced images are presented
with the relevant anatomy in the same cross sectional plane of the ultrasound image. Within
each area of interest, users are guided to acquire the ideal ultrasound image for targeted
intervention with attention to the required ergonomics for operator safety and comfort.
Each approach to the relevant sonoanatomy is accompanied by clinical pearls to aid
readers acquire ultrasound images of the area of interest with ease, provide guidance for
successful intervention and avoid pitfalls.
This Atlas has been written both as an introduction for new users to ultrasonography and
as a review and instruction aid for users familiar with the subject. It is our sincere hope that
the users of this book will develop an appreciation of the ease and usefulness of
ultrasonography and the beauty of sonoanatomy.

7
 ACKNOWLEDGMENTS

We would like to express our deepest gratitude to Philips Medical for their assistance, with
special appreciation to – Inainee binte Abu Bakar, Lynette Barss, Cheong Yew Keong, Doxie
Davis, Nicolaas Delfos, Cellinjit Kaur, William Kok, Nah Lee Tang and Wayne Spittle. And,
of course, our families for their support and encouragement.
The anatomic images are courtesy of the Visible Human Server at Ecole Polytechnique
Fédérale de Lausanne, Visible Human Visualization Software (http://visiblehuman.epfl.ch),
and Gold Standard Multimedia www.gsm.org. All figures and illustrations in this book are
reproduced with the kind permission from www.aic.cuhk.edu.hk/usgraweb of the Department
of Anesthesia and Intensive care of The Chinese University of Hong Kong.
Manoj K. Karmakar, MD, FRCA, DA(UK), FHKCA, FHKAM
Edmund Soh, MD
Victor Chee, MD
Kenneth Sheah, MD

8
CHAPTER 1

Basics of Musculoskeletal and Doppler Ultrasound

Imaging for Regional Anesthesia and Pain Medicine

A sound knowledge of the basic concepts of musculoskeletal ultrasound is essential to obtain

optimal images during ultrasound-guided regional anesthesia (USGRA). This chapter briefly
summarizes the ultrasound principles that the operator should be aware of when performing
USGRA.

Ultrasound Transducer Frequency

Spatial resolution is the ability to distinguish two closely situated objects as separate. Spatial
resolution includes axial resolution (the ability to distinguish two objects at different depths
along the path of the ultrasound beam) and lateral resolution (the ability to distinguish two
objects that are side by side perpendicular to the ultrasound beam). Higher transducer
frequencies increase spatial resolution but penetrate poorly into the tissues. Lower transducer
frequencies penetrate deeper into the tissues at the expense of lower spatial resolution. Spatial
resolution and beam penetration have to be balanced when choosing the transducer
frequency.
Examples: A high-frequency (6–13 MHz) ultrasound transducer is used to image
superficial structures such as the brachial plexus in the interscalene groove or supraclavicular
fossa. A lower-frequency transducer (5–10 MHz) is suitable for slightly deeper structures
such as the brachial plexus in the infraclavicular fossa, and a low-frequency transducer (2–5
MHz) is used to image deep structures such as the lumbar paravertebral region or the sciatic
nerve. High-frequency (6–13 MHz) linear transducers with a small footprint (25–26 mm) are
particularly suited for regional blocks in young children.

Scanning Plane
Scans can be performed in the transverse (axial) or longitudinal plane. During a transverse
scan, the transducer is oriented at right angles to the long axis of the target, producing a
cross-sectional display of the structures (Fig. 1-1A). During a longitudinal (sagittal) scan, the
transducer is oriented parallel to the long axis of the target (eg, a blood vessel or nerve) (Fig.
1-1B). During USGRA, ultrasound scans are most commonly performed in the transverse
plane in order to easily visualize the nerves, the adjacent structures, and the circumferential
spread of the local anesthetic.

9
FIGURE 1-1 Axis of scan.

Transducer and Image Orientation

The ultrasound image must be correctly oriented in order to accurately identify the
anatomical relationships of the various structures on the display monitor. Ultrasound
transducers have an orientation marker (eg, a groove or a ridge) on one side of the transducer,
which corresponds to a marker on the monitor (eg, a dot or logo) (Fig. 1-2). There are no
accepted standards on how to orient a transducer, but it is common to have the orientation
marker on the transducer directed cephalad when performing a longitudinal scan, and
directed towards the right side of the patient when performing a transverse scan (Fig. 1-3). In
this way, the monitor “marker” should be at the upper-left corner of the screen representing
the cephalad end during a longitudinal scan, or the right side of the patient during a transverse
scan (Fig. 1-3). The top of the monitor represents superficial structures, and the bottom of the
monitor deep structures.

10
FIGURE 1-2 Transducer orientation. Note the orientation marker varies between different
providers of ultrasound systems. L, longitudinal, T, transverse and C, coronal.

FIGURE 1-3 Image orientation – transverse scan.

Image Optimization
The image should be optimized by adjusting the depth, focal zone, and gain. Imaging depth
affects temporal resolution (the ability to accurately depict moving structures) and should be
reduced to the smallest field of view (FOV) that is practical. The focal zone should be
positioned at the region of interest to increase lateral resolution at that site. Reducing the total
number of focal zones also improves temporal resolution. Finally, the time gain
compensation (TGC) and overall gain should be adjusted to produce an image with
appropriate brightness. The TGC is usually adjusted with the near field gain turned down and
the far field gain turned up in steady progression to adjust for beam attenuation with depth.

11
Echogenicity
Certain terms are frequently used to describe the sonographic appearance of musculoskeletal
structures (Fig. 1-4):

FIGURE 1-4 Echogenicity of tissues.

Isoechoic: The structure is of the same brightness or echogenicity as the surrounding tissues.
Hyperechoic: The structure is bright.
Hypoechoic: The structure is dark but not completely black.
Anechoic: The structure has no echoes and appears completely black.

Contrast resolution is the ability to distinguish subtle differences in echogenicity between

two adjacent structures.

Axis of Intervention
During USGRA, the block needle can be visualized in its short axis (out-of-plane approach)
(Fig. 1-5) or long axis (in-plane approach) (Fig. 1-6). In the out-of-plane approach, the needle
is initially outside the plane of imaging and therefore not visible. The needle only becomes
visible when it crosses the plane of imaging and is seen as an echogenic dot on the monitor
(Fig. 1-5). It is important to note that this echogenic dot may not represent the tip of the
needle because it is a short-axis view. In the in-plane approach the needle is inserted along
the plane of imaging and therefore both the shaft and tip of the needle are visible on the
monitor (Fig. 1-6).

12
FIGURE 1-5 Axis of intervention – out-of-plane needle insertion.

FIGURE 1-6 Axis of intervention – in-plane needle insertion.

Both approaches are commonly used, and there are no data showing that one is better than

13
the other. Pros and cons for both methods have been debated. Proponents of the out-of-plane
approach have had great success with this method and claim that it causes less needle-related
trauma and pain because the needle is advanced through a shorter distance to the target.
However, critics of the out-of-plane approach express concerns that the inability to reliably
visualize the needle and using tissue movement as a surrogate marker to locate the needle tip
during a procedure can lead to complications. The needle is better visualized in the in-plane
approach, but this requires good hand–eye coordination, and reverberation artifacts from the
shaft of the needle can be problematic. Moreover, there are claims that the in-plane approach
also causes more discomfort in awake patients because longer needle insertion paths are
required.

Field of View and Needle Visibility

Having an adequate FOV during USGRA is important because it not only allows one to
visualize the “target,” but also the neighboring structures (eg, blood vessel, pleura, etc.) that
one wishes to avoid injury to. Linear array transducers have a narrow FOV, whereas curved
array transducers have a divergent ultrasound beam resulting in a wider FOV (Fig. 1-7).

FIGURE 1-7 Comparative field of view of the infraclavicular fossa with linear and curved
array transducers.

Needles are best visualized when imaged perpendicular to the ultrasound beam. Needles at
steep angles required for deep blocks may not be easily visualized with linear array
transducers. Linear array transducers are best suited for superficial blocks (eg, axillary or
interscalene brachial plexus block, femoral nerve block). Curved array transducers are more
suitable for deep blocks (eg, sciatic nerve block, lumbar plexus block, and central neuraxial
blocks). However, curved array transducers have reduced lateral resolution at depth due to
the diverging ultrasound beam.
Other factors can also influence needle visibility. The needle is better visualized in its long
axis than in its short axis, and its visibility decreases linearly with smaller needle diameters.
The needle tip is better visualized when in its long axis for shallow angles of insertion (less
than 30 degrees), and in its short axis when the angle of insertion is steep (greater than 60
degrees). This is also true when the needle is inserted with its bevel facing the ultrasound

14
transducer. To overcome the effect of angle on needle visibility, some high-end ultrasound
machines allow the operator to steer the ultrasound beam (beam steering) towards the needle
during steep insertions. However, this requires experience, and decreases in needle visibility
can still occur. Needle visibility is also enhanced in the presence of a medium-sized guide
wire. Priming a needle with saline or air, insulating it, or inserting a stylet prior to insertion
does not improve visibility.
We believe that the anesthesiologist’s skill in aligning the needle along the plane of
imaging is by far the most important variable influencing needle visibility because minor
deviations of even a few millimeters from this plane can result in an inability to visualize the
needle. Even with experience, needle tip visibility is a problem when performing blocks at
depth, in areas that are rich in fatty tissue, and in the elderly. Under such circumstances
gently jiggling (rapid in-and-out movement) the needle and observing tissue movement or
performing a test injection of saline or 5% dextrose (1–2 mL) and observing tissue distention
can help locate the position of the needle tip. The preference is for 5% dextrose for the latter
when nerve stimulation is used because it does not increase the electric current required to
elicit a motor response.

Anisotropy
Anisotropy, or angular dependence, is a term used to describe the change in echogenicity of a
structure with a change in the angle of insonation of the incident ultrasound beam (Fig. 1-8).
It is frequently observed during scanning of nerves, muscles, and tendons. This occurs
because the amplitude of the echoes returning to the transducer varies with the angle of
insonation. Nerves are best visualized when the incident beam is at right angles; small
changes in the angle away from the perpendicular can significantly reduce their echogenicity.
Therefore, during USGRA the transducer should be tilted from side to side to minimize
anisotropy and optimize visualization of the nerve. Although poorly understood, different
nerves also exhibit differences in anisotropy; this may be related to the internal architecture
of the nerve.

15
FIGURE 1-8 Anisotropy – effect of angulation of the transducer on the echogenicity of the
median nerve (white arrow) in the forearm. The median nerve appears hypoechoic in the
image on the right.

Identification of Normal Structures

Nerve
Peripheral nerves consist of hypoechoic nerve fascicles surrounded by hyperechoic
connective tissue and have a “honeycomb” appearance in the transverse axis (Fig. 1-9). They
have a fibrillar appearance in the longitudinal axis with fine parallel hyperechoic lines
separated by fine hypoechoic lines. Generally, nerves appear hyperechoic, but the appearance
can vary depending on the surrounding structures. For example, nerves appear hyperechoic
when surrounded by hypoechoic muscle, but can appear hypoechoic when surrounded by
hyperechoic fat. The echogenicity of a nerve may also vary depending on the location where
it is scanned; for example, the brachial plexus nerves appear hypoechoic at the interscalene
groove, but are hyperechoic at the infraclavicular fossa and axilla. The exact reason for this is
not clear, but may be related to the relative proportion of neural and connective tissue within
the nerve. The ratio of neural to non-neural tissue content within the epineurium of the nerve
increases from 1:1 in the interscalene/supraclavicular fossa to 1:2 in the mid-
infraclavicular/paracoracoid regions. Nerve motion can also be demonstrated on dynamic
ultrasound imaging.

16
FIGURE 1-9 Echogenicity of muscles and nerves at different locations in the upper and
lower extremity. SA, subclavian artery, CPN, common peroneal nerve, TN, tibial nerve.

Tendon
Tendons are hyperechoic with a fibrillar pattern on longitudinal scans. Tendons are more
hyperechoic than nerves and move more than adjacent nerves when the corresponding muscle
is contracted or passively stretched.

Muscle
Muscle fiber bundles are hypoechoic. The separating and surrounding connective tissue
perimysium and epimysium are hyperechoic (Fig. 1-9). Muscle fibers converge to become
tendons or aponeuroses.

Subcutaneous Fat
Subcutaneous fat lobules appear as round to oval hypoechoic nodules that are separated by
fine hyperechoic septa. They are slightly compressible and appear similar on transverse and
longitudinal scans.

Bone
Bone reflects most of the ultrasound beam. Therefore, the bone surface appears hyperechoic
on ultrasound with posterior acoustic shadowing, and possibly posterior reverberation, distal
to it (Fig. 1-10).

17
FIGURE 1-10 Echogenicity of bone, pleura and lung at the intercostal space. Note the
acoustic shadow deep to the rib.

Fascia
Fascia, peritoneum, and aponeuroses appear as thin hyperechoic layers.

Blood Vessel
Blood vessels have anechoic lumens. Arteries are intrinsically pulsatile and are not
compressible with moderate pressure. Veins are not pulsatile and are compressible. Color
Doppler or Power Doppler modes can also be used to demonstrate the presence of blood flow
and differentiate arteries from veins.

Pleura
The pleura appear as a hyperechoic line slightly deep to the hyperechoic ribs (Fig. 1-10).
“Comet-tail” artifacts may be present as vertically oriented echogenicities arising from the
pleura. On real-time imaging, sliding movement between the parietal and visceral pleura can
be discerned with respiration (lung sliding sign).

Special Ultrasound Features

Tissue Harmonic Imaging
Harmonics refer to frequencies that are integral multiples of the frequency of the transmitted
pulse (the fundamental frequency or first harmonic). The second harmonic has a frequency of
twice the fundamental frequency. Harmonics are generated due to tissues distorting the
transmitted pulse, usually at the center of the image (midfield) rather than at superficial or
deep locations. Structures that cause imaging artifacts also tend to produce less or no
harmonics. Tissue Harmonic Imaging (THI) is a technique in which structures that produce
harmonics are selectively displayed, reducing imaging artifacts. This results in reduced noise
and improved spatial and contrast resolution (Fig. 1-11). THI is most suitable for assessment
of midfield structures.

18
FIGURE 1-11 Effect of Tissue Harmonic Imaging (THI) during ultrasound imaging of the
infraclavicular fossa. Note the improved spatial and contrast resolution on the right.

Compound Imaging
Ultrasound images depend on reflection of the ultrasound beam from tissue interfaces back to
the transducer. Not all tissues are good reflectors, and certain structures cause scattering of
the ultrasound beam resulting in scattered signals radiating in all directions. As a result only a
small amount of energy is reflected back to the transducer. The scattering of the ultrasound
beam results in noise, which makes the ultrasound image appear grainy. In compound
imaging, the same structure is imaged from several different angles using computed beam
steering. The returning echoes are then processed producing a composite image that has
reduced noise and improved definition (Fig. 1-12). The disadvantage of compound imaging is
increased blurring of the image with movement.

FIGURE 1-12 Effect of Compound Imaging during ultrasound imaging of the axilla. Note
the reduction in noise and the improved definition of the image on the right.

19
Panoramic Imaging
Conventional 2-D ultrasound has a limited FOV and allows visualization of only a small
portion of any large structure. Panoramic imaging, as the name implies, is a technique used to
extend the FOV so that larger structures can be visualized in their entirety. During a
panoramic scan, the operator slowly slides the transducer across a region of interest. Image
information obtained during this motion is accumulated and then combined to form the
composite panoramic image (Fig. 1-13). Although useful for annotation, documentation,
teaching, and research, it is rarely used during USGRA at present.

FIGURE 1-13 Panoramic transverse sonogram of the midforearm. FDS, flexor digitorum
superficialis; FDP, flexor digitorum profundus; FPL, flexor pollicis longus; FCU, flexor carpi
ulnaris.

Three-Dimensional Ultrasound
Three-dimensional ultrasound acquires data as a volume and allows reconstruction at any
imaging plane without needing to move the transducer (Figs. 1-14 and 1-15). This can
improve spatial awareness at the region of interest, visualization of the block needle, and
distribution of the local anesthetic. Potential advantages include reduced needle-associated
complications and increased block success with smaller volumes of local anesthetic. In
addition, the volume data can be stored and retrospectively analyzed for teaching or research.
The main challenges with 3-D ultrasound at present include lack of availability of ergonomic
probes that can operate at high frequencies to assess superficial structures, slow screen
refresh rates, and reduced temporal resolution when performing real-time interventions.

20
FIGURE 1-14 A multiplanar 3-D ultrasound image of the sciatic nerve at the midthigh
with the reference marker (green crosshair) placed over the sciatic nerve.

FIGURE 1-15 A rendered 3-D ultrasound image of the sciatic nerve at the midthigh. The
front and right surfaces of the 3-D volume are displayed. Note the hypoechoic perineural
space posterior to the sciatic nerve in this image.

21
Artifacts
An ultrasound artifact is information that is visible in the ultrasound image that does not
correlate with any anatomical structure. The ultrasound machine makes several assumptions
when generating an image:

1.The ultrasound beam travels in a straight line with a constant rate of attenuation.
2.The speed of sound through body tissue is 1540 meters/second.
3.The ultrasound beam is infinitely thin with all echoes originating from its central axis.
4.The depth of a reflector is directly related to the round-trip time of the ultrasound signal.

Artifacts arise when there is deviation from these assumptions. Some artifacts are
undesirable and interfere with interpretation, whereas others help identify certain structures.
It is essential to recognize them in order to avoid misinterpretation. Therefore, whenever a
structure appears abnormal on ultrasound, it must be examined at different angles and
orientations to avoid making a wrong interpretation. Real anatomical structures are visible in
all planes of imaging, whereas artifacts are generally only visible in one plane.
Artifacts that are frequently encountered during USGRA include:

1.Contact artifact
This is the most common artifact that occurs whenever there is a loss of acoustic coupling
between the skin and the transducer. This could simply occur because the transducer is
not touching the skin, but more frequently it is due to air bubbles that are trapped between
the skin and the transducer. Therefore, it is prudent to apply liberal amounts of ultrasound
gel to exclude air from the skin–transducer interface.
2.Reverberation artifact
Reverberation artifacts, also known as “repetitive echoes,” occur whenever there is
repeated reflection of the ultrasound beam between two highly reflective surfaces. Some
of the ultrasound signals returning to the transducer are reflected back, which then strike
the original interface and are reflected back towards the transducer a second time. As a
result the first reverberation artifact is twice as far from the skin surface as the original
interface. One may also see a second or third reverberation artifact (Fig. 1-16). Due to
attenuation, the intensity of the artifacts decreases with increasing distance from the
transducer. Reverberation artifacts are frequently seen during ultrasound-guided axillary
brachial plexus blocks, particularly when the needle is viewed in its long axis (Fig. 1-17).
They are reduced if the needle is less perpendicular to the transducer, but this may also
reduce needle visibility.

22
FIGURE 1-16 Schematic diagram illustrating how a reverberation artifact is produced.

FIGURE 1-17 Reverberation artifact induced by the block needle during an ultrasound-
guided axillary brachial plexus block. AA, axillary artery; MCN, musculocutaneous nerve.

3.Mirror image artifact

Mirror image artifact is a type of reverberation artifact that occurs at highly reflective
interfaces. The first image is displayed in the correct position, and a false image is
produced on the other side of the reflector due to its mirrorlike effect (Fig. 1-18).

23
FIGURE 1-18 Mirror image artifact of the subclavian artery.

4.Propagation speed artifact

These artifacts occur when the media through which the ultrasound beam passes does not
propagate at 1540 meters/second, resulting in echoes that appear at incorrect depths on the
monitor. An example of propagation speed artifact is the “bayonet artifact,” which has
been reported during an ultrasound-guided axillary brachial plexus block. The shaft of the
needle appeared bent when it accidentally traversed the axillary artery. We have observed
the same phenomenon after local anesthetic injection during a popliteal sciatic nerve
block (Fig. 1-19). This happens because of the difference in the velocity of sound between
whole blood (1580 meters/second), or the injected local anesthetic, and soft tissue (1540
meters/second).

24
FIGURE 1-19 Bayonet artifact induced by the local anesthetic injection during an
ultrasound guided popliteal sciatic nerve block. Note the shaft of the needle appears bent
close to the area occupied by the local anesthetic.

5.Acoustic shadowing
An acoustic shadow is a hypoechoic or anechoic region deep to surfaces that are highly
reflective or attenuating such as bone (Fig. 1-10) or metallic implants. The implication for
regional anesthesia is that tissues in the region of the shadow cannot be visualized. One
benefit of this artifact is that the acoustic shadow of the block needle helps in identifying
its location.
6.Acoustic enhancement
Acoustic enhancement results when the ultrasound beam passes through a low-attenuating
structure resulting in brighter echoes from the deeper tissues. It is commonly seen deep to
fluid-filled structures such as blood vessels. The increased brightness may saturate the
display and make it difficult to identify nerves posterior to large blood vessels. A common
example is when one visualizes the posterior cord of the brachial plexus at the
paracoracoid (lateral infraclavicular fossa) location. The bright echoes posterior to the
axillary artery (second part) and deep to the pectoralis major and minor muscles may be
confused as the posterior cord (Fig. 1-20).

FIGURE 1-20 Acoustic enhancement seen posterior to the axillary artery and vein during
an ultrasound guided infraclavicular brachial plexus block. The bright echoes posterior the
axillary artery may be confused as the posterior cord.

Imaging the Challenging Patient

The Elderly Patient
Muscle fibers become hyperechoic with age (Fig. 1-21) due to muscle atrophy and infiltration
by fat and connective tissue. The hyperechoic muscle is more likely to reflect the ultrasound
beam and reduce penetration of deeper structures. Reduced contrast resolution between the

25
echogenic muscle and an adjacent echogenic nerve decreases accurate delineation of the
peripheral nerve. These factors make USGRA in the elderly challenging. Strategies that can
help depict the peripheral nerve in the elderly include THI to improve resolution, compound
imaging to reduce noise, and increasing the dynamic range to improve contrast resolution.

FIGURE 1-21 Effect of age on the echogenicity of musculoskeletal structures. Note the
increase in echogenicity and the loss of contrast between the nerve and the muscle in the
elderly. BM, biceps muscle, RA, radial artery.

The Obese Patient

Excess adipose tissue hinders ultrasound imaging by attenuating the transmitted ultrasound
beam, increasing scatter, and increasing the overall depth to the region of interest. The main
strategies likely to improve image quality include using a low-frequency transducer to
increase penetration, maximizing the power output to boost the signal-to-noise ratio,
decreasing the dynamic range to produce high-contrast images, narrowing the sector width to
improve resolution, and using physical compression to reduce the depth to the region of
interest. Compound imaging, THI, and a speckle reduction filter can also be useful.
Brightness color (B-color or color B-mode imaging) can also be used in imaging the obese
patient. B-color is based on the principle that the human eye can only appreciate a limited
number of shades of gray, but is able to distinguish a greater number of color hues. Subtle
differences in musculoskeletal imaging can be enhanced by using a color-scale display.

Doppler Ultrasound: The Basics

Doppler ultrasound essentially measures a moving object. When ultrasound waves hit a

26
stationary object, the reflected ultrasound has the same frequency as the transmitted
ultrasound. If the object is moving towards the transducer (source of the ultrasound), the
reflected frequency will be higher than the transmitted frequency. If the object is moving
away from the transducer, the reflected frequency will be lower than the transmitted
frequency. This change in frequency of the reflected ultrasound is a result of the Doppler
effect (Fig. 1-22):

FIGURE 1-22 Doppler equation. ∆F – change in frequency (Doppler shift), FR – received

frequency, FT – transmitted frequency, v – velocity of object towards the transducer, θ –
angle between the incident ultrasound beam and the direction of the moving object (Doppler
angle) and C – velocity of sound in the medium (1540 m/s in human tissue).

ΔF = FR − FT = (2FT vcosθ)/C
From this equation, the following points can be made:

1.Doppler shift is dependent on the velocity of the moving object. In addition, information
can be obtained on the direction of the moving object. If the object is moving towards the
transducer, the change in frequency is greater than zero. If the object is moving away
from the transducer, the change in frequency is less than zero.
2.Doppler shift is also dependent on the ultrasound-transmitted frequency. Higher transmitted
ultrasound frequencies produce larger Doppler shifts and better sensitivity to moving
objects, but also result in higher tissue attenuation. Lower transmitted ultrasound
frequencies have better penetration of tissue. Sensitivity and penetration have to be
balanced when choosing the ultrasound-transmitted frequency.
3.Maximum Doppler shift is obtained when the Doppler angle is 0 degrees, and no Doppler
shift is obtained when the Doppler angle is 90 degrees (remember that cos 0 = 1 and cos
90 = 0; Fig. 1-23). Optimal imaging is obtained when the transducer is as parallel as
possible to the direction of the moving object. When the Doppler angle is above 60
degrees, small changes in the Doppler angle result in large changes in cos θ, and
therefore, proportionately larger errors.

27
FIGURE 1-23 Doppler ultrasound image of an artery. A. Poor signal is shown in the
center (white arrows) because flow in that part of the vessel is near 90 degrees to the
ultrasound beam and little Doppler shift is observed. B. Flow is clearly seen when the vessel
is significantly less than 90 degrees to the ultrasound beam.

In contrast, with a conventional gray-scale display, the best images are obtained when the
structures are imaged perpendicular to the ultrasound beam.

Doppler Display
The Doppler shift can be presented as a Color Doppler or a Spectral Doppler image.

Color Doppler
Color Doppler displays different colors (usually red and blue), depending on flow direction,
and uses the degree of color saturation to indicate the amount of Doppler shift (Figs. 1-24 and
1-25). Its limitation compared to Spectral Doppler is that it is a qualitative assessment.

28
FIGURE 1-24 Color Doppler image. In this example, red indicates flow towards the
transducer (or probe) and blue indicates flow away from the transducer. Each color pixel
represents the mean Doppler shift at that point.

FIGURE 1-25 Color Doppler bar and image. In this example, blue indicates flow towards
the transducer and red indicates flow away from the transducer. Deep shades represent low
velocities and light shades represent high velocities. Velocity scale indicators are present at
each end of the color bar.

Power Doppler
Power Doppler is an alternative means of displaying a color map by assessing the number of
moving blood cells (power) rather than mean Doppler shift. It does not measure velocity or
direction and therefore is less dependent on the Doppler angle than Color Doppler. It also

29
does not suffer from aliasing and has less visible noise. This results in increased sensitivity
for detecting flow at the expense of velocity and direction information (Fig. 1-26). Power
Doppler is extremely sensitive to movement, which can cause flash artifacts.

FIGURE 1-26 Power Doppler image of an artery. No direction information is available.

Spectral Doppler
Spectral Doppler presents the Doppler shift data in graphic form as a plot of the frequency
spectrum over time (Fig. 1-27). It displays the peak and range of velocities at a single
location along the ultrasound beam. Specific measurements are made on the Spectral Doppler
display to obtain information related to flow resistance.

FIGURE 1-27 Spectral Doppler image of the external iliac vein. The venous waveform
changes with respiration.

Other Technical Considerations

Aliasing
Doppler data (Pulsed-Wave Doppler) is reconstructed from regularly timed transmitted and
received ultrasound pulses equivalent to the pulse repetition frequency (PRF) of the Doppler
machine. A low PRF is required when assessing deep vessels in order to allow enough time
for the transmitted ultrasound pulse to arrive back before transmitting a new pulse. If the PRF
is less than twice the maximum Doppler shift of the moving object (Nyquist limit), aliasing
results (Figs. 1-28 and 1-29).

30
FIGURE 1-28 A. Spectral Doppler display of an artery demonstrating aliasing –
“wraparound” of the higher velocities to display below the baseline. B. Aliasing can be
reduced in this example by moving the baseline downwards (increasing the velocity scale
above baseline).

FIGURE 1-29 Color Doppler display of an artery demonstrating aliasing (white arrow) –
wraparound of the color map from one flow direction to the opposite direction. Aliasing is
only seen in one portion due to higher velocities in that region.

Aliasing can be reduced by increasing the PRF (increasing the velocity scale) or by
reducing the Doppler shift (increasing the Doppler angle or using a lower-frequency
transducer).

Spectral Broadening
Spectral broadening indicates a large range of flow velocities at a particular location and is
one of the criteria used for diagnosing high-grade vessel stenosis. Artifactual spectral
broadening can also be produced by using an excessively large sample volume, by placing

31
the sample volume too near the vessel wall, or by excessive system gain (Fig. 1-30).

FIGURE 1-30 A. Spectral broadening of an arterial waveform due to placing the sample
volume too near the vessel wall. B. Normal waveform for comparison.

Doppler Gain
Optimal gain settings should be obtained for accurate Doppler assessment (Fig. 1-31). Too
low of a gain can result in underestimation of the peak velocity. Too high of a gain results in
artifactual spectral broadening and can result in overestimation of the peak velocity.

FIGURE 1-31 Spectral Doppler gain. A. Undergain. B. Optimal gain. C. Overgain.

Basic Steps for Doppler Imaging

1.Optimize the gray-scale image with the focal zone at the intended blood vessel.
2.Activate the Color Doppler.

32
 3.Position the color box over the vessel (keep the box size as small as reasonably possible).
4.Steer the color box to align with blood flow.
5.Choose the appropriate velocity scale.
6.Optimize the Color Doppler gain.
7.Place the Pulsed-Wave Doppler cursor within the vessel lumen, and adjust the sample
volume as required (try to avoid the vessel walls).
8.Align the angle-correction cursor with the blood flow. If the Doppler angle is more than
60 degrees, reposition the transducer to obtain a smaller Doppler angle.
9.Activate the Pulsed-Wave Doppler for the Spectral Doppler display.
10.Optimize the Spectral Doppler velocity scale, baseline, and gain.

Suggested Reading
1.Hedrik WR, Hykes DL, Starchman DE, eds. Ultrasound Physics and Intrumentation. 4th
ed. Philadelphia, PA: Elsevier Mosby; 2005.
2.Rumack CM, Wilson SR, Charboneau JW, Levine D, eds. Diagnostic Ultrasound. 4th ed.
Philadelphia, PA: Elsevier Mosby; 2011.
3.Allan P, Dubbins PA, McDicken WN, Pozniak MA, eds. Clinical Doppler Ultrasound.
2nd ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2006.
4.Sites BD, Brull R, Chan VW, et al. Artifacts and pitfall errors associated with ultrasound-
guided regional anesthesia. Part I: understanding the basic principles of ultrasound
physics and machine operations. Reg Anesth Pain Med. 2007;32:412–418.
5.Sites BD, Brull R, Chan VW, et al. Artifacts and pitfall errors associated with ultrasound-
guided regional anesthesia. Part II: a pictorial approach to understanding and avoidance.
Reg Anesth Pain Med. 2007;32:419–433.
6.Schafhalter-Zoppoth I, McCulloch CE, Gray AT. Ultrasound visibility of needles used for
regional nerve block: an in vitro study. Reg Anesth Pain Med. 2004;29(5):480–488.
7.Tsui BC, Kropelin B, Ganapathy S, Finucane B. Dextrose 5% in water: fluid medium for
maintaining electrical stimulation of peripheral nerves during stimulating catheter
placement. Acta Anaesthesiol Scand. 2005 November;49(10):1562–1565.
8.Moayeri N, Bigeleisen PE, Groen GJ. Quantitative architecture of the brachial plexus and
surrounding compartments, and their possible significance for plexus blocks.
Anesthesiology. 2008;108(2):299–304.
9.Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the
critically ill. Lung sliding. Chest. 1995;108(5):1345–1348.
10.Karmakar M, Li X, Li J, Sala-Blanch X, Hadzic A, Gin T. Three-dimensional/four-
dimensional volumetric ultrasound imaging of the sciatic nerve. Reg Anesth Pain Med.
2012 January-February;37(1):60–66.
11.Karmakar MK, Li X, Li J, Hadzic A. Volumetric 3D ultrasound imaging of the anatomy
relevant for thoracic paravertebral block. Anesth Analg. 2012;115(5):1246–1250.
12.Foxall GL, Hardman JG, Bedforth NM. Three-dimensional, multiplanar, ultrasound-
guided, radial nerve block. Reg Anesth Pain Med. 2007;32(6):516–521.
13.Li X, Karmakar MK, Lee A, Kwok WH, Critchley LAH, Gin T. Quantitative evaluation of
the echo-intensity of the median nerve and flexor muscles of the forearm in the young
and the elderly. Br J Radiol. 2012;85:e140–e145.
14.Sofka CM, Lin D, Adler RS. Advantages of color B-mode imaging with contrast
optimization in sonography of low-contrast musculoskeletal lesions and structures in the
foot and ankle. J Ultrasound Med. 2005;24:215–218.

33
34
CHAPTER 2

Sonoanatomy Relevant for Ultrasound-Guided Upper

Extremity Nerve Blocks

Introduction
The neural innervations of the upper extremity provide unique opportunities for a wide
selection of neural blockade options that can be tailored to the desired outcome needed for
anesthesia or analgesia of the extremity.

Gross Anatomy
The brachial plexus traverses the posterior triangle of the neck and the axilla. It provides
complete innervation to the upper extremity. Proximally, the brachial plexus originates from
the ventral primary rami of the cervical spinal nerves (C5–T1) (Figs. 2-1 and 2-2) and
extends from the cervical spinal roots in the neck to its terminal nerves in the axilla (Fig. 2-
3). The C5 and C6 rami unite to form the superior trunk, the C7 rami forms the middle trunk,
and the C8 and T1 rami unite to form the inferior trunk (Fig. 2-4). The trunks of the brachial
plexus are located in the interscalene groove between the scalenus anterior and the scalenus
medius muscles, at the level of the cricoid cartilage (approximate C6 vertebral body level)
and deep to the sternocleidomastoid muscle (Fig. 2-5). The anterior tubercle of the C6
vertebra is the most prominent of all the vertebrae (Chassaignac’s tubercle), and the C7
transverse process lacks the anterior tubercle. This feature can be used to sonographically
identify the C7 nerve root. At the root level, the plexus gives off the dorsal scapular nerve
and the long thoracic nerve (Fig. 2-4).

35
FIGURE 2-1 Anatomical illustration showing the formation of the brachial plexus. The
roots, trunks, and divisions of the brachial plexus have been represented using different
colors to illustrate the formation of the cords and the terminal branches of the plexus.

FIGURE 2-2 A magnetic resonance neurography (MRN) image of the brachial plexus
showing the formation of the brachial plexus in a healthy young volunteer.

36
FIGURE 2-3 Brachial plexus. Note the formation of the plexus and the relation of the
nerve roots to the transverse process of the cervical vertebra.

37
FIGURE 2-4 The brachial plexus and relation of its components to the subclavian and
axillary artery.

38
FIGURE 2-5 Brachial plexus and its relation to the scalene muscles. Note how the brachial
plexus is sandwiched between the anterior and middle scalene muscles.

At the supraclavicular fossa, the trunks of the brachial plexus are superficial and divide
into their anterior and posterior divisions and reunite as the cords distal to the clavicle. The
trunks and divisions lie above the first rib between the scalenus anterior and scalenus medius
muscles (Fig. 2-6). The subclavian artery crosses over the top of the first rib at this point as it
exits the thoracic inlet and travels in the fascial plane between the scalenus anterior and the
scalenus medius and is anteromedial to the trunks and divisions of the brachial plexus at this
level (Fig. 2-6). The subclavian vein crosses the first rib lying anteriorly to the insertion of
the scalenus anterior (Fig. 2-7). The pleura lies immediately deep to the first rib. At the trunk
level, the plexus gives off the nerve to the subclavius and suprascapular nerve.

39
FIGURE 2-6 Anatomy of the brachial plexus at the interscalene groove and
supraclavicular fossa. Note the relation of the suprascapular and transverse cervical artery to
the brachial plexus. SA, subclavian artery; SV, subclavian vein; IJV, internal jugular vein.

FIGURE 2-7 Brachial plexus at the supraclavicular fossa. Note the relation of the trunks of
the brachial plexus to the first rib, subclavian artery, and the scalene muscles. The trunks and
divisions of the brachial plexus are located posterolateral to the subclavian artery. SA,
subclavian artery; SV, subclavian vein.

Lateral to the first rib the six divisions of the brachial plexus regroup to form the three
cords of the brachial plexus. The posterior cord is formed from the three posterior divisions
(C5–C8 and T1), the lateral cord from the anterior division of the upper and middle trunk
(C5–C7), and the medial cord is a continuation of the anterior division of the lower trunk (C8
and T1). The cords then enters the “costoclavicular space” (CCS, Fig. 2-8), which is located
deep and posterior to the middle-third of the clavicle.1,2 Within the CCS the cords are

40
clustered together lateral to the axillary artery and between the clavicular head of the
pectoralis major muscle and the subclavius muscle anteriorly, and the serratus muscle
overlying the second rib posteriorly (Figs. 2-8 and 2-9).1,2 The topography of the cords
relative to the axillary artery and to one another is consistent at the CCS (Figs. 2-9 to 2-11).
The lateral cord is the most superficial of the three cords and always lies anterior to both the
medial and posterior cords (Figs. 2-9 to 2-11).3 The medial cord is directly posterior to the
lateral cord but medial to the posterior cord (Fig. 2-9 to 2-11).3 The posterior cord is the most
lateral of the three cords at the CCS, and it is immediately lateral to the medial cord but
posterolateral to the lateral cord (Figs. 2-9 to 2-11).3 The cords then descend to the lateral
infraclavicular fossa, deep to the pectoralis minor muscle, where they occupy their respective
position relative to the second part of the axillary artery (Fig. 2-12). The posterior cord is
located posterior to the artery, the lateral cord lies in the superolateral aspect of the artery,
and the medial cord lies in the inferomedial aspect of the artery.4 Position of the cords at the
lateral infraclavicular fossa is variable4 and affected by the position (abduction) of the arm.5
The lateral cord gives off the lateral pectoral nerve, musculocutaneous nerve and lateral root
of median nerve; the posterior cord gives off the upper and lower subscapular nerves, the
thoracodorsal nerve, radial nerve, and axillary nerve; the medial cord gives off the medial
pectoral nerve, the medial cutaneous nerve of the arm, medial cutaneous nerve of the
forearm, ulnar nerve, and medial root of the median nerve.

FIGURE 2-8 Sagittal anatomic section through the midpoint of the clavicle showing the
costoclavicular space between the pectoral head of the pectoralis major and subclavius
muscle anteriorly and the upper slips of the serratus anterior muscle overlying the second rib
posteriorly. Note how the cords of the brachial plexus are clustered together and lie cranial to
the first part of the axillary artery. AA, axillary artery; AV, axillary vein.

41
FIGURE 2-9 Transverse anatomic section through the right costoclavicular space showing
the anatomic arrangement and relations of the cords of the brachial plexus. The anatomy is
presented as though one were looking at it from caudal to cranial (caudocranial view). Note
how the cords of the brachial plexus are clustered together lateral to the axillary artery.

FIGURE 2-10 Histological section from the right costoclavicular space, stained with
hematoxylin and eosin, showing the anatomic arrangement and relations of the cords of the
brachial plexus (caudocranial view) to one another and to the axillary artery.

42
FIGURE 2-11 Illustration showing the anatomy of the costoclavicular space and the
anatomic relations of the cords to one another and to the axillary artery.

FIGURE 2-12 Anatomy of the brachial plexus at the infraclavicular fossa (paracoracoid
location, ie, lateral infraclavicular fossa). Note the relation of the cords of the brachial plexus
to the second part of the axillary artery.

The main terminal branches of the brachial plexus—median, radial, ulnar, and
musculocutaneous nerve—leave the axilla with the axillary artery (Fig. 2-13) and continue
their course into the arm (Fig. 2-14). At the anterior axillary fold, the musculocutaneous
nerve leaves the brachial plexus and travels between the biceps brachii and the
coracobrachialis in the proximal arm and subsequently between the biceps brachii and the
brachialis in the midarm. Just before the cubital fossa, it emerges on the lateral border of the
biceps tendon and pierces the deep fascia to become superficial and continue its course down
the lateral aspect of the forearm as the lateral cutaneous nerve of the forearm.

43
FIGURE 2-13 Anatomy of the axilla at the level of the anterior axillary fold (ie, where the
pectoralis major muscle joins the biceps muscle). Note the relation of the median, ulnar, and
radial nerve to the axillary artery and how the musculocutaneous nerve (MCN) is embedded
within the substance of the coracobrachialis muscle. AA, axillary artery; AV, axillary vein.

FIGURE 2-14 Anatomical illustration showing the terminal branches of the brachial
plexus as they course through the arm and upper forearm.

Brachial Plexus: Interscalene Groove

Gross Anatomy

44
In the posterior triangle, the roots and trunks of the brachial plexus lie between scalenus
anterior and medius muscles (Figs. 2-15 and 2-16). As the cervical nerve root (C3–C6) exits
from the intervertebral foramen, it travels between the anterior and posterior tubercle of the
corresponding cervical vertebra (Figs. 2-17 and 2-18). This unique feature can be easily
demonstrated using ultrasound. Deep to the cervical nerve root, the vertebral artery travels in
the foramen transversarium (Fig. 2-17) of the C6 to C1 vertebrae and ascends cranially.

FIGURE 2-15 Coronal anatomical section showing the roots, trunks, divisions, and cords
of the brachial plexus. SCM, sternocleidomastoid muscle; VA, vertebral artery; SA,
subclavian artery.

FIGURE 2-16 Transverse anatomical section of the neck showing the brachial plexus
sandwiched between the scalenus anterior and scalenus medius muscles in the interscalene
groove. SCM, sternocleidomastoid muscle; IJV, internal jugular vein; CA, carotid artery.

45
FIGURE 2-17 Transverse anatomical section of the neck through the C6 vertebral body
showing the anterior and posterior tubercle of the C6 transverse process. Note how the C6
nerve root exits the intervertebral foramen and the location of the vertebral artery in the
foramen transversarium.

FIGURE 2-18 Transverse anatomical section of the neck through the C7 vertebral body
showing the C7 transverse process with only one (posterior) tubercle. The anterior tubercle is
missing.

Computed Tomography Anatomy of the Neck and Interscalene Region

Figs. 2-19 and 2-20

46
FIGURE 2-19 CT image of the cervical region at the level of C6. Note the C6 nerve root
as it exits the intervertebral foramen and lies between the anterior and posterior tubercle of
the C6 transverse process before it enters the interscalene groove. Also note the vertebral
artery in the foramen transversarium of C6 vertebra. SCM, sternocleidomastoid muscle; IJV,
internal jugular vein; NR, nerve root; VB, vertebral body; VA, vertebral artery.

FIGURE 2-20 CT image of the cervical region at the level of C7. Note the vertebral artery
in close proximity to the C7 nerve root before it enters the foramen transversarium of C6.
VA, vertebral artery; NR, nerve root; ScA, scalenus anterior; ScM, scalenus medius; ISG,
interscalene groove; TP, transverse process; SCM, sternocleidomastoid; IJV, internal jugular
vein.

Magnetic Resonance Imaging Anatomy of the Neck and Interscalene Region

47
Figs. 2-21 and 2-22

FIGURE 2-21 MRI image of the neck at the level of C6 vertebra. Note the C6 nerve root
(NR) between the anterior and posterior tubercle of the C6 transverse process and the C5
nerve root in the interscalene groove between the scalenus anterior (ScA) and scalenus
medius (ScM) muscle. The vertebral artery (VA) is seen in the foramen transversarium of the
C6 transverse process. VB, vertebral body; CA, carotid artery; SCM, sternocleidomastoid;
IJV, internal jugular vein.

FIGURE 2-22 MRI image of the neck at the level of C7 vertebra. Note the vertebral artery
in close proximity of the C7 nerve root before it enters the foramen transversarium of C6
vertebra. The nerve roots (C6 and C7) of the brachial plexus are seen in the interscalene
groove (ISG) between the scalenus anterior (ScA) and the scalenus medius (ScM) muscle.
VA, vertebral artery; NR, nerve root; SCM, sternocleidomastoid; IJV, internal jugular vein;

48
CE, cervical esophagus; CA, carotid artery; TP, transverse process.

Technique of Ultrasound Imaging of the Brachial Plexus at the Interscalene

Groove
1.Position:
a.Patient: Supine or semisitting position with head turned to the contralateral side (Fig.
2-23). The head rests on a low pillow with the arm adducted by the side.

FIGURE 2-23 Figure showing the position of the patient and the ultrasound transducer
during a transverse scan of the neck at the level of the interscalene groove. Note how the
ultrasound transducer is tilted (oblique) slightly caudally towards the supraclavicular fossa.

a.Patient: Supine or semisitting position with head turned to the contralateral side (Fig.
2-23). The head rests on a low pillow with the arm adducted by the side.
b.Operator and ultrasound machine: Operator is positioned at the head end of the
patient. The ultrasound machine is placed ipsilateral to the side examined and directly
in front. The position of the operator and ultrasound machine can be easily reversed
for convenience or, for example, to allow a right-handed operator to perform an
ultrasound-guided interscalene brachial plexus block on the left side using his or her
right hand.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: As part of a scan routine, it is advisable to start the ultrasound scan of the
neck by placing the transducer in the midline (Fig. 2-24) at the level of the cricoid
cartilage (C6). Place the transducer in a transverse orientation to image the cricoid
cartilage (Fig. 2-25) or trachea (Fig. 2-26) in cross-section. Slide the transducer laterally
to the side of interest, and identify the sternocleidomastoid muscle, trachea, thyroid,
carotid artery, and internal jugular vein. Continue to manipulate the transducer laterally in
the transverse plane to the lateral edge of the sternocleidomastoid muscle. The scalenus
anterior and scalenus medius with the interscalene groove are located deep to the lateral
edge of the sternocleidomastoid muscle (Figs. 2-27 and 2-28). Alternatively one can
perform a transverse scan of the subclavian artery at the supraclavicular fossa (see later).
The trunks and divisions of the brachial plexus are seen as a cluster of hypoechoic and

49
 rounded nodules on the posterolateral aspect of the subclavian artery, like a “bunch of
grapes,” and between the scalenus anterior and scalenus medius muscles. Now slowly
slide the transducer cephalad with a sweeping action when the roots and/or trunks of the
brachial plexus are clearly delineated in the interscalene groove.

FIGURE 2-24 Figure showing the position of the patient and the ultrasound transducer
during a transverse scan of the neck in the midline at the level of the cricoid cartilage.

FIGURE 2-25 Transverse sonogram of the neck at the level of the cricoid cartilage (CC).
The CC is seen as an “inverted-U” or arched shaped structure. The inner surface of the
anterior wall of the CC is lined by the bright air-mucosal interface (AMI), and the two lobes
of the thyroid gland are seen as uniformly hyperechoic structures lateral to the CC. The
posterior wall of the CC is obscured by an air column and reverberation artifacts, but one can
identify the cricothyroid junction (CTJ) as a hypoechoic gap in the posterolateral wall of the
CC. SM, strap muscles; CA, carotid artery.

50
FIGURE 2-26 Transverse sonogram of the neck at the level of the upper trachea. The
trachea appears hypoechoic, is “U-shaped,” and is outlined by the bright A-M interface
anteriorly. However, unlike at the level of the cricoid cartilage the thyroid isthmus is seen
anterior to the trachea, and the cervical esophagus may also be identified posterolateral and to
the left of the trachea. SCM, sternocleidomastoid muscle; IJV, internal jugular vein; CA,
carotid artery.

FIGURE 2-27 Anatomical section of the neck showing the brachial plexus sandwiched
between the scalenus anterior and scalenus medius muscles in the interscalene groove. IJV,
internal jugular vein; CA, carotid artery.

51
FIGURE 2-28 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan at the level of the interscalene groove.

4.Sonoanatomy: At the interscalene groove, the trunks of the brachial plexus are located
between the scalenus anterior and the scalenus medius muscles (Fig. 2-29). They appear
round to oval in shape, are hypoechoic in appearance, and may have a hyperechoic rim
(Fig. 2-30).6 The carotid artery and internal jugular vein are visualized medially, and the
vertebral artery can also be seen adjacent to the C7 transverse process deep to the
interscalene groove (Fig. 2-29).

FIGURE 2-29 Transverse sonogram of the neck showing the interscalene groove with the
brachial plexus (roots and trunks) between the scalenus anterior and scalenus medius muscle.
VA, vertebral artery; IJV, internal jugular vein. Note that the phrenic nerve is visible on the

52
anterior surface of scalenus anterior muscle.

FIGURE 2-30 Zoomed (coned) view of the interscalene groove showing the hypoechoic
roots and trunks of the brachial plexus sandwiched between the scalenus anterior and
scalenus medius muscles. Also note the hypoechoic phrenic nerve on the anterior surface of
the scalenus anterior.

5.Clinical Pearls: The trunks of the brachial plexus are best visualized within the
interscalene groove just below the level of the cricoid cartilage. They appear as three
hypoechoic round-to-oval shaped structures, which produce a sonographic pattern
resembling “traffic signal lights.” If one traces these neural elements medially and
proximally to their intervertebral foramen, each of the cervical nerve roots can be
identified as they lie anterior to the corresponding transverse processes. The roots of the
brachial plexus are best visualized at the C6 (Fig. 2-31) or C7 (Fig. 2-32) vertebral level.
The C6 transverse process is distinctive, as it is the first cervical vertebra counting from
below, which has two tubercles (anterior and posterior, Fig. 2-31) on the transverse
process. C3 to C6 cervical vertebrae have both the anterior and posterior tubercle on the
transverse process. The C7 transverse process has only one tubercle (the anterior tubercle
is rudimentary or absent), and this is typically posterior to the nerve root (Fig. 2-32). As a
result of the two tubercles, the transverse processes of the lower cervical vertebrae (C3–
C6) produce a “U” shaped or “fish mouth” pattern on the sonogram (Fig. 2-31). The
resultant sonographic pattern has also been referred to as the “two-humped camel” sign.7
The corresponding nerve roots can be visualized, coursing within the groove formed by
the anterior and posterior tubercle just before they enter the neural foramen, by sliding the
transducer proximally and distally. During the sliding maneuver, the vertebral artery can
be visualized in the space between two adjacent transverse processes (intertransverse
space). This can be confirmed using Color or Power Doppler. The vertebral artery is best
visualized at the C7 vertebral level because of the absence of the anterior tubercle on the
transverse process (Fig. 2-32). Alternatively the vertebral artery can be visualized by
performing a sagittal scan at the level of transverse process through the intertransverse
space (Fig. 2-33). The phrenic nerve may be seen on the anterior surface of the scalenus

53
 anterior (Figs. 2-29 and 2-30) as a small hypoechoic structure, and its identity can be
confirmed by tracing the nerve proximally and distally along its course,8 also referred to
as the “trace back technique.”9 It is also common to visualize vascular structures at the
base of the posterior triangle of the neck. These may be the inferior thyroid artery,
vertebral artery, suprascapular artery (see later), or the transverse cervical artery (Fig. 2-
34). Verifying their course and origin allows one to confirm the identity of the artery. The
superficial cervical plexus may also be visualized as a small collection of hypoechoic
nerves deep to or lateral to the sternocleidomastoid muscle.

FIGURE 2-31 Transverse sonogram of the neck at the level of the C6 transverse process.
Note the anterior and posterior tubercles of the C6 transverse process and the roots of the
hypoechoic C5 and C6 nerve root. The outlines of the anterior and posterior tubercles of the
C6 transverse have been highlighted in the sonogram. Also note the location of the vertebral
artery (VA) relative to the transverse process. IJV, internal jugular vein; CA, carotid artery;
VA, vertebral artery; NR, nerve root.

54
FIGURE 2-32 Transverse sonogram of the neck at the level of the C7 transverse process.
Note the transverse process of C7 has only one tubercle (ie, the posterior tubercle). The
anterior tubercle is missing or very rudimentary. Also note the C6 and C7 nerve roots and the
location of the vertebral artery (VA) relative to the transverse process. The outlines of the
posterior tubercle of the C7 transverse have been highlighted in the sonogram. IJV, internal
jugular vein; CA, carotid artery; NR, nerve root.

FIGURE 2-33 Sagittal sonogram of the neck demonstrating the vertebral artery through
the space (intertransverse space) between the C4 and C5 transverse process (TP).

55
FIGURE 2-34 Transverse sonogram of the neck at the level of the interscalene groove (A,
without and B, with Color Doppler) showing the transverse cervical artery, which is a branch
of the thyrocervical trunk. It crosses the neck from a medial to lateral direction lying anterior
to the scalene muscles and in front or in between the divisions of the brachial plexus.

Assessment of Diaphragm Excursions

Ultrasound imaging is a safe, simple, and accurate method of evaluating diaphragmatic
function (excursion) in patients with diaphragmatic paresis or paralysis.10 In regional
anesthesia ultrasound imaging can be used to evaluate phrenic nerve involvement by
assessing diaphragmatic excursion after an interscalene brachial plexus block.11 A 5-2 MHz
curved array transducer is used, and a B-mode ultrasound scan is initially performed with the
patient in the supine position. A transverse scan of the subcostal region is performed with the
ultrasound transducer placed between the midclavicular and midaxillary line. The liver or
spleen (on the left side) provides the acoustic window for the ultrasound scan. For optimal
imaging the ultrasound transducer is also directed cranially, posteriorly, and medially to
image the posterior third of the diaphragm. Once an optimal B-mode image is obtained, the
M-mode function is activated, with the M-mode line passing through the diaphragm (Fig. 2-
35). Resting or forced diaphragmatic excursion after the “sniff test” (rapid nasal inspiration
with the mouth closed) can then be assessed.

56
FIGURE 2-35 Figure showing the use of M-mode ultrasound to evaluate diaphragmatic
excursion. Note the M-mode line passes through the right lobe of the liver, diaphragm, and
part of the lung posteriorly in the B-mode image. The M-mode trace (below) shows the
excursion of the liver, diaphragm (hyperechoic line), and lung toward the transducer along
this line with time.

Brachial Plexus: Supraclavicular Fossa

Gross Anatomy
At the supraclavicular fossa, the brachial plexus is relatively superficial and lies beneath the
subcutaneous tissue and the inferior belly of the omohyoid. The trunks and division of the
brachial plexus are seen as a cluster of nerves on the posterolateral aspect (Figs. 2-6, 2-7, 2-
15, and 2-36) of the subclavian artery (Figs. 2-4 to 2-7). The subclavian artery lies on top of
the first rib (Fig. 2-36), and the subclavian vein is anterior to the scalenus anterior muscle
(Figs. 2-6 and 2-7).

57
FIGURE 2-36 Coronal anatomical section through the supraclavicular fossa. Note the
relation of the components of the brachial plexus to the scalene muscles, subclavian artery,
and the first rib at the supraclavicular fossa. SCM, sternocleidomastoid muscle; IJV, internal
jugular vein; SA, subclavian artery.

Computed Tomography Anatomy of the Supraclavicular Fossa

Fig. 2-37

FIGURE 2-37 Sagittal CT image showing the subclavian artery on top of the first rib and
the close relation of the components of the brachial plexus to the first rib, lung, and scalene
muscles.

58
Magnetic Resonance Imaging Anatomy of the Supraclavicular Fossa
Fig. 2-38

FIGURE 2-38 Coronal MRI image showing the close relation of the components (trunks
and divisions) of the brachial plexus to the first rib, lung, subclavian artery, and the scalene
muscles.

Technique of Ultrasound Imaging of the Brachial Plexus at the Supraclavicular

Fossa
1.Position:
a.Patient: Supine position with head turned to the contralateral side. Position the head on
a low pillow with the arm adducted by the side. A small roll or jelly pad placed under
the shoulder may be helpful, as it increases the distance between the bed and the
transducer. This facilitates needle placement and manipulation during an in-plane
approach for supraclavicular brachial plexus block.
b.Operator and ultrasound machine: The operator sits or stands at the head end of the
patient. The ultrasound machine is placed ipsilateral to the side to be examined and
directly in front of the operator.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: The transducer is placed parallel to the clavicle in the supraclavicular
fossa (Fig. 2-39). The ultrasound beam is directed towards the first rib and thoracic inlet
(Fig. 2-40). The first reference structure to locate is the subclavian artery as it crosses the
first rib.

59
FIGURE 2-39 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan for the brachial plexus at the supraclavicular fossa.

FIGURE 2-40 Figure highlighting the anatomical structures that are insonated during an
ultrasound scan for the brachial plexus at the supraclavicular fossa. SCM,
sternocleidomastoid muscle; IJV, internal jugular vein; SA, subclavian artery.

4.Sonoanatomy: At the supraclavicular fossa the trunks and divisions of the brachial plexus
appear as a cluster of hypoechoic nodules,12 each with a hyperechoic rim (Fig. 2-41).
Collectively, they appear as a “bunch of grapes” on the posterolateral aspect of the
subclavian artery. Variations in this relationship have been described with the brachial
plexus located farther laterally in relation to the subclavian artery.13 The subclavian
artery is pulsatile, can be demonstrated using Color Doppler, and is seen on top of the
first rib. The first rib appears hyperechoic and is associated with an acoustic shadow (Fig.

60
 2-41). The pleura is hyperechoic, deep to or on either side of the first rib, and exhibits the
typical “lung sliding” sign.14

FIGURE 2-41 Transverse sonogram of the supraclavicular fossa. The trunks and divisions
of the brachial plexus are visualized like a “bunch of grapes” on the posterolateral aspect of
the subclavian artery. SA, subclavian artery; IJV, internal jugular vein.

5.Clinical Pearls: With the transducer placed as described earlier and the subclavian artery
visualized, optimization of the image to best visualize the brachial plexus is achieved with
the tilting maneuver. The subclavian vein can often be seen lying on top of the pleura
medially. It is also common to visualize one or more small arteries in this area. These are
the suprascapular artery (Fig. 2-42) and the transverse cervical artery (Figs. 2-6 and 2-
34).15

61
FIGURE 2-42 Doppler sonogram of the supraclavicular fossa demonstrating the
suprascapular artery as it courses through the trunks and divisions of the brachial plexus. SA,
subclavian artery; IJV, internal jugular vein.

Brachial Plexus: Infraclavicular Fossa

Gross Anatomy
The infraclavicular fossa can be divided into two main areas: (1) the medial infraclavicular
fossa (MICF), which extends from the lateral border of the first rib cranially to the superior
(medial) border of the pectoralis minor muscle inferiorly, and (2) the lateral infraclavicular
fossa (LICF), which lies deep to the pectoral muscles and in relation to the second part of the
axillary artery. At the MICF, the cords of the brachial plexus emerge from under the clavicle
and enter the CCS lying deep to the pectoralis major (clavicular head) and subclavius muscle
anteriorly and the upper slips of the serratus anterior muscles posteriorly (Figs. 2-8 and 2-9).
The cords of the plexus are clustered together lateral to the first part of the axillary artery
(Figs. 2-9 to 2-11).1–3 This anatomical arrangement of the cords at the CCS makes it a
suitable site for brachial plexus block (costoclavicular BPB).2 Very few BPB techniques have
been described at the medial infraclavicular fossa.16,17 This may be due to the close
proximity of the pleura to the plexus and the fear of inadvertent pleural or pulmonary
puncture. As the plexus descends laterally towards the axilla, the cords of the brachial plexus
are closely related to the second part of the axillary artery. They lie deep to the pectoralis
major and minor muscles and anterior to the subscapularis muscle (Fig. 2-43). At the
paracoracoid location or LICF, the cords of the brachial plexus have taken up their respective
position around the axillary artery (Figs. 2-43 and 2-44). Generally, the lateral cord is
superior, the posterior cord is posterior, and the medial cord is caudal to the axillary artery,
respectively (Figs. 2-12 and 2-43). The position of the individual cords of the plexus can vary
with the position of the arm (abduction or adduction).5 Also the pleura and lung are not part
of the posterior relation of the brachial plexus at the LICF (Fig. 2-44). Therefore it is a
popular site for infraclavicular BPB,18 as pleural puncture is thought to be unlikely.
However, inadvertent pleural puncture has been reported,19 which may be due to the block
needle being inserted more medially than intended19 when the pleura and lung are posterior
to the axillary artery and brachial plexus (Fig. 2-44). Pleural complications should be
avoidable with ultrasound guidance.

62
FIGURE 2-43 Sagittal anatomical section of the infraclavicular fossa from just medial and
inferior to the coracoid process (paracoracoid). AA, axillary artery.

FIGURE 2-44 Sagittal anatomical section of the infraclavicular fossa from between the
midpoint of the clavicle and the coracoid process (ie, between the medial infraclavicular fossa
and the paracoracoid location). Note that the pleura and lung are visualized posteriorly at this

63
location.

Computed Tomography Anatomy of the Infraclavicular Fossa

Figs. 2-45 to 2-48

FIGURE 2-45 Transverse CT image of the medial infraclavicular fossa showing the
relation of the cords of the brachial plexus to the axillary vessels and the cephalic vein.

FIGURE 2-46 Sagittal CT image of the medial infraclavicular fossa at the level of the
midpoint of the clavicle. Note the relationship of the pectoralis major and subclavius muscles
to the neurovascular bundle and how the cords of the brachial plexus are clustered on the
superior aspect of the axillary artery.

64
FIGURE 2-47 Sagittal CT image of the infraclavicular fossa from midway between the
midpoint of the clavicle and the coracoid process. AA, axillary artery; AV, axillary vein.

FIGURE 2-48 Sagittal CT image of the infraclavicular fossa from immediately medial to
the coracoid process (paracoracoid location). Note the relationship of the cords of the brachial
plexus to the second part of the axillary artery. AA, axillary artery; AV, axillary vein.

Magnetic Resonance Imaging Anatomy of the Infraclavicular Fossa

Figs. 2-49 to 2-52

65
FIGURE 2-49 Transverse (axial) MRI image of the medial infraclavicular fossa.

FIGURE 2-50 Sagittal MRI image of the brachial plexus at the medial infraclavicular
fossa. AA, axillary artery; AV, axillary vein.

66
FIGURE 2-51 Sagittal MRI image of the brachial plexus at the infraclavicular fossa
between the midpoint of the clavicle and the coracoid process. AA, axillary artery; AV,
axillary vein.

FIGURE 2-52 Sagittal MRI image of the brachial plexus at the lateral infraclavicular fossa

67
immediately medial and lateral to the coracoid process. AA, axillary artery; AV, axillary
vein.

Technique of Ultrasound Imaging of the Brachial Plexus at the Medial

Infraclavicular Fossa
1.Position:
a.Patient: Supine with the ipsilateral arm abducted (90 degrees) and the head turned
slightly to the contralateral side.
b.Operator and ultrasound machine: The operator is positioned at the head end of the
patient. The ultrasound machine is placed on the ipsilateral side to be examined and
directly in front.
2.Transducer selection: High-frequency linear array transducer (12-5 or 15-8 MHz).
3.Scan technique:
a.Transverse scan of the MICF: Transverse scan of the MICF is performed in five
sequential steps, over five contiguous sites (Fig. 2-53). This is done to better define
the anatomy of the CCS and the neighboring structures that are relevant for
infraclavicular BPB.

FIGURE 2-53 Illustration showing the positions of the ultrasound transducer during the
ultrasound scan sequence at the medial infraclavicular fossa (MICF). Note that positions 1 to
5 are over contiguous sites over the MICF and in the order in which the scan is performed.

Step 1: The transducer is positioned directly over the midpoint of the clavicle in the
transverse orientation (Fig. 2-54) with its orientation marker directed laterally (outwards).
The clavicle is visualized as a curved hyperechoic structure with an underlying acoustic
shadow (Fig. 2-55).

68
FIGURE 2-54 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan for the brachial plexus at the medial infraclavicular fossa
and the costoclavicular space.

FIGURE 2-55 Figure demonstrating the transverse sonographic view of the clavicle as
obtained during Step 1 of the transverse ultrasound scan sequence at the medial
infraclavicular fossa (MICF).

Step 2: The transducer is gently moved caudally until it slips off the inferior border of the
clavicle and the axillary artery (first part) and vein are visualized. It may be necessary to
gently tilt the transducer cephalad to direct the ultrasound beam towards the CCS, that is,
the space between the posterior surface of the clavicle and the second rib (Figs. 2-56 to 2-
59).2,3 The ultrasound image is optimized until all three cords of the brachial plexus are
clearly visualized lateral to the axillary artery (Figs. 2-56 and 2-58). If the ultrasound
image is less than optimal, the medial end of the ultrasound transducer should be gently
pivoted caudally to try and insonate the ultrasound beam at right angles to the cords and

69
 thus minimize anisotropy (Fig. 2-56).

FIGURE 2-56 Transverse sonogram of the medial infraclavicular fossa immediately below
the midpoint of the clavicle (Step 2 of the transverse ultrasound scan sequence)
demonstrating the cords of the brachial plexus in the costoclavicular space. Note the arm of
the subject is abducted and the three cords are clustered together lateral to the axillary artery
(AA). Accompanying photographs illustrate the position and orientation of the ultrasound
transducer during the scan.

FIGURE 2-57 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the brachial plexus at the medial infraclavicular fossa below
the midpoint of the clavicle. AA, axillary artery.

70
FIGURE 2-58 Transverse sonogram of the medial infraclavicular fossa immediately below
the midpoint of the clavicle (Step 2 of the transverse ultrasound scan sequence)
demonstrating the cords of the brachial plexus in the costoclavicular space. Note the
relationship of the cords to one another and to the axillary artery.

FIGURE 2-59 Coned (zoomed) view of the right costoclavicular space demonstrating the
cords of the brachial plexus within the costoclavicular space and lying lateral to the axillary
artery. Note the relationship of the cords to one another and to the axillary artery.

Step 3: The transducer is then gently manipulated laterally, maintaining the same
transverse orientation and applying minimal pressure over the area scanned, until the
cephalic vein is visualized (Figs. 2-60 and 2-61).

71
FIGURE 2-60 Transverse oblique sonogram of the right medial infraclavicular fossa
(MICF) from just distal to the costoclavicular space (Step 3 of the transverse scan sequence).
Note how the cephalic vein arches over the cords of the brachial plexus and the axillary artery
to join the axillary vein from a lateral to medial direction. PM, pectoralis major muscle; CV,
cephalic vein; AA, axillary artery; AV, axillary vein.

FIGURE 2-61 Transverse oblique sonogram (zoomed view) of the medial infraclavicular
fossa (MICF) showing the cephalic vein joining the axillary vein. Note the cords of the
brachial plexus are located posterior to the cephalic vein and lateral to the axillary artery.

Step 4: From this position the transducer is manipulated further laterally until the

72
 thoracoacromial artery (TAA) is seen to emerge from the axillary artery (second part)
(Figs. 2-62 and 2-63).

FIGURE 2-62 Transverse oblique sonogram of the medial infraclavicular fossa (MICF)
immediately below the level of the cephalic vein (Step 4 of the transverse scan sequence)
demonstrating the origin and division of the thoracoacromial artery (TAA). The TAA may be
seen as one or more vessels because it divides into four (clavicular, acromial, deltoid, and
pectoral) branches close to the upper border of the pectoralis minor (Pm) muscle. PM,
pectoralis major muscle; AA, axillary artery; AV, axillary vein.

FIGURE 2-63 Transverse oblique sonogram of the upper part of the lateral infraclavicular

73
fossa (LICF) close to the upper border of the pectoralis minor muscle (Step 5 of the
transverse scan sequence). Note the thoracoacromial artery (TAA) is seen as a single vessel
(close to its origin) in this sonogram. The cords of the brachial plexus are also seen as a
cluster of nerves lying lateral and superolateral to the axillary artery (second part). The TAA
may be confused for the medial cord in the upper part of the LICF.

Step 5: The ultrasound transducer is manipulated further laterally to the LICF (Fig. 2-64).

FIGURE 2-64 Sagittal sonogram of the lateral infraclavicular fossa (LICF). Note the
lateral and posterior cords are visualized above the axillary artery (second part). Also the
thoracoacromial artery (TAA) is identified as a round, hypoechoic structure between the
axillary artery and vein, and may be confused for the medial cord unless one used Doppler
ultrasound.

b.Sagittal scan of the MICF: A sagittal scan of the MICF can be performed with the
ultrasound transducer (a) at right angles to the midpoint of the clavicle (Figs. 2-65 to
2-67) or (b) with the ultrasound transducer parallel to (or in line with) the
neurovascular structures (Figs. 2-68 to 2-70). From each of these positions the
ultrasound transducer is gently manipulated laterally (ie, towards the shoulder) to
view the related anatomy.

74
FIGURE 2-65 Figure showing the position and orientation of the ultrasound transducer
during a sagittal ultrasound scan of the medial infraclavicular fossa immediately below the
midpoint of the clavicle.

FIGURE 2-66 Sagittal sonogram of the medial infraclavicular fossa immediately below
the midpoint of the clavicle showing the cords of the brachial plexus clustered together above
the axillary artery and in a triangular space (costoclavicular) bound by the clavicular head of
pectoralis major and subclavius muscle anteriorly, and the serratus anterior muscle
posteriorly, the axillary artery inferiorly, and the inferior surface of the clavicle superiorly.
AA, axillary artery; AV, axillary vein.

75
FIGURE 2-67 Sagittal sonogram of the medial infraclavicular fossa lateral to the position
described earlier (Fig. 2-66). Note how the cords of the brachial plexus (BP) are clustered
together and located above the axillary artery in a space (costoclavicular) bound by the
inferior surface of the clavicle superiorly, the axillary artery inferiorly, the subclavius muscle
anteriorly, and the serratus anterior muscle posteriorly. The cephalic vein (CV) is located
anterior to the axillary artery. AA, axillary artery; AV, axillary vein.

FIGURE 2-68 Sagittal sonogram of the medial infraclavicular fossa showing the cephalic
vein joining the axillary vein. Note how the cords of the brachial plexus are clustered together
posterior to the cephalic vein and superior to the axillary artery. The position of the cephalic
vein relative to the cords of the brachial plexus in the sagittal sonogram often precludes safe
needle insertion at this level.

76
FIGURE 2-69 Sagittal sonogram of the medial infraclavicular fossa with the ultrasound
transducer placed parallel (in-line) to the axillary vein (Step 1 of the sagittal scan sequence).
Note the axillary vein lies between the subclavius muscle anteriorly and the serratus anterior
(SA) muscle posteriorly at the costoclavicular space. Also the cephalic vein is seen joining
the anterior wall of the axillary vein (AV) from above. PM, pectoralis major muscle.
Accompanying photograph illustrates the position and orientation of the transducer during the
ultrasound scan.

77
FIGURE 2-70 Sagittal sonogram of the medial infraclavicular fossa (MICF) with the
ultrasound transducer positioned parallel to the axillary artery (Step 2 of the sagittal scan
sequence). Note the axillary artery (AA) enters the MICF by traversing the costoclavicular
space between the clavicular head of the pectoralis major (PM) and subclavius muscle
anterior and the upper slips of the serratus anterior (SA) muscle overlying the second rib
posteriorly. The cephalic vein is also seen in the MICF anterior to the axillary artery. The
thoracoacromial artery also originates from the axillary artery close to the upper border of the
pectoralis minor muscle and ascends cranially before it divides into its four (clavicular,
acromial, deltoid, and pectoral) branches. Accompanying photograph illustrates the position
and orientation of the transducer during the ultrasound scan.

4.Sonoanatomy of the MICF:

a.Transverse sonoanatomy of the MICF: On a transverse sonogram of the upper part of
the MICF immediately below the midpoint of the clavicle (Step 2 of the transverse
scan sequence), one can visualize the CCS between the clavicular head of the
pectoralis major and subclavius muscle anteriorly and the serratus anterior muscle
overlying the second rib posteriorly (Figs. 2-58 and 2-59).1,2 The first part of the
axillary artery and the axillary vein appear as two hypoechoic round-to-oval structures
within the CCS (Fig. 2-58). The axillary artery is pulsatile and located lateral to the
axillary vein (Fig. 2-58). Deep to the axillary artery the upper slips of the serratus
anterior muscle, second rib, intercostal muscles, and parietal pleura are clearly
delineated (Fig. 2-59). The cords are clustered together lateral to the axillary artery,
and they exhibit a consistent triangular topographical arrangement (Figs. 2-58 and 2-
59).1,2 The lateral cord is the most superficial of the three cords and lies anterior to
both the medial and posterior cords (Figs. 2-58 and 2-59).3 The medial cord is directly
posterior to the lateral cord but medial to the posterior cord (Fig. 2-58).3 The posterior
cord is the most lateral of the three cords at the CCS, and it is immediately lateral to
the medial cord but posterolateral to the lateral cord (Figs. 2-58 and 2-59).3 In the
transverse sonogram immediately lateral to the CCS (Step 3 of the transverse scan
sequence), the cephalic vein is seen arching over the axillary artery to join the axillary
vein from a lateral to medial direction (Figs. 2-60 and 2-61). The cephalic vein is
easily compressible with pressure from the transducer, but the axillary artery is more
resistant to compression. The cords of the brachial plexus are seen as a hyperechoic
cluster of nerves that lie deep to the cephalic vein and lateral to the axillary artery
(Figs. 2-60 and 2-61). Because the cephalic vein lies anterior to the cords, this
ultrasound window is not ideal for performing BPB because of the risk of puncturing
the cephalic vein. Also if one does see the cephalic vein in the ultrasound window
during a costoclavicular BPB, then it implies that the transducer is positioned lower
than the desired location. If one now slides or tilts the transducer slightly laterally
from the scan position described earlier (Step 4 of the transverse scan sequence), the
cephalic vein is no longer visible and the TAA, which is a branch of the axillary
artery, is visualized (Figs. 2-62 and 2-63). It is seen emerging from the anterior
surface of the axillary artery and may be seen either as two arteries (Fig. 2-62) or as a
single vessel lying deep and close to the upper border of the pectoralis minor muscle
(Fig. 2-63). From this position gentle lateral manipulation of the transducer will reveal
the LICF where the cords of the brachial plexus are closely related to the second part
of the axillary artery (Fig. 2-64).
b.Sagittal sonoanatomy of the MICF: On a sagittal sonogram of the MICF, with the
ultrasound transducer positioned at a right angle to the midpoint of the clavicle (Fig.

