Pediatric Atlas Of: Ultrasound-And Nerve Stimulation-Guided Regional Anesthesia

Ban C.H.
Tsui
Santhanam Suresh Editors
Pediatric Atlas of
Ultrasound- and Nerve
Stimulation-Guided
Regional Anesthesia
123
Pediatric Atlas of Ultrasound- and Nerve
Stimulation-Guided Regional Anesthesia
Ban C.H. Tsui • Santhanam Suresh
Editors
Pediatric Atlas of Ultrasound-

and Nerve Stimulation-
Guided Regional Anesthesia
Editors
Ban C.H. Tsui, Dip Eng, BSc (Math), B Pharm, Santhanam Suresh, MD
MSc, MD, FRCPC Arthur C. King Professor and Chair of Pediatric
Professor and Director of Clinical Research Anesthesiology
Department of Anesthesiology and Pain Medicine Department of Pediatric Anesthesiology
University of Alberta Ann and Robert H. Lurie Children’s
Edmonton, Alberta Hospital of Chicago
Canada Chicago, IL
USA
Pediatric and Adult Anesthesiologist
Stollery Children’s Hospital/University Professor of Anesthesiology and Pediatrics
of Alberta Hospital Feinberg School of Medicine
Site Chief, Anesthesia, Cross Cancer Institute Northwestern University
Edmonton, Alberta Chicago, IL
Canada USA
ISBN 978-0-387-79963-6 ISBN 978-0-387-79964-3 (eBook)

DOI 10.1007/978-0-387-79964-3
Library of Congress Control Number: 2015949112
Springer New York Heidelberg Dordrecht London

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We would like to dedicate this edition of the book to our patients, our
teachers, our students, and our families. In addition, Dr. Tsui would
especially like to express his deepest appreciation of the great encouragement
provided to him during his academic career by his father, Woon-Tak Tsui,
who he lost suddenly during the preparation of this edition.
Ban C.H. Tsui, MD
Santhanam Suresh, MD
To my wife, Eliza, and my children, Jenkin and Jeremy—the real loves of my

life. Without their support and understanding, I could not have completed this
demanding project. I would also like to dedicate this opus to my parents,
Woon-Tak and Kau-Wan, for their love and guidance throughout my life.
Ban C.H. Tsui, MD
I would like to dedicate this book to my family; my wife, Nina, and my

children, Aneesha, Sunitha, and Madhav, who have been my greatest
inspiration and love in my life; my mother Chandra Santhanam who has been
my avid supporter; and to the memory of my late father R. Santhanam whose
extraordinary love and dedication to our family fostered my growth. I want to
thank all the members of the Department of Pediatric Anesthesiology at the
Ann & Robert H. Lurie Children’s Hospital of Chicago, whose support was
imperative in getting this book off the ground. Finally to my colleague and
friend Ban Tsui whose dedication and commitment is what evolved into
this atlas.
Santhanam Suresh, MD
Foreword
Over the past 30 years, pediatric regional anesthesia has come of age. There is now a large and
rapidly growing body of information regarding the impact of development on pain responses,
local anesthetic pharmacology, and the adaptation of a full range of regional anesthetic tech-
niques for infants and children. There is also a quickly expanding literature on safety and
efficacy from registries and clinical trials. Thirty years ago, in most pediatric centers world-
wide, regional anesthesia was used for only a small fraction of surgeries. Today, it is an essen-
tial part of pediatric anesthetic and analgesic management throughout the world. For children
in tertiary centers in highly developed countries, regional anesthesia is recognized as an essen-
tial component of multimodal analgesic regimens that seek to provide pain relief with move-
ment; diminish opioid use, with a corresponding reduction in opioid side-effects; and facilitate
early mobilization, early enteral feeding, and early hospital discharge. Some preliminary stud-
ies in infant humans and infant animals suggest that regional anesthesia may have an impact
on preventing prolonged changes in central nervous system responses to surgical trauma. In
lower resource settings, pediatric regional anesthesia is more often used as a primary anes-
thetic approach, based on considerations of cost, safety, and reduced need for postoperative
intensive care. In the face of ongoing controversy over the impact of general anesthetics on the
developing brain, regional anesthesia has a growing role for neonates, infants, and toddlers as
an approach to limiting general anesthetic dosing and overall exposure.
Ban Tsui and Santhanam Suresh have been pioneers in this effort, and it is fitting that they
are co-editing this wonderful textbook. Both editors have made fundamental innovations in the
field over the past 20 years, and both continue to innovate and to mentor to a new generation
of investigators and clinicians.
This book is superb in every way. As an atlas, it is first-rate. Anatomic drawings, diagrams,
photos, and ultrasound images are combined in ways that masterfully guide the reader. The
introductory sections outline the physics behind nerve stimulation and ultrasound in a way that
is both sophisticated and highly practical for the clinician. The chapter entitled “Clinical and
Practical Aspects of Ultrasound Use” codifies a set of clinical pearls in a clear and useful man-
ner. The chapters that discuss pain assessment, pharmacology, and complications are practical
and up-to-date. Part III covers the clinical anatomy of the various regions of the body with
relevance to the conduct of regional anesthesia. Throughout these sections, the illustrations are
outstanding, with just the right level of detail and the right points of emphasis. Parts IV, V, VI,
VII, VIII, IX, and X build on these foundations to elucidate the “how-to” for the full range of
regional anesthetic blocks. No other textbook, adult or pediatric, gives such clear guidance on
how to perform a block, how to troubleshoot, how to avoid pitfalls, and how to analyze and
solve clinical problems. Throughout these sections, there is a great balance between the sci-
ence and the art of regional anesthesia. In every chapter, there is an authoritative reference list.
I am left with only one criticism, namely the title. This book is a magnificent atlas, but it is
really much more than that: it is by far the definitive textbook on pediatric regional anesthesia.
Charles Berde, MD, PhD

Professor of Anesthesia (Pediatrics), Harvard Medical School,
Children’s Hospital Boston, Boston, MA, USA
vii
Preface
In 2007, Tsui, with Springer, published the first textbook and atlas devoted entirely to ultra-
sound-guided regional blockade in adults, entitled Atlas of Ultrasound and Nerve Stimulation-
Guided Regional Anesthesia. Since then, many textbooks and atlases with a similar focus have
been written, albeit for the adult population only. Despite the extensive progress made in
regional anesthesia over the past decades, there still exists no textbook and/or atlas dedicated
to both ultrasound- and nerve stimulation-guided regional blockades for the pediatric
population.
In preparing this, the first textbook focused on ultrasound and nerve stimulation for pediat-
ric regional anesthesia; we had the privilege of gathering friends and colleagues as contributing
authors. Similar to the situation for the adult population, pediatric regional anesthesia has long
been regarded as an “art,” and success with these techniques is perceived widely to be the
domain of a few skilled pediatric anesthesiologists. Around 30 years ago, the introduction of
nerve stimulation technology began to nudge regional anesthesia closer toward a “science.”
However, nerve stimulation has its limitations; the technique relies on electrical impulses to
elicit a physiological response from nerves, and considerable variation exists among individu-
als with respect to this phenomenon. Nerve stimulation guidance is also limited by a number
of other factors, including the properties of injectates, physiological fluids (e.g., blood), and
disease. Nevertheless, it proved to be a useful and objective method to place, with some reli-
ability, the needle tip close to a target nerve. Surprisingly, the introduction of nerve stimulation
did not spark a renewed interest in regional anesthesia, although it proved quite a benefit to
those of us who were performing nerve blocks on a regular basis. This is particularly true in
the case of pediatric patients, who are usually unable to provide feedback since their blocks are
administered under heavy sedation and/or general anesthesia.
Ultrasound imaging is one of the most exciting technological advancements to be applied
to regional anesthesia. For the first time in over 100 years, we can visualize the nerve which we
intend to block. Unlike nerve stimulation, we foresee ultrasound being a catalyst to draw anes-
thesiologists toward devoting more of their practice to regional anesthesia. We must remember,
however, that the images ultrasound provides us are indirect and open to individual interpreta-
tion, depending on the user’s experience level, training, and where they received that experi-
ence and training. While some practitioners have a natural gift for interpreting ultrasound
images, this is not the case with the majority. There is a significant learning curve that goes
with mastering ultrasound-guided regional anesthesia. What is more, it has been shown that
combining ultrasound and nerve stimulation can improve block success, meaning that two
techniques must be learned and mastered to be used to achieve a common goal. This was the
main reason for describing and covering the advantages of both technologies in the adult atlas.
It is our hope that the adult atlas spurred readers to incorporate ultrasound (and nerve stimu-
lation) technology into their practice and become better regional anesthesiologists. As with
that book, the main objective of this one is to shorten the learning curve associated with
regional anesthesia—this time for use in pediatric patients. For those practitioners who are
already adept and experienced with pediatric regional anesthesia, this book may serve to
increase their knowledge and provide new insights into this field. The ultimate goal of this
book is to continue to develop and uncover new knowledge by amalgamating landmark, nerve
ix
x Preface
stimulation, and ultrasound guidance techniques in regional anesthesia, thereby improving

patient care.
This atlas follows a layout similar to the one in the adult atlas. The book begins with several
chapters providing information on both ultrasound and nerve stimulation. Equipment and
setup, with a focus on needs for pediatric regional anesthesia, are also discussed. Chapter 4
provides perhaps the most important information, including many practical ideas and
approaches for using ultrasound during pediatric regional blockade. As with the adult book, we
have also included a chapter discussing the fundamental ideas and physical tenets underlying
electrical stimulation for regional blockade. In the clinical chapters, the reader will find helpful
tables and flowcharts which describe step-by-step procedures for finding a nerve using electri-
cal stimulation as well as troubleshooting tips in case of unexpected or unwanted responses
during nerve stimulation. This atlas also includes a chapter on the use of ultrasound for place-
ment of perineural catheters for continuous nerve blocks; many readers will find this chapter
applicable to blocks in adults as well.
In the same way that a sound knowledge of anatomy forms the basis of success in regional
anesthesia, anatomy forms the core of this book. As Gaston Labat, the father of modern
regional anesthesia, stated, “Anatomy is the foundation upon which the entire concept of
regional anesthesia is built. Anyone who wishes to be an expert in the art of regional anesthesia
must be thoroughly grounded in anatomy.” This advice remains as true today as when it was
given a century ago. Thus, there are six consecutive chapters discussing pediatric anatomy
with relevance to regional anesthesia, each supplemented with diagrams and illustrations to
provide the reader with a comprehensive rendering of the anatomy associated with blocks in a
particular region of the body. In the clinical chapters, there is a brief description of relevant
anatomy with illustrations. In the absence of a readily available pediatric cadaver, we utilized
an adult cadaver software program to obtain cross-sectional images showing gross anatomy,
and we have used MRI and ultrasound, in pediatric subjects where possible, to capture detailed
images of the corresponding block location. This is followed by a clinical description of how
to perform ultrasound imaging during regional blockade. These sections describe and illustrate
the positioning of the probe, the specific needling technique used, how to use nerve stimula-
tion, and pre- and post-local anesthetic application. This sequential format gives the reader a
realistic simulation of the management of each clinical situation.
The images used in this book are those from our everyday practice and are achievable by
any newcomer using ultrasound for regional anesthesia. We have been mindful not to concen-
trate on anatomically perfect ultrasound images—which can be obtained occasionally—but
instead show images that are representative of those encountered on an average day. As with
the adult atlas, MRI images were captured from consenting patients to further illustrate the
neuroanatomy and relationship to surrounding anatomical structures. Where possible, we have
also provided schematic drawings to show the relationship between nerves, vessels, bone,
muscle, and other structures that one must contend with when using ultrasound to guide nerve
blocks. For the ultrasound images, we have again provided unlabeled and labeled images along
with a diagram showing the location of the ultrasound probe footprint. The unlabeled image
allows the reader to familiarize themselves with a realistic clinical image without the distrac-
tion of labels. In our experience, the side-by-side presentation of unlabeled and labeled ultra-
sound images acts as a helpful learning tool for novice users.
Since ultrasound-guided regional anesthesia is still an emerging field, the literature is con-
stantly being updated with new ideas about how to best apply this technology. In this book, we
focus on the most common approaches used and supplement these by including, in clinical
pearls and notes, alternative approaches as described in the literature or by the chapter authors.
This allows the reader to attempt and select the most suitable approach for his/her own needs.
Throughout the book, dynamic and systematic scanning techniques are emphasized. As with
adults, ultrasound-guided visualization of obvious nearby landmarks (i.e., blood vessels) is
recommended as a first step in identifying target nerves in pediatric patients. From there, shift-
ing the view to the associated neural structures and “tracing back” to the desired block site is,
Preface xi
in our experience, a more user-friendly method than “hunting” for the target nerve and block
site without the guidance of any familiar subcutaneous landmarks. In this way, the dynamic
method reemphasizes the importance of anatomical knowledge as the foundation for success-
ful regional anesthesia.
It is almost certain that when they are first beginning to use ultrasound for regional block-
ade, anesthesiologists will encounter difficulty in learning how to use the technology to iden-
tify neural structures and place the needle tip accurately. In many cases, this will result in
frustration and failure, which likely deters many anesthesiologists from persisting in improv-
ing their technique and adopting the technology for their practice. This is especially pertinent
to pediatric regional anesthesia since the patients are, in general, uncooperative and the anat-
omy is that much smaller and, in some cases, underdeveloped compared to adults. We antici-
pate that the concepts and methods described in this textbook will ease the learning curve for
pediatric anesthesiologists wishing to incorporate regional blockade into their repertoire.
Finally, the contents of this book provide a useful refresher and resource for all regional anes-
thesiologists wishing to hone their skills and adapt cutting-edge techniques into their
practice.
Edmonton, Alberta, Canada Ban C.H. Tsui, MSc, MD, FRCPC

Chicago, IL, USA Santhanam Suresh, MD
Acknowledgments
We wish to acknowledge the following individuals for their support, hard work, and contri-
butions in preparing this book. Dr. Tsui’s research manager, Dr. Gareth Corry, spent many
extra hours and worked diligently to contribute toward and assemble the material contained
in this book. His continual assistance with editing helped organize and expedite our and our
colleagues’ writing and editing process. We also wish to thank a group of students, medical
students, fellows, and research assistants over the past 5 years, including Natalie Chua, Kim
Cochrane, Jason Ha, Sarah Henschke, Alex Kwan, Danika Leung, Paul Li, Jennifer Pillay,
and Jenkin Tsui from the University of Alberta, and Dr. Amod Sawardekar from Northwestern
University, who assisted in organizing chapter drafts, labeling of the images, and contribu-
tion of the written material. The Chair of the University of Alberta Department of
Anesthesiology and Pain Medicine, Dr. Mike Murphy, provides ongoing support and encour-
agement. Dr. Michelle Noga, of the University of Alberta Department of Diagnostic Imaging
and Radiology, facilitated access to the institution’s MRI technology and operators. We also
acknowledge the work done by Teresa Liang, now a radiology resident at the University of
British Columbia, who diligently collected the MRI images used in this book. We acknowl-
edge the Ecole Polytechnique Fédérale de Lausanne, Switzerland, Visible Human Web
Server (http://visiblehuman.epfl.ch) as the data source for the anatomical slices used
throughout the book. Staff members from the University of Alberta Hospital, the Stollery
Children’s Hospital, and Northwestern University/Lurie Children’s Hospital Chicago always
provide an excellent environment for patient care, teaching, and research that has directly
facilitated the advancement of clinical regional anesthesia practice. A Clinical Scholar
Award from the Alberta Heritage Foundation for Medical Research allowed Dr. Tsui to pur-
sue this project by helping to support his academic work. The unrestricted grant from
Springer to start this project was a financial help and support, and Shelley Reinhardt and
Michael D. Sova from Springer are greatly appreciated for providing their expertise and
assistance for this project.
Edmonton, Alberta, Canada Ban C.H. Tsui, MSc, MD, FRCPC

Chicago, IL, USA Santhanam Suresh, MD
xiii
Contents
Part I Equipment and Technique for Nerve Stimulation and Ultrasound Guidance
in Regional Anesthesia
1 Regional Block Area Setup, Equipment, and Monitoring . . . . . . . . . . . . . . . . 3

Vivian H.Y. Ip and Ban C.H. Tsui
1.1 Differences Between the Pediatric and Adult Populations
That Affect Regional Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2 Block Area and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.1 General Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2.2 Emergency Drugs and Resuscitating Equipment . . . . . . . . . . . . . . 5
1.2.3 Resuscitation Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.4 Resuscitation Drugs (Intravenous Doses). . . . . . . . . . . . . . . . . . . . 6
1.2.5 Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.6 Nerve Block and Catheter Equipment . . . . . . . . . . . . . . . . . . . . . . 6
1.2.7 Needles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.8 Peripheral Nerve Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.2.9 Neuraxial Nerve Blocks/Catheters . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.2.10 Additional Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2 Pediatric Electrical Nerve Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Kelly P.A. Byrne and Ban C.H. Tsui
2.1 Nerve Stimulation Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2 Electrophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2.1 Characteristics of Electrical Impulses . . . . . . . . . . . . . . . . . . . . . . 12
2.2.2 Current Intensity and Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2.3 Rate of Current Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2.4 Polarity of Stimulating and Returning Electrodes . . . . . . . . . . . . . 13
2.2.5 Distance-Current Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2.6 Current Density of Electrodes and Injectates . . . . . . . . . . . . . . . . . 15
2.2.7 Electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2.8 Injectates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2.9 Electrical Impedance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.3 Electrical Epidural Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.3.1 Test Equipment and Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.4 Mechanisms of the Epidural Stimulation Test . . . . . . . . . . . . . . . . . . . . . . . 18
2.4.1 Stimulating Epidural Catheter Requirements . . . . . . . . . . . . . . . . . 19
2.4.2 Effective Conduction of Electrical Current . . . . . . . . . . . . . . . . . . 19
2.4.3 Advancement of the Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.4.4 Considerations for Test Performance and Interpretation . . . . . . . . 20
2.4.5 Limitations of Epidural Stimulation . . . . . . . . . . . . . . . . . . . . . . . . 20
xv
xvi Contents
2.5 Useful Equipment Features in Nerve Stimulation . . . . . . . . . . . . . . . . . . . . 21

2.5.1 Constant Current Output and Display . . . . . . . . . . . . . . . . . . . . . . 21
2.5.2 Variable Pulse Width and Frequency . . . . . . . . . . . . . . . . . . . . . . . 22
2.5.3 Other Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.6 Practical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.6.1 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.6.2 Population Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.6.3 Does Nerve Stimulation Make a Difference? . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 Ultrasound Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Michelle L. Noga, Vivian H.Y. Ip, and Ban C.H. Tsui
3.1 Basic Ultrasound Physics and Technology . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1.1 Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.2 Transducers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.2.1 Types of Ultrasound Transducers . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3 Sound Wave Properties in Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.3.1 Speed of Sound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.2 Reflection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.3 Scattering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.4 Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.5 Refraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.6 Absorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.4 Optimization of Image Quality: Knobology. . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.1 Frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.2 Depth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.3 Gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.4 Time Gain Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.5 Focal Zone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.6 Doppler Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.5 Anisotropy and Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.1 Anisotropy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.2 Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.6 Echogenic Appearance of Various Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.7 Equipment Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.8 Current Advances for Future Developments . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.1 Compound Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.2 Single-Crystal Transducers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.3 Capacitive Micromachined Ultrasound Transducers (CMUT) . . . 39
3.8.4 Sonix GPS (Ultrasonix Medical Corp, Richmond, BC, Canada) . . 39
3.8.5 Power Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.6 Robot-Assisted Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . . 39
4 Clinical and Practical Aspects of Ultrasound Use . . . . . . . . . . . . . . . . . . . . . . . 41
4.1 Image Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.2 Probe Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.3 Image Optimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.3.1 Probe Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.3.2 Practical Approach: Traceback Method . . . . . . . . . . . . . . . . . . . . . 46
Contents xvii
4.4 Control of Needle Trajectory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

4.4.1 Visibility of Needles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.4.2 Hand-Eye Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.4.3 Needling Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
5 Regional Block Catheter Insertion Using Ultrasonography
and Stimulating Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.1 Indications, Contraindications, and Safety of
Peripheral Nerve Catheter Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.2 Equipment and Injectates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.2.1 Equipment Required . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.2.2 Sterile Transducer Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5.2.3 Choice of Injectates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.3.1 Confirming Catheter Tip Location with Ultrasonography . . . . . . . 66
5.3.2 Confirming Catheter Tip Location with Nerve Stimulation . . . . . . 67
5.3.3 Catheter-Over-Needle Assembly Insertion. . . . . . . . . . . . . . . . . . . 67
5.3.4 Securing the Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
5.4 Examples of Common Peripheral Nerve Catheterization
Procedures Used in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
5.4.1 Infraclavicular Nerve Block Catheterization . . . . . . . . . . . . . . . . . 69
5.4.2 Femoral Nerve Block Catheterization . . . . . . . . . . . . . . . . . . . . . . 69
5.4.3 Sciatic Nerve Block Catheterization. . . . . . . . . . . . . . . . . . . . . . . . 70
5.5 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Part II Considerations in Pediatric Regional Anesthesia

6 Pain Assessment in Children Undergoing Regional Anesthesia . . . . . . . . . . . . 75
Bruce D. Dick, Kathy Reid, Michelle J. Verrier, and Alex Baloukov
6.1 Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.2 Principles of Pain Assessment in Infants and Children . . . . . . . . . . . . . . . . 76
6.3 Assessing Pain in Neonates and Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.3.1 The Premature Infant Pain Profile (PIPP). . . . . . . . . . . . . . . . . . . . 78
6.3.2 Neonatal Pain Agitation and Sedation Scale (N-PASS) . . . . . . . . . 79
6.3.3 CRIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.3.4 Assessing Postoperative Pain in Infants and Young Children . . . . 81
6.4 Assessing Pain in Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.1 Faces Pain Scale-Revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.2 Numeric Rating Scales (NRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.3 Oucher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.4 Pieces of Hurt/Poker Chip Scale . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.5 Wong-Baker FACES Pain Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.6 Visual Analogue Scale (VAS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.7 Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) . . . 83
6.5 Assessing Postoperative Pain in Critically Ill Children . . . . . . . . . . . . . . . . 84
6.6 Assessing Postoperative Pain in Children with Cognitive Impairments . . . 86
6.7 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
6.8 Developmental, Familial, and Psychological Factors. . . . . . . . . . . . . . . . . . 90
xviii Contents
6.8.1 Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
6.8.2 Developmental Delays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
6.8.3 Psychological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6.8.4 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
6.8.5 Cultural Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
7 Pediatric Pharmacological Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Derek Dillane
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7.2 Structure and Physiochemical Properties . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7.2.1 Onset of Action, Potency, and Duration . . . . . . . . . . . . . . . . . . . . . 99
7.2.2 Sodium Channel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
7.2.3 Physiological Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
7.3 Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
7.3.1 Absorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
7.3.2 Absorption from Epidural Space . . . . . . . . . . . . . . . . . . . . . . . . . . 102
7.3.3 Absorption from Other Routes of Administration . . . . . . . . . . . . . 102
7.3.4 Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
7.3.5 Plasma Protein Binding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
7.3.6 Hepatic Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
7.4 Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.4.1 Central Nervous System Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . 106
7.4.2 Cardiac Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
7.4.3 Treatment of Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
7.4.4 Prevention of Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
7.5 Dosing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
8 Complications of Regional Anesthesia in the Pediatric Population . . . . . . . . . 111
Adam M. Dryden and Ban C.H. Tsui
8.1 General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
8.2 Adverse Events Related to Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . 115
8.2.1 Allergic Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.2.2 Systemic Toxic Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.3 Complications Related to Regional Anesthesia Equipment . . . . . . . . . . . . . 119
8.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
8.3.2 Adverse Events Caused by Needles . . . . . . . . . . . . . . . . . . . . . . . . 119
8.3.3 Adverse Events Caused by Nerve Stimulators . . . . . . . . . . . . . . . . 124
8.3.4 Adverse Events Caused by Ultrasound Probes. . . . . . . . . . . . . . . . 124
8.3.5 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
8.4 Block Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8.4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8.4.2 Complications of Peripheral Nerve Blocks . . . . . . . . . . . . . . . . . . 125
8.4.3 Complications of Neuraxial Blocks . . . . . . . . . . . . . . . . . . . . . . . . 126
8.4.4 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Contents xix
Part III Clinical Anatomy

9 Clinical Anatomy of the Head and Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Glenn Merritt, Anil H. Walji, and Ban C.H. Tsui
9.1 Clinical Anatomy of Trigeminal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
9.1.1 Ophthalmic Nerve (V1 Division of the Trigeminal Nerve,
Pure Sensory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
9.1.2 Maxillary Nerve (V2 Division of the Trigeminal Nerve,
Pure Sensory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
9.1.3 Mandibular Nerve (V3 Division of the Trigeminal Nerve,
Sensory and Motor to Muscles of Mastication) . . . . . . . . . . . . . . . 142
9.2 Clinical Anatomy of the Cervical Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
9.3 Clinical Anatomy of Occipital Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
9.3.1 Lesser Occipital Nerve (C2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
9.3.2 Greater Occipital Nerve (C2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
9.4 Clinical Anatomy of the Nerve of Arnold . . . . . . . . . . . . . . . . . . . . . . . . . . 146
10 Clinical Anatomy of the Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Anil H. Walji and Ban C.H. Tsui
10.1 Brachial Plexus: Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
10.2 Branches of the Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
10.2.1 Branches from the Roots (Ventral Rami) . . . . . . . . . . . . . . . . . . . . 153
10.2.2 Branches from the Trunks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
10.2.3 Branches from the Cords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
10.2.4 Terminal Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
11 Clinical Anatomy of the Lumbar Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
11.1 Lumbar Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
11.1.1 Branches of the Lumbar Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
11.1.2 Iliohypogastric Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
11.1.3 Ilioinguinal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
11.1.4 Genitofemoral Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
11.1.5 Lateral Femoral Cutaneous Nerve
(Lateral Cutaneous Nerve of Thigh) . . . . . . . . . . . . . . . . . . . . . . . . 170
11.1.6 Femoral Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
11.1.7 Obturator Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
12 Clinical Anatomy of the Sacral Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
12.1 Sacral Plexus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
12.2 Direct Muscular Branches of the Sacral Plexus . . . . . . . . . . . . . . . . . . . . . . 179
12.2.1 Nerve to the Piriformis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
12.2.2 Nerve to Obturator Internus and Gemellus Superior . . . . . . . . . . . 179
12.2.3 Nerve to Quadratus Femoris and Gemellus Inferior . . . . . . . . . . . 179
12.3 Major Terminal Nerves of the Sacral Plexus . . . . . . . . . . . . . . . . . . . . . . . . 179
12.3.1 Superior Gluteal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
12.3.2 Inferior Gluteal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
12.3.3 Posterior Femoral Cutaneous Nerve . . . . . . . . . . . . . . . . . . . . . . . . 179
12.3.4 Sciatic Nerve. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
12.3.5 Tibial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
xx Contents
12.3.6 Common Peroneal (Fibular) Nerve . . . . . . . . . . . . . . . . . . . . . . . . 183