78
 2-65), the cords of the brachial plexus are seen as multiple hypoechoic round to oval,
structures each with a hyperechoic rim lying superior to the pulsatile axillary artery
(Figs. 2-66 to 2-68). The cords lie within the CCS formed by the pectoralis major and
subclavius muscle anteriorly and the upper slips of the serratus anterior muscle and
chest wall posteriorly (Figs. 2-66 to 2-68). The axillary vein is located caudal to the
axillary artery (Figs. 2-66 to 2-68), and the cephalic vein joins the axillary vein from
above (Fig. 2-68). Deep to the serratus anterior muscle outlines of the anterior
intercostal space and the hyperechoic pleura are clearly visualized. The arrangement
of the cords in the sagittal sonogram is also consistent,20 with the lateral cord lying
anterior to the medial cord, and the posterior cords lying superior to the medial and
lateral cord (Figs. 2-66 to 2-68).20
On a sagittal sonogram of the MICF, with the ultrasound transducer positioned parallel to
the long axis of the neurovascular structures (Figs. 2-69 to 2-71) and from a medial to lateral
direction, the axillary vein is the first structure visualized (Fig. 2-69). The axillary vein is
hypoechoic, nonpulsatile, easily compressible, and lies on the anterior chest wall. The
cephalic vein is also delineated and, after it traverses the gap between the clavicular head of
the pectoralis major and the subclavius muscle, joins the axillary vein from above (Fig. 2-69).
In the adjoining sagittal sonogram, the pulsatile axillary artery is visualized (Fig. 2-70). The
axillary artery, after it emerges from the CCS, lies in the MICF, deep to the clavicular head of
the pectoralis major muscle and above the superior border of the pectoralis minor muscle
(Fig. 2-69). The cephalic vein lies anterior to the axillary artery at the MICF (Fig. 2-69). The
axillary artery continues distally to enter the LICF, where it is located posterior to the
pectoralis major and minor muscles (Fig. 2-70). The axillary artery also gives off the TAA
from its anterior wall, and the latter ascends cranially, lying close to the posterior surface of
the pectoralis minor muscle (Fig. 2-70). In the sagittal sonogram acquired immediately lateral
and parallel to the axillary artery, the cords of the brachial plexus are visualized as
longitudinal hyperechoic structures (Fig. 2-71) and lying within the CCS (close to the
clavicle), MICF and LICF from a cranial to caudal direction (Fig. 2-71). At the MICF the
cephalic vein and TAA (possibly the pectoral branch) lie anterior to the cords (Fig. 2-71).
Due to the anatomic arrangement of the cords at the MICF (Figs. 2-10 and 2-11), all three
cords of the brachial plexus are rarely visualized in a single sagittal sonogram. It is more
common to visualize two cords, that is, the lateral cord lying anterior to the medial cord (Fig.
2-71).

79
FIGURE 2-71 Sagittal sonogram of the medial infraclavicular fossa (MICF) with the
ultrasound transducer positioned parallel to the axillary artery (Step 3 of the sagittal scan
sequence). The cords of the brachial plexus are seen as hyperechoic longitudinal structures
exiting the costoclavicular space to enter the MICF and then the lateral infraclavicular fossa
deep to the pectoralis minor. Note the relationship of the cephalic vein (CV) and
thoracoacromial artery (TAA) to the cords of the brachial plexus at the MICF. Accompanying
photograph illustrates the position and orientation of the transducer during the ultrasound
scan. PM, pectoralis major muscle; Pm, pectoralis minor muscle; SA, serratus anterior
muscle.

5.Clinical Pearls: The CCS may offer advantages for BPB, and ultrasound-guided
costoclavicular BPB has recently been described.2 At the CCS, and in contrast to that at
the LICF, the cords of the brachial plexus are relatively superficial (2–3 cm) in location,
they are clustered together lateral to the axillary artery,1–3 and they share a consistent
anatomical relationship with one another and to the axillary artery.1–3 All three cords of
the brachial plexus are also visualized in a single transverse sonogram of the MICF.2
Therefore, it is possible to produce BPB at the CCS using a single injection of a relatively
low volume (20 mL) of local anesthetic,2 unlike that at the LICF where multiple
injections21 and relatively large volumes of local anesthetics (up to 35 mL) are often
required to produce an effective BPB.21,22 The CCS is also a useful site for catheter
placement when a continuous BPB is planned for postoperative pain management,2
because the cords are close to one another. In our experience continuous BPB can be
achieved via the CCS using very small volumes of local anesthetic for the infusion (eg, 4–
5 mL/h of levobupivacaine 0.125%). However, currently there are limited published data
on the safety and efficacy of BPB at the MICF.16,17 Overall, a medial approach may be
desirable for BPB, but needle interventions at the MICF carry a definite risk of pleural
puncture. Therefore, until more data on safety and efficacy are available, infraclavicular
BPB techniques at the MICF should be considered an advanced technique and used with

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 caution because the lateral sagittal infraclavicular BPB technique, despite some of its
limitations, is effective and has a long track record of safety.18,23

Ultrasound Imaging of the Brachial Plexus at the Lateral Infraclavicular Fossa

1.Position:
a.Patient: Supine with the ipsilateral arm abducted (90 degrees) and the head turned
slightly to the contralateral side.
b.Operator and ultrasound machine: The operator is positioned at the head end of the
patient. The ultrasound machine is placed on the ipsilateral side to be examined and
directly in front.
2.Transducer selection: High-frequency linear array transducer (12-5 or 15-8 MHz). For
ultrasound imaging of the LICF (paracoracoid location), we prefer to use a high-
frequency linear array transducer (12-5 or 15-8 MHz, Fig. 2-72). However, in muscular or
obese individuals, a high-frequency curved array transducer (eg, 8-5 MHz) with a small
footprint may be preferable.

FIGURE 2-72 Figure showing the position and orientation of the ultrasound transducer
during a sagittal ultrasound scan of the lateral infraclavicular fossa immediately medial and
inferior to the coracoid process (paracoracoid location).

3.Scan technique: The transducer is positioned just below the clavicle and over the
deltopectoral groove, medial and inferior to the coracoid process (Figs. 2-64 and 2-72).
The first objective is to locate the axillary artery and vein. It may be necessary to gently
tilt, slide, or rotate the transducer to obtain an optimal view of the axillary artery. Also
during the scan it is possible to obtain a sagittal view of the LICF with (medial position,
Figs. 2-73 and 2-74) or without (lateral position, Figs. 2-75 to 2-77) insonating the chest
wall and pleura.

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FIGURE 2-73 Figure highlighting the anatomical structures that are insonated during a
sagittal ultrasound scan for the brachial plexus immediately medial and inferior to the
coracoid process (paracoracoid location). AA, axillary artery.

FIGURE 2-74 Sagittal sonogram of the lateral infraclavicular fossa midway between the
midpoint of the clavicle and the coracoid process. Note the pleura is visible posteriorly and
deep to the axillary artery and vein. AA, axillary artery; AV, axillary vein.

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FIGURE 2-75 Figure highlighting the anatomical structures that are insonated during a
sagittal ultrasound scan for the brachial plexus in the lateral infraclavicular fossa midway
between the midpoint of the clavicle and the coracoid process (paracoracoid location). AA,
axillary artery.

FIGURE 2-76 Sagittal sonogram of the lateral infraclavicular fossa with the ultrasound
transducer placed immediately medial and inferior to the coracoid process. AA, axillary
artery; AV, axillary vein.

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FIGURE 2-77 Sagittal sonogram of the lateral infraclavicular fossa in chroma mode with
the ultrasound transducer placed immediately medial and inferior to the coracoid process.
Chroma mode using different shades of color (color maps) is often used to improve contrast
resolution and therefore recognition of structures in an ultrasound image. AA, axillary artery;
AV, axillary vein.

4.Sonoanatomy at the LICF: On a sagittal sonogram of the LICF (paracoracoid location),

the axillary artery (second part) appears as a hypoechoic round-to-oval pulsatile structure
under the pectoralis major and minor muscles (Figs. 2-76 and 2-77). The axillary vein is
also hypoechoic, oval to elliptical in shape, and located caudal to the artery. The shape
and size of the axillary vein may change during the respiratory cycle. The cords of the
brachial plexus are closely related to the axillary artery. If one likens the cross-sectional
image of the axillary artery to a clock face with its 12 o’clock position located anteriorly
and the 6 o’clock position located posterior to the artery, then with the arm adducted at
the shoulder, the lateral, medial, and posterior cords of the brachial plexus are most
frequently observed in the 10 o’clock, 3 o’clock, and 6 o’clock positions, respectively
(Figs. 2-76 and 2-77). Despite this relation in most cases it is not easy to identify all three
cords of the brachial plexus in a single ultrasound scan plane.24 Also the position of the
cords of the brachial plexus varies with abduction or adduction of the arm.5 If the
transducer is moved medially, the pleura comes into view (Fig. 2-74). One can understand
how inadvertent pleural puncture can occur during an infraclavicular (lateral sagittal)
BPB (Fig. 2-74).19 We recommend that the pleura be routinely identified as part of the
scan during a lateral sagittal infraclavicular BPB and the needle inserted lateral to this
site, that is, through an ultrasound window where no pleura is visualized (Figs. 2-76 and
2-77).
5.Clinical Pearls: Ultrasound visualization of the brachial plexus at the LICF is best
achieved with the arm in the abducted position. Abduction of the arm brings the cords
closer to the skin and elevates the lateral part of the clavicle, which makes more space
available below the clavicle for placement of the ultrasound transducer. In the
paracoracoid area, the axillary artery is 3 to 7 cm under the skin surface.16 This makes
confirmation of the artery by compressibility insensitive. Also, although one may expect

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 to be able to compress the axillary vein with pressure at the LICF, it may not always be
possible. Therefore, it is advisable to use Doppler ultrasound whenever possible to
differentiate the artery from the vein. Rarely one may visualize a bifid axillary artery25 in
the infraclavicular fossa as a normal variant of the axillary artery anatomy. It is also
common to see a hyperechoic shadow posterior to the axillary artery at the 6 o’clock
position. This is usually an artifact caused by acoustic enhancement resulting from the
sudden reduction in acoustic impedance as the ultrasound signal travels through the blood
in the axillary artery. This hyperechoic shadow may be mistaken as the posterior cord.
Tilting the transducer or performing a “trace back technique”9 may help to differentiate
an artifact from the posterior cord. The LICF is a popular site for brachial plexus catheter
placement. The target location for the catheter placement should be posterior (ie, at the 6
or 7 o’clock position) to the axillary artery. The muscles of the chest wall, through which
the catheter is passed, help stabilize the catheter and may prevent catheter dislodgement.

Brachial Plexus: Axilla

Gross Anatomy
As the brachial plexus enters the arm, its four main terminal nerves (median, ulnar, radial,
and musculocutaneous) travel in close proximity to the third part of the axillary artery (Fig. 2-
13 and 2-78). The nerves lie superficial to the conjoint tendon of the teres major and
latissimus dorsi muscles and under the subcutaneous tissue lateral to the anterior axillary fold
(Fig. 2-78). When the arm is abducted and externally rotated, the median nerve is located on
the anterior or anterolateral aspect of the axillary artery (97.9%), the ulnar nerve is located on
the anteromedial side of the artery (91.3%), and the radial nerve is located posterior to the
axillary artery (89.9%).26 The musculocutaneous nerve lies between the coracobrachialis and
biceps muscles, but can also be within the substance of the coracobrachialis muscle (Figs. 2-
78 to 2-81). Occasionally the musculocutaneous nerve may also be located adjacent to the
median nerve.

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FIGURE 2-78 Cross-sectional anatomy of the axilla at the level of the anterior axillary
fold (ie, where the pectoralis major muscle joins the biceps muscle). Note the relation of the
median, ulnar, and radial nerve to the axillary artery and how the musculocutaneous nerve is
embedded within the substance of the coracobrachialis muscle.

FIGURE 2-79 Transverse anatomical section of the axilla. AA, axillary artery; M, median
nerve; U, ulnar nerve; R, radial nerve; CB, coracobrachialis muscle; MC, musculocutaneous
nerve.

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Magnetic Resonance Imaging Anatomy of the Axilla
Figs. 2-80 and 2-81

FIGURE 2-80 Transverse (axial) MRI of the axilla above the anterior axillary fold. Note
the position of the musculocutaneous nerve.

FIGURE 2-81 Transverse (axial) MRI of the axilla at the level of the anterior axillary fold.
Note the musculocutaneous nerve is located between the biceps and coracobrachialis muscle.

Technique of Ultrasound Imaging of the Brachial Plexus at the Axilla

1.Position:

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 a.Patient: Supine with the ipsilateral arm abducted 90 degrees at the shoulder.
b.Operator and ultrasound machine: The operator sits at the head end of the patient,
and the ultrasound machine is placed directly in front on the ipsilateral side.
Alternatively, the position of the operator and the ultrasound machine can be reversed.
2.Transducer selection: High-frequency linear array transducer (15-8 or 12-5 MHz).
3.Scan technique: The ultrasound transducer is placed transversely across the upper arm
(Figs. 2-82 and 2-83) at the axillary fold just lateral to the pectoralis major muscle (Figs.
2-84 and 2-85). The initial goal is to identify the axillary artery. Minor adjustments
(tilting or rotation) in the position of the ultrasound transducer may be required to obtain
a true or optimal cross-sectional image of the axillary artery. The axillary vein is
compressible and lies medial to the axillary artery. Doppler ultrasound can also be used to
differentiate the axillary artery from the vein. It is common to see more than one vein in
the sonogram. These vascular structures should be confirmed by compression and
occlusion before any needle intervention. Doppler ultrasound can also be used to confirm
hypoechoic structures that are suspected to be vascular in nature. The conjoint tendon of
the latissimus dorsi and teres major muscles and its humeral insertion should
subsequently be identified. It may be necessary to slide the transducer medially to
visualize this tendon. The conjoint tendon is a useful sonographic landmark to locate the
radial nerve as it often lies on top of this tendon.

FIGURE 2-82 Figure showing the position of the ultrasound transducer relative to the

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humerus during an ultrasound scan of the axilla at the axillary fold.

FIGURE 2-83 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan of the axilla. AA, axillary artery; M, median nerve; U, ulnar nerve;
R, radial nerve; CB, coracobrachialis muscle; MC, musculocutaneous nerve.

FIGURE 2-84 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan of the axilla at the axillary fold.

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FIGURE 2-85 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan of the axilla at the axillary fold (different view compared
to Figure 2-84). Note how the ultrasound transducer is positioned just distal to the anterior
axillary fold.

4.Sonoanatomy: The axillary artery, when imaged in true cross-section, is typically round,
pulsatile, and relatively superficial in location (Figs. 2-86 to 2-88). The axillary vein is
also hypoechoic, situated caudal to the artery, oval or elliptical in shape, and may collapse
from pressure of the transducer. The shape and size of the axillary vein may also vary
during the respiratory cycle. Lateral to the axillary artery is the biceps and the
coracobrachialis muscles. The musculocutaneous nerve lies in a fascial plane between
these two muscles and is frequently visualized as an elliptical hyperechoic structure (Fig.
2-89). However, the shape and size of the musculocutaneous nerve are variable27 and can
also be oval, round, flat-oval, or triangular (Figs. 2-86 to 2-90) in shape.27 On the
posterior aspect of the axillary artery, a diagonal hyperechoic structure travelling from the
anteromedial to the posterolateral direction can be visualized. This is the conjoint tendon,
and the triceps muscle is seen posterior to this tendon (Figs. 2-86 to 2-89). The nerves in
the axilla have mixed echogenicity, but are more frequently hyperechoic in appearance.
The position of the various terminal nerves of the brachial plexus, relative to the axillary
artery, in the axilla is also variable. The nerves are highly mobile and can be seen to
change their position relative to the artery when pressure is applied on the ultrasound
transducer. If one imagines the transverse image of the axillary artery as a clock face
where the 9 o’clock position represents the lateral aspect and the 3 o’clock position
represents the medial aspect of the artery, then the median nerve is typically located in the
anterolateral (9 to 12 o’clock) sector. The radial nerve is typically located on the surface
of the conjoint tendon,28 in the posteromedial (4 to 6 o’clock) sector deep to the axillary
artery. The ulnar nerve is typically located in the caudal (2 to 4 o’clock) sector, and there
may be several veins between it and the axillary artery.

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FIGURE 2-86 Transverse sonogram of the axilla. AV, axillary vein; AA, axillary artery;
U, ulnar nerve; R, radial nerve; CB, coracobrachialis muscle; MC, musculocutaneous nerve.

FIGURE 2-87 Transverse sonogram of the axilla showing all four terminal branches of the
brachial plexus. M, median nerve; R, radial nerve; U, ulnar nerve; MC, musculocutaneous
nerve; CB, coracobrachialis muscle; AA, axillary artery; AV, axillary vein.

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FIGURE 2-88 High-resolution transverse sonogram of the axilla acquired using a 13-MHz
linear ultrasound transducer. All four terminal branches of the brachial plexus are clearly
delineated. Note the tissues plane/compartment separating the radial nerve from the ulnar
nerve in this sonogram. AA, axillary artery; AV, axillary vein.

FIGURE 2-89 Transverse sonogram of the musculocutaneous nerve at the upper arm. The
musculocutaneous nerve is located between the biceps and coracobrachialis muscles and
appears oval in shape. AA, axillary artery; AV, axillary vein.

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FIGURE 2-90 Transverse sonogram of the musculocutaneous nerve at the upper arm in
sepia chroma mode. The musculocutaneous nerve is located between the biceps and
coracobrachialis muscles and appears triangular in shape. AA, axillary artery; AV, axillary
vein.

5.Clinical Pearls: The axillary region is highly vascular, and examination of the brachial
plexus in this area should be preceded by a careful examination to locate the arteries and
veins around the potential target nerves. Alternating firm and light pressure on the
ultrasound transducer can be used to delineate the veins in the axilla during the scout
scan. It is common for the veins in the axilla to be occluded by light pressure. This may
increase the potential risk for inadvertent intravascular injection if intravascular
placement of the block needle or spread of the injectate is not recognized on the
ultrasound image during the injection. Rarely a bifid axillary artery may be seen as a
normal variant in the axilla. The “trace back” technique is useful to confirm the identity
of a particular nerve in the axilla. The median nerve can be traced and observed to travel
with the brachial artery. The ulnar nerve can be traced and is seen on the medial aspect of
the brachial artery. The radial nerve typically lies on the anterior surface of the conjoint
tendon28 and descends deep towards the spiral groove of the humerus with the deep
artery of the arm. The musculocutaneous nerve lies in a plane between the biceps and
coracobrachialis muscles and moves away from the axillary artery as it descends down
the arm.27

Midhumeral Region – Median and Ulnar Nerve

Gross Anatomy
In the upper arm the terminal branches of the brachial plexus (ie, the median, ulnar, and
radial nerves) separate from one another and take up their respective positions. The median
nerve is closely related to the brachial artery throughout its course in the arm. In the
midhumeral region, the median nerve lies lateral to the artery (Figs. 2-91 and 2-92); in the
middle of the arm it crosses the artery anteriorly from the lateral to medial side and continues

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to descend on the medial side of the artery (Figs. 2-14, 2-93, and 2-94) up to the elbow. At
the antecubital fossa the median nerve is relatively superficial and lies medial to the brachial
artery, posterior to the bicipital aponeurosis, and anterior to the brachialis muscle (Figs. 2-95
and 2-96).

FIGURE 2-91 Cross-sectional anatomy of the arm at the midhumeral level. Note the
relation of the median and ulnar nerve to the brachial artery. MACN, medial antebrachial
cutaneous nerve; MBCN, medial brachial cutaneous nerve.

FIGURE 2-92 Transverse anatomical section of the arm at the midhumeral level. BA,
brachial artery; BV, brachial vein; CB, coracobrachialis muscle.

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FIGURE 2-93 Cross-sectional anatomy of the lower arm above the elbow joint. MACN,
medial antebrachial cutaneous nerve; LACN, lateral antebrachial cutaneous nerve; PACN,
posterior antebrachial cutaneous nerve.

FIGURE 2-94 Transverse anatomical section of the lower arm above the elbow joint. M,
median nerve, U, ulnar nerve; BA, brachial artery; BV, brachial vein.

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FIGURE 2-95 Anatomy of the median, radial, and ulnar nerve at the cubital fossa.

In the arm, the ulnar nerve lies medial to the brachial artery up to about the insertion of the
coracobrachialis muscle, where it pierces the medial intermuscular septum to enter the
posterior compartment of the arm. It then continues its distal course and passes behind the
medial epicondyle to enter the ulnar nerve sulcus (Fig. 2-96).

FIGURE 2-96 Cross-sectional anatomy of the arm at the level of the elbow joint. FCR,
flexor carpi radialis; PL, palmaris longus; FDS, flexor digitorum superficialis.

Magnetic Resonance Imaging Anatomy of the Midhumeral Region

Fig. 2-97

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FIGURE 2-97 Transverse (axial) MRI of the arm at the midhumeral level.

Technique of Ultrasound Imaging for the Median and Ulnar Nerve at the
Midhumeral Region
1.Position:
a.Patient: Supine with the ipsilateral arm abducted and externally rotated such that the
palm of the hand is facing the ceiling.
b.Operator and ultrasound machine: For a right-sided scan, a right-handed operator
sits or stands at the head end of the patient and the ultrasound machine is placed
directly in front on the ipsilateral side. Alternatively, the position of the operator and
ultrasound machine can be reversed.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: The transducer is placed transversely across the groove between the
biceps and triceps muscle at the middle of the humerus on the medial aspect (Figs. 2-98 to
2-100). The initial goal is to identify the brachial artery. The image should be optimized
by rotation or tilting the transducer to obtain a true cross-sectional image of the brachial
artery. Vascular structures should be identified by compression and occlusion before
intervention. Doppler can be used to confirm hypoechoic structures that are suspected to
be vascular in nature.

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FIGURE 2-98 Figure showing the position of the ultrasound transducer relative to the
humerus during an ultrasound scan of the arm at the level of the midhumerus.

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FIGURE 2-99 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan of the arm at the midhumeral level.

FIGURE 2-100 Figure highlighting the anatomical structures that are insonated during a
transverse scan of the arm at the midhumeral level. M, median nerve; U, ulnar nerve; BA,
brachial artery; BV brachial vein; CB, coracobrachialis muscle.

4.Sonoanatomy: The median and ulnar nerves are visualized as hyperechoic structures with
a honeycomb appearance. Both nerves lie adjacent to the brachial artery at this level (Fig.
2-101).

FIGURE 2-101 Transverse sonogram of the median nerve and ulnar nerve at the
midhumeral level. BA, brachial artery; BV, brachial vein; CB, coracobrachialis muscle.

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 5.Clinical Pearls: The median and ulnar nerves are confirmed in this region using the “trace
back” technique. Both nerves can easily be followed proximally and distally along the
arm. The median nerve typically lies on the lateral aspect of the brachial artery
proximally, crosses the brachial artery anteriorly, and continues on its medial side
distally. The ulnar nerve lies in the medial side of the brachial artery. The position of both
nerves in relation to the artery are variable, and they can be observed “rolling” from one
to the other side of the artery.

Midhumeral Region – Radial Nerve

Gross Anatomy
At the level of the anterior axillary fold, the radial nerve lies deep to the axillary artery and
superficial to the conjoint tendon (Figs. 2-78 and 2-88). It then enters the posterior
compartment of the arm to lie in the spiral groove on the posterior aspect of the humerus and
in between the medial and lateral heads of the triceps muscles (Figs. 2-88, 2-102, and 2-103).
The radial nerve then emerges on the lateral aspect of the humerus and comes to lie between
the brachialis, brachioradialis, and extensor carpi radialis longus muscles. It gives off the
posterior antebrachial cutaneous nerve and continuous to the radial tunnel in the forearm
(upper), where it divides into its superficial and deep branches.

FIGURE 2-102 Anatomy of the radial nerve at the level of the spiral groove of the
humerus.

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FIGURE 2-103 Transverse anatomical section of the arm at the level of the radial groove.

Magnetic Resonance Imaging of the Midhumeral Region (Radial Nerve)

Figs. 2-104 and 2-105

FIGURE 2-104 Transverse (axial) MRI of the arm at the level of the radial groove.

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FIGURE 2-105 Transverse (axial) MRI of the arm distal to the radial groove showing the
radial nerve at the lateral aspect of the humerus.

Ultrasound Scan Technique for Radial Nerve at the Radial Groove

1.Position:
a.Patient: Supine with the patient asked to touch the opposite shoulder tip with the
ipsilateral hand. An assistant may help to steady the arm in position.
b. Operator and ultrasound machine: The operator sits or stands caudal to the abducted
arm facing the head of the patient. The ultrasound machine is placed cephalad to the
abducted arm on the ipsilateral side and directly in front of the operator.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: The transducer is placed transversely over the posterolateral aspect of the
midhumerus (Figs. 2-106 to 2-108). The initial goal is to image the triceps muscle and the
humerus. The image should be optimized by gently rotating and tilting the transducer to
minimize anisotropy and obtain a true cross-sectional image of the radial nerve in the
radial groove (spiral or musculospiral groove), together with the deep artery of the arm,
which is also referred to as the profunda brachii artery (Figs. 2-109 and 2-110).

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FIGURE 2-106 Figure showing the position of the ultrasound transducer relative to the
humerus during an ultrasound scan of the arm at the level of the radial groove.

FIGURE 2-107 Figure showing the position and orientation of the ultrasound transducer

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during an ultrasound scan for the radial nerve at the radial groove.

FIGURE 2-108 Figure highlighting the anatomical structures that are insonated during a
transverse scan of the arm at the level of the radial groove.

FIGURE 2-109 Transverse sonogram of the radial nerve at the radial groove of the
humerus.

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FIGURE 2-110 Transverse sonogram of the arm at the level of the radial groove showing
the radial nerve accompanied by the profunda brachii artery. Accompanying photograph
illustrates the position and orientation of the transducer during the ultrasound scan.

4.Sonoanatomy: The posterior surface of the humerus appears as a hyperechoic curvilinear

structure with a corresponding acoustic shadow anteriorly. The radial nerve is visualized
as an oval hypoechoic structure with a hyperechoic outline in the spiral groove between
the two heads of the triceps muscle. It is also common to visualize the pulsatile deep
artery of the arm, which accompanies the radial nerve at the spiral groove (Figs. 2-109
and 2-110).
5.Clinical Pearls: The radial nerve is confirmed at the spiral groove using the “trace back”
technique. Although the radial nerve can be imaged at the spiral groove of the humerus,
its blockade at this site does not confer any advantage to blockade nearer the elbow.29

Ultrasound Scan Technique for Radial Nerve at the Lateral Aspect of the Arm
1.Position:
a.Patient: Supine with the arm abducted and internally rotated such that the hand and
forearm are resting on the abdomen (Fig. 2-111).

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FIGURE 2-111 Figure showing the position and orientation of the ultrasound transducer
during an ultrasound scan for the radial nerve at the lateral aspect of the arm.

b.Operator and ultrasound machine: The operator sits or stands at the patient’s side on
the side to be examined, and the ultrasound machine is placed directly in front of the
operator on the ipsilateral side.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: The ultrasound transducer is positioned transversely over the lateral
aspect of the lower arm (Fig. 2-111).
4.Sonoanatomy: The lateral aspect of the humerus is visualized as a hyperechoic structure
with a corresponding acoustic shadow anteriorly (Figs. 2-112 and 2-113). The radial
nerve and its posterior antebrachial cutaneous branch are often seen as round-to-oval
hypoechoic structures between the brachialis (medially) and the brachioradialis and
extensor carpi radialis longus muscles (laterally).

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FIGURE 2-112 Transverse sonogram of the radial nerve at the lateral aspect of the arm.
Accompanying photograph illustrates the position and orientation of the transducer during the
ultrasound scan.

FIGURE 2-113 Transverse sonogram of the radial nerve at the lateral aspect of the arm.
PACN, posterior antebrachial cutaneous nerve.

5.Clinical Pearls: The lateral aspect of the lower arm can be a useful site for rescue block
of the radial nerve during forearm and hand surgery because a single injection of local
anesthetic at this site will block both the superficial and deep branches of the nerve.

Elbow Region – Median, Ulnar, and Radial Nerves

Gross Anatomy
At the elbow, the median nerve lies medial to the brachial artery, deep to the bicipital
aponeurosis and on the anterior surface of the brachialis muscle (Figs. 2-14, 2-95, and 2-96).
The ulnar nerve winds around the medial aspect of the medial epicondyle in the ulnar groove
(Figs. 2-95, 2-96, and 2-102) and enters the anterior compartment of the forearm between the
two heads of the flexor carpi ulnaris and comes to lie between the flexor carpi ulnaris
(medially), flexor digitorum superficialis, and the flexor digitorum profundus in the forearm
(Figs. 2-114 and 2-115). The radial nerve lies beneath the brachioradialis in the anterior
compartment of the lower arm (Figs. 2-93 and 2-95). Within 3 cm of the elbow joint the
radial nerve divides into its superficial (cutaneous branch) and deep (posterior interosseous
nerve) branches (Fig. 2-9). The deep branch winds around the neck of the radius and travels
distally between the superficial and deep layers of the supinator muscle (Fig. 2-115) in the
“radial tunnel” (Fig. 2-114)30 and enters the posterior compartment of the arm as the
posterior interosseous nerve. The deep branch of the radial nerve is often accompanied by the
recurrent branch of the radial artery and its vena comitans.31 The superficial branch of the
radial nerve runs under the brachioradialis and on the supinator and pronator teres muscles

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(Fig. 2-116). It then descends close to the lateral aspect of the radial artery in the midforearm
(Figs. 2-116 and 2-117) after which it leaves the artery and courses backward under the
tendon of the brachioradialis to reach the posterior surface of the wrist.

FIGURE 2-114 Transverse anatomical section of the upper forearm at the radial tunnel.
FCR, flexor carpi radialis muscle; PL, palmaris longus muscle; FDS, flexor digitorum
superficialis muscle; FCU, flexor carpi ulnaris muscle; BCR, brachioradialis muscle; FDP,
flexor digitorum profundus muscle.

FIGURE 2-115 Cross-sectional anatomy of the proximal forearm just below the elbow
joint. LACN, lateral antebrachial cutaneous nerve; PACN, posterior antebrachial cutaneous

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nerve.

FIGURE 2-116 Cross-sectional anatomy of the mid forearm showing the median, ulnar,
and radial nerves.

FIGURE 2-117 Median, radial, and ulnar nerve at the forearm.

Magnetic Resonance Imaging of the Elbow Region

Figs. 2-118 to 2-120

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FIGURE 2-118 Transverse (axial) MRI demonstrating the median nerve at the level of the
elbow joint (cubital fossa).

FIGURE 2-119 Transverse (axial) MRI of the upper forearm demonstrating the radial
nerve in the radial tunnel. ECRL, extensor carpi radialis longus muscle; ECRB, extensor
carpi radialis brevis muscle; EDC, extensor digitorum communis muscle; FDP, flexor
digitorum profundus muscle; FCU, flexor carpi ulnaris muscle; FDS, flexor digitorum
superficialis.

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FIGURE 2-120 Transverse (axial) MRI demonstrating the ulnar nerve in the ulnar groove.

Elbow Region Ultrasound Scan Technique

1.Position:
a.Patient: Supine with the arm abducted 90 degrees at the shoulder and externally rotated
such that the palm of the hand is facing the ceiling.
b.Operator and ultrasound machine: The operator is positioned at the caudal side of
the abducted arm facing the head of the patient. The ultrasound machine is placed on
the ipsilateral side cephalad to the abducted arm directly in front of the operator.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: The median nerve is imaged by placing the transducer transversely across
the elbow joint (Figs. 2-121 and 2-122). The initial goal is to image the brachial artery in
a true cross-sectional view. The brachial artery and median nerve are relatively superficial
at this level with only the bicep aponeurosis, subcutaneous tissue, and skin covering it.
The median nerve is located medial to the brachial artery (Fig. 2-123). To locate the
radial nerve at the elbow, identify the brachial artery as described earlier and slide the
transducer laterally towards the lateral humeral epicondyle and 2 to 3 cm below the elbow
joint (Figs. 2-124 and 2-125). The radial nerve or its branches are located between the
brachioradialis and supinator muscle. The ulnar nerve can be imaged by abducting the
arm at the shoulder with external rotation to expose the posteromedial aspect of the
medial humeral epicondyle (Figs. 2-126 and 2-127). Manual palpation of the ulnar groove
may aid initial transducer placement. The ultrasound transducer is placed transversely
across the ulnar groove to obtain a transverse image of the ulnar nerve. Contact artifacts
are a problem when scanning for the ulnar nerve at the ulnar groove. Therefore, it is
easier to locate the ulnar nerve just proximal to the ulnar groove (Fig. 2-128).

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FIGURE 2-121 Figure showing the position and orientation of the ultrasound transducer
during an ultrasound scan for the median nerve at the cubital fossa.

FIGURE 2-122 Figure highlighting the anatomical structures that are insonated during an
ultrasound scan for the median nerve at the level of the elbow joint. Basilic V, basilic vein;
FCR, flexor carpi radialis muscle; PL, palmaris longus muscle; FDS, flexor digitorum
superficialis muscle.

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FIGURE 2-123 Transverse sonogram of the median nerve at the elbow. Note the median
nerve lies immediately medial to the brachial artery. BA, brachial artery.

FIGURE 2-124 Figure showing the position and orientation of the ultrasound transducer
during an ultrasound scan for the radial nerve at the lateral aspect of the upper forearm (radial
tunnel).

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FIGURE 2-125 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the radial nerve at the lateral aspect of the upper forearm
(radial tunnel). FCR, flexor carpi radialis muscle; PL, palmaris longus muscle; FDS, flexor
digitorum superficialis muscle; FCU, flexor carpi ulnaris muscle; BCR, brachioradialis
muscle.

FIGURE 2-126 Figure showing the position and orientation of the ultrasound transducer
during an ultrasound scan for the ulnar nerve at the posteromedial aspect of the elbow.

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FIGURE 2-127 Figure highlighting the anatomical structures that are insonated during an
ultrasound scan for the ulnar nerve at the ulnar groove. PL, palmaris longus muscle; FDS,
flexor digitorum superficialis muscle; FCR, flexor carpi radialis muscle.

FIGURE 2-128 Transverse sonogram of the ulnar nerve just above the ulnar groove and
on the posteromedial aspect of the lower arm. Accompanying photograph illustrates the
position and orientation of the transducer during the ultrasound scan.

4.Sonoanatomy: The median nerve appears as an oval or elliptical-shaped, hyperechoic, and

honeycombed structure medial to the brachial artery at the elbow (Fig. 2-123). The ulnar
nerve at the ulnar groove is frequently triangular in shape and hypoechoic in appearance
(Fig. 2-129). Proximal to the ulnar groove the ulnar nerve is relatively superficial and
appears hypoechoic (Fig. 2-128). When examining the radial nerve at the elbow, the

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 radius appears as a curved hyperechoic structure with an accompanying acoustic shadow
anteriorly. The two branches of the radial nerve are seen as discrete hypoechoic structures
between the brachioradialis and the supinator muscle (Fig. 2-130). The recurrent branch
of the radial artery accompanies the deep branch and can be identified using Doppler
ultrasound.

FIGURE 2-129 Transverse sonogram of the ulnar nerve at the elbow just proximal to the
ulnar groove.

FIGURE 2-130 Transverse sonogram showing the superficial and deep branches of the
radial nerve lying in between the brachioradialis and supinator muscle at the lateral aspect of
the upper forearm.

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 5.Clinical Pearls: The identity of the nerves at the elbow is confirmed using the “trace
back” technique and visualized along their expected course based on anatomical
knowledge. Median nerve block at the elbow can be performed as a rescue block or when
there is surgical dressing or plaster casts covering the forearm. When examining the ulnar
nerve at the ulnar groove or cubital tunnel, apply liberal amounts of ultrasound gel and
apply minimal pressure during the ultrasound scan to reduce contact artifacts. It may also
be safer to perform an ulnar nerve block at a more proximal site rather than at the ulnar
groove because of the perceived increased risk of nerve injury at the ulnar groove.

Midforearm Region – Median, Ulnar, and Radial Nerves

Gross Anatomy
In the midforearm the median nerve lies in a fascial plane between the flexor digitorum
superficialis and the flexor digitorum profundus muscle (Figs. 2-116 and 2-131). At the wrist,
the median nerve lies lateral to the flexor digitorum superficialis muscle and beneath the
palmaris longus tendon (Fig. 2-132) and continues under the flexor retinaculum to enter the
hand. At the midforearm the ulnar nerve runs between the flexor digitorum profundus
(posteriorly), the flexor digitorum superficialis (anteriorly), and the flexor carpi ulnaris
(medially) muscle (Fig. 2-116). In the distal forearm the ulnar nerve is accompanied by the
ulnar artery (Fig. 2-132) and enters the hand superficial to the flexor retinaculum.

FIGURE 2-131 Transverse anatomical section through the midforearm showing the
median nerve. FCR, flexor carpi radialis muscle; PL, palmaris longus muscle; FDS, flexor
digitorum superficialis muscle; FCU, flexor carpi ulnaris muscle; BCR, brachioradialis
muscle; FPL, flexor pollicis longus muscle; FDS, flexor digitorum superficialis muscle; FDP,
flexor digitorum profundus muscle; ECU, extensor carpi ulnaris muscle; APL, abductor
pollicis longus muscle.

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FIGURE 2-132 Cross-sectional anatomy of the distal forearm showing the median, ulnar,
and superficial and deep (posterior interosseous nerve) branches of the radial nerve.

Magnetic Resonance Imaging Anatomy of the Midforearm

Figs. 2-133 and 2-134

FIGURE 2-133 Transverse (axial) MRI of the midforearm demonstrating the median,
radial, and ulnar nerves. FDP, flexor digitorum profundus.

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FIGURE 2-134 Transverse (axial) MRI of the distal forearm demonstrating the median
and radial nerve. FDS, flexor digitorum superficialis muscle; FDP, flexor digitorum
profundus muscle.

Midforearm Ultrasound Scan Technique

1.Position:
a.Patient: Supine with the arm abducted and externally rotated such that the palm of the
hand is facing the ceiling.
b.Operator and ultrasound machine: The operator is positioned at the caudad side of
the abducted arm facing the head of the patient. The ultrasound machine is placed on
the ipsilateral side to be examined on the cephalad side of the abducted arm directly in
front of the operator.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: To image the median nerve, the ultrasound transducer is placed in the
transverse orientation across the volar surface of the midforearm (Figs. 2-135 to 2-137).
The median nerve is seen as a hyperechoic nodule between the flexor digitorum
superficialis, which is superficial to the nerve, and the flexor digitorum profundus, which
is deep to the nerve (Figs. 2-138 to 2-141). To image the ulnar nerve, slide the ultrasound
medially from the earlier position. It may be easier to start the ultrasound scan at the wrist
by locating the ulnar artery (Figs. 2-142 and 2-143). The ulnar nerve lies medial to the
ulnar artery at the wrist. One can then trace the ulnar nerve back to the midforearm (Figs.
2-144 and 2-145). To image the superficial (cutaneous) branch of the radial nerve, the
ultrasound transducer is placed laterally on the volar surface of the midforearm and traced
distally (Fig. 2-146). The superficial branch of the radial nerve is seen lateral to the radial
artery (Fig. 2-147).

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FIGURE 2-135 Figure showing the position of the ultrasound transducer relative to the
forearm during an ultrasound scan for the median nerve at the midforearm.

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FIGURE 2-136 Figure showing the position and orientation of the ultrasound transducer
during an ultrasound scan for the median nerve at the midforearm.

FIGURE 2-137 Figure highlighting the anatomical structures that are insonated during an
ultrasound scan for the median nerve at the midforearm. FCR, flexor carpi radialis muscle;
PL, palmaris longus muscle; FDS, flexor digitorum superficialis muscle; FCU, flexor carpi
ulnaris muscle; BCR, brachioradialis muscle; FPL, flexor pollicis longus muscle; FDP, flexor
digitorum profundus muscle; ECU, extensor carpi ulnaris; APL, abductor pollicis longus
muscle.

FIGURE 2-138 Transverse sonogram of the median nerve at the midforearm.

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FIGURE 2-139 Transverse sonogram of the median nerve at the midforearm in sepia
mode.

FIGURE 2-140 Sagittal sonogram of the median nerve at the midforearm.

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FIGURE 2-141 Three-dimensional multiplanar image of the median nerve at the
midforearm. Reference marker has been placed over the median nerve: (a) transverse view,
(b) sagittal view, and (c) coronal view.

FIGURE 2-142 Figure showing the position and orientation of the ultrasound transducer
during a ultrasound scan for the median nerve at the distal forearm.

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FIGURE 2-143 Figure highlighting the anatomical structures that are insonated during an
ultrasound scan for the ulnar nerve at the midforearm. FCR, flexor carpi radialis muscle;
FDS, flexor digitorum superficialis muscle; FPL, flexor pollicis longus muscle; FDP, flexor
digitorum profundus muscle; FCU, flexor carpi ulnaris.

FIGURE 2-144 Transverse sonogram of the median and ulnar nerves at the midforearm.

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FIGURE 2-145 Transverse sonogram of the median and ulnar nerves at the midforearm in
sepia mode.

FIGURE 2-146 Figure showing the position and orientation of the ultrasound transducer
during an ultrasound scan at the distal forearm to insonate the superficial branch of the radial
nerve and the median nerve.

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FIGURE 2-147 Transverse sonogram demonstrating the superficial branch of the radial
nerve at the distal forearm. Note the superficial branch of the radial nerve is hyperechoic and
located lateral to the radial artery.

4.Sonoanatomy: The median, radial, and ulnar nerves all appear as an elliptical/oval,
hyperechoic, and honeycombed structure on a transverse sonogram of the midforearm.
5.Clinical Pearls: The nerves in the forearm are markedly anisotropic. Therefore, one should
gently tilt or rotate the ultrasound transducer during the ultrasound scan to minimize
anisotropy and optimize the image. The “trace back” technique is particularly useful for
confirmation of nerves in the forearm. The course of the nerves can be followed
throughout the forearm, and the flat surface of the forearm also allows for easy
manipulation of the transducer to image the nerves in their long (sagittal) axis for
confirmation. In the distal forearm and wrist, it may be more challenging to image the
median nerve, as there are many tendons at this location. In the forearm the median nerve
is accompanied by the median artery, which is a branch of the anterior interosseous
artery. The radial nerve below the elbow is small and hard to visualize using ultrasound.
Therefore, the “trace back” technique should be used to confirm the identity of the radial
nerve below the elbow. The superficial branch of the radial nerve is also a small nerve
and may not be readily visualized in the distal forearm.

References
1.Demondion X, Herbinet P, Boutry N, Fontaine C, Francke JP, Cotten A. Sonographic
mapping of the normal brachial plexus. AJNR Am J Neuroradiol. 2003;24:1303–1309.
2.Karmakar MK, Sala-Blanch X, Songthamwat B, Tsui BC. Benefits of the costoclavicular
space for ultrasound-guided infraclavicular brachial plexus block: description of a
costoclavicular approach. Reg Anesth Pain Med. 2015;40:287–288
3.Sala-Blanch X, Reina MA, Pangthipampai P, Karmakar MK. Anatomic basis for brachial
plexus block at the costoclavicular space: a cadaver anatomic study. Reg Anesth Pain
Med. 2017;42:233–240.
4.Sauter AR, Smith HJ, Stubhaug A, Dodgson MS, Klaastad O. Use of magnetic resonance

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 imaging to define the anatomical location closest to all three cords of the infraclavicular
brachial plexus. Anesth Analg. 2006;103:1574–1576.
5.Ruiz A, Sala X, Bargallo X, Hurtado P, Arguis MJ, Carrera A. The influence of arm
abduction on the anatomic relations of infraclavicular brachial plexus: an ultrasound
study. Anesth Analg. 2009;108:364–366.
6.Chan VW. Applying ultrasound imaging to interscalene brachial plexus block. Reg Anesth
Pain Med. 2003;28:340–343.
7.Narouze S, Peng PW. Ultrasound-guided interventional procedures in pain medicine: a
review of anatomy, sonoanatomy, and procedures. Part II: axial structures. Reg Anesth
Pain Med. 2010;35:386–396.
8.Canella C, Demondion X, Delebarre A, Moraux A, Cotten H, Cotten A. Anatomical study
of phrenic nerve using ultrasound. Eur Radiol. 2010;20:659–665.
9.Tsui BC, Finucane BT. The importance of ultrasound landmarks: a “traceback” approach
using the popliteal blood vessels for identification of the sciatic nerve. Reg Anesth Pain
Med. 2006;31:481–482.
10.Gerscovich EO, Cronan M, McGahan JP, Jain K, Jones CD, McDonald C.
Ultrasonographic evaluation of diaphragmatic motion. J Ultrasound Med. 2001;20:597–
604.
11.Sinha SK, Abrams JH, Barnett JT, et al. Decreasing the local anesthetic volume from 20 to
10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the
incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med. 2011;36:17–20.
12.Perlas A, Chan VW, Simons M. Brachial plexus examination and localization using
ultrasound and electrical stimulation: a volunteer study. Anesthesiology. 2003;99:429–
435.
13.Manickam BP, Oosthuysen SA, Parikh MK. Supraclavicular brachial plexus block-variant
relation of brachial plexus to subclavian artery on the first rib. Reg Anesth Pain Med.
2009;34:383–384.
14.Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the
critically ill. Lung sliding. Chest. 1995;108:1345–1348.
15.Murata H, Sakai A, Hadzic A, Sumikawa K. The presence of transverse cervical and dorsal
scapular arteries at three ultrasound probe positions commonly used in supraclavicular
brachial plexus blockade. Anesth Analg. 2012;115:470–473.
16.Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided
infraclavicular block. Br J Anaesth. 2006;96:502–507.
17.Kilka HG, Geiger P, Mehrkens HH. [Infraclavicular vertical brachial plexus blockade. A
new method for anesthesia of the upper extremity. An anatomical and clinical study].
Anaesthesist. 1995;44:339–344.
18.Sandhu NS, Capan LM. Ultrasound-guided infraclavicular brachial plexus block. Br J
Anaesth. 2002;89:254–259.
19.Crews JC, Gerancher JC, Weller RS. Pneumothorax after coracoid infraclavicular brachial
plexus block. Anesth Analg. 2007;105:275–277.
20.Moayeri N, Renes S, van Geffen GJ, Groen GJ. Vertical infraclavicular brachial plexus
block: needle redirection after elicitation of elbow flexion. Reg Anesth Pain Med.
2009;34:236–241.
21.Rodriguez J, Barcena M, Taboada-Muniz M, Lagunilla J, Alvarez J. A comparison of
single versus multiple injections on the extent of anesthesia with coracoid infraclavicular
brachial plexus block. Anesth Analg. 2004;99:1225–1230.
22.Tran DQ, Dugani S, Dyachenko A, Correa JA, Finlayson RJ. Minimum effective volume
of lidocaine for ultrasound-guided infraclavicular block. Reg Anesth Pain Med.

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 2011;36:190–194.
23.Sandhu NS, Manne JS, Medabalmi PK, Capan LM. Sonographically guided infraclavicular
brachial plexus block in adults: a retrospective analysis of 1146 cases. J Ultrasound Med.
2006;25:1555–1561.
24.Di Filippo A, Orando S, Luna A, et al. Ultrasound identification of nerve cords in the
infraclavicular fossa: a clinical study. Minerva Anestesiol. 2012;78:450–455.
25.Bigeleisen PE. The bifid axillary artery. J Clin Anesth. 2004;16:224–225.
26.Retzl G, Kapral S, Greher M, Mauritz W. Ultrasonographic findings of the axillary part of
the brachial plexus. Anesth Analg. 2001;92:1271–1275.
27.Schafhalter-Zoppoth I, Gray AT. The musculocutaneous nerve: ultrasound appearance for
peripheral nerve block. Reg Anesth Pain Med. 2005;30:385–390.
28.Gray AT. The conjoint tendon of the latissimus dorsi and teres major: an important
landmark for ultrasound-guided axillary block. Reg Anesth Pain Med. 2009;34:179–180.
29.Foxall GL, Skinner D, Hardman JG, Bedforth NM. Ultrasound anatomy of the radial nerve
in the distal upper arm. Reg Anesth Pain Med. 2007;32:217–220.
30.Ferdinand BD, Rosenberg ZS, Schweitzer ME, et al. MR imaging features of radial tunnel
syndrome: initial experience. Radiology. 2006;240:161–168.
31.Hazani R, Engineer NJ, Mowlavi A, Neumeister M, Lee WP, Wilhelmi BJ. Anatomic
landmarks for the radial tunnel. Eplasty. 2008;8:e37.

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CHAPTER 3

Sonoanatomy Relevant for Ultrasound-Guided Lower

Extremity Nerve Blocks

Introduction
Four main nerves of the lumbosacral plexus provide sensory and motor innervation to the
lower extremity: the femoral, lateral femoral cutaneous, obturator, and the sciatic nerve.

Gross Anatomy
The anatomy of the lumbar plexus is described in detail in Chapter 8 (Fig. 3-1). The terminal
nerves of the lumbosacral plexus relevant for innervating the lower extremity include the
lateral cutaneous nerve of the thigh, the femoral nerve, the obturator nerve, and the sciatic
nerve. The lateral cutaneous nerve of the thigh and the femoral nerve leave the lumbar plexus
along the posterolateral border of the psoas major muscle; the obturator nerve emerges from
the medial border of the psoas muscle at the pelvic brim and crosses in front of the sacroiliac
joint.1 The sacral plexus provides sensorimotor innervation to the posterior thigh, most of the
lower extremity, the entire foot, and parts of the pelvis. It is formed by the union of the
anterior primary rami of the spinal nerves of L4, L5, S1, S2, S3, and S4 (lumbosacral plexus,
Fig. 3-2). The sacral plexus lies deep within the pelvis between the piriformis muscle
posteriorly and the pelvis fascia anteriorly (Fig. 3-3). The sigmoid colon, ureter, internal iliac
artery, and vein lie anterior to it. The superior gluteal artery and vein lies between the
lumbosacral trunk and the first sacral nerve, and the inferior gluteal artery and vein lie
between the second and third sacral nerves. The nerves forming the sacral plexus converge as
they descend towards the lower part of the greater sciatic foramen and unite within the pelvis
to form the sciatic nerve (Fig. 3-4). The sciatic nerve is the largest (thickest) nerve of the
body and exits the pelvis through the greater sciatic foramen, between the piriformis and the
superior gemellus muscles (Fig. 3-5), to enter the “subgluteal space” between the greater
trochanter and ischial tuberosity (Figs. 3-6 and 3-7).2,3 Sciatic nerve and piriformis muscle
anomaly are seen in 16.2% (95% CI: 10.7–23.5%) of individuals.4 The entire sciatic nerve or
one of its components (tibial or common peroneal) may rarely exit the pelvis by passing
through or above the superior border of the piriformis muscle.4 The sciatic nerve, after it
emerges from the pelvis, descends along the back of the thigh, lying deep to the
semitendinosus and biceps femoris muscles, to about its lower third (Figs. 3-8 and 3-9),
where it bifurcates into its two branches: the tibial and common peroneal (fibular) nerves.
This bifurcation may take place at any point between its origin at the sacral plexus and the
lower third of the thigh or at a variable distance from the popliteal crease.5 The tibial and
common peroneal nerves may also arise separately from the sacral plexus.

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FIGURE 3-1 Anatomical illustration showing the formation of the lumbosacral plexus.

FIGURE 3-2 Anatomical illustration (frontal view) showing the formation of the sacral
plexus and the sciatic nerve.

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FIGURE 3-3 Anatomical illustration (frontal view) showing the relation of the sacral
plexus to the piriformis muscle and the greater sciatic foramen. Note how the superior
gluteal, inferior gluteal, and pudendal nerve exit the greater sciatic foramen.

FIGURE 3-4 Anatomical illustration (dorsal view) showing the sciatic nerve as it exits the
pelvis through the greater sciatic foramen. Note the relation of the superior and inferior
gluteal nerves, posterior cutaneous nerve of the thigh, nerve to obturator internus, and
pudendal nerve to the sciatic nerve as they exit the greater sciatic foramen.

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FIGURE 3-5 Anatomical illustration showing the relation of the sciatic nerve to the
muscles of the buttock and upper thigh.

FIGURE 3-6 Multiplanar 3-D anatomy (rendered from the Visible Human Server) of the
sciatic nerve at the subgluteal space. Note the reference marker (green crosshair) has been
placed over the sciatic nerve in the transverse view and its corresponding position in the
sagittal and coronal images can be seen. AM, adductor magnus; VL, vastus lateralis; IT,
ischial tuberosity; QF, quadratus femoris; GM, gluteus maximus; GS, gemellus superior; GI,
gemellus inferior; BF, biceps femoris; OI, obturator internus; PF, piriformis.

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FIGURE 3-7 Anatomical illustration showing the transverse anatomy of the gluteal region
at the level of the greater trochanter and ischial tuberosity. Note the subgluteal space and its
contents between the gluteus maximus and quadratus femoris muscles.

Femoral Nerve at the Inguinal Region

Gross Anatomy
The femoral nerve is the largest branch of the lumbar plexus and originates from the posterior
divisions of the anterior primary rami of the L2, L3, and L4 spinal nerves. It descends
through the fibers of the psoas muscle and exits the lateral border of the inferior part of the
psoas muscle in the retroperitoneal space. It then descends between the psoas and the iliacus
muscle deep to the fascia iliaca. It enters the femoral triangle of the thigh behind the inguinal
ligament, lying lateral to the femoral artery and in a groove between the iliacus and psoas
muscles (Fig. 3-10 and 3-11). In between the inguinal ligament and the inguinal crease, the
femoral vein, femoral artery, and the femoral nerve have a “VAN” (vein, artery, nerve)
relation from the medial to lateral side (Fig. 3-11). The femoral artery and vein are enclosed
by the femoral sheath and lie deep to the fascia lata (deep fascia of the thigh), and the femoral
nerve lies outside the femoral sheath and deep to both the fascia lata and fascia iliaca on the
anteromedial aspect of the iliopsoas muscle (Fig. 3-12). The femoral nerve divides into its
anterior and posterior branch after a short course of about 2 cm below the inguinal ligament
or at the level of the inguinal crease.6

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FIGURE 3-8 Multiplanar 3-D anatomy of the sciatic nerve at the midthigh. AL, adductor
longus; AM, adductor magnus; BF, biceps femoris; GM, gluteus maximus; RF, rectus
femoris; SM, semimembranosus; SR, sartorius; ST, semitendinosus; VI, vastus intermedialis;
VL, vastus lateralis; VM, vastus medialis.

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FIGURE 3-9 Multiplanar 3-D anatomy of the sciatic nerve at or close to the apex of the
popliteal fossa. AM, adductor magnus; AL, adductor longus; BF, biceps femoris; GR,
gracilis; SM, semimembranosus; SR, sartorius; ST, semitendinosus; VI, vastus intermedialis;
VL, vastus lateralis; VM, vastus medialis; RF; rectus femoris.

FIGURE 3-10 Anatomy of the femoral nerve at the inguinal region. Note the relation of
the femoral nerve to the femoral artery and vein and the iliopsoas muscle.

FIGURE 3-11 Transverse anatomical section of the inguinal region at the level of the
inguinal ligament. Note the relation of the femoral nerve to the iliopsoas muscle.

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FIGURE 3-12 Fascial anatomy in relation to the femoral nerve at the level of the inguinal
crease. Note both the femoral artery and vein lie deep to the fascia lata and are enclosed by
the femoral sheath, and the femoral nerve lies outside the femoral sheath and deep to both the
fascia lata and iliaca.

Computed Tomography Anatomy of the Inguinal Region

Fig. 3-13

FIGURE 3-13 Transverse (axial) CT of the inguinal region at the level of the inguinal
crease showing the relation of the femoral nerve to the femoral vessel, fascia lata, fascia
iliaca, and iliopsoas muscle. FA, femoral artery; FV, femoral vein.

Magnetic Resonance Imaging Anatomy of the Inguinal Region

Fig. 3-14

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FIGURE 3-14 Transverse (axial) MRI image of the inguinal region showing the femoral
nerve at the level of the inguinal crease. Note the relation of the femoral nerve to the femoral
vessels and the neighboring fascia (lata and iliaca).

Femoral Nerve Ultrasound Scan Technique

1.Position:
a.Patient: Supine with the ipsilateral leg slightly abducted and externally rotated and the
knee slightly flexed.
b.Operator and ultrasound machine: The operator stands on the side of the
intervention and faces the patient’s head. The ultrasound machine is placed on the
same side between the operator and the patient’s head. Alternatively, the operator may
choose to position the ultrasound machine based on his or her “handedness.” Right-
handed operators who hold the ultrasound transducer with their left hand and carry
out needle interventions with their right hand should stand on the right side of the
patient and position the ultrasound machine on the contralateral side and directly in
front. This is vice versa for left-handed operators.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: For a transverse scan of the femoral nerve, place the ultrasound
transducer parallel to the inguinal ligament and approximately 1 cm proximal to the
inguinal crease (Figs. 3-15 to 3-17). Gently slide the transducer in a medial to lateral
direction until a cross-sectional view of the femoral artery is obtained. The femoral vein
lies medial to the femoral artery, and the femoral nerve is lateral to the artery (Fig. 3-18).
The femoral vein is compressible, but the femoral artery may not be easily compressible.
Color or Power Doppler should be used to differentiate the femoral artery from the vein
as part of one’s scan routine (Fig. 3-19). The femoral nerve is most commonly seen on the
anteromedial surface of the iliopsoas muscle (Fig. 3-18).

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FIGURE 3-15 Figure showing the position of the ultrasound transducer during a
transverse ultrasound scan for the femoral nerve at the inguinal region.

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FIGURE 3-16 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan for the femoral nerve at the inguinal region.

FIGURE 3-17 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the femoral nerve at the inguinal region. FA, femoral artery;
FV, femoral vein.

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FIGURE 3-18 Transverse sonogram of the femoral nerve at the inguinal region. Note the
relation of the femoral nerve to the femoral vessel, iliopsoas muscle, and the neighboring
fascia (lata and iliaca). FV, femoral vein; FA, femoral artery.

FIGURE 3-19 Color Doppler sonogram of the femoral vessels at the inguinal region. FA,
femoral artery; FV, femoral vein.

4.Sonoanatomy: The femoral nerve is typically identified on the anteromedial surface of the
psoas muscle as a flat, hyperechoic, and elliptical-shaped structure (Fig. 3-18). Outlines
of the fascia iliaca, with the femoral nerve lying deep to this fascia, may be visualized in
some individuals (Fig. 3-18).
5.Clinical Pearls: The femoral nerve is markedly anisotropic in the inguinal region.7
Therefore, it may be necessary to gently tilt or rotate the transducer during the ultrasound

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 scan before it can be clearly delineated. It is our experience that the position of the
femoral nerve, relative to the femoral artery, in the femoral triangle is quite variable.
Therefore, we prefer to look for the femoral nerve on the anteromedial surface of the
iliopsoas muscle rather than immediately lateral to the femoral artery during the scan.
Also in order to locate the femoral nerve before it divides into its anterior and posterior
branches, it is preferable to start the ultrasound scan immediately below the inguinal
ligament rather than at the inguinal crease. The profunda femoris artery, which is the
largest branch of the femoral artery, can be a useful clue as to the level at which the
ultrasound scan is being performed. If the profunda femoris artery is seen adjacent
(lateral) to the femoral artery in the ultrasound image (Fig. 3-20), it indicates that the
ultrasound scan is being performed too low and below the division of the femoral nerve
because the profunda femoris artery is generally given off from the femoral artery, about
4 cm below the inguinal ligament.

FIGURE 3-20 Transverse sonogram of the inguinal region showing the origin of the
profunda femoris artery from the femoral artery.

Obturator Nerve at the Inguinal Region

Gross Anatomy
The obturator nerve is a branch of the lumbar plexus and formed by the anterior division of
the anterior primary rami of the L2, L3, and L4 spinal nerves. It exits the pelvis and enters the
thigh through the obturator canal. It then divides into its anterior and posterior divisions,
usually lateral and distal to the pubic tubercle (Fig. 3-1).8 The anterior division courses
distally, lying between the adductor brevis and the adductor longus muscles, and the posterior
division passes distally between the adductor brevis and adductor magnus muscles (Figs. 3-
21 and 3-22).

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FIGURE 3-21 Anatomical section of the anterior and medial compartments of the thigh 5
to 8 cm distal to the inguinal crease.

FIGURE 3-22 Cross-sectional anatomy of the thigh distal to the inguinal crease. Note the
relation of the anterior and posterior divisions of the obturator nerve to the adductor muscles
(longus, brevis, and magnus).

Computed Tomography Anatomy of the Upper Thigh

Fig. 3-23

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FIGURE 3-23 Transverse (axial) CT of the proximal thigh showing the obturator nerves
and their relations. FV, femoral vein.

Magnetic Resonance Imaging Anatomy of the Upper Thigh

Fig. 3-24

FIGURE 3-24 Transverse (axial) MRI image of the proximal thigh showing the obturator
nerves and their relations.

Obturator Nerve Ultrasound Scan Technique

1.Position:

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 a.Patient: Supine with the ipsilateral leg straight and slightly externally rotated at the hip.
This position allows optimal visualization of the obturator nerve and its branches.8
b.Operator and ultrasound machine: The operator stands on the ipsilateral side of the
scan or intervention and faces the patient’s head. The ultrasound machine is placed on
the ipsilateral side directly in front of the operator. Alternatively, the operator may
choose to position the ultrasound machine depending on his or her “handedness.”
Right-handed operators who hold the ultrasound transducer with their left hand and
carry out needle interventions with their right hand should stand on the right side of
the patient and position the ultrasound machine on the opposite side of the patient.
This is vice versa for left-handed operators.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: The transducer is placed in the transverse orientation 2 cm distal to the
pubic tubercle on the medial aspect of the thigh (Figs. 3-25 and 3-26). Alternatively start
the ultrasound scan by placing the transducer parallel to the inguinal ligament and over
the inguinal crease.9 Then slide the transducer medially until the pectineus is visualized
on the lateral aspect of the ultrasound screen.9 At this point, the adductor muscles
(longus, brevis, and magnus) are visualized adjacent to the pectineus (Fig. 3-27). Because
the anterior and posterior divisions of the obturator nerve are flat and small nerves,8 it is
easier to identify them in their respective intermuscular fascial planes by sliding the
transducer proximally and distally analogous to the trace back technique. Slightly tilting
or rotating the transducer may also help improve visualization. If one traces the two
divisions of the obturator nerve proximally, they are seen to come together to form the
common obturator nerve.8 Color or Power Doppler ultrasound can also be used to
identify the obturator artery that accompanies the common obturator nerve.8

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FIGURE 3-25 Figure showing the position of the ultrasound transducer relative to the
thigh during a transverse scan for the anterior and posterior divisions of the obturator nerve.

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FIGURE 3-26 Transverse sonogram of the medial compartment of the upper thigh
showing the branches of the obturator nerve in the intermuscular plane between the adductor
muscles. Accompanying photographs show the position and orientation of the transducer
during the ultrasound scan.

FIGURE 3-27 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the anterior and posterior division of the obturator nerve at the
medial aspect of the upper thigh.

4.Sonoanatomy: The common obturator nerve or its divisions (anterior and posterior) are
not readily identified as discrete nerves on ultrasound imaging, as they are small and flat

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 nerves.8 Unlike other peripheral nerves, the anterior and posterior divisions of the
obturator nerve appear as two flat and hyperechoic structures in the intermuscular fascial
planes between the adductor muscles (Fig. 3-28).

FIGURE 3-28 Transverse sonogram of the medial compartment of the proximal thigh
showing the adductor muscles (longus, brevis, and magnus) and the anterior and posterior
divisions of the obturator nerve in the intermuscular plane between the adductor muscles.

5.Clinical Pearls: The anterior division travels in the intermuscular plane between the
adductor longus and adductor brevis muscles. The posterior division travels in the plane
between the adductor brevis and adductor magnus muscles. The typical appearance on a
transverse sonogram would include the pectineus muscle on the lateral aspect of the
screen and the three adductors muscles on the medial aspect, with the adductor longus
being most superficial, the adductor brevis in the middle, and the adductor magnus
deepest, respectively (Figs. 3-27 and 3-28). Small branches of the obturator vessels
accompany the divisions of the obturator nerve in the intermuscular plane and can be
identified using Color or Power Doppler ultrasound.8 However, to what extent this is
reliable in locating the nerves is yet to be determined, as the position of the obturator
vessels relative to the nerves is variable.

Lateral Cutaneous Nerve of the Thigh

Gross Anatomy
The lateral cutaneous nerve of the thigh, also called the lateral femoral cutaneous nerve of the
thigh, innervates the skin on the lateral aspect of the thigh. It is a branch of the lumbar plexus
and formed within the psoas muscle by the fusion of the posterior divisions of the L2 and L3
spinal nerves. It exits the psoas muscle from its lateral border, in the retroperitoneum, at
about its middle and travels across the iliacus muscle obliquely lying deep to the fascia iliaca
(Fig. 3-1). It enters the thigh medial to the anterior superior iliac spine (ASIS) lying under the
lateral edge of the inguinal ligament (Figs. 3-29 and 3-30). It then crosses over the sartorius

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muscle in a medial to lateral direction. The course of the lateral cutaneous nerve of the thigh
is highly variable. It is found most commonly 10 to 15 millimeters medial to the ASIS but
can be located as far medially as 46 millimeters.10 Its depth in relation to the soft tissues in
the region, the sartorius, and the inguinal ligament is also highly variable. Five different
variations have been identified: type A, posterior to the ASIS, across the iliac crest; type B,
anterior to the ASIS and superficial to the origin of the sartorius muscle but within the
substance of the inguinal ligament; type C, medial to the ASIS, ensheathed in the tendinous
origin of the sartorius muscle; type D, medial to the origin of the sartorius muscle located in
an interval between the tendon of the sartorius muscle and thick fascia of the iliopsoas muscle
deep to the inguinal ligament; and type E, most medial and embedded in loose connective
tissue, deep to the inguinal ligament, overlying the thin fascia of the iliopsoas muscle, and
contributing the femoral branch of the genitofemoral nerve.11

FIGURE 3-29 Anatomical illustration showing the lateral femoral cutaneous nerve
entering the thigh under the lateral edge of the inguinal ligament and medial to the anterior
superior iliac spine (ASIS).

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FIGURE 3-30 Transverse anatomical section of the upper thigh and lower abdomen a few
centimeters distal to the anterior superior iliac spine showing the anatomy related to the
lateral femoral cutaneous nerve (the nerve is not seen in this image), which usually lies on the
anterior surface of the sartorius muscle or in the groove between the sartorius and the iliacus
muscles at this level. IO, internal oblique muscle; TA, transversus abdominis muscle.

Magnetic Resonance Imaging Anatomy of the Lateral Cutaneous Nerve of the

Thigh
Fig. 3-31

FIGURE 3-31 Transverse (axial) MRI image of the upper thigh showing the lateral
cutaneous nerve of the thigh.

Lateral Cutaneous Nerve of the Thigh Ultrasound Scan Technique

1.Position:
a.Patient: Supine position
b.Operator and ultrasound machine: The operator may stand on the ipsilateral side of
the intervention and face the patient’s head. The ultrasound machine is placed on the
same side between the operator and the patient’s head. Alternatively, the operator may
choose to position the ultrasound machine depending on his or her “handedness.”
Right-handed operators who hold ultrasound transducer with their left hand and carry
out needle interventions with their right hand should stand on the right side of the
patient and position the ultrasound machine on the opposite side of the patient. This is
vice versa for left-handed operators.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: The transducer is placed with one edge on the ASIS. The medial edge of
the transducer is rotated slightly caudally such that the transducer is parallel to the
inguinal ligament. Slide the transducer medially along the inguinal ligament (Figs. 3-32 to
3-34). The ASIS appears as a hyperechoic line with an acoustic shadow. Immediately

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 medial to the ASIS is the iliacus muscle. At the level of the inguinal ligament, the lateral
cutaneous nerve can be visualized deep to the fascia lata just medial to the ASIS.12 The
transducer can be slid distally approximately 5 cm caudad to the ASIS and rotated to a
transverse orientation relative to the femur. At this location, the lateral cutaneous nerve of
the thigh is located on the sartorius muscle or in the groove between the sartorius and the
iliacus muscles (Fig. 3-35).

FIGURE 3-32 Figure showing the position of the ultrasound transducer during a
transverse scan for the lateral femoral cutaneous nerve at the inguinal region.

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FIGURE 3-33 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan for the lateral femoral cutaneous nerve at the inguinal
region. Note the ultrasound transducer is positioned a few centimeters distal and medial to the
anterior superior iliac spine.

FIGURE 3-34 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the lateral femoral cutaneous nerve at the inguinal region.

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FIGURE 3-35 Transverse sonogram of the inguinal region at the level of the anterior
superior iliac spine showing the lateral cutaneous nerve of the thigh lying on the anterior
surface (superficial to) the iliacus muscle.

4.Sonoanatomy: The lateral cutaneous nerve of the thigh is a small nerve that may appear as
a hypoechoic to hyperechoic structure. At the level of the inguinal ligament, it lies medial
to the ASIS and deep to the fascia iliacus. It then courses distally in the groove between
the sartorius and iliacus, crossing over the anterior surface of the sartorius (Fig. 3-35) to
the lateral aspect of the sartorius muscle.
5.Clinical Pearls: The lateral cutaneous nerve of the thigh is a small nerve and can be best
visualized using a high-frequency linear transducer. The “trace back” technique is
important and useful to confirm the identity of the nerve. The important landmarks here
are the medial edge of the ASIS, the groove between the satorius and iliacus, and the
anterior surface of the sartorius. The nerve can usually be located at one of these areas
and “traced back” to confirm its identity along the course. Injection of a small volume of
normal saline around the nerve can be used to delineate its course (hydrolocation). It is
common to see the injectate spread along its course proximally under the inguinal
ligament and under the fascia iliaca within the pelvis.

Saphenous Nerve at the Adductor Canal

Gross Anatomy
Distal to the inguinal crease, the femoral nerve divides into its terminal branches.6 The
saphenous nerve is a branch of the anterior division of the femoral nerve and supplies the skin
on the medial aspect of the leg and foot up to the ball of the big toe. It travels with the
femoral artery within the anterior fascial compartment of the thigh under the sartorius muscle
(subsartorial), and local anesthetic injected into this intermuscular space produces saphenous
nerve block.13 The “subsartorial canal” is also referred to as the adductor canal or Hunter’s
canal and is located on the medial aspect of the middle one-third of the thigh (Fig. 3-36). The
adductor canal is triangular in cross-section (Figs. 3-37 and 3-38) and extends from the apex

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of the femoral triangle, above, to the tendinous opening in the adductor magnus muscle
(adductor hiatus), below. The anterior wall of the adductor canal is formed by the vastus
medialis muscle; the posterior wall or floor is formed by the adductor longus, above, and the
adductor magnus, below; and the roof or medial wall is formed by a strong fibrous membrane
underlying the sartorius muscle (Figs. 3-37 and 3-38).
The adductor canal contains the following structures: femoral artery and vein, saphenous
nerve, anterior and posterior division of the obturator nerve, and nerve to vastus medialis
(Fig. 3-38). The femoral vein lies posterior to the femoral artery in the upper part of the
adductor canal and lateral to the artery in the lower part of the canal (Fig. 3-39). The
saphenous nerve crosses the femoral artery anteriorly from a lateral to medial direction. The
“subsartorial plexus” of nerves lie on the fibrous roof of the adductor canal deep to the
sartorius muscle (Fig. 3-38) and are formed by branches from the medial cutaneous nerve of
the thigh, saphenous nerve, and anterior division of the obturator nerve. It supplies the
neighboring skin and overlying fascia lata. The femoral artery exits the adductor canal
through the adductor hiatus and continues as the popliteal artery. At the adductor hiatus, the
saphenous nerve leaves the femoral artery and travels along the lower edge of the aponeurosis
of the canal and is closely related to the saphenous branch of the descending genicular
artery.14 The saphenous nerve then courses distally along the medial side of the knee deep to
the sartorius and pierces the fascia lata, between the tendons of the sartorius and gracilis
muscles.