12.3.7 Pudendal Nerve. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
12.3.8 Pelvic Splanchnic Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
13 Clinical Anatomy of the Trunk and Central Neuraxis . . . . . . . . . . . . . . . . . . . 187
13.1 Spinal Nerves and the Vertebral Column . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
13.1.1 Origin of Spinal Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
13.1.2 Vertebral Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
13.2 Development of the Vertebral Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
13.2.1 Developmental Anatomy of the
Thoracic and Lumbar Vertebral Column (Spine) . . . . . . . . . . . . . . 191
13.2.2 Developmental Anatomy of the Sacrum. . . . . . . . . . . . . . . . . . . . . 193
13.3 Costovertebral Articulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
13.4 Paravertebral Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
13.5 Thoracic Spinal Nerves and Intercostal Nerves . . . . . . . . . . . . . . . . . . . . . . 196
13.6 Vertebral (Spinal) Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
13.6.1 Vertebral Levels, Spinal Nerve Roots, and Spinal Cord Segments 201
13.6.2 Spinal Nerves Above the Sacrum . . . . . . . . . . . . . . . . . . . . . . . . . . 202
13.6.3 Termination of the Spinal Cord and Dural Sac. . . . . . . . . . . . . . . . 203
13.6.4 CSF Volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
14 Clinical Anatomy of the Dermatomes and Innervation of the Joints. . . . . . . . 205
14.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
14.1.1 Dermatomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
14.1.2 Myotomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
14.1.3 Osteotomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
14.2 Innervation of the Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
14.2.1 Dermatomes and Cutaneous Distribution
of the Peripheral Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
14.2.2 Myotomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
14.2.3 Osteotomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
14.2.4 Innervation of the Major Joints of the Upper Extremity . . . . . . . . 211
14.3 Innervation of the Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
14.3.1 Dermatomes and Cutaneous Distribution
of the Peripheral Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
14.3.2 Myotomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
14.3.3 Osteotomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
14.3.4 Innervation of the Major Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Part IV Nerve Blocks of the Head and Neck

15 Trigeminal Nerve Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Glenn Merritt and Ban C.H. Tsui
15.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
15.2 Block Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
15.2.1 Superficial Transcutaneous Approach to Trigeminal Nerve Blocks:
Supraorbital, Infraorbital, and Mental Nerve Block . . . . . . . . . . . . 226
Contents xxi
15.2.2 Intraoral Approach to Trigeminal Nerve Blocks:

Infraorbital, Mental, and Greater Palatine Nerves . . . . . . . . . . . . . 233
15.2.3 Deep Trigeminal Nerve Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
15.3 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . 239
15.4 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
16 Cervical Plexus Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Ban C.H. Tsui
16.1 Indications for Cervical Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
16.1.1 Indications for Superficial Cervical Plexus Block . . . . . . . . . . . . . 242
16.1.2 Indications for Combined Superficial and
Deep Cervical Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
16.2 Classic (Deep) Cervical Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
16.2.1 Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
16.2.2 Landmarks and Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . 243
16.2.3 Needle Insertion Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
16.2.4 Nerve Localization and Local Anesthetic Application. . . . . . . . . . 244
16.2.5 Current Literature for Deep Cervical Plexus Block . . . . . . . . . . . . 246
16.3 Ultrasound-Guided Superficial Cervical Plexus Block . . . . . . . . . . . . . . . . 247
16.3.3 Scanning Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
16.3.4 Sonographic Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
16.3.6 Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
16.3.7 Current Literature for Superficial Cervical Block . . . . . . . . . . . . . 252
16.4 Great Auricular Nerve Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
16.4.4 Nerve Localization and Local Anesthetic Application. . . . . . . . . . 254
16.4.5 Current Literature for Great Auricular Nerve Block . . . . . . . . . . . 254
16.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
17 Occipital Nerve Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Ban C.H. Tsui
17.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
17.4 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
xxii Contents
18 Blockade of the Auricular Branch of the Vagus Nerve (Nerve of Arnold) . . . . . 261
Ban C.H. Tsui
18.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
18.2 Block Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
18.4 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Part V Nerve Blocks Above the Clavicle

19 Interscalene Brachial Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Ban C.H. Tsui
19.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
19.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
19.3 Nerve Stimulation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
19.3.1 Needle Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
19.3.2 Current Application and Appropriate Responses . . . . . . . . . . . . . . 271
19.3.3 Modifications to Inappropriate Responses . . . . . . . . . . . . . . . . . . . 272
19.4 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
19.4.1 Preparing the Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
19.5 Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
19.5.1 Clinical Pearls: Interscalene Block . . . . . . . . . . . . . . . . . . . . . . . . . 279
19.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
20 Supraclavicular Brachial Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Ban C.H. Tsui
20.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
20.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
20.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Contents xxiii
Part VI Nerve Blocks Below the Clavicle

21 Infraclavicular Brachial Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Ban C.H. Tsui
21.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
21.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
21.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
22 Axillary Block of the Brachial Plexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Ban C.H. Tsui
22.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
22.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
22.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
23 Terminal Nerve Blocks of the Upper Extremity. . . . . . . . . . . . . . . . . . . . . . . . . 321
Ban C.H. Tsui
23.1 Median Nerve Block. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
23.1.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
23.1.2 Nerve Stimulation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
23.1.3 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
23.1.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
23.2 Radial Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
23.2.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
23.2.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
23.3 Ulnar Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
23.3.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
xxiv Contents

23.3.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Part VII Nerve Blocks of the Lumbar Plexus

24 Posterior Lumbar Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Karen R. Boretsky and Ban C.H. Tsui
24.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
24.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
24.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
25 Terminal Nerve Blocks of the Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . 355
Ban C.H. Tsui
25.1 Femoral Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
25.1.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
25.1.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
25.1.6 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . 363
25.1.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
25.2 Lateral Femoral Cutaneous Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
25.2.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
25.2.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
25.2.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
25.3 Obturator Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
25.3.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
25.3.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
25.3.6 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Contents xxv
25.4 Saphenous Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374

25.4.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
25.4.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
25.4.6 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Part VIII Nerve Blocks of the Sacral Plexus

26 Sciatic and Popliteal Nerve Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Heather Y.Z. Ting and Ban C.H. Tsui
26.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
26.2 Posterior Gluteal (Labat) Sciatic Nerve Block . . . . . . . . . . . . . . . . . . . . . . . 384
26.2.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
26.3 Infragluteal/Subgluteal Sciatic Nerve Block Approach . . . . . . . . . . . . . . . . 393
26.3.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
26.3.4 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
26.4 Anterior Sciatic Nerve Block Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
26.4.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
26.5 Popliteal or Mid-Thigh Sciatic Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . 410
26.5.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
26.5.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Part IX Nerve Blocks at the Ankle

27 Ankle Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Ban C.H. Tsui
27.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
27.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
xxvi Contents

27.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Part X Nerve Blocks at the Trunk

28 Paravertebral Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Heather Yizhen Z. Ting, Karen R. Boretsky, and Ban C.H. Tsui
28.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
28.2 Clinical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
28.3.1 Landmark-Based Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
28.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
29 Intercostal Nerve Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Ban C.H. Tsui
29.1.1 Intercostal Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
29.1.2 Costovertebral Articulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
29.2 Landmark-Based Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
29.6 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
30 Rectus Sheath and Transversus Abdominis Plane (TAP) Blocks . . . . . . . . . . . 463
Bryan J. Dicken and Ban C.H. Tsui
30.1 Rectus Sheath Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
30.1.1 Clinical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
30.1.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
30.2 Transversus Abdominis Plane (TAP) Block . . . . . . . . . . . . . . . . . . . . . . . . . 470
30.2.1 Clinical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
Contents xxvii

30.2.4 Catheter Placement Under Direct Visualization . . . . . . . . . . . . . . . 473
30.2.6 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
31 Ilioinguinal and Iliohypogastric Nerve Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Ban C.H. Tsui
31.2 Landmark-Based Technique (Fascial “Click” Method) . . . . . . . . . . . . . . . . 478
31.4.2 Ultrasonographic Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480
31.6 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
32 Penile Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Heather Yizhen Z. Ting, Peter D. Metcalfe, and Ban C.H. Tsui
32.2 Landmark-Based Technique (Subpubic Approach) . . . . . . . . . . . . . . . . . . . 488
32.3.2 Ultrasonographic Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
32.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
Part XI Neuraxial Blockade

33 Epidural and Caudal Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495
Ban C.H. Tsui
33.1 Epidural Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
33.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
33.1.2 Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
33.1.3 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
33.1.4 Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
xxviii Contents
33.1.5 Nerve Stimulation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499

33.1.6 Electrocardiograph (ECG) Monitoring Technique . . . . . . . . . . . . . 502
33.1.7 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
33.1.8 Needle Insertion Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
33.1.9 Catheter Insertion and Confirmation . . . . . . . . . . . . . . . . . . . . . . . . 512
33.1.10 Case Study: Lumbar Epidural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
33.2 Caudal Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
33.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
33.2.3 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
33.2.5 Ultrasound-Guided Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
33.2.6 Case Study: Caudal Epidural. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
33.3 Advancing a Catheter to the Lumbar or Thoracic Area from a
Caudal Insertion Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
33.3.1 Epidural Stimulation Guidance Technique. . . . . . . . . . . . . . . . . . . . 520
33.3.2 Local Anesthetic Application (“Test”) to
Confirm Avoidance of Intravascular Placement . . . . . . . . . . . . . . . . 521
33.3.3 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
33.3.4 Scanning Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
33.3.5 Sonographic Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
33.3.6 Catheter Insertion and Local Anesthetic Application . . . . . . . . . . . 522
33.3.7 Case Study: Thoracic Epidural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
33.4 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . 524
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
34 Spinal Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Adam O. Spencer, Santhanam Suresh, and Ban C.H. Tsui
34.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
34.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
34.2.1 Clinical Use and Special Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . 528
34.2.2 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
34.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
34.3.1 Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
34.3.3 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
34.3.4 Sonographic Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
34.4 Equipment and Spinal Needle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
34.4.1 Needles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
34.5 Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
34.5.1 Adjuvants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
34.6 Assessment of the Block Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
34.7 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
34.8 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . . . . 535
34.9 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539
Contributors
Alex Baloukov, MPH Faculty of Health Sciences, Simon Fraser University, Burnaby,
BC, Canada
Karen R. Boretsky, MD Department of Anesthesia, Perioperative and Pain Medicine,
Harvard Medical School, Boston Children’s Hospital, Boston, MA, USA
Kelly P.A. Byrne, MB ChB, FANZCA Department of Anesthesia, Waikato Hospital,
Hamilton, New Zealand
Bruce D. Dick, PhD, R Psych Division of Pain Medicine, Department of Anesthesiology and
Pain Medicine, Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
Bryan J. Dicken, MSc, MD, FRCSC Division of Pediatric Surgery, Department of Surgery,
University of Alberta Hospital, Edmonton, AB, Canada
Derek Dillane, MB, BCh, BAO, MMedSci, FFARCSI Department of Anesthesiology and
Pain Medicine, University of Alberta Hospital, Edmonton, AB, Canada
Adam M. Dryden, MD Department of Anesthesiology and Pain Medicine, University
of Alberta Hospital, Edmonton, AB, Canada
Vivian H.Y. Ip, MB ChB, MRCP, FRCA Department of Anesthesiology and Pain Medicine,
Glenn Merritt, MD Department of Anesthesiology, University of Colorado Hospital
and Children’s Hospital Colorado, Aurora, CO, USA
Peter D. Metcalfe, MD, MSc, FRCSC Division of Pediatric Surgery, Division of Urology,
Department of Surgery, Stollery Children’s Hospital, University of Alberta Hospital, Edmonton,
AB, Canada
Michelle L. Noga, MD, FRCPC Department of Radiology and Diagnostic Imaging,
University of Alberta, Edmonton, AB, Canada
Kathy Reid, RN, MN, NP Pediatric Anesthesia, Stollery Children’s Hospital, Edmonton,
AB, Canada
Adam O. Spencer, MSc, MD, FRCPC Vi Riddell Complex Pain and Rehabilitation Centre,
Alberta Children’s Hospital, Calgary, AB, Canada
Santhanam Suresh, MD Department of Pediatric Anesthesiology, Ann & Robert Lurie
Children’s Hospital of Chicago, Chicago, IL, USA
Heather Yizhen Z. Ting, MD, FRCPC Department of Anesthesiology and Pain Medicine,
xxix
xxx Contributors
Ban C.H. Tsui, Dip Eng, BSc (Math), B Pharm, MSc, MD, FRCPC Department of
Anesthesiology and Pain Medicine, Stollery Children’s Hospital/University of Alberta
Hospital, Edmonton, AB, Canada
Michelle J. Verrier, BA Department of Anesthesiology and Pain Medicine, University
of Alberta, Edmonton, AB, Canada
Anil H. Walji, MD, PhD Division of Anatomy, Department of Surgery, Faculty of Medicine
and Dentistry, University of Alberta, Edmonton, AB, Canada
Part I
Equipment and Technique for Nerve Stimulation and
Ultrasound Guidance in Regional Anesthesia
Regional Block Area Setup, Equipment,
and Monitoring 1
Contents
1.1 Differences Between the Pediatric and Adult Populations That Affect Regional Blocks ........... 4
1.2 Block Area and Monitoring .............................................................................................................. 4
1.2.1 General Equipment ................................................................................................................ 5
1.2.2 Emergency Drugs and Resuscitating Equipment .................................................................. 5
1.2.3 Resuscitation Equipment ....................................................................................................... 6
1.2.4 Resuscitation Drugs (Intravenous Doses).............................................................................. 6
1.2.5 Monitoring ............................................................................................................................. 6
1.2.6 Nerve Block and Catheter Equipment ................................................................................... 6
1.2.7 Needles .................................................................................................................................. 6
1.2.8 Peripheral Nerve Catheters .................................................................................................... 9
1.2.9 Neuraxial Nerve Blocks/Catheters ........................................................................................ 9
1.2.10 Additional Equipment ........................................................................................................... 9
Suggested Reading ....................................................................................................................................... 10
V.H.Y. Ip, MB ChB, MRCP, FRCA