FIGURE 3-36 Transverse anatomical section of the midthigh showing the anatomy of the
anterior, medial, and posterior compartment of the thigh.

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FIGURE 3-37 Transverse anatomical illustration of the midthigh showing the anatomy of
the adductor canal.

FIGURE 3-38 Anatomical illustration showing the boundaries and contents of the
adductor canal.

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FIGURE 3-39 Anatomical illustration showing the course of the saphenous nerve relative
to the femoral vessels within the adductor canal.

Computed Tomography Anatomy of the Midfemoral/Adductor Canal Region

Fig. 3-40

FIGURE 3-40 Transverse (axial) CT of the midthigh showing the relation and contents of
the adductor canal.

Magnetic Resonance Imaging Anatomy of the Midfemoral/Adductor Canal

Region

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Fig. 3-41

FIGURE 3-41 Transverse (axial) MRI image of the midthigh showing the relation and
contents of the adductor canal.

Midfemoral/Adductor Canal Region Ultrasound Scan Technique

1.Position:
a.Patient: Supine position with the ipsilateral hip slightly externally rotated and knee
slightly flexed.
b.Operator and ultrasound machine: The operator may choose to position the
ultrasound machine based on his or her “handedness.” Right-handed operators who
hold ultrasound probes with their left hand and carry out needle interventions with
their right hand should stand on the right side of the patient and position the
ultrasound machine on the opposite side of the patient. This is vice versa for left-
handed operators.
2.Transducer selection: High-frequency (15-8 MHz) linear array transducer. A curved array
low-frequency (5-2 MHz) transducer can also be used if one wishes to visualize the
sciatic nerve, which is located at a depth, at the same time.
3.Scan technique: The ultrasound transducer is placed on a medial aspect of the thigh of the
middle third of the thigh (midfemoral region) in the transverse orientation (Figs. 3-42 to
3-46). The reference structure to identify is the femoral artery in the transverse view.
Thereafter slide the transducer along the medial border of the sartorius to visualize the
artery at its most superficial location and just proximal to the point where the femoral
artery passes the adductor hiatus to become the popliteal artery.15 The sartorius is
typically triangular/elliptical in shape when imaged transversely. Beneath the sartorius,
the femoral artery and veins can be imaged and followed until they pass through the
adductor hiatus.

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FIGURE 3-42 Figure showing the position of the ultrasound transducer relative to the
thigh during a transverse ultrasound scan for the saphenous nerve at the adductor canal
(midthigh).

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FIGURE 3-43 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan of the adductor canal at the midthigh.

FIGURE 3-44 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan of the adductor canal at the midthigh.

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FIGURE 3-45 Figure highlighting the anatomical structures that are imaged during a
transverse ultrasound scan at the level of the midthigh using a low-frequency transducer.
Note that the sciatic nerve is also included in the highlighted area and can be visualized
during the midthigh (midfemoral) scan.

FIGURE 3-46 Anatomical structures that are visualized during a midfemoral (midthigh)
ultrasound scan.

4.Sonoanatomy: The saphenous nerve is a small nerve and may not be visualized as a
discrete structure in all individuals at the adductor canal. When visualized, it is seen as a

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 hyperechoic structure that is closely related to the femoral artery (Fig. 3-47).

FIGURE 3-47 Transverse sonogram showing the boundaries and contents of the adductor
canal. FA, femoral artery; FV, femoral vein.

5.Clinical Pearls: Because the saphenous nerve is a small nerve, the trace back technique16
is useful for locating it. It can also be followed distally where it lies between the sartorius
and the gracilis muscles and with the saphenous branch of the descending genicular
artery. When there is difficulty visualizing the saphenous nerve, imaging the most
superficial portion of the distal adductor canal and using a periarterial injection deep to
the sartorius, medial to the artery is adequate for a successful saphenous nerve block.15

Sciatic Nerve at the Parasacral Region

Gross Anatomy
A parasacral sciatic nerve block is the technique of injecting local anesthetic in a fascial plane
around the nerves of the sacral plexus before the sciatic nerve is formed.17,18 Therefore, it
may be considered a sacral plexus block.17,18 Currently, the majority of published data
describe using peripheral nerve stimulation19–21 but recently ultrasound-guided parasacral
sciatic nerve block has been described.22 Because the sacral plexus is located deep within the
pelvis in a fascial plane between the piriformis muscle and the pelvic fascia (Figs. 3-2 and 3-
3), the block needle has to enter the pelvis through the greater sciatic foramen during a
parasacral sciatic nerve block (Fig. 3-48). The internal iliac artery and vein or their branches
and the pelvic veins are also closely related to the sacral plexus in the pelvis (Figs. 3-49 to 3-
51). The following structures also pass through the greater sciatic foramen: (a) piriformis
muscle; (b) structures passing above the piriformis muscle: superior gluteal vessels and
nerve; and (c) structures passing below the piriformis: inferior gluteal vessels and nerve,
sciatic nerve, posterior cutaneous nerve of thigh, nerve to quadratus femoris muscle,
pudendal nerve and vessels, and nerve to obturator internus.

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FIGURE 3-48 Anatomical illustration showing the sacral plexus (within the pelvis)
formation of the sciatic nerve and how it exits the pelvis through the greater sciatic foramen
to enter the gluteal region. Note in this anatomical section one of the components of the
sciatic nerve is seen to exit the pelvis by traversing the piriformis muscle to join the other
component in the infrapiriformis fossa (a normal anatomical variation).

FIGURE 3-49 Sagittal oblique CT image demonstrating the sciatic nerve between the
ilium and ischium (greater sciatic foramen).

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FIGURE 3-50 Sagittal oblique CT image depicting the parasacral relations and course of
the sciatic nerve in the gluteal region. Note the close proximity of the iliac veins and large
bowel to the sacral plexus and sciatic nerve at the level of the greater sciatic foramen.

FIGURE 3-51 Sagittal oblique MRI image at the level of the greater sciatic foramen
demonstrating the sacral plexus and the parasacral relation of the sciatic nerve.

Computed Tomography Anatomy of the Sciatic Nerve – Parasacral Region

Figs. 3-49 and 3-50

Magnetic Resonance Imaging Anatomy of the Sciatic Nerve – Parasacral

Region

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Fig. 3-51

Sciatic Nerve – Parasacral Region Ultrasound Scan Technique

1.Position:
a.Patient: Semiprone (Sims’) position with the side to be examined uppermost and the
upper hip flexed to about 90 degrees.
b.Operator and ultrasound machine: The operator sits or stands behind the patient with
the ultrasound machine placed directly in front.
2.Transducer selection: Low-frequency (5-2 MHz) curved array transducer.
3.Scan technique: Various techniques for identifying the sonoanatomy relevant for
parasacral sciatic nerve block have been described in the literature.22 We prefer to start
the ultrasound scan by placing the transducer in the transverse orientation between the
greater trochanter and ischial tuberosity. Here the sciatic nerve is consistently identified
as a hyperechoic oval structure in the subgluteal space between the gluteus maximus
muscle posteriorly and the quadratus femoris muscle anteriorly.2,3 The ultrasound image
is optimized after which the transducer is rotated through 90 degrees to obtain a sagittal
view of the sciatic nerve. Then gently slide the transducer cephalad, keeping the sciatic
nerve in view until it is seen to lie in the infrapiriformis fossa between the gluteus
maximus posteriorly and the gemelli muscles and tendon of obturator internus anteriorly
(Figs. 3-52 to 3-54). Dynamic scanning by asking an assistant to rotate the hip (externally
and internally), with the knee flexed, will demonstrate a side-to-side gliding motion of the
piriformis muscle on the ultrasound image. Color or Power Doppler ultrasound can be
used to identify the inferior gluteal artery, which emerges from under the inferior border
of the piriformis muscle. The inferior border of the ilium and ischium, with their acoustic
shadows, and the greater sciatic foramen can then be delineated in the sagittal sonogram.
One can then rotate the transducer to the transverse orientation to obtain a transverse view
of the sciatic nerve as it exits the pelvis through the greater sciatic foramen (Figs. 3-55
and 3-56).

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FIGURE 3-52 Figure showing the position of the ultrasound transducer during a sagittal
scan for the sacral plexus and sciatic nerve at the level of the greater sciatic foramen
(parasacral scan).

FIGURE 3-53 Figure highlighting the anatomical structures that are insonated during a
sagittal ultrasound scan for the sacral plexus and sciatic nerve at the level of the greater
sciatic foramen (parasacral scan).

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FIGURE 3-54 Sagittal sonogram of the sciatic nerve as it exits the pelvis through the
greater sciatic foramen. Accompanying photograph shows the position and orientation of the
ultrasound transducer during a sagittal ultrasound scan for the sacral plexus and sciatic nerve
at the level of the greater sciatic foramen (parasacral scan). RPS, retroperitoneal space.

FIGURE 3-55 Figure showing the position of the ultrasound transducer during a
transverse scan for the sciatic nerve at the level of the greater sciatic foramen (parasacral
scan).

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4.Sonoanatomy: The sciatic nerve appears as a thick, hyperechoic linear structure in a
sagittal sonogram of this region (Figs. 3-57 and 3-58). In some individuals a distinct
perineural space, similar to that seen at the subgluteal space3 or thigh,2 can be delineated
at the parasacral region (Figs. 3-57 and 3-58). Proximally the greater sciatic foramen is
seen as an acoustic window between the acoustic shadows of the inferior border of the
ilium and the ischium (Fig. 3-57). The pelvic peritoneum can be identified as a
hyperechoic linear shadow through this acoustic window, and the sacral plexus nerves
appear as hyperechoic linear elements posterior (external) to the peritoneum (Fig. 3-57).
The inferior gluteal artery can also be identified using Doppler ultrasound (Fig. 3-59). On
a transverse sonogram at the level or just distal to the greater sciatic foramen, the sciatic
nerve is seen as a flat-to-oval hyperechoic structure in between the gluteus maximus and
gemelli muscles (Fig. 3-60).

FIGURE 3-56 Transverse sonogram of the sciatic nerve as it exits the pelvis through the
greater sciatic foramen. Accompanying photograph shows the position and orientation of the
ultrasound transducer during a transverse ultrasound scan for the sciatic nerve at the level of
the greater sciatic foramen (parasacral scan). RPS, retroperitoneal space.

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FIGURE 3-57 Sagittal sonogram at the level of the greater sciatic foramen (parasacral
scan) showing the sacral plexus and the sciatic nerve as it exits the pelvis to enter the infra-
piriformis fossa.

FIGURE 3-58 Sagittal sonogram showing the sciatic nerve, between the piriformis muscle
posteriorly and the gemelli muscles anteriorly, immediately distal to the greater sciatic
foramen. Note the hypoechoic perineural space between the sciatic nerve and the piriformis
muscle posteriorly. The sciatic nerve is also seen to continue distally to enter the subgluteal
space between the gluteus maximus posteriorly and the quadratus femoris anteriorly.

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FIGURE 3-59 Color Doppler sonogram showing the inferior gluteal artery as it exits the
greater sciatic foramen.

FIGURE 3-60 Transverse sonogram showing the sciatic nerve, between the gluteus
maximus and the gemelli muscles, immediately distal to the greater sciatic foramen
(parasacral position).

5. Clinical Pearls: Because the parasacral sciatic nerve block is a deep block with potential
for complications such as pelvic hematoma formation, visceral injury (colon or ureter),
inadvertent intravascular injection, transient sciatic neuralgia,19 we believe it should be
considered an advanced regional anesthetic technique and only used when other sciatic
nerve block techniques are considered inadequate or inappropriate. Also the presence of
an “intermuscular perineural space”2 through which the sciatic nerve exits the pelvis and

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 descends caudally deserves further investigation as a site for local anesthetic injection
because it can be identified using ultrasound imaging (Figs. 3-57 and 3-58). We believe
that local anesthetic injected into this perineural space close to the greater sciatic foramen
will not only anesthetize the sacral plexus nerves, but also the sciatic nerve because of
cranial and caudal spread of the local anesthetic through the intermuscular “conduit.”
This may also be safer than inserting the block needle into the pelvis to anesthetize the
sacral plexus nerves during a parasacral sciatic nerve block. Future research to validate
this hypothesis in clinical practice is warranted.

Sciatic Nerve – At the Subgluteal Region

Gross Anatomy
Once the sciatic nerve exits the greater sciatic foramen, it enters the subgluteal space below
the piriformis muscle. It then descends on the dorsal surface of the ischium, together with the
posterior cutaneous nerve of the thigh, lying on the posterior surface of the gemellus superior
muscle, tendon of obturator internus, gemellus inferior muscle, and the quadratus femoris
muscle (in a cranial to caudal direction) before it enters the hollow between the greater
trochanter and the ischial tuberosity (Figs. 3-5 to 3-7).23 The “subgluteal space” is a well-
defined anatomical space between the anterior surface of the gluteus maximus and the
posterior surface of the quadratus femoris muscle (Fig. 3-61)23 and contains the sciatic nerve,
posterior cutaneous nerve of the thigh, inferior gluteal vessels and nerve, nerve to the short
and long heads of the biceps femoris, the comitans artery and vein of the sciatic nerve, and
the ascending branch of the medial circumflex femoral artery (Fig. 3-7).23

FIGURE 3-61 Anatomical illustration showing the sciatic nerve at the subgluteal space
between the gluteus maximum muscle posteriorly and the quadratus femoris muscle
anteriorly.

Computed Tomography Anatomy of the Sciatic Nerve – Subgluteal Region

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Fig. 3-62

FIGURE 3-62 Transverse (axial) CT image demonstrating the subgluteal space at the level
of the greater trochanter and ischial tuberosity. Note the subgluteal space between the gluteus
maximus muscle posteriorly and the quadratus femoris muscle anteriorly.

Magnetic Resonance Imaging Anatomy of the Sciatic Nerve – Subgluteal Region

Fig. 3-63

FIGURE 3-63 Transverse (axial) MRI image demonstrating the subgluteal space, between
the gluteus maximus muscle posteriorly and the quadratus femoris muscle anteriorly, at the
level of the greater trochanter and ischial tuberosity. Note the tendons of semitendinosus and
biceps femoris at the medial end of the subgluteal space.

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Sciatic Nerve at the Subgluteal Region – Ultrasound Scan Technique
1.Position:
a.Patient: Lateral position with the side to be examined uppermost (nondependent side)
and the hip and knees slightly flexed. It is also possible to position the patient in the
semiprone (Sims’) position.
b.Operator and ultrasound machine: The operator sits or stands behind the patient with
the ultrasound machine placed directly in front.
2.Transducer selection: Low-frequency (5-2 MHz) curved array transducer.
3.Scan technique: The ultrasound transducer is placed parallel to a line joining the greater
trochanter and the ischial tuberosity (Figs. 3-64 to 3-66) to obtain a transverse image of
the sciatic nerve in the subgluteal space. It may be necessary to slide the transducer in a
cranial to caudal direction to obtain an optimal image of the sciatic nerve. The greater
trochanter and the ischial tuberosity are visualized at the edges of the ultrasound image.
They appear hyperechoic with a corresponding acoustic shadow and are key landmarks
for imaging this region. Rotating the transducer through 90 degrees produces a sagittal
image of the sciatic nerve and the subgluteal space.

FIGURE 3-64 Figure showing the position of the ultrasound transducer during a

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transverse scan for the sciatic nerve at the level of the subgluteal space between the greater
trochanter and ischial tuberosity.

FIGURE 3-65 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan for the sciatic nerve at the subgluteal space between the greater
trochanter and ischial tuberosity.

FIGURE 3-66 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the sciatic nerve at the subgluteal space between the greater
trochanter and ischial tuberosity.

4.Sonoanatomy: The sciatic nerve in the subgluteal region appears as a triangular to oval

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 hyperechoic structure approximately 1.5 to 2 cm in diameter and lying deep to the gluteus
maximus muscle.23 The sciatic nerve is visualized in a hypoechoic space, the “subgluteal
space,”23 between the epimysium of the gluteus maximus muscle and the quadratus
femoris muscle (Fig. 3-67).23 Although well defined, the subgluteal space can vary in
width, is more prominent close to the greater trochanter, and is generally obscured close
to the ischial tuberosity (Fig. 3-67).23 This may be due to the attachment of the tendon of
biceps femoris and semitendinosus to the ischial tuberosity (Fig. 3-63). The subgluteal
space also extends in a cranial and caudal direction as an intermuscular perineural tunnel
or as a conduit for the sciatic nerve.2 This is clearly visualized on a sagittal sonogram
(Fig. 3-68), multiplanar 3-D ultrasound images (Fig. 3-69), or i-slice display (Fig. 3-70)
of the subgluteal region.

FIGURE 3-67 Transverse sonogram demonstrating the hypoechoic subgluteal space

between the hyperechoic epimysium of the gluteus maximus muscle and the quadratus
femoris muscle. The sciatic nerve is seen as a hyperechoic nodule in the medial aspect of the
subgluteal space. Also note the origin of the tendon of biceps femoris from the ischial
tuberosity.

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FIGURE 3-68 Sagittal sonogram in color mode demonstrating the hypoechoic subgluteal
space and sciatic nerve between the hyperechoic epimysium of the gluteus maximus muscle
posteriorly and the quadratus femoris muscle anteriorly.

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FIGURE 3-69 A multiplanar 3-D view of the sciatic nerve at the subgluteal space,
between the greater trochanter and ischial tuberosity. The “reference maker” (green crosshair)
has been placed over the sciatic nerve and corresponding views of the sciatic nerve in the
transverse, sagittal, and coronal planes are visualized. GT, greater trochanter; IT, ischial
tuberosity.

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FIGURE 3-70 A transverse i-slice display of the sciatic nerve at the subgluteal space in
color (sepia tone) mode. In this figure 16 contiguous sagittal cuts of the sciatic nerve volume,
which are 0.9 mm apart, are displayed.

5.Clinical Pearls: The sciatic nerve exhibits anisotropy at the subgluteal region and requires
slight tilting or rotation of the transducer during the ultrasound scan to clearly delineate
the nerve. Color or Power Doppler ultrasound is useful in delineating the inferior gluteal
artery, which is close to the sciatic nerve in the subgluteal space.

Sciatic Nerve at the Infragluteal Region

Gross Anatomy
After the sciatic nerve descends from the subgluteal space, it enters the back of the thigh

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lying relatively superficial at the infragluteal region (ie, below the gluteal crease). Here the
sciatic nerve is relatively flat in shape and lies in an intermuscular fascial plane between the
lower slips of the gluteus maximus and biceps femoris muscle posteriorly and the adductor
magnus muscle anteriorly (Figs. 3-71 and 3-72).

FIGURE 3-71 Transverse anatomical section of the thigh showing the sciatic nerve at the
infragluteal location (ie, distal to the inferior border of the gluteus maximus). Note the sciatic
nerve is relatively superficial and located between the biceps femoris muscle posteriorly and
the adductor magnus muscle anteriorly. Some of the lower slips of the gluteus maximus
muscle are also seen posterior to the biceps femoris muscle.

FIGURE 3-72 Sagittal anatomical section of the thigh showing the sciatic nerve at the
infragluteal location.

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Computed Tomography Anatomy of the Sciatic Nerve – Infragluteal Region
Fig. 3-73

FIGURE 3-73 Transverse (axial) CT image of the thigh showing the relations of the
sciatic nerve at the infragluteal location. FA, femoral artery; FV, femoral vein; PFA,
profunda femoris artery; PFV, profunda femoris vein.

Magnetic Resonance Anatomy of the Sciatic Nerve – Infragluteal Region

Fig. 3-74

FIGURE 3-74 Transverse (axial) MRI image of the thigh showing the relations of the
sciatic nerve at the infragluteal location. Note the posterior femoral cutaneous nerve of the

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thigh on the posterior aspect of the semitendinosus muscle.

Sciatic Nerve at the Infragluteal Region – Ultrasound Scan Technique

1.Position:
a.Patient: Lateral position with the side to be examined uppermost (nondependent side)
and the hip and knees slightly flexed. It is also possible to position the patient in the
semiprone (Sims’) or prone position.
b.Operator and ultrasound machine: The operator sits or stands behind the patient with
the ultrasound machine placed directly in front.
2.Transducer selection: Because the sciatic nerve is relatively superficial at this level, it is
possible to use a high-frequency (12-5 MHz) linear array transducer for the ultrasound
scan. We prefer to use a low-frequency (5-2 MHz) curved array transducer because it
provides a wider field of view.
3.Scan technique: Start by placing the ultrasound transducer parallel to a line joining the
greater trochanter and the ischial tuberosity as described earlier for the sciatic nerve at the
subgluteal space (Figs. 3-75 to 3-77). Once the sciatic nerve is identified in the transverse
sonogram, slide the transducer caudally until it is below the gluteal crease. The sciatic
nerve is seen lying superficially between the biceps femoris muscle posteriorly and the
adductor magnus muscle anteriorly. It is not uncommon to visualize the lower slips of the
gluteus maximus muscle posterior to the biceps femoris muscle in the transverse
sonogram.

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FIGURE 3-75 Figure showing the position of the ultrasound transducer during a
transverse scan for the sciatic nerve at the infragluteal position.

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FIGURE 3-76 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan for the sciatic nerve at the infragluteal position.

FIGURE 3-77 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the sciatic nerve at the infragluteal position.

4.Sonoanatomy: The sciatic nerve is visualized as a triangular hyperechoic structure

between the biceps femoris muscle posteriorly and the adductor magnus muscle anteriorly
(Fig. 3-78). Some of the lower slips of the gluteus maximus muscle may also be
visualized posterior to the biceps femoris muscle in the transverse sonogram.

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FIGURE 3-78 Transverse sonogram showing the sciatic nerve as an oval-to-elliptical
hyperechoic structure between the gluteus maximus muscle posteriorly and the adductor
magnus anteriorly at the infragluteal position.

5.Clinical Pearls: Because the sciatic nerve is relatively superficial at the infragluteal
region, it is a recommended site for sciatic nerve block in the obese.

Sciatic Nerve at the Popliteal Fossa

Gross Anatomy
The popliteal fossa is a diamond-shaped space that lies posterior to the knee joint, lower part
of the femur, and upper part of the tibia (Fig. 3-79). It is bound superolaterally by the tendon
of biceps femoris, superomedially by the tendon of semitendinosus and semimembranosus,
inferolaterally by the lateral head of gastrocnemius, and inferomedially by the medial head of
gastrocnemius (Fig. 3-79). The sciatic nerve descends vertically downwards from the
infragluteal region to the apex of the superior triangle of the popliteal fossa, lying deep to the
biceps femoris and semitendinosus muscle, where it terminates by dividing into its terminal
branches, the tibial and common peroneal nerves (Figs. 3-80 to 3-82), at a variable distance
(3–7 cm) from the popliteal crease.5 The tibial nerve is the larger terminal branch of the
sciatic nerve. It lies relatively superficial near the popliteal crease, with only overlying
subcutaneous tissue, and extends from the superior angle to the inferior angle of the popliteal
fossa. During its descent the tibial nerve crosses the popliteal vessels from a lateral to medial
side. The common peroneal nerve extends from the superior angle to the lateral angle of the
popliteal fossa along the medial border of the biceps femoris muscle. Continuing downwards
the common peroneal nerve winds around the posterolateral aspect of the neck of the fibula,
pierces the peroneus longus muscle, and then divides into the superficial and deep peroneal
nerves.

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FIGURE 3-79 Anatomical illustration showing the sciatic nerve at the popliteal fossa.

FIGURE 3-80 Transverse anatomical illustration showing the relations of the tibial and
common peroneal nerve at the popliteal fossa.

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FIGURE 3-81 Transverse anatomical section of the lower thigh showing the anatomy of
the sciatic nerve before its division into the tibial and common peroneal nerve at the popliteal
fossa.

FIGURE 3-82 Transverse anatomical section of the lower thigh showing the sciatic nerve
after its division into the tibial and common peroneal nerves at the popliteal fossa.

Computed Tomography Anatomy of the Popliteal Fossa

Figs. 3-83 to 3-85

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FIGURE 3-83 Transverse (axial) CT image of the lower thigh showing the anatomy of the
sciatic nerve before its division into the tibial and common peroneal nerve at the popliteal
fossa. Note the large fat-filled perineural space (intermuscular tunnel) surrounding the sciatic
nerve.

FIGURE 3-84 Transverse (axial) CT image of the lower thigh showing the anatomy of the
sciatic nerve after its division into the tibial and common peroneal nerve at the popliteal
fossa. The perineural space is also delineated at this level.

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FIGURE 3-85 Coronal CT image of the thigh showing the relations of the sciatic nerve.
Note the large fat-filled perineural space (intermuscular tunnel) surrounding the sciatic nerve.
Please refer to Figs. 3-82 and Fig. 3-83 for the corresponding transverse CT images.

Magnetic Resonance Imaging Anatomy of the Popliteal Fossa

Figs. 3-86 to 3-88

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FIGURE 3-86 Transverse (axial) MRI image of the lower thigh showing the relations of
the sciatic nerve before its division into the tibial and common peroneal nerve. The perineural
space is clearly delineated and filled with hyperintense fat.

FIGURE 3-87 Transverse (axial) MRI image of the lower thigh showing the relations of
the sciatic nerve after its division into the tibial and common peroneal nerve.

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FIGURE 3-88 Coronal MRI image of the thigh showing the relations of the sciatic nerve.

Sciatic Nerve at the Popliteal Fossa – Ultrasound Scan Technique

1.Position:
a.Patient: Prone position with the knee slightly bent and ankle supported.
b.Operator and ultrasound machine: The operator sits or stands on the side to be
examined and faces the patient’s head. The ultrasound machine is placed on the same
side between the operator and the patient’s head. Alternatively the operator may
choose to position the ultrasound machine based on his or her “handedness.” Right-
handed operators who hold ultrasound probes with their left hand and carry out needle
interventions with their right hand should stand on the right side of the patient and
position the ultrasound machine on the opposite side of the patient. This is vice versa
for left-handed operators.
2.Transducer selection: Because the sciatic nerve or its branches are relatively superficial at
the popliteal fossa, a high-frequency (13-5 or 15-8 MHz) linear array transducer is
adequate for imaging.
3.Scan technique: The transducer is placed in the transverse orientation at the lower thigh
(Figs. 3-89 to 3-91). Slowly slide the transducer distally towards the popliteal crease. The
sciatic nerve is typically oval in shape in the lower thigh and can be seen to bifurcate into
its terminal branches at the popliteal fossa. Close to the popliteal crease, the popliteal
artery and vein can be visualized on the posteromedial aspect of the sciatic nerve.

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FIGURE 3-89 Figure showing the position of the ultrasound transducer during a
transverse scan for the sciatic nerve at the popliteal fossa.

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FIGURE 3-90 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan for the sciatic nerve at the popliteal fossa.

FIGURE 3-91 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the sciatic nerve at the popliteal fossa.

4.Sonoanatomy: The sciatic nerve appears as an oval hyperechoic structure in the mid to
lower thigh (Fig. 3-92). It divides into its terminal branches at a variable distance from
the popliteal crease (Fig. 3-93). A hypoechoic perineural space surrounds the sciatic nerve
at the thigh (Figs. 3-94 and 3-95).2 This is continuous with the perineural space in the
subgluteal (Figs. 3-67 and 3-68) and parasacral (Figs. 3-57 and 3-58) regions2,3 and acts
like an intermuscular tunnel or conduit through which the sciatic nerve travels from the
parasacral region to the popliteal fossa.2 With high-definition ultrasound imaging it is
now possible to delineate an additional hyperechoic layer of connective tissue that is
interposed between the epimysium of the surrounding muscle and the outer surface
(epineurium) of the sciatic nerve (Figs. 3-95 and 3-96). This represents the “paraneural
sheath,”24 which is distinct from the epineurium24 and better delineated after local
anesthetic injection (Fig. 3-97)24 and envelopes not only the sciatic nerve but also the
common peroneal and tibial nerves separately.24 Local anesthetic injected during a
popliteal sciatic nerve block is seen to compartmentalize into two areas around the sciatic
nerve (Fig. 3-97)—that is, subepimyseal (but external to the paraneural sheath) and
subparaneural (beneath or deep to the paraneural sheath). The subepimyseal perineural
compartment (Fig. 3-96), also referred to as the perineural space,25 is a well-defined
intermuscular space surrounding the sciatic nerve.2,3,25 It is filled with fat and blood
vessels25 and clearly delineated in ultrasound (2-D3 and 3-D2), CT25 (Figs. 3-83 to 3-85),
and MRI images (Figs. 3-86 and 3-87) of the thigh. In contrast the subparaneural
compartment is a potential space with a thin layer of fat separating the paraneural sheath
from the epineurium of the nerve (Fig. 3-96)24 and serves like a “plane of cleavage”26
that provides some degree of mobility and protection to the neural elements housed
within.

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FIGURE 3-92 Transverse sonogram showing the sciatic nerve as a hyperechoic structure
between the hyperechoic epimysium of the biceps femoris muscle posteriorly and the
adductor magnus muscle anteriorly at the lower thigh. Also note an additional hyperechoic
layer of connective tissue posterior to the sciatic nerve which represents the “paraneural
sheath.”24 The hypoechoic perineural space is also seen posteriorly between the epimysium
of the biceps muscle posteriorly and the sciatic nerve.

FIGURE 3-93 Transverse sonogram showing the sciatic nerve after its division into the
tibial and common peroneal nerve at the popliteal fossa. Note the relations of the tibial nerve
to the popliteal vessels and common peroneal nerve to the biceps femoris muscle (tendon).
PA, popliteal artery; PV, popliteal vein.

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FIGURE 3-94 Sagittal sonogram showing the sciatic nerve as a hyperechoic structure
within a narrow hypoechoic space (perineural space) between the hyperechoic epimysium
(short white arrows) of the surrounding muscles at the lower thigh.

FIGURE 3-95 High-definition transverse sonogram of the sciatic nerve at the level of its
bifurcation into the tibial and common peroneal nerve at the popliteal fossa. The paraneural
sheath (white arrow heads) is interposed between the epimysium (short white arrows) of the
surrounding muscles and the outer surface of the sciatic nerve (epineurium), which also
appears hyperechoic. The subepimyseal (perineural) and subparaneural compartments are
seen as hypoechoic areas between the epimysium and the paraneural sheath and between the
paraneural sheath and the epineurium, respectively.

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FIGURE 3-96 Schematic diagram illustrating the fascial compartments surrounding the
sciatic nerve at the popliteal fossa. CPN, common peroneal nerve; TN, tibial nerve.

FIGURE 3-97 Multiplanar 3-D view of the common peroneal (CPN) and tibial (TN) nerve
at the popliteal fossa after an ultrasound-guided sciatic nerve block. A rendered 3D volume
demonstrating the front, right, and top surfaces of the volume is also presented in Fig. 3-97D.
The reference marker has been placed over the tibial nerve (Fig. 3-97A). Spread of the local
anesthetic (LA) relative to the sciatic nerve and its divisions or the paraneural sheath is
clearly delineated in the multiplanar views.

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 5.Clinical Pearls: The site where the sciatic nerve bifurcates into its terminal branches at
the popliteal fossa is best identified using the “trace back” technique. One can also locate
the popliteal artery to identify the tibial nerve as it lies posterior and lateral to the artery.

Sciatic Nerve at the Thigh – Anterior Approach

Gross Anatomy
The anterior approach for sciatic nerve block is technically demanding and generally
performed when the patient cannot be positioned in the lateral decubitus position. It produces
complete anesthesia of the leg below the knee joint except for the skin on the medial aspect
of the leg and foot supplied by the saphenous nerve. The point for needle insertion is
approximately 6 to 7 cm distal to the inguinal crease with the patient in the supine position.27
This usually corresponds to the level of the lesser trochanter of the femur in the thigh (Figs.
3-98 to 3-100). In a transverse anatomical section of the thigh at this level, the sciatic nerve
lies deep in between the adductor magnus or quadratus femoris muscle anteriorly and the
gluteus maximus muscle posteriorly (Figs. 3-22 and 3-98).

FIGURE 3-98 Transverse anatomical section of the upper thigh at the level of the lesser
trochanter.

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FIGURE 3-99 Transverse (axial) CT image of the upper thigh at the level of the lesser
trochanter. PFA, profunda femoris artery.

FIGURE 3-100 Transverse (axial) MRI image of the upper thigh at the level of the lesser
trochanter. PFA, profunda femoris artery.

Computed Tomography Anatomy of the Sciatic Nerve at the Thigh

Fig. 3-99

Magnetic Resonance Imaging Anatomy of the Sciatic Nerve at the Thigh

Fig. 3-100

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Sciatic Nerve at the Thigh – Anterior Approach Ultrasound Scan Technique
1.Position:
a.Patient: Supine with the leg fully extended and slightly internally rotated.28
b.Operator and ultrasound machine: The operator may choose to position the
ultrasound machine based on his or her “handedness.” Right-handed operators who
hold ultrasound probes with their left hand and carry out needle interventions with
their right hand should stand on the right side of the patient and position the
ultrasound machine on the opposite side of the patient. This is vice versa for left-
handed operators.
2.Transducer selection: Low-frequency (5-2 MHz) curve array transducer.
3.Scan technique: The transducer is placed on the medial aspect of the thigh approximately
6 to 7 cm distal and parallel to the inguinal crease in a transverse orientation (Figs. 3-101
to 3-103). The reference structure to visualize is the femur (lesser trochanter). Once
visualized, slide the transducer medially to bring the femur to the lateral edge of the
ultrasound image. The sciatic nerve is visualized as a hyperechoic structure between the
adductor magnus muscle anteriorly and gluteus maximus muscle posteriorly (Fig. 3-104).

FIGURE 3-101 Figure showing the position of the ultrasound transducer during a

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transverse scan for the sciatic nerve at the upper thigh during an anterior approach for sciatic
nerve block.

FIGURE 3-102 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan for the sciatic nerve at the upper thigh during an anterior approach
for sciatic nerve block. GT, greater trochanter; ASIS, anterior superior iliac spine.

FIGURE 3-103 Figure highlighting the anatomical structures that are insonated during a
transverse ultrasound scan for the sciatic nerve at the upper thigh during an anterior approach
for sciatic nerve block.

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FIGURE 3-104 Sonogram demonstrating the sciatic nerve at the upper thigh at the level of
the lesser trochanter during an anterior approach for sciatic nerve block.

4.Sonoanatomy: In a transverse sonogram the sciatic nerve is typically visualized as an

elliptical and hyperechoic structure between the adductor magnus and gluteus maximus
muscle (Fig. 3-104). This can be confirmed by rotating the transducer to the sagittal
orientation in relation to the femur to visualize the hyperechoic laminated appearance of
the sciatic nerve.
5.Clinical Pearls: The anterior approach for sciatic nerve block is an advanced regional
anesthetic technique and can be technically demanding. The sciatic nerve is deep at this
level, and there are no reference vascular structures in close vicinity. The sagittal axis
may be superior to the transverse axis for visualizing the sciatic nerve at this level.29

Terminal Nerves in the Leg

Gross Anatomy
The four terminal nerves of the leg below the knee provide sensation and motor function to
the foot and ankle (Figs. 3-105 to 3-107). The tibial nerve is a terminal branch of the sciatic
nerve. It lies deep to the gastrocnemius and soleus muscles and on the posterior surface of the
tibialis posterior muscle (Fig. 3-106). The tibial nerve accompanies the posterior tibial artery
(Fig. 3-106) and at the level of the medial malleolus lies medial to the artery and lateral to the
flexor hallucis longus tendon under the flexor retinaculum (Figs. 3-108 and 3-109). The
saphenous nerve is a terminal branch of the femoral nerve (Fig. 3-110). It typically pierces
the deep fascia on the medial aspect of the knee after emerging between the tendons of the
sartorius and gracilis. It then travels down the leg superficially along the course of the great
saphenous vein (Figs. 3-105 to 3-107, 3-110, and 3-111).

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FIGURE 3-105 Transverse anatomical illustration of the leg at the level of the tibial
tuberosity.

FIGURE 3-106 Transverse anatomical illustration of the leg above the middle of the leg.

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FIGURE 3-107 Transverse anatomical illustration of the leg above the medial malleolus.

FIGURE 3-108 Transverse anatomical section through the distal leg at the ankle region
demonstrating tibial nerve. TA, tibialis anterior; FDL, flexor digitorum longus; FHL, flexor
hallucis longus; PB, peroneus brevis; PL, peroneus longus.

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FIGURE 3-109 Anatomical illustration of the foot and ankle demonstrating the relations
of the tibial nerve on the medial aspect of the ankle.

FIGURE 3-110 Anatomical illustration demonstrating the saphenous and tibial nerves on
the medial aspect of the foot.

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FIGURE 3-111 Transverse anatomical section through the distal leg at the level of the
ankle. The saphenous nerve is located in the same fascial plane as the saphenous vein.

The deep peroneal nerve is a terminal branch of the common peroneal nerve and originates
within the substance of the peroneus longus muscle on the lateral aspect of the proximal
fibula. The nerve enters the anterior compartment of the leg by piercing the interosseous
membrane and descends deep to the extensor digitorum longus muscle (Fig. 3-106). As it
descends distally towards the ankle, the nerve lies lateral, then anterior, and finally lateral to
the anterior tibial artery (Figs. 3-106, 3-107 and 3-112) as it enters the extensor retinaculum
at the ankle.

FIGURE 3-112 Transverse anatomical section through the distal leg at the level of the
ankle demonstrating the deep peroneal nerve and the anterior tibial artery. EHL, extensor
hallucis longus; EDL, extensor digitorum longus.

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 The superficial peroneal nerve is also a terminal branch of the common peroneal nerve
(Fig. 3-113) and like the deep peroneal nerve originates within the substance of the peroneus
longus muscle. It descends first between the peroneus longus and brevis muscle and then
between the intermuscular septum of the peroneus brevis and extensor digitorum longus
muscle (Fig. 3-114). It then pierces the deep crural fascia and becomes cutaneous in the lower
part of the leg at a variable distance from the ankle (Fig. 3-107).30

FIGURE 3-113 Anatomical illustration of the foot demonstrating the course and divisions
of the saphenous, superficial, and deep peroneal nerves.

FIGURE 3-114 Transverse anatomical section through the distal leg demonstrating the
intermuscular plane between the peroneus brevis and the extensor digitorum longus in which
the superficial peroneal nerve is located.

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 The sural nerve (Fig. 3-115) arises from cutaneous branches of the tibial nerve and
common peroneal nerve. It descends on the posterior aspect of the leg between the two heads
of the gastrocnemius and descends along the lateral edge of the Achilles tendon (Figs. 3-107
and 3-116), lying close to the short saphenous vein (Fig. 3-116), to the space between the
lateral malleolus and the calcaneus.

FIGURE 3-115 Anatomical illustration of the foot demonstrating the course and divisions
of the superficial peroneal and sural nerves.

FIGURE 3-116 Anatomical section through the distal leg at the ankle region
demonstrating the sural nerve in the vicinity of the small saphenous vein.

Computed Tomography Anatomy of the Terminal Nerves of the Leg

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Fig. 3-117

FIGURE 3-117 Transverse (axial) CT image of the distal leg demonstrating the tibial
nerve and vascular structures on the medial aspect of the ankle. TA, tibialis anterior; EHL,
extensor hallucis longus; EDL, extensor digitorum longus; Tib Post, tibialis posterior; FHL,
flexor hallucis longus; FDL, flexor digitorum longus.

Magnetic Resonance Imaging Anatomy of the Terminal Nerves of the Leg

Figs. 3-118 and 3-119

FIGURE 3-118 Transverse (axial) MRI image of the distal leg demonstrating the terminal
nerves of the leg. EDL, extensor digitorum longus; EHL, extensor hallucis longus; TA,
tibialis anterior; TP, tibialis posterior; PB, peroneus brevis; FHL, flexor hallucis longus; FDL,
flexor digitorum longus.

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FIGURE 3-119 Transverse (axial) MRI image of the ankle region demonstrating the
terminal nerves of the leg. EDL, extensor digitorum longus, EHL; extensor hallucis longus;
FHL, flexor hallucis longus; FDL, flexor digitorum longus.

Terminal Nerves of the Leg – Ultrasound Scan Technique

1.Position:
a.Patient: Supine position. The leg that is examined is positioned according to the nerve
to be examined. For the saphenous (Fig. 3-120) and tibial (Fig. 3-121) nerves the
ipsilateral knee and hip is slightly flexed and externally rotated. For the superficial
peroneal (Fig. 3-122), deep peroneal (Fig. 3-123), and sural (Fig. 3-124) nerves the
ipsilateral knee is flexed and the sole of the foot is placed flat on the bed. An assistant
may be asked to support the leg during the examination.

FIGURE 3-120 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan for the saphenous nerve at the distal leg.

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FIGURE 3-121 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan for the tibial nerve at the distal leg.

FIGURE 3-122 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan for the superficial peroneal nerve at the distal leg. Note an
assistant is supporting the leg during the ultrasound scan.

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FIGURE 3-123 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan for the deep peroneal nerve at the distal leg.

FIGURE 3-124 Figure showing the position and orientation of the ultrasound transducer
during a transverse ultrasound scan for the sural nerve at the distal leg.

b.Operator and ultrasound machine: The operator is positioned at the caudal end of the
patient. The ultrasound machine is placed on the ipsilateral side to be examined on the
cephalad side.
2.Transducer selection: High-frequency (15-8 or 17-5 MHz) linear array transducer.
3.Scan technique: To image the tibial nerve, the transducer is placed between the medial
malleolus and the Achilles tendon (Fig. 3-121) to obtain a transverse sonographic view of
the posterior tibial artery, which is the key sonographic landmark for this nerve block
(Fig. 3-125). The structures visualized should be surveyed proximally to confirm the

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 identity of the flexor hallucis longus and observe the characteristic course of the tibial
nerve and tibial artery. The flexor hallucis longus tendon, which lies on the medial and
posterior aspect of the tibial nerve, can be confirmed by moving the first toe and
observing the movement of the tendon and muscle.

FIGURE 3-125 Transverse sonogram demonstrating the tibial nerve and its relations at the
distal leg.

a.To image the saphenous nerve (Fig. 3-120), the transducer is placed just above the
medial malleolus. Apply light pressure over the skin with the transducer during the
scan as the long saphenous vein is easily compressible. The long saphenous vein is
the key sonographic landmark for this nerve block (Fig. 3-126). In some individuals,
the saphenous nerve may not be consistently visualized at this level.

FIGURE 3-126 Transverse sonogram demonstrating the saphenous nerve and its relations
at the distal leg.

b.To image the deep peroneal nerve, the transducer is placed along a line joining the
medial malleoli and the lateral malleoli (Fig. 3-123). The anterior tibial artery is
confirmed by observing its pulsations and using Color/Power Doppler ultrasound. At

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 this level, the deep peroneal nerve appears as a small hypoechoic structure lateral to
the artery (Fig. 3-127). The anterior tibial artery is the key sonographic landmark for
this nerve block.

FIGURE 3-127 Transverse sonogram demonstrating the deep peroneal nerve and its
relations at the distal leg. EDL, extensor digitorum longus; EHL, extensor hallucis longus;
TA, tibialis anterior.

c.To image the superficial peroneal nerve (Fig. 3-122), the transducer is placed
transversely across the fibula just above the lateral malleoli to image the fibula in a
transverse section (Fig. 3-128). The transducer is then moved proximately along the
fibula. During this survey, the fibula is observed to move deeper as the muscle of the
lateral and anterior leg compartments become more pronounced. An intermuscular
septum arises from the edge of the fibula which separates the extensor digitorum
longus and the peroneus brevis/peroneus longus. This is the intermuscular septum that
divides the anterior and lateral compartment of the leg. This is the key sonographic
landmark to identify the superficial peroneal nerve. The superficial peroneal nerve
appears as a honeycomb structure (Fig. 3-128) that lies in the groove within the
intermuscular septum approximately 5 to 10 cm above the lateral malleoli (Fig. 3-
114). It lies below the deep crural fascia of the leg in the midleg and pierces this
fascia to lie superficial to it as the nerve travels down the leg towards the lateral
malleolus.

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FIGURE 3-128 Transverse sonogram demonstrating the superficial peroneal nerve and its
relations at the distal leg.

d.To image the sural nerve, the transducer is placed transversely along a line joining the
lateral malleolus and the Achilles tendon (Fig. 3-124). Apply light pressure over the
skin with the transducer during the scan, as the short saphenous vein is easily
compressible. The short saphenous vein is visualized and confirmed by compression
and surveyed proximally along its course. The short saphenous vein is the key
sonographic landmark for this nerve block. The sural nerve appears as a honeycomb
structure and usually lies posterior to the short saphenous vein between the short
saphenous vein and the Achilles tendon (Fig. 3-129) and can be confirmed by tracing
it back and forth along its course.

FIGURE 3-129 Transverse sonogram demonstrating the sural nerve and its relations at the
distal leg. Note the short saphenous vein adjacent to the sural nerve.

4.Sonoanatomy: The tibial nerve has a typical honeycomb appearance and is located deep
and medial to the tibial artery at the level just above the medial malleolus (Fig. 3-125).
The saphenous nerve also has a honeycombed appearance in the short axis (Fig. 3-126)
but is not consistently visualized in all individuals. The deep peroneal nerve appears as a
hyperechoic structure with hypoechoic dots in the short axis (Fig. 3-127). The superficial
peroneal nerve appears as one or two fusiform hypoechoic structures in the short axis
(Fig. 3-128). The sural nerve appears as a honeycombed structure in the short axis (Fig. 3-
129).
5.Clinical Pearls: The “trace back” technique is particularly useful for confirming the nerves
in the leg. Compared with the traditional ankle block using landmark techniques,
ultrasound-guided ankle blocks are generally administered more proximal to the malleoli.
Sonographic study of the peripheral nerves at the ankle typically involves the
identification of key anatomical landmarks (artery, vein, or intermuscular septum)
associated with the nerve and then tracing it proximally until it is best visualized and
targeted for nerve blockade. At the level of the malleoli, numerous tendons look similar to
the nerves in a sonogram. Muscles can be differentiated from nerves by observing
movement on sonography by asking the patient to move his or her toes or ankle. In
addition, the tendons will change in appearance as a dynamic scan is performed
proximally. The tendons transform into their corresponding muscle proximally. The

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 nerves are mobile and may “slip” on either side of the vessels with transducer pressure.
With respect to the superficial peroneal nerve there are several variations on where the
nerve is located, that is, whether it is deep to the crural fascia, where it divides into the
medial dorsal cutaneous nerve and the intermediate dorsal cutaneous nerve, and where it
pierces the crural fascia to lie superficial to it. These variations may be difficult to
appreciate using ultrasound. The use of ultrasound for ankle blocks may improve the
success rates of sural and tibial nerve blocks.31,32 Also blockade of the saphenous nerve
at the ankle may not be necessary for forefoot surgery.33

References
1.Farny J, Drolet P, Girard M. Anatomy of the posterior approach to the lumbar plexus
block. Can J Anaesth. 1994;41:480–485.
2.Karmakar M, Li X, Li J, Sala-Blanch X, Hadzic A, Gin T. Three-dimensional/four-
dimensional volumetric ultrasound imaging of the sciatic nerve. Reg Anesth Pain Med.
2012;37:60–66.
3.Karmakar MK, Kwok WH, Ho AM, Tsang K, Chui PT, Gin T. Ultrasound-guided sciatic
nerve block: description of a new approach at the subgluteal space. Br J Anaesth.
2007;98:390–395.
4.Smoll NR. Variations of the piriformis and sciatic nerve with clinical consequence: a
review. Clin Anat. 2010;23:8–17.
5.Vloka JD, Hadzic A, April E, Thys DM. The division of the sciatic nerve in the popliteal
fossa: anatomical implications for popliteal nerve blockade. Anesth Analg. 2001;92:215–
217.
6.Gustafson KJ, Pinault GC, Neville JJ, et al. Fascicular anatomy of human femoral nerve:
implications for neural prostheses using nerve cuff electrodes. J Rehabil Res Dev.
2009;46:973–984.
7.Soong J, Schafhalter-Zoppoth I, Gray AT. The importance of transducer angle to
ultrasound visibility of the femoral nerve. Reg Anesth Pain Med. 2005;30:505.
8.Soong J, Schafhalter-Zoppoth I, Gray AT. Sonographic imaging of the obturator nerve for
regional block. Reg Anesth Pain Med. 2007;32:146–151.
9.Sinha SK, Abrams JH, Houle TT, Weller RS. Ultrasound-guided obturator nerve block: an
interfascial injection approach without nerve stimulation. Reg Anesth Pain Med. 2009;
34:261–264.
10.Hospodar PP, Ashman ES, Traub JA. Anatomic study of the lateral femoral cutaneous
nerve with respect to the ilioinguinal surgical dissection. J Orthop Trauma. 1999;13:17–
19.
11.Aszmann OC, Dellon ES, Dellon AL. Anatomical course of the lateral femoral cutaneous
nerve and its susceptibility to compression and injury. Plast Reconstr Surg.
1997;100:600–604.
12.Hurdle MF, Weingarten TN, Crisostomo RA, Psimos C, Smith J. Ultrasound-guided
blockade of the lateral femoral cutaneous nerve: technical description and review of 10
cases. Arch Phys Med Rehabil. 2007;88:1362–1364.
13.Saranteas T, Anagnostis G, Paraskeuopoulos T, et al. Anatomy and clinical implications of
the ultrasound-guided subsartorial saphenous nerve block. Reg Anesth Pain Med.
2011;36:399–402.
14.Horn JL, Pitsch T, Salinas F, Benninger B. Anatomic basis to the ultrasound-guided
approach for saphenous nerve blockade. Reg Anesth Pain Med. 2009;34:486–489.

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15.Tsui BC, Ozelsel T. Ultrasound-guided transsartorial perifemoral artery approach for
saphenous nerve block. Reg Anesth Pain Med. 2009;34:177–178.
16.Tsui BC, Finucane BT. The importance of ultrasound landmarks: a “traceback” approach
using the popliteal blood vessels for identification of the sciatic nerve. Reg Anesth Pain
Med. 2006;31:481–482.
17.Gaertner E, Lascurain P, Venet C, et al. Continuous parasacral sciatic block: a
radiographic study. Anesth Analg. 2004;98:831–834, table.
18.Morris GF, Lang SA, Dust WN, Van der Wal M. The parasacral sciatic nerve block. Reg
Anesth. 1997;22:223–228.
19.Ripart J, Cuvillon P, Nouvellon E, Gaertner E, Eledjam JJ. Parasacral approach to block
the sciatic nerve: a 400-case survey. Reg Anesth Pain Med. 2005;30:193–197.
20.Hagon BS, Itani O, Bidgoli JH, Van der Linden PJ. Parasacral sciatic nerve block: does the
elicited motor response predict the success rate? Anesth Analg. 2007;105:263–266.
21.Ho AM, Karmakar MK. Combined paravertebral lumbar plexus and parasacral sciatic
nerve block for reduction of hip fracture in a patient with severe aortic stenosis. Can J
Anaesth. 2002;49:946–950.
22.Ben-Ari AY, Joshi R, Uskova A, Chelly JE. Ultrasound localization of the sacral plexus
using a parasacral approach. Anesth Analg. 2009;108:1977–1980.
23.Guardini R, Waldron BA, Wallace WA. Sciatic nerve block: a new lateral approach. Acta
Anaesthesiol Scand. 1985;29:515–519.
24.Andersen HL, Andersen SL, Tranum-Jensen J. Injection inside the paraneural sheath of the
sciatic nerve: direct comparison among ultrasound imaging, macroscopic anatomy, and
histologic analysis. Reg Anesth Pain Med. 2012;37:410–414.
25.Floch H, Naux E, Pham DC, Dupas B, Pinaud M. Computed tomography scanning of the
sciatic nerve posterior to the femur: Practical implications for the lateral midfemoral
block. Reg Anesth Pain Med. 2003;28:445–449.
26.Franco CD. Connective tissues associated with peripheral nerves. Reg Anesth Pain Med.
2012;37:363–365.
27.Ota J, Sakura S, Hara K, Saito Y. Ultrasound-guided anterior approach to sciatic nerve
block: a comparison with the posterior approach. Anesth Analg. 2009;108:660–665.
28.Vloka JD, Hadzic A, April E, Thys DM. Anterior approach to the sciatic nerve block: the
effects of leg rotation. Anesth Analg. 2001;92:460–462.
29.Tsui BC, Ozelsel TJ. Ultrasound-guided anterior sciatic nerve block using a longitudinal
approach: “expanding the view.” Reg Anesth Pain Med. 2008;33:275–276.
30.Canella C, Demondion X, Guillin R, Boutry N, Peltier J, Cotten A. Anatomic study of the
superficial peroneal nerve using sonography. AJR Am J Roentgenol. 2009;193:174–179.
31.Redborg KE, Sites BD, Chinn CD, et al. Ultrasound improves the success rate of a sural
nerve block at the ankle. Reg Anesth Pain Med. 2009;34:24–28.
32.Redborg KE, Antonakakis JG, Beach ML, Chinn CD, Sites BD. Ultrasound improves the
success rate of a tibial nerve block at the ankle. Reg Anesth Pain Med. 2009;34:256–260.
33.Lopez AM, Sala-Blanch X, Magaldi M, Poggio D, Asuncion J, Franco CD. Ultrasound-
guided ankle block for forefoot surgery: the contribution of the saphenous nerve. Reg
Anesth Pain Med. 2012;37:554–557.

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CHAPTER 4

Sonoanatomy Relevant for Ultrasound-Guided

Abdominal Wall Nerve Blocks

Introduction
Ultrasound-guided abdominal wall blocks are a recent innovation of the traditional landmark-
based techniques of performing abdominal wall field blocks.1 These blocks include the
transverse abdominis plane (TAP) block (lateral/midaxillary and subcostal),1–8 rectus sheath
block, iliohypogastric and ilioinguinal nerve block,8 and the quadratus lumborum block
(QLB).,,8–12 They are fairly simple to perform, largely devoid of complications, and produce
sensory and motor blockade of the abdominal wall.

Gross Anatomy
Muscles of the Anterior Abdominal Wall
The anterior abdominal wall is made of four large, flat muscles on either side of the midline.
They are the external oblique muscle (EOM, Figs. 4-1 to 4-3), internal oblique muscle (IOM,
Figs. 4-3 to 4-5), transversus abdominis muscle (TAM, Figs. 4-3, 4-6, and 4-7), and the rectus
abdominis muscle (RAM, Figs. 4-3 and 4-6). Two other smaller muscles, the cremaster and
the pyrimidalis, are also present. The EOM, IOM, and the TAM each end in a fibrous
aponeurosis that extends up to the midline (Figs. 4-1, 4-4, and 4-6). The aponeuroses on
either side fuse in the midline to form a median band called the linea alba. The RAM is
longitudinal in shape, runs vertically on either side of the linea alba (Fig. 4-6), and is
enclosed in a fibrous sheath called the “rectus sheath” (see later, Fig. 4-4).

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FIGURE 4-1 Figure showing the innervation of the trunk and the abdominal wall. Note the
aponeurosis of the external oblique muscle and the anterior and posterior wall of the rectus
sheath (cutout view).

FIGURE 4-2 Figure showing the origin, insertion, and arrangement of the muscle fibers of
the external oblique muscle.

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FIGURE 4-3 Figure showing the anatomical arrangement of the muscles of the anterior
abdominal wall (external oblique, internal oblique, transversus abdominis, and rectus
abdominis) with their aponeurosis, including the rectus sheath. Note the three tendinous
insertions on the anterior surface of the rectus abdominis muscle.

FIGURE 4-4 Figure showing the anatomical arrangement of the internal oblique muscle
with its aponeurosis.

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FIGURE 4-5 Figure showing the origin and insertion of the muscle fibers of the internal
oblique deep to the external oblique muscle. Also note the direction of the muscle fibers of
the internal oblique muscle (upwards and medially) relative to the external oblique muscle.

FIGURE 4-6 Figure showing the anatomical arrangement of the transversus abdominis
muscle. Note the direction of the muscle fibers of the transversus abdominis muscle
(transversely).

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FIGURE 4-7 Figure showing the origin and insertion of the transversus abdominis muscle
and its relation to the external and internal oblique muscles.

The EOM originates as eight fleshy slips from the lower eight ribs (Fig. 4-2). The upper
slips of the origin of the EOM interdigitate with that of the serratus anterior muscle, and the
lower slips of the EOM interdigitate with that of the latissimus dorsi muscle. The fibers of the
muscle run downwards, forward, and medially (Fig. 4-2) to end in a broad aponeurosis (Fig.
4-1), which is inserted (from above downwards) to the xiphoid process, pubic symphysis,
pubic crest, and the pectineal line of the pubis. The caudal fibers of the muscle are inserted to
the anterior two-thirds of the outer lip of the iliac crest (Fig. 4-2). The caudal end of the
external oblique aponeurosis is folded on itself to form the inguinal ligament, and above the
pubic tubercle there is a small triangular opening called the superficial inguinal ring. Medial
to the lateral edge of the rectus abdominis muscle the external oblique aponeurosis
contributes to forming the rectus sheath (Fig. 4-6, see later).
The IOM originates from the lateral two-thirds of the inguinal ligament, anterior two-
thirds of the intermediate area of the iliac crest (Fig. 4-5), and the thoracolumbar fascia
posteriorly. From its origin the fibers of the IOM run obliquely upwards, forwards, and
medially, crossing the fibers of the EOM at right angles (Fig. 4-5), to end in an aponeurosis
through which it is attached to the xiphoid process, the seventh to ninth costal cartilage, linea
alba, pubic crest, and pectineal line. The IOM aponeurosis also contributes to the formation
of the rectus sheath (Fig. 4-4, see later).
The TAM has a fleshy origin from the lateral one-third of the inguinal ligament, anterior
two-thirds of the inner lip of the iliac crest, thoracolumbar fascia posteriorly, and the inner
surface of the lower six costal cartilages. The fibers of the TAM are directed horizontally
forwards (Figs. 4-6 and 4-7) and end in an aponeurosis that is attached to the xiphoid process,
linea alba, pubic crest, and pectineal line of the pubis. At the lower part of the TAM the lower
fibers of the muscle fuse with the lower fibers of the IOM to form the conjoint tendon. The
TAM aponeurosis also takes part in the formation of the rectus sheath (Fig. 4-6, see later).
The neurovascular structures of the abdominal wall lie in between the IOM and TAM (Fig. 4-
8). This intermuscular plane is also referred to as the transversus abdominis plane (TAP, Figs.
4-9 to 4-11) and is a popular site for ultrasound-guided abdominal wall nerve blocks.

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FIGURE 4-8 Figure showing the anatomical course and divisions of a typical
thoracolumbar nerve. Note the posterior primary rami and the lateral and anterior cutaneous
divisions of the nerve.

FIGURE 4-9 Cross-sectional cadaver anatomical section of the upper abdomen (rendered
from the Visible Human Server) showing the relations of the rectus abdominis muscle to the
TAP (transversus abdominis plane).

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FIGURE 4-10 Coronal cadaver anatomic section (rendered from the Visible Human
Server) showing anatomical relations of the TAP (transversus abdominis plane).

FIGURE 4-11 Cross-sectional cadaver anatomical section of the abdomen (rendered from
the Visible Human Server) showing the posterior relations of the TAP (transversus abdominis
plane).

The rectus abdominis muscle (RAM) originates as two heads from the lateral (lateral head)
part of the pubic crest and from the anterior pubic ligament (medial head). The fibers of the
RAM run vertically upwards to be inserted into the anterior aspect of the chest wall, that is, to
the xiphoid process and the fifth to seventh costal cartilages (Fig. 4-12). There are three
fibrous bands, also called the tendinous insertions or inscriptions, on the anterior surface of
the RAM (Figs. 4-6 and 4-12). The most cephalad tendinous insertion lies opposite the free

220
end of the xiphoid process, the second opposite the umbilicus, and the third approximately
midway between the two (Fig. 4-6). This divides the RAM into six or eight bellies (sections),
which is also colloquially called the “six-pack” (Fig. 4-4). The tendinous insertions pass
transversely or obliquely across the muscle, are adherent to the anterior wall of the rectus
sheath, and traverse only the anterior half of the muscle. The RAM is enclosed in a sheath,
the rectus sheath (see later, Fig. 4-6), formed by the aponeurosis of the three flat muscles of
the abdomen.

FIGURE 4-12 Sagittal cadaver anatomic section (rendered from the Visible Human
Server) showing the rectus abdominis muscle. Note the tendinous insertions on the rectus
muscle.

Nerves of the Anterior Abdominal Wall

The skin and musculature of the abdominal wall is innervated by the anterior primary rami of
the lower six thoracic nerves (T7-T12, Fig. 4-8) and the first lumbar nerve (L1) through its
iliohypogastric and ilioinguinal branches (Fig. 4-1). The anterior primary rami of the lower
five intercostal nerves (T7-T11) emerge from their respective intercostal spaces and come to
lie in a neurovascular plane between the internal oblique and transversus abdominis muscles
(Fig. 4-8). This intermuscular plane is also referred to as the transversus abdominis plane
(TAP). The segmental nerves travel anteriorly and medially towards the midline in the TAP,
giving off their lateral cutaneous branches at the level of the midaxillary line and pierce the
posterior lamina of the internal oblique aponeurosis anteriorly to enter the rectus sheath (Fig.
4-8). While within the rectus sheath the nerves pass behind the rectus abdominis muscle and

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lie in front of the epigastric arteries. They then pierce the rectus muscle and the anterior
rectus sheath to emerge anteriorly as the anterior cutaneous branches, which supply the
overlying skin (Fig. 4-8). The lateral and anterior cutaneous branches supply the skin of the
abdomen from the midline to the anterior axillary line. T7 provides sensory supply to the
epigastrium, T10 to the umbilicus, and L1 to the groin.
The subcostal nerve is the anterior primary rami of the 12th thoracic nerve and enters the
abdomen posteriorly under the lateral arcuate ligament of the diaphragm. It then passes
laterally on the anterior surface of the quadratus lumborum muscle and pierces the
transversus abdominis muscle to enter the TAP. The remaining part of the course of the
subcostal nerve is similar to that of the other thoracolumbar nerves except that it supplies the
pyramidalis muscle, and its lateral cutaneous branch supplies the upper and lateral aspect of
the gluteal region (Fig. 4-1).
The first lumbar nerve (L1) divides in front of the quadratus lumborum muscle into the
iliohypogastric and ilioinguinal nerves after which they pierce the transversus abdominis
muscle to enter the TAP (Figs. 4-13 and 4-14). The iliohypogastric nerve then travels
anteriorly in the TAP and pierces the internal oblique muscle about 1 inch in front of the
anterior superior iliac spine (Fig. 4-1). It then becomes superficial by piercing the external
oblique aponeurosis close to the superficial inguinal ring and supplies the skin over the
suprapubic region. The lateral cutaneous branch of the iliohypogastric nerve supplies the
upper and lateral aspect of the gluteal region (Fig. 4-1). The ilioinguinal nerve has no lateral
cutaneous branch but also pierces the internal oblique muscle. It then traverses the inguinal
canal with the spermatic cord or the round ligament of the uterus to emerge through the
superficial inguinal ring or through the adjacent external oblique aponeurosis to supply the
skin of the upper and medial aspect of the thigh and the genitals.

FIGURE 4-13 Cross-sectional cadaver anatomical section of the lower abdomen (rendered
from the Visible Human Server) from the level of the anterior superior iliac spine showing
the relations of the TAP (transversus abdominis plane) to the lower abdomen.

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FIGURE 4-14 Cross-sectional cadaver anatomical section of the lower abdomen (rendered
from the Visible Human Server) from below the level of the anterior superior iliac spine.
Note the external oblique muscle is missing because it is an aponeurotic layer at this level.

Lateral (Midaxillary) Transverse Abdominis Plane

Gross Anatomy
The lateral (midaxillary) TAP refers to the neurovascular plane between the internal oblique
and transversus abdominis muscle along the lateral abdominal wall (Figs. 4-10 and 4-11).
The thoracolumbar nerves (T10-L1) traverse through the lateral (midaxillary) TAP.

Computed Tomography Abdomen Showing the Lateral (Midaxillary)

Transverse Abdominis Plane
Fig. 4-15

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FIGURE 4-15 Transverse CT of the abdomen showing the anatomical relations of the
TAP (transversus abdominis plane) relevant for a lateral (midaxillary) TAP block.

Magnetic Resonance Imaging Abdomen Showing the Lateral (Midaxillary)

Transverse Abdominis Plane
Fig. 4-16

FIGURE 4-16 Transverse MRI of the abdomen showing the anatomical relations of the
TAP (transversus abdominis plane) relevant for a lateral (midaxillary) TAP block.

Ultrasound Scan Technique

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1.Position:
a.Patient: Supine with the abdomen exposed between the subcostal margin and the iliac
crest.
b.Operator and ultrasound machine: Right-handed operators who hold the ultrasound
transducer with their left hand and carry out needle interventions with their right hand
should stand on the right side of the patient and position the ultrasound machine on
the contralateral side and directly in front. This is vice versa for left-handed operators.
2.Transducer selection: High-frequency (13-8 MHz) linear array transducer.
3.Scan technique: The ultrasound transducer is placed in the transverse orientation to the
lateral abdominal wall in the midaxillary line between the costal margin and the iliac crest
(Fig. 4-17). The aim is to identify the three muscular layers of the lateral abdominal wall
with the fascial layers that separate them in the sonogram. It may be necessary to gently
slide the transducer in a craniocaudal direction or even gently tilt or rotate the transducer
to obtain an optimal ultrasound image.

FIGURE 4-17 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan of the lateral abdominal wall for the lateral (midaxillary) TAP block.

4.Sonoanatomy: On a transverse sonogram, the EOM, IOM, and TAM are identified as
three longitudinal and hypoechoic structures deep to the skin and subcutaneous tissue
(Fig. 4-18). A hyperechoic fascial layer (possibly the epimysium of the individual
muscle) is seen between the three muscles (Fig. 4-18). The EOM is the outermost
(superficial) layer, the IOM the intermediate, and the TAM is the innermost layer. The
thickness of the muscles also varies, but the TAM is in general the thinnest and it also
appears darkest (hypoechoic) of the three muscles on the sonogram (Fig. 4-18). The TAP
is located between the IOM and TAM (Fig. 4-18). Deep to the TAM are the fascia
transversalis and the underlying peritoneum, which also appear hyperechoic (Fig. 4-18). It
is difficult to differentiate the fascia transversalis from the peritoneum on a sonogram, but
the peritoneum can be identified as a hyperechoic layer by observing peristaltic
movement of the bowel loops (Fig. 4-18). The segmental thoracolumbar nerves are small
terminal branches and are difficult to define within the TAP using ultrasound.
Occasionally the terminal nerves may be seen in the TAP as multiple flat, hyperechoic
structures (Fig. 4-19). This is best done by locating the nerves distally in the groin

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 (iliohypogastric and ilioinguinal nerve) and then tracing them (trace back technique) back
to the TAP.

FIGURE 4-18 Transverse sonogram of the lateral abdominal wall showing the TAP
(transversus abdominis plane) between the hypoechoic internal oblique and transversus
abdominis muscles. Also note the hyperechoic fascial layers, which probably represent the
epimysium of the muscles, separating the three abdominal muscles.

FIGURE 4-19 Transverse sonogram of the lateral abdominal wall showing the TAP
(transversus abdominis plane) in sepia mode (colorize mode). Note the flat hypoechoic
structures, which represent branches of the thoracolumbar nerves, within the TAP
(transversus abdominis plane).

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 5.Clinical Pearls: During a lateral (midaxillary) TAP block with an in-plane needle
insertion, the point of needle insertion (ie, how far medial to the transducer) can be
determined by noting the depth at which the TAP is located on the ultrasound monitor
(depth scale). Normal saline can be used to hydrodissect the TAP to confirm correct
needle tip position before the local anesthetic is injected. It is common to see a prominent
bulge along the lateral abdominal wall, indicating paralysis of the abdominal muscles,
during the postoperative period after a posterior TAP block.

Subcostal Transverse Abdominis Plane

Gross Anatomy
Subcostal TAP refers to the neurovascular plane between the IOM and the TAM that lies just
below the costal margin (Fig. 4-9). The terminal branches of the intercostal nerves (T7-T9)
emerge from under the costal margin and enter the subcostal TAP. T7 and T8 nerves pass
deep to the costal margin and between the digitations of the TAM to enter the TAP, and T9
and T10 nerves exit from their respective intercostal spaces directly into the TAP.

Computed Tomography Abdomen Showing the Subcostal Transverse

Abdominis Plane
Fig. 4-20

FIGURE 4-20 Transverse CT of the upper abdomen showing the anatomical relations of
the TAP (transversus abdominis plane) relevant for a subcostal TAP block. Note how the
transversus abdominis muscle extends deep to and posterior to the rectus abdominis muscle
anteriorly.

Magnetic Resonance Imaging Abdomen Showing the Subcostal Transverse

Abdominis Plane

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Fig. 4-21

FIGURE 4-21 Transverse MRI of the upper abdomen showing the anatomical relations of
the TAP (transversus abdominis plane) relevant for a subcostal TAP block.

Ultrasound Scan Technique

1.Position:
a.Patient: Supine with the abdomen exposed between the costal margin and the iliac
crest.
b.Operator and ultrasound machine: For a bilateral subcostal TAP block, right-handed
operators who hold the ultrasound transducer with their left hand and carry out needle
interventions with their right hand should stand on the left side of the patient and
position the ultrasound machine on the contralateral side and directly in front. This is
vice versa for left-handed operators.
2.Transducer selection: High-frequency (13-8 MHz) linear array transducer.
3.Scan technique: The ultrasound transducer is placed immediately below and parallel to the
costal margin, typically lateral to the linea semilunaris (Fig. 4-22). The aim is to identify
the three muscular layers of the lateral abdominal wall with the fascial layers that separate
them on the sonogram.

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FIGURE 4-22 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan of the anterior abdominal wall for a TAP (transversus abdominis
plane) block at the subcostal region.

4.Sonoanatomy: At the medial end, the linea semilunaris is seen lateral to the RAM (Figs. 4-
23 and 4-24), and the TAM may be the only muscle between the skin and the peritoneum.
Laterally and along the midclavicular line the three muscular layers of the abdominal wall
and the TAP are clearly delineated and appear similar to the lateral (midaxillary) TAP
(Figs. 4-23 to 4-26).

FIGURE 4-23 Transverse sonogram of the anterior abdominal wall showing the formation
of the linea semilunaris and the transversus abdominis plane (TAP) lateral to the lateral edge
of the rectus abdominis muscle (in colorize mode). Also note how the transversus abdominis
muscle extends deep to and posterior to the rectus abdominis muscle medially.

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FIGURE 4-24 Transverse sonogram of the anterior abdominal wall showing a close-up
view of the aponeurotic layers of the three abdominal muscles at the level of the linea
semilunaris lateral to the lateral edge of the rectus abdominis muscle.

FIGURE 4-25 Transverse sonogram (panoramic view) of the right subcostal region
showing the anatomic relations of the anterior abdominal muscles and the formation of the
transversus abdominis plane (TAP).

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FIGURE 4-26 Transverse sonogram (panoramic view) of the left subcostal region showing
the anatomic relations of the anterior abdominal muscles and the formation of the transversus
abdominis plane (TAP).

5.Clinical Pearls: During a subcostal TAP block, a multiple injection technique produces
greater spread of the injectate compared to a single injection in the TAP lateral to the
linea semilunaris.,13 The aim during a multiple injection technique is to hydrodissect the
TAP plane such that the injection is deposited progressively more laterally from the linea
semilunaris.

Rectus Sheath
Gross Anatomy
The rectus sheath is an aponeurotic sheath that covers the rectus abdominis muscle (Fig. 4-1).
It is made up of an anterior and a posterior wall that are formed by the aponeurosis of the
three flat muscles of the abdomen (Figs. 4-27 to 4-29). The anterior wall is complete
throughout its length and adherent to the tendinous insertions of the RAM. In contrast, the
posterior wall of the rectus sheath is free (not adherent) from the RAM and incomplete below
the “arcuate line” (Fig. 4-29). The latter is also referred to as the “linea semicircularis” or
“fold of Douglas” and lies about one-third the distance from the umbilicus to the pubic crest,
but there are variations. Above the costal margin the anterior wall is formed by the external
oblique aponeurosis, and the posterior wall is deficient and the muscle lies directly on the
costal cartilages with an intervening layer of fatty tissue (Fig. 4-27). In between the costal
margin and the arcuate line the anterior wall is formed by the external oblique aponeurosis
and the anterior lamina of the IOM, and the posterior wall is formed by the posterior lamina
of the IOM and the aponeurosis of the TAM (Fig. 4-28). Below the arcuate line the anterior
wall is formed by the aponeurosis of all the three flat muscles of the anterior abdominal wall,
but the posterior wall is deficient and the RAM lies directly on the fascia transversalis, being
separated from it by a layer of loose extraperitoneal fatty tissue (Fig. 4-29). The rectus sheath
on either side is held together in the midline by a median raphe, the linea alba (Fig. 4-1),

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which extends form the xiphoid process to the pubic symphysis.

FIGURE 4-27 Figure showing the formation of the rectus sheath in transverse section
above the costal margin.

FIGURE 4-28 Figure showing the formation of the rectus sheath in transverse section
between the costal cartilage and the arcuate line.

FIGURE 4-29 Figure showing the formation of the rectus sheath in transverse section
below the arcuate line.

Computed Tomography Abdomen Showing the Rectus Abdominis Muscle

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Fig. 4-30

FIGURE 4-30 Correlative transverse CT (Fig. 4-30A and C), MRI (Fig. 4-30B and D)
images of the rectus abdominis muscle from above and below the level of the umbilicus
(arcuate line). IEV, inferior epigastric vessels; EIV, external iliac vessels.

Magnetic Resonance Imaging Abdomen Showing the Rectus Abdominis Muscle

Figs. 4-30 and 4-31

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FIGURE 4-31 Sagittal MRI image of the lower abdomen showing the rectus abdominis
muscle and the transition zone at the level of the arcuate line on the posterior aspect of the
muscle.

Ultrasound Scan Technique

1.Position:
a.Patient: Supine with the abdomen exposed between the costal margin and the iliac
crest.
b.Operator and ultrasound machine: For a scan of the RAM and rectus sheath, the
operator stands on one side of the subject and the ultrasound machine is placed
directly opposite on the contralateral side. For a bilateral rectus sheath block, right-
handed operators who hold the ultrasound transducer with their left hand and carry
out needle interventions with their right hand should stand on the left side of the
patient and position the ultrasound machine directly in front on the contralateral side.
This is vice-versa for left-handed operators.
2.Transducer selection: High-frequency (13-8 MHz) linear array transducer.
3.Scan technique: For a transverse scan of the RAM and the rectus sheath, the ultrasound
transducer is positioned above the umbilicus (ie, above the arcuate line) and to one side of
the midline (Fig. 4-32). The aim is to obtain a transverse view of the RAM, which is seen
as a hypoechoic oval-to-elliptical structure that is surrounded by its hyperechoic
epimysium (Figs. 4-33 and 4-34). For a sagittal scan, the ultrasound transducer is rotated
through 90 degrees and positioned midway between the xiphisternum and the umbilicus
to obtain a longitudinal view of the RAM (Fig. 4-35).

FIGURE 4-32 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan of the anterior abdominal wall for the rectus abdominis muscle
above the arcuate line.

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FIGURE 4-33 Transverse (Fig. 4-33A and B) and sagittal (Fig. 4-33C and D) sonograms
of the rectus abdominis muscle (RAM) above the arcuate line in colorize mode showing (Fig.
4-33A) the anterior and posterior rectus sheath from both sides fusing in the midline to form
the linea alba. In this image the posterior rectus sheath is seen as a well-defined hyperechoic
fascial layer from the epimysium of the rectus abdominis muscle (RAM) and the parietal
peritoneum (Fig. 4-33B). Close-up view of the medial aspect of the left RAM showing the
linea alba and the anterior and posterior layers of the rectus sheath (Fig. 4-33C and D),
sagittal views of the RAM, and the anterior and posterior layers of the rectus sheath. Note the
hypoechoic space posterior to the RAM into which local anesthetic is injected during a rectus
sheath block.

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FIGURE 4-34 Transverse sonogram of the anterior abdominal wall (close to the midline)
above the arcuate line showing the medial aspect of the rectus abdominis muscle (RAM)
from both sides with the rectus sheath and the linea alba.

FIGURE 4-35 Figure showing the position and orientation of the ultrasound transducer
during a sagittal scan of the anterior abdominal wall for the rectus abdominis muscle above
the arcuate line.

4.Sonoanatomy: On a transverse sonogram, the RAM is seen as a hypoechoic oval-to-

elliptical structure that is surrounded by a hyperechoic epimysium (Figs. 4-33 and 4-34).
Between the costal margin and the arcuate line, the RAM is enveloped by a further layer
of fibrous connective tissue, the rectus sheath (details provided earlier), which also
appears hyperechoic and can be traced medially to the midline where it is continuous with
the linea alba (Fig. 4-34). Below the arcuate line the posterior rectus sheath is deficient

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 (Fig. 4-36) and the RAM lies directly on the fascia transversalis, being separated from it
by a layer of loose, extraperitoneal fatty tissue (Fig. 4-29). With currently available
ultrasound technology, we believe it is not possible to delineate the fascia transversalis on
a transverse sonogram.

FIGURE 4-36 Transverse sonogram of the anterior abdominal wall from below the level
of the arcuate line showing the right rectus abdominis muscle (RAM). Note that the anterior
rectus sheath is clearly visible but the posterior rectus sheath is deficient at this site.

On a sagittal sonogram the RAM is seen as a cylindrical, hypoechoic structure lying deep
to the skin and subcutaneous fat (Figs. 4-37 to 4-40). Interspersed within the RAM are
multiple hyperechoic strands (Figs. 4-37 to 4-39) that probably represent intramuscular
tendon fibers. The epimysium of the RAM also appears hyperechoic and covers both the
anterior and posterior walls of the muscle (Figs. 4-37 to 4-39). The rectus sheath appears as
an additional hyperechoic layer lying external to the epimysium of the muscle (Fig. 4-38).
The posterior rectus sheath is generally better delineated than the anterior rectus sheath. This
may be because the anterior rectus sheath is adherent to the tendinous insertions of the RAM.
A hypoechoic space is also clearly visualized between the posterior rectus sheath and the
epimysium covering the posterior surface of the RAM (Fig. 4-37). This is the potential space
into which local anesthetic is injected during a rectus sheath block. The three tendinous
insertions of the RAM may also be seen as hyperechoic areas within the muscle on a sagittal
sonogram (Figs. 4-37 and 4-40). The “transition zone” in the posterior aspect of the RAM
where the posterior rectus sheath ends can also be clearly delineated (Figs. 4-38 to 4-40).
Distal to the transition zone the parietal peritoneum is seen as a hyperechoic structure deep to
the RAM and easily recognized by the peristaltic movement of the underlying bowel (Fig. 4-
39).

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FIGURE 4-37 Sagittal sonogram of the anterior abdominal wall showing the rectus
abdominis muscle (RAM) with the anterior and posterior layers of the rectus sheath. Also
note the hyperechoic tendinous insertion of the rectus abdominis muscle and the hypoechoic
space between the epimysium of the RAM and the posterior rectus sheath.

FIGURE 4-38 Sagittal sonogram of the anterior abdominal wall at the level of the arcuate
line showing the “transition zone” where the posterior rectus sheath ends. RAM, rectus
abdominis muscle.

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FIGURE 4-39 Sagittal sonogram of the anterior abdominal wall showing the intermuscular
tendons (hyperechoic) of the rectus abdominis muscle (RAM). Because the ultrasound scan is
at the level of the arcuate line, the “transition zone” is clearly visible. The peritoneum is also
seen as a hyperechoic structure and distinct from the posterior rectus sheath.

FIGURE 4-40 Sagittal sonogram (panoramic view) of the rectus abdominis muscle (RAM)
showing the anatomy of the rectus sheath. Note the posterior rectus sheath is deficient distal
to the “transition zone” (ie, distal to the arcuate line). Also one of the tendinous insertions is
visible above the arcuate line in this sonogram.

Ilioinguinal and Iliohypogastric Nerve

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Gross Anatomy
The gross anatomy of the ilioinguinal and iliohypogastric nerves is described earlier.

Computed Tomography Abdomen – Transverse View at the Level of the

Anterior Superior Iliac Spine
Figs. 4-41 and 4-42

FIGURE 4-41 Transverse CT of the lower abdomen at the level of the anterior superior
iliac spine (ASIS) showing the location of the iliohypogastric and ilioinguinal nerve in the
fascial plane between the internal oblique and the transversus abdominis muscle.

FIGURE 4-42 Transverse CT of the lower abdomen below the level of the anterior

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superior iliac spine (ASIS) showing the location of the iliohypogastric and ilioinguinal nerve
in the fascial plane between the internal oblique and the transversus abdominis muscle. Note
the external oblique muscle is only an aponeurotic layer at this level.

MRI Abdomen – Transverse View at the Level of the Anterior Superior Iliac
Spine
Figs. 4-43 and 4-44

FIGURE 4-43 Transverse MRI of the lower abdomen at the level of the anterior superior
iliac spine (ASIS) showing the iliohypogastric and ilioinguinal nerve in the fascial plane
between the internal oblique and the transversus abdominis muscle.

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FIGURE 4-44 Transverse MRI of the lower abdomen below the level of the anterior
superior iliac spine (ASIS) showing the iliohypogastric and ilioinguinal nerves in the fascial
plane between the internal oblique and the transversus abdominis muscles. Note the external
oblique muscle is only an aponeurosis at this level.

Ultrasound Scan Technique

1.Position:
a.Patient: Supine with the lower abdomen exposed.
b.Operator and ultrasound machine: For an ultrasound scan of the ilioinguinal and
iliohypogastric nerves, right-handed operators who hold the ultrasound transducer
with their left hand and carry out needle interventions with their right hand should
stand on the left side of the patient and position the ultrasound machine directly in
front on the contralateral side. This is vice-versa for left-handed operators.
2.Transducer selection: High-frequency (13-8 MHz) linear array transducer.
3.Scan technique: The ilioinguinal and iliohypogastric nerves are best visualized close to the
anterior superior iliac spine (ASIS). The ultrasound transducer is positioned close to the
ASIS and parallel to a line joining the ASIS and the umbilicus (Fig. 4-45).

FIGURE 4-45 Figure showing the position and orientation of the ultrasound transducer
during a transverse scan of the lower abdomen at the level of the anterior superior iliac spine
(ASIS) for the iliohypogastric and ilioinguinal nerves.

4.Sonoanatomy: The ilioinguinal and iliohypogastric nerves are identified as two small,
rounded hypoechoic structures lying side by side between the internal oblique and
transversus abdominis muscles (Fig. 4-46). Below the level of the iliac crest the
aponeurosis of the external iliac muscle is seen as a hyperechoic aponeurotic layer (Fig.
4-47). Deep to the transversus abdominis muscle the peritoneum and bowel are also
visualized (Fig. 4-47).

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FIGURE 4-46 Transverse sonogram of the lower abdomen, at the level of the anterior
superior iliac spine (ASIS) showing the iliohypogastric and ilioinguinal nerves between the
internal oblique and the transversus abdominis muscles.

FIGURE 4-47 Transverse sonogram of the lower abdomen, from just below the level of
the anterior superior iliac spine, showing the iliohypogastric and ilioinguinal nerves between
the internal oblique and the transversus abdominis muscles. Also note the external oblique
aponeurosis, which is seen as a hyperechoic layer, superficial to the internal oblique muscle.

5.Clinical Pearls: The ilioinguinal and iliohypogastric nerves are best visualized close to
the ASIS. Also during an ultrasound-guided ilioinguinal iliohypogastric nerve block, the
authors prefer to perform an in-plane technique with the needle inserted from a medial-to-
lateral direction and towards the iliac bone. This not only allows the needle to be better

243
 visualized, but also in the event of inadvertent deep needle insertion the iliac bone will
prevent further needle advancement. We believe this approach may also prevent serious
complications like bowel and visceral perforation because the needle is inserted away
from the peritoneum and bowel.

Quadratus Lumborum Block

Gross Anatomy
Quadratus lumborum block (QLB) is a recently introduced abdominal wall field block9 in
which the local anesthetic is injected into a fascial plane that is deep to the fascia transversalis
(the deep fascia of the abdominal wall) and on the anterolateral aspect of the quadratus
lumborum muscle (Fig. 4-48).9–12 The point of injection is believed to approximate to the
landmark-based technique of performing a TAP block at the lumbar triangle of Petit.8,,14
Several ultrasound-guided techniques for QLB10–12,,15 or their variations have been
described in the literature (Fig. 4-48), but the optimal technique or the site of injection is still
not known. There are also limited clinical data on QLB8,10,12 and in particular the
mechanism by which it produces clinical efficacy. Preliminary reports suggest that a QLB
acts by a combination of mechanisms: (a) craniocaudal spread of the local anesthetic in the
fascial plane anterior to the quadratus lumborum,10,14 (b) ipsilateral paravertebral
spread,10,14 and (c) possibly ipsilateral epidural spread.14 There is also an anatomical plane
of communication between the retroperitoneal space and the thoracic paravertebral
space,,16–19 which may also be involved in the extended lumbothoracic spread of the local
anesthetic after a QLB injection.

FIGURE 4-48 Figure showing the facial planes in the posterior abdomen where the local
anesthetic is injected during a quadratus lumborum block (QLB). TAM, transversus
abdominis muscle; IOM, internal oblique muscle; EOM, external oblique muscle; QLN,
quadratus lumborum muscle; VB, vertebral body; Ao, aorta; IVC, inferior vena cava.

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 The fascia transversalis of the abdominal wall blends medially with the anterior layer of
the quadratus lumborum fascia and the psoas fascia (psoas sheath, Fig. 4-49).,20 The
subcostal (T12), iliohypogastric (L1), and ilioinguinal (L1) nerves course anterior to and in
close contact with the quadratus lumborum muscle,,21 and the lateral femoral cutaneous
nerve of the thigh (L2, L3) crosses the lateral border of the psoas muscle at the level of the
inferior border of the L4 vertebra in this fascial plane.,21 The potential space behind the
fascia covering the psoas major and quadratus lumborum muscles in the abdomen is
continuous cranially with the subendothoracic fascial compartment of the lower thoracic
paravertebral spaces in the thorax (Fig. 4-50).16,17,19 This continuity occurs dorsal to the
diaphragm through the medial and lateral arcuate ligaments (lumbocostal arch) and the aortic
hiatus.16,19,,22 This thoracolumbar continuity is the anatomical basis for “extended unilateral
anesthesia”18 after a lower thoracic paravertebral injection and may apply when ipsilateral
lumbothoracic spread of contrast10,14 or anesthesia12 occurs after a QLB injection.

FIGURE 4-49 Figure showing the anatomical relationship of the transversus abdominis
plane (TAP), fascia transversalis, and the fascia of the quadratus lumborum (quadratus
lumborum fascia) and psoas (psoas fascia/sheath) muscles in the retroperitoneal space. Note
the subcostal and ilioinguinal nerves are located on the anterior surface of the quadratus
lumborum muscle. Ao, aorta; IVC, inferior vena cava; PM, psoas major muscle; ESM,
erector spine muscle; TAM, transversus abdominis muscle; IO, internal oblique muscle;
EOM, external oblique muscle.

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FIGURE 4-50 Sagittal section showing the fascial relations of the lower thoracic
paravertebral space and the retroperitoneal space. Note the path of communication between
the subendothoracic compartment of the lower thoracic paravertebral space and the space
behind the fascia covering the psoas muscle (psoas fascia/sheath).

A QLB produces multidermatomal ipsilateral anesthesia of the thoracolumbar nerves.12 A

bilateral single injection QLB (20 mL of 0.375% ropivacaine on each side) produces loss of
sensation to cold from T7-T12 dermatomes.12 The segmental anesthesia produced by a QLB
is significantly wider than that produced by a lateral (midaxillary) TAP block (with
ropivacaine 0.5%, 15 mL per side, T10-T12).12 Also the duration of analgesia after a bilateral
QLB in patients undergoing laparoscopic ovarian surgery is significantly longer than that
produced by a bilateral lateral (midaxillary) TAP block.12 The prolonged duration of
analgesia after a QLB has been attributed to the paravertebral spread of the local anesthetic.
QLB may also produce ipsilateral sympathetic blockade because paravertebral spread of
contrast has been demonstrated.10,14 Therefore, QLB may be effective in relieving
sympathetic mediated visceral pain, which is otherwise not affected by a lateral (midaxillary)
TAP block. However, because there is a paucity of data on the use of bilateral QLB for major
abdominal surgery, no recommendations can be made at this time, but QLB holds promise as
a technique for perioperative pain management. The following section briefly describes the
ultrasound scan technique and sonoanatomy relevant for QLB.

Ultrasound Scan Technique

1.Position:
a.Patient: For a bilateral QLB the patient is placed in the supine position with the
abdomen exposed between the costal margin and the iliac crest. The ultrasound scan
for a bilateral QLB can also be performed with the patient in the sitting position. For a
unilateral QLB it may be preferable to place the patient in the lateral position (Figs. 4-
51 and 4-52) because the block needle can then be inserted from the posterior aspect
of the ultrasound transducer,11 which is otherwise not possible when the patient is in

246
 the supine position. In doing so the needle is inserted through the quadratus lumborum
muscle (transmuscular QLB)11 until the needle tip is in the target site between the
psoas and quadratus lumborum muscle (Fig. 4-48).11

FIGURE 4-51 Figure showing the position of the patient, ultrasound transducer, and the
plane of ultrasound imaging during a quadratus lumborum block (QLB) with the patient in
the lateral decubitus position. Note the anatomical relationship of the psoas major, quadratus
lumborum, and erector spinae muscle to the transverse process and the transversus abdominis
plane.

FIGURE 4-52 Transverse sonogram, acquired with a curvilinear transducer (C5-1 MHz)
showing the anatomy relevant for quadratus lumborum block (QLB) at the level of the

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transverse process. Note the site for local anesthetic during a QLB I and QLB II injection.
Accompanying photograph on the right is demonstrating the position of the patient and the
ultrasound transducer during a QLB. EOM, external oblique muscle; IOM, internal oblique
muscle; TAM, transversus abdominis muscle; VB, vertebral body; TP, transverse process;
ESM, erector spinae muscle; AP, articular process.

b.Operator and ultrasound machine: The operator stands on one side of the subject,
and the ultrasound machine is placed directly opposite on the contralateral side. For a
bilateral QLB, right-handed operators who hold the ultrasound transducer with their
left hand and carry out needle interventions with their right hand should stand on the
left side of the patient and position the ultrasound machine directly in front on the
contralateral side. This is vice versa for left-handed operators.
2.Transducer selection: It is preferable to use a curvilinear transducer (5-1 MHz, Fig. 4-51)
because it provides better penetration and a wider field of view than a linear transducer
(Fig. 4-53). A high-frequency (13-8 MHz) linear transducer, which provides higher-
resolution images, can be used in slim individuals (Fig. 4-53).

FIGURE 4-53 Transverse sonogram, acquired with a high-frequency (13-8 MHz) linear
array transducer showing the anatomy relevant for a quadratus lumborum block (QLB) at the
level of the transverse process. The resolution of the muscles and intermuscular facial planes
is significantly improved, but the field of view is limited (compare with Fig. 4-52). Also note
the sites for local anesthetic injection during a QLB. Accompanying photograph on the right
is demonstrating the position of the patient and the ultrasound transducer during a QLB.
EOM, external oblique muscle; IOM, internal oblique muscle; TAM, transversus abdominis
muscle; RPS, retroperitoneal space; QLM, quadratus lumborum muscle; PM, psoas major
muscle; VB, vertebral body; TP, transverse process; ESM, erector spinae muscle; TM-QLB,
transmuscular QLB.

3.Scan technique: Start the ultrasound scan by placing the transducer in the transverse
orientation in the flank immediately above the iliac crest (Figs. 4-51 to 4-53). Then gently

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 slide the transducer posteriorly, aiming to identify the anterolateral surface of the
vertebral body and the transverse process in the transverse sonogram (Fig. 4-52). Once
the transverse process is located and the relevant anatomy identified, tilt or slide the
transducer slightly caudally to perform the transverse scan through the intertransverse
space (Fig. 4-54). The acoustic shadow of the transverse process will no longer be visible
and will be replaced by the hyperechoic articular process (Fig. 4-54).

FIGURE 4-54 Transverse sonogram, acquired with a curvilinear transducer (C5-1 MHz),
showing the anatomy relevant for quadratus lumborum block (QLB) at the level of the
articular process (AP). Note the site for local anesthetic injection during a QLB I and QLB II.
The lumbar plexus nerves are visualized on the posterior aspect of the psoas muscle. Also the
spinal canal is visualized through the intervertebral foramen (IVF). EOM, external oblique
muscle; IOM; internal oblique muscle, TAM; transversus abdominis muscle; VB, vertebral
body; ESM, erector spinae muscle.

4.Sonoanatomy: On the transverse sonogram the vertebral body and transverse process of
the vertebra appear as hyperechoic structures with a corresponding acoustic shadow (Fig.
4-52). The psoas major, quadratus lumborum, and erector spinae muscles are easily
recognized surrounding the transverse process. Also depending on the side scanned, the
inferior vena cava (on the right) and aorta (on the left) are visualized anterolateral to the
vertebral body (Fig. 4-52). The arrangement of the three muscles around the transverse
process, that is, the psoas muscle lying anterior, the erector spinae muscle lying posterior,
and the quadratus lumborum muscle lying at the apex (Fig. 4-52), produces a sonographic
pattern that has been likened to a “shamrock” with the muscles representing the three
leaves.,23 Superficial and anterior to these three muscles the external oblique, internal
oblique, and transversus abdominis muscles can be identified (Figs. 4-52 to 4-54). In the
transverse sonogram through the lumbar intertransverse space the acoustic shadow of the
transverse process is no longer visualized, and the intervertebral foramen and spinal canal
may also be visualized in addition to the psoas major, quadratus lumborum, and erector
spine muscles (Fig. 4-54).
5.Clinical Pearls: One must identify the lower pole of the kidney and the peritoneal cavity
during the scout scan to avoid deep needle insertion and visceral injury. When performing
a QLB scan in individuals with a thick abdominal wall, gentle inward pressure may be

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 applied with the transducer to compress the abdominal tissues. This maneuver reduces the
overall depth to the target and thereby may improve the overall quality of the image.

References
1.Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia.
2001;56:1024–1026.
2.Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The transversus abdominis
plane block provides effective postoperative analgesia in patients undergoing total
abdominal hysterectomy. Anesth Analg. 2008;107:2056–2060.
3.Carney J, Finnerty O, Rauf J, Curley G, McDonnell JG, Laffey JG. Ipsilateral transversus
abdominis plane block provides effective analgesia after appendectomy in children: a
randomized controlled trial. Anesth Analg. 2010;111:998–1003.
4.Hebbard P, Royse C. Audit of transverse abdominus plane block for analgesia following
caesarean section. Anaesthesia. 2008;63:1382.
5.Hebbard PD, Barrington MJ, Vasey C. Ultrasound-guided continuous oblique subcostal
transversus abdominis plane blockade: description of anatomy and clinical technique.
Reg Anesth Pain Med. 2010;35:436–441.
6.McDonnell JG, O’Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic
efficacy of transversus abdominis plane block after abdominal surgery: a prospective
randomized controlled trial. Anesth Analg. 2007;104:193–197.
7.McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis
plane block after cesarean delivery: a randomized controlled trial. Anesth Analg.
2008;106:186–191.
8.Abrahams M, Derby R, Horn JL. Update on ultrasound for truncal blocks: a review of the
evidence. Reg Anesth Pain Med. 2016;41:275–288.
9.Blanco R. Tap block under ultrasound guidance: the description of a “nonpopstechnique.”
Reg Anesth Pain Med. 2007;32(Suppl 1):130.
10.Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after
caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015;32:812–818.
11.Borglum J, Morrigl B, Jensen K, et al. Ultrasound-guided transmuscular quadratus
lumborum blockade. Br J Anaesth. (2013) 111 (eLetters Supplement)
(http://bja.oxfordjournals.org/forum/topic/brjana_el%3B9919). Accessed 14 March,
2016.
12.Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum block: analgesic effects and
chronological ropivacaine concentrations after laparoscopic surgery. Reg Anesth Pain
Med. 2016;41:146–150.
13.Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P. Spread of injectate after ultrasound-
guided subcostal transversus abdominis plane block: a cadaveric study. Anaesthesia
2009;64:745–750.
14.Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell JG. Studies on the spread
of local anaesthetic solution in transversus abdominis plane blocks. Anaesthesia
2011;66:1023–1030.
15.Hansen CK, Dam M, Bendtsen TF, Borglum J. Ultrasound-guided quadratus lumborum
blocks: definition of the clinical relevant endpoint of injection and the safest approach.
Anesth Analg Case Rep. 2016;6:39.
16.Karmakar MK, Chung DC. Variability of a thoracic paravertebral block. Are we ignoring
the endothoracic fascia? Reg Anesth Pain Med. 2000 May-Jun;25(3):325–327.

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17.Karmakar MK, Gin T, Ho AM. Ipsilateral thoraco-lumbar anaesthesia and paravertebral
spread after low thoracic paravertebral injection. Br J Anaesth. 2001;87:312–316.
18.Saito T, Gallagher ET, Cutler S, et al. Extended unilateral anesthesia. New technique or
paravertebral anesthesia? Reg Anesth. 1996;21:304–307.
19.Saito T, Den S, Tanuma K, Tanuma Y, Carney E, Carlsson C. Anatomical bases for
paravertebral anesthetic block: fluid communication between the thoracic and lumbar
paravertebral regions. Surg Radiol Anat. 1999;21:359–363.
20.Donovan PJ, Zerhouni EA, Siegelman SS. CT of the psoas compartment of the
retroperitoneum. Semin Roentgenol. 1981;16:241–250.
21.Farny J, Drolet P, Girard M. Anatomy of the posterior approach to the lumbar plexus
block. Can J Anaesth. 1994;41:480–485.
22.Dugan DJ, Samson PC. Surgical significance of the endothoracic fascia. The anatomic
basis for empyemectomy and other extrapleural technics. Am J Surg. 1975;130:151–158.
23.Sauter AR, Ullensvang K, Bendtsen TF, Boerglum J. The “Shamrock Method”—a new
and promising technique for ultrasound guided lumbar plexus blocks. Br J Anaesth.
(2013) 111 eLetters Supplement.
(http://bja.oxfordjournals.org/forum/topic/brjana_el%3B9814). Accessed 14 March,
2016.

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CHAPTER 5

Ultrasound Imaging of the Spine: Basic Considerations

Introduction
Ultrasound has revolutionized the practice of regional anesthesia, particularly peripheral
nerve blockade, and it has also been used for central neuraxial blocks (spinal and epidural
injections).1–3 However, the use of ultrasound for central neuraxial blocks is still in its
infancy and not as popular4 as that for peripheral nerve blocks. The reasons for this are not
clear, but may be related to the high success rate of landmark-based techniques, limited data
on ultrasound for neuraxial blocks, perceived difficulty in performing spinal sonography,
limited acoustic window for ultrasound imaging, and poor understanding of spinal
sonoanatomy. However, recently published data suggest that ultrasound is beneficial for
central neuraxial blocks. Identification of a given lumbar intervertebral level for central
neuraxial block using surface anatomical landmarks (Tuffier line) is often imprecise,5 and
ultrasound is more accurate than clinical assessment.6 It can also be used to accurately
measure the depth to the epidural space or thecal sac7–9 and predict the ease of performing a
neuraxial block.10 Ultrasound also offers technical advantage by reducing the number of
puncture attempts,11–14 improves the success rate of epidural access on the first attempt,12
reduces the need to puncture multiple levels,12–14 and improves patient comfort during the
procedure.13 Ultrasound may also be beneficial for central neuraxial blocks in patients with
difficult (ie, abnormal or variant) spinal anatomy.15,16 Therefore, it is envisioned that the use
of ultrasound for central neuraxial blocks will grow in the near future. A sound knowledge of
the anatomy of the spine is a prerequisite for understanding the sonoanatomy of the spine. In
this chapter, we describe general details of spine anatomy and basic considerations relevant
for spinal sonography and central neuraxial blocks.

Basics of Spine Anatomy

The human spine or vertebral column is made up of 33 vertebrae—7 cervical, 12 thoracic, 5
lumbar, 5 sacral, and 4 coccygeal—that are stacked on top of each other (Fig. 5-1). A typical
vertebra has unique features (Fig. 5-2), and they differ at different levels (Figs. 5-3 to 5-5).
The number of spinal nerves in the thoracic, lumbar, and sacral region corresponds to the
number of vertebra, each lying below the corresponding vertebra. In the cervical region there
are eight spinal nerves. The first seven spinal nerves lie above the corresponding vertebra, but
the eighth cervical nerve lies below the seventh cervical vertebra. In the coccygeal region
there is only one coccygeal nerve.

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FIGURE 5-1 Human vertebral (spinal) column. (A) Posterior view and (B) lateral view.

FIGURE 5-2 Structure of a typical vertebra with its different components.

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FIGURE 5-3 A typical cervical vertebra (C4). Note the triangular spinal canal and the
foramen transversarium on the transverse processes. SAP, superior articular process; IAP,
inferior articular process; SAF, superior articular facet; IAF, inferior articular facet.

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FIGURE 5-4 A typical thoracic vertebra (T6). TP, transverse process; SC, spinal canal;
SVN, superior vertebral notch; SC, spinal canal; VB, vertebral body; TP, transverse process;
SAP, superior articular process; IAP, inferior articular process.

FIGURE 5-5 A typical lumbar vertebra (L4). Note the large vertebral body. SAP, superior
articular process; IAP, inferior articular process; SAF, superior articular facet; IAF, inferior
articular facet; VB, vertebral body; TP, transverse process; SC, spinal canal; SVN, superior
vertebral notch.

The spine has two primary curves (ie, the thoracic and sacral curve) that are concave
anteriorly, present at birth, and due to the shape of the vertebral bodies (Fig. 5-1). There are
also two secondary curves—the cervical and lumbar curves (Fig. 5-1)—that are convex
anteriorly and develop after birth. The cervical curvature develops after the infant starts to
support the weight of the head (usually between 4 and 9 months of age), and the lumbar
curvature develops between 12 and 18 months of age once the child assumes the upright
posture.
A typical vertebra is made up of two components: the vertebral body and the vertebral
arch (Fig. 5-6). The latter is formed by the supporting pedicles and laminae (Fig. 5-6). Seven
processes arise from the vertebral arch: one spinous process, two transverse processes, two
superior articular processes, and two inferior articular processes (Fig. 5-6). Adjacent vertebra
articulate with each other at the facet joints between the superior and inferior articular
processes and the intervertebral disc between the vertebral bodies (Fig. 5-7). This produces
two gaps between the lamina and the spinous processes (ie, the “interlaminar space” and
“interspinous space”). It is through these spaces that the ultrasound energy enters the spinal
canal and is therefore relevant for spinal sonography and central neuraxial blocks. The three
major ligaments of the spine are the ligamentum flavum, anterior longitudinal ligament, and

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posterior longitudinal ligament (Fig. 5-7). The posterior longitudinal ligament is attached
along the length of the anterior wall of the vertebral canal (Figs. 5-7 and 5-8). The
ligamentum flavum, also referred to as the “yellow ligament,” is a dense layer of connective
tissue that bridges the interlaminar spaces and connects the lamina of adjacent vertebra (Figs.
5-7 to 5-9). It is archlike on cross-section and widest posteriorly in the midline and in the
lumbar region. The ligamentum flavum is attached to the anterior surface of the inferior
margin of the lamina above, but it splits inferiorly to attach to both the posterior surface
(superficial component) and anterior surface (deep component) of the lamina below. The
spinous processes are attached at their tips by the supraspinous ligament (Fig. 5-7), which is
thick and cordlike, and along their length by the interspinous ligament (Fig. 5-9), which is
thin and membranous.

FIGURE 5-6 The vertebral arch (highlighted in green).

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FIGURE 5-7 Ligaments of the vertebral column.

FIGURE 5-8 Ligamentum flavum (yellow ligament) and its attachment to the laminae.

FIGURE 5-9 Sagittal section of the lumbosacral spine showing the relationship of the
spinal cord, conus medullaris, cauda equina, filum terminale, and thecal sac to the vertebral
column.

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 The spinal canal (vertebral canal) is formed by the vertebral arch and the posterior surface
of the vertebral body (Fig. 5-6). The openings into the spinal canal are through the
intervertebral foramen along its lateral wall and the interlaminar space on its posterolateral
wall. Within the spinal canal lies the thecal sac (formed by the dura mater and arachnoid
mater) and its contents (spinal cord, cauda equina, and cerebrospinal fluid, Fig. 5-9). The
spinal cord extends from the foramen magnum to the conus medullaris, near the lower border
of the first lumbar vertebra (Fig. 5-9), finally terminating as the filum terminale. However,
there are normal variations in the position of the conus medullaris, and it can extend from
T12 to upper third of L3.17 The cauda equina, named after its resemblance to a “horse’s tail,”
is made up of lumbar, sacral, and coccygeal nerves that originate in the conus medullaris and
descend caudally to exit the spinal canal through their respective intervertebral foramen. The
dural sac ends at the level of the second sacral vertebra (S2) (Fig. 5-9), but can vary from the
upper border of S1 to the lower border of S4.18 The epidural space is an anatomical space
within the spinal canal, but outside the dura mater (extradural). It extends from the level of
the foramen magnum cranially to the tip of the sacrum at the sacrococcygeal ligament (Fig. 5-
9). The posterior epidural space is of importance for central neuraxial blocks. The only
structure of importance in the anterior epidural space for neuraxial blocks is the internal
vertebral venous plexus.

Spinal Sonography – Basic Consideration

Spinal sonography typically requires the use of low-frequency ultrasound (5-2 MHz) and a
curved array transducer because the spine is located at a depth. Low-frequency ultrasound
provides good tissue penetration, but it lacks spatial resolution at the depths at which
neuraxial structures are imaged (approximately 5–8 cm). The osseous framework of the
spine, which envelopes the neuraxial structures, also reflects much of the incident ultrasound
signal. Furthermore, the acoustic window for ultrasound imaging (interlaminar and
interspinous space) is relatively narrow, and this poses an additional challenge in obtaining
high-quality images of the neuraxis. Recent improvements in ultrasound technology, image
processing capabilities of ultrasound machines, availability of advanced imaging modalities
(tissue harmonic imaging [THI], tissue aberration correction, color B-mode imaging), and the
development of new ultrasound scan protocols1 have all contributed to improving our ability
to image the neuraxis. Currently it is possible to accurately delineate the neuraxial anatomy
relevant for central neuraxial blocks using ultrasound.1,3 Also of note is technology that was
once only available in the high-end cart-based ultrasound systems are now available in
portable ultrasound devices, making them practical for spinal sonography and ultrasound-
guided neuraxial blocks.

Ultrasound Scan Planes

There are basically three anatomical planes: median, transverse, and coronal plane (Fig. 5-
10). The median plane is a longitudinal plane that passes through the midline and bisects the
body into equal right and left halves. The sagittal plane is also a longitudinal plane but is
parallel to the median plane and perpendicular to the ground. Therefore, the median plane can
also be defined as the sagittal plane that is exactly in the middle of the body (median sagittal
plane). The transverse plane, also known as the axial or horizontal plane, is parallel to the
ground. The coronal plane, also known as the frontal plane, is perpendicular to the ground.

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FIGURE 5-10 Anatomical planes of the body.

The spine can be imaged using ultrasound in the transverse (transverse scan, Fig. 5-11) or
longitudinal (sagittal scan, Fig. 5-12) plane and with the patient in the sitting, lateral
decubitus, or prone position. The latter is useful in patients presenting for chronic pain
interventions when fluoroscopy may also be used in conjunction with ultrasound. The
transverse and sagittal scan planes complement each other during an ultrasound examination
of the spine. Coronal plane images are displayed exclusively during multiplanar three-
dimensional (3-D) ultrasound imaging, and they are rendered images from the acquired 3-D
volume. During a transverse scan of the lumbar spine, the ultrasound beam can be insonated
at the level of the spinous process (transverse spinous process view, TSPV, Fig. 5-11A) or
through the interspinous space (transverse interspinous view, TISV, Fig. 5-11B). A sagittal
scan can be performed through the midline (median sagittal scan) or through a paramedian
(paramedian sagittal scan, PMSS) plane. The latter is more frequently used (less bone), and
during a paramedian sagittal scan (PMSS) the ultrasound beam is insonated lateral to the
midline (paramedian), and ultrasound images are acquired from the level of the lamina
(paramedian sagittal lamina view, Fig. 5-12A), articular process (paramedian sagittal articular
process view, Fig. 5-12B), or transverse process (paramedian sagittal transverse process
view, Fig. 5-12C). The neuraxial structures are better visualized through a paramedian
sagittal plane than through the median sagittal or median transverse plane.19 The ultrasound
visibility of neuraxial structures is further improved when the spine is imaged in the
paramedian sagittal oblique axis (Fig. 5-13). During a paramedian sagittal oblique scan
(PMSOS), the transducer is positioned 2 to 3 cm lateral to the midline (paramedian) in the
sagittal plane, and it is also tilted slightly medially, that is, towards the midline (Fig. 5-14).
The purpose of the medial tilt is to ensure that the majority of the ultrasound energy (signal)

259
enters the spinal canal through the widest part of the interlaminar space. The same applies,
and is probably more important, during a paramedian sagittal scan of the thoracic spine (Fig.
5-15).

FIGURE 5-11 Axis of scan – transverse scan (A) at the level of the spinous process and
(B) at the level of the interspinous space.

FIGURE 5-12 Axis of scan – paramedian sagittal scan (A) at the level of the lamina, (B) at
the level of the articular process, and (C) at the level of the transverse process.

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FIGURE 5-13 Axis of scan. (A) Paramedian sagittal scan at the level of the lamina and (B)
paramedian sagittal oblique scan at the level of the lamina.

FIGURE 5-14 Axis of scan – paramedian sagittal oblique scan of the lumbar spine. Note
the medial direction of the ultrasound beam (blue color). PMSS, paramedian sagittal scan
(red color); PMSOS, paramedian sagittal oblique scan. VB, vertebral body; IVC, inferior
vena cava; ESM, erector spinae muscle.

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FIGURE 5-15 Axis of scan – thoracic spine. (A) Paramedian sagittal scan and (B)
paramedian sagittal oblique scan.

Sonoanatomy of the Osseous Elements of the Spine

The bony framework of the spine, which wraps around the neuraxial structures, does not lend
itself to optimal conditions for ultrasound imaging because it reflects the majority of the
incident ultrasound energy, except for what gets through to the spinal canal through the
interspinous and interlaminar spaces. This creates a narrow acoustic window for imaging
(Fig. 5-16) and is narrower in the thoracic region than in the lumber spine (Fig. 5-16). Age-
related changes in the spine also cause narrowing of the acoustic window, making spinal
sonography more challenging in the elderly. Being able to accurately define the osseous
anatomy of the spine in a spinal sonogram is, in our opinion, the first step towards learning
how to interpret ultrasound images of the spine. Let’s consider that the spine is made up of
bone and soft tissue. If one is able to identify individual osseous elements of the spine, then
one should be able to identify the gaps in the bony framework (ie, the interlaminar space or
the interspinous space) through which the ultrasound beam is insonated to visualize the
neuraxial structures within the spinal canal. It is also through these same gaps that a spinal or
an epidural needle is inserted during an ultrasound-guided central neuraxial block.

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FIGURE 5-16 Sagittal sonogram of the lumbar and thoracic spine demonstrating the
acoustic window between the acoustic shadows of the laminae. Note the acoustic window is
larger in the lumbar spine.

The water-based spine phantom is a simple model to study the osseous anatomy of the
spine.1,3,20 It is prepared by immersing a commercially available spine model in a water bath
(Fig. 5-17) and imaging it in the transverse and sagittal plane through the water using a low-
frequency curved array transducer (Fig. 5-18). The water-based spine phantom, although
originally developed to study the osseous anatomy of the lumbosacral spine,1,3,20 can also be
used for the thoracic (Fig. 5-18) and cervical spine. Ultrasonography is often a case of
“pattern recognition,” and this is also true for spinal sonography. Each osseous element of the
spine produces a characteristic (signature) sonographic pattern that is comparable with that
seen in vivo (Figs. 5-19 to 5-24).1,3 Because water produces an anechoic (black) background,
the hyperechoic reflections from the bone are clearly visualized. Also because one can see the
spine model through the water, it is possible to validate the sonographic appearance of a
given osseous element by performing the scan with a marker (eg, a needle) in contact with it
(Fig. 5-20A). The water-based spine phantom is also relatively cheap, easily prepared,
requires little setup time, and can be repeatedly used without it deteriorating or decomposing

263
like animal tissues do.

FIGURE 5-17 The water-based lumbosacral spine phantom. Note the lumbosacral spine is
immersed in a water bath and is imaged through the water using a curved linear transducer.

FIGURE 5-18 Water-based thoracic spine phantom. Note the acute angulation of the
spinous processes in the midthoracic area (seen on the ultrasound monitor).

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FIGURE 5-19 Sonograms from the water-based lumbosacral spine phantom showing (A)
the transverse spinous process (SP) view, (B) the median sagittal spinous process view, and
(C) the transverse interspinous view. An inset image has been placed next to image C to
illustrate the resemblance of the sonographic appearance of the transverse interspinous view
to a cat’s head (refer to text for details). TS; transverse scan; SP, spinous process; ISS,
interspinous space; TP, transverse process; AP, articular process; VB, vertebral body; SC,
spinal canal.

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FIGURE 5-20 Paramedian sagitttal sonogram of the (A) lamina, (B) articular process, and
(C) transverse process frrom the lumbosacral water-based spine phantom. A graphic overlay
has been placed over the lamina in (A) to illustrate the “horse head sign” and over the
articular process in (B) to illustrate the “camel hump sign.” SS, sagittal scan; AP, articular
process; TP, transverse process. Note a needle has been placed over the lamina, which is used
to validate the structure imaged.

FIGURE 5-21 Sonograms from a water-based lumbosacral spine phantom showing (A)
median sagittal view of the sacrum, sacral hiatus, and coccyx and (B) transverse view of the

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sacral hiatus. SS, sagittal scan; TS, transverse scan.

FIGURE 5-22 Paramedian sagittal sonogram of the lumbosacral junction (L5-S1 gap)
from the water-based lumbosacral spine phantom.

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FIGURE 5-23 Paramedian sagittal sonogram of thoracic spine at the level of the lamina. A
simulated epidural needle is shown being inserted towards the interlaminar space in (B) as
one would do with a paramedian thoracic epidural. PMSOS, paramedian sagittal oblique
scan.

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FIGURE 5-24 Sonograms from a water-based cervical spine phantom. Note the bifid
spinous process of C2 in (B), the C1 spinous process is hypoplastic relative to C2 and
recessed in (D), lamina in (E), and articular process in (F). TS, transverse scan; PMSS,
paramedian sagittal scan; PMSOS, paramedian sagittal oblique scan.

With a lumbosacral water-based spine phantom the spinous processes produce an inverted
Y-shaped pattern in the transverse spinous process view (Fig. 5-19A), but in a median sagittal
scan they appear as crescent-shaped structures with their concavity facing anteriorly (Fig. 5-
19B). The gaps between the spinous processes represent the interspinous spaces (Fig. 5-19B).
The transverse interspinous view produces a sonographic pattern that resembles a cat’s head
(Fig. 5-19C) with the ears of the cat representing the articular processes, the head
representing the spinal canal, and the whiskers the transverse processes. We refer to this as
the cat’s head sign. On a paramedian sagittal scan the lamina resembles the head and neck of
a horse (Fig. 5-20A) and is referred to as the horse-head sign.3 The articular processes appear
as one continuous hyperechoic wavy line with no intervening gaps (Fig. 5-20B), resembling a
camel’s hump (camel hump sign). The transverse processes are also crescent-shaped (Fig. 5-
20C), but much smaller than the spinous process, and their acoustic shadows produce a
sonographic pattern referred to as the trident sign.21 The sacrum is recognized as a large
hyperechoic structure with a large acoustic shadow anterior to it on a sagittal sonogram (Fig.
5-21).3 The gap between the lamina of L5 and the sacrum is the L5-S1 gap (lumbosacral
interlaminar space, Fig. 5-22).3 Representative ultrasound images of the lamina of the
thoracic spine (Fig. 5-23), and the spinous process (Fig. 5-24), lamina, and articular pillars
(Fig. 5-24) of the cervical spine are presented in Figs. 5-23 and 5-24. Other models that are
useful in understanding the osseous anatomy of the spine are the CIRS lumbar training
phantom (Figs. 5-25 and 5-26)3 and gelatin-agar spine phantom (Figs. 5-27 to 5-29).22
Because the former can be imaged using computerized tomography (CT), 3-D reconstruction

269
of high-definition CT scan data (3-D volume data set) can also be used to study the osseous
anatomy (Figs. 5-25 and 5-26).

FIGURE 5-25 The CIRS lumbar training phantom (A) shown being imaged using
ultrasound (C and D). Also shown is a 3-D reconstructed image of the volume CT data set of
the CIRS phantom (B).

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FIGURE 5-26 Rendered CT images of the CIRS lumbar training phantom. (A) Median
sagittal section showing the spinous processes, interspinous space (ISS), and the L5-S1 gap.
(B) Transverse interspinous section showing the articular processes (AP), facet joints (FJ),
transverse process (TP), and spinal canal. (C) Paramedian sagittal section showing the
laminae and interlaminar spaces (ILS). (D) Paramedian sagittal section at the level of the
articular processes.

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FIGURE 5-27 Gelatin-agar spine phantom. (A) Lumbosacral spine model secured to the
base of the plastic box. (B) Spine phantom after being embedded in the gelatin-agar mixture.
(C) Performing ultrasound scan of the gelatin-agar spine phantom. (D) Simulated in-plane
needle insertion in the gelatin-agar spine phantom.

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FIGURE 5-28 Ultrasound scan of the gelatin-agar spine phantom (A). Transverse
sonogram of the spinous process (B) and through the interspinous space (D). Paramedian
sagittal oblique scan of the L3-L4-L5 level (C).

FIGURE 5-29 Paramedian sagittal sonogram from the gelatin-agar spine phantom. (A) L5-
S1 gap, (B) the laminae, (C) articular processes, and (D) the transverse processes at L3-L4
and L4-L5 levels. A graphic overlay has been placed over the L4 lamina in image B to
illustrate the sonographic pattern resembling the head and neck of a horse, and an inset has
been placed in image C to illustrate the camel hump–like appearance of the articular
processes. SC, spinal canal; AC, anterior complex; ILS, interlaminar space; LF, ligamentum
flavum; AP, articular process; TPn transverse process.

References
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for central neuraxial blockade. Anesthesiology. 2011;114:1459–1485.
2.Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time ultrasound-guided
paramedian epidural access: evaluation of a novel in-plane technique. Br J Anaesth.
2009;102:845–854.
3.Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD. Sonoanatomy relevant for
ultrasound-guided central neuraxial blocks via the paramedian approach in the lumbar
region. Br J Radiol. 2012;85:e262–e269.
4.Mathieu S, Dalgleish DJ. A survey of local opinion of NICE guidance on the use of
ultrasound in the insertion of epidural catheters. Anaesthesia. 2008;63:1146–1147.
5.Broadbent CR, Maxwell WB, Ferrie R, Wilson DJ, Gawne-Cain M, Russell R. Ability of
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7.Arzola C, Davies S, Rofaeel A, Carvalho JC. Ultrasound using the transverse approach to
the lumbar spine provides reliable landmarks for labor epidurals. Anesth Analg.
2007;104:1188–1192.
8.Balki M, Lee Y, Halpern S, Carvalho JC. Ultrasound imaging of the lumbar spine in the
transverse plane: the correlation between estimated and actual depth to the epidural
space in obese parturients. Anesth Analg. 2009;108:1876–1881.
9.Cork RC, Kryc JJ, Vaughan RW. Ultrasonic localization of the lumbar epidural space.
Anesthesiology. 1980;52:513–516.
10.Weed JT, Taenzer AH, Finkel KJ, Sites BD. Evaluation of pre-procedure ultrasound
examination as a screening tool for difficult spinal anaesthesia. Anaesthesia.
2011;66:925–930.
11.Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for presumed difficult
epidural puncture. Acta Anaesthesiol Scand. 2001;45:766–771.
12.Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Ultrasound imaging facilitates
localization of the epidural space during combined spinal and epidural anesthesia. Reg
Anesth Pain Med. 2001;26:64–67.
13.Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in
obstetric epidural anesthesia. J Clin Anesth. 2002;14:169–175.
14.Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of
combined spinal-epidural anaesthesia. Eur J Anaesthesiol. 2004;21:25–31.
15.Chin KJ, Chan VW, Ramlogan R, Perlas A. Real-time ultrasound-guided spinal anesthesia
in patients with a challenging spinal anatomy: two case reports. Acta Anaesthesiol Scand.
2010;54:252–255.
16.Yeo ST, French R. Combined spinal-epidural in the obstetric patient with Harrington rods
assisted by ultrasonography. Br J Anaesth. 1999;83:670–672.
17.Saifuddin A, Burnett SJ, White J. The variation of position of the conus medullaris in an
adult population. A magnetic resonance imaging study. Spine (Phila Pa 1976).
1998;23:1452–1456.
18.MacDonald A, Chatrath P, Spector T, Ellis H. Level of termination of the spinal cord and
the dural sac: a magnetic resonance study. Clin Anat. 1999;12:149–152.
19.Grau T, Leipold RW, Horter J, Conradi R, Martin EO, Motsch J. Paramedian access to the
epidural space: the optimum window for ultrasound imaging. J Clin Anesth.
2001;13:213–217.
20.Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD. The “water-based-spine-
phantom” — A small step towards learning the basics of spinal sonography. Br J Anaest.
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December 31, 2014.
21.Karmakar MK, Ho AM, Li X, Kwok WH, Tsang K, Kee WD. Ultrasound-guided lumbar
plexus block through the acoustic window of the lumbar ultrasound trident. Br J Anaesth.
2008;100:533–537.
22.Li JW, Karmakar MK, Li X, Kwok WH, Ngan Kee WD. Gelatin-agar lumbosacral spine
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sonographically guided central neuraxial blocks. J Ultrasound Med. 2011;30:263–272.

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CHAPTER 6

Sonoanatomy Relevant for Ultrasound-Guided Injections

of the Cervical Spine

Introduction
Injections of the cervical spine are frequently used for pain management in chronic pain
medicine. The concentration of bony structures and nerves in the cervical spine, each of
which can be a cause of pain, as well as vessels, requires an intimate knowledge of the
anatomy. The relevant procedures in the cervical spine include facet joint and medial branch
blocks, selective nerve root injection, third occipital nerve block, epidural steroid injection,
and stellate ganglion block. In this chapter we discuss the anatomy relevant for these
procedures.

Basic Cervical Spine Anatomy

The cervical spine (Figs. 6-1 to 6-3) is a column of seven vertebrae supporting the skull and
neck structures. The atlanto-occipital and atlantoaxial joints are unique. The former is an
ellipsoid joint, and the atlantoaxial joint is a rotatory joint. The atlantoaxial joint is bordered
by the C2 dorsal root ganglion and vertebral artery. The cervical vertebrae are identified by
the presence of the foramen transversarium (transverse foramen) for the vertebral artery.

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FIGURE 6-1 Cervical spine – lateral view.

FIGURE 6-2 Cervical spine – anterior view. VB, vertebral body.

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FIGURE 6-3 Cervical spine – posterior view.

Typical Cervical Vertebra (C3 to C6)

The third to sixth cervical vertebra are considered typical cervical vertebra (Fig. 6-4),
whereas the first, second, and seventh cervical vertebra are atypical with certain unique
features (Figs. 6-5 and 6-6). The general characteristics of a typical cervical vertebra are
described next. The upper five cervical vertebrae (C3 to C7) each have a concave superior
surface and are convex on the inferior surface. They articulate with the adjacent vertebrae via
uncovertebral joints (joints of Luschka). These are thought to be due to degenerative tears in
the annulus of the intervertebral disc, leading to creation of the uncovertebral joint.
Uncovertebral joint osteophytes can contribute to narrowing of the exit foramina. The spinal
canal (vertebral canal) in the cervical spine is larger than the size of the body. It is also
triangular shaped because the pedicles are directed backwards and laterally (Fig. 6-4). The
superior and inferior vertebral notches are usually equal sized. The laminae are relatively
long and narrow and thinner above than below. The superior and inferior articular processes
form the articular pillars and project laterally at the junction of the pedicle and transverse
process. The superior articular facets are directed backwards and upwards, whereas the
inferior articular facets are directed forwards and downwards (Fig. 6-1). The transverse
process of each vertebra is pierced by the foramen transversarium (Fig. 6-4) to allow for the
passage of the vertebral arteries on their upward course to the foramen magnum (Fig. 6-7).
Each transverse process has an anterior and a posterior tubercle with the groove for the spinal
nerve between them (Figs. 6-1 and 6-2). The anterior tubercle of the sixth cervical vertebra is
large and called the “carotid tubercle” (tubercle of Chassaignac). The posterior tubercles of
C3 to C5 are located lower and laterally (Figs. 6-1 and 6-2). The spinous processes of C3 to
C6 can be bifid (Figs. 6-3 and 6-8), and the two divisions can be of unequal size. The first
bifid spinous process is C2, and this landmark is used to identify the remaining cervical
vertebrae. The facet joints are oriented at 45 degrees to the axial plane and allow sliding of
one articular facet on another (Figs. 6-9 and 6-10).

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FIGURE 6-4 A typical cervical vertebra (C4 - fourth cervical vertebra). SAF, superior
articular facet; SAP, superior articular process; VB, vertebral body; IAF, inferior articular
facet; IAP, inferior articular process.

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FIGURE 6-5 Atlas (superior, anterior, and lateral view). Note the kidney-shaped SAFs.
SAF, superior articular facet; IAF, inferior articular facet.

FIGURE 6-6 Axis (superior, anterior, and lateral view). SAF, superior articular facet; VB,
vertebral body; IAF, inferior articular facet; AAF, anterior articular facet; IAP, inferior
articular process; PAF, posterior articular facet.

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FIGURE 6-7 Cervical spine (anterior view) showing the relationship of the cervical spinal
nerves and the vertebral artery to the transverse processes of the vertebra. Note the transverse
processes of the C7 vertebra lack an anterior tubercle and the relationship of the vertebral
artery to the C7 spinal nerve and the transverse processes.

FIGURE 6-8 Cross-sectional cadaver anatomic section through the C2 vertebral body
showing the bifid spinous process of C2. This is an anatomical landmark used to identify the
C2 vertebra as it is the first cervical vertebra with a bifid spinous process. The spinous
process may be tilted to the right or left. Gentle left and right angulation of the probe in the
longitudinal sagittal plane may be required to visualize these spinous processes.

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FIGURE 6-9 Paramedian sagittal cadaver anatomic section through the cervical spine
demonstrating the lamina of the cervical vertebrae. VB, vertebral body.

FIGURE 6-10 Cross-sectional cadaver anatomic section through the cervical spine
demonstrating the facet joints. Note that the facet joints are orientated at about 45 degrees to
the horizontal plane in transverse section.

The cervical spinal canal measures about 14 to 20 mm in the mediolateral dimension and
15 to 20 mm in the anteroposterior dimension. The spinal nerves (formed by the anterior and
posterior nerve roots) exit through the neural foramina. These foramina are largest at C2 to
C3 and progressively decrease in size to the C6 to C7 levels. The spinal nerve and ganglion
take up about 33% of the foraminal space. The foramen is bordered anteromedially by the
uncovertebral joints and posterolaterally by the facet joints. The pedicles border the exit
foramina superior and inferiorly. The spinal nerves exit above their corresponding vertebral
bodies. The C1 nerve exits above the C1 vertebra (atlas). The next spinal nerve is C2, exiting
above the C2 vertebra (axis). Following this naming convention, the last cervical nerve root is
C8, and it exits between the C7 and T1 vertebrae (Figs. 6-11 and 6-12).

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FIGURE 6-11 Cross-sectional cadaver anatomic section through the cervical spine
demonstrating the exiting C5 nerve root. The C5 nerve root exits the neural foramen and is in
close relation to the vertebral artery posteriorly. Both these structures are bound by the larger
anterior tubercle and the smaller posterior tubercle. TP, transverse process.

FIGURE 6-12 Sagittal cadaver anatomic section of the exit neural foramina demonstrating
the C5 nerve root exiting between the transverse processes (TP) of C4 superiorly (C4 TP) and
C5 (C5 TP) inferiorly. The bulk of sternocleidomastoid muscle lies anteriorly and may be
traversed during procedures in the cervical spine.

The anterior spinal artery is located in the central sulcus of the cord, with paired posterior
arteries running on the posterolateral aspect of the cord dorsally. The anterior spinal artery is
an important artery: it supplies the anterior two-thirds of the cervical spinal cord. The artery

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receives blood supply from the paired anterior spinal branches that arise from the
cervicomedullary junction portion of the vertebral arteries. This anatomy is relevant for
epidural steroid injections. The radicular arteries also supply the nerve roots and spinal cord.
These radicular arteries arise from the aorta. In the lower cervical spine, they arise from the
vertebral arteries and run in an anteromedial direction with respect to the neural foramina. In
the lower cervical spine, large radiculomedullary branches contribute blood supply to the
anterior spinal artery as well. Branches of the ascending and deep cervical arteries
anastomose with the vertebral artery branches and contribute to the anterior spinal artery. The
ascending cervical artery arises from the thyrocervical trunk or subclavian artery.
The posterior subclavian artery also gives off the deep cervical artery and the superior
intercostal artery. The deep cervical artery gives spinal branches from levels C7 to T1, known
as the cervical radiculomedullary arteries. As mentioned earlier, these arteries can contribute
supply to the anterior spinal artery. These radiculomedullary arteries are found along the
length of the intervertebral foramina and can be compromised during injection, potentially
leading to damage to the anterior spinal artery. The posterior third of the cervical spinal cord
is supplied by small paired posterior spinal branches.

Atlas (C1)
The atlas is the first cervical vertebra (Fig. 6-5) and forms the joint that connects the spine to
the skull (Fig. 6-13). It is ring shaped and lacks both a vertebral body and spinous process
(Fig. 6-5). It also lacks a true facet joint and has two arches: anterior and posterior. The
posterior arch is usually quite small. A thick anterior arch, lateral masses, and transverse
processes on either side make up the rest of the atlas ring. It also has a rudimentary posterior
tubercle. On each lateral mass is a facet (zygapophyseal) joint. The superior articular facets
are kidney shaped (Fig. 6-5), concave, and face upwards and inwards (imagine your hands
cupping water from a running tap). The inferior articular facets are flat and face downwards
and outwards. The transverse processes project laterally from each lateral mass and are longer
than all the others (Figs. 6-2 and 6-3).

FIGURE 6-13 Median sagittal cadaveric anatomic section through the cervical spine
demonstrating C1 in relation to the occiput and the rest of the cervical vertebrae. Note how

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closely the dura and the cervical spinal cord are to the spinous processes. The vertebral
bodies (VB) are labeled as anterior complex to demonstrate that sonographically, the
individual components (including the posterior longitudinal ligament complex) are difficult to
distinguish individually. SP, spinous process.

Axis (C2)
The second cervical vertebra (Fig. 6-6) is recognized by the presence of the dens (odontoid
process), which is a strong toothlike process that projects upwards from the body (Fig. 6-6).
The dens is believed to represent the body (centrum) of the atlas, which has fused with the
body of the axis. The odontoid process articulates with the atlas to form the rotatory
atlantoaxial joint. The joint is strengthened by periarticular ligaments (the apical, alar, and
transverse ligaments). The axis is made up of a vertebral body, pedicles, lamina, and
transverse and spinous processes. The atlas articulates with the axis (Fig. 6-2) at the superior
articular facets of C2. In order to meet the inferior articular processes of C1, the C2 superior
articular facets face upwards and outwards. There is an extensive and densely packed
network of blood vessels around the dens. These are supplied by the paired anterior and
posterior ascending arteries (which arise from the vertebral arteries at the C3 level, carotid
wall vessels, and the ascending pharyngeal arteries).
The transverse ligament secures the odontoid process to the posterior atlas and acts to
prevent subluxation of C1 on C2. Accessory ligaments arise posterior to the transverse
ligament and insert on the lateral aspects of the atlantoaxial joint. The apical ligament, part of
the accessory ligaments mentioned earlier, connect the anterior lip of the foramen magnum to
the tip of the dens. Paired alar ligaments also attach the tip of the dens to the anterior foramen
magnum. The tectorial membrane is a cranial continuation of the posterior longitudinal
ligament, attaching to the anterior lip of the foramen magnum. A broad accessory atlantoaxial
ligament connects C1 and C2 and connects to the occiput. They contribute to craniocervical
stability. The lack of bony borders at the atlantoaxial joint results in wider acoustic windows
at this level, but this is countered by the tortuous course of the ascending vertebral arteries.

Seventh Cervical Vertebra (C7)

This is also known as the “vertebral prominence” because it has a long and prominent
spinous process (Fig. 6-1) that is palpable from the skin surface. The spinous process is also
thick, nearly horizontal, and is not bifid but ends in a tubercle. The transverse process of C7
is relatively large and lacks an anterior tubercle (Fig. 6-7). The foramen transversarium on the
transverse processes of C7 are small but may be duplicated or even absent.

Computed Tomography Anatomy of the Cervical Spine

Figs. 6-14 to Fig. 6-21

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FIGURE 6-14 Transverse CT section through the cervical spine demonstrating the facet
joints at the C5 to C6 level. The inferior articular pillar of the C6 (vertebra inferior to the
joint) is located anterior to the joint space. The superior articular pillar of the C5 (vertebra
superior to the joint) is located posterior to the joint space.

FIGURE 6-15 Transverse CT section through the cervical spine demonstrating the facet
joints at the C6 to C7 level. Note the relatively horizontal orientation of the facet joint as
opposed to the obliquity of the C5 to C6 facet superiorly.

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FIGURE 6-16 Transverse CT section through the cervical spine. The lamina on the
posterolateral aspect of the vertebra flows into the transverse process. The longus colli
muscle lies on the anteromedial aspect of the transverse process.

FIGURE 6-17 Transverse CT section through the body of the seventh cervical spine
demonstrating its large and prominent spinous process (vertebra prominence). VB, vertebral
body.

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FIGURE 6-18 Sagittal CT section of the cervical spine demonstrating the posterior arch of
C1 and the corresponding laminae of the vertebrae inferiorly.

FIGURE 6-19 Sagittal CT section of the cervical spine more laterally in the cervical spine
demonstrating the overlapping articular pillars that form the facet joints. In the same cut,
transverse processes may also be visualized on CT. The transverse processes may be
obscured on ultrasound by the bony reflections of the facet joints.

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FIGURE 6-20 Sagittal CT section of the cervical spine in the midline demonstrating the
spinous processes aligned with the occiput. The tips of the spinous processes are echogenic
on ultrasound. Starting with the broad echogenic base of the occiput, these echogenic points
can be used to identify the levels of the cervical spine. Note that the spinous process of C1 is
hypoplastic relative to C2 and recessed. It is important to identify this recess to avoid
mislabeling C2 as the first cervical vertebra on ultrasound.

FIGURE 6-21 Sagittal CT section of the cervical spine demonstrating the relationships of
the articular pillars, facet joints, and the vertebral artery within the foramen transversarium.
Also note the oblique angulation of the facet joints in the sagittal plane. In order for
successful facet joint injection, the needle should be parallel to the angulation of the joint.

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Magnetic Resonance Anatomy of the Cervical Spine
Figs. 6-22 to 6-38

FIGURE 6-22 Sagittal T2-weighted MRI section of the cervical spine demonstrating the
posterior arch of C1 and the corresponding laminae of the vertebrae inferiorly. Note the slight
overlap of the laminae, which is seen on ultrasound as a “horse head” configuration.
Cerebrospinal fluid (hyperintense signal) bathes the small nerve roots in the spinal canal.

FIGURE 6-23 Sagittal T2-weighted MRI section of the cervical spine more laterally in the
cervical spine demonstrating the overlapping articular pillars that form facet joints.

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FIGURE 6-24 Sagittal MRI section of the cervical spine demonstrating the vertebral artery
within the foramen transversarium. The exiting nerve roots are well demonstrated as ovoid
hypointense foci as they are seen en face. The nerve roots are closely related to the vertebral
artery.

FIGURE 6-25 Sagittal MRI section of the cervical spine in the midline demonstrating the
spinous processes aligned with the occiput. The tips of the spinous processes are echogenic
on ultrasound. Starting with the broad echogenic base of the occiput, these echogenic points
can be used to identify the levels of the cervical spine. Note that the spinous process of C1 is
hypoplastic relative to C2 and recessed. It is important to identify this recess to avoid
mislabeling C2 as the first cervical vertebra on ultrasound. MRI demonstrates the relationship
of the cervical spine relative to the dura, with surrounding cerebrospinal fluid.

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FIGURE 6-26 Sagittal MRI section of the cervical spine demonstrating the broad base of
the occiput. Note that the spinous process of C1 is hypoplastic relative to C2 and recessed. It
is important to identify this recess to avoid mislabeling C2 as the first cervical vertebra on
ultrasound.

FIGURE 6-27 Sagittal oblique MRI section of the cervical spine demonstrating the

292
epidural space and the dura posteriorly. The epidural space in the cervical spine is a potential
space (unlike the lumbar spine, where fat fills the epidural space).

FIGURE 6-28 Transverse MRI section through the cervical spine demonstrating the
laminae of C2. The cervical spinal cord is well visualized centrally, with nerve roots exiting
on either side of the cord, extending beyond through the exit foramina.

FIGURE 6-29 Transverse MRI section through the cervical spine demonstrating the facet
joints. The facets are angled posteriorly at this level and gradually assume a more horizontal
orientation in the lower cervical spine. The vertebral body and anterior and posterior
longitudinal ligaments are collectively referred to as the anterior complex in sonography as
they are not separately distinguishable.

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FIGURE 6-30 Paramedian sagittal MRI of the cervical spine demonstrating the almost
vertical oblique course of the cervical nerve roots of C4 and C5 as they plunge toward the
interscalene groove. The large overlying sternocleidomastoid muscle is demonstrated.

FIGURE 6-31 Paramedian sagittal MRI section of the cervical spine demonstrates the C5
nerve root beyond the exit foramen. It runs between the transverse processes of C4 and C5 en
route to the interscalene groove (between the anterior and middle scalene muscles).

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FIGURE 6-32 Transverse MRI section through the cervical spine demonstrating the
exiting C5 nerve root. The C5 nerve root exits the neural foramen and is in close relation to
the vertebral artery posteriorly. Both these structures are bound by the larger anterior tubercle
and the smaller posterior tubercle.

FIGURE 6-33 Transverse MRI section through the cervical spine demonstrating the facet
joints at the C5 to C6 level. The inferior articular pillar of the C6 (vertebra inferior to the
joint) is located anterior to the joint space. The superior articular pillar of the C5 (vertebra
superior to the joint) is located posterior to the joint space. Note that at C5 to C6, the facets
remain oblique relative to the horizontal plane. They take a more horizontal course from the
C6 to-C7 and C7 to T1 levels.

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FIGURE 6-34 Transverse MRI section through the cervical spine demonstrating the
prominent anterior tubercle of C6 (Chassaignac’s tubercle). This is a sonoanatomical
landmark to identify C6 and the exiting C6 nerve root immediately posterior to the tubercle.
The longus colli muscle lies anteromedial to the Chassaignac tubercle in close relationship
with the carotid artery on its lateral aspect.

FIGURE 6-35 Transverse MRI section through the cervical spine demonstrating the C6 to
C7 facet joints. In comparison with the C5 to C6 level, the facets are orientated in a more
horizontal plane.

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FIGURE 6-36 Transverse MRI section through the cervical spine at the C6 to C7 foramen
demonstrating the exiting C7 nerve root running immediately posterior to the vertebral artery.
The nerve root is en route between the anterior and middle scalene to form the brachial
plexus. Note the presence of the internal jugular vein (IJV), carotid artery, and the vertebral
artery.

FIGURE 6-37 Transverse MRI section through the cervical spine demonstrating the C7
transverse processes. The anterior complex (vertebral body) is flanked by the vertebral
arteries on both sides.

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FIGURE 6-38 Transverse MRI section through the cervical spine demonstrating the
longus colli muscles running anterior to the transverse processes. Note that the vertebral
arteries lie immediately posterior to the longus colli at the C7 level. The carotid artery is
located on the anterolateral aspect of the muscle, and the thyroid gland forms the anterior
border of the muscle. With ultrasound, a safe trajectory between the artery and thyroid gland
toward the longus colli can be planned. The sternocleidomastoid muscle overlies the
anterolateral aspect of the neck and may be traversed during a stellate ganglion block.

Ultrasound for Cervical Facet Joint Injection

Ultrasound Scan Technique
1a. Patient position:
a.Lateral approach: The patient is placed in the lateral decubitus position. The head is
placed on a pillow so that the shoulders are square to the examination couch. Hair
should be tied and lifted clear from the side of the neck to prevent contamination
during the procedure (Fig. 6-39).

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FIGURE 6-39 Position of the patient and ultrasound transducer during a paramedian
sagittal scan of the cervical facet joints. The transducer is placed about 1 to 2 cm away from
the midline and angulated medially toward the facet joints. A similar position is used for
performing third occipital nerve blocks (refer to text).

b.Posterior approach: The posterior approach has the distinct advantage of allowing the
patient to be placed prone and both joints being accessible without having to change
position. It can be uncomfortable to the patient if multiple levels are blocked, so this
position is suited for faster access to both sides of the neck (Fig. 6-40).

FIGURE 6-40 Position of the patient and ultrasound transducer during a paramedian
sagittal scan of the cervical facet joints. The transducer is placed about 1 to 2 cm away from
the midline and angulated medially toward the facet joints. The posterior approach allows
more room to maneuver the needle and probe. It also allows simultaneous access to both
sides of the spine, but is generally more uncomfortable for patients.

299
1b. Position of operator and ultrasound machine:
The operator sits or stands facing the patient’s back in the lateral position or on the side of
the patient for the posterior approach. It is more comfortable for the operator if the
nondominant hand anchors the transducer and the dominant hand manipulates the needle.
2.Transducer selection:
Due to the density of muscular structures around the cervical spine, a curvilinear probe
(5–2 MHz) is used for imaging and blocks in the cervical spine (facet blocks and occipital
nerve blocks). The in-plane resolution of the images is reduced compared with a linear
probe, but this is often necessary due to the depth of the facet joints in relation to the skin.
The probe footprint is often large, and maneuvering the transducer into the correct
position requires practice. Although visualization of small (2 mm and below) structures is
compromised by using a curvilinear probe traditionally, processing techniques such as
spatial compound imaging and tissue harmonic imaging on new ultrasound machines
enable us to examine tissues at those depths with reasonable clarity. Beam steering
technology (which is an offshoot of compound imaging) enhances needle visualization,
and color B-mode imaging (such as indigo or sepia hue) aids the human eye for image
visualization when image contrast is poor.
3.Scanning technique for facet joint blocks:
A sagittal plane scan is performed in the midline, using the spinous processes to identify
the level to inject. Align the transducer in a craniocaudal direction with respect to the
cervical spine, starting at the occiput and sliding inferiorly. C1 has a very small or absent
spinous process (Figs. 6-41 and 6-42), and the first bifid spinous process will be C2. The
transducer can be slid inferiorly until the desired level for the injection is reached. Having
identified the level, the transducer should be shifted slightly laterally along the lamina by
about 1 to 2 cm from the midline. From there, a slight lateral shift of the transducer will
reveal facet joints, which appear with a characteristic “saw sign.” The probe may have to
be angled medially to produce a slightly paramedian sagittal oblique image. The needle is
inserted in a posterior-to-anterior plane and followed in real time (Fig. 6-43).1

FIGURE 6-43 Paramedian sagittal sonogram of the cervical spine lateral to the laminae
demonstrating the overlying echogenic “hills” of the facet joints.

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FIGURE 6-41 Median sagittal sonogram of the cervical spine. The broad echogenic base
of the occiput is immediately followed by the recessed spinous process of C1. The C2
spinous process is larger and appears as a step superficially relative to the C1 vertebra.

FIGURE 6-42. Coned (zoomed) sagittal view of the cervical spine. The occiput and C1
articulation is clearly demonstrated.

4.Sonoanatomy of the facet joint:

On ultrasound, cervical segments can be identified with respect to the occiput by counting
the echogenic points, which represent the spinous processes. The first echogenic point
located inferior to the occiput is the C1 cervical vertebra. The C2 vertebra is located
immediately inferior to that and has a characteristic bifid appearance. This presents as two

301
 echogenic points on ultrasound performed in the transverse plane. The spinous processes
in the cervical spine can appear bifurcated and can be asymmetrical. They can also
deviate to the right or left (Figs. 6-8 and 6-13).
The occipitoatlantal and atlantoaxial joints may be demonstrated once these levels are
identified. The articular processes are echogenic, and the facet joint is represented as a
hypoechoic gap between the articular processes. The needle can then be inserted from
inferior to superior in plane to the transducer. This approach allows the needle to be
inserted parallel to the facet joint (Fig. 6-43).
The facet joints are angled at about 45 degrees to the transverse plane in the cervical
spine.2 They start to assume a more vertical position in the upper thoracic spine. The
superior articular process faces more posteromedial in the upper cervical levels, and it
becomes more posterolateral at the lower cervical level (Figs. 6-44 and 6-45). The facet
joints are synovial joints. Each facet joint has a fibrous capsule and is lined by synovial
membrane. The joint capsules are lax in the lower cervical spine, allowing the spine to
glide smoothly during movement (Figs. 6-9, 6-14, 6-29, and 6-46).