Department of Anesthesiology and Pain Medicine,
University of Alberta Hospital, 2-150 Clinical Sciences Building,
Edmonton, AB T6G 2G3, Canada
e-mail: [email protected]
B.C.H. Tsui, Dip Eng, BSc (Math), B Pharm, MSc, MD, FRCPC (*)
Stollery Children’s Hospital/University of Alberta Hospital,
2-150 Clinical Sciences Building, Edmonton, AB T6G 2G3, Canada
© Springer Science+Business Media New York 2016 3

B.C.H. Tsui, S. Suresh (eds.), Pediatric Atlas of Ultrasound- and Nerve Stimulation-Guided Regional Anesthesia,
DOI 10.1007/978-0-387-79964-3_1
4 V.H.Y. Ip and B.C.H. Tsui
1.1 Differences Between the Pediatric 1.2 Block Area and Monitoring
and Adult Populations That Affect
Regional Blocks Performing regional anesthesia in children requires meticu-
lous attention to detail and concentration. Having a quiet
It is important to recognize that there are distinct differences environment with all of the drugs and equipment needed to
between the pediatric and adult populations that can affect perform regional anesthesia and resuscitation on hand is of
regional block technique. In order to understand the setup paramount importance. An induction room is an ideal place
and equipment used for children in regional anesthesia, one where the patient can be sedated or anesthetized away from
must appreciate that: surgical staff and where the regional block could be per-
formed before entering into the operating room. Available
• Children do not understand the importance of lying still space and setups will, however, vary between hospitals. In
for a procedure. adults, a designated block area can be used to provide the
• Children are not able to communicate or differentiate par- ideal environment while speeding up turnover time; however,
esthesia, pain, or pressure on injection. this type of area may be unnecessary for pediatric patients, as
• Anatomical structures are smaller and are situated more the majority will receive a general anesthetic before regional
closely to each other and to the adjacent vessels. anesthesia is performed. Also, since the regional block is for
• Target nerves are more superficial to the skin. analgesia, the time for the block to take effect is not as essen-
• There is a lower concentration of plasma protein binding, tial as compared to its application for surgical anesthesia.
especially in young children. An assistant trained in regional anesthesia, with experi-
ence in monitoring pediatric patients under sedation or gen-
To overcome these differences, regional anesthesia is usu- eral anesthesia, should be present. This is important not only
ally performed in children under deep sedation or general for monitoring the child during the procedure but also to
anesthesia. There is ongoing debate regarding performing handle the nerve stimulator and to help with the injectate.
regional anesthesia in anesthetized adults, but such practice Regardless of the area, it is critical to have all equipment,
is well accepted in pediatric patients, primarily due to the drugs, and monitoring available in the room where the block
differences outlined above. This encourages development of is to be performed. The best way to gather all the necessary
other techniques to minimize the incidence of nerve damage, equipment and drugs is to use a well-labeled storage cart
namely, nerve stimulators, ultrasonography, and injection (Fig. 1.1) where the supplies are organized and easily
pressure monitoring. identifiable.
When performing a regional block, the equipment should
be appropriate for the size of the patient. In particular, the
size of the needle must be adapted to the size of the child.
This allows for improved control of the needle while per-
forming the blocks, which are often superficial. The SLA
“hockey stick” (25 mm, 13–6 MHz) is a good example of an
ultrasound transducer that provides good resolution for
superficial structures and has a small footprint. These are
essential characteristics when using ultrasound to guide
regional blocks in the pediatric population.
1 Regional Block Area Setup, Equipment, and Monitoring 5
The following outlines the contents of this cart: 1.2.1 General Equipment
• Sterile skin preparation solution.

• Sponges/gauze.
• Drape.
• Marking pen and ruler for landmark identification.
• Selection of different sizes of syringes.
• A variety of needles with a selection of gauges for skin
infiltration, drawing up 5 % dextrose, local anesthetics,
sedation, or induction of general anesthetic.
• In pediatric patients, most regional blocks are performed
under general anesthesia without a muscle relaxant.
However, selections of sedatives and hypnotics can be
used for cooperative mature pediatric patients as follows:
– Midazolam (IM/IV: 0.1–0.15 mg/kg up to 0.5 mg/kg,
IV infusion with loading dose of 0.05–0.2 mg/kg over
2–3 min. Continuous infusion initiated at a rate of
0.06–0.12 mg/kg/h)
– Propofol (IV: 1–2 mg/kg for sedation, then 100–150 μg/
kg/min infusion)
– Short-acting opioids:
• Fentanyl (IV sedation: 1–2 μg/kg, then 0.5–1 μg/
kg/h IV infusion).
• Remifentanil (IV: 2–18 years: 1 μg/kg over 30–60 s,
then 0.05–0.1 μg/kg/min IV infusion). All sedation
medication should be titrated to response.
– Several commonly used local anesthetics with differ-
ent concentrations, as well as 50 mL bags or ampules
of normal saline for drug dilution if necessary.
Fig. 1.1 Equipment storage cart with clear identification of equipment, – All local anesthetics should be stored separately from
supplies, and medication the intravenous drugs.
1.2.2 Emergency Drugs and Resuscitating

Equipment
• Although the use of ultrasound allows reduced volumes

of local anesthetic to accomplish a successful nerve block,
it is pertinent to have resuscitation equipment and drugs
available.
• Children have a higher tolerance to local anesthetic on a
weight-dependent basis owing to a greater volume of dis-
tribution; this increases the threshold in reaching the toxic
dose. However, in newborns less than 6 months, the thresh-
old in reaching the toxic dose is reduced due to the lower
concentration of serum protein for local anesthetic bind-
ing, namely, alpha-1 acid glycoprotein. This results in a
higher plasma concentration of unbound local anesthetic.
1.2.3 Resuscitation Equipment 1.2.7 Needles
• Oxygen supply, nasal prongs, and face masks. 1.2.7.1 Needle Tip Design
• A selection of different sizes of Guedel airways, face A blunt needle (Fig. 1.2) reduces the risk of nerve damage
masks, laryngeal masks, and endotracheal tubes. and provides a better feel for the “pop” of puncturing through
• Laryngoscopes (Macintosh and Miller blades) and gum the fascia. However, if the needle is too blunt, the user may
elastic bougie. have to apply extra pressure to perforate the fascia, which
• Ambu® bag (bagger). can result in “overshooting” the nerve.
• Suction. Long-beveled needles increase the risk of damage to
• Selections of various sizes of intravenous cannulae. nerves and vascular structures in the case of intraneural
• Defibrillator should also be accessible. puncture.
• For continuous peripheral nerve blocks, the commonly

1.2.4 Resuscitation Drugs used needles are:
(Intravenous Doses) – Tuohy needles (Fig. 1.3), 18G (20G catheter) or 20G
(22–24G catheter). These are the same needles as used
• Atropine (0.02 mg/kg) for epidural anesthesia.
• Epinephrine (0.01 mg/kg) – Special Sprotte® cannulas (Fig. 1.4) have a lateral
• Suxamethonium (2 mg/kg) “eye” with smooth edges to prevent shearing of the
• Ephedrine (1–12 years: 0.2–0.3 mg/kg; 12–18 years: catheter. They also have an atraumatic tip.
2.5–5 mg) – Facet tip needles (Fig. 1.5) are used when the catheter
• Glycopyrrolate (5–10 μg/kg) is to be positioned parallel to the nerve.
• Intralipid® 20 % (1.5 mL/kg bolus over 1 min followed by
0.25 mL/kg/min infusion; bolus dose can be repeated at
5-min intervals if there is no return of spontaneous circu-
lation) (see Chaps. 7 and 8).
1.2.5 Monitoring
• Routine monitoring should be applied before sedation or

general anesthetic is induced. This includes:
– Electrocardiogram
– Noninvasive blood pressure
– Pulse oximetry
– Capnography
– End-tidal gas monitoring
Fig. 1.2 Blunt needles for single-shot nerve blocks

1.2.6 Nerve Block and Catheter Equipment
There is a variety of different needles for single-shot nerve

blocks and Tuohy needles for peripheral nerve catheter inser-
tion. The needles for single-shot nerve blocks usually have a
female attachment for the nerve stimulator and another
extension to facilitate aspiration and injection of 5 % dex-
trose or local anesthetics. Extension tubing is also available
to facilitate flexible attachment of a syringe to the Tuohy
needle for catheter insertions.
1.2.7.2 Needle Lengths

The choice of the needle length depends on the specific block
and the size of the child. The use of ultrasound can help
determine the depth to the target nerve. Some needles have
centimeter markings (Fig. 1.6) which indicate the depth of
penetration into the tissue. The use of the shortest possible
needle for the required block allows for better handling and
manipulation. The range of needles available is given by the
following examples:
• 25 mm (ProBloc SC® by Life-Tech INC., Texas, USA;

Arrow, Reading, PA)
• 30 mm (Life-Tech INC., Texas, USA; Pajunk, Geisingen,
Germany; B Braun, Melsungen, Germany)
• 40 mm (ProBloc SC® by Life-Tech INC., Texas, USA)
• 50 mm (Life-Tech INC., Texas, USA; Pajunk, Geisingen,
Fig. 1.3 Tuohy needle for continuous peripheral nerve blocks Germany; Arrow, Reading, PA)
1.2.7.3 Needle Gauges

• Generally, a 22G insulated needle is used for single-shot
peripheral nerve blocks, although 25G insulated needles
are also available.
• For catheter insertion, 20–21G and 24G catheters are
inserted with 18G and 20G Tuohy needles, respectively.
Fig. 1.4 Special Sprotte® cannula with a lateral “eye” with smooth
edges and an atraumatic tip
Fig. 1.6 Centimeter markings along the entire length of needles are
useful for measuring depth of penetration
Fig. 1.5 Facet tip needle. To be used when the catheter is to be posi-
tioned parallel to the nerve
1.2.7.4 Other Needle Designs

Other needles are echogenic (e.g., Stimuplex®, B Braun,
Melsungen, Germany) or have echogenic “dots” made by
“Cornerstone” reflectors (e.g., SonoPlex®, Pajunk, Geisingen,
Germany) (Fig. 1.7) to facilitate better imaging of the needle
under ultrasound.
a b
Fig. 1.7 (a) Echogenic needles or (b) needles with echogenic “dots” made by “Cornerstone” reflectors facilitate better imaging of the needle
under ultrasound
1.2.8 Peripheral Nerve Catheters To ensure a good-quality image, selecting an appropriate

transducer and a high-resolution machine is essential. Good
Approaches (see Chap. 5) needling technique needle and visualization are also crucial
when performing blocks in children since anatomical struc-
1. Catheter through needle tures are close together.
There are two broad types of catheters: stimulating cath-
eters and non-stimulating catheters. The advancement 1.2.10.3 Injection Pressure Monitoring
and course of stimulating catheters are guided by the Monitoring of injection pressure is important when perform-
motor response achieved by nerve stimulation. ing peripheral nerve blocks. High-pressure injections may
2. Catheter over needle indicate intraneural injection, which can cause persistent
The approach has just recently been introduced into the neurological deficit. There are commercially available,
market. Ultrasound guidance is critical when using single-use, in-line pressure monitors (Fig. 1.8), as well as the
the catheter-over-needle approach. The introducing nee- use of a column of air in the syringe and the compressed air
dle can be stimulating or non-stimulating, whereas the injection technique (CAIT) (Fig. 1.9) to prevent high injec-
catheter itself is only available in non-stimulating format. tion pressure. A compressed air injection technique involves
Detailed discussion is presented in Chap. 5. withdrawing a set amount of air above a volume of injectate
in a syringe, with the subsequent compression and mainte-
nance of this volume during injection to maintain the pres-
1.2.9 Neuraxial Nerve Blocks/Catheters sure at a chosen level. The compression of the air volume in
the syringe during injection at 50 % or less will ensure an
There are ready-made packs with various needles, syringes, injection pressure below 760 mmHg. This is substantially
drapes, gauze/sponges, aseptic solutions, and catheters (if lower than the threshold associated with increased risk for
appropriate) for caudal, spinal, and epidural anesthesia. These clinical neurological deficit (1,293 mmHg); however, there
should also be available in the storage cart. Details of epidural are no data for injection pressure limits associated with neu-
catheter placement are presented in Chaps. 5 and 33. rological injury in the pediatric population.
1.2.10 Additional Equipment
When performing a regional block, patient feedback and

communication are often used as one of the indicators of
neural damage. As children are more often than not anesthe-
tized when performing a regional block, it is important to
have other tools to increase success rate while minimizing
adverse effects. These include:
1.2.10.1 Nerve Stimulator