FIGURE 6-46 Transverse sonogram clearly demonstrating the facet joint of C5 to C6.
Sometimes, this joint is obscured by osteophyte formation.

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FIGURE 6-44 Transverse sonogram of the cervical spine at the C2 articular pillars level.
With the probe orientated in a transverse plane and angulated superiorly between the spinous
processes, the spinal cord and anterior complex can be visualized.

FIGURE 6-45 Transverse sonogram at the C2 to C4 articulation demonstrating the facet

joints on either side of the central canal containing the spinal cord. The echogenic lines
denoting the apposing articular surfaces can be seen. Whereas an in-plane injection technique
is frequently used with cross-sectional imaging, ultrasound-guided facet injections are usually
performed in the longitudinal plane relative to the patient.

The facet joint capsules contain dense mechanoreceptors, which play a role in
proprioception and pain sensation. This is thought to neuromodulate the cervical spine
and prevent excessive joint movement.3 The facet joints are innervated by articular

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 branches derived from the medial branches of the cervical ventral and dorsal rami. The
atlanto-occipital and atlantoaxial joints are innervated by the anterior rami of the first and
second cervical spinal nerves. The C2 to C3 facet joint is innervated by the two branches
of the posterior ramus of the third cervical spinal nerve: a communicating branch and the
third occipital nerve (Fig. 6-9).
The C3 to C7 dorsal rami arise from their respective spinal nerves and pass dorsally
over the root of the corresponding transverse processes. The medial branches of the
cervical dorsal rami run transversely across the centroid of the corresponding articular
pillars (Fig. 6-47). They are bound to the periosteum by investing fascia and secured by
the tendon of semispinalis capitis. The articular branches arise as the nerve approaches
the posterior aspect of that articular pillar, one innervating the zygapophyseal joint above
and the other innervating the joint below. Hence each typical cervical facet joint below
C2 and C3 has dual innervation from the medial branch above and below.

FIGURE 6-47 Coned down (zoomed) ultrasound view of the facet joints and articular
pillars. Echogenic medial branch rami are visualized in apposition to the echogenic bone
cortex. These superficial structures are well visualized and can be targeted for radiofrequency
ablation and injection.

The medial branches of the C3 dorsal ramus differ in their anatomy. A deep medial
branch passes around the waist of the C3 articular pillar, similar to other typical medial
branches, and supplies the C3 to C4 zygapophyseal joint. The superficial medial branch
of C3 is large and known as the third occipital nerve (TON). It curves around the lateral
and then the posterior aspect of the C2 to C3 zygapophyseal joint, giving articular
branches to the joint. Beyond the C2 to C3 zygapophyseal joint, the TON becomes
cutaneous over the suboccipital region. Another anatomical exception is the course of the
medial branch of C7. The C7 medial branch passes more cranial, closer to the foramen of
C7, crossing the triangular superior articular process of C7 vertebrae.
5.Clinical Pearls:
Do not introduce too much craniocaudal rocking movement of the transducer as it
increases the chances of losing one’s position. Axial scans of the cervical spine to identify

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 the facet joints are usually not practiced routinely. The reason is that rotating the
transducer to produce an axial image increases the chances of losing one’s position along
the cervical vertebrae, requiring a recount. Furthermore, visualization of the facet joint in
the axial plane does not facilitate needle positioning, as the sonographic technique uses a
craniocaudal approach (as opposed to a lateral-to-median approach).
The skin entry point of the needle is usually about 2 to 3 cm inferior to the end of the
probe, rather than at the probe itself. This allows the needle to enter at a shallower angle
and to be inserted parallel to the facet joint. Confirmation of injectate can be done by
watching out for a hyperechoic flush (representing a small pocket of air trapped within
the needle). However, once the air has been expelled, it can be difficult to visualize the
injectate. Turning on the Color Doppler function on the ultrasound machine allows flow
to be visualized, and injection can be done under continuous Doppler monitoring.

Ultrasound for Third Occipital Nerve Block

Gross Anatomy of the Third Occipital Nerve
As described in the facet joint section, the joints are innervated by articular branches derived
from medial branches of the cervical dorsal rami. The C3 to C7 dorsal rami arise from the
corresponding spinal nerves and travel dorsally over the transverse processes posteriorly.
Now, the C3 medial branches have a different anatomy. A deep medial branch passes around
the waist of the C3 articular pillar to supply the C3 to C4 facet (similar to the other levels
caudally). The superficial medial branch of C3 (the TON) curves laterally and around the
posterior aspect of the C2 to C3 facet. It supplies branches to the joint prior to traveling
dorsal to the semispinalis obliquus capitis muscle. So, each facet joint is innervated by the
medial branch at the levels inferior and superior to it (dual innervation), with the exception of
C2 to C3, which is innervated by a single nerve (TON). The TON is the only nerve that
crosses over the facet joint. The TON measures about 2 mm in diameter (range of 1–3 mm)
and is located about 2 cm (range 1.4–2.7 cm) from the skin.

Ultrasound Scan Technique

1.Position:
a.Patient: The patient is placed in the lateral decubitus position, similar to a lateral facet
injection position (Fig. 6-39). The head is placed on a pillow so that the shoulders are
square to the examination couch. Hair should be tied and lifted clear from the side of
the neck to prevent contamination during the procedure.

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FIGURE 6-48 Position of the patient and ultrasound transducer during a scan for selective
nerve root injection. The high-frequency linear array transducer is placed in a transverse
oblique plane with respect to the long axis of the cervical spine, allowing visualization of the
nerve root.

b.Operator and ultrasound machine: The operator sits or stands facing the patient’s
back in the lateral position. It is more comfortable for the operator if the nondominant
hand anchors the transducer and the dominant hand manipulates the needle.
2.Transducer selection:
A high-frequency (15–12 MHz) linear transducer is generally used. This allows
visualization of the greater occipital nerve at the level of the obliquus capitis inferior
muscle. Imaging techniques like beam steering technology and compound and harmonic
imaging are available on most new ultrasound machines. These generally improve
visualization of the anatomy and the needle. A lower-frequency curvilinear transducer (3–
5 MHz) can be used in obese patients, but nerve visualization will be more difficult
compared with the linear transducer. The footprint of the curvilinear transducer is also
bigger than the linear transducer. Circumstances will usually dictate the appropriate
transducer to use.
3.Scanning technique and sonoanatomy:
Starting in the midline of the posterior spine, the probe can be slid anteriorly and laterally
to the level of the mastoid process. This will allow identification of the occipital bone and
the C1 and C2 transverse processes. Turning on the Color Doppler function at this level is
useful to identify aberrant branches of the vertebral artery. The probe can be slid
inferiorly and posteriorly, and the articular pillars of C2 and C3 will come into view. The
TON runs perpendicular to the probe at this point and is located dorsal to the C2 to C3
articulation. Sonographically, the fibrillar ovoid nerve can be seen overlying the C2 to C3
facet joint. The TON crosses the C2 to C3 articular pillars about 1 mm from the bone, and
the operator can identify the typical fibrillar pattern of the nerve on ultrasound by angling
the probe slightly back and forth. The facets can also be confirmed by visualizing the
echogenic “hills” representing the facet joints caudally. The medial branch nerves are
located in the troughs or valleys of these echogenic “hills”4 (Figs. 6-43 and 6-47).
Another technique to detect the TON involves placing the transducer in an oblique

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 transverse orientation, with the cranial end of the transducer anchored to the occipital
bone. The caudal end of the transducer can then be tilted inferiorly (keeping the cranial
end anchored to the mastoid), until the semispinalis obliquus capitis muscle comes into
view in the longitudinal plane. The third occipital nerve can be seen as an ovoid fibrillar
structure overlying the muscle. This corresponds to the traditional suboccipital landmark
used in palpation-based injection techniques.
4.Clinical Pearls:
The ultrasound technique is a modification of the blind palpation technique. The nerve is
blocked at a more proximal level, prior to branching of the nerve, increasing the treated
area. Using Doppler prior to injection is important to identify aberrant vessels in the
suboccipital area.

Ultrasound for Selective Nerve Root Block

Ultrasound Scan Technique
1.Position:
a.Patient:
i.Lateral approach: The patient is placed in the lateral decubitus position (Fig. 6-48).
The head is placed on a pillow so that the shoulders are square to the examination
couch. Hair should be tied and lifted clear from the side of the neck to prevent
contamination during the procedure.
ii.Posterior approach: The posterior approach has the distinct advantage of allowing the
patient to be placed prone and both sides being accessible without having to change
position. It can be uncomfortable to the patient if multiple levels are blocked, so this
position is suited for faster access to both sides of the neck.
b.Position of operator and ultrasound machine:
The operator sits or stands facing the patient’s back in the lateral position or on the
side of the patient for the posterior approach. It is more comfortable for the operator if
the nondominant hand anchors the transducer and the dominant hand manipulates the
needle.
2.Transducer selection:
For selective nerve root blocks, a high-frequency (15–12 MHz) linear array transducer
can be used. The linear footprint is smaller than the curvilinear transducer and can be
placed at the base of the neck for the lower cervical nerve roots. Imaging techniques like
beam steering technology and compound and harmonic imaging are generally available
on most new ultrasound machines and improve visualization of the anatomy and the
needle point.
3.Scanning technique:
Locating the correct cervical vertebral level has been described in the section on facet
joint injection. This involves identifying the C1 vertebra (with a small or nonexistent
spinous process) and the C2 vertebra inferiorly (the first bifid cervical spinous process,
Fig. 6-8). The levels are then labeled sequentially from C2 (Fig. 6-41). Another technique
of identifying the cervical vertebral levels on a lateral image is to count upwards
(cephalad direction) from C6. The C6 vertebral anterior tubercle is the largest in the
cervical spine (Chassaignac’s tubercle). The transducer is maintained in the same axial
orientation and gently moved upwards. The anterior tubercles of the respective cervical
vertebrae are identified and counted. The vertebral artery must be identified at the same

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 time and documented. The vessel runs anteriorly at C7 before it enters the foramen
transversarium from C6 in about 90% of cases (Fig. 6-7). In the remaining cases, the
vertebral artery enters the foramen transversarium at C5 or at a higher vertebral level. The
ultrasound transducer is positioned to obtain an oblique axial image of the cervical spine.
The landmark structures are the transverse processes and their anterior and posterior
tubercles, resulting in a camel hump sign. The nerve root is visualized as an oval
hypoechoic punctate structure between the tubercles (Figs. 6-49 and 6-50). Subsequently,
a 22-G needle can be introduced in a posterior-to-anterior direction. The needle is slowly
advanced toward the oval hypoechoic target located between the “camel humps.”5 This
approach is extraforaminal, but it provides a margin of safety given the density of
radicular arteries in the foramen itself.

FIGURE 6-49 Transverse sonogram demonstrating the exited C5 nerve root between the
anterior and posterior tubercles of the C5 transverse process. The nerve will proceed between
the anterior and middle scalene muscles with the other brachial plexus roots. The overlying
sternocleidomastoid muscle is hypoechoic with fibrofatty striations.

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FIGURE 6-50 Transverse sonogram demonstrating the exited C6 nerve root between the
anterior and posterior tubercles. The nerve will proceed between the anterior and middle
scalene muscles, with the other brachial plexus roots. The overlying sternocleidomastoid
muscle is hypoechoic, with fibrofatty striations.

The anterior tubercle at C7 is hypoplastic. Hence, there is no bony landmark to

indicate the anteriormost extent of the nerve root. More importantly, the vertebral artery
at C7 runs in close proximity to the exited nerve root. It takes a vertical course toward the
subclavian artery, and the C7 nerve root eventually runs laterally as part of the brachial
plexus (Fig. 6-51). Due to the inherent risks of cervical spine procedures, monitoring with
fluoroscopy is still advisable.6–12

FIGURE 6-51 Transverse sonogram demonstrating the exited C7 nerve root. The anterior

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tubercle of C7 is hypoplastic and barely seen.

4.Sonoanatomy:
The cervical spinal nerves exit primarily through the lower part of the foramen (Figs. 6-
11, 6-12, 6-31, and 6-52). Epiradicular veins generally occupy the upper part of the
foramen. Radicular arteries also lie in close approximation to the cervical spine nerves
within the foramen. Hoeft showed that radicular branches from the vertebral artery course
over the anteromedial aspect of the foramen and the branches arising from the ascending
or deep cervical arteries run medially throughout the foramen.13 These arteries are at risk
for inadvertent injury during transforaminal injections.9

FIGURE 6-52 Sagittal sonogram demonstrating the exited C5 nerve root running lateral to
the transverse process. The C4 transverse process superiorly is demonstrated on the left of the
image.

The C3 to C6 vertebrae constantly demonstrate an anterior (usually bigger) and a

posterior tubercle with the groove for the spinal nerve between them. The posterior
tubercles of C3 to C5 are situated lower and lateral to the anterior ones. The transverse
processes lie beside the vertebral bodies slightly directed downward and anteriorly. The
transverse processes in the cervical spine are relatively short, with the exception of the
atlas and C7. The transverse processes at C1 project more laterally then all the others. The
anterior tubercle at C2 is not well developed, resulting in a small transverse process. This
feature can be used to differentiate C1 from C2 vertebrae on the axial plane. The anterior
tubercle at C6 is usually the largest (tubercle of Chassaignac). This is an important
sonographic landmark as the prominent anterior tubercle allows identification of C6 and
location of the stellate ganglion in relation to the longus colli muscles. The transverse
process of C7 has no anterior tubercle. This is an important characteristic to note as it
helps to identify the vertebra. More importantly, injections performed around C7 should
be done with caution, as the vertebral artery course is more variable then the other levels
of the cervical spine (Figs. 6-8, 6-28, 6-34, 6-37, 6-53, and 6-54).

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FIGURE 6-53 Transverse cadaver anatomic section through the cervical spine
demonstrating the prominent anterior tubercle of C6 (Chassaignac’s tubercle). This is a
sonoanatomical landmark to identify C6 and the exiting C6 nerve root immediately posterior
to the tubercle. The longus colli muscle lies anteromedial to the Chassaignac tubercle.

FIGURE 6-54 Anterior sagittal sonogram of the cervical spine at the tips of the transverse
processes. The nerve is a hypoechoic structure located between the transverse processes. A
linear tubular structure located deep to the nerve with echogenic walls is the vertebral artery.
It can be confirmed using Color Doppler.

Cervical ribs of various lengths and size may also occur and are usually bilateral when
present. They can indent or impinge on the brachial plexus nerve roots. The foramen
transversarium at C1 to C7 contain vertebral arteries and sympathetic nervous plexus

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 from C6 upwards. Intervertebral foramina are largest at C2 and C3 (Figs. 6-55 and 6-56).

FIGURE 6-55 Sagittal cadaver anatomic section of the cervical spine showing the
vertebral artery immediately posterior to the transverse processes of C4 and C5. The relative
positions of the vertebral bodies and cervical spinal cord are also demonstrated. The large
belly of the sternocleidomastoid muscle is located anteriorly.

FIGURE 6-56 Anterior sagittal sonogram of the cervical spine at the level of the C4 and
C5 transverse processes demonstrating the hypoechoic nerve roots. The vertebral arteries
within the foramen transversarium are well demonstrated with Color Doppler mode.

5.Clinical Pearls:

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 Although ultrasound guidance is useful in identification of the vertebral and inferior
thyroid arteries, spinal radicular arteries are often too small in caliber to visualize
consistently with ultrasound. Hence, using a smaller volume of injectate and continuous
sonographic and Doppler monitoring are suggested. Epidural extension of the injectate
through a transforaminal approach can result in a wider area of pain relief.

Ultrasound for Stellate Ganglion (Cervical Sympathetic

Chain) Block
Gross Anatomy
The cervical sympathetic chain is composed of the superior, middle, intermediate, and
inferior cervical ganglia. In 80% of cases, the inferior cervical ganglion is fused with the first
thoracic ganglion, forming the stellate (cervicothoracic) ganglion. It measures approximately
2.5 cm in length, 1 cm in width, and 0.5 cm in anteroposterior depth. The ganglion is usually
found between the inferior border of the C7 transverse process to T1 (especially if the lower
cervical and upper thoracic ganglia remained separate) or adjacent to the pleural dome. It is
contained within the fascial plane of the prevertebral fascia, overlying the longus colli
muscles, on either side of the cervical vertebrae. The postganglionic fibers from the stellate
ganglion and seventh and eighth cervical nerves to the first thoracic nerve provide
sympathetic innervation to the upper limbs. The preganglionic fibers travel in a cephalad
direction to the superior and middle cervical ganglia through the cervical sympathetic trunk.
Hence, injection of local anesthetic at the level of the stellate ganglion blocks the sympathetic
supply to a larger area (the head, neck, and upper limbs) than injection of the cervical
sympathetic trunk (which results in sympathetic blockade of the head and neck regions only).
The vertebral artery is relatively free floating at the C7 level prior to entering the foramen
transversarium at C6 as it ascends the neck. This is true in about 90% of cases. It can enter
the foramen transversarium at C5 or higher instead in the remaining 10% of cases and is
vulnerable to injury.14 The inferior thyroid artery is also exposed at the base of the neck. It
arises from the thyrocervical trunk of the subclavian artery (running anterior to the vertebral
artery and the longus colli muscle) and has a tortuous and variable course.15 These vascular
structures can be visualized with Color Doppler and avoided during ultrasound-guided
injections.

Ultrasound Scan Technique

1.Position:
a.Patient: The patient is placed in a supine position, with the neck slightly extended (Fig.
6-57). A high-resolution linear transducer (17–9 MHz) is placed slightly lateral to the
midline at the base of the neck.16

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FIGURE 6-57 Position of the patient and the ultrasound transducer during a cervical
sympathetic (stellate ganglion) block. The stellate ganglion is best visualized with the
patient’s neck gently extended. The transducer is orientated in a transverse oblique plane
relative to the long axis of the cervical spine.

b.Position of operator and ultrasound machine: With the patient supine, the operator
sits or stands on the side to be blocked. The ultrasound display should be placed
diametrically opposite the operator. The operator can also sit or stand cephalad to the
patient (at the head end). This gives access to both sides of the neck without the need
to shift position. This position helps if the side to be blocked is ipsilateral to the
operator’s dominant hand (ie, right stellate ganglion for right-handed individuals). It
is more comfortable for the operator if the nondominant hand anchors the transducer
and the dominant hand manipulates the needle.
2.Transducer selection:
For cervical sympathetic chain blocks, a high-frequency (15–12 MHz) linear array
transducer can be used. The linear footprint is smaller than the curvilinear probe and can
be placed at the base of the neck. Imaging techniques like beam steering technology and
compound and harmonic imaging are generally available on most new ultrasound
machines. These improve visualization of the anatomy and the needle.
3.Scanning technique:
The ultrasound transducer is placed in transverse orientation with respect to the cervical
spine, in a paramedian position, at the base of the neck, above the prominence of the
medial clavicle. From there, the probe is angled in a craniocaudal direction gently until
the anterior tubercle of C6 (Chassaignac’s tubercle) transverse process comes into view.
At this point, Color Doppler should be used to identify the important vessels and
esophagus described later. A lateral-to-medial approach can be planned through the
sternocleidomastoid muscle or lateral to it. The needle track must avoid the vascular
structures and should run posterior to the vessels. The fluoroscopic technique of touching
bone with the needle followed by gentle retraction can also be followed here. With
ultrasound, the needle can be finessed into the space between the prevertebral fascia
superficial to the muscle and reduce the amount of injection into the muscle. Usually 5 to
10 mL of local anesthetic is adequate (as opposed to larger quantities when the injection

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 was performed without imaging guidance). Injection should be monitored with Color
Doppler.
4.Sonoanatomy:
On axial sections, the twin anechoic circular structures denoting the internal jugular vein
and carotid artery are visible. The vein is differentiated from the artery by their
compressibility. On computed tomography (CT) and magnetic resonance imaging (MRI),
differentiation is based on relative locations of the vessels with respect to each other (the
internal jugular vein is superficial to the carotid artery) and by scrolling in a craniocaudal
direction. The thickness of the overlying sternocleidomastoid can be gauged in cross-
section. The longus colli muscle runs anterior to the cervical transverse process at this
level. It appears as an ovoid hypoechoic structure in transverse section, with fibrous tissue
giving rise to internal striations (Fig. 6-58). These fibrous strands are also associated with
fatty tissue, which adds to the striated hyperechoic appearance. On CT fibrous strands
present as hypodense streaks within the muscle. On T1-weighted MRI images, the
muscles appear hypointense with the fatty-fibrous strands appearing hyperintense in
signal. This relationship is preserved on T2-weighted sequences. Whereas palpation and
fluoroscopy are techniques used to perform stellate ganglion blocks, ultrasound confers
the additional advantage of real-time visualization of the inferior thyroid, vertebral,
cervical, and carotid arteries. Structures like the thyroid gland and esophagus can also be
demonstrated with ultrasound and avoided during the procedure. The esophagus has a
variable course at the level of the cricoid cartilage at the C6 vertebral level. It tends to
project to the left side of the neck. The esophagus in transverse section presents as an
ovoid structure with an irregular lumen (representing the mucosal folds). On both CT and
MRI, the esophagus can be followed craniocaudally on sequential slices. It has a
characteristic appearance similar to that seen on ultrasound. Care should be taken to
identify the esophagus, especially during left-sided stellate ganglion blocks. The needle
should not traverse the esophagus, to avoid bacterial contamination.

FIGURE 6-58 Transverse sonogram of the cervical spine demonstrating the longus colli
muscle. Note it is surrounded by the internal jugular vein, the carotid artery, the transverse
cervical artery, and the vertebral artery.

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 5.Clinical Pearls:
The esophagus can be distinguished from the other structures in the neck by observing
peristaltic movements when the patient is asked to swallow. It is important to ensure the
inferior (caudal) flow of injectate from C6 to T1 to ensure that the stellate ganglion is
appropriately targeted. Recall that the ganglion is usually located at C7 to T1 levels and
that the injection is performed at C6 due to a slightly better safety profile (the vertebral
artery is usually contained in the foramen transversarium at this level). If the injectate
only stays at C6, then the middle cervical sympathetic ganglion is treated and not the
stellate ganglion. The traditional practice of stellate ganglion block avoided bilateral
injections. The reasons for this included potential for local anesthetic toxicity with the use
of high volumes of local anesthetic (and hence higher plasma concentration) and recurrent
laryngeal nerve palsy (up to 10% of cases).17 With real-time ultrasound monitoring, flow
of the injectate between the carotid sheath, thyroid, and esophagus may be detected, and
needle positioning can be adjusted if necessary.

References
1.Galiano K, Obwegeser AA, Bodner G, et al. Ultrasound-guided facet joint injections in the
middle to lower cervical spine: a CT-controlled sonoanatomic study. Clin J Pain.
2006;22:538–543.
2.Pal GP, Routal RV, Saggu SK. The orientation of the articular facets of the zygapophyseal
joints at the cervical and upper thoracic region. J Anat. 2001;198:431–441.
3.Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofrequency neurotomy of the
cervical medial branches: a validated treatment for cervical zygapophyseal joint pain.
Neurosurgery Quaterly. 1998;8:288–308.
4.Eichenberger U, Greher M, Kapral S, et al. Sonographic visualization and ultrasound-
guided block of the third occipital nerve: prospective for a new method to diagnose C2-
C3 zygapophysial joint pain. Anesthesiology. 2006;104:303–308.
5.Galiano K, Obwegeser AA, Bodner G, et al. Ultrasound-guided periradicular injections in
the middle to lower cervical spine: an imaging study of a new approach. Reg Anesth
Pain Med. 2005;30:391–396.
6.Narouze SN, Vydyanathan A, Kapural L, Sessler DI, Mekhail N. Ultrasound-guided
cervical selective nerve root block: a fluoroscopy-controlled feasibility study. Reg
Anesth Pain Med. 2009;34:343–348.
7.Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical anterior spinal artery
syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001;91:397–399.
8.Muro K, O’Shaughnessy B, Ganju A. Infarction of the cervical spinal cord following
multilevel transforaminal epidural steroid injection: case report and review of the
literature. J Spinal Cord Med. 2007;30:385–388.
9.Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of
corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain.
2003;103:211–215.
10.Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after
selective transforaminal block: the role of corticosteroids. Spine J. 2004;4:468–474.
11.Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P. Complications of cervical
selective nerve root blocks performed with fluoroscopic guidance. AJR Am J Roentgenol.
2007;188:1218–1221.
12.Narouze SN. Ultrasound-guided interventional procedures in pain management: Evidence-

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 based medicine. Reg Anesth Pain Med. 2010;35:S55–S58.
13.Hoeft MA, Rathmell JP, Monsey RD, Fonda BJ. Cervical transforaminal injection and the
radicular artery: variation in anatomical location within the cervical intervertebral
foramina. Reg Anesth Pain Med. 2006;31:270–274.
14.Higa K, Hirata K, Hirota K, Nitahara K, Shono S. Retropharyngeal hematoma after stellate
ganglion block: Analysis of 27 patients reported in the literature. Anesthesiology.
2006;105:1238–1245.
15.Narouze S. Beware of the “serpentine” inferior thyroid artery while performing stellate
ganglion block. Anesth Analg. 2009;109:289–290.
16.Kapral S, Krafft P, Gosch M, Fleischmann D, Weinstabl C. Ultrasound imaging for stellate
ganglion block: direct visualization of puncture site and local anesthetic spread. A pilot
study. Reg Anesth. 1995;20:323–328.
17.Hardy PA, Wells JC. Extent of sympathetic blockade after stellate ganglion block with
bupivacaine. Pain. 1989;36:193–196.

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CHAPTER 7

Ultrasound of the Thoracic Spine for Thoracic Epidural

Injections

Introduction
Ultrasound imaging of the thoracic spine can be challenging due to peculiarities in its
anatomy. The osseous framework of the thoracic spine makes up for a narrow acoustic
window with limited ultrasound visibility of the spinal canal and neuraxial structures.1,2
Ultrasound visibility of the thoracic spine also varies depending on the plane1 of the
ultrasound imaging and which part of the thoracic spine is being imaged.1 Ultrasound
visibility progressively decreases as one moves up the thoracic spine.1 Currently data are
limited on the use of ultrasound to guide or assist thoracic epidural injections.3,4 This chapter
briefly outlines the anatomy, the technique of ultrasound imaging, and sonoanatomy of the
thoracic spine relevant for thoracic epidural injection.

Basic Anatomy of the Thoracic Spine

The thoracic spine is made up of a column of 12 vertebrae (Fig. 7-1) that makes up the
midsection of the vertebral column. The thoracic vertebrae are identified by the presence of
articular facets on the lateral surface of the vertebral bodies for articulation with the head of
the ribs (Figs. 7-1 to 7-4). There are also facets on the transverse processes of all, except the
11th and 12th vertebrae, for articulation with the tubercle of the ribs (Fig. 7-1). The thoracic
vertebrae are intermediate in size between the cervical and lumbar vertebrae, with the lower
thoracic vertebrae being a lot larger than the upper thoracic vertebrae (Fig. 7-4) and the upper
thoracic vertebrae (T1–T2) being similar in size to the cervical vertebrae (Fig. 7-2). The
thoracic spine has a primary curvature, which is concave anteriorly, but also has a lateral
curvature that is slightly concave to the left, most likely from greater use of the right upper
extremity and pressure from the aorta.

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FIGURE 7-1 Thoracic spine (lateral view). VB, vertebral body.

FIGURE 7-2 Second thoracic vertebra (superior, anterior, and lateral view). TP, transverse
process; VB, vertebral body; SC, spinal canal; SAP, superior articular process; IAP, inferior
articular process; IVN, inferior vertebral notch.

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FIGURE 7-3 Sixth thoracic vertebra (superior, anterior, and lateral view). TP, transverse
process; SVN, superior vertebral notch; SC, spinal canal; SAP, superior articular process;
IAP, inferior articular process.

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FIGURE 7-4 Twelfth thoracic vertebra (superior, anterior, and lateral view). TP,
transverse process; SC, spinal canal; SAP, superior articular process; IAP, inferior articular
process; SVN, superior vertebral notch; VB, vertebral body.

Typical Thoracic Vertebrae

The 2nd to 8th thoracic vertebrae are considered typical thoracic vertebrae (Figs. 7-2 and 7-
3), whereas the remaining five vertebrae (1st, 9th, 10th, 11th, and 12th) are atypical as they
have certain unique features. The body of a typical thoracic vertebra is heart-shaped (Fig. 7-
3) with its anteroposterior and lateral diameters being roughly the same (Fig. 7-3). Also the
distance between the two lamina of the vertebra is greater than the width of the vertebral
body (Fig. 7-3).5 On either side of the vertebral body are two costal (superior and inferior)
facets (Fig. 7-3). The superior costal facets are larger, located on the superior border of the
vertebra near the pedicle, and articulate with the head of the numerically identical rib (Figs.
7-2 and 7-3). The inferior costal facets are smaller in size, they are located near the inferior
border of the vertebra and in front of the inferior vertebral notch, and they articulate with the
next lower rib. The spinal canal is relatively small and circular (Fig. 7-3) and contains the
spinal cord and meninges.
The pedicles of the thoracic vertebra are short and directed backwards (Fig. 7-2). The
superior vertebral notch is shallow, whereas the inferior vertebral notch is large and deep
(Figs. 7-1 and 7-5). The laminae are broad and thick, overlap the one from the adjacent
vertebrae (Fig. 7-6), and are connected to the pedicle anteriorly (Fig. 7-5). The interlaminar
spaces are also narrow, and using ultrasound they measure approximately 0.9 cm at the lower
thoracic spine to 0.8 cm and 0.6 cm at the mid- and upper thoracic spine, respectively.1 The
transverse processes are large and are directed laterally and backwards (Figs. 7-3 and 7-6)
from the junction of the lamina and pedicle (Fig. 7-5). The costal facets on the anterior
surface of the transverse process of the upper six vertebrae are concave (Fig. 7-3), facing
forward, and articulate with the tubercle of the corresponding rib. The inferior articular
processes are fused to the laminae, and their articular facets are directed forwards and slightly
downwards and medially (Fig. 7-5). The superior articular processes in contrast project from
the junction of the pedicle and laminae and are directed backwards and slightly laterally and
upwards. The articulation of the rib to the transverse process anteriorly results in the neck of
the rib being hidden anteriorly by the transverse process at the vertebral levels T1 to T4, but
from there on until T9 the neck of the rib progressively projects above the transverse
process.5 The spinous processes are long and directed backwards, downwards (Figs. 7-1, 7-6
and 7-7), and often slightly obliquely. Therefore even in a perfectly normal spine, the tips of
the spinous processes may be slightly deviated from the midline (ie, paramedian in location,
Fig. 7-7). The spinous processes are longest between T2 and T9 levels and overlap each other
like “tiles on a roof.” This creates an acute angle for epidural needle insertion or insonation of
the ultrasound beam if one were to do so through the midline. The spinous processes are less
oblique above T2 and below T9. The spinous processes of T11 and T12 are directed
backwards as with the lumbar spinous processes. The orientation of the T10 spinous process
varies, with it being only slightly caudally directed to resemble that of the T11 and T12.

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FIGURE 7-5 Lateral view of the sixth thoracic vertebra. VB, vertebral body; TP,
transverse process; IAP, inferior articular process.

FIGURE 7-6 Articulation of the thoracic vertebrae and the rib with the transverse process
(costotransverse junction) in the midthoracic region. Note the acute angulation of the spinous
processes and the posteriorly directed transverse processes.

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FIGURE 7-7 Different views of the thoracic spine that were rendered from a single 3-D
volume CT data set. Note that although there is no scoliosis in this patient, the spinous
processes of the vertebrae are slightly deviated from the midline (Fig. 7-7F).

The ligamentum flavum is attached to the upper border and the upper part of the anterior
surface of the laminae. The transverse process gives attachment to the following ligaments
(Fig. 11-3): (i) lateral costotransverse ligament at the tip, (ii) superior costotransverse
ligament to the lower border, (iii) the inferior costotransverse ligament to the anterior surface,
(iv) intertransverse ligament to the superior and inferior borders, and (v) the levator costae to
the posterior surface (T1–T11). The spinous processes give attachment to the supraspinous
and interspinous ligaments. Also the superior and inferior borders of the vertebral bodies give
attachment in front and behind to the anterior and posterior longitudinal ligaments,
respectively. There are also several muscles attached to the spine of the thoracic vertebrae,
including the latissimus dorsi, trapezius, rhomboids, and many deep muscles of the back.

Gross Anatomy of the Upper Thoracic Spine (T1–T4)

Figs. 7-8 and 7-9

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FIGURE 7-8 Cross-sectional cadaver anatomic section through the third thoracic vertebra
demonstrating the relationship of the spinous process of the T2 vertebra with the posterior
elements of the T3 thoracic vertebra. Also note the posteriorly directed transverse process and
the costotransverse articulation. VB, vertebral body; CE, cervical esophagus.

FIGURE 7-9 Paramedian sagittal cadaver anatomic section through the thoracic spine
demonstrating the lamina and the interlaminar spaces of the thoracic vertebrae. VB, vertebral
body.

Computed Tomography Anatomy of the Upper Thoracic Spine (T1–T4)

Figs. 7-10 to 7-13

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FIGURE 7-10 Transverse CT section through the lower part of the body of the second
thoracic vertebra. VB, vertebral body.

FIGURE 7-11 Transverse CT section through the interspinous space of the T2 to T3

thoracic vertebrae. VB, vertebral body; TP, transverse process.

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FIGURE 7-12 Median sagittal CT section of the upper thoracic spine (T1–T4). VB,
vertebral body; ISS, interspinous space.

FIGURE 7-13 Paramedian sagittal CT section of the upper thoracic spine. ILS,
interlaminar space; VB, vertebral body.

Magnetic Resonance Imaging Anatomy of the Upper Thoracic Spine (T1–T4)

Figs. 7-14 to 7-17

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FIGURE 7-14 Transverse MRI section of the upper thoracic spine through the base of the
T3 spinous process. VB, vertebral body; CSF, cerebrospinal fluid.

FIGURE 7-15 Transverse MRI section of the upper thoracic spine through the
interspinous space of the T2 to T3 vertebrae. VB, vertebral body; CSF, cerebrospinal fluid.

327
FIGURE 7-16 Median sagittal MRI section of the upper thoracic spine (T1–T4). VB,
vertebral body; ISS, interspinous space.

FIGURE 7-17 Paramedian sagittal MRI section of the upper thoracic spine (T1–T4). VB,
vertebral body; ILS, interlaminar space.

Gross Anatomy of the Midthoracic Spine (T5–T8)

Figs. 7-18 and 7-19

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FIGURE 7-18 Cross-sectional cadaver anatomic section through the midthoracic spine
(7th thoracic vertebra). VB, vertebral body.

FIGURE 7-19 Paramedian sagittal cadaver anatomic section of the midthoracic spine.
Note the acute caudal angulation of the laminae and the narrow interlaminar spaces. VB,
vertebral body.

Computed Tomography Anatomy of the Midthoracic Spine (T5–T8)

Figs. 7-20 to 7-23

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FIGURE 7-20 Transverse CT section of the midthoracic spine through the base of the T6
spinous process. VB, vertebral body.

FIGURE 7-21 Transverse CT section of the midthoracic spine through the T6 to T7

interspinous space. VB, vertebral body; TP, transverse process.

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FIGURE 7-22 Median sagittal CT section of the midthoracic spine (T5–T8). Note the
acute caudal angulation of the spinous processes and the narrow interspinous spaces (ISS).

FIGURE 7-23 Paramedian sagittal CT section of the midthoracic spine. Note the narrow
interlaminar spaces (ILS).

Magnetic Resonance Imaging Anatomy of the Midthoracic Spine (T5–T8)

Figs. 7-24 to 7-27

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FIGURE 7-24 Transverse MRI section of the midthoracic spine through the base of the T6
spinous process. VB, vertebral body.

FIGURE 7-25 Transverse MRI section of the midthoracic spine through the T6 to T7
interspinous space. VB, vertebral body.

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FIGURE 7-26 Median sagittal MRI section of the midthoracic spine. Note the sharp acute
caudal angulation of the spinous processes and the narrow interspinous spaces. VB, vertebral
body.

FIGURE 7-27 Paramedian sagittal MRI section of the midthoracic spine. VB, vertebral
body.

Gross Anatomy of the Lower Thoracic Spine (T9–T12)

Figs. 7-28 and 7-29

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FIGURE 7-28 Cross-sectional cadaver anatomic section through the lower thoracic spine
(11th thoracic vertebra). VB, vertebral body.

FIGURE 7-29 Paramedian sagittal cadaver anatomic section of the lower thoracic spine
(T9–T12). Note the acute caudal angulation of the laminae and the narrow interlaminar
spaces. VB, vertebral body; ITS, intrathecal space.

Computed Tomography Anatomy of the Lower Thoracic Spine (T9–T12)

Figs. 7-30 to 7-33

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FIGURE 7-30 Transverse CT section of the lower thoracic spine through the base of the
T10 spinous process. VB, vertebral body.

FIGURE 7-31 Transverse CT section of the lower thoracic spine through the T10 to T11
interspinous space. VB, vertebral body; TP, transverse process.

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FIGURE 7-32 Median sagittal CT section of the lower thoracic spine (T9–T12). Note the
spinous process of T11 and T12 are broad, directed backwards, and similar to the lumbar
spinous processes.

FIGURE 7-33 Paramedian sagittal CT section of the lower thoracic spine. ILS,
interlaminar spaces.

Magnetic Resonance Imaging Anatomy of the Lower Thoracic Spine (T9–T12)

Figs. 7-34 to 7-37

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FIGURE 7-34 Transverse MRI section of the lower thoracic spine through the T10 to T11
interspinous space. VB, vertebral body; CSF, cerebrospinal fluid.

FIGURE 7-35 Transverse MRI section of the lower thoracic spine through the T10
spinous process. VB, vertebral body; CSF, cerebrospinal fluid.

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FIGURE 7-36 Median sagittal MRI section of the lower thoracic spine (T9–T12). VB,
vertebral body.

FIGURE 7-37 Paramedian sagittal MRI section of the lower thoracic spine (T9–T12). VB,
vertebral body.

Ultrasound Imaging of the Thoracic Spine – Basic

Considerations
Because of the peculiarities of the anatomy of the thoracic spine, as described earlier, we will
be considering ultrasound imaging of the thoracic spine under three sections: (a) upper (T1–
T4), (b) middle (T5–T8), and (c) lower (T9–T12) (Fig. 7-38). Ultrasound imaging of the

338
thoracic spine can be performed in the transverse or sagittal plane. Because the depth from
the skin to the lamina and epidural space in the mid- and lower thoracic regions—where the
majority of thoracic epidural catheters are placed in clinical practice—is relatively shallow
(median distance approx. 3.3–4 cm)1,4 the use of a high-frequency linear (12–8 MHz)
transducer may suffice for ultrasound imaging. However, although the ultrasound images are
generally of high resolution, the field of view with a high-frequency linear transducer is
narrow and it gets progressively narrower with increasing depth of imaging. Therefore, it is
desirable to use a curvilinear transducer, which emits a divergent beam and provides both
high-quality images and a wide field of view (Fig. 7-39).1,4 The authors prefer to use a high-
frequency (9–4 MHz) curvilinear transducer for imaging the thoracic spine, but a low
frequency (5–2 MHz) is perfectly fine.

FIGURE 7-38 Thoracic spine and its division into the upper (T1–T4), mid (T5–T8), and
lower (T9–T12) thoracic regions.

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FIGURE 7-39 Figure illustrating the osseous structures insonated during a median
transverse scan of the thoracic spine at the level of the spinous process. Note the angle
formed between the spinous process and the lamina and the posteriorly directed transverse
process.

Ultrasound visibility of the neuraxial structures decreases progressively as one moves up

the thoracic spine, with ultrasound visibility being best in the lower thoracic region.1 The
acute angulation of the spinous processes and the overlapping laminae in the midthoracic
region make it difficult to image the neuraxis through the median plane in the transverse axis
(median transverse scan). Ultrasound visualization of the spinal canal and neuraxial structures
is better through the paramedian sagittal plane than through the median transverse plane.1
Therefore, the thoracic spine is generally imaged via the paramedian plane (Fig. 7-40) and
through the interlaminar spaces.1 The laminae of the thoracic vertebrae are hyperechoic and
relatively flat (Fig. 7-41) compared to the “horse head–like appearance” of the laminae in the
lumbar spine (Fig. 5-20).6,7 Due to the narrow interlaminar spaces in the thoracic spine,1 the
acoustic window for ultrasound imaging is significantly narrower than that in the lumbar
region (Fig. 7-42). Therefore, ultrasound visibility of the neuraxial structures in the thoracic
spine is not as good as in the lumbar region. For optimal imaging, it is also necessary to tilt
the ultrasound transducer slightly medially, that is, insonate the beam slightly medially
(paramedian sagittal oblique scan, Fig. 7-40), so that the majority of the ultrasound energy
enters the spinal canal through the widest part of the interlaminar space, similar to that in the
lumbar region.

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FIGURE 7-40 Axis of scan – thoracic spine. (A) paramedian sagittal scan and (B)
paramedian sagittal oblique scan.

FIGURE 7-41 Water-based thoracic spine phantom with a sagittal sonogram showing the
lamina and interlaminar spaces.

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FIGURE 7-42 Acoustic window for ultrasound imaging in the (A) lumbar and (B) thoracic
spine. Note the narrow interlaminar spaces and acoustic window for ultrasound imaging in
the thoracic spine.

The spinal cord, which lies within the thoracic spinal canal, can be clearly defined in
newborns and young infants8 using ultrasound (Figs. 7-43 and 7-44) but cannot be delineated
in adults with currently available ultrasound technology. The central canal is also seen as an
echogenic line in the center of the spinal cord in young infants (Fig. 7-43).8 Various factors
may contribute to the inability to visualize the spinal cord in adults: (a) a narrow acoustic
window for imaging, (b) attenuation of the ultrasound beam, (c) the spinal cord is inherently
hypoechoic, and (d) the spinal cord is surrounded by anechoic cerebrospinal fluid (Fig. 7-
44).8 Therefore, in the thoracic region one has to rely on recognizing the osseous structures of
the vertebral arch, interspinous and interlaminar spaces, ligamentum flavum, and the anterior
complex (AC).3 The latter represents the composite echo created by the posterior surface of
the vertebral body, posterior longitudinal ligament, and the anterior dura. Also because it is
often difficult to define the ligamentum flavum and posterior dura as two separate structures
in a thoracic sonogram, they are collectively referred to as the ligamentum flavum–dura
matter complex,1 or the posterior complex (PC).3

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FIGURE 7-43 Sagittal sonogram of the thoracic spine in a neonate to illustrate the
hypoechoic spinal cord, hyperechoic central canal, hyperechoic anterior and posterior dura,
and the epidural spaces. CSF, cerebrospinal fluid.

FIGURE 7-44 Transverse sonogram of the thoracic spine in a neonate to illustrate the
hypoechoic spinal cord, the thecal sac, dentate ligaments, dura (anterior and posterior), and
the epidural space. CSF, cerebrospinal fluid.

Ultrasound Imaging of the Upper Thoracic Spine (T1–T4)

1.Position:

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 a.Patient: The patient is positioned comfortably in the sitting position with the arms
hanging down and resting on the thigh or on a pillow or support in front. The patient
is also asked to slightly flex the head anteriorly. However, if the patient is unable to
sit or is unwell, then the patient can be positioned in the lateral decubitus position
with the head flexed anteriorly.
b.Operator and ultrasound machine: The operator stands behind the patient, and the
ultrasound machine is placed directly in front of the patient.
2.Transducer selection: Due to the thick musculature of the nape of the neck and relatively
greater depth from the skin to the neuraxial structures, curvilinear transducers are best for
imaging the upper thoracic spine. The authors prefer to use a high-frequency (9–4 MHz)
curvilinear transducer, but it is feasible to use a low-frequency (5–2 MHz) curvilinear
transducer for the ultrasound scan.
3.Scanning technique: The upper thoracic spine can be imaged in the transverse (Fig. 7-45)
or sagittal (Fig. 7-46) planes. During the median transverse scan, the aim is to obtain a
transverse spinous process view (TSPV, Fig. 7-47) or a transverse interspinous view
(TISV, Fig. 7-48). Because the spinous processes in the upper thoracic region are not
inclined as steeply as in the midthoracic region, especially above the T3 levels, it may be
feasible to obtain a TISV. Below this level it gets increasingly difficult to obtain a TISV.
For a sagittal scan the ultrasound transducer is placed 2 to 3 cm lateral to the midline and
gently tilted medially (paramedian sagittal oblique scan, PMSOS) until the thoracic
lamina and the interlaminar spaces are visualized (Fig. 7-49).

FIGURE 7-45 Position and orientation of the ultrasound transducer during a transverse
scan of the upper thoracic spine with the subject in the sitting position.

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FIGURE 7-46 Position and orientation of the ultrasound transducer during a paramedian
sagittal oblique scan of the upper thoracic spine with the subject in the sitting position.

FIGURE 7-47 Transverse sonogram demonstrating the spinous process view of the upper
thoracic spine.

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FIGURE 7-48 Transverse sonogram demonstrating the interspinous view of the upper
thoracic spine.

FIGURE 7-49 Paramedian sagittal oblique sonogram of the upper thoracic spine. Note the
narrow acoustic window for ultrasound imaging and the anterior complex.

4. Sonoanatomy of the upper thoracic spine: On a median TSPV the spinous process is
visualized as a hyperechoic structure with an acoustic shadow anteriorly (Fig. 7-47).
Laterally the lamina and transverse process or the inferior articular processes of the
thoracic vertebra with their corresponding acoustic shadow are visualized. Because the
spinal canal and neuraxis are obscured by the acoustic shadow of the spinous process and
lamina in this view, it is only useful for locating the midline if the spinous processes are
not palpable. If one now slides the transducer slightly caudally and/or gently inclines the

346
 ultrasound beam cranially, the acoustic shadow of the spinous process disappears and the
median TISV is obtained (Fig. 7-48). On a median TISV the transverse processes are
visualized as linear hyperechoic shadows, one on each side of the midline, and they are
also directed slightly backwards and outwards (Fig. 7-48). The AC is visualized anteriorly
as a hyperechoic shadow (Fig. 7-48). The outlines of the spinal canal can be recognized,
but the spinal cord is not visualized for reasons described earlier (Fig. 7-48).
On a PMSOS of the upper thoracic region the lamina and interlaminar spaces are clearly
visualized posteriorly (Fig.7-49). The intervening gaps between the lamina of the adjacent
vertebrae are the interlaminar spaces, and they are relatively narrow (width approximately
0.6 mm)1 compared to that at the lower thoracic (width approximately 0.9 mm)1 or
lumbar spine (Fig. 7-42). This results in a narrow acoustic window for imaging, and thus
ultrasound visibility of the neuraxial structures is also limited when compared to that at
the mid or lower thoracic region.1 Nevertheless it may still be possible to visualize the
ligamentum flavum, epidural space, posterior dura, spinal canal, and AC from a posterior-
to-anterior direction within the acoustic window (Fig. 7-49).

Ultrasound Imaging of the Midthoracic Spine (T5-T8)

1.Position:
a.Patient: Sitting (Figs. 7-50 and 7-51) or lateral decubitus (Fig. 7-52) position.

FIGURE 7-50 Position and orientation of the ultrasound transducer during a transverse
scan of the midthoracic spine with the subject in the sitting position.

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FIGURE 7-51 Paramedian sagittal oblique sonogram of the midthoracic spine with the
subject in the sitting position.

FIGURE 7-52 Paramedian sagittal oblique sonogram of the midthoracic spine with the
patient in the lateral position.

b.Operator and ultrasound machine: The operator sits or stands behind the patient, and
the ultrasound machine is positioned directly in front of the patient.
2.Transducer selection: Curved array transducer. The authors prefer to use a high-frequency
(9–4 MHz) curvilinear transducer, but a low-frequency (5–2 MHz) curvilinear transducer
will suffice.
3.Scanning technique: Ultrasound imaging is more demanding in the midthoracic region
than at the lower thoracic region due to the acute caudal angulation of the spinous

348
 processes and the overlapping lamina. The narrow interspinous and interlaminar spaces
(approximately 0.8 cm)1 create a narrow acoustic window for imaging with variable
quality of ultrasound images of the neuraxis. The midthoracic spine can be imaged in the
transverse (Fig. 7-50) or sagittal (Figs. 7-51 and 7-52) axis. The median transverse scan
(median TSPV, Fig. 7-53) is not very useful, as it provides little information relevant for
neuraxial blockade other than identifying the midline and measuring the depth to the
lamina. Also acquiring a median TISV (Fig. 7-54) at the midthoracic region is
challenging, and in some individuals it may be impossible. Because the paramedian
sagittal axis provides better visualization of the neuraxis than the transverse axis,1 it is the
preferred route for imaging. Also for optimal paramedian sagittal imaging one has to
perform a PMSOS (Fig. 7-52) as described earlier.

FIGURE 7-53 Transverse sonogram demonstrating the spinous process view of the
midthoracic spine.

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FIGURE 7-54 Transverse sonogram demonstrating the interspinous view of the
midthoracic spine. Note the posteriorly directed transverse processes.

4.Sonoanatomy of the midthoracic spine: On a median TSPV the spinous process, lamina,
transverse processes, the costotransverse junction, and the ribs produce a sonographic
pattern that we describe as the “flying swan sign” due to its resemblance to a swan in
flight. The posteriorly directed transverse processes are also easily recognized, and they
are symmetrically located. One must note that due to the acute angulation of the spinous
processes in the midthoracic region, when one performs a median transverse scan to
obtain a median TSPV, the osseous elements in the sonogram look congruous, but the
spinous process shadow is from the vertebra one level higher than that from which the
shadows of the laminae and transverse processes arise (Fig. 7-55). The exact clinical
significance of this observation for central neuraxial blocks is not clear.

350
FIGURE 7-55 Figure highlighting the osseous structures insonated during a transverse
scan of the midthoracic spine at the spinous process level (transverse spinous process view).

On a PMSOS in the midthoracic region the laminae and interlaminar spaces are clearly
visualized posteriorly (Fig. 7-56). The laminae appear relatively flat (Figs. 7-56 and 7-
57), and the interlaminar spaces are also relatively narrow (width approximately 0.8
mm).1 However, despite the narrow acoustic window, it may be possible to define the
ligamentum flavum, epidural space, posterior dura, spinal canal, and AC from a posterior-
to-anterior direction within the acoustic window (Fig. 7-56). Age-related changes in the
vertebral column and/or ossification of the ligamentum flavum can make visualization of
the neuraxial structures difficult in the elderly.

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FIGURE 7-56 Paramedian sagittal oblique sonogram of the midthoracic spine.

FIGURE 7-57 Correlative sagittal (A) CT, (B) sonogram, (C) cadaver anatomic, and (D)
MRI (T1 weighted) images of the midthoracic spine. ILS, interlaminar space; SC, spinal
canal; VB, vertebral body; LF, ligamentum flavum; PD, posterior dura; AC, anterior
complex; ITS, intrathecal space.

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Ultrasound Imaging of the Lower Thoracic Spine (T9–
T12)
1.Position:
a.Patient: Sitting (Fig. 7-58) or lateral decubitus position.

FIGURE 7-58 Position and orientation of the ultrasound transducer during a transverse
scan of the lower thoracic spine with the subject in the sitting position.

b.Operator and ultrasound machine: The operator stands behind the patient, and the
ultrasound machine is positioned directly in front of the patient.
2.Transducer selection: Curved array transducer. The authors prefer to use a high-frequency
(9–4 MHz) curvilinear transducer (Figs. 7-58 and 7-59), but a low-frequency (5–2 MHz)
curvilinear transducer is perfectly adequate.

353
FIGURE 7-59 Position and orientation of the ultrasound transducer during a paramedian
sagittal oblique scan of the lower thoracic spine with the subject in the sitting position.

3.Scanning technique: Ultrasound imaging is less demanding in the lower thoracic region
than at the upper and midthoracic regions due to the wider acoustic window for
ultrasound imaging. Ultrasound imaging at the lower two to three thoracic intervertebral
levels is similar to imaging the lumbar spine. The lower thoracic spine can be imaged in
the transverse (Fig. 7-58) or sagittal (Fig. 7-59) axis, and because of the relatively larger
acoustic window it is possible to acquire high-quality images of the neuraxis (Figs. 7-60
to 7-62).

FIGURE 7-60 Transverse sonogram demonstrating the transverse spinous process view of
the midthoracic spine.

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FIGURE 7-61 Transverse sonogram demonstrating the transverse interspinous view of the
midthoracic spine.

FIGURE 7-62 Paramedian sagittal oblique sonogram of the lower thoracic spine. The
white linear streak in the middle of the acoustic window probably represents one of the cauda
equina nerves.

4.Sonoanatomy of the lower thoracic spine: On a median TSPV the spinous process,
lamina, and transverse processes produce a typical acoustic shadow (Fig. 7-60). Although
this view is not useful for visualizing the neuraxial structures, it is useful for locating the
midline. Laterally the parietal pleura and underlying lung are visualized and recognized
by the characteristic “lung-sliding sign” (Fig. 7-60).9 On a median TISV the spinal canal
and anterior complex are clearly defined in the midline with the transverse processes
laterally (Fig. 7-61). The posterior dura or the posterior complex may also be visualized
in a median TISV in some individuals. The PMSOS provides better visibility of the
neuraxial structures (Fig. 7-62), relevant for central neuraxial blocks, than the median
TISV.6,7,10 One can clearly recognize the wide interlaminar spaces and the posterior and
anterior complexes (Fig. 7-62). Outlines of the cauda equina fibers may also be rarely
visualized (Fig. 7-62).

Identification of Thoracic Intervertebral Spaces Using

Ultrasound
Accurate identification of a given thoracic intervertebral level using anatomical landmarks is
inaccurate.11 Ultrasound has been used to identify a given thoracic intervertebral space by
“counting up” from the L5 to S1 junction.1,11 Identification errors can be expected with this
method because lumbosacral transitional anomalies (lumbarization of S1 or sacralization of
L5) are present in approximately 4% to 21% of the general population.12,13 Therefore to
enhance accuracy, others have elected to include identification of the 12th rib and its

355
articulation with the T12 vertebra as a secondary ultrasound landmark to the “counting up”
method.1,14 It is not known if this combined method improves accuracy because an accessory
L1 rib can also be present in approximately 2% of individuals.15 An alternative sonographic
method, which has been used to identify the level of thoracic paravertebral injection, relies on
identifying the first rib.16 However, a limitation of this method is that the presence of a
cervical rib can affect its accuracy. Therefore, although various sonographic methods have
been described, they have inherent inaccuracies. More importantly, none of these methods
have been tested against a gold-standard imaging modality such as computed tomography
(CT) or magnetic resonance imaging (MRI). Despite these limitations it is our opinion that
for day-to-day practice of thoracic epidural catheter placement, the sonographic methods
described earlier are clinically useful because sonographic methods are generally more
accurate than methods that solely reply on anatomical landmarks.11

Clinical Pearls
Currently there are limited published data on ultrasound imaging of the thoracic spine or on
the use of ultrasound for thoracic epidural catheter placement. Based on published data, it is
most frequently used to preview the anatomy of the spine before thoracic epidural catheter
placement.4 During the preprocedural or scout scan, ultrasound can be used to identify the
midline, determine the presence of any underlying spinal abnormality (eg, scoliosis,17
underlying spinal instrumentation), determine the degree of axial rotation of the thoracic
spine in scoliosis,17 accurately measure the depth to the lamina or posterior dura,4 and
determine the optimal site for epidural needle placement. During a median transverse (for
midline approach) or PMSOS (for a paramedian approach), the angle of insonation that
produces the best ultrasound visualization of the neuraxial structures or the anterior complex
closely mirrors the angle or trajectory for needle insertion. Currently there are no published
data on the use of ultrasound to guide or assist real-time epidural needle placement in the
thoracic region. In the authors’ experience ultrasound can be used to assist epidural catheter
placement in the thoracic region, especially in patients with obesity or difficult backs, by
guiding the tip of the epidural needle to the target interlaminar space before the traditional
loss-of-resistance method is used to confirm correct epidural needle placement. This may
translate into reduced needle passes and higher success rates on the first attempt. Future
research to establish the utility of ultrasound for thoracic epidural catheter placement is
warranted.

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2.Grau T, Leipold RW, Delorme S, Martin E, Motsch J. Ultrasound imaging of the thoracic
epidural space. Reg Anesth Pain Med. 2002;27:200–206.
3.Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult thoracic and lumbar spine
for central neuraxial blockade. Anesthesiology. 2011;114:1459–1485.
4.Salman A, Arzola C, Tharmaratnam U, Balki M. Ultrasound imaging of the thoracic spine
in paramedian sagittal oblique plane: the correlation between estimated and actual depth
to the epidural space. Reg Anesth Pain Med. 2011;36:542–547.
5.Moriggl B. Spine anatomy and sonoanatomy for pain physicians. In: Narouze S, ed. Atlas

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 of Ultrasound Guided Procedures in Interventional Pain Management. New York, NY:
Springer; 2010:79–105.
6.Karmakar MK. Ultrasound guided central neuraxial blocks. In: Narouze S, ed. Atlas of
Ultrasound Guided Procedures in Interventional Pain Management. 1st ed. New York,
NY: Springer; 2010:161–178.
7.Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD. Sonoanatomy relevant for
ultrasound-guided central neuraxial blocks via the paramedian approach in the lumbar
region. Br J Radiol. 2012;85:e262–e269.
8.Unsinn KM, Geley T, Freund MC, Gassner I. US of the spinal cord in newborns: spectrum
of normal findings, variants, congenital anomalies, and acquired diseases.
Radiographics. 2000;20:923–938.
9.Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the
critically ill. Lung sliding. Chest. 1995;108:1345–1348.
10.Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time ultrasound-guided
paramedian epidural access: evaluation of a novel in-plane technique. Br J Anaesth.
2009;102:845–854.
11.Arzola C, Avramescu S, Tharmaratnam U, Chin KJ, Balki M. Identification of
cervicothoracic intervertebral spaces by surface landmarks and ultrasound. Can J
Anaesth. 2011;58:1069–1074.
12.Hughes RJ, Saifuddin A. Imaging of lumbosacral transitional vertebrae. Clin Radiol.
2004;59:984–991.
13.Bron JL, van Royen BJ, Wuisman PI. The clinical significance of lumbosacral transitional
anomalies. Acta Orthop Belg. 2007;73:687–695.
14.Arzola C, Davies S, Rofaeel A, Carvalho JC. Ultrasound using the transverse approach to
the lumbar spine provides reliable landmarks for labor epidurals. Anesth Analg.
2007;104:1188–1192.
15.Tyl RW, Chernoff N, Rogers JM. Altered axial skeletal development. Birth Defects Res B
Dev Reprod Toxicol. 2007;80:451–472.
16.Bouzinac A, Delbos A, Rontes O. [Ultrasound location of the first rib confirm the level of
realization of thoracic paravertebral block]. Ann Fr Anesth Reanim. 2012;31:571–572.
17.McLeod A, Roche A, Fennelly M. Case series: Ultrasonography may assist epidural
insertion in scoliosis patients. Can J Anaesth. 2005;52:717–720.

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CHAPTER 8

Ultrasound Imaging of the Lumbar Spine for Central

Neuraxial Blocks

Introduction
Central neuraxial blocks (CNBs), which include spinal, epidural, and combined spinal
epidural (CSE) injections, are frequently performed in the lumbar region for anesthesia and
analgesia and for managing chronic pain.1 Traditionally, they are performed using a
combination of surface anatomic landmarks, the operator’s tactile perception of “loss of
resistance” during needle advancement through the ligamentum flavum, and/or visualizing
the efflux of cerebrospinal fluid. Anatomic landmarks (eg, the spinous processes) are useful
but they are not always easily palpable in patients with edema, obesity,2 underlying spinal
deformity, or previous back surgery. The “Tuffier’s line,” which is a line joining the highest
points of the iliac crests, is another surface anatomical landmark that is widely used to
estimate the location of the L4 to L5 interspace; however, the correlation is inconsistent.3
Even in the absence of spine abnormalities, estimation of a specific intervertebral level may
not be accurate in many patients4,5 and may result in needle placement one or two spinal
levels higher than intended.4–7 This inaccuracy is exaggerated in the obese and in the upper
spinal levels.4,6,8 Furthermore, using surface anatomical landmarks alone, it is not possible to
predict the ease or difficulty of needle placement prior to skin puncture. Unanticipated
technical difficulty, multiple attempts at needle placement, and failure of CNB are therefore
prevalent in clinical practice.9,10
Recently, ultrasound imaging of the spine11–13 has emerged as a useful tool to overcome
many of the shortcomings of the traditional approach to CNBs, and it has been used with
great success. Ultrasound is most frequently used as a preprocedural tool,11 but can also be
used to guide the epidural or spinal needle in real time during CNBs.14 Advantages of the
preprocedural scan include being able to accurately locate the midline,15 identify a given
lumbar interspace, predict the depth to the epidural space, detect any vertebral rotational
defects (eg, in scoliosis), and identify patients with a potentially difficult CNB.11,16 In expert
hands the use of ultrasound for epidural needle insertion reduces the number of puncture
attempts,17–22 improves the success rate of epidural access on the first attempt,18 reduces the
need to puncture multiple levels,18–20 and improves patient comfort during the procedure.19
This chapter briefly outlines the anatomy, the technique of ultrasound imaging, and
sonoanatomy relevant for CNBs in the lumbar region.

Basic Lumbar Spine Anatomy

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The lumbar spine makes up the lower back and is made up of five vertebra, numbered L1 to
L5 (Figs. 8-1 and 8-2). It connects with the thoracic spine above and with the sacrum below
at the lumbosacral joint. L1 to L4 are typical lumbar vertebrae because they share common
characteristics, but L5 is atypical because it has certain peculiarities. The lumbar vertebral
body is designed to bear weight, and therefore the size of the lumbar vertebrae increases from
L1 to L5. The lumbar spine also has a curvature, being slightly convex anteriorly, and this is
referred to as lordosis.

FIGURE 8-1 Lumbosacral spine – lateral view.

FIGURE 8-2 Lumbar spine – lateral view.

Typical Lumbar Vertebra

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A typical lumbar vertebra (L1–L4) is identified by its large vertebral body and the absence of
costal facets on the body (Fig. 8-3). The body of a typical lumbar vertebra is wider in the
transverse axis than in the anteroposterior axis (Fig. 8-3). The height of the vertebral body is
also greater anteriorly than posteriorly, and this difference contributes to the forward
convexity of the lumbar spine. The vertebral foramen is triangular in shape (Fig. 8-3) and
larger than that in the thoracic region but smaller than that in the cervical region. The pedicles
are short and strong and directed posteriorly from the upper part of the body (Figs. 8-2 and 8-
3). This results in an inferior vertebral notch that is significantly deeper than the superior
vertebral notch (Figs. 8-2 and 8-3). The laminae are short and thick, directed backwards and
medially, and form the posterior part of the vertebral arch. The spinous process is thick, wide,
and quadrilateral in shape, and directed backwards (Figs. 8-1 to 8-3). The transverse
processes are thin and directed laterally and slightly backwards (Fig. 8-4). The width of the
transverse process increases from L1 to L3 after which it decreases as one moves caudally. In
a typical lumbar vertebra, the superior articular processes lie farther apart from each other
than the inferior articular processes (Fig. 8-4). The superior articular processes face
backwards and medially, whereas the inferior articular process faces laterally and forward
(Figs. 8-3 and 8-4).

FIGURE 8-3 A typical (fourth) lumbar vertebra – superior, anterior, and lateral views. TP,
transverse process; SAP, superior articular process; SC, spinal canal; SVN, superior vertebral
notch; VB, vertebral body; IAP, inferior articular process.

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FIGURE 8-4 Posterior articulation of the lumbar vertebra. Note the superior and inferior
articular processes and the facet joints on either side of the midline.

Fifth Lumbar Vertebra (L5)

The body of the L5 vertebra is the largest of all the lumbar vertebrae. Its anterior surface is
wider than its posterior surface (Fig. 8-5), and this difference results in the sharp lumbosacral
angulation (Fig. 8-1). The pedicles are short and directed backwards and laterally (Fig. 8-5).
The superior articular processes face more backwards than medially, and the inferior articular
process also looks more anteriorly than laterally when compared to the other lumbar
vertebrae (Fig. 8-5). The distance between the inferior articular processes are also equal to or
more than the distance between the superior articular processes. The transverse process of L5
is short, thick, pyramidal in shape, and attached to the entire thickness of the pedicle (Fig. 8-
5). The spine of L5 is also relatively short and has a rounded tip.

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FIGURE 8-5 An atypical (fifth) lumbar vertebra – superior, lateral, and anterior views. TP,
transverse process; SAP, superior articular process; SC, spinal canal; SVN, superior vertebral
notch; VB, vertebral body; IAP, inferior articular process.

The adjacent lumbar vertebrae articulate with each other at the facet joints between the
superior and inferior articular processes and the intervertebral disc between the vertebral
bodies (Fig. 5-7). This results in two gaps—the “interspinous space” and the “interlaminar
space”—between the adjacent spinous processes and the laminae of the vertebrae,
respectively (Fig. 8-4). These gaps allow the ultrasound energy to enter the spinal canal and
thereby act as acoustic windows for ultrasound imaging during spinal sonography. The reader
should refer to Chapter 5 for a detailed description of the anatomy of the interlaminar and
interspinous spaces, major ligaments that support the lumbar vertebra (ie, ligamentum
flavum, supraspinous and interspinous ligament, and the anterior and posterior longitudinal
ligament), spinal canal, and the epidural space in the lumbar region.

Gross Anatomy of the Lumbar Spine

Figs. 8-6 to 8-11

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FIGURE 8-6 Cross-sectional cadaver anatomic section through the L4 vertebral body and
transverse process illustrating the attachment of the ligamentum flavum to the laminae,
posterior epidural space, and the relationship of the articular process to the transverse
process. ESM, erector spinae muscle; QLM, quadratus lumborum muscle; PM, psoas major
muscle; VB, vertebral body.

FIGURE 8-7 Cross-sectional cadaver anatomic section from just inferior to the L4
transverse process and through the lower part of the L4 vertebral body illustrating the lamina
of the lumbar vertebra, the articular processes, and the intervertebral foramina. VB, vertebral
body; IVF, intervertebral foramen; QLM, quadratus lumborum muscle; ESM, erector spinae

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muscle.

FIGURE 8-8 Median sagittal cadaver anatomic section of the lumbar spine showing the
spinous processes (L3–L5), interspinous spaces, ligamentum flavum, posterior epidural
space, and the thecal sac. Also note the cauda equina (CE) within the thecal sac. ITS,
intrathecal sac; VB, vertebral body.

FIGURE 8-9 Paramedian sagittal cadaver anatomic section of the lumbar spine at the level
of the lamina. The laminae have been shaded in green, and a graphic overlay has been placed
over the L3 lamina to illustrate the horse head–like appearance of the lamina of the lumbar
vertebra. ESM, erector spinae muscle; ILS, interlaminar space; ITS, intrathecal space; VB,

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vertebral body; IVD, intervertebral disc.

FIGURE 8-10 Paramedian sagittal cadaver anatomic section of the lumbar spine at the
level of the articular processes. A graphic overlay has been placed over the articular
processes of the L4 vertebra to illustrate the camel hump–like appearance formed by the
articulations of the superior and inferior articular processes and the facet joints. VB, vertebral
body.

FIGURE 8-11 Paramedian sagittal cadaver anatomic section of the lumbar spine at the
level of the transverse processes. Note the large fleshy muscle (ie, the psoas major muscle)
lying anterior to the transverse processes. Also the lumbar plexus nerves can be identified
within the substance of the psoas muscle. ESM, erector spinae muscle; TP, transverse
process; NR, nerve root.

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Computed Tomography Anatomy of the Lumbar Spine
Figs. 8-12 to 8-18

FIGURE 8-12 Transverse CT image of the lumbar spine at the level of the spinous
process. IVC, inferior vena cava; VB, vertebral body; ITS, intrathecal space; PM, psoas
major muscle; QLM, quadratus lumborum muscle; ESM, erector spinae muscle.

FIGURE 8-13 Transverse CT image of the lumbar spine at the level of the articular
process. IVC, inferior vena cava; VB, vertebral body; ESM, erector spinae muscle; ITS,
intrathecal space; PM, psoas major muscle; QLM, quadratus lumborum muscle.

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FIGURE 8-14 Median sagittal CT image of the lumbosacral spine. Note the L5 to S1 gap
between the spinous processes of L5 and S1 vertebra posteriorly. SP, spinous process; VB,
vertebral body.

FIGURE 8-15 Paramedian sagittal oblique (rendered) CT section of the lumbosacral spine
at the level of the lamina. Note the wide interlaminar space (L5–S1 gap) between the lamina
of L5 and the sacrum. ITS, intrathecal space; VB, vertebral body.

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FIGURE 8-16 Paramedian sagittal CT image of the lumbosacral spine at the level of the
lamina. Note the relatively narrow interlaminar and intrathecal space (ITS) when compared to
that in Fig. 8-15 (same subject). VB, vertebral body.

FIGURE 8-17 Paramedian sagittal CT image of the lumbar spine at the level of the
articular processes. Note how the articular processes articulate to form the facet joints. VB,
vertebral body.

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FIGURE 8-18 Paramedian sagittal CT image of the lumbosacral spine at the level of the
transverse processes. TP, transverse process; NR, nerve root.

Magnetic Resonance Imaging Anatomy of the Lumbar Spine

Figs. 8-19 to 8-26

FIGURE 8-19 Transverse T1-weighted magnetic resonance image of the lumbar spine
through the interspinous space. Note the attachment of the ligamentum flavum to the laminae
and the wide posterior epidural space. IVC, inferior vena cava; PM, psoas major muscle; VB,
vertebral body; QLM, quadratus lumborum muscle; ESM, erector spinae muscle; ITS,
intrathecal space.

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FIGURE 8-20 Transverse T1-weighted magnetic resonance image of the lumbar spine at
the level of the spinous process. Note the relationship of the articular processes to the
intervertebral foramen and the lumbar nerve root. VB, vertebral body; LPVS, lumbar
paravertebral space; ITS, intrathecal space; PM, psoas major muscle; QLM, quadratus
lumborum muscle; SP, spinous process.

FIGURE 8-21 Zoomed magnetic resonance image of the lumbar epidural and intrathecal
space. Note the attachment of the ligamentum flavum to the laminae, the posterior epidural
space, and the cauda equina nerves within the hyperintense cerebrospinal fluid. VB, vertebral
body.

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FIGURE 8-22 Median sagittal magnetic resonance image of the lumbar spine
demonstrating the spinous processes (SP), interspinous spaces, posterior epidural space, and
the thecal sac. The hyperintense oval structures on the surface of the skin posteriorly are cod
liver oil capsules that were used as skin markers to identify the lumbar interspinous spaces.

FIGURE 8-23 Sagittal magnetic resonance image of the lumbar spine at the level of the
lamina.

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FIGURE 8-24 Sagittal oblique (rendered) T1-weighted magnetic resonance image of the
lumbar spine at the level of the lamina. Note the wide interlaminar and intrathecal spaces
when compared to that in Fig. 8-23 (same subject).

FIGURE 8-25 Sagittal magnetic resonance image of the lumbosacral spine at the level of
the lumbar articular processes. VB, vertebral body. IVD, intervertebral disc.

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FIGURE 8-26 Sagittal T1-weighted magnetic resonance image of the lumbosacral spine at
the level of the transverse processes (TP). Note the relationship of the psoas muscle to the TP
and the steep caudal course of the lumbar nerve roots.

Ultrasound Imaging of the Lumbar Spine

The lumbar spine is imaged using a low-frequency (5–2 MHz) curved array transducer and in
the transverse or sagittal plane. During a median transverse scan (Figs. 8-27 to 8-38) the
“transverse spinous process view” (Figs. 8-27 to 8-29) and “transverse interspinous view”
(Figs. 8-34 to 8-36) are acquired. During a median sagittal scan (Figs. 8-39 to 8-41) the
lumbar spinous processes and the interspinous spaces are visualized.12,13 The lumbar spinous
processes appear as crescent-shaped structures (Figs. 8-40 and 8-41) and occupy most of the
median plane (ie, there is a lot of bone). Therefore, the acoustic window for imaging is
relatively narrow in the midline (Fig. 8-41). Also any clinical condition that causes narrowing
of the interspinous spaces (eg, in the elderly) further compromises the acoustic window.
Consequently ultrasound imaging through the median plane provides a limited view of the
neuraxial structures (Fig. 8-41). In contrast there is less bony obstruction in the paramedian
sagittal plane, particularly at the level of the lamina, which creates a large acoustic window
for imaging through the interlaminar spaces. Sonographic views of the neuraxis are also more
detailed through the paramedian sagittal plane (Figs. 8-42 to 8-67). Therefore it is the
preferred route for spinal sonography and for real-time ultrasound-guided CNBs.11–13 For a
detailed ultrasound examination of the lumbar spine, it must be imaged in both the transverse
and sagittal planes because the information obtained from either plane complements the
other.

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FIGURE 8-27 Position and orientation of the ultrasound transducer during a transverse
scan of the lumbar spine with the subject in the lateral position.

FIGURE 8-28 Transverse sonogram of the lumbar spine with the transducer positioned
directly over the lumbar spinous process (ie, the transverse spinous process view). Note the
acoustic shadow of the spinous process and lamina completely obscures the spinal canal and
the neuraxial structures. SP, spinous process; ESM, erector spinae muscle.

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FIGURE 8-29 Transverse sonogram of the lumbar spine illustrating the transverse spinous
process view. Photographs on the right illustrate the position and orientation of the ultrasound
transducer with the subject in the lateral position.

FIGURE 8-30 Multiplanar 3-D CT images of the lumbar spinous process that were
rendered from a volume CT data set of the CIRS lumbar training phantom. (A) Transverse
view, (B) sagittal view, and (C) coronal view.

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FIGURE 8-31 Correlative transverse (A) CT, (B) ultrasound, (C) cadaver anatomic, and
(D) MRI images of the lumbar spinous process and lamina. SP, spinous process; SC, spinal
canal; VB, vertebral body; ESM, erector spinae muscle; QLM, quadratus lumborum muscle;
PM, psoas major muscle; ITS, intrathecal space; PD, posterior dura; CE, cauda equina; ITS,
intrathecal space.

FIGURE 8-32 Multiplanar 3-D ultrasound images of the lumbar spinous process with the
reference marker (white crosshair) placed over the tip of the spinous process. (A) Transverse

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view, (B) sagittal view, (C) coronal view, and (D) slice plane. SP, spinous process; ITS,
intrathecal space; ISS, interspinous space.

FIGURE 8-33 Multiplanar 3-D ultrasound images of the lumbar spinous process with the
reference marker (white crosshair) placed over the base of the spinous process. (A)
Transverse view, (B) sagittal view, (C) coronal view, and (D) slice plane. SP, spinous
process; ITS, intrathecal space; ISS, interspinous space.

FIGURE 8-34 Transverse sonogram of the lumbar spine with the ultrasound beam being
insonated through the lumbar interspinous space (ie, the transverse interspinous view). The
photographs on the right illustrate the position and orientation of the ultrasound transducer
with the subject in the lateral position.

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FIGURE 8-35 Transverse sonogram of the lumbar spine – coned (zoomed) transverse
interspinous view. The epidural space, posterior dura, intrathecal space, and the anterior
complex are visible in the midline, and the articular process (AP) is visible laterally on either
side of the midline. Note how the articular processes on either side are symmetrically located.

FIGURE 8-36 Transverse sonogram of the lumbar spine – transverse interspinous view.
Note the posterior epidural space is clearly delineated in this sonogram. ESM, erector spinae
muscle; ITS, intrathecal space; VB, vertebral body.

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FIGURE 8-37 Multiplanar 3-D CT images of the lumbar spine that were rendered from a
volume CT data set of the CIRS lumbar training phantom. The reference marker (crosshair)
has been placed at the L3 to L4 interspinous space. (A) Sagittal view, (B) transverse view,
and (C) coronal view.

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FIGURE 8-38 Correlative transverse (A) CT, (B) ultrasound, (C) cadaver anatomic, and
(D) high-definition coned (zoomed) ultrasound images of the lumbar interspinous view. Note
how the inferior and superior articular processes of the vertebrae make up the facet joints on
either side of the midline. TP, transverse process; FJ, facet joint; SC, spinal canal; IAP,
inferior articular process; SAP, superior articular process; ESM, erector spinae muscle; ES,
epidural space; ITS, intrathecal space; LF, ligamentum flavum; CE, cauda equina; PM, psoas
major muscle; QLM, quadratus lumborum muscle; PD, posterior dura; AP, articular process;
VB, vertebral body; AC, anterior complex; AD, anterior dura.

FIGURE 8-39 Position and orientation of the ultrasound transducer during a median
sagittal scan of the lumbar spine with the subject in the lateral position.

FIGURE 8-40 Median sagittal sonogram of the lumbar spine showing the crescent-shaped
hyperechoic reflections of the spinous processes. The interspinous space is interposed

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between the spinous processes in the midline.

FIGURE 8-41 Correlative median sagittal (A) CT, (B) ultrasound, (C) cadaver anatomic
section, and (D) magnetic resonance images of the lumbar spine. SP, spinous process; ISS,
interspinous space; VB, vertebral body; SC, spinal canal; IVD, intervertebral disc; LF,
ligamentum flavum; PD, posterior dura; ES, epidural space; ITS, intrathecal space; CE, cauda
equina.

FIGURE 8-42 Position and orientation of the ultrasound transducer during a paramedian
sagittal scan of the lumbar spine with the subject in the lateral position.

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FIGURE 8-43 Paramedian sagittal sonogram of the lumbar spine. Note the narrow
intrathecal space in this sonogram. ESM, erector spinae muscle.

FIGURE 8-44 Position and orientation of the ultrasound transducer during a paramedian
sagittal oblique scan of the lumbar spine with the subject in the lateral position.

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FIGURE 8-45 Figure illustrating how to identify a given lumbar intervertebral space by
performing a paramedian sagittal scan. (A) Locate the L5 to S1 gap and (B) slide the
transducer cephalad until the lamina of L3, L4, and L5 are identified.

FIGURE 8-46 Paramedian sagittal sonogram of the lumbosacral junction. The dip or gap
between the posterior surface of the sacrum and the lamina of L5 is the L5 to S1 gap. ESM,
erector spinae muscle; LF, ligamentum flavum; ITS, intrathecal space. The photographs on
the right illustrate the position and orientation of the ultrasound transducer to locate the L5 to
S1 gap with the subject in the lateral position.

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FIGURE 8-47 Paramedian sagittal oblique scan of the lumbar spine at the level of the
lamina showing the L3 to L4 and L4 to L5 interlaminar spaces. Note the hypoechoic epidural
space (few millimeters wide) between the hyperechoic ligamentum flavum and the posterior
dura. The intrathecal space is the anechoic space between the posterior dura and the anterior
complex in the sonogram. The hyperechoic reflections anterior of the anterior complex are
from the intervertebral disc (IVD). The cauda equina nerve fibers are also seen as
hyperechoic longitudinal structures within the thecal sac. The photograph on the right
illustrates the position and orientation of the ultrasound transducer during a paramedian
sagittal oblique scan of the lumbar spine with the subject in the lateral position.

FIGURE 8-48 Paramedian sagittal oblique sonogram of the lumbar spine demonstrating
the L3 to L4 and L4 to L5 interlaminar spaces. The posterior epidural space is clearly
delineated between the hyperechoic ligamentum flavum and the posterior dura in this
sonogram. Also note the cauda equina nerves within the thecal sac at the L4 to L5 level.

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FIGURE 8-49 Paramedian sagittal oblique sonogram of the lumbar spine at the L3 to L5
level demonstrating color Doppler signals from the vasculature within the erector spinae
muscle (ESM).

FIGURE 8-50 Panoramic view of a paramedian sagittal oblique scan of the lumbosacral
spine.

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FIGURE 8-51 Multiplanar 3-D CT images of the lumbar spine that were rendered from a
volume CT data set of the CIRS lumbar training phantom. The reference marker (crosshair)
has been placed over the L4 lamina. (A) Transverse view, (B) sagittal view, and (C) coronal
view.

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FIGURE 8-52 Paramedian sagittal oblique sonogram of the lumbar spine at the level of
the laminae (L3–L5) from (A) the water-based spine phantom and (B) volunteers and a
representative anatomical section from (C) a representative cadaver anatomical section from
the Visible Human Server. In the latter, the lamina has been shaded in green (C). Note the
marker (needle) in contact with the lamina in the water-based spine phantom (A). This was
done to ensure that the lamina was being scanned and also helped in validating its
sonographic appearance. A graphic overlay has been placed over the lamina in (A) to
illustrate the “horse head sign.” AC, anterior complex; CE, cauda equina; ES, epidural space;
ESM, erector spinae muscle; ILS, interlaminar space; ITS, intrathecal space; IVD,
intervertebral disc; LF, ligamentum flavum; PD, posterior dura; SC, spinal canal; VB,
vertebral body.

FIGURE 8-53 Correlative paramedian sagittal (A) CT, (B) ultrasound, (C) cadaver
anatomic section, and (D) magnetic resonance images of the lumbar spine. ILS, interlaminar
space; ESM, erector spinae muscle; ES, epidural space; SC, spinal canal; VB, vertebral body;
IVD, intervertebral disc; LF, ligamentum flavum; ITS, intrathecal space; CE, cauda equina;
PD, posterior dura; AC, anterior complex.

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FIGURE 8-54 Correlative paramedian sagittal (A) sonogram and (B) T2-weighted
magnetic resonance images of the neuraxis via the L4 to L5 interlaminar space. LF,
ligamentum flavum; ES, epidural space; ITS, intrathecal space; CE, cauda equina.

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FIGURE 8-55 Multiplanar 3-D ultrasound images of the lumbar spine with the reference
marker (green crosshair) placed over the lamina. (A) Transverse view, (B) sagittal view, and
(C) coronal view. AP, articular process; ITS, intrathecal space.

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FIGURE 8-56 Paramedian sagittal sonogram of the lumbar spine showing the articular
processes. The photographs on the right illustrate the position and orientation of the
ultrasound transducer during a paramedian sagittal scan of the lumbar spine at the level of the
articular processes of the vertebra with the subject in the lateral position.

FIGURE 8-57 Paramedian sagittal sonogram of the lumbar spine at the level of the
articular processes of the vertebra. A graphic overlay has been placed in this image to
illustrate the camel hump–like appearance of the articular processes.

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FIGURE 8-58 Multiplanar 3-D CT images of the lumbar spine that were rendered from a
volume CT data set of the CIRS lumbar training phantom. The reference marker (crosshair)
has been placed over the articular process (AP) of the L4 vertebra. (A) Sagittal view, (B)
transverse view, and (C) coronal view.

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FIGURE 8-59 Paramedian sagittal sonogram of the articular process from the (A) water-
based spine phantom, (B) volunteer, and (C) a representative cadaver anatomical section. A
graphic overlay has been placed in (B) to illustrate the camel hump–like appearance of the
articular processes. AP, articular process; ESM, erector spinae muscle; FJ, facet joint; VB,
vertebral body.

FIGURE 8-60 Correlative sagittal (A) CT, (B) ultrasound, (C) cadaver anatomic section,
and (D) magnetic resonance images of the lumbar spine at the level of the articular processes
(AP). IAP, inferior articular process; SAP, superior articular process; VB, vertebral body;
IVD, intervertebral disc; ESM, erector spinae muscle; FJ, facet joint.

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FIGURE 8-61 Multiplanar 3-D ultrasound images of the lumbar spine with the reference
marker (white crosshair) placed over the articular process of the vertebra. (A) Transverse
view, (B) sagittal view, and (C) coronal view. AP, articular process; ITS, intrathecal space.

FIGURE 8-62 Paramedian sagittal sonogram of the lumbar spine at the level of the
transverse processes. Note the hyperechoic reflections of the transverse processes with their
acoustic shadows that produce the “trident sign.” The psoas major muscle is seen in the
acoustic window between the transverse processes and is recognized by its typical
hypoechoic and striated appearance. Hyperechoic longitudinal striations within the substance
of the psoas muscle may represent intramuscular tendons of the psoas muscle. The

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photographs on the right illustrate the position and orientation of the ultrasound transducer
during a paramedian sagittal scan of the lumbar spine at the level of the transverse processes
of the vertebra with the subject in the lateral position. ESM, erector spinae muscle; TP,
transverse process; PM, psoas major muscle; RPS, retroperitoneal space.

FIGURE 8-63 Paramedian sagittal sonogram of the lumbar spine at the level of the
transverse processes. The acoustic shadows of the transverse processes produce the “trident
sign.” In this sonogram the lumbar plexus is visualized as a hyperechoic shadow in the
posterior part of the psoas muscle between the L3 and L4 transverse process (TP).
Intramuscular tendons of the psoas muscle are also seen within the substance of the psoas
muscle and should not to be confused with the lumbar plexus nerves. ESM, erector spinae
muscle.

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FIGURE 8-64 Multiplanar 3-D CT images of the lumbar spine that were rendered from a
volume CT data set of the CIRS lumbar training phantom. The reference marker (crosshair)
has been placed over the transverse process of the L4 vertebra. (A) Transverse view, (B)
sagittal view, and (C) coronal view.

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FIGURE 8-65 Correlative sagittal (A) CT, (B) ultrasound, (C) cadaver anatomic section,
and (D) magnetic resonance images of the lumbar spine at the level of the transverse
processes (TP). PM, psoas muscle; ESM, erector spinae muscle; RPS, retroperitoneal space;
NR, nerve root; LP, lumbar plexus.

FIGURE 8-66 Multiplanar 3-D ultrasound images of the lumbar spine with the reference
marker (green crosshair) placed over the transverse process of the vertebra. (A) Transverse
view, (B) sagittal view, and (C) coronal view. AP, articular process; PM, psoas major muscle;
TP, transverse process; ESM, erector spinae muscle.

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FIGURE 8-67 A sagittal iSlice display that was rendered from a 3-D ultrasound data set of
the lumbar spine. In this figure, 16 contiguous sagittal ultrasound images of the lumbar spine
that are approximately 1.8 mm apart from the level of the spinous process (SP) to the
articular process (AP) are displayed. Note the change in the sagittal sonoanatomy of the
lumbar spine from a medial to lateral direction.

Transverse Ultrasound Imaging of the Lumbar Spine

For a transverse scan of the lumbar spine, the ultrasound transducer is positioned in the
midline and initially over the spinous process (transverse spinous process view, TSPV, Figs.
8-27 to 8-29) with the patient in the sitting, lateral, or prone position. On a TSPV, the spinous
process and the lamina on either side are seen as hyperechoic reflections anterior to which
there is an acoustic shadow that completely conceals the underlying spinal canal and thus the
neuraxial structures (Figs. 8-28 and 8-29). Therefore, the TSPV is not suitable for imaging
the neuraxial structures but can be used to identify the midline when the spinous processes
cannot be palpated (eg, in patients with edema over the back or obese patients). From this
position, by sliding the transducer slightly cranially or caudally, a transverse scan of the
lumbar spine through the interspinous/interlaminar space (transverse interspinous view,
TISV, Figs. 8-34 to 8-38) is obtained.12,15 A slight tilt of the ultrasound transducer cranially
or caudally may be needed to align the ultrasound beam with the interspinous space and
optimize the TISV. In the TISV, the posterior dura, thecal sac, and the anterior complex can
be visualized (from a posterior-to-anterior direction) within the spinal canal in the midline,
and the articular processes and the transverse processes are visualized laterally (Figs. 8-34 to
8-36).12,15 The osseous elements produce a sonographic pattern that resembles a “cat’s
head,” with the spinal canal representing the head, the articular processes representing the
ears of the cat, and the transverse processes representing the whiskers (Figs. 8-35 to 8-38).
The ligamentum flavum is rarely visualized in the TISV (Figs. 8-35 and 8-36), possibly due

397
to anisotropy caused by the archlike attachment of the ligamentum flavum to the lamina (Fig.
8-38). The epidural space is also less frequently visualized in the TISV (Fig. 8-6) than in the
paramedian sagittal oblique scan (PMSOS). In the TISV the depth of the posterior dura from
the skin can be easily measured using the internal caliper of the ultrasound system. The TISV
can also be used to examine for rotational defects of the vertebra, such as in scoliosis.
Normally, both the lamina and the articular processes on either side are symmetrically located
(Figs. 8-35 and 8-36). However, if there is asymmetry, then a rotational deformity of the
vertebral column23 should be suspected and a difficult CNB should be anticipated.

Sagittal Ultrasound Imaging of the Lumbar Spine

For a sagittal scan (Figs. 8-39 to 8-67) the patient is positioned in the sitting, lateral (Fig. 8-
39), or prone position with the lumbosacral spine maximally flexed. The transducer is placed
1 to 2 cm lateral to the spinous process (paramedian sagittal scan, PMSS) at the lower back
with its orientation marker directed cranially (Fig. 8-39). For optimal imaging the transducer
is also tilted slightly medially during the scan (paramedian sagittal oblique scan, PMSOS,
Fig. 8-44) so that majority of the ultrasound signal enters the spinal canal through the widest
part of the interlaminar space.
The sagittal scan routine begins by locating the sacrum as a flat hyperechoic structure with
a large acoustic shadow anteriorly (Figs. 8-45 to 8-47, details in Chapter 9). When the
transducer is gently manipulated in a cranial direction, a gap is seen between the sacrum and
the lamina of the L5 vertebra, which is the L5 to S1 interlaminar space, also referred to as the
L5 to S1 gap (Fig. 8-46).13,24 The L3 to L4 and L4 to L5 interlaminar spaces can now be
located by moving the transducer cranially and counting upward (Figs. 8-45 and 8-47).13,14
The erector spinae muscles are hypoechoic and lie superficial to the laminae. The lamina
appears hyperechoic and is the first osseous structure visualized (Figs. 8-47 and 8-48).
Because bone impedes the penetration of ultrasound, there is an acoustic shadow anterior to
each lamina. The sonographic appearance of the lamina produces a pattern that resembles the
head and neck of a horse (the “horse head sign”) (Fig. 8-52).13 The interlaminar space is the
gap between the adjoining lamina (Fig. 8-48) and is the “acoustic window” through which the
neuraxial structures are visualized within the spinal canal. The ligamentum flavum appears as
a hyperechoic band across adjacent lamina (Figs. 8-47 to 8-50). The posterior dura is the
adjoining hyperechoic structure anterior to the ligamentum flavum, and the epidural space is
the hypoechoic area (a few millimeters wide) between the ligamentum flavum and the
posterior dura (Figs. 8-47 and 8-48). The ligamentum flavum and posterior dura may also be
seen as a single linear hyperechoic structure, which is referred to as the “posterior
complex”11 or “ligamentum flavum-posterior dura complex.”25 The posterior dura is
generally more hyperechoic than the ligamentum flavum.13 The thecal sac with the
cerebrospinal fluid is the anechoic space anterior to the posterior dura (Fig. 8-53). The cauda
equina, which is located within the thecal sac, may also be seen as multiple horizontal,
hyperechoic shadows within the anechoic thecal sac. Pulsations of the cauda equina are also
identified in some individuals.13,14 The anterior dura is also hyperechoic, but it is often
difficult to differentiate it from the posterior longitudinal ligament and the posterior surface
of the vertebral body because they are of similar echogenicity (isoechoic) and closely
apposed to each other. What results is a single, composite, hyperechoic reflection anteriorly,
which is referred to as the “anterior complex” (Figs. 8-53 and 8-54).13,14
If the transducer is now slid laterally from the level of the lamina, the paramedian sagittal
articular process view (Figs. 8-56 and 8-57) is seen. The articular processes of the vertebrae
appear as one continuous, hyperechoic wavy line with no intervening gaps (Figs. 8-56 to 8-

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61).12,13 This produces a sonographic pattern that resembles multiple camel humps—the
“camel hump sign” (Fig. 8-59).12,13 A sagittal scan lateral to the articular processes brings
the transverse processes of the L3 to L5 vertebrae into view and produces the paramedian
sagittal transverse process view (Figs. 8-62 and 8-63). The transverse processes (Figs. 8-62 to
67) are recognized by their crescent-shaped, hyperechoic reflections and fingerlike acoustic
shadows anteriorly (Figs. 8-62 and 8-63).13,26 This produces a sonographic pattern that is
referred to as the “trident sign” because of its resemblance to the trident (Latin tridens or
tridentis) that is often associated with Poseidon, the god of the sea in Greek mythology, and
the Trishula of the Hindu God Shiva.26

References
1.Cook TM, Counsell D, Wildsmith JA. Major complications of central neuraxial block:
report on the Third National Audit Project of the Royal College of Anaesthetists. Br J
Anaesth. 2009;102:179–190.
2.Stiffler KA, Jwayyed S, Wilber ST, Robinson A. The use of ultrasound to identify
pertinent landmarks for lumbar puncture. Am J Emerg Med. 2007;25:331–334.
3.Hogan QH. Tuffier’s line: the normal distribution of anatomic parameters. Anesth Analg.
1994;78:194–195.
4.Broadbent CR, Maxwell WB, Ferrie R, Wilson DJ, Gawne-Cain M, Russell R. Ability of
anaesthetists to identify a marked lumbar interspace. Anaesthesia. 2000;55:1122–1126.
5.Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound imaging for identification of
lumbar intervertebral level. Anaesthesia. 2002;57:277–280.
6.Holmaas G, Frederiksen D, Ulvik A, Vingsnes SO, Ostgaard G, Nordli H. Identification of
thoracic intervertebral spaces by means of surface anatomy: a magnetic resonance
imaging study. Acta Anaesthesiol Scand. 2006;50:368–373.
7.Reynolds F. Damage to the conus medullaris following spinal anaesthesia. Anaesthesia.
2001;56:238–247.
8.Hamandi K, Mottershead J, Lewis T, Ormerod IC, Ferguson IT. Irreversible damage to the
spinal cord following spinal anesthesia. Neurology. 2002;59:624–626.
9.Seeberger MD, Lang ML, Drewe J, Schneider M, Hauser E, Hruby J. Comparison of
spinal and epidural anesthesia for patients younger than 50 years of age. Anesth Analg.
1994;78:667–673.
10.Tarkkila P, Huhtala J, Salminen U. Difficulties in spinal needle use. Insertion
characteristics and failure rates associated with 25-, 27- and 29-gauge Quincke-type
spinal needles. Anaesthesia. 1994;49:723–725.
11.Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult thoracic and lumbar spine
for central neuraxial blockade. Anesthesiology. 2011;114:1459–1485.
12.Karmakar MK. Ultrasound for central neuraxial blocks. Tech Reg Anesth Pain Manag.
2009;13:161–170.
13.Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD. Sonoanatomy relevant for
ultrasound-guided central neuraxial blocks via the paramedian approach in the lumbar
region. Br J Radiol. 2012;85:e262–e269.
14.Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time ultrasound-guided
paramedian epidural access: evaluation of a novel in-plane technique. Br J Anaesth.
2009;102:845–854.
15.Carvalho JC. Ultrasound-facilitated epidurals and spinals in obstetrics. Anesthesiol Clin.

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 2008;26:145–158.
16.Chin KJ, Ramlogan R, Arzola C, Singh M, Chan V. The utility of ultrasound imaging in
predicting ease of performance of spinal anesthesia in an orthopedic patient population.
Reg Anesth Pain Med. 2013;38:34–38.
17.Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for presumed difficult
epidural puncture. Acta Anaesthesiol Scand. 2001;45:766–771.
18.Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Ultrasound imaging facilitates
localization of the epidural space during combined spinal and epidural anesthesia. Reg
Anesth Pain Med. 2001;26:64–67.
19.Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in
obstetric epidural anesthesia. J Clin Anesth. 2002;14:169–175.
20.Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of
combined spinal-epidural anaesthesia. Eur J Anaesthesiol. 2004;21:25–31.
21.Perlas A, Chaparro LE, Chin KJ. Lumbar neuraxial ultrasound for spinal and epidural
anesthesia: a systematic review and meta-analysis. Reg Anesth Pain Med. 2016;41:251–
260.
22.Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and
epidural catheterisations: systematic review and meta-analysis. BMJ. 2013;346:f1720.
23.Suzuki S, Yamamuro T, Shikata J, Shimizu K, Iida H. Ultrasound measurement of
vertebral rotation in idiopathic scoliosis. J Bone Joint Surg Br. 1989;71:252–255.
24.Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound imaging for identification of
lumbar intervertebral level. Anaesthesia. 2002;57:277–280.
25.Avramescu S, Arzola C, Tharmaratnam U, Chin KJ, Balki M. Sonoanatomy of the thoracic
spine in adult volunteers. Reg Anesth Pain Med. 2012;37:349–353.
26.Karmakar MK, Ho AM, Li X, Kwok WH, Tsang K, Kee WD. Ultrasound-guided lumbar
plexus block through the acoustic window of the lumbar ultrasound trident. Br J Anaesth.
2008;100:533–537.

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CHAPTER 9

Ultrasound Imaging of Sacrum and Lumbosacral

Junction for Central Neuraxial Blocks

Introduction
Ultrasound imaging of the sacrum1,2 and lumbosacral (L5–S1) interlaminar space3–7 is
frequently performed to identify the sonoanatomy relevant for central neuraxial blocks, that
is, spinal and epidural (lumbar and caudal) injection.1–7 Because the lumbosacral
interlaminar space and sacrum are relatively superficial structures, they lend themselves well
to ultrasound imaging.3–5,7 This chapter briefly outlines the anatomy, technique of ultrasound
imaging, and sonoanatomy of the sacrum and lumbosacral interlaminar space relevant for
central neuraxial blocks.

Basic Anatomy of the Sacrum

The sacrum is a large, triangular bone formed by the fusion of the five sacral vertebrae (Figs.
9-1 and 9-2). It makes up the posterior aspect of the bony pelvis and articulates with the
corresponding hip bones laterally at the sacroiliac junctions. Because it is triangular in shape
it has a base, an apex, and four surfaces (right and left lateral surfaces, dorsal and ventral or
pelvic surface). Anatomically the pelvic surface of the sacrum faces downwards and forward,
whereas the dorsal surface faces backwards and slightly upwards. The sacrum is divided by a
row of foramina on either side of the midline into a median section and a pair of lateral
masses (Fig. 9-1). The median section is traversed by the sacral canal, which contains adipose
tissue, cauda equina nerves (including the filum terminale), epidural space, spinal meninges
(dura and arachnoid), and the thecal sac. The thecal sac ends at the level of the S2 but can
vary from S1 to S3. The sacral canal also contains the epidural venous plexus, which
generally ends at the level of the S4 but may extend more caudally. The lateral masses are
formed by fusion of the transverse processes posteriorly and the costal elements anteriorly.
The base is formed by the superior surface of the body of the S1 vertebra, which is large,
lumbar in type, and articulates with the L5 vertebra at the lumbosacral junction. The vertebral
foramen of the S1 vertebra is triangular in shape and continuous cranially with the lumbar
spinal canal and caudally with the sacral canal. The spine of the S1 vertebra forms the first
spinous tubercle. The apex of the sacrum is formed by the body of the S5 vertebra (inferior
surface) that articulates with the coccyx (Figs. 9-1 and 9-2).

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FIGURE 9-1 The sacrum – ventral or pelvic surface. SAP, superior articular process.

FIGURE 9-2 The sacrum – dorsal surface. SAP, superior articular process.

The pelvic surface of the sacrum (Fig. 9-1), although not visualized during ultrasound
imaging, is concave and directed downwards and forward. Four transverse ridges on the
median area indicate the lines of fusion of the bodies of the four sacral vertebrae (Fig. 9-1).
These transverse ridges connect the four pelvic sacral foramina on either side of the midline
and are continuous with the sacral canal through the intervertebral foramen. The pelvic sacral
foramen decrease in size in a craniocaudal direction consistent with the decrease in size of the
sacral vertebra. In contrast the dorsal surface (Fig. 9-2), which can be visualized using
ultrasound, is convex, irregular in appearance, narrower than the pelvic surface, and directed
backwards and slightly upwards (Fig. 9-2). The median area bears the median sacral crest
with three to four spinous tubercles representing the fused spines of the upper four sacral

402
vertebrae (Fig. 9-2). A ridge joining the articular tubercles forms the intermediate sacral crest.
Four dorsal sacral foramina lie lateral to the intermediate sacral crest (Fig. 9-2) and
communicate with the sacral canal through the intervertebral foramina (Fig. 9-3). The lateral
sacral crest lies lateral to the dorsal sacral foramina. Below the fourth sacral tubercle there is
an inverted U-shaped defect on the posterior aspect of the sacrum: the “sacral hiatus” (Fig. 9-
2). This results from a failure of fusion of the laminae of the fourth and fifth sacral vertebrae.
The inferior articular processes of the fifth sacral vertebra form the sacral cornua and lie
lateral to the sacral hiatus (Fig. 9-2). The sacral hiatus is roofed by a firm elastic membrane,
the sacrococcygeal ligament, which is an extension of the ligamentum flavum. The terminal
end of the filum terminale exits through the sacral hiatus and traverses the dorsal surface of
the S5 vertebra and sacrococcygeal joint to end at the coccyx. The fifth spinal nerve also exits
through the sacral hiatus lying medial to the sacral cornua.

FIGURE 9-3 Sagittal section of the sacrum showing the sacral canal and the sacral
foraminae.

Gross Anatomy of the Sacrum

Fig. 9-4

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FIGURE 9-4 Transverse (upper images) and sagittal (lower images) cadaver anatomic
sections of the sacrum at the level of the sacral hiatus that was rendered from the Visible
Human Server male data set.

Computed Tomography Anatomy of the Sacrum

Figs. 9-5 to 9-7

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FIGURE 9-5 Transverse CT image of the sacrum. Note the sacral canal and the sacroiliac
joints. ESM, erector spinae muscle.

FIGURE 9-6 Median sagittal CT image of the sacrum. Inset image is a transverse CT
section of the sacrum at the level of the sacral hiatus.

FIGURE 9-7 3-D CT reconstruction demonstrating the dorsal surface of the sacrum. Note
the large L5 to S1 interlaminar space, dorsal sacral foramina, and the sacral hiatus.

Magnetic Resonance Imaging Anatomy of the Sacrum

Figs. 9-8 and 9-9

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FIGURE 9-8 Transverse MRI image of the midsection of the sacrum. Note the cauda
equina nerves within the fat-filled sacral canal. SIJ, sacroiliac joint.

FIGURE 9-9 Median sagittal MRI image of the sacrum. The superficial and deep
components of the sacrococcygeal ligament are seen in this image. Inset image is a transverse
MRI section of the sacrum at the level of the sacral hiatus.

Ultrasound Imaging of the Sacrum for Caudal Epidural

Injection – Basic Considerations
406
The caudal epidural space is the continuation of the lumbar epidural space and can be
accessed via the sacral hiatus. Ultrasound imaging of the sacrum and sacral hiatus can be
performed in the transverse or sagittal axis (Fig. 9-10).1,2,5 Because the sacral hiatus is a
superficial structure, it can be imaged using a high-frequency linear transducer (12–5
MHz).1,2,5 Ultrasound imaging of the sacrum for a caudal epidural injection produces a
typical sonographic appearance of the osseous structures that are illustrated in Fig. 9-11.

FIGURE 9-10 Figure illustrating the position of the ultrasound transducer during a (A)
transverse and (B) sagittal scan of the sacrum.

FIGURE 9-11 Sonograms of the sacral hiatus (A, sagittal view and B, transverse view)

407
and lumbosacral interlaminar space (L5–S1 gap, sagittal view) from the water-based spine
phantom. SS, sagittal scan; TS, transverse scan.

Ultrasound Imaging of the Sacrum for Caudal Epidural

Injection
1.Position:
a.Patient: The patient is positioned in the lateral decubitus position for a caudal epidural
injection (Fig. 9-12). When fluoroscopy is used in conjunction with ultrasound for the
caudal epidural injection, as in chronic pain medicine, then the patient may be
positioned in the prone position with a pillow under the abdomen.

FIGURE 9-12 (A) Transverse sonogram of the sacrum at the level of the sacral hiatus that
was acquired with the patient in the (B) lateral position.

b.Operator and ultrasound machine: The operator stands behind the patient, and the
ultrasound machine is placed directly in front of the patient.
2.Transducer selection: High-frequency linear transducer (12–5 MHz).
3.Scanning technique: Ultrasound scan for the sacral hiatus is commenced by placing the
ultrasound transducer at the lower end of the sacrum and over the coccyx. Thereafter the
transducer is gradually moved cranially until the sacral cornua and hiatus are visualized
(Fig. 9-12).
4.Sonoanatomy: The sacral hiatus is covered by the sacrococcygeal ligament. Its lateral
margins are formed by the two sacral cornua. On a transverse sonogram of the sacrum at
the level of the sacral hiatus, the sacral cornua are seen as two hyperechoic reversed U-
shaped structures, one on either side of the midline (Figs. 9-12 and 9-13). Connecting the
two sacral cornua and deep to the skin and subcutaneous tissue is a hyperechoic band, the
sacrococcygeal ligament (Figs. 9-12 and 9-13). Anterior to the sacrococcygeal ligament is
another hyperechoic linear structure, which represents the dorsal surface of the sacrum
(Fig. 9-12). The hypoechoic space between the sacrococcygeal ligament and the bony

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 dorsal surface of the sacrum is the caudal epidural space (Figs. 9-12 and 9-13). The two
sacral cornua and the posterior surface of the sacrum produce a sonographic pattern that
we refer to as the “frog eye sign” because of its resemblance to the eyes of a frog (Figs. 9-
12 and 9-13). If one moves the transducer slightly cephalad to the midsection of the
sacrum, the dorsal surface of the sacrum with the median sacral crest is visualized (Fig. 9-
14). On a sagittal sonogram of the sacrum at the level of the sacral cornua, the
sacrococcygeal ligament, the base of sacrum, and the sacral hiatus are also clearly
visualized (Figs. 9-15 and 9-16). However, due to the acoustic shadow of the posterior
surface of the sacrum, only the lower part of the caudal epidural space is seen (Fig. 9-16).

FIGURE 9-14 Transverse sonogram of the midsection of the sacrum showing the median
sacral crest and the large acoustic shadow of the sacrum.

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FIGURE 9-15 (A) Sagittal sonogram of the sacrum at the level of the sacral hiatus that
was acquired with the patient in the (B) lateral position.

FIGURE 9-16 (A) Sagittal sonogram of the sacrum at the level of the sacral hiatus. Note
the hyperechoic sacrococcygeal ligament that extends from the sacrum to the coccyx and the
acoustic shadow of the sacrum that completely obscures the sacral canal. Inset images in the

410
figure: (B) shows the sacral hiatus from the water-based spine phantom, (C) shows a 3-D
reconstructed image of the sacrum at the level of the sacral hiatus from a 3-D CT data set
from the author’s archive, and (D) shows a sagittal CT slice of the sacrum at the level of the
sacral cornua.

FIGURE 9-13 (A) Transverse sonogram of the sacrum at the level of the sacral hiatus.
Note the two sacral cornua and the hyperechoic sacrococcygeal ligament that extends
between the two sacral cornua. The hypoechoic space between the sacrococcygeal ligament
and the posterior surface of the sacrum is the sacral hiatus. Inset images in the figure: (B)
shows the sacral cornua from the water-based spine phantom, (C) shows a 3-D reconstructed
image of the sacrum at the level of the sacral hiatus from a 3-D CT data set from the author’s
archive, and (D) shows a transverse CT slice of the sacrum at the level of the sacral cornua.

Clinical Pearls
1.There is marked variability in the anatomy of the sacral hiatus.
2.Age-related changes in the sacral hiatus (ie, thickening and calcification of the
sacrococcygeal ligament and cornua) can lead to significant narrowing of the hiatus.
3.Avoid advancing the epidural needle too deep into the caudal epidural space during an
ultrasound-guided caudal epidural injection because the acoustic shadow of the sacrum
obscures ultrasound visualization of the needle tip and injectate. Therefore, unintentional
intravascular injection may be missed.
4.Color Doppler ultrasound should be used to confirm correct position of the needle tip and
injection into the caudal epidural space.8

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Basic Anatomy of the Lumbosacral Interlaminar Space
The lumbosacral (L5–S1) interlaminar space, also referred to as the L5 to S1 gap,5,7 is the
intervertebral space between the lamina of L5 and S1 vertebrae (Fig. 9-17). It is one of the
routes (paramedian approach) for needle insertion during central neuraxial blocks (CNBs,
spinal and epidural injection), and spinal injections via the L5 to S1 interlaminar space
originally described by Taylor in 1940.9 However, a review of the literature indicates that
CNBs are most frequently performed via the L3 to L4 or L4 to L5 intervertebral space and
rarely via the L5 to S1 interlaminar space. The exact reason for this practice is not known,
although the interlaminar space at the L5 to S1 is wider than that at the other lumbar
intervertebral levels.10 This may be due to a poor understanding of the anatomy of the L5 to
S1 interlaminar space or a lack of data comparing CNBs via the L3 to L4 or L4 to L5 and L5
to S1 intervertebral spaces. However, with recent improvements in our understanding of the
sonoanatomy of the spine,3,7 there are several reports on the use of ultrasound for CNB via
the L5 to S1 interlaminar space in patients with difficult spine (eg, scoliosis, instrumented or
operated backs).11,12 Ultrasound has also been successfully used to accurately locate the
lumbar intervertebral (L3–L4 or L4–L5) space during CNB.6,7,13 This method relies on
identifying the L5 to S1 interlaminar space or the L5 to S1 gap in a paramedian sagittal scan
and then sliding the transducer cephalad to locate the lamina of the L3, L4, and L5
vertebrae3,6,7,13 and thereby the L4 to L5 and L3 to L4 intervertebral spaces.3,6,7,13

FIGURE 9-17 The lumbosacral spine – dorsal view. IAP, inferior articular process; SAP,
superior articular process.

There are certain peculiarities in the anatomy of the L5 to S1 interlaminar space that
deserve attention as a route for CNB. As described earlier, the L5 to S1 interlaminar space is
wider than the interlaminar spaces at the L4 to L5 and L3 to L4 intervertebral levels.10 Also,
because the dorsal surface of the sacrum is directed backwards and slightly upwards in vivo

412
(Figs. 9-7, 9-18, and 9-19), the L5 to S1 interlaminar space may be closer to the skin than the
L4 to L5 intervertebral space. At the L5 to S1 intervertebral level, the ligamentum flavum is
also relatively thinner, there is a lack of posterior epidural fat,14 and there is a greater amount
of epidural fat in the midline superficial (external) to the epidural space,14 when compared to
that at the other lumbar intervertebral spaces.

FIGURE 9-18 Cadaver anatomic section showing the lumbosacral interlaminar space (L5–
S1 gap) in the (A) transverse, (B) median (sagittal), and (C) paramedian sagittal axis. IVD,
intervertebral disc; ILS, interlaminar space; ITS, intrathecal space; CE, cauda equina.

413
FIGURE 9-19 Sagittal cadaver anatomic section of the lumbosacral spine, through the
laminae of L4 and L5 vertebrae and the L5 to S1 interlaminar space that was rendered from
the Visible Human Server male data set. The lamina and dorsal surface of the sacrum are
highlighted in green. Also note how the dorsal surface of the sacrum is directed backwards
and slightly upwards. ESM, erector spinae muscle; IVD, intervertebral disc; VB, vertebral
body.

Gross Anatomy of the Lumbosacral Interlaminar Space

Figs. 9-18 and 9-19

Computed Tomography Anatomy of the Lumbosacral Interlaminar Space

Figs. 9-20 to 9-22

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FIGURE 9-20 Transverse CT image of the lumbosacral intervertebral space (junction).
VB, vertebral body; ESM, erector spinae muscle.

FIGURE 9-21 Median sagittal CT image of the lumbosacral intervertebral space. ESM,
erector spinae muscle.

415
FIGURE 9-22 Paramedian sagittal CT image of the lumbosacral interlaminar space (L5–
S1 gap). VB, vertebral body.

Magnetic Resonance Imaging Anatomy of the Lumbosacral Interlaminar Space

Figs. 9-23 to 9-25

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FIGURE 9-23 Transverse MRI image of the lumbosacral interverebral space. VB,
vertebral body.

FIGURE 9-24 Median sagittal MRI image of the lumbosacral spine. Note the tapered
thecal sac and its termination at the level of S1 in this subject. Also note the cauda equina
nerves within the thecal sac. ITS, intrathecal sac. SP, spinous process.

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FIGURE 9-25 Paramedian sagittal MRI image of the lumbosacral spine illustrating the
laminae of L4 and L5 and the lumbosacral interlaminar space (L5–S1 gap). ITS, intrathecal
space. VB, vertebral body.

Ultrasound Imaging of the Lumbosacral Interlaminar

Space
1.Position:
a.Patient: The L5 to S1 interlaminar space is imaged with the patient in the lateral
decubitus position (Fig. 9-26), but it can also be imaged with the patient in the prone
position.

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FIGURE 9-26 Transverse sonogram illustrating the transverse interspinous view of the L5
to S1 intervertebral space. ITS, intrathecal space; VB, vertebral body.

b.Operator and ultrasound machine: The operator stands behind the patient, and the
ultrasound machine is placed directly in front of the patient.
2.Transducer selection: Because the L5 to S1 interlaminar space is relatively superficial, it
can be imaged using a high-frequency linear transducer (12–5 MHz). However, because
the L5 to S1 interlaminar space is imaged as part of a “scan routine” during spinal
sonography for CNB, a low-frequency (5–2 MHz) curvilinear transducer is most
frequently used.
3.Scanning technique: For a transverse scan the ultrasound transducer is placed over the
midsection of the sacrum (Fig. 9-26). Once the sacrum with the median sacral crest (Fig.
9-14) is visualized, the transducer is slowly moved in a cephalad direction until the
acoustic shadow of the dorsal surface of the sacrum disappears and the spinal canal with
the thecal sac, posterior surface of the L5 vertebral body (anterior complex), and the
articular process of L5 (laterally) at the L5 to S1 intervertebral space are clearly
visualized (Figs. 9-26 and 9-27).

FIGURE 9-27 Transverse sonogram (zoomed view) illustrating the transverse interspinous
view of the L5 to S1 intervertebral space. Note the posterior epidural space and cauda equina
nerves are visible in this image. ESM, erector spinae muscle.

For a sagittal scan the ultrasound transducer is placed over the sacrum in the sagittal
orientation (Fig. 9-28) and then slowly moved in a cranial direction until the L5 to S1
interlaminar space is visualized (Figs. 9-28 and 9-29). During image optimization it may
be necessary to tilt the transducer slightly medially to produce a paramedian sagittal
oblique scan (Fig. 9-28).

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FIGURE 9-28 (A) Paramedian sagittal oblique ultrasound scan of the lumbosacral
interlaminar space (L5–S1 gap) (B) with the patient in the lateral position. Note the slight
oblique tilt in the ultrasound transducer in the inset image.

FIGURE 9-29 Correlative image of the lumbosacral interlaminar space (L5–S1 gap)
anatomy. (A) sagittal sonogram from the water-based spine phantom, (B) sagittal sonogram
in vivo, and (C) cadaver anatomical section. ESM, erector spinae muscle; PD, posterior dura;
CE, cauda equina; ITS, intrathecal space.

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 4.Sonoanatomy: On a transverse sonogram of the L5 to S1 intervertebral space the thecal
sac is seen as a round-to-oval anechoic structure within the spinal canal (Figs. 9-26 and 9-
27). The anterior complex of the posterior surface of the L5 vertebral body produces a
hyperechoic shadow anterior to the thecal sac (Figs. 9-26 and 9-27). The ligamentum
flavum with the posterior epidural space may also be seen in some individuals (Fig. 9-27).
The cauda equina nerves appear as small hyperechoic shadows within the thecal sac (Fig.
9-27). The articular processes are seen laterally (Figs. 9-27 and 9-28). If one now slowly
slides the transducer in a cephalad direction, one can easily recognize the transition of the
anatomy from the L5 to S1 intervertebral space to the spinous process of L5, the L4 to L5
intervertebral space, L4 spinous process, and the L3 to L4 intervertebral space,
respectively (Figs. 9-30 to 9-32). The transverse scan sequence described earlier is rarely
used to identify a given lumbar intervertebral space, but it may be used.

FIGURE 9-30 A sequence of transverse sonogram (same subject) from (A) midsection of
sacrum, (B) lumbosacral (L5–S1) intervertebral space, (C) L5 spinous process, (D) L4 to L5
intervertebral space, (E) L4 spinous process, and (F) L3 to L4 intervertebral space. MSC,
median sacral crest; SIJ, sacroiiac joint; TP, transverse process; AP, articular process; ITS,
intrathecal sac; SP, spinous process; FJ, facet joint; AC, anterior complex; ES, erector spinae
muscle.

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FIGURE 9-31 A sequence of transverse CT images of the lumbosacral spine (same
subject) from (A) midsection of sacrum, (B) lumbosacral (L5–S1) intervertebral space, (C)
L5 spinous process, (D) L4 to L5 intervertebral space, (E) L4 spinous process, and (F) L3 to
L4 intervertebral space. ESM, erector spinae muscle; MSC, median sacral crest; SIJ,
sacroiliac joint; AP, articular process; SP, spinous process; FJ, facet joint.

FIGURE 9-32 A sequence of transverse MRI images of the lumbosacral spine (same
subject) from (A) midsection of sacrum, (B) lumbosacral (L5–S1) intervertebral space, (C)
L5 spinous process, (D) L4 to L5 intervertebral space, (E) L4 spinous process, and (F) L3 to
L4 intervertebral space. ESM, erector spinae muscle; MSC, median sacral crest; SIJ,
sacroiliac joint; AP, articular process; SP, spinous process; FJ, facet joint; LF, ligamentum
flavum; TP, transverse process.

On a paramedian sagittal sonogram (Figs. 9-33 and 9-34) the dorsal surface of the sacrum
appears as a linear hyperechoic structure with a large acoustic shadow anteriorly (Fig. 9-

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 33). The osseous structure visualized immediately cranial to the sacrum is the lamina
(horse-head appearance) of the L5 vertebra, and the intervening gap is the L5 to S1
interlaminar space (Figs. 9-33 and 9-34). One must not confuse this with a median sagittal
scan through the L5 to S1 intervertebral space when the spinous processes of the L5 and
S1 are visualized (Fig. 9-35). At the L5 to S1 interlaminar space and within the acoustic
window, the following structures are visualized in a posterior-to-anterior direction:
erector spinae muscle, ligamentum flavum, posterior epidural space, posterior dura, thecal
sac, and the anterior complex, respectively (Figs. 9-33 and 9-34). Occasionally the
tapered distal end of the thecal sac can be seen. The cauda equina nerves may also be seen
as hyperechoic streaks within the anechoic cerebrospinal fluid–filled thecal sac (Fig. 9-
33).

FIGURE 9-33 Paramedian sagittal oblique sonogram of the lumbosacral (L5–S1)

interlaminar space. Note the wide interlaminar space, and correspondingly, the wide acoustic
window for ultrasound imaging at this level. The posterior surface of the sacrum is identified
as a flat hyperechoeic structure with a large acoustic shadow anterior to it. The dip or gap
between the sacrum and the lamina of L5 is the L5 to S1 intervertebral space or the L5 to S1
gap. ESM, erector spinae muscle.

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FIGURE 9-34 Correlative images (A) paramedian sagittal oblique sonogram and (B)
sagittal MRI of the lumbosacral interlaminar space (L5–S1 gap).

FIGURE 9-35 Median sagittal sonogram of the lumbosacral interlaminar (L5–S1 gap)
space. ESM, erector spinae muscle.

Clinical Pearls
1.Identification of a given lumbar intervertebral space using anatomical landmark (intercristal
or Tuffier’s line) is imprecise15 and often results in identification of an intervertebral
space one or two spinal levels higher.16,17
2.Cumulative evidence suggests that ultrasound is more accurate than anatomical landmarks

424
 in locating a given lumbar intervertebral space.13
3.To identify a given lumbar intervertebral space using ultrasound, one has to rely on
locating the L5 to S1 interlaminar space on a paramedian sagittal scan (described earlier).
Therefore, inaccuracies can result in individuals with lumbosacral transitional vertebra,
that is, lumbarized S1 (Figs. 9-36 and 9-37) or sacralized L5 (Figs. 9-38 and 9-39) that is
present in 4% to 21% of individuals.18

FIGURE 9-36 Lumbosacral transitional vertebra I: Lumbarization of the S1 vertebra is

seen on the plain radiographs (anteroposterior and lateral views).

FIGURE 9-37 Lumbosacral transitional vertebra II: Lumbarization of the S1 vertebra is

seen on the CT scan images (sagittal and 3-D reconstructed views).

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FIGURE 9-38 Lumbosacral transitional vertebra III: Sacralization of the L5 vertebra is
seen on the plain radiographs (anteroposterior and lateral views).

FIGURE 9-39 Lumbosacral transitional vertebra IV: Sacralization of the L5 vertebra is

seen on the CT scan images (sagittal and 3-D reconstructed views).

4.The anatomy of the L5 to S1 intervertebral space is rarely altered during spinal

instrumentation or scoliosis (particularly idiopathic scoliosis) surgery. Therefore, it
should be considered as a route for CNB in such patients.
5.Dry taps are common during spinal access through the L5 to S1 interlaminar space. This is
particularly true when the spinal puncture is performed with the patient in the lateral
decubitus position and the spinal needle is inserted from the nondependent side (personal
experience).

426
References
1.Chen CP, Tang SF, Hsu TC, et al. Ultrasound guidance in caudal epidural needle
placement. Anesthesiology. 2004;101:181–184.
2.Chen CP, Wong AM, Hsu CC, et al. Ultrasound as a screening tool for proceeding with
caudal epidural injections. Arch Phys Med Rehabil. 2010;91:358–363.
3.Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult thoracic and lumbar spine
for central neuraxial blockade. Anesthesiology. 2011;114:1459–1485.
4.Karmakar MK. Ultrasound for central neuraxial blocks. Tech Reg Anesth Pain Manag.
2009;13:161–170.
5.Karmakar MK. Ultrasound guided central neuraxial blocks. In: Narouze S, ed. Atlas of
Ultrasound Guided Procedures in Interventional Pain Management. New York:
Springer; 2010.
6.Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time ultrasound-guided
paramedian epidural access: evaluation of a novel in-plane technique. Br J Anaesth.
2009;102:845–854.
7.Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD. Sonoanatomy relevant for
ultrasound-guided central neuraxial blocks via the paramedian approach in the lumbar
region. Br J Radiol. 2012;85:e262–e269.
8.Yoon JS, Sim KH, Kim SJ, Kim WS, Koh SB, Kim BJ. The feasibility of color doppler
ultrasonography for caudal epidural steroid injection. Pain. 2005;118:210–214.
9.Taylor JA. Lumbosacral subarachnoid tap. J Urology. 1940;43:561–564.
10.Ebraheim NA, Miller RM, Xu R, Yeasting RA. The location of the intervertebral lumbar
disc on the posterior aspect of the spine. Surg Neurol. 1997;48:232–236.
11.Costello JF, Balki M. Cesarean delivery under ultrasound-guided spinal anesthesia
[corrected] in a parturient with poliomyelitis and harrington instrumentation. Can J
Anaesth. 2008;55:606–611.
12.Yamauchi M, Honma E, Mimura M, Yamamoto H, Takahashi E, Namiki A. Identification
of the lumbar intervertebral level using ultrasound imaging in a post-laminectomy
patient. J Anesth. 2006;20:231–233.
13.Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound imaging for identification of
lumbar intervertebral level. Anaesthesia. 2002;57:277–280.
14.Hameed F, Hunter DJ, Rainville J, Li L, Suri P. Prevalence of anatomic impediments to
interlaminar lumbar epidural steroid injection. Arch Phys Med Rehabil. 2012;93:339–
343.
15.Broadbent CR, Maxwell WB, Ferrie R, Wilson DJ, Gawne-Cain M, Russell R. Ability of
anaesthetists to identify a marked lumbar interspace. Anaesthesia. 2000;55:1122–1126.
16.Whitty R, Moore M, Macarthur A. Identification of the lumbar interspinous spaces:
Palpation versus ultrasound. Anesth Analg. 2008;106:538–540, table.
17.Pysyk CL, Persaud D, Bryson GL, Lui A. Ultrasound assessment of the vertebral level of
the palpated intercristal (Tuffier’s) line. Can J Anaesth. 2010;57:46–49.
18.Hughes RJ, Saifuddin A. Imaging of lumbosacral transitional vertebrae. Clin Radiol.
2004;59:984–991.

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CHAPTER 10

Sonoanatomy Relevant for Thoracic Interfascial Nerve

Blocks: Pectoral Nerve Block and Serratus Plane Block

Introduction
Blanco and colleagues1–3 have recently described novel ultrasound-guided thoracic
interfascial nerve blocks, the pectoral nerve block (PECS)1,2 and serratus plane block (SPB),3
for anesthesia and/or analgesia of the anterior/anterolateral chest wall.1–4 The SPB may also
anesthetize the axilla via blockade of the intercostobrachial nerve.3 These blocks were
originally developed for breast surgery in an attempt to avoid some of the rare but serious
complications of thoracic paravertebral and neuraxial blocks. During a PECS-I block, the
local anesthetic (0.4 mL/kg or approximately 20–30 ml)1 is injected as a single injection into
the myofascial plane between the pectoralis major and minor muscle, aiming to block the
medial and lateral pectoral nerves.1 PECS-II block is a modification of the PECS-I block
(modified PECS-I block) and involves two injections.2 The first injection is the same as that
for a PECS-I block (but with 10 mL of local anesthetic),2 but the second injection is
performed deep to the pectoralis minor muscle, at the level of the third and fourth rib, into the
interfascial plane between the pectoralis minor and serratus anterior muscle (with 20 mL of
local anesthetic).2 The aim of the PECS-II block is to anesthetize the pectoral nerves,
intercostobrachial nerve, third to sixth intercostal nerves, and the long thoracic nerve.2,4 The
PECS-II block is therefore used for more extensive breast surgery, including mastectomy
with or without axillary clearance.2 The SPB3 is a more recent addition to the family of
thoracic interfascial nerve blocks and involves a single injection of 0.4 mL/kg of local
anesthetic into the myofascial plane between the latissimus dorsi and the serratus anterior
muscle more posteriorly and at the level of the fifth rib.3 Local anesthetic spreads in the
serratus plane, deep to the latissimus dorsi, and along the lateral chest wall to affect the lateral
cutaneous branches of the second to ninth intercostal nerves and possibly the long thoracic
and thoracodorsal nerves.3,4 A clear understanding of the sonoanatomy of the thoracic wall is
a prerequisite to effectively using a PECS or SPB. The following section describes the gross
anatomy, ultrasound scan technique, and sonoanatomy of the thoracic wall relevant for the
thoracic interfascial nerve blocks. Because these blocks are frequently used for breast
surgery, a brief description of the innervation of the breast is also included.

Gross Anatomy
1.Muscles: Muscles involved with thoracic interfascial nerve blocks are pectoralis major,
pectoralis minor, serratus anterior, intercostal muscles, and the latissimus dorsi.

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 a.Pectoralis major: The pectoralis major muscle is a triangular, fan-shaped muscle that
makes up the bulk of the anterior chest wall (Figs. 10-1 and 10-2). It has two parts:
the clavicular head and the sternocostal head (Fig. 10-1). The clavicular head
originates from the medial half of the clavicle, and the sternocostal head arises from
the anterior surface of the lateral margin of the sternum, the first seven costal
cartilages, and aponeurosis of the external oblique muscle. Muscle fibers from the two
heads converge laterally to form a flat tendon that is inserted into the lateral lip of the
bicipital groove (intertubercular sulcus) of the humerus. It also forms the anterior fold
of the axilla. The pectoralis major muscle receives its innervation from the lateral and
medial pectoral nerves of the brachial plexus. The clavicular head is innervated by the
lateral pectoral nerve, and the sternocostal head is innervated by both the lateral and
medial pectoral nerve. It is involved with flexion, adduction, and medial rotation of
the humerus; depression of the arm and shoulder; and elevation of the ribs.

FIGURE 10-1 Figure showing the anatomy of the anterior chest wall and arrangement of
the lateral and medial mammary branches of the lateral cutaneous and anterior cutaneous
branches of the intercostal nerve (ICN), respectively.

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FIGURE 10-2 Figure showing the anatomical arrangement of the pectoralis major,
serratus anterior, and latissimus dorsi muscles.

b.Pectoralis minor: The pectoralis minor muscle is a thin, triangular-shaped muscle

located deep to the pectoralis major muscle (Figs. 10-3 to 10-5). It is significantly
smaller in size than the pectoralis major muscle and originates from the outer surface
of the third to fifth ribs (Fig. 10-4). The muscle fibers converge superolaterally to
form a flat tendon that is attached to the coracoid process of the scapula (Fig. 10-4). It
also forms part of the anterior wall of the axilla. The pectoralis minor also receives its
innervation from the lateral and medial pectoral nerves of the brachial plexus. It is
involved with depression of the elevated shoulder, and along with the serratus anterior
muscles, pulls the scapula forward.

FIGURE 10-3 Figure showing the anatomical arrangement of the pectoral nerves and their

430
relation to the pectoralis major (cutout view) and minor muscles, thoracoacromial artery and
its branches, the chest wall, and breast in a female. Note the medial mammary branches of the
anterior cutaneous branch of the intercostal nerve (ICN) on the anteromedial aspect of the
breast.

FIGURE 10-4 Figure showing the pectoral nerves and their relation to the pectoral
muscles (cutout view of the pectoralis major muscle), thoracoacromial artery, and its pectoral
branch.

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FIGURE 10-5 Figure showing the sagittal anatomy of the right axilla. Note the relation of
the pectoral nerves and ansa pectoralis to the thoracoacromial artery and pectoral muscles.
Also note the attachment of the clavipectoral fascia and suspensory (Gerdy’s) ligament of the
axilla.

c.Serratus anterior: The serratus anterior muscle covers most of the lateral thoracic wall
(Fig. 10-2) and originates as 9 to 10 muscular slips from the external surface of the
first to eighth or ninth ribs (Fig. 10-2). Because two slips originate from the second
rib, the number of slips is usually greater than the number of ribs from which they
arise. The muscle fibers converge posteriorly to be inserted into the medial border of
the scapula. It contributes to forming the medial wall of the axilla. It is also called the
“boxer’s muscle” because it causes protraction of the scapula around the rib cage—a
movement that occurs when throwing a punch. It is also involved with upward
rotation of the scapula that occurs while lifting a load overhead. The serratus anterior
muscle is innervated by the long thoracic nerve, which travels caudally on the outer
surface of the muscle. Injury to the long thoracic nerve can lead to a “winged
scapula.”
d.Latissimus dorsi: The latissimus dorsi muscle is a large, flat muscle located on the
dorsum of the trunk. It originates from the spinous processes of the last six thoracic
vertebra (T7–T12), the thoracolumbar fascia, and the posterior third of the external lip
of the iliac crest. The muscle fibers converge cranially to form a flattened tendon that
is inserted into the floor of the bicipital (intertubercular) groove anterior to the
attachment of the teres major muscle. It is involved with adduction, extension, and
internal rotation of the arm at the shoulder and innervated by the thoracodorsal nerve.
The thoracodorsal artery descends inferiorly with the thoracodorsal nerve and supplies
the latissimus dorsi muscle.
e.Teres major: The teres major muscle is a rounded muscle that is attached between the
scapula and humerus. It originates from the posterior surface of the inferior angle and
lower part of the lateral border of the scapula. The fibers converge laterally to a flat

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 tendon that is inserted into the medial lip of the bicipital groove. The teres major is
located superior to the latissimus dorsi, and the muscle fibers run parallel to each
other to its insertion in the humerus. It is innervated by the lower subscapular and
thoracodorsal nerves, which are branches of the posterior cord of the brachial plexus,
and receives spinal contributions from the C5 to C8 spinal nerves. It is involved with
extension and medial rotation of the humerus.
2.Nerves: The nerves involved with thoracic interfascial nerve blocks are intercostal nerves,
pectoral nerves, long thoracic nerve, and thoracodorsal nerve.
a.Intercostal nerve: The intercostal nerves are the anterior primary rami of the spinal
nerves T1 to T11. The anterior primary rami of the 12th spinal nerve form the
subcostal nerve. The first and second intercostal nerve, in addition to supplying the
intercostal spaces, provide innervation to the upper limb. The lower five intercostal
nerves (T7–T11) also supply the abdominal wall and are therefore called the
thoracoabdominal nerves. The intercostal nerves. T3 to T6 are typical intercostal
nerves because they only supply the thoracic wall. The anterior division of the first
thoracic spinal nerve divides into two branches: a larger branch that exits the thorax
close to the neck of the first rib, and a smaller branch, the first intercostal nerve, that
runs through the intercostal space and ends close to the sternum as the anterior
cutaneous branch of T1. The first intercostal nerve also receives a small
communication from the second intercostal nerve posteriorly along the neck of the
rib. This is the “nerve of Kuntz,” which is present in 40% to 80% of individuals.
Each typical intercostal nerve (Fig. 10-6) passes below the neck of the rib (with the
same number) to enter the costal groove. At the posterior part of the costal groove, the
intercostal nerve lies between the parietal pleura (with the endothoracic fascia) and the
internal intercostal membrane (Fig. 10-6). Otherwise, throughout its course through
the intercostal space, the intercostal nerve lies between the innermost intercostal and
the internal intercostal muscle (Figs. 10-6 and 10-7). The lateral cutaneous branch
pierces the intercostal and serratus anterior muscle complex at the level of the
midaxillary line and gives off its anterior and posterior branches (Figs. 10-6, 10-8, and
10-9). The anterior branch (T2–T6) courses forward and supplies the skin on the
lateral and anterior aspect of the chest wall (Figs. 10-1, 10-6, and 10-9). In females
they form the lateral mammary branches of the intercostal nerve (same number) and
supply the breast (Figs. 10-6 and 10-10). The posterior branch courses backwards and
supplies the skin over the scapula and the latissimus dorsi muscle. The anterior
cutaneous branch of the intercostal nerve (ie, the main intercostal nerve) courses
forward through the intercostal space and emerges close to the sternum by crossing
anterior to the internal thoracic (mammary) artery (Fig. 10-6). It then pierces the
internal intercostal muscle, the external intercostal membrane, and the pectoralis major
muscle to terminate as the anterior cutaneous nerve of the thorax and innervate the
overlying skin after dividing into its medial and lateral branches (Fig. 10-6). The
lateral branch supplies the medial and anterior aspect of the chest wall and in females
the medial and anterior aspect of the breast and thus is referred to as the medial
mammary nerves (T2–T6) (Figs. 10-3, 10-6, and 10-10). The intercostobrachial nerve,
which corresponds to the lateral cutaneous branch of the second intercostal nerve (T2),
emerges from the intercostal space and runs oblique towards the arm to supply the
axilla and upper part of the medial aspect of the arm (Figs. 10-3, 10-8, and 10-10). The
intercostobrachial nerve may also receive contributions from the first, third, and fourth
intercostal nerves.5

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FIGURE 10-6 Transverse section of the thorax showing a typical intercostal nerve and its
relation to the intercostal and pectoral muscles. Note the formation of the medial and lateral
mammary nerves from the intercostal nerve (ICN).

FIGURE 10-7 Figure showing the anatomy of the intercostal space.

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FIGURE 10-8 Figure showing the emergence of the lateral cutaneous branch of the
intercostal nerve (lateral cutaneous nerve of the thorax) and its branching along the lateral
chest wall. Note the formation of the intercostobrachial nerve from the second intercostal
nerve.

FIGURE 10-9 Figure showing the innervation of the trunk and abdominal wall. Note the
anatomical arrangement of the typical intercostal nerves (T3–T6) and the areas innervated by
their lateral and anterior cutaneous branches. In females, the anterior branch of the lateral

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cutaneous branch of the intercostal nerve (T2–T7) form the lateral mammary nerve, and the
medial branch of the anterior cutaneous branch of the intercostal nerve (T1–T6) form the
medial mammary nerve.

FIGURE 10-10 Sensory innervation of the female breast – lateral (T2–T7) and medial
(T1–T6) mammary nerves and supraclavicular nerve (medial and intermediate). The axilla is
innervated by the intercostobrachial nerve. Also note the course of the long thoracic and
thoracodorsal nerve along the lateral chest wall. ICN, intercostal nerve.

b. Pectoral nerves: The pectoral nerves are frequently described as “pure motor nerves,”
but there is growing evidence that they are also involved with afferent nociception6
and proprioception, similar to that with other pure motor nerves.7 Afferent
nociception may be transferred by the pectoral nerves from the acromioclavicular
joint, coracoclavicular ligaments, subacromial bursa, articular capsule of the shoulder
joint, periosteum of the clavicle, and pectoral muscles, and via cutaneous branches
they may innervate the anterior chest wall and anterior margin of the deltoid muscle.6
The pectoral nerves are also traditionally described as two nerves, the medial and
lateral pectoral nerves, with the lateral pectoral nerve (LPN) being larger than the
medial pectoral nerve (MPN).8,9 The ansa pectoralis is a loop of communication
between the LPN and MPN (Figs. 10-3 and 10-4). Published data suggest that the LPN
most frequently arises from the anterior divisions of the upper and middle trunk
(33.8%), but it may also arise from the lateral cord (23.4%), of the brachial plexus.6
The MPN also has a variable origin and may arise from the medial cord (49.3%) or
anterior division of the lower trunk (43.8%) or lower trunk (4.7%).6 Spinal
contribution to the LPN and MPN also varies.10 Two types of spinal origin of the LPN
(C5–C7 in 50% and C6 and C7 in 50%) and three types of spinal origin of the MPN
(C8 and T1 in 73,3%, C8 in 23.4%, and T1 in 3.3%) have been described.10 After its
origin the LPN crosses anterior to the axillary vessels, pierces the clavipectoral fascia,
and supplies the pectoralis major muscle (Fig. 10-5).6,8 The LPN also shares a
constant course with the thoracoacromial vessels and lies on the deep surface of the
pectoralis major, beneath the muscle fascia, with the pectoral branch of the
thoracoacromial artery (TAA) (Figs. 10-3, 10-4, and 10-11).6,8,11 After its origin, the
MPN courses downwards lying anterior to the axillary artery and deep to the pectoralis

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 minor muscle (Figs. 10-3, 10-4, and 10-11).8,11 It then pierces the pectoralis minor
muscle from beneath at about the midclavicular line and over the third intercostal
space.8 A few branches of the MPN may also loop around the inferior border of the
pectoralis minor muscle to enter the pectoralis major.8

FIGURE 10-11 Figure showing the anatomical structures that are relevant for thoracic
interfascial nerve blocks at the medial infraclavicular fossa (ie, between the inferior border of
the clavicle and the medial border of the pectoralis minor muscle). Note how the cephalic
vein arches over the cords of the brachial plexus and axillary artery from a lateral-to-medial
direction to join the axillary vein. Also note the relations of the superior, medial, and inferior
branches of the pectoral nerve to the axillary artery, the thoracoacromial artery, and pectoralis
minor muscle.

The pectoral nerves may also be present as three constant branches (Figs. 10-3, 10-
4, and 10-11),10–12 that is, a superior branch that supplies the clavicular fibers of the
pectoralis major, the middle branch that courses on the undersurface of the pectoralis
major muscle (beneath its fascia) with the pectoral branch of the TAA to innervate the
sternal part of the pectoralis major muscle, and the inferior branch that passes under
the pectoralis minor muscle to innervate it and the costal part of the pectoralis major
muscle.11 Given the variable spinal origin and formation of the pectoral nerves, a
“subpectoral plexus”10 (Fig. 10-12) of nerves with the C5–T1 nerve roots, the two
pectoral nerves, and the three terminal branches has been described.10,12 With this
arrangement the superior and middle branches are divisions of the LPN, and the
inferior branch is formed by fusion of the MPN and ansa pectoralis from the C7 (Figs.
10-11 and 10-12).10,12

437
FIGURE 10-12 Schematic diagram showing the formation of the “subpectoral plexus”10
of nerves with both the medial and lateral pectoral nerve and the three terminal branches (ie,
the superior, middle, and inferior branches). The superior and middle branches are derived
from the lateral pectoral nerve, and the inferior branch is derived from the ansa pectoralis (C7
spinal nerve root) and medial pectoral nerve.

c.Long thoracic nerve: The long thoracic nerve, also known as the Bell’s nerve,
originates from the ventral rami of the C5, C6, and C7 and descends to the lateral
thoracic wall (Fig. 10-9) where it innervates the serratus anterior muscle.
d.Thoracodorsal nerve: The thoracodorsal nerve originates from the posterior cord of the
brachial plexus with spinal contributions from the C6 to C8. As it descends along the
posterior wall of the axilla, it is accompanied by the thoracodorsal artery and
innervates the latissimus dorsi muscle.
3.Blood vessels: The following blood vessels are of interest while performing thoracic
interfascial nerve blocks: axillary, thoracoacromial, and thoracodorsal artery.
a.Axillary artery: The axillary artery is a continuation of the subclavian artery into the
axilla. It begins at the lateral border of the first rib and ends at the lower border of the
teres major muscle after which it continues distally as the brachial artery. It has three
parts: the first part lies between the lateral border of the first rib and the medial border
of the pectoralis minor muscle and gives off the superior thoracic artery; the second
part lies deep to the pectoralis minor muscle and gives off the lateral thoracic and
TAA; the third part lies between the lateral border of the pectoralis minor muscle and
the lower border of the teres major muscle and gives off three branches: the
subscapular artery, the anterior circumflex humeral artery, and the posterior
circumflex humeral artery.
b.Thoracoacromial artery: The TAA, after its origin (Figs. 10-3 and 10-4), runs a short
course along the upper margin of the pectoralis minor muscle, penetrates the
clavipectoral fascia (Fig. 10-5), and divides into its terminal branches: the clavicular,

438
 acromial, deltoid, and pectoral branches. The TAA is important for a PECS block
because, as described earlier, the pectoral nerves and the ansa pectoralis have a
constant relationship with the artery (Fig. 10-11).8,9 The LPN also runs parallel to the
pectoral branch of the TAA in the myofascial plane between the pectoralis major and
minor muscles (Figs. 10-4 and 10-11), lying deep to the muscle fascia.8,9 The ansa
pectoralis nerve is also formed immediately distal to the origin of the TAA (Fig. 10-
4).6
c.Thoracodorsal artery: The thoracodorsal artery (Fig. 10-3) is a branch of the
subscapular artery and travels inferiorly along the lateral chest wall (Fig. 10-3), lying
deep to the latissimus dorsi muscle initially and then on the external surface of the
serratus anterior muscle. It is accompanied by the thoracodorsal nerve (Fig. 10-3) and
supplies the latissimus dorsi.
4.Fascia
a.Clavipectoral fascia: This is a fascial layer that is interposed between the clavicle and
upper border of the pectoralis minor muscle (Fig. 10-5). The portion of the
clavipectoral fascia that is attached between the first costosternal articulation and the
coracoid process is usually denser than the rest and is referred to as the “costocoracoid
ligament.” Inferiorly it is thin, and at the upper border of the pectoralis minor muscle
it splits to invest the muscle (Fig. 10-5). Below the inferior border of the pectoralis
minor muscle the clavipectoral fascia continues downwards as a single layer, the
suspensory ligament of axilla, or Gerdy’s ligament, and attaches to the axillary fascia
(Fig. 10-5). The clavipectoral fascia is pierced by the cephalic vein, lateral pectoral
nerve, TAA, and lymphatics (Fig. 10-5).

Innervation of the Breast

The sensory and glandular innervation of the female breast comes from multiple sources.
Medially it is innervated by the anterior cutaneous branches (medial mammary nerves) of the
first to sixth intercostal nerves (Figs. 10-6 and 10-13) and laterally by the lateral cutaneous
branches (lateral mammary nerves) of the second to seventh intercostal nerves (Fig. 10-10).13
The nipple–areola complex is supplied mainly by the anterior and lateral cutaneous branches
of the fourth intercostal nerve (Fig. 10-13), with additional contributions from the cutaneous
branches of the third and fifth intercostal nerves.13 The skin of the superior part of the breast
(infraclavicular region) receives innervation from the superficial cervical plexus via the
medial and intermediate supraclavicular nerves (C3 and C4, Figs. 10-10 and 10-14). The
lateral supraclavicular nerve mainly provides sensory supply to the upper and posterior aspect
of the shoulder, but may also contribute to sensory innervation of the breast (Fig. 10-14).
Sympathetic nerves reach the breast via the somatic nerves (described earlier) and blood
vessels. There is no parasympathetic nerve supply to the breast. When breast surgery involves
the axilla (eg, axillary dissection) and pectoral muscles (eg, modified radical mastectomy),
the intercostobrachial and pectoral nerves (LPN and MPN) may also be involved in afferent
nociception (discussed earlier).

439
FIGURE 10-13 Figure showing the arrangement of the lateral and medial mammary
nerves of the female breast. Note the breast is supplied medially by the medial mammary
nerves (T1–T6) and laterally by the lateral mammary nerve (T2–T7).13

FIGURE 10-14 Figure showing the contribution of the supraclavicular nerves to the
sensory innervation of the breast. ICN, intercostal nerve.