A functioning, high-quality nerve stimulator with digital dis-
play of the current amplitude between 0 and 5 mA and short
pulse width is adequate for peripheral nerve blocks. When
performing nerve stimulation, the negative electrode is
attached to the needle, and the positive electrode is attached
Fig. 1.8 Commercially available single-use, in-line pressure monitor
to the patient. Higher current (1–15 mA) is required for elec-
for monitoring injection pressure during peripheral nerve blockade
trical stimulation via the epidural catheter (the Tsui test).
A smooth, gradual increment and decrement of current is
important for fine adjustment of the block needle or catheter.
1.2.10.2 Ultrasound Machine

A detailed discussion about the principles of ultrasound
machines and related equipment is discussed in Chap. 3, and
the practical aspects of ultrasound-guided anesthesia are dis-
cussed in Chap. 4.
1.2.10.4 Syringe/Infusion Pumps

Syringe pumps are devices which enable continuous infusion
(with or without boluses of local anesthetic) to be adminis-
tered during the postoperative period, thereby increasing the
duration of the peripheral/neuraxial nerve block(s). There is
a range of commercially available pumps that are most often
classified as mechanical, electrical spring driven, or elastic
30 % Compression
50 % Compression
0 % Compression
balloon driven.
Quality of life can be improved with disposable infusion
10 ml
7 ml pumps for ambulatory continuous peripheral blocks. The use
Air
Air 5 ml
Air
of these pumps has been reported in children as young as
8 years of age, although it requires vigilant patient selection,
LA LA LA education, and follow-up. The flow of local anesthetic
through the catheter should be confirmed before discharge.
Suggested Reading
Cave G, Harvey M. Intravenous lipid emulsion as antidote beyond local
0 mmHg 228 mmHg 760 mmHg anesthetic toxicity: a systematic review. Acad Emerg Med. 2009;16:
815–24.
Fig. 1.9 Compressed air injection technique (CAIT) to prevent high Gadsden J, McCally C, Hadzic A. Monitoring during peripheral nerve
injection pressure. 50 % compression of air volume in the syringe cor- blockade. Curr Opin Anaesthesiol. 2010;23:656–61.
responds to an injection pressure of 760 mmHg. LA local anesthetic Hadzic A, Dilberovic F, Shah S, et al. Combination of intraneural injec-
(Adapted from Tsui BC, Li LX, Pillay JJ. Compressed air injection tion and high injection pressure leads to fascicular injury and neuro-
technique to standardize block injection pressures. Can J Anesth. logic deficits in dogs. Reg Anesth Pain Med. 2004;29:417–23.
2006;53:1098–102. With permission from Springer Verlag) Ilfeld BM, Smith DW, Enneking FK. Continuous regional analgesia
following ambulatory pediatric orthopedic surgery. Am J Orthop.
2004;33:405–8.
Kapur E, Vuckovic I, Dilberovic F, et al. Neurologic and histologic out-
come after intraneural injections of Lidocaine in canine sciatic
nerves. Acta Anaesthesiol Scand. 2007;51:101–7.
Pitcher CE, Raj PP, Ford DJ. The use of peripheral nerve stimulators for
regional anaesthesia: a review of experimental characteristics, tech-
nique, and clinical applications. Reg Anesth. 1985;10:49–58.
Tsui BC. Equipment for regional anesthesia in children. Tech Reg
Anesth Pain Manag. 2007a;11:235–46.
Tsui BC. Regional block room setup and equipment. In: Tsui BC, edi-
tor. Atlas of ultrasound and nerve stimulation-guided regional anes-
thesia. New York: Springer; 2007b. p. 1–7.
Tsui BC, Li LX, Pillay JJ. Compressed air injection technique to stan-
dardize block injection pressures. Can J Anesth. 2006;53:1098–102.
Weinberg G, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infu-
sion rescues dogs from bupivacaine-induced cardiac toxicity. Reg
Anesth Pain Med. 2003;28:198–202.
Pediatric Electrical Nerve Stimulation
2
Kelly P.A. Byrne and Ban C.H. Tsui
Contents
2.1 Nerve Stimulation Procedure ............................................................................................................. 12
2.2 Electrophysiology ................................................................................................................................ 12
2.2.1 Characteristics of Electrical Impulses ....................................................................................... 12
2.2.2 Current Intensity and Duration ................................................................................................. 13
2.2.3 Rate of Current Change ............................................................................................................ 13
2.2.4 Polarity of Stimulating and Returning Electrodes .................................................................... 13
2.2.5 Distance-Current Relationship .................................................................................................. 14
2.2.6 Current Density of Electrodes and Injectates............................................................................ 15
2.2.7 Electrodes.................................................................................................................................. 15
2.2.8 Injectates ................................................................................................................................... 15
2.2.9 Electrical Impedance ................................................................................................................. 16
2.3 Electrical Epidural Stimulation ......................................................................................................... 17
2.3.1 Test Equipment and Procedure ................................................................................................. 17
2.4 Mechanisms of the Epidural Stimulation Test ................................................................................. 18
2.4.1 Stimulating Epidural Catheter Requirements ........................................................................... 19
2.4.2 Effective Conduction of Electrical Current............................................................................... 19
2.4.3 Advancement of the Catheter.................................................................................................... 20
2.4.4 Considerations for Test Performance and Interpretation .......................................................... 20
2.4.5 Limitations of Epidural Stimulation ......................................................................................... 20
2.5 Useful Equipment Features in Nerve Stimulation ........................................................................... 21
2.5.1 Constant Current Output and Display ....................................................................................... 21
2.5.2 Variable Pulse Width and Frequency ........................................................................................ 22
2.5.3 Other Features ........................................................................................................................... 22
2.6 Practical Considerations .................................................................................................................... 23
2.6.1 Documentation .......................................................................................................................... 23
2.6.2 Population Considerations ........................................................................................................ 23
2.6.3 Does Nerve Stimulation Make a Difference? ........................................................................... 23
References ..................................................................................................................................................... 23
Suggested Reading ....................................................................................................................................... 23
K.P.A. Byrne, MB ChB, FANZCA

Department of Anesthesia, Waikato Hospital,
Pembroke Street, Hamilton 3204, New Zealand
2-150 Clinical Sciences Building,

DOI 10.1007/978-0-387-79964-3_2
12 K.P.A. Byrne and B.C.H. Tsui
2.1 Nerve Stimulation Procedure stimulate the nerve; however, more recent work by Tsui
et al. [1], suggests that the underlying cause is dispersion
The general procedure for nerve stimulation with peripheral of the electrical current by injection of ionic solutions (i.e.,
nerve blocks is as follows: normal saline or local anesthetic). The use of nonionic
solutions, such as 5 % dextrose in water (D5W), leads to
1. The patient is anesthetized or sedated without the use of preservation of the muscle twitch and improved accuracy
muscle relaxants and positioned appropriately for the of placement of blocks and perineural catheters.
desired block.
2. The stimulating needle is connected to the cathode. Other applications of electrical stimulation include the
3. After the patient has been draped and the skin has been use of percutaneous electrodes to guide the initial needle
prepared, the needle is advanced toward the nerve with a puncture site. This is particularly useful in children, where
current of 1–2 mA and pulse width of 0.1–0.2 ms. the distance from skin to nerve is small. Electrical stimula-
4. At this high current, the nerve will depolarize and muscle tion can also be used to place epidural catheters; a descrip-
twitches will be seen when the needle tip is between 1 and tion of this technique will be given later in this chapter.
2 cm from the nerve.
5. The current intensity is then decreased as the needle is
advanced further toward the nerve. The aim is to obtain 2.2 Electrophysiology
nerve depolarization and a resulting muscle twitch at a
current of 0.4–0.5 mA. The muscle twitch should disap- The characteristics of the electrical impulse will determine
pear at currents below this (i.e., the threshold current is its ability to stimulate a nerve, and the quality of stimulation
0.4–0.5 mA). will be affected by the polarity and type of the electrode, by
6. Attempting to observe a twitch at lower current levels the distance between the needle and the nerve, and by poten-
(<0.4 mA) may result in inadvertent intraneural injection tial interactions at the tissue-needle interface.
and is not necessary to increase success.
7. When attempting to place perineural catheters, a higher
current is generally required for stimulation of the nerve. 2.2.1 Characteristics of Electrical Impulses
This is true especially if normal saline is used for
hydrodissection since the ionic conduction of normal Spinal nerves are comprised of fascicles containing neurons
saline will disperse the electrical stimulus. and small blood vessels held together by endoneurium
8. Once an acceptable threshold current is reached, aspira- (Fig. 2.1). The current intensity required to stimulate a nerve
tion for potential intravascular placement is performed. is determined by the nerve fiber type and diameter. Larger,
If this is negative, then the Raj test is preformed, where myelinated fibers are more easily stimulated than smaller,
1–2 mL of injectate, either local anesthetic or normal unmyelinated ones. It is important to choose the current judi-
saline, is given. With the administration of the injectate, ciously as higher currents becomes less specific for stimula-
the muscle twitch should diminish. This phenomenon was tion of motor nerves. Thus, when the correct current is used,
initially attributed to the displacement of the nerve by the one can theoretically produce a motor response without
injectate, where the distance between nerve and needle tip stimulating the pain fibers, allowing the patient to remain
increases such that the current is no longer sufficient to awake for the procedure.
Epineurium
Fibrofatty tissue
Spinal nerve
Fascicle
Axon of neuron
Myelinated fiber
Fig. 2.1 Schematic of cross section Perineurium

of a spinal nerve Endoneurium Blood vessels
Unmyelinated
2 Pediatric Electrical Nerve Stimulation 13
2.2.2 Current Intensity and Duration 2.2.3 Rate of Current Change
Whether or not a nerve is stimulated depends on a combina-

tion of both the strength and duration of the stimulus and the • Regardless of the stimulus intensity, a rate of current
polarity of the electrode. All modern nerve stimulators pro- change that is too low will reduce nerve excitability.
duce a square wave pulse of current. The total energy (or • Low subthreshold intensity or slowly increasing rates will
charge) applied to the nerve (Q) is a product of the current inactivate sodium conductance and prevent depolariza-
intensity (I) and the duration of the stimulus (t): Q = (I)(t). tion – this is termed accommodation.
The relationship between the characteristics of the nerve, its
excitability, and the current required to stimulate it is
described by the formula I = Ir (1 + C / t ) (Fig. 2.2), where I 2.2.4 Polarity of Stimulating and Returning
is current required, Ir is the rheobase, C is the chronaxie, and Electrodes
t is the duration of the stimulus. Rheobase is the minimum
current (in mA) required to stimulate a nerve using a long The polarity of the needle will affect its ability to stimulate
pulse duration or pulse width. As seen in Fig. 2.2, the current the nerve at a given current. If the needle is connected to the
required to stimulate the nerve is at a minimum once the anode, the current required to stimulate the nerve will be up
pulse duration exceeds 0.3 ms. The chronaxie is determined to four times greater than if the needle is attached to the cath-
from the strength-duration curve and is defined as the dura- ode. The flow of current within the needle when it is attached
tion of stimulus (in ms) required to stimulate the nerve at to the cathode produces an area of depolarization around the
twice the rheobase; in other words, the stimulus applied is needle tip. This reduces the resting membrane potential of
twice the strength of the minimum strength required to stim- the neuronal cell membrane, causing depolarization and an
ulate the nerve. As Raj et al. [2] stated, “The chronaxie can action potential. When the needle is connected to the anode,
be used as a measure of the threshold for any particular nerve the flow of current produces hyperpolarization in the area
and is useful when comparing different nerves or nerve fiber around the needle tip and leads to a higher current being
types.” The pulse width can therefore be varied in order to required for stimulation. This phenomenon is known as pref-
target different fiber types. In mammalian peripheral nerves, erential cathodal stimulation (Fig. 2.3) and refers to the sig-
the respective chronaxies are Aα fibers, 0.05–0.1 ms; Aδ nificantly reduced current that is required to elicit a motor
fibers, 0.17 ms; and C fibers, 0.4 ms. response when the cathode is used as the stimulating elec-
trode. Hence, it is normal practice to attach the cathode to the
needle. The anode is then attached to the patient’s skin and
acts as a returning electrode to complete the circuit. It was
previously thought that the distance between the needle and
the returning electrode was an important contributor to the
resistance of the entire circuit; however, it is now known that
the overall resistance remains much the same regardless of
where the returning electrode is positioned.
Fig. 2.2 Stimulation curve plotting current intensity and pulse duration
Fig. 2.3 Preferential cathodal stimulation. The flow of current within