Ultrasound Imaging for Thoracic Interfascial Blocks

Ultrasound Scan Technique
1.Position:
a.Patient: Supine with the arm abducted and the head turned away slightly to the
contralateral side. Blanco describes using the supine position for both the PECS1,2
and SPB,3,4 but we prefer the lateral position for the SPB because it allows easy
placement of the ultrasound transducer along the lateral chest wall for the coronal
scan (described later) and also allows easy needle manipulation.

440
 b.Operator and ultrasound machine: With the patient in the supine position, the
operator stands at the head end of the patient, and the ultrasound machine is
positioned ipsilateral to the side to be examined and directly in front of the operator.
With the patient in the lateral position and with the side to be scanned uppermost, the
operator stands behind the patient, and the ultrasound machine is positioned on the
contralateral side and directly in front of the operator.
2.Transducer selection: High-frequency (13–15 MHz) linear array transducer.
3.Scan technique: The ultrasound scan can be performed in the sagittal, transverse, and
coronal axis. The sagittal scan is performed in five sequential steps (Steps I–V) over five
contiguous sites starting immediately below the midsection of the clavicle and ending at
the lateral chest wall. This is done to better understand the anatomy of the thoracic wall
(Fig. 10-15) and the myofascial planes (Fig. 10-16) for local anesthetic injection during a
thoracic interfascial nerve block.

FIGURE 10-15 A sagittal oblique panoramic ultrasound image of the chest wall extending
from the midsection of the clavicle to the posterior axillary line showing the musculature and
fascial planes relevant for thoracic interfascial nerve blocks. R, rib.

441
FIGURE 10-16 Sagittal oblique panoramic ultrasound image of the chest wall highlighting
the PECS-I (in blue) and serratus plane (in green) that are targets for local anesthetic injection
during thoracic interfascial nerve blocks. R, rib.

a.Sagittal scan sequence:

Step I: The ultrasound transducer is positioned with its proximal end resting on the
midsection of the clavicle and with its orientation marker directed cephalad (Fig. 10-
17). The distal end of the transducer is pivoted slightly laterally (directed slightly
outwards) towards the anterior axillary fold to produce a sagittal oblique scan of the
thoracic wall. The clavicle is visualized as a hyperechoic structure with an underlying
acoustic shadow. The second rib is seen lying posterior and distal to the acoustic
shadow of the clavicle (Fig. 10-18), and the third rib is visualized immediately caudal
to it (Figs. 10-19 to 10-21).

442
FIGURE 10-17 Figure showing the position of the patient and ultrasound transducer
during Step I of the sagittal scan sequence. Inset sagittal sonogram shows the plane of
ultrasound imaging (blue color) over the second intercostal space. R, rib.

FIGURE 10-18 A. Sagittal oblique sonogram of the medial infraclavicular fossa (MICF),
near the midsection of the clavicle, acquired during Step I of the sagittal scan sequence. Note
the second rib lies immediately posteroinferior to the clavicle, and the medial border of the
pectoralis minor muscle extends to the upper border of the third rib. B. Position of patient and
ultrasound transducer during Step I of the sagittal scan sequence. R, rib.

443
FIGURE 10-19 A. Sagittal oblique sonogram of the anterior chest wall with the ultrasound
transducer positioned slightly lateral to that in Fig. 10-18. The axillary artery (AA) is
visualized deep to the subclavius muscle and cranial to the axillary vein (AV). Also note how
the cephalic vein (CV) joins the axillary vein from above in the medial infraclavicular fossa
(MICF). B. Position of patient and ultrasound transducer during the sagittal oblique scan. R,
rib.

444
FIGURE 10-20 A. Sagittal oblique sonogram of the anterior chest wall acquired during
Step I of the sagittal scan sequence with the ultrasound transducer positioned over the axillary
artery (midclavicular point). Note the cords of the brachial plexus are clustered together
cranial to the axillary artery and within the costoclavicular space (CCS), which is between the
clavicular head of the pectoralis major and subclavius muscle anteriorly and the upper slips of
the serratus anterior muscle overlying the second rib posteriorly. The axillary vein (AV) lies
caudal to the axillary artery in this sonogram. Also note parts of the thoracoacromial artery
(TAA) can be seen near the upper border of the pectoralis minor muscle. B. Position of the
patient and ultrasound transducer during the scan. R, rib; PC, posterior cord; MC, medial
cord; LA, lateral cord.

445
FIGURE 10-21 Sagittal oblique sonogram of the anterior chest wall acquired during Step I
of the sagittal scan sequence with the ultrasound transducer lying parallel to the axillary
artery. Note the origin of the thoracoacromial artery from the anterior wall of the first part of
the axillary artery in this subject. R, rib.

FIGURE 10-22 Figure showing the position of the patient and ultrasound transducer
during Step II of the sagittal scan sequence. The inset sagittal sonogram shows the plane of
ultrasound imaging (green) over the third intercostal space. R, rib.

446
FIGURE 10-23 Sagittal oblique sonogram of the anterior chest wall acquired during Step
II of the sagittal scan sequence. Note the PECS-I plane lies between the posterior surface of
the pectoralis major muscle and the anterior surface of the pectoralis minor muscles
(interpectoral plane), and the serratus plane lies between the posterior surface of the
pectoralis minor muscle and the outer surface of the serratus anterior muscle. During a PECS-
I and PECS-II block, the local anesthetic is injected into their respective planes at this level.
B. Position of the patient and ultrasound transducer during the sagittal oblique scan. R, rib.

FIGURE 10-24 A zoomed sagittal oblique sonogram of the anterior chest wall acquired

447
during Step II of the sagittal scan sequence. The serratus plane is highlighted in green color.
During a PECS-II block local anesthetic is injected into both the PECS-I and serratus plane at
this level. R, rib.

FIGURE 10-25 Figure showing the position of the patient and ultrasound transducer
during Step III of the sagittal scan sequence. The inset sagittal sonogram shows the plane of
ultrasound imaging (purple color) over the fourth intercostal space. R, rib.

448
FIGURE 10-26 A. Sagittal oblique sonogram of the anterior chest wall acquired during
Step III of the sagittal scan sequence. Note the inferior border of the pectoralis minor lies
over the fifth rib. B. Position of patient and ultrasound transducer during the sagittal oblique
scan. R, rib.

FIGURE 10-27 Sagittal oblique sonogram of the anterior chest wall acquired with the
transducer positioned slightly caudal to that in Figure 10-26 (same subject). Note the sixth rib
is now visualized and the lateral border of the pectoralis minor muscle ends at the level of the
fifth rib. R, rib.

FIGURE 10-28 Figure showing the position of the patient and ultrasound transducer
during Step IV of the sagittal scan sequence. The inset sagittal sonogram shows the plane of
ultrasound imaging (yellow color) over the fifth intercostal space. R, rib.

449
FIGURE 10-29 A. Sagittal oblique sonogram of the anterolateral chest wall acquired
during Step IV of the sagittal scan sequence. Note the inferior border of the pectoralis major
muscle ends at the upper border of the sixth rib, and only the serratus anterior muscle overlies
the ribs below that. The lateral cutaneous branch of the intercostal nerve emerges from the
intercostal space by passing through the intercostal and serratus anterior muscle, along the
midclavicular line, and lies subcutaneously at this level. B. Position of the patient and
ultrasound transducer during the sagittal oblique scan. R, rib.

450
FIGURE 10-30 Sagittal oblique sonogram of the lateral chest wall acquired during Step IV
of the sagittal scan sequence. Note the lower slips of the serratus anterior muscle are much
more bulky than the upper slips. R, rib.

FIGURE 10-31 Figure showing the position of the patient and ultrasound transducer
during Step V of the sagittal scan sequence near the posterior axillary line. The inset sagittal
sonogram shows the plane of ultrasound imaging (dark green) over the sixth intercostal
space. R, rib.

FIGURE 10-32 Sagittal oblique sonogram of the lateral chest wall acquired during Step V
of the sagittal scan sequence. Note the thick serratus anterior muscle overlying the sixth and
seventh ribs and the inferolateral aspect of the latissimus dorsi muscle lying superficial to the
serratus anterior muscle caudally. The myofascial plane between the latissimus dorsi and

451
serratus anterior muscle is the serratus anterior plane posteriorly.

FIGURE 10-33 A. Doppler ultrasound demonstrating the thoracodorsal artery in the

myofascial plane between the latissimus dorsi and the serratus anterior muscle close to the
posterior axillary line. The thoracodorsal nerve accompanies the thoracodorsal artery at this
level, but is more difficult to delineate with current ultrasound technology. B. Position of the
patient and ultrasound transducer during the sagittal scan. R, rib.

Steps II to V: From the earlier position the ultrasound transducer is moved laterally in
small steps until the anatomy of the thoracic wall at the level of the third to fourth
(Figs. 10-22 to 10-24), fourth to fifth (Figs. 10-25 to 10-27), fifth to sixth (Figs. 10-28
to 10-30), and seventh to eighth (Figs. 10-31 to 10-33) ribs is visualized.
b.Coronal scan sequence: The coronal scan is performed at the lateral chest wall and for
an SPB. The ultrasound transducer is placed in the coronal orientation over the lateral
chest wall (Fig. 10-34) and close to the posterior–axillary line. The aim at this stage is
to identify the underlying ribs and the overlying serratus anterior muscle (Fig. 10-35).
The transducer is then gently moved posteriorly until the inferolateral margin of the
latissimus dorsi muscle is seen overlying the serratus anterior muscle (Fig. 10-36).
The thoracodorsal artery is consistently seen in the myofascial plane between the
latissimus dorsi and serratus anterior muscle at this level (Fig. 10-37). The ultrasound
image is optimized, after which the transducer is gently moved cranially along the
same coronal plane until the inferolateral margin of the teres major muscle and the
serratus plane (Fig. 10-38), between the latissimus dorsi and serratus anterior muscle,
are clearly visualized. This is the target ultrasound window for a SPB.4

452
FIGURE 10-34 Figure showing the position of the patient and ultrasound transducer
during a coronal scan of the lateral chest wall for a serratus plane block. Note the orientation
marker of the ultrasound transducer is directed cranially.

FIGURE 10-35 Coronal sonogram of the lateral chest wall showing the serratus anterior
muscle overlying the ribs. Note the serratus anterior muscle is relatively thick at this location.

453
FIGURE 10-36 A. Coronal sonogram of the lateral chest wall with the transducer
positioned slightly posterior to that in Fig. 10-35. The inferolateral border of the latissimus
dorsi muscle is now seen lying superficial to the serratus anterior muscle at the cranial end of
the sonogram. The thoracodorsal artery is also seen lying superficial to the serratus anterior
muscle in this sonogram. B. Position of the patient and ultrasound transducer during the
coronal scan.

FIGURE 10-37 Color Doppler sonogram showing the thoracodorsal artery in the
myofascial plane between the latissimus dorsi and serratus anterior muscle along the lateral

454
chest wall near the posterior axillary line.

FIGURE 10-38 Coronal sonogram of the lateral chest wall near the posterior axillary line
showing the serratus plane between the latissimus dorsi and the serratus anterior muscle. Note
the position of the teres major muscle at the cranial end of the sonogram. The myofascial
plane between the latissimus dorsi and serratus anterior muscle at this level is our target for
local anesthetic injection during a serratus plane block.

c.Transverse scan sequence: In Blanco’s original descriptions of the thoracic

interfascial nerve blocks, only the sagittal ultrasound scan technique is described.1,3,4
We have found the transverse ultrasound scan window to be useful for both the
PECS-I and PECS-II blocks. For a transverse scan the patient is positioned supine
with the head turned to the contralateral side. The ipsilateral arm is also abducted
(Fig. 10-39) and flexed at the elbow, and the hand is tucked behind the head. A linear
ultrasound transducer (13–15 MHz) is positioned in the transverse orientation slightly
above and medial to the coracoid process with its orientation marker directed laterally
(outwards). The medial end of the transducer is also pivoted slightly downwards
(inferiorly) such that it is directed towards the midsection of the sternum (Fig. 10-39).
The ultrasound image acquired is a transverse oblique view of the underlying thoracic
wall anatomy (Figs. 10-40 to 10-45).

455
FIGURE 10-39 Figure showing the position of the patient and ultrasound transducer
during a transverse oblique scan of the anterior chest wall for a PECS block. Note the medial
end of the ultrasound transducer has been pivoted slightly caudally for the scan.

FIGURE 10-40 A. Transverse oblique sonogram of the anterior chest wall showing the
myofascial plane between the pectoralis major and minor muscles (PECS-I plane). The
pectoral branch of the thoracoacromial artery is seen as a hypoechoic and pulsatile structure
within the PECS-I plane. B. Position of the patient and ultrasound transducer during the
transverse oblique scan.

456
FIGURE 10-41 A. Power Doppler sonogram showing the pectoral branch of the
thoracoacromial artery in the myofascial plane between the pectoralis major and minor
muscles (PECS-I plane). B. Position of the patient and ultrasound transducer during the scan.

FIGURE 10-42 Transverse oblique sonogram of the anterior chest wall showing the
PECS-I plane and the origin of the thoracoacromial artery (TAA) from the anterior wall of
the axillary artery (second part). The cords of the brachial plexus are seen as a cluster of
nerves lying lateral to the axillary artery in this sonogram.

457
FIGURE 10-43 Transverse oblique sonogram of the anterior chest wall showing the
thoracoacromial artery lying deep to the pectoralis minor muscle, and its pectoral branches in
the PECS-I plane.

FIGURE 10-44 Transverse oblique sonogram of the anterior chest wall, above the superior
border of the pectoralis minor muscle, showing the bifurcation of the thoracoacromial artery.
Note the pectoralis minor muscle is not visualized in this ultrasound window and the
neurovascular structures lie directly on the serratus anterior muscle at this site.

458
FIGURE 10-45 A. Color Doppler sonogram showing the bifurcation of the
thoracoacromial artery near the upper border of the pectoralis minor muscle. B. Position of
the patient and ultrasound transducer during the transverse oblique scan.

4.Sonoanatomy of the thoracic wall:

a.Sagittal sonoanatomy: The sagittal sonoanatomy of the thoracic wall changes as one
moves the ultrasound transducer from a medial-to-lateral direction near the
midsection of the clavicle (Figs. 10-18 to 10-21) or inferolaterally from the
midsection of the clavicle to the lateral chest wall (Figs. 10-22 to 10-33).
i.Sonoanatomy with Step I of the sagittal scan sequence: With the upper end of the
ultrasound transducer positioned medial to the mid-point of the clavicle during the
sagittal scan one is able to visualize the anechoic and compressible axillary vein
lying immediately below the clavicle and between the pectoralis major and
subclavius muscle anteriorly and the upper slips of the serratus anterior muscle,
overlying the second rib, posteriorly (Fig. 10-18). This represents the
costoclavicular space,14–16 through which the neurovascular structures pass from
the neck to the arm and vice versa. Distally the clavicular head of the pectoralis
major muscle and upper border of the pectoralis minor muscle are seen lying
anterior to the serratus anterior muscle and the second intercostal space with the
second and third ribs, intervening intercostal muscles, the hyperechoic pleura, and
lung (Fig. 10-18). The space between the undersurface of the clavicle and
subclavius muscle cranially, the pectoral muscles anteriorly, and the second and
third ribs with the serratus anterior muscle posteriorly is the medial infraclavicular
fossa (MICF, Fig. 10-18).15,16 The clavipectoral fascia is seen as a hyperechoic
linear structure interposed between the subclavius muscle and the upper border of
the pectoralis minor muscle (Figs. 10-5 and 10-18). Slightly lateral to the earlier

459
 position (ie, at the midclavicular point), the axillary artery is visualized as an
anechoic and pulsatile structure within the costoclavicular space (Fig. 10-19).15,16
The cephalic vein joins the axillary vein from above within the MICF (Fig. 10-19).
Lateral to the midpoint of the clavicle the cords of the brachial plexus are seen as
multiple round-to-oval structures, each with a hyperechoic rim, within the
costoclavicular space and lying superior to the pulsatile axillary artery (Fig. 10-20).
The axillary vein is located caudal to the axillary artery (Fig. 10-20). Branches of
the TAA are also seen close to the upper border of the pectoralis minor muscle
(Fig. 10-20). The TAA in most cases originates from the axillary artery deep to the
pectoralis minor muscles, but it may also originate above the medial border of the
pectoralis minor muscle (Fig. 10-21). Deep to the serratus anterior muscle, outlines
of the anterior intercostal space with the hyperechoic parietal pleura are clearly
delineated (Fig. 10-20). The arrangement of the brachial plexus in the sagittal
sonogram is also consistent with the lateral cord lying anterior to the medial cord
and the posterior cord lying superior to the lateral and medial cord (Fig. 10-
20).15,16
ii.Sonoanatomy with Step II of the sagittal scan sequence: During Step II of the
sagittal scan sequence, the ultrasound transducer is placed over the third intercostal
space (Fig. 10-22). The third and fourth ribs with the intercostal muscles, pleura,
and lung are clearly delineated (Fig. 10-23). The pectoralis major and minor
muscles overlie the serratus anterior muscle, and the latter is closely attached to the
adjoining ribs (Fig. 10-23). The myofascial plane between the pectoralis major and
minor muscles at the level of the fourth rib may be referred to as the PECS-I plane
(Fig. 10-24) because it is the target site for local anesthetic injection during a
PECS-I block.1
iii.Sonoanatomy with Step III of the sagittal scan sequence: During Step III of the
sagittal scan sequence, the ultrasound transducer is placed over the fourth
intercostal space (Fig. 10-25) and the fourth and fifth ribs are clearly visualized
(Fig. 10-26). As seen during Step II (described earlier), the pectoralis major and
minor muscles overlie the serratus anterior muscle (Figs. 10-26 and 10-27). The
myofascial plane between the pectoralis minor and the serratus anterior muscle is
the target site for local anesthetic injection during a PECS-II injection.2 The inferior
border of the pectoralis minor muscle can also be defined at the level of the fifth rib
(Fig. 10-27). Distal to that and at the level of the sixth rib there is a hyperechoic
layer of connective tissue which probably represents the Gerdy’s ligament
(suspensory ligament of the axilla) fusing with the axillary fascia (Fig. 10-5).
iv.Sonoanatomy with Step IV of the sagittal scan sequence: During Step IV of the
sagittal scan sequence, the ultrasound transducer overlies the fifth intercostal space
along the lateral chest wall (Fig. 10-28) and at the level of the anterior axillary line.
With the lower border of the pectoralis minor muscle having attached to the fifth
rib, only the pectoralis major and serratus anterior muscles are seen overlying the
fifth rib (Fig. 10-29), and only the serratus anterior muscle overlies the sixth rib
(Fig. 10-29). The lateral branches of the intercostal nerves pierce the intercostal and
serratus anterior muscle complex and emerge to lie subcutaneously at this location
and along the midaxillary line (Fig. 10-6). Slightly more inferolaterally, the serratus
anterior muscle becomes thicker and is the only muscle overlying the lateral chest
wall (Fig. 10-30).
v.Sonoanatomy with Step V of the sagittal scan sequence: During Step V of the
sagittal scan sequence, the transducer overlies the sixth intercostal space close to

460
 the posterior axillary line (Fig. 10-31). The inferolateral aspect of the latissimus
dorsi muscle overlies the thick serratus anterior muscle (Fig. 10-32), and the
thoracodorsal artery lies in the myofascial plane between the latissimus dorsi and
serratus anterior muscle (Fig. 10-33). The thoracodorsal nerve, which innervates
the latissimus dorsi muscle, accompanies the thoracodorsal artery (Fig. 10-3).
b.Sonoanatomy of the thoracic wall: Coronal sonoanatomy: During the coronal scan
(Fig. 10-34) the ultrasound transducer is placed along the lateral chest wall and near
the posterior–axillary line. The serratus anterior muscle is seen overlying the ribs (Fig.
10-35). As one gently moves the transducer posteriorly, the inferolateral border of the
latissimus dorsi muscle is seen lying superficial to the serratus anterior muscle at the
cranial end of the sonogram (Fig. 10-36). The thoracodorsal artery is consistently
visualized in the serratus plane between the latissimus dorsi and serratus anterior
muscle (Figs. 10-36 and 10-37). The myofascial plane between the latissimus dorsi
and the serratus anterior muscle at the level of the fifth rib (Fig. 10-38) is the target
site for local anesthetic injection during a SPB.3
c.Sonoanatomy of the thoracic wall: Transverse sonoanatomy: On the transverse
sonogram the pectoralis major and minor muscles lie anterior to the axillary vein,
serratus anterior muscle, and the pleura (Fig. 10-40) or the third to fourth ribs (Fig.
10-40) medially. The pectoral branch of the TAA lies in the myofascial plane between
the pectoral major and minor muscles (Figs. 10-40 and 10-41). With the transducer
positioned slightly lateral to the earlier position, the axillary artery is also visualized
deep to the pectoral muscles and lateral to the axillary vein (Fig. 10-42). The cords of
the brachial plexus are clustered together lateral to the axillary artery (Fig. 10-42).
The origin of the TAA from the axillary artery (Figs. 10-42 and 10-43) and its
bifurcation (Figs. 10-44 and 10-45) can also be visualized near the upper border of the
pectoralis minor muscle. The TAA is an important anatomical landmark because the
LPN, MPN, and ansa pectoralis are all closely related to the artery (Fig. 10-11).8,9

Clinical Pearls
1.Locating the second rib under the clavicle on the sagittal scan (Figs. 10-15 and 10-18) is a
useful sonographic landmark for counting the ribs along the anterior and anterolateral
chest wall.
2.Due to the complex spinal origin and anatomical arrangement of the pectoral nerves (noted
earlier), a single injection of local anesthetic into the myofascial plane between the
pectoralis major and minor muscles (PECS-I plane) is unlikely to consistently block all
the pectoral nerves or the “subpectoral plexus” of nerves. Cadaver data suggest that a 10-
mL injection at three sites: (a) deep and lateral aspect of the pectoralis minor muscle (3.3
mL), (b) in between the pectoralis major and minor muscle (3.3 mL), and (c) superficial
to the posterior fascia of the pectoralis major muscle (3.4 mL), is adequate in affecting all
the pectoral nerves.17 However, this observation has not been clinically validated, and
there are no data evaluating pectoral nerve block dynamics after a PECS-I and or PECS-II
block. Future research in this area is warranted.
3.Age-related changes in musculoskeletal structures18 can make it difficult to accurately
define the PECS-I plane in the elderly. Doppler (Color or Power) ultrasound helps locate
the pectoral branch of the TAA (Fig. 10-41) and facilitates accurate injection of local
anesthetic into the PECS-I plane during a PECS-I block.
4.Doppler ultrasound can also be used to locate the thoracodorsal artery in the serratus plane

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 during a SPB.
5.A SPB affects the lateral cutaneous branches of the ipsilateral T2 to T9 intercostal nerves
and possibly also the long thoracic and thoracodorsal nerves.3,4 However, it does not
affect the anterior cutaneous branch of the main intercostal nerve, and therefore the
anteromedial aspect of the thorax, or the breast in females, is spared by an SPB.
6.The long thoracic and thoracodorsal nerve may be anesthetized by an SPB, but their role in
afferent nociception after major breast or thoracic surgery is still not known.

References
1.Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery.
Anaesthesia. 2011;66:847–848.
2.Blanco R, Fajardo M, Parras MT. Ultrasound description of Pecs II (modified Pecs I): a
novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012;59:470–475.
3.Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel
ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68:1107–1113.
4.Blanco R. Thoracic interfascial nerve blocks: PECS (I and II) and serratus plane block,
musculoskeletal ultrasound for regional anaesthesia and pain medicine. In: Karmakar
MK, ed. 2nd ed. Hong Kong: Department of Anaesthesia and Intensive Care, The
Chinese University of Hong Kong; 2016:377–82.
5.Loukas M, Hullett J, Louis RG Jr., Holdman S, Holdman D. The gross anatomy of the
extrathoracic course of the intercostobrachial nerve. Clin Anat. 2006;19:106–111.
6.Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De CR. Surgical anatomy of the
pectoral nerves and the pectoral musculature. Clin Anat. 2012;25:559–575.
7.Bremner-Smith AT, Unwin AJ, Williams WW. Sensory pathways in the spinal accessory
nerve. J Bone Joint Surg Br. 1999;81:226–228.
8.Macchi V, Tiengo C, Porzionato A, Parenti A, Stecco C, Mazzoleni F, De CR. Medial and
lateral pectoral nerves: course and branches. Clin Anat. 2007;20:157–162.
9.Kg P, K S. Anatomical study of pectoral nerves and its implications in surgery. J Clin
Diagn Res. 2014;8:AC01–AC05.
10.Lee KS. Anatomic variation of the spinal origins of lateral and medial pectoral nerves. Clin
Anat. 2007;20:915–918.
11.David S, Balaguer T, Baque P, Peretti F, Valla M, Lebreton E, Chignon-Sicard B. The
anatomy of the pectoral nerves and its significance in breast augmentation, axillary
dissection and pectoral muscle flaps. J Plast Reconst Aesthet Surg. 2012;65:1193–1198.
12.Aszmann OC, Rab M, Kamolz L, Frey M. The anatomy of the pectoral nerves and their
significance in brachial plexus reconstruction. J Hand Surg Am. 2000;25:942–947.
13.Jaspars JJ, Posma AN, van Immerseel AA, Gittenberger-de Groot AC. The cutaneous
innervation of the female breast and nipple-areola complex: implications for surgery. Br
J Plast Surg. 1997;50:249–259.
14.Demondion X, Herbinet P, Boutry N, Fontaine C, Francke JP, Cotten A. Sonographic
mapping of the normal brachial plexus. AJNR Am J Neuroradiol. 2003;24:1303–1309.
15.Karmakar MK, Sala-Blanch X, Songthamwat B, Tsui BC. Benefits of the costoclavicular
space for ultrasound-guided infraclavicular brachial plexus block: description of a
costoclavicular approach. Reg Anesth Pain Med. 2015;40:287–288.
16.Sala-Blanch X, Reina MA, Pangthipampai P, Karmakar MK. Anatomic basis for brachial
plexus block at the costoclavicular space: a cadaver anatomic study. Reg Anesth Pain
Med. 2016;41(3):387–391.

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17.Desroches J, Grabs U, Grabs D. Selective ultrasound guided pectoral nerve targeting in
breast augmentation: How to spare the brachial plexus cords? Clin Anat. 2013;26(1):49–
55.
18.Li X, Karmakar MK, Lee A, Kwok WH, Critchley LA, Gin T. Quantitative evaluation of
the echo intensity of the median nerve and flexor muscles of the forearm in the young
and the elderly. Br J Radiol. 2012;85:e140–e145.

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CHAPTER 11

Sonoanatomy Relevant for Ultrasound-Guided Thoracic

Paravertebral Block

Introduction
Thoracic paravertebral block (TPVB) is the technique of injecting local anesthetic alongside
the thoracic vertebral body close to where the spinal nerves emerge from the intervertebral
foramen. This produces unilateral (ipsilateral), segmental, somatic, and sympathetic nerve
blockade in multiple contiguous thoracic dermatomes,1,2 which is effective for managing
acute and chronic pain of unilateral origin from the thorax and abdomen.2 TPVB can also be
used for surgical anesthesia in patients undergoing inguinal herniorrhaphy3 and breast
surgery4–6 with improved postoperative outcomes.2,5 TPVB is traditionally performed using
surface anatomical landmarks.2 Recently there has been an increase in interest in the use of
ultrasound for peripheral nerve blocks,7–9 including TPVB.10–18 However, published data on
ultrasound-guided (USG) TPVB are limited.10–20 This chapter describes the sonoanatomy
relevant for USG TPVB.

Gross Anatomy
The thoracic paravertebral space (TPVS) is a wedge-shaped space2,21 that lies on either side
of the vertebral column (Fig. 11-1). It is wider on the left than on the right.22 The parietal
pleura forms the anterolateral boundary. The base is formed by the vertebral body,
intervertebral disc, and the intervertebral foramen with its contents (Fig. 11-1).21,23 The
superior costotransverse ligament (SCTL), which extends from the lower border of the
transverse process above to the upper border of the transverse process below (Figs. 11-2 and
11-4), forms the posterior wall of the TPVS. Also interposed between two transverse
processes is the intertransverse ligament (Figs. 11-2 and 11-4). The SCTL is continuous
laterally with the internal intercostal membrane, which is the medial extension of the internal
intercostal muscle, medial to the angle of the rib (Fig. 11-4). The apex of the TPVS is
continuous with the posterior intercostal space lateral to the tips of the transverse processes
(Fig. 11-4).21,23

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FIGURE 11-1 Transverse anatomy of the thoracic paravertebral region.

FIGURE 11-2 Sagittal anatomy of the thoracic paravertebral region.

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FIGURE 11-3 Paravertebral ligaments relevant for thoracic paravertebral block.

FIGURE 11-4 Anatomy of the thoracic paravertebral region showing the various
paravertebral ligaments and their anatomical relationship to the thoracic paravertebral space.

Interposed between the parietal pleura anteriorly and the superior costotransverse ligament
posteriorly is a fibroelastic structure,24 the “endothoracic fascia”25–30 (Figs. 11-1 and 11-2),
which is the deep fascia of the thorax2,25–27 and lines the internal aspect of the thoracic cage

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(Figs. 11-5 and 11-6).24–30 The presence of the endothoracic fascia in the TPVS was until
recently ignored in the paravertebral literature. We have drawn attention to the presence of
the endothoracic fascia in the TPVS27 and proposed that it may play a role in explaining the
variable expressions of a TPVB.27 In the paravertebral location, the endothoracic fascia is
loosely applied to the ribs23 (Fig. 11-2) and fuses medially with the periosteum at the
midpoint of the vertebral body28 (Fig. 11-1). There is an intervening layer of loose areolar
connective tissue, “the subserous fascia,”25–28 between the parietal pleura and the
endothoracic fascia (Figs. 11-1 and 11-2). The endothoracic fascia therefore divides the
TPVS into two potential fascial compartments,30 the anterior “extrapleural paravertebral
compartment,” and the posterior “subendothoracic paravertebral compartment” (Figs. 11-1
and 11-2).2,27,30 The TPVS contains fatty tissue2,23,24 within which lie the intercostal
(spinal) nerve, the dorsal ramus, intercostal vessels, rami communicantes, and anteriorly the
sympathetic chain (Figs. 11-1 and 11-5).2,23 The spinal nerves in the TPVS are segmented
into small bundles lying freely among the fat and devoid of a fascial sheath, which make
them susceptible to local anesthetic block.31 The intercostal nerve and vessels are located
behind the endothoracic fascia,2,30,32,33 and the sympathetic trunk is located anterior to
it2,28,30,33 in the TPVS (Figs. 11-1 and 11-5).

FIGURE 11-5 The endothoracic fascia and its anatomical relationship to the thoracic

467
paravertebral space. Note the fascial compartments and the location of the neurovascular
structures in relation to the endothoracic fascia.

FIGURE 11-6 Paravertebral sagittal section of the thorax showing how the endothoracic
fascia lines the internal aspect of the thoracic cage.

Communications of the Thoracic Paravertebral Space

The TPVS is continuous with the epidural space medially via the intervertebral
foramen,23,34–36 the intercostal space laterally,26,28,31,34,35,37,38 and the contralateral TPVS
via the epidural23 and prevertebral space.2,26,27,29 The cranial extension of the TPVS is still
not defined, but we have observed direct paravertebral spread of radio-opaque contrast
medium from the thoracic to the cervical region (unpublished data) indicating that there is a
direct anatomical continuity between the thoracic and cervical paravertebral regions.
Ipsilateral Horner syndrome after thoracic paravertebral injections has also been
reported.29,36,39,40 The anatomical pathway for cranial spread of an injectate from the
thoracic to the cervical paravertebral space is still not clear.
The caudal boundary of the TPVS is formed by the origin of the psoas major muscle,41
and inferior (lumbar) spread through the TPVS is thought to be unlikely.41 Ipsilateral lumbar
spinal nerves are also occasionally involved after a lower thoracic paravertebral injection1,42
Saito and colleagues have demonstrated ipsilateral thoracolumbar spread of colored dye in
cadavers.43 We have also reported ipsilateral thoracolumbar anesthesia and radiological
spread of contrast below the diaphragm.44 These observations challenge the concept of
lumbar nerve root sparing following TPVB.41 The exact mechanism for the ipsilateral
thoracolumbar spread of local anesthetic or contrast medium is not clear, but we have
proposed that it occurs via the subendothoracic fascial compartment44 to the retroperitoneal
space anterior to the psoas major and quadratus lumborum muscle where the ilioinguinal and
iliohypogastric nerves are located (Fig. 4-50).44

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Computed Tomography Anatomy of the Thoracic
Paravertebral Region
Figs. 11-7 to 11-10.

FIGURE 11-7 Transverse CT of the thoracic spine showing the anatomical relationship of
the transverse process, rib, and the costotransverse junction to the thoracic paravertebral
space. VB, vertebral body.

FIGURE 11-8 Transverse CT of the thoracic spine showing the anatomical relationship of
the vertebral body (VB) and transverse process to the thoracic paravertebral space (TPVS).
IVF, intervertebral foramen.

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FIGURE 11-9 Transverse CT of the thoracic spine showing the anatomical relationship of
the inferior articular process of the vertebra to the intervertebral foramen (IVF) and the
thoracic paravertebral space (TPVS). VB, vertebral body; SCTL, superior costotransverse
ligament.

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FIGURE 11-10 Sagittal CT of the thorax through the thoracic paravertebral space (TPVS).
Note the anatomical relationship of the neck of the rib to the transverse process (TP) and the
costotransverse junction (CTJ). SCTL, superior costotransverse ligament.

Magnetic Resonance Imaging Anatomy of the Thoracic

Paravertebral Region
Figs. 11-11 to 11-14.

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FIGURE 11-11 Transverse T2-weighted MRI of the thoracic spine showing the
anatomical relationship of the transverse process, rib, and the costotransverse junction to the
thoracic paravertebral space. VB, vertebral body; TP, transverse process; PSM, paraspinal
muscle.

FIGURE 11-12 Transverse T2-weighted MRI of the thoracic spine showing the
anatomical relationship of the vertebral body (VB) and transverse process (TP) to the thoracic
paravertebral space (TPVS). PSM, paraspinal muscle; SCTL, superior costotransverse
ligament.

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FIGURE 11-13 Transverse T2-weighted MRI of the thoracic spine showing the
anatomical relationship of the inferior articular process of the vertebra to the intervertebral
foramen (IVF) and the thoracic paravertebral space (TPVS). Note the spinal nerve root as it
exits the IVF. SP, spinous process; VB, vertebral body; PSM, paraspinal muscles; SCTL,
superior costotransverse ligament.

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FIGURE 11-14 Sagittal T2-weighted MRI of the thorax through the thoracic paravertebral
space (TPVS). Note the intercostal neurovascular bundle in the TPVS. TP, transverse
process; PSM, paraspinal muscle; SCTL, superior costotransverse ligament.

Sonoanatomy of the Thoracic Paravertebral Region

Ultrasound Scan Technique
1.Position:
a.Patient: An ultrasound scan of the thoracic paravertebral region can be performed in
the transverse (axial scan) or longitudinal (sagittal scan) axis with the patient in the
sitting (Fig. 11-15), lateral decubitus (Fig. 11-16), or prone position. The prone
position is useful in patients presenting for a chronic pain procedure when
fluoroscopy can also be used in conjunction with ultrasound imaging. Currently there
are no data demonstrating an optimal axis or position for the ultrasound scan or the
paravertebral injection. It is often a matter of individual preference and experience.

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FIGURE 11-15 Transverse ultrasound scan of the thoracic paravertebral region with the
patient in the sitting position. Note the position of the ultrasound transducer (linear) relative
to the spine.

FIGURE 11-16 Transverse ultrasound scan of the thoracic paravertebral region with the
patient in the right lateral position. Note the position of the ultrasound (curved array)
transducer relative to the spine.

b.Operator and ultrasound machine: The operator sits or stands behind the patient, and
the ultrasound machine is placed directly in front on the contralateral side (Fig. 11-17)
for an USG TPVB.

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FIGURE 11-17 Figure demonstrating the ergonomics during an ultrasound scan of the
thoracic paravertebral region with the patient in the right lateral position. Note a low-
frequency curved array transducer is being used for the ultrasound scan.

2.Transducer selection: The transducer used for the ultrasound scan depends on the body
habitus of the patient. High-frequency ultrasound provides better resolution than low-
frequency ultrasound, but its penetration is poor. Moreover if one has to scan at a depth
using high-frequency ultrasound, then the field of vision is also significantly narrow.
Under such circumstances it may be preferable to use a low-frequency curved array
transducer (5–2 MHz) with a divergent beam and a wider field of vision. Published data
suggest that a high-frequency linear transducer (13–6 MHz) is frequently used for
scanning the thoracic paravertebral region.10,11,14,18 This may be because the transverse
process, costotransverse ligament, and the pleura in the midthoracic region are located at
a relatively shallow depth and lend themselves to ideal conditions for imaging with a
high-frequency linear array transducer. However, ultrasound imaging of the TPVS is not
similar at all thoracic levels, and high-frequency transducers are generally not suitable in
the upper thoracic region. Recently we have used a low-frequency curved array
transducer (5–2 MHz) to perform a transverse scan of the thoracic paravertebral region (at
all levels) with great success (Fig. 11-17, see details later).
3.Sonoanatomy:
a.Transverse sonoanatomy of the thoracic paravertebral region:
A transverse scan of the thoracic paravertebral region can be performed using a linear
(high-frequency) or curved (low-frequency) array transducer. In slim individuals a
high-frequency linear array transducer will suffice, but in those with a larger body
habitus, a curved array transducer is preferable. The high-frequency linear array
transducer is positioned lateral to the thoracic spinous process at the target level (Figs.
11-15 and 11-18). On a transverse sonogram the paraspinal muscles are clearly
delineated and lie superficial to the transverse process (Figs. 11-19 to 11-21). The
transverse process is seen as a hyperechoic structure, anterior to which there is a dark
acoustic shadow that completely obscures the TPVS (Figs. 11-19 and 11-20). Lateral

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to the transverse process, the hyperechoic pleura that moves with respiration and
exhibits the typical “lung sliding sign,”45 which is the sonographic appearance of the
pleural surfaces moving relative to each other within the thorax. Comet tail artifacts,
which are reverberation artifacts, may also be seen deep to the pleura and within the
lung tissue, and are often synchronous with respiration.45 A hypoechoic space is also
seen between the parietal pleura and the internal intercostal membrane (Figs. 11-19 to
11-21), which is the medial extension of the internal intercostal muscle and is
continuous medially with the superior costotransverse ligament (SCTL, Fig. 11-4).
This hypoechoic space represents the medial limit of the posterior intercostal space or
the apex of the TPVS, and the two communicate with each other (Figs. 11-19 to 11-
21). Therefore, local anesthetic injected medially into the TPVS can often be seen to
spread laterally to distend this space; vice versa, local anesthetic injected laterally into
the posterior intercostal space can also spread medially to the paravertebral space and
is the basis of the intercostal approach for USG TPVB10,18 where the needle is
inserted in the plane of the ultrasound beam from a lateral-to-medial direction. From
the scan position described earlier (ie, over the transverse process), if one now slides
the transducer slightly cranially or caudally, it is possible to perform a transverse scan
of the paravertebral region with the ultrasound beam being insonated between the two
transverse processes (intertransverse space) and over the inferior articular process
medially (Fig. 11-22). The ultrasound signal is now not impeded by the transverse
process or the costotransverse junction, and parts of the parietal pleura and the “true”
TPVS can be faintly visualized (Fig. 11-23). However, one must note that the inferior
vertebral notch and the intervertebral foramen are located immediately anterior to the
inferior articular process (Figs. 11-22 and 11-23). The SCTL, which forms the
posterior border of the TPVS, is also visible and it blends laterally with the internal
intercostal membrane, which forms the posterior border of the posterior intercostal
space (Fig. 11-23). The communication between the TPVS and the posterior
intercostal space is also clearly visualized (Figs. 11-19 and 11-23).

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FIGURE 11-18 Figure illustrating the orientation of the ultrasound transducer and how the
ultrasound beam is insonated during a transverse scan of the thoracic paravertebral region
with a linear transducer. The TP (transverse process) usually casts an acoustic shadow
(represented in black), which obscures the ultrasound visibility of the thoracic paravertebral
space.

FIGURE 11-19 Transverse sonogram of the right thoracic paravertebral region using a
high-frequency linear transducer with the ultrasound beam being insonated over the
transverse process. Note how the acoustic shadow of the transverse process (TP) obscures the
thoracic paravertebral space (TPVS). The hypoechoic space posterior to the parietal pleura
and anterolateral to the TP is the apex of the TPVS, or the medial limit of the posterior
intercostal space.

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FIGURE 11-20 Transverse sonogram of the left thoracic paravertebral region using a
high-frequency linear transducer with the ultrasound beam being insonated over the
transverse process. Note how the acoustic shadow of the transverse process (TP) obscures the
TPVS. The hypoechoic space between the parietal pleura and the internal intercostal
membrane laterally represents the apex of the TPVS, or the medial limit of the posterior
intercostal space.

FIGURE 11-21 A multiplanar 3-D view of the thoracic paravertebral region with the
reference marker placed immediately lateral to the transverse process and over the superior
costotransverse ligament (SCTL). Note how the three slice planes (red – transverse, green –
sagittal, and blue – coronal) are obtained. PSM, paraspinal muscles; TPVS, thoracic
paravertebral space; TP, transverse process.

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FIGURE 11-22 Figure illustrating the osseous structures that are insonated during a
transverse ultrasound scan of the thoracic paravertebral region through the thoracic
intertransverse space and at the level of the inferior articular process. Note the relationship of
the inferior articular process to the inferior vertebral notch and the intervertebral foramen.
VB, vertebral body.

FIGURE 11-23 Transverse sonogram of the left thoracic paravertebral region using a
high-frequency linear transducer. The ultrasound beam is being insonated through the
intertransverse space and at the level of the articular (inferior) process. Note the acoustic
shadow of the transverse process is no longer visible and parts of the thoracic paravertebral
space (TPVS) and the anteromedial reflection of the pleura are now partly visible. The
superior costotransverse ligament (SCTL), which forms the posterior border of the TPVS, is

480
also visible posteriorly, and it blends laterally with the internal intercostal membrane, which
forms the posterior border of the posterior intercostal space. The communication between the
TPVS and the posterior intercostal space is also clearly delineated. PSM, paraspinal muscle.

FIGURE 11-24 The thoracic spine in the midthoracic region and the various transducer
positions for a transverse scan of the thoracic paravertebral region using a low-frequency
curved array transducer. Position 1 – midline over the spinous process, position 2 – at the
level of the transverse process and rib, position 3 – at the level of the transverse process, and
position 4 – at the level of the articular process.

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FIGURE 11-25 Cross-sectional cadaver anatomic section of the thoracic spine through the
T4 vertebral body, transverse process, and the rib corresponding to the level at which the
transverse scan is performed in the midline (position 1 in Fig. 11-24). Note the
costotransverse junction (CTJ) on either side.

FIGURE 11-26 Cross-sectional cadaver anatomic section of the thoracic spine through the
T3 vertebral body and transverse process corresponding to the level at which the transverse
scan is performed at the level of the transverse process (position 3 in Fig. 11-24). CTJ,
costotransverse junction; TPVS, thoracic paravertebral space; Eo, esophagus.

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FIGURE 11-27 Cross-sectional cadaver anatomic section of the thoracic spine through the
T4 vertebral body and inferior articular process of the vertebra corresponding to the level at
which the transverse scan is performed at the level of the articular process (position 4 in Fig.
11-24). Note the position of the intervertebral foramen (IVF) relative to the inferior articular
process and the spinal nerve root as it exits the IVF. TPVS, thoracic paravertebral space.

A low-frequency (5–2 MHz) curved array transducer (authors’ choice) can also be
used to perform a transverse scan of the thoracic paravertebral region and USG TPVB.
To the best of our knowledge there are limited published data describing the use of a
low-frequency ultrasound transducer for sonography during TPVB,17 and there are no
published data describing the detailed sonoanatomy of the thoracic paravertebral
region using a low-frequency curved array transducer. Our preliminary experience is
that satisfactory ultrasound images of the paravertebral region are obtained using a
low-frequency transducer. Also the wide field of vision produced by the divergent
ultrasound beam is an added advantage when compared to the narrow rectangular field
of view produced by a linear array transducer during USG TPVB. Furthermore the
ability to image at a depth with a low-frequency curved array transducer is an
advantage in the upper thoracic region because the thoracic paravertebral space is at a
greater depth. Using a curved array transducer the transverse scan can be performed
with the ultrasound beam being insonated at four different locations (Fig. 11-24): (1)
midline over the spinous process, (2) at the level of the rib and costotransverse
articulation/junction, (3) at the level of the transverse process, and (4) at the level of
the articular process. Corresponding cadaver anatomical sections are presented in Figs.
11-25 to 11-27 to demonstrate the anatomy visualized during the ultrasound scan.
Each of these four ultrasound scan windows produces a distinct sonogram
reflecting the different osseous and musculoskeletal structures that are visualized in
the sonograms. On a transverse sonogram in the midline (position 1, Fig. 11-24), the
spinous process is visualized as a bright hyperechoic dot with a corresponding
acoustic shadow anteriorly (Fig. 11-28). Due to the steep caudal angulation of the
thoracic spinous processes in the midthoracic region, the spinous process that is
visualized on the sonogram arises from the vertebra above rather than that from which

483
 the transverse process, lamina, and the articular process arise (Fig. 11-29). Because the
spinous process and transverse process cast a large acoustic shadow, visualization of
the paravertebral anatomy is limited in this ultrasound scan window. Also the acoustic
shadow of the spinous process, lamina, transverse process, and ribs produce a
sonographic pattern that we refer to as the “flying swan sign” due to its close
resemblance to a swan in flight (Fig. 11-30).

FIGURE 11-28 Median transverse scan of the thoracic spine (midthoracic region) using a
low-frequency curved array transducer with the ultrasound beam being insonated over the
spinous process (position 1 in Fig. 11-24). Note the hyperechoic spinous process with its
acoustic shadow in the midline. The hyperechoic lamina and the posteriorly directed
transverse process (TP) are also seen laterally on either side of the midline. The acoustic
shadow of the SP, TP, and the lamina produces a sonographic pattern that resembles a “flying
swan” (details in text) and completely obscures the spinal canal and the paravertebral space.

484
FIGURE 11-29 Figure illustrating the structures that are insonated during a median
transverse scan of the midthoracic spine. Note the posteriorly directed transverse processes.
Also due to the acute caudal angulation of the thoracic spinous processes, the posterior
elements of the vertebra (ie, the lamina and transverse process), which are insonated, are
from the vertebra one level below.

FIGURE 11-30 Figure demonstrating the outlines of the bony elements that are insonated
during a median transverse ultrasound scan of the thoracic spine and how the acoustic
shadow produced resembles a swan in flight (“flying swan sign”).

485
 With the ultrasound transducer positioned slightly laterally (position 2, Fig. 11-24),
the hyperechoic outlines of the lamina, transverse process, and the rib with their
corresponding acoustic shadows are clearly delineated (Fig. 11-31). However, unlike
the transverse process of the lumbar vertebra, which are more or less at right angles to
the vertebral body, the transverse processes in the thoracic spine are directed
posteriorly (Fig. 11-32), and this posterior angulation can be clearly delineated in the
transverse sonogram (Fig. 11-31). Once the transverse process, costotransverse
articulation, and the rib are identified, one can gently slide or tilt the transducer
caudally until the acoustic shadow of the rib is no longer visualized (position 3, Fig.
11-24), and the hyperechoic outline of the lamina and transverse process with their
acoustic shadow are seen (Fig. 11-33). Lateral to the transverse process, the
hyperechoic pleura and lung are visualized anteriorly, the thick hyperechoic SCTL
posteriorly, and the hypoechoic apical part of the TPVS is interposed between the two
(Fig. 11-33). If one now gently slides or tilts the ultrasound transducer slightly
caudally (position 4, Fig. 11-24), the acoustic shadow of the transverse process
disappears, and the hyperechoic articular process (inferior) with its acoustic shadow is
seen medially (Fig. 11-34). As in the ultrasound scan at the level of the transverse
process (Fig. 11-33), the SCTL, parietal pleura, lung, and the apical part of the
paravertebral space are also clearly delineated. However, because the acoustic shadow
of the transverse process is no longer present, outlines of the true TPVS can now be
visualized (Fig. 11-34). Currently the majority of the published data describing the use
of a transverse scan for TPVB have used the ultrasound scan window at the level of
the transverse process (position 3, Fig. 11-24),17,18,20 and there are limited published
data describing the use of the transverse ultrasound scan window at the level of the
articular process for TPVB. Because there is less bony obstruction through the
intertransverse space and at the level of the articular process (position 4, Fig. 11-24), it
is our preferred route for imaging and needle insertion during an USG TPVB.
However, ultrasound visibility of the paravertebral anatomy is more challenging in the
upper thoracic region (Figs. 11-35 to 11-37). This may be related to the increased
depth to the paravertebral space and anisotropy, from the pleura reflecting away from
the paravertebral space, in the upper thoracic region (Fig. 11-36). Despite some of
these limitations, it is possible to perform a transverse scan of the TPVS at all
segments of the thoracic spine for TPVB (Figs. 11-35 to 11-44). We have successfully
used this approach for both single-injection and multi-injection TPVB at all levels of
the thoracic spine.

486
FIGURE 11-31 Paramedian transverse scan of the right thoracic paravertebral region using
a low-frequency curved array transducer with the ultrasound beam being insonated over the
transverse process (TP) and the rib (position 2 in Fig. 11-24). Note the posteriorly directed
TP and how the acoustic shadow of the TP and rib completely obscures the underlying
paravertebral anatomy.

FIGURE 11-32 Figure showing the difference in the size, shape, and orientation of the
transverse process (TP) of a thoracic and lumbar vertebra. Note how the TP of a thoracic
vertebra is directed posteriorly. SP, spinous process; AP, articular process; TP, transverse
process; SC, spinal canal; VB, vertebral body.

487
FIGURE 11-33 Paramedian transverse scan of the right thoracic paravertebral region using
a low-frequency curved array transducer with the ultrasound beam being insonated over the
transverse process (TP, position 3 in Fig. 11-24). Note the hyperechoic TP and its acoustic
shadow. The apex of the thoracic paravertebral space (TPVS), parietal pleura, and the
superior costotransverse ligament are seen lateral to the TP. SCTL, superior costotransverse
ligament.

FIGURE 11-34 Paramedian transverse scan of the right thoracic paravertebral region using
a low-frequency curved array transducer with the ultrasound beam being insonated through
the intertransverse space, that is, between two adjoining thoracic transverse processes
(position 4 in Fig. 11-24). Note the hyperechoic inferior articular process and its acoustic
shadow medially, which obscures the underlying intervertebral foramen (IVF). As with the
paramedian transverse scan at position 3, the apex of the thoracic paravertebral space

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(TPVS), parietal pleura, and the superior costotransverse ligament (SCTL) are visualized
laterally, but the area of the acoustic shadow is smaller in this ultrasound scan window
(compare with Fig. 11-33). PSM, paraspinal muscle.

FIGURE 11-35 Paramedian transverse scan of the right upper thoracic paravertebral
region (T1 level), using a low-frequency curved array transducer, with the ultrasound beam
being insonated at the level of the transverse process (TP) and rib. CTJ, costotransverse
junction.

FIGURE 11-36 Paramedian transverse scan of the right upper thoracic paravertebral
region (T1 level) using a low-frequency curved array transducer, with the ultrasound beam
being insonated at the level of the articular process. Note the pleura is not clearly delineated
in the transverse sonogram, and it is also located at a depth at this level (compare with that in

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the midthoracic region, Fig. 11-41). TPVS, thoracic paravertebral space.

FIGURE 11-37 Paramedian transverse scan of the right upper thoracic paravertebral
region (T1 level) using a low-frequency curved array transducer with the ultrasound beam
being insonated at the level of the transverse process (TP). Note the slight caudal orientation
of the ultrasound transducer. SCTL, superior costotransverse ligament.

FIGURE 11-38 Paramedian transverse scan of the right upper thoracic paravertebral
region (T1 level) using a low-frequency curved array transducer with the ultrasound beam
being insonated at the level of the articular process. Once again, note the slight caudal
orientation of the ultrasound transducer. SCTL, superior costotransverse ligament; TPVS,
thoracic paravertebral space.

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FIGURE 11-39 Paramedian transverse scan of the right midthoracic paravertebral region
using a low-frequency curved array transducer, with the ultrasound beam being insonated at
the level of the transverse process (TP) and rib. SP, spinous process; CTJ, costotransverse
junction.

FIGURE 11-40 Paramedian transverse scan of the right midthoracic paravertebral region
using a low-frequency curved array transducer, with the ultrasound beam being insonated at
the level of the transverse process (TP). SCTL, superior costotransverse ligament; TPVS,
thoracic paravertebral space.

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FIGURE 11-41 Paramedian transverse scan of the right midthoracic paravertebral region
using a low-frequency curved array transducer with the ultrasound beam being insonated at
the level of the articular process and rib. IVF, intervertebral foramen; TPVS, thoracic
paravertebral space; SCTL, superior costotransverse ligament.

FIGURE 11-42 Paramedian transverse scan of the right lower thoracic paravertebral
region using a low-frequency curved array transducer with the ultrasound beam being
insonated at the level of the transverse process (TP) and rib. CTJ, costotransverse junction.

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FIGURE 11-43 Paramedian transverse scan of the right lower thoracic paravertebral
region using a low-frequency curved array transducer with the ultrasound beam being
insonated at the level of the transverse process (TP). TPVS, thoracic paravertebral space.

FIGURE 11-44 Paramedian transverse scan of the right lower thoracic paravertebral
region using a low-frequency curved array transducer with the ultrasound beam being
insonated at the level of the articular process. IVF, intervertebral foramen; SCTL, superior
costotransverse ligament; TPVS, thoracic paravertebral space.

b.Sagittal sonoanatomy of the thoracic paravertebral region:

Published data on sagittal sonography of the thoracic paravertebral region in the
clinical setting are limited and have been described with the use of a high-frequency
linear array transducer.11,15 During a sagittal scan of the thoracic paravertebral region,

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 the ultrasound transducer is positioned 2 to 3 cm lateral to the midline (paramedian)
with its orientation marker directed cranially (Figs. 11-45 to 11-47). On a sagittal
sonogram the transverse processes are seen as hyperechoic and rounded structures
deep to the paraspinal muscles, and they cast an acoustic shadow anteriorly (Fig. 11-
48). In between the acoustic shadows of two adjacent transverse processes, an acoustic
window is produced by reflections from the SCTL and intertransverse ligaments, the
paravertebral space and its contents, the parietal pleura, and lung tissue (in a posterior-
to-anterior direction) (Fig. 11-48).

FIGURE 11-45 Figure demonstrating the position of the patient (lateral in this image) and
how the ultrasound transducer is oriented during a paramedian sagittal scan of the thoracic
paravertebral region.

FIGURE 11-46 Figure showing how the ultrasound beam is insonated during a

494
paramedian sagittal scan of the thoracic paravertebral region.

FIGURE 11-47 Figure illustrating the various anatomical structures that are insonated
during a paramedian sagittal ultrasound scan of the thoracic paravertebral region.

FIGURE 11-48 Paramedian sagittal sonogram of the thoracic paravertebral region. Note
that although the superior costotransverse ligament, pleura, and the paravertebral space are
visible, they are not clearly delineated (compare with Fig. 11-52 from the same patient). TP,
transverse process.

Ultrasound visibility of the paravertebral structures is relatively poor in a true

sagittal scan (Figs. 11-49 and 11-50), and this is true with both high-frequency (Fig.
11-49) and low-frequency (Fig. 11-50) transducers. This may be due to the loss of
spatial resolution at the depth at which the paravertebral structures are located. Also
anisotropy from the ultrasound beam not being at right angles to the pleura due to its

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 anteromedial reflection close to the vertebral bodies (Fig. 11-46) may play a part.
Ultrasound visibility of the paravertebral structures can be improved by gently tilting
the ultrasound transducer laterally (ie, outward) during the sagittal scan (paramedian
sagittal oblique axis, Figs. 11-51 and 11-52). This maneuver improves imaging by
reducing the distance from the skin to pleura (reduced attenuation), and the ultrasound
beam is also more at right angles to the pleura (reduced anisotropy (Fig. 11-51). It is
difficult to define an optimal angle of lateral tilt for the paramedian sagittal oblique
scan, but in clinical practice we recommend that one should gently tilt the transducer
outward (laterally) until the parietal pleura is clearly visualized (Fig. 11-52). A pitfall
of the lateral tilt maneuver is that one may see the same result if the ultrasound
transducer is inadvertently manipulated or tilted too far laterally so that it is now
insonating the rib and the posterior intercostal space (Figs. 11-53 and 11-54) instead of
the transverse process and the apical part of the paravertebral space. The clinical
implication is that one may unknowingly perform a posterior intercostal injection
instead of a paravertebral injection, and depending on the approach used the potential
for pleural puncture may be greater with the intercostal injection. Also segmental
spread of anesthesia is limited with an intercostal injection. Therefore, it is important
to differentiate the transverse process (Fig. 11-55) from a rib (Fig. 11-56) in the
sagittal sonogram of the thoracic paravertebral region (Fig. 11-57).

FIGURE 11-49 Paramedian sagittal scan of the right midthoracic paravertebral region
using a high-frequency linear transducer. Note the paravertebral structures, including the
parietal pleura and the paravertebral space, are not clearly delineated in this image. TP,
transverse process; SCTL, superior costotransverse ligament; TPVS, thoracic paravertebral
space.

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FIGURE 11-50 Paramedian sagittal scan of the right midthoracic paravertebral region
using a low-frequency curvilinear transducer. Note the paravertebral structures, including the
parietal pleura and the paravertebral space, are not clearly delineated in the sagittal sonogram.
TP, transverse process; SCTL, superior costotransverse ligament; TPVS, thoracic
paravertebral space.

FIGURE 11-51 Figure illustrating how the ultrasound beam is insonated during a
paramedian sagittal oblique scan of the thoracic paravertebral region.

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FIGURE 11-52 Paramedian sagittal oblique sonogram of the thoracic paravertebral region.
Note the pleura, superior costotransverse ligament, and the paravertebral space are now
clearly delineated (same patient as in Fig. 11-48). TP, transverse process.

FIGURE 11-53 Paramedian sagittal oblique scan of the right midthoracic paravertebral
region, using a high-frequency linear transducer, whereby the ribs instead of the transverse
process are being insonated. Note the intercostal muscles (not the superior costotransverse
ligament), pleura, and the posterior intercostal space are clearly delineated in this sonogram.

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FIGURE 11-54 Paramedian sagittal oblique scan of the right midthoracic paravertebral
region using a low-frequency curved array transducer whereby the ribs instead of the
transverse processes are being insonated. Note the pleura is clearly delineated in this
sonogram.

FIGURE 11-55 A multiplanar 3-D view of the thoracic paravertebral region with the
reference marker, or “marker dot,” placed over the transverse process (TP). Note how the
three slice planes (red – transverse, green – sagittal, and blue – coronal) have been obtained
and how the superior costotransverse ligament (SCTL) is continuous with the internal
intercostal membrane (IICM) laterally in the coronal plane. TPVS, thoracic paravertebral
space; CTJ, costotransverse junction.

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FIGURE 11-56 A multiplanar 3-D view of the thoracic paravertebral region in color (sepia
tone) with the reference marker, or “marker dot,” placed over the apex of the thoracic
paravertebral space (TPVS). Note the hyperechoic pleura in the coronal plane. SCTL,
superior costotransverse ligament; TPVS, thoracic paravertebral space; TP, transverse
process.

FIGURE 11-57 A sequence of sagittal sonograms of the thoracic paravertebral region

(from the same subject) showing the transition of the anatomy from the level of the lamina to
the ribs. Note the difference in the sonographic appearance of the lamina, transverse process
(TP), and the ribs. Also note the relative depths at which each structure is located. The
articulation of the rib with the transverse process at the CTJ (costotransverse junction) is

500
clearly delineated in Fig. 11-57D. Also note that the pleura is not clearly visualized at the
level of the TP, but it is at the level of the ribs. ES, epidural space; ILS, interlaminar space;
LF, ligamentum flavum; SCTL, superior costotransverse ligament; TPVS, thoracic
paravertebral space; ICM, intercostal muscles; ICS, intercostal space.

We are not aware of any published data validating the sonoanatomy of the thoracic
paravertebral region, but it is our experience that there is good correlation between
structures that are visualized in a thoracic paravertebral sonogram and that in
corresponding anatomical sections, CT, and MRI images of the thoracic paravertebral
region (Figs. 11-58 to Fig. 11-60). However, irrespective of the plane of ultrasound
imaging, we still have not been able to delineate the intercostal nerve or its branches
with currently available ultrasound technology. The intercostal blood vessels are more
readily visualized close to the inferior border of the transverse process using Color or
Power Doppler ultrasound (Figs. 11-61 and 11-62).

FIGURE 11-58 Correlative transverse cadaver anatomic (Fig. 11-58A), CT (Fig. 11-58B),
MRI (T2-weighted, Fig. 11-58C), and ultrasound (Fig. 11-58D) images of the thoracic
paravertebral region from the level of the thoracic vertebral body, transverse process, and the
rib corresponding to the level at which the transverse scan was performed in the midline
(position 1, Fig. 11-24). PSM, paraspinal muscle; VB, vertebral body; TP, transverse process.

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FIGURE 11-59 Correlative transverse cadaver anatomic (Fig. 11-59A), CT (Fig. 11-59B),
MRI (T2-weighted, Fig. 11-59C), and ultrasound (Fig. 11-59D) images of the thoracic
paravertebral region from the level of the vertebral body and transverse process
corresponding to the level at which the transverse scan was performed (position 3, Fig. 11-
24). E0, esophagus; CTJ, costotransverse junction; TPVS, thoracic paravertebral space; VB,
vertebral body; PSM, paraspinal muscle; IVF, intervertebral foramen; TP, transverse process;
SCTL, superior costotransverse ligament.

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FIGURE 11-60 Correlative transverse cadaver anatomic (Fig. 11-60A), CT (Fig. 11-60B),
MRI (T2-weighted, Fig. 11-60C), and ultrasound (Fig. 11-60D) images of the thoracic
paravertebral region from the level of the vertebral body and inferior articular process
corresponding to the level at which the transverse scan was performed (position 4, Fig. 11-
24). TPVS, thoracic paravertebral space; IVF, intervertebral foramen; SCTL, superior
costotransverse ligament; VB, vertebral body; PSM, paraspinal muscle; SP, spinous process.

FIGURE 11-61 Paramedian sagittal oblique sonogram of the thoracic paravertebral region
showing the Color Doppler signal from the intercostal artery at the apex of the paravertebral
space. TP, transverse process.

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FIGURE 11-62 Paramedian transverse sonogram of the thoracic paravertebral region at
the level of the inferior articular process showing the Power Doppler signal from the
intercostal artery in the paravertebral space. PSM, paraspinal muscle; SCTL, superior
costotransverse ligament; TPVS, thoracic paravertebral space.

Three-Dimensional Sonography of the Thoracic

Paravertebral Region
As described earlier, it is possible to obtain high-resolution 2-D ultrasound images of the
paravertebral anatomy in the transverse10,14,17,18 and sagittal11,15 axes. However, this
requires the operator to rotate the ultrasound transducer through 90 degrees. Three-
dimensional ultrasound imaging technology is currently available (Fig. 11-63) and allows one
to simultaneously visualize the anatomy of a volume or area of interest in the transverse,
sagittal, and coronal planes without having to move or rotate the transducer.46 Using
traditional 2-D ultrasound it is not possible to obtain ultrasound images of the paravertebral
anatomy in the coronal axis. The coronal view presents the anatomy as though one were
looking down on to the surface being imaged, analogous to a “bird’s-eye view” and has also
been referred to as the “architectural” or “plan view.”47 The potential utility of the coronal
view during USG regional anesthesia is not clear, but has been used to visualize the spread of
a local anesthetic on either side of a nerve47 during peripheral nerve blockade. We have
recently demonstrated that it is feasible to perform volumetric 3-D ultrasound imaging of the
thoracic paravertebral region and study the acquired data set in various 3-D formats.46

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FIGURE 11-63 3-D ultrasound scan. (A). The Philips iU22 Ultrasound System, (B) the
high-frequency 3-D and 4-D integrated mechanical volume linear array transducer (VL13,
13–5 MHz) used for the scan, and (C) the position of the volunteer and the orientation of the
transducer during the data acquisition.

In a multiplanar view of the thoracic paravertebral volume (anatomy) it is possible to

simultaneously visualize the transverse (x-axis), sagittal (y-axis), and coronal (z-axis) images
of the paravertebral anatomy46 (Figs. 11-21, 11-55, and 11-56). Moreover, when the
“reference marker,” a point where all the three orthogonal planes intersect, is moved in any of
the 2-D images of the multiplanar display, it automatically updates its position in the other 2-
D images. This allows one to navigate through or electronically dissect through the
paravertebral volume, which helps in better understanding the 3-D anatomy of the
paravertebral region. Also, by using the reference marker it is possible to visualize a specific
point or anatomical structure in all three planes simultaneously. This feature facilitates
validation of the sonographic appearance of a given anatomical structure in the paravertebral
region (Figs. 11-55 and 11-56) and to exclude artifacts. We have also demonstrated that the
anatomical information obtained in a 3-D ultrasound image is more detailed than that seen in
a 2-D ultrasound image.46 Structures such as the costotransverse junction (Fig. 11-55)46 and
all six surfaces (faces) (Fig. 11-64) or a given surface (Fig. 11-65) of the paravertebral
volume, which are otherwise not visualized using 2-D ultrasound imaging, are clearly
delineated using 3-D ultrasound. One is also able to display and study the acquired data set
like a computerized tomogram (Figs. 11-66 and 11-67). Overall, volumetric 3-D ultrasound
imaging allows the anesthesiologists to develop a better spatial awareness of the paravertebral
anatomy.46

505
FIGURE 11-64 Rendered 3-D volumes of the thoracic paravertebral region showing the
cranial, caudal, lateral, medial, and posterior surfaces of the acquired paravertebral volume.

FIGURE 11-65 A rendered 3-D volume of the thoracic paravertebral region. The acquired
paravertebral volume has been rendered such that the sagittal anatomy is being visualized
from the lateral (intercostal space) side. Note the apical part of the TPVS (thoracic
paravertebral space) is clearly delineated between the SCTL (superior costotransverse
ligament) and the parietal pleura. TP, transverse process.

506
FIGURE 11-66 A transverse iSlice display of the thoracic paravertebral region in color
(blue tone). In this figure, 16 contiguous transverse ultrasound images of the acquired
paravertebral volume that are 1 mm apart are displayed. CTJ, costotransverse junction;
SCTL, superior costotransverse ligament; TPVS, thoracic paravertebral space; TP, transverse
process.

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FIGURE 11-67 A sagittal iSlice display of the thoracic paravertebral region in color (sepia
tone). In this figure, 16 contiguous sagittal ultrasound images of the acquired paravertebral
volume that are 1 mm apart are displayed. CTJ, costotransverse junction; SCTL, superior
costotransverse ligament; TPVS, thoracic paravertebral space; TP, transverse process.

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17.Renes SH, Bruhn J, Gielen MJ, Scheffer GJ, van Geffen GJ. In-plane ultrasound-guided
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mode of action. Br J Anaesth. 1984;56:627–630.
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40.Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. Single-injection
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CHAPTER 12

Sonoanatomy Relevant for Ultrasound-Guided Lumbar

Plexus Block

Introduction
Lumbar plexus block (LPB),1,2 also referred to as a psoas compartment block (PCB),3,4 is
frequently used on its own or in combination with a sciatic nerve block for anesthesia and/or
analgesia during hip or lower extremity surgery.1,3,5,6 During an LPB the local anesthetic is
injected into a fascial plane within the posterior aspect of the psoas muscle.7 This produces
complete blockade of the major components of the ipsilateral lumbar plexus, namely the
femoral nerve (FN), lateral femoral cutaneous nerve (LFC), and the obturator nerve (OBN).8
The term PCB was originally coined by Chayen and colleagues.4 They believed that branches
of the lumbar plexus and parts of the sacral plexus were located close to each other in a
“compartment,” between the psoas and quadratus lumborum muscle (an “intermuscular
compartment”) at the level of the L4 vertebra, which could be identified using a “loss of
resistance” technique.4 However, recent research has demonstrated that the lumbar plexus is
located within the substance of the psoas muscle.7 PCB is also referred to as posterior lumbar
plexus block,1 and several variations of this technique have been described in the
literature.2,3 LPB is traditionally performed using peripheral nerve stimulation,8 but with the
recent widespread use of ultrasound guidance for regional anesthesia ultrasound-guided
(USG) LPB has also been described.9,10 A clear understanding of the sonoanatomy of the
lumbar paravertebral region9––11 is a prerequisite to safely performing USG LPB.9,10

Gross Anatomy
The lumbar plexus is formed by the union of the anterior primary rami of the L1, L2, and L3
spinal nerves and the greater part of the L4 nerve (Figs. 3-1 and 12-1). The L1 nerve root may
also receive contribution from the T12 spinal nerve. In the majority of individuals the lumbar
plexus is located in a fascial plane or compartment within the substance of the psoas muscle
(Figs. 12-2 to 12-4).7,11 We will henceforth refer to this intramuscular fascial compartment as
the psoas compartment. Anatomically the psoas compartment is located between the fleshy
anterior two-thirds of the psoas muscle and the posterior one-third of the muscle (Figs. 12-3
and 12-4).7,11 Therefore, the lumbar plexus is sandwiched between two portions of the psoas
muscle and closely related to the lumbar transverse processes (Figs. 12-2 to 12-8). The
bulkier anterior (fleshy) part of the psoas muscle originates from the anterolateral surface of
the lumbar vertebral bodies and their intervertebral disc, whereas the thinner posterior
(accessory) portion of the muscle originates from the anterior aspect of the lumbar transverse

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processes (Fig. 12-3).7 Also the anterior and posterior parts of the psoas muscle fuse to form
the main muscle bulk, but close to the vertebral bodies these two parts are separated by a
fascia7 or space within which the lumbar nerve roots, branches of the lumbar artery, and the
ascending lumbar veins are located (Figs. 12-2 to 12-6).7,11 This wedge-shaped space close
to the intervertebral foramen is the lumbar paravertebral space (LPVS) (Fig. 12-7).11

FIGURE 12-1 Anatomy of the lumbar plexus with its three major components: the lateral
femoral cutaneous nerve, obturator nerve, and the femoral nerve. Note the anatomical relation
of the lumbar plexus to the transverse processes.

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FIGURE 12-2 Figure showing the anatomical relation of the lumbar plexus to the psoas
muscle and how the nerves of the lumbar plexus (iliohypogastric, ilioinguinal, lateral femoral
cutaneous, femoral, and obturator) emerge from the psoas muscle.

FIGURE 12-3 Location of the lumbar nerve root within the substance of the psoas muscle
and their relation to the transverse process.

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FIGURE 12-4 Transverse anatomy of the lumbar paravertebral region at the L4 vertebral
level. Note the origin and branching of the lumbar artery. Ao, aorta; IVC, inferior vena cava;
RPS, retroperitoneal space; EOM, external oblique muscle; IOM, internal oblique muscle;
TAM, transversus abdominis muscle; PM, psoas muscle; QLM, quadratus lumborum muscle;
IVF, intervertebral foramen; DBLA, dorsal branch of lumbar artery; LPVS, lumbar
paravertebral space; NR, nerve root; PC, psoas compartment; LPlx, lumbar plexus; VB,
vertebral body; AP, articular process; ESM, erector spinae muscle.

FIGURE 12-5 Cadaver dissection image showing the lumbar plexus nerves within the
substance of the psoas muscle. The psoas muscle has been split longitudinally to expose the
lumbar plexus nerves within the posterior aspect of the muscle.

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FIGURE 12-6 Cross-sectional cadaver anatomic section through the L4 vertebral body and
transverse process corresponding to the level at which the PMTOS-TP (paramedian
transverse oblique scan at the level of the transverse process) was performed. ESM, erector
spinae muscle; PM, psoas muscle; QLM, quadratus lumborum muscle; AP, articular process;
LF, ligamentum flavum; ES, epidural space; VB, vertebral body; TP, transverse process.

FIGURE 12-7 Cross-sectional cadaver anatomical section from just inferior to the L4
transverse process and through the lower part of the L4 vertebral body corresponding to the
level at which the PMTOS-ITS (paramedian transverse oblique scan through the space
between two adjacent transverse processes) was performed. Note the intervertebral foramen

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(IVF) and the L4 spinal nerve root as it exits the IVF to enter the lumbar paravertebral space
(LPVS). Also note the relation of the L3 nerve of the lumbar plexus to the L4 nerve root
close to the L4 IVF. This is because the L3 lumbar nerve root after it exits the IVF takes a
steep caudal course through the posterior part of the psoas muscle. PM, psoas muscle; QLM,
quadratus lumborum muscle; IVF, intervertebral foramen; AP, articular process; LPVS,
lumbar paravertebral space; ESM, erector spinae muscle; VB, vertebral body.