the needle when attached to the cathode causes depolarization around
the needle tip. This reduces the resting membrane potential of the neu-
ronal cell membrane, resulting in an action potential
2.2.5 Distance-Current Relationship intraneural injection. Bigeleisen et al. [3] examined supracla-
vicular blocks and found that in 54 % of patients intraneural
As one would expect, the further the distance between the needle placement was associated with a motor response in the
stimulating electrode and the nerve, the greater the current 0.2–0.5 mA range. These results contradicted the previously
that is required to stimulate the nerve (Fig. 2.4). This relates established guidelines which stated that a motor response
to the current intensity at a given distance from the stimulat- below 0.2 mA indicated intraneural needle placement.
ing electrode and is described by Coulomb’s law, I = k(i/r2), Robards et al. [4] combined ultrasound and nerve stimula-
where I = current required, k is Coulomb’s constant, i = mini- tion for localization of the sciatic nerve at the popliteal fossa
mal current, and r = distance from nerve. From this equation and found that, in 20 of 24 patients, a motor response was not
it can be seen that the current required is inversely propor- obtained until the needle tip was advanced into an intraneural
tional to the square of the distance from the nerve. Hence, location. Given these findings, other methods of determining
small changes in the distance from the nerve greatly affect intraneural placement of the needle, such as changes in elec-
the current required. The current required to stimulate the trical impedance, have been explored.
nerve at 2 cm away can be 400 times greater than that Percutaneous electrode guidance can be used to determine
required to stimulate the nerve when the electrode is in direct the optimal site for needle insertion. The negative electrode
contact with the nerve. of the nerve stimulator connects to a commercially available
Another factor in determining whether or not the nerve surface electrode (0.5 cm diameter) (Fig. 2.6). The initial
will be stimulated at a particular distance and current is the current used is generally 5 mA with a 0.2 ms pulse width.
pulse width of the stimulus. As shown by the pulse width- The current is then reduced to a minimum using the tech-
current curve, short pulse widths (i.e., 0.04 ms) are a better nique explained above. The widespread use of ultrasound
indicator of the distance between the nerve stimulator and has led to a significant reduction in the use of percutaneous
the nerve, based on changes in current (Fig. 2.5). With long guidance systems.
pulse widths (i.e., 1 ms), there is little difference in the cur-
rent required to stimulate the nerve, regardless of whether
the stimulating needle is in direct contact with the nerve or Distance-current curve
1 cm away. In contrast, at a pulse width of 0.04 ms, there is a Stimulus
large difference in the stimulating current required when (mA)
15 Non-insulated needle
comparing direct contact with the nerve versus a distance of Insulated needle
1 cm away. 12
When undertaking a peripheral nerve block, an initial cur-
rent of between 1 and 2 mA (pulse width of 0.1–0.2 ms) is 7 mA
used to elicit a response superficially. Accurate placement of 6
the needle is indicated when a response is still generated
once the current is reduced to between 0.2 and 0.5 mA. If 3
stimulation of the nerve continues at a current below 0.2 mA, 0.5 mA
then intraneural injection is possible and the needle should 0
–2 –1 0 +1
be repositioned. Thus, nerve stimulation below 0.2 mA has a Distance (cm) from the nerve
high positive predictive value for intraneural placement of
the needle. Fig. 2.4 Distance-current curve. Noninsulated needles require more
current than insulated needles at the same distance from the nerve and
Several recent studies have raised concerns that intra-
have less discrimination of distances as the needle approaches the
neural injection can occur in the absence of nerve stimula- nerve. The current threshold is minimal (0.5 mA) for insulated needles
tion within a range that is normally considered a risk for when the needle is on the nerve
Pulse width-current curve 2.2.6 Current Density of Electrodes

Stimulus and Injectates
(mA) 40 1 cm from the nerve
On nerve At the needle tip, the conductive area for current flow will
30
modify the current density and response threshold. Small
conductive areas will condense the current and reduce the
20
threshold current needed for motor responses. The needle/
catheter-tissue interface can also affect the density of the cur-
10 rent, as the area of conductance can change with different
injectates and with different tissue compositions. Whether
0 the injectate has conducting properties or not will signifi-
∞1 0.5 0.2 0.1 0.04
cantly affect the current at the needle tip.
Pulse width (ms)
Fig. 2.5 Current intensity at different pulse widths. A shorter pulse

width requires more current with greater nerve-needle distances but is a 2.2.7 Electrodes
good discriminator
Types of electrodes include insulated and noninsulated nee-
dles and stimulating catheters. Insulated needles have non-
conducting shafts (e.g., Teflon) that direct the current density
to a sphere around the uncoated needle tip – the smaller the
conducting area, the higher the density of current. This
means that a lower stimulating current can be used to elicit a
motor response. Noninsulated needles are bare metal and
transmit current throughout their entire shaft. The current
density at the tip is therefore much lower as compared to
insulated needles, meaning that noninsulated needles often
require more than 1 mA of current for nerve stimulation.
Stimulating catheters are similar to insulated needles,
although when normal saline is used as a priming solution or
a dilating medium, a much higher threshold current is often
required to determine correct placement due to the disper-
sion of current by the ionic solution.
Fig. 2.6 Surface electrodes for percutaneous electrode guidance. The

large diameter (0.5 cm) electrodes attach to the negative electrode of the 2.2.8 Injectates
nerve stimulator
• Injection of ionic solutions such as local anesthetic or
normal saline results in an increase in the conductive area
at the needle tip and an increase in the threshold require-
ment for stimulation of the nerve (Fig. 2.7). This effect,
rather than the displacement of the nerve from the needle
tip, is responsible for the abolition of motor response with
test dose of local or normal saline (the Raj test).
• The use of nonelectrolyte/nonconducting injectates, such
as D5W, reduces the conductive area and increases the
current density at the needle tip, resulting in maintenance
or augmentation of the motor response at a low current
(<0.5 mA).
• Nerve stimulation is clearly sensitive to changes at the
tissue-needle/catheter interface. In a physiological con-
text, the electrical field surrounding the needle tip and the
conductive area generated by the needle tip are nonuni-
form, occasionally leading to an unstable electrical stimu-
lation response.
• During advancement of a stimulating catheter, it may be 2.2.9 Electrical Impedance

beneficial to use nonconducting solutions to dilate the
perineural space, because as long as the tip of the stimu- At the most basic level, impedance is defined as resistance in
lating catheter stays in proximity to the nerve, the use of an AC circuit. It is calculated as the voltage-current ratio for
nonconducting solutions will reduce the current leakage a single complex exponential at a particular frequency.
and promote continued motor response during advance- Impedance is highly sensitive to tissue composition and has
ment of the catheter. been shown to vary depending on the water content of the
tissue. A significant difference between extraneural and
intraneural impedance, resulting from differences in the
physical composition of tissue components, has been dem-
onstrated in the porcine sciatic nerve [5]. This difference in
electrical impedance may be explained by variation in water
and lipid content between the intraneural and extraneural
space (Fig. 2.8): the intraneural compartment contains con-
siderably greater amounts of nonconducting lipid and lower
water content (5–20 % by weight) compared to the surround-
ing muscle (73–78 % water by weight).
The highly variable response to nerve stimulation as
observed during ultrasound-guided regional anesthesia may
be explained in part by the significant difference between
intraneural and extraneural tissue impedance at different sites
along the same nerve. An inverse relationship between elec-
trical impedance and current threshold was demonstrated for
the median nerve [6]; stimulation of the nerve in the axilla
required significantly higher current thresholds than at the
elbow. The lower impedance of the axillary muscle tissue
may have produced a region of highly conductive tissue
around the needle tip, dispersing current away from the nerve.
Higher current settings may be required when a stimulating
needle is advanced through low-impedance muscle tissue. On
the other hand, lower current settings may be needed for
nerves located in high-impedance fat or connective tissue.
A recent study assessing accidental nerve puncture during
ultrasound-guided blocks in adult patients demonstrated the
utility of electrical impedance in clinical scenarios [7]. It was
shown that a >4.3 % increase in impedance may indicate
intraneural needle placement. To date, an investigation of the
use of electrical impedance in guiding needle placement in
Fig. 2.7 Conductive properties of electrodes and injectates. Top row, pediatric regional blocks has yet to be performed.
insulated needles have a small conducting area, allowing low threshold
current stimulation, while noninsulated needles transmit current
through their entire length and have a lower current density at the tip.
Bottom row, conducting solutions (e.g., saline or local anesthetic)
increase the conductive area at the needle tip and increase the threshold
current requirement. Nonconducting (nonelectrolyte) solutions (e.g.,
D5W) reduce the conductive area at the tip and increase the current
density. The motor response from nerve stimulation after D5W injec-
tion remains the same (or is augmented) during needle/catheter
placement
Fig. 2.8 Differences in intra- and extraneural impedance. This may be

explained by variation in water and lipid content between the two spaces
2.3 Electrical Epidural Stimulation 6. Carefully and slowly increase the current intensity until
motor activity begins.
Electrical stimulation of an epidural catheter can confirm epi- 7. Depending on the characteristics of the response, as
dural placement and can be used to determine the optimal described in Table 2.1, the catheter location can be
position to deliver postoperative analgesia. This technique indentified and appropriate adjustments can be made.
is particularly relevant in children where small distances 8. If a single-shot epidural is planned, a similar technique
can significantly alter the nerve distribution blocked by the can be used to confirm needle placement. The only
epidural. exception is that the nerve stimulator is attached to an
The epidural stimulation test (aka the Tsui test) [8] applies insulated needle (e.g., 18–24 G insulated needles) rather
similar principles to those of peripheral nerve blockade, that than to the already positioned catheter.
is, using electrical pulses and the current versus nerve- 9. The threshold current for determining correct needle
distance relationship. This test possesses between 80 and placement is similar for the lumbar and caudal routes,
100 % positive predictive value for epidural placement and but the upper limit of 10 mA may be extended for tho-
has been effective in guiding catheters within two segmental racic epidural placement (up to 17 mA).
levels of the target level, as confirmed by radiological imag- 10. The stimulator should be versatile enough to allow the
ing. This can facilitate appropriate placement and allow current to be increased by small increments and applied
adjustments in the event of catheter migration, kinking, or for short intervals.
coiling. In addition to confirming and guiding epidural cath-
eter placement, this test has the potential to detect intrathe-
cal, subdural, or intravascular catheter placement. The
principles of this test can be applied to both catheter and
single-shot techniques with both epidural and caudal
approaches.
2.3.1 Test Equipment and Procedure
There are specialized kits available for use in electrical epi-

dural stimulation (Tsui epidural kit, Pajunk, Geisingen,
Germany). A conventional epidural kit can also be modified
for electrical stimulation. This test is designed to be used in
addition to the traditional loss-of-resistance technique:
Fig. 2.9 An adaptor (Arrow-Johans ECG Adaptor) is attached to the
1. Anesthetize or sedate the patient without the use of mus- connector of the epidural catheter (19 G Arrow FlexTip Plus); the adap-
tor and catheter are filled with normal saline, and the cathode lead of the
cle relaxants, and position them appropriately. Insert the nerve stimulator is attached to the metal hub of the adapter
epidural via the traditional loss-of-resistance technique,
and advance the catheter into the epidural space. The
Table 2.1 Test dose with dextrose 5 % in water (D5W) prior to local
epidural catheter must contain a metal coil to enable anesthetic injection
electrical stimulation.
• A test dose of a nonconducting solution (e.g., D5W) is beneficial
2. After sterile preparation, connect a nerve stimulator to prior to local anesthetic injection during peripheral nerve
the epidural catheter using an electrode adaptor (e.g., blockade
Arrow-Johans ECG adaptor, Arrow International Inc., • The solution can be visualized easily with ultrasound, especially
Reading, PA, USA) (Fig. 2.9). with color Doppler, and can indicate the approximate spread of
local anesthetic.
3. Prime the catheter and adaptor with sterile normal saline.
• Carefully observing the spread of D5W will help confirm
4. Attach the cathode lead of the nerve stimulator to the extravascular and extraneural needle placement, especially when
metal hub of the adaptor. Attach the grounding anode the threshold current during nerve stimulation is <0.4 mA
lead to an electrode on the patient’s body surface. • When used with nerve stimulation, D5W will confirm needle
5. Set the nerve stimulator to low frequency and pulse placement near the nerve if the motor response is maintained or
augmented
width (1 Hz, 0.2 ms).
2.4 Mechanisms of the Epidural the motor threshold current should increase after the local
Stimulation Test anesthetic application. This is due to the dispersion of the
current by the ionic solution. If the catheter is in an intra-
Catheter placement is confirmed by stimulating the spinal vascular position, then the local anesthetic will be removed
nerve roots (not the spinal cord) with a catheter that conducts from the area into the systemic circulation resulting in no
a low-amplitude electrical current through normal saline. change in the current required for motor stimulation. To
A correct motor response (1–10 mA) confirms accurate further confirm placement of the catheter, administering an
placement of the epidural catheter tip (Table 2.2). Correct epinephrine test dose (0.5 μg/kg) and observing the sub-
placement is defined as 1–2 cm from the nerve roots (Fig. 2.4). sequent ECG changes, in particular >25 % increase in T
Responses observed with a significantly lower threshold cur- wave or ST segment changes irrespective of chosen lead, is
rent (<1 mA), especially if substantially diffuse or bilateral, recommended.
may warn of incorrect catheter placement, either in proximity The electrical resistance and threshold currents differ
to a nerve root or in the subarachnoid or subdural space, between stimulating needles and catheters. Insulated needles
where the catheter contacts the highly conductive cerebrospi- will provide a lower electrical resistance and should there-
nal fluid (CSF). Previous studies have used insulated needles fore be used for stimulation. When using a needle to stimu-
to elicit a motor response in the epidural space (11.1 ± 3.1 mA late, the upper limit of the threshold current indicating a
[9] and 3.84 ± 0.99 mA) [10] and showed that these currents positive test is similar to catheter placement at the caudal
are higher than that required in the intrathecal space space (mean = 3.7 mA); however, at the thoracic level, the
(0.77 ± 0.32 mA and 0.6 ± 0.3 mA) [11]. The segmental level threshold current becomes higher (up to 17 mA). The lower
of the catheter tip may be predicted based on the progressive limit of >1 mA applies to all segmental levels. The higher
nature of the motor twitches (i.e., from lower limbs and back threshold currents that may be seen with direct insertion at
to intercostals and upper limb) as the catheter is advanced. the thoracic level may be related to the minimal depth of
A local anesthetic test dose helps confirm epidural ver- needle penetration that is normally used for precautionary
sus intravascular location. If the catheter is placed correctly, measures at this level.
Table 2.2 Epidural catheter location determined by standard test dose (lidocaine with 1:200,000 epinephrine) versus the epidural stimulation test
Catheter location Test dose Epidural stimulation test
Subarachnoid Hypotension/total spinal response (<1 mA) Positive unilateral/bilateral motor
Subdural ? (<1 mA) Diffuse motor response in many segments
Epidural space
Close to nerve ? Unilateral motor response (<1 mA)
Against nerve root ? Positive motor response (1–10 mA); threshold current increase after local
anesthetic injection
Non-intravascular Heart rate increase Remains or returns to baseline positive motor response (1–10 mA) even
after local anesthetic injection
Intravascular Blood pressure increase ECG changes
Subcutaneous ? Negative response
2.4.1 Stimulating Epidural Catheter catheter. A metal coil in the lumen is required because of the
Requirements catheter length and the risk of air trapping, both of which
can increase the resistance to current flow. A soft, metal-
There are two major areas where the requirements for stimu- containing epidural catheter (Fig. 2.10a) (e.g., Flextip Plus
lating epidural catheters vary from that of conventional epi- from Arrow International, Reading, PA, USA; Perifix from
dural kits: (1) the need for effective conduction of electrical B. Braun, Bethlehem, PA, USA; Spirol from Sims, Portex,
current and (2) the ability to advance the catheter significant Markham, ON, Canada) is effective for epidural stimulation
distances. testing. Peripheral stimulating catheters (e.g., StimuLong
Plus from Pajunk, Geisingen, Germany, or StimuCath,
Arrow International, Reading, PA, USA) contain an inter-
2.4.2 Effective Conduction of Electrical nal fixed wire that extends beyond the distal lumen tip
Current (Fig. 2.10b); these have been used for the epidural stimula-
tion test without the requirement for priming with normal
In order to induce electrical pulses, the catheter’s electri- saline. However, there is limited experience with these cathe-
cal resistance must remain low. Any highly conductive ters, and they may not have any benefit over the conventional
ionic solution (e.g., normal saline) can be used to prime the metal-coil-containing catheters.
a b
Fig. 2.10 (a) Soft, metal-containing epidural catheters can be used for wire extension beyond the distal tip, have been used for epidural cath-
the epidural stimulation test (metal wire has been exposed and unwound eter insertion using electrical stimulation
in the top catheter); (b) other peripheral stimulating catheters, with a
2.4.3 Advancement of the Catheter 2.4.4 Considerations for Test Performance

and Interpretation
Conventional metal-coil-containing catheters are soft and
pliable in nature, and as a result, when threading them, they Because local muscle contraction in the trunk region can be
either require modification with a metal stylet or substitution confused with epidural stimulation, it is recommended that
with a specialized styletted catheter setup (Fig. 2.11; an anode be placed on the upper extremity for lumbar epidur-
StimuLong Tsui, Pajunk, Geisingen, Germany) that includes als and the lower extremity for thoracic epidurals. The
an injection port system. When advancing the catheter, minor 1–10 mA range for epidural stimulation should be used only
resistance to the passage of the catheter can be overcome by as a guideline, as epidural stimulation may occur outside this
injecting normal saline through the catheter or by flexion or range. Some cases will require stimulation of greater than
extension of the patient’s vertebral column. The ejected fluid 17 mA, for example, when using insulated needles in the tho-
may reduce the friction between the catheter and surround- racic region. We recommend this range for several reasons: it
ing tissues, and this may be more effective when a multiport is easy to remember, and stimulation below 1 mA is sugges-
catheter is used. Clinicians must remain vigilant as epidural tive of intrathecal placement or placement in close proximity
catheter placement has the potential for neurological injury. to a nerve root.
Therefore, under no circumstances should any force be used The best predictor of correct epidural placement is a com-
to advance the catheter. bination of threshold current level and distribution of elicited
motor responses (i.e., correlation with approximate segmen-
tal location) since subcutaneous placement would not elicit
such predictive and segmental responses.
Although no known complications of epidural electrical
stimulation have been described, it is recommended that the
current remain fairly low (<15–20 mA) and that the period of
stimulation last only a few minutes. This helps to confirm the
safety of epidural electrical stimulation. Other studies of spi-
nal cord stimulators in chronic pain settings and intraopera-
tive spinal cord monitoring during spinal surgery have used
stimulation in the 2–40 mA range.
2.4.5 Limitations of Epidural Stimulation
• Significant clinical neuromuscular blockade or local

Fig. 2.11 A specialized styletted catheter setup (StimuLong Tsui, anesthetics in the epidural space limit the use of this test.
Pajunk, Geisingen, Germany) that includes an injection port system An alternative technique to the epidural stimulation test
uses an ECG to monitor catheter location. When the cath-
eter tip is at or near the target level, the ECG complex
recorded from the epidural catheter should match the
ECG measured from a surface electrode. Unlike the epi-
dural stimulation test, the ECG technique cannot warn of
intrathecal or intravascular position of the catheter nor
can it guide catheter placement when the threading dis-
tance is short (see Fig. 33.7).
• Ultrasound imaging is an alternative method for catheter
guidance and placement in young children.
• Limitations of electrical stimulation are minor and include
the need for and cost of a “specialized” stimulating cath-
eter. This, however, is offset by the more accurate postop-
erative analgesia and avoidance of intrathecal or
intravascular placement of the catheter.
2.5 Useful Equipment Features in Nerve constant current (Fig. 2.12). This means that the resistance of
Stimulation the circuit is monitored and the voltage adjusted accordingly
to provide a constant current. Most nerve stimulators have an
In 1985, Pither et al. [12] described essential features of a adjustable frequency, pulse width, and current strength
nerve stimulator, and there have been few alterations to these (Fig. 2.13). Additionally, clear digital displays show the cur-
criteria since then. There are multiple different makes and rent delivered to the patient, the target current setting, and
models of nerve stimulators, many of which share similar fea- impedance. Some stimulators have low (<6 mA) and high
tures. Anesthesiologists should familiarize themselves with (<80 mA) ranges for increased accuracy during localization
the equipment that is commonly used at their institution. of peripheral nerves and monitoring neuromuscular block-
ade, respectively. The current requirements for epidural stim-
ulation (1–17 mA) often fall outside the usual working range
2.5.1 Constant Current Output and Display for peripheral nerve stimulators. Other makes and models of
nerve stimulators may be required for this technique.
Historically, nerve stimulators produced a constant voltage,
although most modern nerve stimulators now produce a
Fig. 2.12 Many constant current nerve

stimulators are on the market and will
vary in their current output ranges
Fig. 2.13 Peripheral nerve stimulators showing display of stimulus

amplitude, pulse width, frequency, and impedance
2.5.2 Variable Pulse Width and Frequency 2.5.3 Other Features
Pulse width determines the amount of charge delivered to the A specialized male connector designed to fit into the female
patient and may enable selective stimulation of different conducting portion of the stimulating needle is a useful addi-
types of nerve fibers. For example, sensory fibers are more tion. Indicators displaying the battery status and warning of
effectively stimulated at longer pulse widths (0.4 ms), an incomplete circuit or pulse delivery failure are important
whereas shorter pulse widths (0.05–0.15 ms) are sufficient components of the nerve stimulator. Foot pedal or handheld
for motor fibers. Some devices allow width ranges from 0.05 remote controls to adjust current output (Fig. 2.14) may
to 1 ms for high variation and selectivity, depending on spe- improve the operator’s ability to undertake the procedure
cific nerve location. The frequency of stimulation will affect without assistance.
the needle advancement rate, as low frequencies (<1 Hz) Probes may be available for surface mapping during per-
may result in the target nerve being missed, and high fre- cutaneous electrode guidance procedures (Fig. 2.6).
quencies can cause twitches which are similar to involuntary
fasciculations. Most practitioners use 2 Hz as a compromise
between these two extremes.
Fig. 2.14 Foot pedal or

handheld remote control
adjusters of current output
2.6 Practical Considerations – In addition, a recent report suggests that threshold

currents used for motor response from nerve stimu-
2.6.1 Documentation lation under general anesthesia might be higher
than those used for awake patients [13].
Documentation of the procedure and performance of the • Central neuraxial blocks:
nerve block is a critical part of the procedure, both for qual- – The authors find it useful and practical to monitor
ity assurance and medicolegal reasons. It is important to and guide epidural catheter advancement when
document the block procedure, the specific current at which threading the catheter from the caudal space.
the muscle twitch is present and at which it disappears, and
the presence or absence of any pain or paresthesia.
References
2.6.2 Population Considerations 1. Tsui BCH, Kropelin B, Ganapathy S, Finucane B. Dextrose 5% in