FIGURE 12-8 Sagittal cadaver anatomic section showing the relation of the lumbar plexus
to the transverse process (TP) and the psoas muscle (PM). The reference marker of the Java
application, seen in this figure as a green cross-hair, is over the L3 nerve of the lumbar plexus
(same as in Fig. 8-7). The L3 nerve of the lumbar plexus is seen in a fat-filled “intramuscular
compartment,” that is, the psoas compartment between the thick fleshy anterior and a thin
posterior part of the psoas muscle between the L3 and L4 TP. ESM, erector spinae muscle.

The lumbar nerve root after it exits the intervertebral foramen enters the fat-filled LPVS
(Fig. 12-7). However, the lumbar nerve root, instead of entering the psoas muscle at the same
vertebral level, takes a steep caudal course and enters the substance of the psoas muscle at the
vertebral level below (Fig. 12-9). This explains why the L3 nerve of the lumbar plexus lies
opposite the L4 intervertebral foramen and the L4 nerve root (Fig. 12-7). Also as seen in the
sagittal anatomic section (Fig. 12-8), the L3 nerve of the lumbar plexus is located in an
intramuscular compartment (ie, the psoas compartment) between the thick fleshy anterior and
a thin posterior part of the psoas muscle. Outlines of the psoas compartment with the lumbar
plexus can also be delineated in the transverse anatomic section (Fig. 12-7). Once the plexus
is formed it displays a triangular shape, narrow in its superior portion and wider in its lower
portion (Fig. 12-1). The nerves that originate from the plexus also exhibit a fanned-out

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distribution with the LFC being outermost, the OBN innermost, and the femoral nerve in
between (Fig. 12-1). Being a fusiform muscle (ie, shaped like a spindle), the width of the
psoas muscle is wider at its belly, close to the lower lumbar region, than at its origin and
insertion. There are also gender- (male > female)–12 and race- (black > white)–13 related
differences in the width and cross-sectional area of the psoas muscle. The position of the
lateral femoral cutaneous nerve and femoral nerve within the psoas compartment is relatively
consistent,7 but the position of the obturator can be variable and may even lie in a fold of the
psoas muscle separate from that enclosing the other two nerves (Fig. 12-10).7 The depth from
the skin to the lumbar plexus also varies with gender and body mass index (BMI). Such
differences in anthropometric parameters may be relevant when performing an LPB.

FIGURE 12-9 Coronal cadaver anatomic section showing how the lumbar nerve roots
after they exit the intervertebral foramen take a steep caudal course and enter the substance of
the psoas muscle (PM) more caudally. Also seen is the formation of the lumbar plexus within
the substance of the psoas muscle (PM). The reference marker of the Java application, seen in
this figure as a green cross-hair, is over the L3 nerve of the lumbar plexus (same as in Figs. 8-
7 and 8-8). VB, vertebral body; ITS, intrathecal space; CE, cauda equina; NR, nerve root.

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FIGURE 12-10 Figure showing the position of the (1) lateral femoral cutaneous nerve, (2)
femoral nerve, and (3) obturator nerve in the psoas compartment. Note that whereas the
position of 1 and 2 are fairly consistent, the position of 3 can vary and may even lie in a
separate intramuscular fold (C) or compartment separate from the psoas compartment (D).

Computed Tomography Anatomy of the Lumbar Paravertebral Region

Figs. 12-11 and 12-12

FIGURE 12-11 Transverse CT of the abdomen at the level of the body and transverse
process of the L4 vertebra corresponding to the level at which the PMTOS-TP (paramedian
transverse oblique scan at the level of the transverse process) is performed. Note the position
of the inferior vena cava and the aorta relative to the vertebral body. VB, vertebral body.

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FIGURE 12-12 Transverse CT of the abdomen at the level of the body and articular
process (inferior) of the L4 vertebra corresponding to the level at which the PMTOS-ITS
(paramedian transverse oblique scan through the intertransverse space) is performed. VB,
vertebral body; LPVS, lumbar paravertebral space.

Magnetic Resonance Imaging Anatomy of the Lumbar Paravertebral Region

Figs. 12-13 to 12-16

FIGURE 12-13 Transverse T1-weighted MRI at the level of the L4 vertebral body and the
transverse process corresponding to the level at which the PMTOS-TP (paramedian
transverse oblique scan at the level of the transverse process) is performed. The L3 nerve root
of the lumbar plexus is seen as the hypointense nerve outlined by a layer of hyperintense fat
in the posterior aspect of the psoas muscle close to the angle between the vertebral body and

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the transverse process. PM, psoas major muscle; QLM, quadratus lumborum muscle; ESM,
erector spinae muscle; IVC, inferior vena cava; NR, nerve root; ITS, intrathecal space; VB,
vertebral body.

FIGURE 12-14 Transverse T1-weighted MRI image from just below the L4 transverse
process and through the lower half of the body of L4 vertebra and the articular process
(inferior) corresponding to the level at which the PMTOS-ITS (paramedian transverse
oblique scan through the intertransverse space) is performed. Note the hypointense L4 nerve
root as it exits the intervertebral foramen (IVF) and enters the hyperintense fat-filled lumbar
paravertebral space (LPVS). Also seen in the posterior aspect of the psoas muscle is the L3
nerve of the lumbar plexus, which is surrounded by a layer of hyperintense fat, and in an
intramuscular compartment (ie, the “psoas compartment”). PM, psoas major muscle; QLM,
quadratus lumborum muscle; ESM, erector spinae muscle; VB, vertebral body; AP, articular
process; LPVS, lumbar paravertebral space; ITS, intrathecal space; NR, nerve root; IVF,
intervertebral foramen.

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FIGURE 12-15 Sagittal T1-weighted MRI image of the lumbar paravertebral region at the
L3-L4-L5 vertebral level showing the steep caudal course of the lumbar nerve roots. Note the
hypointense lumbar plexus nerves are located in an intramuscular compartment in the
posterior part of the psoas muscle (ie, the “psoas compartment”), which is filled with
hyperintense fatty tissue. TP, transverse process; PM, psoas major muscle.

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FIGURE 12-16 Coronal T1-weighted MRI image at the L3-L4-L5 vertebral level showing
the steep caudal course of the lumbar spinal nerves after they emerge from the intervertebral
foramen (IVF). Note the hypointense lumbar nerve roots (NR), after they emerge from the L4
IVF, enter a hyperintense fat-filled space on the medial aspect of the psoas muscle (PM), that
is, the lumbar paravertebral space (LPVS), comparable to that seen in Figs. 12-12 and 12-14.
VB, vertebral body.

Lumbar Paravertebral Sonography

Ultrasound Scan Technique
1.Position:
a.Patient: The authors prefer to position the patient in the lateral position with the side to
be blocked uppermost (Fig. 12-17A).9,10 The hips and knees of the patient are also
flexed to mimic the position normally adapted during an LPB. The ultrasound scan
can also be performed with the patient in the prone position, but the disadvantage is
impaired visualization of the quadriceps muscle contraction during an LPB if nerve
stimulation is used.
b.Operator and ultrasound machine: The operator sits or stands behind the patient, and
the ultrasound machine is placed directly in front on the contralateral side.
2.Transducer selection: Because the lumbar plexus and psoas muscle are located at a depth
in the abdomen and pelvis, it necessitates the use of a low-frequency ultrasound (5–2
MHz) and curved array transducer to image the lumbar paravertebral region.9–11 Low-
frequency ultrasound provides good penetration but lacks spatial resolution at the depths
(5–9 cm) at which the anatomy relevant for LPB is located. The latter often compromises
the ability to locate the lumbar plexus within the psoas muscle. However, recent
improvements in ultrasound technology, image processing capabilities of ultrasound

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 machines, the availability of compound imaging and tissue harmonic imaging (THI), and
the use of new scan protocols have significantly improved our ability to image the lumbar
paravertebral region. Today, we are not only able to accurately delineate the lumbar
plexus, but also the adjoining paravertebral anatomy.9–11

FIGURE 12-17 Position of the volunteer (Fig. 12-17A) and the plane of ultrasound
imaging during a sagittal and transverse scan of the lumbar paravertebral region. A picture of
the ultrasound transducer and the plane of the ultrasound beam (green pane) has been
superimposed onto the transverse cadaver anatomic sections to illustrate how the ultrasound
beam was insonated during the sagittal (Fig. 12-17B), PMTOS-TP (paramedian transverse
oblique scan at the level of the transverse process, Fig. 12-17C), and PMTOS-ITS
(paramedian transverse oblique scan through the intertransverse space, Fig. 12-17D). A –
midline, B – intercristal line, C – sagittal scan line, X – a point 4 cm from the midline along
the intercristal line.

3.Scan technique: An ultrasound scan of the lumbar paravertebral region for USG LPB can
be performed in the sagittal (Fig. 12-17B)9,–14 or transverse (Figs. 12-15C and 12-
15D)10,11,14 axis. The following anatomical landmarks are identified and marked on the
skin of the nondependent side of the back using a skin marking pen: posterior superior
iliac spine, iliac crest, lumbar spinous processes (midline, line A, Fig. 12-17A) and the
intercristal line (line B, Fig. 12-17A). Thereafter a line (line C) parallel to the midline and
which intersects the intercristal line (line B) at a point 4 cm lateral to the midline,
corresponding to the point of needle insertion during a landmark-based LPB, is also
marked (sagittal scan line) (Fig. 12-17A). The target vertebral level for the ultrasound
scan (L3-L4-L5) is then identified as previously described.–15,–16 This involves
visualizing the lumbosacral junction (L5–S1 gap) on a sagittal sonogram and then
counting cranially to locate the lamina and transverse processes of the L3, L4, and L5
vertebrae. For a sagittal scan, the ultrasound transducer is positioned over the sagittal scan
line (Fig. 12-18) with its orientation marker directed cranially. For a transverse scan the
ultrasound transducer, with its orientation marker directed laterally, is positioned 4 cm

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 lateral to the midline along the intercristal line and just above the iliac crest (Fig. 12-19).
The transducer is also directed slightly medially (Fig. 12-19) so as to produce a transverse
oblique view of the lumbar paravertebral region.10,11 During the paramedian transverse
oblique scan (PMTOS), the ultrasound beam can be insonated either at the level of the
transverse process (PMTOS-TP, Fig. 12-17C) or through the intertransverse space
(PMTOS-ITS, Fig. 12-17D).11 Alternatively a transverse scan can be performed by
placing the ultrasound transducer more anteriorly in the flank and above the iliac crest
(Figs. 12-15 to 12-20) as described by Sauter and colleagues with the “shamrock
technique.”–17

FIGURE 12-18 Position of the patient and the ultrasound transducer during a paramedian
sagittal scan of the lumbar paravertebral region. Note the ultrasound transducer with its
orientation marker directed cranially has been placed over the sagittal scan line (refer to Fig.
12-17A), which is a line 4 cm lateral and parallel to the midline (paramedian), at the level of
the iliac crest.

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FIGURE 12-19 Position of the patient and the ultrasound transducer during a paramedian
transverse oblique scan of the lumbar paravertebral region. The ultrasound transducer has
been placed lateral to the sagittal scan line and over the intercristal line with its orientation
marker directed laterally (outward). Also note how the transducer is angled medially for the
ultrasound scan.

FIGURE 12-20 The shamrock method of ultrasound imaging of the lumbar paravertebral
region for lumbar plexus block. (A) Position of the patient and the ultrasound transducer. (B)
The plane of ultrasound imaging during the shamrock method. A picture of the ultrasound
transducer and the plane of the ultrasound beam (green pane) have been superimposed onto
the transverse cadaver anatomic section of the lumbar region to illustrate how the ultrasound

525
beam is insonated during the scan.

4.Sonoanatomy:
a.Sagittal sonoanatomy:
On a sagittal sonogram the transverse processes of the lumbar vertebrae (L3-L4-L5)
are identified by their hyperechoic reflection and their corresponding acoustic shadow
anteriorly (Fig. 12-21).9 This produces a sonographic pattern that we refer to as the
lumbar ultrasound trident or the “trident sign”9 because of its similarity to the trident
(Latin for tridens or tridentis) that is often associated with Poseidon (the god of the sea
in Greek mythology) and the Trishula of the Hindu god Shiva. However one must bear
in mind that because the L5 transverse process is the shortest of the lumbar transverse
processes, it may be more difficult to locate and may require some degree of medial
orientation of the transducer until the ultrasound trident is visible. The psoas muscle is
seen in the acoustic window of the lumbar ultrasound trident (Fig. 12-21) as multiple
longitudinal hyperechoic striations against a hypoechoic background typical of muscle
(Fig. 12-22).9 The lumbar plexus may also be visualized in the posterior aspect of the
psoas muscle (Fig. 12-22).9 It appears hyperechoic (Fig. 12-22), is sonographically
distinct from the muscle fibers, and is more posterior in location than the
intramuscular tendons of the psoas muscle.9 The lumbar plexus nerves are also thicker
than the muscle fibers (Fig. 12-22) and take an oblique course through the psoas
muscle.9 A laterally positioned ultrasound transducer will produce a suboptimal view
without the ultrasound trident, but may visualize the lower pole of the kidney, which
lies anterior to the quadratus lumborum muscle (QLM), and can reach the L3 to L4
vertebral level in some individuals.

FIGURE 12-22 Sagittal sonogram of the lumbar paravertebral region showing the lumbar
plexus as a hyperechoic structure in the posterior aspect of the psoas muscle (PM) between
the L4 and L5 transverse processes. Also note the hyperechoic intramuscular tendons within
the substance of the psoas muscle. ESM, erector spinae muscle; IM, intramuscular.

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FIGURE 12-21 Sagittal sonogram of the lumbar paravertebral region showing the acoustic
shadows of the lumbar transverse processes (L3, L4, and L5), which produce a sonographic
pattern called the “trident sign.” The psoas muscle (PM) is seen in the intervening acoustic
window.

b.Transverse sonoanatomy – Paramedian transverse oblique scan:

In a typical PMTOS–TP, the erector spinae muscle, the transverse process, the psoas
muscle, quadratus lumborum muscle, and the anterolateral surface of the vertebral
body are visualized (Fig. 12-23).11 The psoas muscle appears hypoechoic, but areas of
hyperechogenicity are interspersed within the central part of the muscle (Fig. 12-23 to
12-25). These dots or speckles represent the intramuscular tendon fibers of the psoas
muscle, and they are more pronounced below the level of the iliac crest. The IVC (on
the right side, Fig. 12-24) and the aorta (on the left side) are also identified anterior to
the vertebral body and are useful landmarks to look out for while performing a
transverse scan.11 The lower pole of the kidney, which can extend to the L3 vertebral
level, is visualized as an oval structure and moves synchronously with respiration in
the retroperitoneal space (Fig. 12-25). The acoustic shadow of the transverse process
obscures the posterior aspect of the psoas muscle (Fig. 12-23).11 Therefore, the
lumbar nerve root or lumbar plexus are rarely visualized through the PMTOS-TP scan
window. However, the dura, epidural space, and the intrathecal space may be
visualized during a PMTOS-TP (Fig. 12-23).11 We believe this is because the
ultrasound signal, which is medially directed, enters the spinal canal through the
interlaminar space (Fig. 12-17C). Being able to visualize the neuraxial structures
during a lumbar paravertebral scan may be useful in documenting epidural spread after
an LPB.

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FIGURE 12-23 Paramedian transverse oblique scan of the right lumbar paravertebral
region at the level of the transverse process (PMTOS-TP). Note how the acoustic shadow of
the transverse process obscures the posterior part of the psoas muscle and the intervertebral
foramen and how parts of the spinal canal and neuraxial structures (dura and intrathecal
space) are seen through the interlaminar space. VB, vertebral body; IVC, inferior vena cava;
PM, psoas muscle; QLM, quadratus lumborum muscle; ESM, erector spinae muscle.

FIGURE 12-24 Paramedian transverse oblique scan of the right lumbar paravertebral
region through the space between two adjacent transverse processes (PMTOS-ITS). Note the
intervertebral foramen (IVF), articular process (AP), and lumbar nerve root (LNR) after it has
emerged from the IVF and the hypoechoic space surrounding the lumbar nerve root adjacent

528
to the IVF (ie, the LPVS: lumbar paravertebral space). The lumbar plexus is also seen in a
separate hypoechoic intramuscular compartment, which is the psoas compartment, in the
posterior part of the psoas muscle (PM). VB, vertebral body; PM, psoas muscle; QLM,
quadratus lumborum muscle; ESM, erector spinae muscle; RPS, retroperitoneal space; IVC,
inferior vena cava.

FIGURE 12-25 Paramedian transverse oblique scan of the right lumbar paravertebral
region through the space between two adjacent transverse processes (PMTOS-ITS). The
lumbar nerve root is seen emerging from the intervertebral foramen, and the lumbar plexus
(hyperechoic) is located within a hypoechoic space (psoas compartment) in the posterior
aspect of the psoas muscle. Also note the lower pole of the right kidney is seen anterior to the
psoas muscle in this sonogram. ESM, erector spinae muscle; AP, articular process; VB,
vertebral body; IVF, intervertebral foramen; IVC, inferior vena cava.

In the PMTOS-ITS11 apart from the erector spinae, psoas, and quadratus lumborum
muscles, the intervertebral foramen, articular process, and the lumbar spinal nerve root
are clearly delineated (Figs. 12-24 to 12-26).11 The LPVS is also seen as a hypoechoic
space adjacent to the intervertebral foramen (Figs. 12-24 to 12-26), and the lumbar
spinal nerve root can be seen exiting the foramen (Figs. 12-24 and 12-25).11 The latter
does not enter the psoas muscle directly opposite the intervertebral foramen from
which it emerges (Figs. 12-24 and 12-25), but takes a caudal course as seen in the CT
(Fig. 12-12), MRI (Figs. 12-14 to 12-16), and cadaver anatomical section (Fig. 12-9).
In some individuals an additional hyperechoic structure surrounded by a hypoechoic
space (Figs. 12-24 to 12-26) is seen in the posterior aspect of the psoas muscle.11
Based on our observation in the anatomical sections (Fig. 12-7) and MRI images (Fig.
12-14) we believe this represents the lumbar plexus within the psoas compartment.11
Currently there are limited data validating the transverse sonoanatomy of the lumbar
paravertebral region, but it is our experience that there is good correlation between
structures that are visualized in a lumbar paravertebral sonogram and that in
corresponding cadaver anatomical sections, CT, and MRI images of the lumbar

529
 paravertebral region (Figs. 12-27 to 12-30).11 Because the lumbar plexus and the
paravertebral anatomy are clearly delineated through the PMTOS-ITS ultrasound scan
window, it is our preferred window for imaging during an ultrasound-guided LPB.10

FIGURE 12-26 Paramedian transverse oblique scan of the right lumbar paravertebral
region through the space between two adjacent transverse processes (PMTOS-ITS) showing
the lumbar plexus as a discrete hyperechoic structure inside a hypoechoic intramuscular space
(psoas compartment) in the posteromedial aspect of the psoas muscle. ESM, erector spine
muscle; QLM, quadratus lumborum muscle; PM, psoas muscle; AP, articular process; VB,
vertebral body; IVC, inferior vena cava.

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FIGURE 12-27 Correlative sagittal (A) cadaver anatomic, (B) CT, (C) MRI (T1-
weighted), and (D) ultrasound images of the lumbar paravertebral region from the level of the
L3, L4, and L5 lumbar transverse processes. ESM, erector spinae muscle; PM, psoas muscle;
NR, nerve root; RPS, retroperitoneal space; TP, transverse process.

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FIGURE 12-28 Correlative transverse (A) cadaver anatomic, (B) CT, (C) MRI (T1-
weighted), and (D) ultrasound images of the lumbar paravertebral region from the level of the
L4 vertebral body (VB) and transverse process (TP). ESM, erector spinae muscle; QLM,
quadratus lumborum muscle; PM, psoas muscle; AP, articular process; LF, ligamentum
flavum; ES, epidural space; IVC, inferior vena cava.

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FIGURE 12-29 Correlative transverse (A) cadaver anatomic, (B) CT, (C) MRI (T1-
weighted), and (D) ultrasound images of the lumbar paravertebral region from the level of the
L4 vertebral body (VB) and articular process (AP). ESM, erector spinae muscle; QLM,
quadratus lumborum muscle; PM, psoas muscle; AP, articular process; LPVS, lumbar
paravertebral space; VB, vertebral body; IVC, inferior vena cava.

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FIGURE 12-30 Correlative coronal (A) cadaver anatomic and (B) MRI (T1-weighted)
images of the lumbar paravertebral showing the exit of the lumbar nerve roots (NR) from the
intervertebral foramen (IVF) and the formation of the lumbar plexus within the substance of
the psoas muscle (PM). ITS, intrathecal space; CE, cauda equina.

c. Transverse sonoanatomy – Shamrock method:

In a transverse sonogram produced by the shamrock method (Fig. 12-20) the psoas,
erector spinae, and quadratus lumborum muscles are also clearly visualized (Figs. 12-
31 and 12-32). The anatomical arrangement of the three muscles around the transverse
process, that is, the psoas muscle lying anterior, the erector spinae muscle lying
posterior, and the quadratus lumborum muscle lying at the apex (Fig. 12-31), produces
a sonographic pattern that has been likened to a shamrock, with the muscles
representing its three leaves.17 The lumbar nerve root is visualized close to the angle
between the vertebral body and the transverse process (Figs. 12-32 and 12-33), and the
lumbar plexus within the posterior aspect of the psoas muscle, typically about 2 cm
anterior to the transverse process (Figs. 12-31 to 12-33).17 From this position if the
transducer is gently tilted caudally, the acoustic shadow of the L4 transverse process
disappears and the ultrasound beam is now insonated through the intertransverse space
and at the level of the articular process of L4 vertebra, similar to that with a PMTOS-
AP (Fig. 12-17D).10,11,17 In the resultant sonogram the psoas, erector spinae and
quadratus lumborum muscles, the intervertebral foramen, and lumbar plexus are now
clearly visualized (Figs. 12-34 and 12-35). In our experience, the lumbar plexus is
better visualized with the shamrock method than with a PMTOS. This may be because
the ultrasound beam is more at right angles to the lumbar plexus nerves during a
shamrock scan.

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FIGURE 12-31 Transverse sonogram of the lumbar paravertebral area obtained with the
shamrock method at the level of the transverse process of the L4 vertebra. Note the prominent
transverse process and the arrangement of the psoas major (PM), quadratus lumborum
(QLM), and erector spine (ESM) muscles around the transverse process that has been likened
to a shamrock. The accompanying photograph on the right illustrates the position of the
patient and the ultrasound transducer during the scan. VB, vertebral body; IVC, inferior vena
cava.

FIGURE 12-32 Transverse sonogram of the lumbar paravertebral region with the

535
ultrasound beam being insonated at the level of the transverse process during the shamrock
method. Note the lumbar nerve root is visualized close to the angle between the vertebral
body and the transverse process and the lumbar plexus nerve is located within the substance
of the psoas muscle. TAM, transversus abdominis muscle; ESM, erector spine muscle; PM,
psoas major muscle; QLM, quadratus lumborum muscle; RPS, retroperitoneal space; IVC,
inferior vena cava; Ao, abdominal aorta; VB, vertebral body; LPVS, lumbar paravertebral
space; ITS, intrathecal space; TP, transverse process.

FIGURE 12-33 Biplanar ultrasound image of the lumbar paravertebral region obtained
with the shamrock method and with the ultrasound beam being insonated through the lumbar
intertransverse space and at the level of the articular process. Note the transverse axis (A) is
the primary data acquisition plane and the corresponding image along the secondary data
acquisition plane (x-plane – dotted line with blue arrow head in A) is a coronal view showing
the lumbar plexus nerves within the psoas muscle. PM, psoas muscle; VB, vertebral body;
ITS, intrathecal space; AP, articular process.

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FIGURE 12-34 Transverse sonogram of the lumbar paravertebral region with the
ultrasound beam being insonated through the lumbar intertransverse space and at the level of
the articular process (AP) during the shamrock method. The lumbar plexus nerves are clearly
delineated in the posterior aspect of the psoas major (PM) muscle. The accompanying
photograph on the right illustrates the position of the patient and the ultrasound transducer
during the scan. VB, vertebral body; IVC, inferior vena cava; ESM, erector spine muscle;
PM, psoas major muscle; QLM, quadratus lumborum muscle; IVC, inferior vena cava; VB,
vertebral body; IVF, intervertebral foramen.

FIGURE 12-35 Transverse sonogram of the lumbar paravertebral region with the
ultrasound beam being insonated through the lumbar intertransverse space and at the level of
the articular process of the lumbar vertebra during the shamrock scan. ESM, erector spine
muscle; PM, psoas major muscle; QLM, quadratus lumborum muscle; IVC, inferior vena
cava; VB, vertebral body; ITS, intrathecal space.

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Clinical Pearls
1.The lumbar paravertebral region is highly vascular and contains the ascending lumbar veins
and the lumbar arteries (Fig. 12-36), which can be visualized using Color and Power
Doppler ultrasound (Figs. 12-37 and 12-38). There is also a rich network of blood vessels
(arteries and veins) within the substance of the psoas muscle. The dorsal branch of the
lumbar artery is also closely related to the transverse process and the posterior part of the
psoas muscle (Fig. 12-38) where the lumbar plexus is located. Therefore, it may be at risk
for needle-related injury during an LPB, as it is directly in the path of the advancing
needle. Considering the rich vascularity of the lumbar paravertebral region, it is not
surprising that inadvertent intravascular injection of local anesthetic,2,3,–18 psoas
hematoma,–19 lumbar plexopathy,19 and delayed retroperitoneal hematoma–20,–21 have
all been reported after an LPB. It is for the same reason, and because the psoas muscle
lies in an incompressible area, that we recommend one must avoid LPB in patients with
coagulopathy.

FIGURE 12-36 Three-dimensional reconstruction of a CT angiogram showing the origin

of the lumbar artery from the abdominal aorta and how it is closely related to the anterolateral
surface of the lumbar vertebral body. The spinal artery, which is a branch of the lumbar
artery, is also seen entering the spinal canal through the intervertebral foramen (C).

538
FIGURE 12-37 Color Doppler ultrasound image of the right lumbar paravertebral region
showing the lumbar artery and the ascending lumbar vein close to the anterolateral surface of
the lumbar vertebra and medial to the psoas muscle. QLM, quadratus lumborum muscle;
ESM, erector spinae muscle; PM, psoas muscle; VB, vertebral body; IVC, inferior vena cava.

FIGURE 12-38 Color Doppler ultrasound images of the lumbar paravertebral region in the
transverse (A and B) and sagittal (C and D) scan planes. Note the dorsal branch of the lumbar

539
artery (DBLA) on the posterior aspect of the psoas muscle in both the transverse and sagittal
sonograms. PMTOS-ITS, paramedian transverse oblique scan through the lumbar
intertransverse space; SS, sagittal scan; LA, lumbar artery; VB, vertebral body; AP, articular
process; PM, psoas muscle; TP, transverse process.

2.The echo-intensity (EI) of skeletal muscles is significantly increased in the elderly,–22,–23

and there is a strong correlation between EI of muscles and age (EI of the biceps increases
1.8% per year and EI of the quadriceps increases 1.9% per year).23 The increase in EI of
skeletal muscles with age is due to age-related changes in the muscle.23 In the elderly
there is a reduction in skeletal muscle mass (sarcopenia),–24,–25 replacement of the
contractile elements in the muscle by fat and connective tissue,23 and an increase in
extracellular water content in the muscle.–26 There is also an increase in body fat.24
Normally subcutaneous fat, water, and skeletal muscle fibers are hypoechoic, but
infiltration of skeletal muscles by fat results in increased muscular EI.–27 This may be
due to a change in acoustic impedance at the surface of the fat cells and an increase in
scattering of the ultrasound energy by the intramuscular fat. Therefore, ultrasound images
of the lumbar paravertebral region in the elderly appear whiter and brighter, and there is
also loss of contrast between the muscle and the adjoining structures (Fig. 12-39), making
it difficult to delineate the lumbar plexus when compared to that in the young. Therefore,
lumbar paravertebral sonography and ultrasound-guided LPB in the elderly can be
challenging. The same may also be true when LPB is performed in the obese when
excessive fat and increased depth to the relevant structure can make ultrasound imaging
of the lumbar paravertebral region difficult (Fig. 12-40).

FIGURE 12-39 Paramedian transverse oblique scan of the right lumbar paravertebral
region through the space between two adjacent transverse processes (PMOTS-ITS) in an
elderly subject (85 yrs.). Note the relatively small psoas muscle (PM) and the loss of contrast
between the various paravertebral structures. ESM, erector spinae muscle; QLM, quadratus

540
lumborum muscle; VB, vertebral body; AP, articular process.

FIGURE 12-40 Sagittal sonogram of the lumbar paravertebral region in a morbidly obese
patient (BMI = 50 kg·m−2). Note the transverse processes (TP) of the lumbar vertebra are
barely recognizable in this ultrasound image. There is also a marked loss of contrast between
the various lumbar paravertebral structures. ESM, erector spinae muscle.

References
1.Awad IT, Duggan EM. Posterior lumbar plexus block: anatomy, approaches, and
techniques. Reg Anesth Pain Med. 2005;30:143–149.
2.Capdevila X, Coimbra C, Choquet O. Approaches to the lumbar plexus: success, risks, and
outcome. Reg Anesth Pain Med. 2005;30:150–162.
3.de Leeuw MA, Zuurmond WW, Perez RS. The psoas compartment block for hip surgery:
the past, present, and future. Anesthesiol Res Pract. 2011;2011:159541.
4.Chayen D, Nathan H, Chayen M. The psoas compartment block. Anesthesiology.
1976;45:95–99.
5.Farny J, Girard M, Drolet P. Posterior approach to the lumbar plexus combined with a
sciatic nerve block using lidocaine. Can J Anaesth. 1994;41:486–491.
6.Ho AM, Karmakar MK. Combined paravertebral lumbar plexus and parasacral sciatic
nerve block for reduction of hip fracture in a patient with severe aortic stenosis. Can J
Anaesth. 2002;49:946–950.
7.Farny J, Drolet P, Girard M. Anatomy of the posterior approach to the lumbar plexus
block. Can J Anaesth. 1994;41:480–485.
8.Parkinson SK, Mueller JB, Little WL, Bailey SL. Extent of blockade with various
approaches to the lumbar plexus. Anesth Analg. 1989;68:243–248.
9.Karmakar MK, Ho AM, Li X, Kwok WH, Tsang K, Kee WD. Ultrasound-guided lumbar
plexus block through the acoustic window of the lumbar ultrasound trident. Br J
Anaesth. 2008;100:533–537.
10.Karmakar MK, Li JW, Kwok WH, Hadzic A. Ultrasound-guided lumbar plexus block

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 using a transverse scan through the lumbar intertransverse space: a prospective case
series. Reg Anesth Pain Med. 2015;40:75–81.
11.Karmakar MK, Li JW, Kwok WH, Soh E, Hadzic A. Sonoanatomy relevant for lumbar
plexus block in volunteers correlated with cross-sectional anatomic and magnetic
resonance images. Reg Anesth Pain Med. 2013;38:391–397.
12.Ikezoe T, Mori N, Nakamura M, Ichihashi N. Atrophy of the lower limbs in elderly
women: Is it related to walking ability? Eur J Appl Physiol. 2011;111:989–995.
13.Hanson P, Magnusson SP, Sorensen H, Simonsen EB. Anatomical differences in the psoas
muscles in young black and white men. J Anat. 1999;194(Pt 2):303–307.
14.Kirchmair L, Entner T, Kapral S, Mitterschiffthaler G. Ultrasound guidance for the psoas
compartment block: an imaging study. Anesth Analg. 2002;94:706–710.
15.Karmakar MK. Ultrasound for central neuraxial blocks. Tech Reg Anesth Pain Manag.
2009;13:161–170.
16.Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD. Sonoanatomy relevant for
ultrasound-guided central neuraxial blocks via the paramedian approach in the lumbar
region. Br J Radiol. 2012;85:e262–e269.
17.Sauter AR, Ullensvang K, Bendtsen TF, Boerglum J. The “Shamrock Method” — a new
and promising technique for ultrasound guided lumbar plexus blocks. Br J Anaesth. 2013
(http://bja.oxfordjournals.org/forum/topic/brjana_el%3B9814). Accessed March 15,
2015.
18.Huet O, Eyrolle LJ, Mazoit JX, Ozier YM. Cardiac arrest after injection of ropivacaine for
posterior lumbar plexus blockade. Anesthesiology 2003;99:1451–1453.
19.Klein SM, D’Ercole F, Greengrass RA, Warner DS. Enoxaparin associated with psoas
hematoma and lumbar plexopathy after lumbar plexus block. Anesthesiology
1997;87:1576–1579.
20.Aveline C, Bonnet F. Delayed retroperitoneal haematoma after failed lumbar plexus block.
Br J Anaesth. 2004;93:589–591.
21.Weller RS, Gerancher JC, Crews JC, Wade KL. Extensive retroperitoneal hematoma
without neurologic deficit in two patients who underwent lumbar plexus block and were
later anticoagulated. Anesthesiology 2003;98:581–585.
22.Li X, Karmakar MK, Lee A, Kwok WH, Critchley LA, Gin T. Quantitative evaluation of
the echo intensity of the median nerve and flexor muscles of the forearm in the young
and the elderly. Br J Radiol. 2012;85:e140–e145.
23.Maurits NM, Bollen AE, Windhausen A, De Jager AE, Van Der Hoeven JH. Muscle
ultrasound analysis: normal values and differentiation between myopathies and
neuropathies. Ultrasound Med Biol. 2003;29:215–225.
24.Evans WJ. Exercise, Nutrition and Aging. Journal of Nutrition. 1992;122:796–801.
25.Gallagher D, Visser M, deMeersman RE, Sepulveda D, Baumgartner RN, Pierson RN,
Harris T, Heymsfield SB. Appendicular skeletal muscle mass: Effects of age, gender,
and ethnicity. Journal of Applied Physiology. 1997;83:229–239.
26.Tsubahara A, Chino N, Akaboshi K, Okajima Y, Takahashi H. Age-related changes of
water and fat content in muscles estimated by magnetic resonance (MR) imaging.
Disabil Rehabil. 1995;17:298–304.
27.Reimers K, Reimers CD, Wagner S, Paetzke I, Pongratz DE. Skeletal-Muscle Sonography
— A Correlative Study of Echogenicity and Morphology. J Ultrasound Med.
1993;12:73–77.

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543
 INDEX
Please note that index links point to page beginnings from the print edition. Locations are
approximate in e-readers, and you may need to page down one or more times after clicking a
link to get to the indexed material.

Note: Page numbers followed by f indicate figures; and page numbers followed by t indicate
tables.

A
Abdominal wall nerve blocks, 106–125
anterior abdominal wall nerve, 109–111
ilioinguinal and iliohypogastic nerve, 119–120, 120f
lateral transverse abdominis plane, 111–112, 111f, 112f
muscles of anterior abdominal wall, 106–109, 106f, 107f, 108f, 109f, 110f
quadratus lumborum block, 120–125, 121f, 122f, 123f, 124f
rectus sheath, 114–119, 115f, 116f, 117f, 118f, 119f
subcostal transverse abdominis plane, 112–114, 113f, 114f
Acoustic enhancement artifacts, 12, 12f
Acoustic shadowing artifacts, 12
Aliasing in Doppler ultrasound imaging, 15–16, 15f, 16f
Anechoic appearance, 3, 3f
Anesthesia, ultrasound-guided regional. See Muscoskeletal and Doppler ultrasound imaging
Anisotrophy, in Doppler ultrasound imaging, 5–6, 6f
Anterior superior iliac spine (ASIS), 120, 121f
Artifacts, in Doppler ultrasound imaging, 10–12
Atlas vertebrae, in cervical spine, 143, 143f
Axial scans, 1f
Axilla, brachial plexus, 20, 21f, 42–46, 43f, 45f, 46f
Axis of intervention, 3, 4f
Axis vertebrae, in cervical spine, 143–144

B
Bayonet artifacts, 12, 12f
Blood vessels, 7, 225
Bone, Doppler ultrasound imaging of, 7, 8f
Brachial plexus
axilla, 20, 21f, 42–46
gross anatomy of, 18, 18f, 19f, 22f
infraclavicular fossa
gross anatomy, 20f, 30–31, 30f, 31f
lateral, ultrasound imaging technique for, 38–42
medial, ultrasound imaging technique for, 31–38

544
 interscalene groove
diaphragm excursion assessment, 27–28
gross anatomy, 20f, 22
ultrasound imaging technique for, 23–27
supraclavicular fossa, 20f, 28–30, 28f, 29f, 30f
Breast, innervation of, 226, 226f
Brightness color (B-color) mode imaging, 12–13

C
caudal epidural injection, ultrasound for, 205–208, 206f, 207f, 208f
CCS (costoclavicular space), 19–20, 21f, 36f
Central neuraxial blocks. See Lumbar spine; Sacrum and lumbosacral junction
Cervical spine, 139–161. See also Lumbar spine; Spine, basic considerations for; Thoracic
spine
anatomy of
vertebra C1 (atlas), 143, 143f
vertebra C2 (axis), 143–144
vertebra C3 to C6, 139–143, 139f, 140f, 141f, 142f, 143f, 144f
vertebra C7, 144
cervical facet joint injection, ultrasound for, 144, 150–153, 150f, 151f, 152f, 153f
computed tomography (CT) anatomy of, 144f, 145f, 146f
magnetic resonance imaging (MRI) anatomy of, 146f, 147f, 148f, 149f, 150f
selective nerve root block, ultrasound for, 154–157, 154f, 155f, 156f
stellate ganglion block., ultrasound for, 157–159, 157f, 158f, 159f
third occipital nerve block., ultrasound for, 153–154
Color Doppler imaging display, 14, 14f, 15f, 16f
Compound imaging, 8–9, 9f
Computed tomography (CT) anatomy
anterior superior iliac spine, 119f
cervical spine, 144f, 145f, 146f
femoral nerve at inguinal region, 68f
infraclavicular fossa, 31f, 32f
lateral transverse abdominis plane, 111f
lower thoracic spine, 169f
lumbar plexus block (LPB), 268f
lumbar spine, 183f, 184f, 185f
midfemoral/adductor canal region, 77f
mid thoracic spine, 166f, 167f
neck and interscalene region, 22–23, 23f
obturator nerve at inguinal region, 71f
rectus abdominis muscle, 116f
sacrum and lumbosacral junction, 205f, 211f
sciatic nerve
infragluteal region, 88f
parasacral region, 80f
popliteal fossa, 91f, 92f
subgluteal region, 84f

545
 thigh–anterior approach, 95f
subcostal transverse abdominis plane, 113f
terminal nerves in leg, 101f
thoracic paravertebral blocks, 242f, 243f
upper thoracic spine, 165f
Contact artifacts, 11
Coronal anatomical plane, 130, 130f
Costoclavicular space (CCS), 19–20, 21f, 36f
Curved array transducers, 5, 5f

D
Diaphragmatic excursion assessment, 27–28, 28f
Doppler gain in ultrasound imaging, 16–17, 17f
Doppler shift, 14, 14f
Doppler ultrasound imaging. See Muscoskeletal and Doppler ultrasound imaging

E
Echogenicity, in Doppler ultrasound imaging, 3, 7f, 8f, 13f
Echo-intensity of skeletal muscles, 278
Elbow region: median, ulnar, and radial nerves
gross anatomy, 52–54, 54f, 55f, 56f, 57f, 58f
ultrasound scan technique for, 54–58
Elderly patients
Doppler ultrasound imaging of, 12, 13f
echo-intensity of skeletal muscles increased in, 278
sacral hiatus changes in, 209
spinal changes of, 132–133
Epidural injections, thoracic. See Thoracic spine
Equation, Doppler, 13–14, 13f
External oblique muscle (EOM), 106–107, 106f, 107f, 108f

F
Fascia
Doppler ultrasound imaging of, 7
in thoracic interfacial nerve blocks, 225
Femoral nerve at inguinal region
computed tomography (CT) anatomy of, 68f
gross anatomy, 66–67, 67f
magnetic resonance imaging (MRI) anatomy of, 68f
ultrasound scan technique for, 67–70
Field of view (FOV), in Doppler ultrasound imaging, 3–5, 5f

H
Hyperechoic appearance, 3, 3f
Hypoechoic appearance, 3, 3f

I
Ilioinguinal and iliohypogastic nerve, 119–120, 120f

546
Image orientation, 2, 2f
Imaging, ultrasound. See Muscoskeletal and Doppler ultrasound imaging
Infraclavicular fossa
gross anatomy, 20f, 30–31, 30f, 31f
lateral, ultrasound imaging technique for, 38–42, 38f, 39f, 41f, 42f
medial, ultrasound imaging technique for, 31–38, 33f, 34f, 35f, 36f, 37f, 38f, 39f, 40f
scan of, 5f
Inguinal region. See Femoral nerve at inguinal region; Obturator nerve at inguinal region
Innervation of breast, 226, 226f
Interlaminar space anatomy. See Sacrum and lumbosacral junction
Ixternal oblique muscle (IOM), 106–108
Internal oblique muscle (IOM), 106, 107f, 108f, 115
Interscalene groove
Diaphragmatic excursion assessment, 27–28
gross anatomy, 20f, 22
ultrasound imaging technique for, 23–27
Intervertebral spaces identified by ultrasound, 177
Isoechoic appearance, 3, 3f

L
Lateral cutaneous nerve of thigh
gross anatomy, 73–74
magnetic resonance imaging (MRI) anatomy of, 74f
ultrasound scan technique for, 74–75
Lateral transverse abdominis plane, 111–112, 112f
Ligaments, Doppler ultrasound imaging of, 8f
Linear array transducers, 5, 5f
Longitudinal scans, 1–2, 1f
Lower extremity nerve blocks, 64–105
femoral nerve at inguinal region
computed tomography (CT) anatomy of, 68f
gross anatomy, 66–67, 67f
magnetic resonance imaging (MRI) anatomy of, 68f
ultrasound scan technique for, 67–70, 68f, 69f
gross anatomy of, 64–66, 64f, 65f, 66f
lateral cutaneous nerve of thigh
gross anatomy, 73–74
magnetic resonance imaging (MRI) anatomy of, 74f
ultrasound scan technique for, 74–75, 74f, 75f
midfemoral/adductor canal region
computed tomography (CT) anatomy of, 77f
magnetic resonance imaging (MRI) anatomy of, 77f
ultrasound scan technique for, 77–79, 78f, 79f
obturator nerve at inguinal region
computed tomography (CT) anatomy of, 71f
gross anatomy, 70, 70f

547
 magnetic resonance imaging (MRI) anatomy of, 71f
ultrasound scan technique for, 71–73, 71f, 72f, 73f
saphenous nerve at adductor canal, 75–77, 76f
sciatic nerve at infragluteal region
computed tomography (CT) anatomy of, 88f
gross anatomy, 86–87, 88f
magnetic resonance imaging (MRI) anatomy of, 88f
ultrasound scan technique for, 87–89, 88f, 89f
sciatic nerve at parasacral region
computed tomography (CT) anatomy of, 80f
gross anatomy, 79–80
magnetic resonance imaging (MRI) anatomy of, 80f
ultrasound scan technique for, 80–83, 81f, 82f, 83f
sciatic nerve at popliteal fossa
computed tomography (CT) anatomy of, 91f, 92f
gross anatomy, 90–91, 90f, 91f
magnetic resonance imaging (MRI) anatomy of, 91f, 92f
ultrasound scan technique for, 92–94, 93f, 94f, 95f
sciatic nerve at subgluteal region
computed tomography (CT) anatomy of, 84f
gross anatomy, 83–84, 84f
magnetic resonance imaging (MRI) anatomy of, 84f
ultrasound scan technique for, 84–86, 84f, 85f, 86f
sciatic nerve at thigh--anterior approach
computed tomography (CT) anatomy of, 95f
gross anatomy, 94–95, 95f
magnetic resonance imaging (MRI) anatomy of, 95f
ultrasound scan technique for, 95–97, 96f, 97f
terminal nerves in leg
computed tomography (CT) anatomy of, 101f
gross anatomy, 97–100, 98f, 99f, 100f
magnetic resonance imaging (MRI) anatomy of, 101f
ultrasound scan technique for, 101–104, 101f, 102f, 103f
Lumbar plexus block (LPB), 265–283
anatomy, 265–268, 265f, 266f, 267f, 268f
computed tomography (CT) anatomy of, 268f
magnetic resonance imaging (MRI) anatomy of, 268f, 269f
ultrasound technique for
overview, 269–270, 270f
paramedian transverse oblique scan, 272–275, 273f, 274f, 275f, 279f
sagittal sonoanatomy, 271–272, 271f
shamrock method for transverse sonoanatomy, 275–277, 275f, 276f, 277f
Lumbar spine, 179–203. See also Cervical spine; Sacrum and lumbosacral junction; Spine,
basic considerations for; Thoracic spine
anatomy of, 179–183, 179f, 180f, 181f, 182f, 183f
computed tomography (CT) anatomy of, 183f, 184f

548
 magnetic resonance imaging (MRI) anatomy of, 184f, 185f, 186f
sagittal ultrasound imaging of, 199–202, 200f, 201f
transverse ultrasound imaging of, 196–199, 197f, 198f, 199f
ultrasound imaging of, 186–196, 186f, 187f, 188f, 189f, 190f, 191f, 192f, 193f, 194f, 195f,
196f
Lumbosacral junction. See Sacrum and lumbosacral junction
Lungs, Doppler ultrasound imaging of, 8f

M
Magnetic resonance imaging (MRI) anatomy
anterior superior iliac spine, 119f
axilla, 44f
brachial plexus, 29f
cervical spine, 146f, 147f, 148f, 149f, 150f
elbow region, 55f
femoral nerve at inguinal region, 68f
infraclavicular fossa, 32f
lateral transverse abdominis plane, 111f
lower thoracic spine, 169f
lumbar plexus block (LPB), 268f, 269f
lumbar spine, 184f, 185f, 186f
midfemoral/adductor canal region, 77f
midforearm region, 59f
midhumeral region, 50f, 51f
mid thoracic spine, 166f, 167f
neck and interscalene region, 24f
obturator nerve at inguinal region, 71f
rectus abdominis muscle, 116f
sacrum and lumbosacral junction, 205f, 211f, 212f
sciatic nerve
infragluteal region, 88f
parasacral region, 80f
popliteal fossa, 91f, 92f
subgluteal region, 84f
thigh–anterior approach, 95f
subcostal transverse abdominis plane, 113f
terminal nerves in leg, 101f
thoracic paravertebral blocks, 243f, 244f
upper thoracic spine, 165f, 166f
Magnetic resonance neurography (MRN) imaging, 18f
Median anatomical plane, 130, 130f
Median nerve
elbow region, 52–58, 54f, 55f, 56f, 58f
midforearm region, 58–62, 59f, 60f, 61f, 62f
midhumeral region, 46–49
Midfemoral/adductor canal region
computed tomography (CT) anatomy of, 77f

549
 magnetic resonance imaging (MRI) anatomy of, 77f
ultrasound scan technique for, 77–79, 78f, 79f
Midforearm region: median, ulnar, and radial nerves, 58–62, 59f, 60f, 61f, 62f
Midhumeral region
median and ulnar nerve, 46–49, 46f, 47f, 48f, 50f, 51f, 52f
radial nerve, 48f, 49–52, 50f, 51f, 53f
Mirror image artifacts, 11, 11f
MRI (magnetic resonance imaging) anatomy. See Magnetic resonance imaging (MRI)
anatomy
MRN (magnetic resonance neurography) imaging, 18f
Muscles
of anterior abdominal wall, 106–109, 106f, 107f, 108f, 109f, 110f
Doppler ultrasound imaging of, 6, 7f
echo-intensity of skeletal, 278
in thoracic interfacial nerve blocks, 219–222, 219f, 220f, 221f
Muscoskeletal and Doppler ultrasound imaging, 1–17
aliasing in, 15–16, 15f, 16f
anisotrophy, 5–6, 6f
artifacts in, 10–12, 11f, 12f
axis of intervention, 3, 4f
basic steps for, 17
display of, 14–15
Doppler gain in, 16–17, 17f
echogenicity, 3, 3f
of elderly patients, 12, 13f
field of view and needle visibility, 3–5, 5f
normal structures identification
blood vessels, 7
bone, 7, 8f
fascia, 7
muscles, 6–7, 7f
nerves, 6, 7f
pleura, 7, 8f
subutaneous fat, 7
tendons, 6
of obese patients, 12–13
optimization of, 2–3
scanning plane, 1–2, 1f, 2f
science of, 13–14, 13f, 14f, 15f
special features
compound imaging, 8–9, 10f
panoramic imaging, 9, 9f
three-dimensional ultrasound, 9–10, 10f
tissue harmonic imaging, 7–8
spectral broadening in, 16
transducer and image orientation, 2, 2f

550
 ultrasound transducer frequency, 1

N
Neck and interscalene region
computed tomography (CT) anatomy of, 22–23
magnetic resonance imaging (MRI) of, 24f
sagittal sonogram of, 27f
transverse sonogram of, 25f, 26f, 27f
Needle visibility, in Doppler ultrasound imaging, 3–5
Nerve blocks. See Abdominal wall nerve blocks; Lower extremity nerve blocks; Thoracic
interfacial nerve blocks; Upper extremity nerve blocks
Nerves
of anterior abdominal wall, 109–111
Doppler ultrasound imaging of, 6, 7f
in thoracic interfacial nerve blocks, 222–225, 222f, 223f, 224f, 225f
Neuraxial blocks, central. See Lumbar spine; Sacrum and lumbosacral junction

O
Obese patients
Doppler ultrasound imaging of, 12–13
lumbar paravertebral region sonogram of, 279f
Obturator nerve at inguinal region
computed tomography (CT) anatomy of, 71f
gross anatomy, 70
magnetic resonance imaging (MRI) anatomy of, 71f
ultrasound scan technique for, 71–73, 71f, 72f, 73f
Osseous elements of spine, 131–137, 132f, 133f, 134f, 135f, 136f, 137f

P
Panoramic imaging, 9, 9f
Paramedian sagittal oblique scan (PMSOS), 131, 131f, 132f, 137f, 199
Paramedian transverse oblique scan, 272–275, 273f, 274f, 275f, 279f
Pectoral nerve blocks. See Thoracic interfacial nerve blocks
Pleura, Doppler ultrasound imaging of, 7, 8f
Power Doppler imaging display, 14–15, 15f
Propagation speed artifacts, 11–12, 12f
Psoas compartment block (PCB). See Lumbar plexus block (LPB)

Q
Quadratus lumborum block (QLB), 120–125, 121f, 122f, 123f, 124f

R
Radial nerve
elbow region, 52–58, 54f, 55f, 56f, 58f
midforearm region, 58–62, 59f, 62f
midhumeral region, 49–52, 50f, 51f, 52f, 53f
Rectus abdominis muscle (RAM), 106, 107f, 108f, 109, 115–116, 117f, 118f, 119f
Rectus sheath, 106f, 114–119, 115f, 116f, 117f, 118f, 119f

551
Reverberation artifacts, 11, 11f

S
Sacrum and lumbosacral junction, 203–219
anatomy of, 203–204, 203f, 204f
caudal epidural injections, ultrasound for, 205–208, 206f, 207f, 208f
computed tomography (CT) anatomy of, 205f, 211f
interlaminar space anatomy, 209–210, 209f, 210f, 211f, 212f
magnetic resonance imaging (MRI) anatomy of, 205f, 211f, 212f
ultrasound of interlaminar space in, 211–216, 212f, 213f, 214f, 215f, 216f, 217f
Sagittal scans, 1–2, 1f
Sagittal sonoanatomy, 271–272, 271f
Saphenous nerve at adductor canal, 75–77, 76f
Scalene muscles, brachial plexus relation to, 19f
Scanning plane, in Doppler ultrasound imaging, 1–2
Sciatic nerve
infragluteal region
computed tomography (CT) anatomy of, 88f
gross anatomy, 86–87, 88f
magnetic resonance imaging (MRI) anatomy of, 88f
ultrasound scan technique for, 87–89, 88f, 89f
parasacral region
computed tomography (CT) anatomy of, 80f
gross anatomy, 79–80
magnetic resonance imaging (MRI) anatomy of, 80f
ultrasound scan technique for, 80–83, 81f, 82f, 83f
popliteal fossa
computed tomography (CT) anatomy of, 91f, 92f
gross anatomy, 90–91, 90f, 91f
magnetic resonance imaging (MRI) anatomy of, 91f, 92f
ultrasound scan technique for, 92–94, 93f, 94f, 95f
subgluteal region
computed tomography (CT) anatomy of, 84f
gross anatomy, 83–84, 84f
magnetic resonance imaging (MRI) anatomy of, 84f
ultrasound scan technique for, 84–86, 84f, 85f, 86f
thigh–anterior approach
computed tomography (CT) anatomy of, 95f
gross anatomy, 94–95, 95f
magnetic resonance imaging (MRI) anatomy of, 95f
ultrasound scan technique for, 95–97, 96f, 97f
SCTL (superior costotransverse ligament), 240
Selective nerve root block, ultrasound for, 154–157, 154f, 155f, 156f
Serratus plane block. See Thoracic interfascial nerve blocks
Shamrock method for transverse sonoanatomy, 275–277, 275f, 276f, 277f
Spectral broadening in Doppler ultrasound imaging, 16, 16f, 17f

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Spectral Doppler imaging display, 15, 15f
Spine. See also Cervical spine; Lumbar spine; Sacrum and lumbosacral junction; Thoracic
spine
basic considerations for, 126–139
anatomy of, 126–129, 126f, 127f, 128f, 129f
osseous element sonoanatomy, 131–137, 132f, 133f, 134f, 135f, 136f, 137f
sonography of, 129–131, 129f, 130f, 131f
Stellate ganglion block, ultrasound for, 157–159, 157f, 158f, 159f
Subcostal transverse abdominis plane, 112–114, 113f, 114f
Subcutaneous fat, Doppler ultrasound imaging of, 7
Superior costotransverse ligament (SCTL), 240
Supraclavicular fossa, of brachial plexus, 20f, 28–30, 28f, 29f, 30f

T
TAM (transverse abdominis muscle), 106, 107f, 108, 108f, 112
TAP (transverse abdominis plane), 110–112, 111f, 122f
Tendons, Doppler ultrasound imaging of, 6
Terminal nerves in leg
computed tomography (CT) anatomy of, 101f
gross anatomy, 97–100, 98f, 99f, 100f
magnetic resonance imaging (MRI) anatomy of, 101f
ultrasound scan technique for, 101f, 102f, 103f
TGC (time gain compensation), 3
THI (tissue harmonic imaging), 7–8, 8f, 12
Third occipital nerve block., ultrasound for, 153–154
Thoracic interfacial nerve blocks, 219–240
anatomy
blood vessels, 225
fascia, 225
muscles, 219–222, 219f, 220f, 221f
nerves, 222–225, 222f, 223f, 224f, 225f
innervation of breast, 226, 226f
overview, 219
ultrasound for, 226–238, 227f, 228f, 229f, 230f, 231f, 232f, 233f, 234f, 235f, 236f, 237f,
238f
Thoracic paravertebral block (TPVB), 240–265
anatomy of, 240–242, 240f, 241f, 242f
communications of thoracic paravertebral space, 242
computed tomography (CT) anatomy of, 242f, 243f
magnetic resonance imaging (MRI) anatomy of, 243f, 244f
three-dimensional sonography of, 260–262, 261f, 262f
ultrasound scan technique for, 244–260, 245f, 246f, 247f, 248f, 249f, 250f, 251f, 252f, 253f,
254f, 255f, 256f, 257f, 258f, 259f, 260f
Thoracic spine, 161–179. See also Cervical spine; Spine, basic considerations for
anatomy of, 161–164, 161f, 162f, 163f, 164f, 166f, 168f
computed tomography (CT) anatomy
lower, 168f, 169f

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 mid, 166f, 167f
upper, 165f
magnetic resonance imaging (MRI) anatomy
lower, 169f
mid, 166f, 167f
upper, 165f, 166f
ultrasound of
intervertebral spaces identified by, 177
lower, 175–177, 176f, 177f
mid, 173–175, 174f, 175f
overview, 169–171, 170f, 171f
upper, 171–173, 172f, 173f
Three-dimensional sonography of thoracic paravertebral blocks, 260–262, 261f, 262f
Three-dimensional ultrasound, 9–10, 10f
Time gain compensation (TGC), 3
Tissue harmonic imaging (THI), 7–8, 8f, 12
TPVB (thoracic paravertebral block). See Thoracic paravertebral block (TPVB)
Transducers. See also ultrasound descriptions for various body regions
curved array, 5, 5f
frequency of ultrasound, 1
linear array, 5, 5f
orientation of, 2, 2f
Transverse abdominis muscle (TAM), 106, 107f, 108, 108f, 112
Transverse abdominis plane (TAP), 110–112, 111f, 122f
Transverse anatomical plane, 130, 130f
Transverse scans, 1, 1f, 2f

U
Ulnar nerve
elbow region, 52–58, 54f, 55f, 57f
midforearm region, 58–62, 59f, 61f, 62f
midhumeral region, 46–49
Ultrasound-guided regional anesthesia (USGRA). See Muscoskeletal and Doppler ultrasound
imaging
Ultrasound imaging. See Muscoskeletal and Doppler ultrasound imaging
Ultrasound transducer frequency, 1
Uncovertebral joint osteophytes, 140
Upper extremity nerve blocks, 18–63
brachial plexus: axilla, 42–46, 43f, 44f, 45f, 46f
brachial plexus: infraclavicular fossa
gross anatomy, 30–31, 30f, 31f
lateral, ultrasound imaging technique for, 38–42, 38f, 39f, 40f, 41f, 42f
medial, ultrasound imaging technique for, 31–38, 32f, 33f, 34f, 35f, 36f, 37f
brachial plexus: interscalene groove, 22–28
diaphragmatic excursion assessment, 27–28, 28f
gross anatomy, 22, 23f
ultrasound imaging technique for, 23–27, 24f, 25f, 26f, 27f

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 brachial plexus: supraclavicular fossa, 28–30, 28f, 29f, 30f
elbow region: median, ulnar, and radial nerves
gross anatomy, 52–54
ultrasound scan technique for, 54–58
gross anatomy of, 18–22, 18f, 19f, 20f, 21f, 22f
midforearm region: median, ulnar, and radial nerves, 58–62
midhumeral region
median and ulnar nerve, 46–49
radial nerve, 49–52
USGRA (ultrasound-guided regional anesthesia). See Muscoskeletal and Doppler ultrasound
imaging

V
Vertebrae. See Cervical spine; Lumbar spine; Spine, basic considerations for; Thoracic spine

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Mục lục
COVER 1
TITLE 3
COPYRIGHT 4
CONTENTS 6
PREFACE 7
ACKNOWLEDGMENTS 8
1. Basics of Musculoskeletal and Doppler Ultrasound Imaging for
9
Regional Anesthesia and Pain Medicine
Ultrasound Transducer Frequency 9
Scanning Plane 9
Transducer and Image Orientation 10
Image Optimization 11
Echogenicity 12
Axis of Intervention 12
Field of View and Needle Visibility 14
Anisotropy 15
Identification of Normal Structures 16
Nerve 16
Tendon 17
Muscle 17
Subcutaneous Fat 17
Bone 17
Fascia 18
Blood Vessel 18
Pleura 18
Special Ultrasound Features 18
Tissue Harmonic Imaging 18
Compound Imaging 19
Panoramic Imaging 20
Three-Dimensional Ultrasound 20
Artifacts 22
Imaging the Challenging Patient 25
The Elderly Patient 25
The Obese Patient 26
Doppler Ultrasound: The Basics 26
Doppler Display 28
Color Doppler 28
Power Doppler 29
Spectral Doppler 30

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 Other Technical Considerations 30
Aliasing 30
Spectral Broadening 31
Doppler Gain 32
Basic Steps for Doppler Imaging 32
Suggested Reading 33
2. Sonoanatomy Relevant for Ultrasound-Guided Upper Extremity Nerve
35
Blocks
Introduction 35
Gross Anatomy 35
Brachial Plexus: Interscalene Groove 44
Gross Anatomy 44
Computed Tomography Anatomy of the Neck and Interscalene Region 46
Magnetic Resonance Imaging Anatomy of the Neck and Interscalene Region 47
Technique of Ultrasound Imaging of the Brachial Plexus at the Interscalene
49
Groove
Assessment of Diaphragm Excursions 56
Brachial Plexus: Supraclavicular Fossa 57
Gross Anatomy 57
Computed Tomography Anatomy of the Supraclavicular Fossa 58
Magnetic Resonance Imaging Anatomy of the Supraclavicular Fossa 59
Technique of Ultrasound Imaging of the Brachial Plexus at the Supraclavicular
59
Fossa
Brachial Plexus: Infraclavicular Fossa 62
Gross Anatomy 62
Computed Tomography Anatomy of the Infraclavicular Fossa 64
Magnetic Resonance Imaging Anatomy of the Infraclavicular Fossa 65
Technique of Ultrasound Imaging of the Brachial Plexus at the Medial
68
Infraclavicular Fossa
Ultrasound Imaging of the Brachial Plexus at the Lateral Infraclavicular Fossa 81
Brachial Plexus: Axilla 85
Gross Anatomy 85
Magnetic Resonance Imaging Anatomy of the Axilla 87
Technique of Ultrasound Imaging of the Brachial Plexus at the Axilla 87
Midhumeral Region – Median and Ulnar Nerve 93
Gross Anatomy 93
Magnetic Resonance Imaging Anatomy of the Midhumeral Region 96
Technique of Ultrasound Imaging for the Median and Ulnar Nerve at the
97
Midhumeral Region
Midhumeral Region – Radial Nerve 100
Gross Anatomy 100
Magnetic Resonance Imaging of the Midhumeral Region (Radial Nerve) 101
Ultrasound Scan Technique for Radial Nerve at the Radial Groove 102

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 Ultrasound Scan Technique for Radial Nerve at the Lateral Aspect of the Arm 105
Elbow Region – Median, Ulnar, and Radial Nerves 107
Gross Anatomy 107
Magnetic Resonance Imaging of the Elbow Region 109
Elbow Region Ultrasound Scan Technique 111
Midforearm Region – Median, Ulnar, and Radial Nerves 117
Gross Anatomy 117
Magnetic Resonance Imaging Anatomy of the Midforearm 118
Midforearm Ultrasound Scan Technique 119
References 126
3. Sonoanatomy Relevant for Ultrasound-Guided Lower Extremity
129
Nerve Blocks
Introduction 129
Gross Anatomy 129
Femoral Nerve at the Inguinal Region 133
Gross Anatomy 133
Computed Tomography Anatomy of the Inguinal Region 136
Magnetic Resonance Imaging Anatomy of the Inguinal Region 136
Femoral Nerve Ultrasound Scan Technique 137
Obturator Nerve at the Inguinal Region 141
Gross Anatomy 141
Computed Tomography Anatomy of the Upper Thigh 142
Magnetic Resonance Imaging Anatomy of the Upper Thigh 143
Obturator Nerve Ultrasound Scan Technique 143
Lateral Cutaneous Nerve of the Thigh 147
Gross Anatomy 147
Magnetic Resonance Imaging Anatomy of the Lateral Cutaneous Nerve of the
149
Thigh
Lateral Cutaneous Nerve of the Thigh Ultrasound Scan Technique 149
Saphenous Nerve at the Adductor Canal 152
Gross Anatomy 152
Computed Tomography Anatomy of the Midfemoral/Adductor Canal Region 155
Magnetic Resonance Imaging Anatomy of the Midfemoral/Adductor Canal
155
Region
Midfemoral/Adductor Canal Region Ultrasound Scan Technique 156
Sciatic Nerve at the Parasacral Region 160
Gross Anatomy 160
Computed Tomography Anatomy of the Sciatic Nerve – Parasacral Region 162
Magnetic Resonance Imaging Anatomy of the Sciatic Nerve – Parasacral
162
Region
Sciatic Nerve – Parasacral Region Ultrasound Scan Technique 163
Sciatic Nerve – At the Subgluteal Region 169
Gross Anatomy 169

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 Computed Tomography Anatomy of the Sciatic Nerve – Subgluteal Region 169
Magnetic Resonance Imaging Anatomy of the Sciatic Nerve – Subgluteal
170
Region
Sciatic Nerve at the Subgluteal Region – Ultrasound Scan Technique 171
Sciatic Nerve at the Infragluteal Region 176
Gross Anatomy 176
Computed Tomography Anatomy of the Sciatic Nerve – Infragluteal Region 178
Magnetic Resonance Anatomy of the Sciatic Nerve – Infragluteal Region 178
Sciatic Nerve at the Infragluteal Region – Ultrasound Scan Technique 179
Sciatic Nerve at the Popliteal Fossa 182
Gross Anatomy 182
Computed Tomography Anatomy of the Popliteal Fossa 184
Magnetic Resonance Imaging Anatomy of the Popliteal Fossa 186
Sciatic Nerve at the Popliteal Fossa – Ultrasound Scan Technique 188
Sciatic Nerve at the Thigh – Anterior Approach 194
Gross Anatomy 194
Computed Tomography Anatomy of the Sciatic Nerve at the Thigh 195
Magnetic Resonance Imaging Anatomy of the Sciatic Nerve at the Thigh 195
Sciatic Nerve at the Thigh – Anterior Approach Ultrasound Scan Technique 196
Terminal Nerves in the Leg 198
Gross Anatomy 198
Computed Tomography Anatomy of the Terminal Nerves of the Leg 204
Magnetic Resonance Imaging Anatomy of the Terminal Nerves of the Leg 205
Terminal Nerves of the Leg – Ultrasound Scan Technique 206
References 212
4. Sonoanatomy Relevant for Ultrasound-Guided Abdominal Wall Nerve
214
Blocks
Introduction 214
Gross Anatomy 214
Muscles of the Anterior Abdominal Wall 214
Nerves of the Anterior Abdominal Wall 221
Lateral (Midaxillary) Transverse Abdominis Plane 223
Gross Anatomy 223
Computed Tomography Abdomen Showing the Lateral (Midaxillary)
223
Transverse Abdominis Plane
Magnetic Resonance Imaging Abdomen Showing the Lateral (Midaxillary)
224
Transverse Abdominis Plane
Ultrasound Scan Technique 224
Subcostal Transverse Abdominis Plane 227
Gross Anatomy 227
Computed Tomography Abdomen Showing the Subcostal Transverse
227
Abdominis Plane
Magnetic Resonance Imaging Abdomen Showing the Subcostal Transverse

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 Abdominis Plane
Ultrasound Scan Technique 228
Rectus Sheath 231
Gross Anatomy 231
Computed Tomography Abdomen Showing the Rectus Abdominis Muscle 232
Magnetic Resonance Imaging Abdomen Showing the Rectus Abdominis Muscle 233
Ultrasound Scan Technique 234
Ilioinguinal and Iliohypogastric Nerve 239
Gross Anatomy 240
Computed Tomography Abdomen – Transverse View at the Level of the
240
Anterior Superior Iliac Spine
MRI Abdomen – Transverse View at the Level of the Anterior Superior Iliac
241
Spine
Ultrasound Scan Technique 242
Quadratus Lumborum Block 244
Gross Anatomy 244
Ultrasound Scan Technique 246
References 250
5. Ultrasound Imaging of the Spine: Basic Considerations 252
Introduction 252
Basics of Spine Anatomy 252
Spinal Sonography – Basic Consideration 258
Ultrasound Scan Planes 258
Sonoanatomy of the Osseous Elements of the Spine 262
References 273
6. Sonoanatomy Relevant for Ultrasound-Guided Injections of the
276
Cervical Spine
Introduction 276
Basic Cervical Spine Anatomy 276
Typical Cervical Vertebra (C3 to C6) 278
Atlas (C1) 284
Axis (C2) 285
Seventh Cervical Vertebra (C7) 285
Computed Tomography Anatomy of the Cervical Spine 285
Magnetic Resonance Anatomy of the Cervical Spine 290
Ultrasound for Cervical Facet Joint Injection 298
Ultrasound Scan Technique 298
Ultrasound for Third Occipital Nerve Block 305
Gross Anatomy of the Third Occipital Nerve 305
Ultrasound Scan Technique 305
Ultrasound for Selective Nerve Root Block 307
Ultrasound Scan Technique 307
Ultrasound for Stellate Ganglion (Cervical Sympathetic Chain) Block 313

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 Ultrasound for Stellate Ganglion (Cervical Sympathetic Chain) Block 313
Gross Anatomy 313
Ultrasound Scan Technique 313
References 316
7. Ultrasound of the Thoracic Spine for Thoracic Epidural Injections 318
Introduction 318
Basic Anatomy of the Thoracic Spine 318
Typical Thoracic Vertebrae 321
Gross Anatomy of the Upper Thoracic Spine (T1–T4) 323
Computed Tomography Anatomy of the Upper Thoracic Spine (T1–T4) 324
Magnetic Resonance Imaging Anatomy of the Upper Thoracic Spine (T1–T4) 326
Gross Anatomy of the Midthoracic Spine (T5–T8) 328
Computed Tomography Anatomy of the Midthoracic Spine (T5–T8) 329
Magnetic Resonance Imaging Anatomy of the Midthoracic Spine (T5–T8) 331
Gross Anatomy of the Lower Thoracic Spine (T9–T12) 333
Computed Tomography Anatomy of the Lower Thoracic Spine (T9–T12) 334
Magnetic Resonance Imaging Anatomy of the Lower Thoracic Spine (T9–T12) 336
Ultrasound Imaging of the Thoracic Spine – Basic Considerations 338
Ultrasound Imaging of the Upper Thoracic Spine (T1–T4) 343
Ultrasound Imaging of the Midthoracic Spine (T5-T8) 347
Ultrasound Imaging of the Lower Thoracic Spine (T9–T12) 353
Identification of Thoracic Intervertebral Spaces Using Ultrasound 355
Clinical Pearls 356
References 356
8. Ultrasound Imaging of the Lumbar Spine for Central Neuraxial Blocks 358
Introduction 358
Basic Lumbar Spine Anatomy 358
Typical Lumbar Vertebra 359
Fifth Lumbar Vertebra (L5) 361
Gross Anatomy of the Lumbar Spine 362
Computed Tomography Anatomy of the Lumbar Spine 366
Magnetic Resonance Imaging Anatomy of the Lumbar Spine 369
Ultrasound Imaging of the Lumbar Spine 373
Transverse Ultrasound Imaging of the Lumbar Spine 397
Sagittal Ultrasound Imaging of the Lumbar Spine 398
References 399
9. Ultrasound Imaging of Sacrum and Lumbosacral Junction for Central
401
Neuraxial Blocks
Introduction 401
Basic Anatomy of the Sacrum 401
Gross Anatomy of the Sacrum 403
Computed Tomography Anatomy of the Sacrum 404

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 Ultrasound Imaging of the Sacrum for Caudal Epidural Injection – Basic
406
Considerations
Ultrasound Imaging of the Sacrum for Caudal Epidural Injection 408
Clinical Pearls 411
Basic Anatomy of the Lumbosacral Interlaminar Space 412
Gross Anatomy of the Lumbosacral Interlaminar Space 414
Computed Tomography Anatomy of the Lumbosacral Interlaminar Space 414
Magnetic Resonance Imaging Anatomy of the Lumbosacral Interlaminar Space 416
Ultrasound Imaging of the Lumbosacral Interlaminar Space 418
Clinical Pearls 424
References 427
10. Sonoanatomy Relevant for Thoracic Interfascial Nerve Blocks:
428
Pectoral Nerve Block and Serratus Plane Block
Introduction 428
Gross Anatomy 428
Innervation of the Breast 439
Ultrasound Imaging for Thoracic Interfascial Blocks 440
Ultrasound Scan Technique 440
Clinical Pearls 461
References 462
11. Sonoanatomy Relevant for Ultrasound-Guided Thoracic
464
Paravertebral Block
Introduction 464
Gross Anatomy 464
Communications of the Thoracic Paravertebral Space 468
Computed Tomography Anatomy of the Thoracic Paravertebral Region 469
Magnetic Resonance Imaging Anatomy of the Thoracic Paravertebral Region 471
Sonoanatomy of the Thoracic Paravertebral Region 474
Ultrasound Scan Technique 474
Three-Dimensional Sonography of the Thoracic Paravertebral Region 504
Reference 508
12. Sonoanatomy Relevant for Ultrasound-Guided Lumbar Plexus Block 511
Introduction 511
Gross Anatomy 511
Computed Tomography Anatomy of the Lumbar Paravertebral Region 518
Magnetic Resonance Imaging Anatomy of the Lumbar Paravertebral Region 519
Lumbar Paravertebral Sonography 522
Ultrasound Scan Technique 522
Clinical Pearls 538
References 541
INDEX 544

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