water: fluid medium for maintaining electrical stimulation of
peripheral nerves during stimulating catheter placement. Acta
Specific groups of patients may require increased current Anaesthesiol Scand. 2005;49:1562–5.
intensity levels (e.g., diabetics, obese, nerve conduction dis- 2. Raj PP, Rosenblatt R, Montgomery SJ. Use of the nerve stimulator
orders, and under anesthesia [13]); however, this is not as for peripheral blocks. Reg Anesth. 1980;5:14–21.
3. Bigeleisen PE, Moayeri N, Groen GJ. Extraneural versus intraneu-
relevant in the pediatric population.
ral stimulation thresholds during ultrasound-guided supraclavicular
block. Anesthesiology. 2009;110:1235–43.
4. Robards C, Hadzic A, Somasundaram L, Iwata T, Gadsden J, Xu D,
2.6.3 Does Nerve Stimulation Make Sala-Blanch X. Intraneural injection with low-current stimulation
during popliteal sciatic nerve block. Anesth Analg. 2009;109:
a Difference? 673–7.
5. Tsui BC, Pillay J, Tsung C, Dillane D. Electrical impedance to dis-
Current research has evaluated the success and side effects of tinguish intraneural from extraneural needle placement in porcine
nerve stimulator-based blocks compared to ultrasound-guided nerves under direct exposure and ultrasound guidance.
Anesthesiology. 2008;109:479–83.
blocks. There is emerging evidence to show that ultrasound-
6. Sauter AR, Dodgson MS, Kalvøy H, Grimnes S, Stubhaug A,
guided blocks may have an earlier onset time, a reduced local Klaastad O. Current threshold for nerve stimulation depends on
anesthetic dose, and possibly an increased success rate in cer- electrical impedance of the tissue: a study of ultrasound-guided
tain settings. Does this mean that nerve stimulation is a relic electrical nerve stimulation of the median nerve. Anesth Analg.
2009;108:1338–43.
of the past? We argue strongly that this is not the case. While
7. Bardou P, Merle JC, Woillard JB, Nathan-Denizot N, Beaulieu
ultrasound is rapidly becoming the standard of care in many P. Electrical impedance to detect accidental nerve puncture during
parts of the world, nerve stimulation should at least be consid- ultrasound-guided peripheral nerve blocks. Can J Anesth. 2013;60:
ered the minimum standard of safety when performing a 253–8.
8. Tsui BC, Gupta S, Finucane B. Confirmation of epidural catheter
nerve block. In the pediatric setting, nerve stimulation has
placement using nerve stimulation. Can J Anesth. 1998;45:640–4.
been vital in providing an objective method of identifying 9. Tsui BC, Wagner A, Cave D, Seal R. Threshold current for an insulated
nerves in anesthetized patients and provides a complementary epidural needle in pediatric patients. Anesth Analg. 2004;99:694–6.
role to ultrasound in performing nerve blocks. Currently 10. Tsui BC, Wagner AM, Cunningham K, Perry S, Desai S, Seal
R. Can continuous low current electrical stimulation distinguish
ultrasound is limited, as it cannot reliably detect intraneural
insulated needle position in the epidural and intrathecal spaces in
injection while nerve blockade is performed. Intraneural pediatric patients? Paediatr Anaesth. 2005;15:959–63.
injection may be avoided if ultrasound is used in conjunction 11. Tsui BCH, Wagner AM, Cunningham K, et al. Threshold current of
with nerve stimulation. The development of new approaches, an insulated needle in the intrathecal space in pediatric patients.
Anesth Analg. 2005;100:662–5.
such as the measurement of electrical impedance and the epi-
12. Pither CE, Raj PP, Ford DJ. The use of peripheral nerve stimulators
dural stimulation test, may provide other advantages to the for regional anaesthesia: a review of experimental characteristics,
use of nerve stimulation in regional anesthesia. technique, and clinical applications. Reg Anesth. 1985;10:49–58.
13. Tsui BC. The effects of general anaesthesia on nerve-motor
response characteristics (rheobase and chronaxie) to peripheral
Clinical Pearls
nerve stimulation. Anaesthesia 2014;69:374–9.
• In children, since the regional block is typically per-
formed under general anesthesia, it is critical to not use
muscle relaxant if one is planning to utilize nerve
stimulation. Suggested Reading
• Peripheral nerve blocks:
– There is no clear evidence to prove the benefits of Baranoswski AP, Pither CE. A comparison of three methods of axillary
brachial plexus anaesthesia. Anaesthesia. 1990;45:362–5.
nerve stimulation, but it can help to make the block
Bosenberg AT, Raw R, Boezaart AP. Surface mapping of peripheral
safer; the authors use nerve stimulation at 0.2 mA to nerves in children with a nerve stimulator. Pediatr Anesth. 2002;12:
warn if the needle tip is too close to the nerve. 398–403.
Bouaziz H, Narchi P, Mercier FJ, Labaille T, Zerrouk N, Girod J, nerve localization-nerve stimulation versus paresthesia. Anesth
Benhamou D. Comparison between conventional axillary block and Analg. 2000;91:647–51.
a new approach at the midhumeral level. Anesth Analg. 1997;84: Tamai H, Sawamura S, Kanamori Y, Takeda K, Chinzei M, Hanaoka
1058–62. K. Thoracic epidural catheter insertion using the caudal approach
Capdevila X, Lopez S, Bernard N, Dadure C, Motais F, Biboulet P, assisted with an electrical nerve stimulator in young children. Reg
Choquet O. Percutaneous electrode guidance using the insulated Anesth Pain Med. 2005;29:92–5.
needle for prelocation of peripheral nerves during axillary plexus Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation of caudal nee-
blocks. Reg Anesth Pain Med. 2004;29:206–11. dle placement using nerve stimulation. Anesthesiology. 1999;91:
de Medicis E, Tetrault JP, Martin R, Robichaud R, Laroche L. A pro- 374–8.
spective comparison study of two indirect methods for confirming Tsui BC, Gupta S, Finucane B. Detection of subarachnoid and intravas-
the localization of an epidural catheter for postoperative analgesia. cular epidural catheter placement. Can J Anesth. 1999;46:
Anesth Analg. 2005;101:1830–3. 675–8.
Dillane D, Tsui BC. Is there still a place for the use of nerve stimula- Tsui BC, Seal R, Koller J, Entwistle L, Haugen R, Kearney R. Thoracic
tion? Pediatr Anesth. 2012;22:102–8. epidural analgesia via the caudal approach in pediatric patients
Ganta R, Cajee RA, Henthorn RW. Use of transcutaneous nerve stimu- undergoing fundoplication using nerve stimulation guidance.
lation to assist interscalene block. Anesth Analg. 1993;76:914–5. Anesth Analg. 2001;93:1152–5.
Goldberg ME, Gregg C, Larijani GE, Norris MC, Marr AT, Seltzer Tsui BC, Wagner A, Finucane B. Electrophysiologic effect of injectates
JL. A comparison of three methods of axillary approach to brachial on peripheral nerve stimulation. Reg Anesth Pain Med. 2004;29:
plexus blockade for upper extremity surgery. Anesthesiology. 1987; 189–93.
66:814–6. Tsui BC, Wagner A, Cave D, Kearney R. Thoracic and lumbar epidur-
Guyton AC, Hall JE. Textbook of medical physiology. 9th ed. als via the caudal approach using electrical stimulation guidance in
Philadelphia: WB Saunders; 1995. p. 57–71. pediatric patients: a review of 289 patients. Anesthesiology. 2004;
Hadzic A, Vloka JD, Claudio RE, Hadzic N, Thys DM, Santos 100:683–9.
AC. Electrical nerve localization: effects of cutaneous electrode Tsui BC, Hopkins D. Electrical stimulation for regional anesthesia. In:
placement and duration of the stimulus on motor response. Boezaart AP, editor. Anesthesia and orthopaedic surgery. New York:
Anesthesiology. 2004;100:1526–30. McGraw-Hill; 2006. p. 249–56.
Kimura J. Electrodiagnosis in diseases of nerve and muscle: principles Tsui BC. Electrical nerve stimulation. In: Tsui BC, editor. Atlas of
and practice. 3rd ed. Oxford: Oxford University Press; 2001. ultrasound and nerve stimulation-guided regional anesthesia.
p. 178–214. New York: Springer; 2007. p. 9–18.
Lena P, Martin R. Subdural placement of an epidural catheter detected Urmey WF, Stanton J. Inability to consistently elicit a motor response
by nerve stimulation. Can J Anesth. 2005;52:618–21. following sensory paresthesia during interscalene block.
Magora F, Rozin R, Ben-Menachem Y, Magora A. Obturator nerve Anesthesiology. 2002;96:552–4.
block: an evaluation of technique. Br J Anaesth. 1969;41:695–8. Urmey WF, Grossi P. Percutaneous electrode guidance: a noninvasive
Marhofer P, Schrogendorfer K, Koinig H, Kapral S, Weinstabl C, technique for prelocation of peripheral nerves to facilitate periph-
Mayer N. Ultrasonographic guidance improves sensory block and eral plexus or nerve block. Reg Anesth Pain Med. 2002;27:
onset time of three-in-one blocks. Anesth Analg. 1997;85:854–7. 261–7.
Shannon J, Lang SA, Yip RW, Gerard M. Lateral femoral cutaneous Urmey WF, Grossi P. Use of sequential electrical nerve stimulation
nerve block revisited. A nerve stimulator technique. Reg Anesth. (SENS) for location of the sciatic nerve and lumbar plexus. Reg
1995;20:100–4. Anesth Pain Med. 2006;31:463–9.
Sia S, Bartoli M, Lepri A, Marchini O, Ponsecchi P. Multiple-injection Williams R, Saha B. Ultrasound placement of needle in three-in-one
axillary brachial plexus block: a comparison of two methods of nerve block. Emerg Med J. 2006;23:401–3.
Ultrasound Basics
3
Contents
3.1 Basic Ultrasound Physics and Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1.1 Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.2 Transducers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.2.1 Types of Ultrasound Transducers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3 Sound Wave Properties in Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.3.1 Speed of Sound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.2 Reflection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.3 Scattering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.4 Resolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.5 Refraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.3.6 Absorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.4 Optimization of Image Quality: Knobology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.1 Frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.2 Depth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.3 Gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.4 Time Gain Compensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.5 Focal Zone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.4.6 Doppler Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
M.L. Noga, MD, FRCPC

Department of Radiology and Diagnostic Imaging,
University of Alberta, 2A2.41 Walter Mackenzie
Centre 8440-112 Street, Edmonton, AB T6G 2B7, Canada
Department of Anesthesia and Pain Medicine,
University of Alberta Hospital,

DOI 10.1007/978-0-387-79964-3_3
26 M.L. Noga et al.
3.5 Anisotropy and Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

3.5.1 Anisotropy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.5.2 Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.6 Echogenic Appearance of Various Tissues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.7 Equipment Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.8 Current Advances for Future Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.1 Compound Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.2 Single-Crystal Transducers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.3 Capacitive Micromachined Ultrasound Transducers (CMUT) . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.4 Sonix GPS (Ultrasonix Medical Corp, Richmond, BC, Canada). . . . . . . . . . . . . . . . . . . . . . . 39
3.8.5 Power Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.8.6 Robot-Assisted Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3 Ultrasound Basics 27
3.1 Basic Ultrasound Physics 3.2 Transducers

and Technology
• These are the most important part of the ultrasound
3.1.1 Basic Principles machine, as they affect the quality of the image in scan-
ning a patient. Higher frequencies result in higher spatial
resolution, but penetrate less depth of tissue.
• Ultrasound waves are oscillating sound pressure waves • They emit ultrasound waves in pulses.
with frequencies that typically exceed 20,000 cycles per • A typical ultrasound pulse contains two to five cycles of
second (Hertz; Hz). the same frequency.
• An image is acquired by sending a pulse of ultrasound • Pulse length is the duration of each pulse.
waves which propagates through a medium (such as liq- • Pulse repetition frequency is the number of pulse emitted
uid or soft tissue) until it encounters an interface with a by the transducer and is measured in pulses per second.
different medium; at this point, an echo is produced. The pulse repetition frequency must be set such that all
Returning echoes are processed and an image is created. the echoes from the target have returned before the next
• Ultrasound waves are created by converting electrical pulse is generated.
energy into sound waves or mechanical energy through
vibrating objects known as piezoelectric crystals such as
barium titanate or lead zirconate.
• A transducer houses the piezoelectric crystals which tem-
porarily deform when an alternating voltage is applied.
• The sound wave generated travels in a well-defined beam
and direction.
• These crystals also detect ultrasound that is reflected back
(echo) and convert the pressure change into electrical
energy.
• The receiver amplifies the signals and displays them in
the following ways:
– A-mode: echo information as amplitude signals
– B-mode: brightness information as an image slices
down the beam (most commonly used in regional
anesthesia)
– M-mode: motion with respect to time
28 M.L. Noga et al.
3.2.1 Types of Ultrasound Transducers Broadband Transducers

• These transducers cover a range of bandwidths, such
The transducers are named after the geometric arrangement as 10–5 MHz or 14–8 MHz.
of their piezoelectric elements. There are many different • They have shorter pulse length, giving higher axial
transducers available commercially (Fig. 3.1). In general, resolution and a wide bandwidth, which is important
there are three array types: for harmonic imaging (at the expense of axial
resolution).
Linear Array • They offer an excellent resolution of superficial struc-
• Piezoelectric elements are arranged in parallel, form- tures in the upper limbs and good penetration depths in
ing a row of rectangular elements that produces a rect- the lower limbs without having to change the
angular image. transducer.
• High frequency with good resolution but shallow
depth penetration. a
• There is a one-to-one ratio of coupling between the
contact (footing) area and the image size (i.e., large
coupling area) which can be a disadvantage of these
transducers.
• This array is widely used in the pediatric population
owing to its good imaging quality in superficial struc-
tures of 3–4 cm in depth.
Convex (or Curved) Arrays

• These are curved linear transducers with linear arrays
shaped into convex curves, covering a large surface
field of view.
• The advantage is the larger image field produced with
less coupling to the contact (footing) area.
• The main disadvantage is the nonlinear line density in
the image, which can make it slightly more difficult for
the beginner to comprehend the image. b
• The C60 probe is a low-frequency transducer
(5–2 MHz), giving good penetration but poor resolu-
tion in superficial structures. Therefore, it is seldom
used in children.
• The C11 probe is a medium-frequency (7–4 MHz)
transducer which can be used for abdominal imaging
in children for ilioinguinal/iliohypogastric nerve
blocks.
Phased Array (12–2 MHz)

• These transducers are similar to the linear array in that
they contain a row of rectangular elements, but there
are fewer elements in this transducer, and the elements
Fig. 3.1 (a) Schematic of ultrasound transducer types: linear array,
are smaller.
convex linear array, and phased array. (b) Linear and curved (convex
• The advantage with this transducer is the large field of linear) transducers (e.g., SonoSite MicroMaxx) are the most common
view produced despite the small coupling area. types used for regional anesthesia. Each has different beam
• The disadvantages are the small near field (see below) frequencies
and the nonlinear line density.
• This transducer is generally dedicated to cardiac imag-
ing or pediatric abdominal imaging.
3.3 Sound Wave Properties in Tissue
In order to understand and interpret the image obtained by

ultrasound scanning, it is important to grasp the basic prin-
ciple of the propagation of ultrasound through tissues.
Table 3.1 shows the summary of the practical aspects of
ultrasound imaging.
Table 3.1 Practical aspects of ultrasound wave characteristics

Frequency (Hz)
Number of periods per second
High frequency provides high spatial resolution for superficial structures, but poor penetration; lower frequencies are required for deeper
structures
Wavelength (mm)
Length of one cycle in one direction of propagation of the wave
Velocity (m/s)
Displacement of the wave per unit of time
Different acoustic impedances (densities) of tissue determine the velocity of ultrasound waves
Period (s)
Time for one complete wave cycle
Amplitude
Strength of the wave, calculated by the square root of the wave energy
Amplifier gain function adjusts the strength of weak echoes to improve the signal-to-noise ratio
Attenuation
Ultrasound wave amplitude decreases with time as it travels through tissue
Time gain compensation (TGC) compensates for the attenuation of the wave by increasing the amplification factor of the signal as a function
of time after the initial pulse; all interfaces are then uniform in signal regardless of their depth
Field
Characterizes the propagation of ultrasound energy within a medium
Near field (Fresnel region) is the non-diverging portion of the beam adjacent to the transducer face; the length is a function of transducer
frequency and diameter
Far field (Fraunhofer region) is the diverging portion of the ultrasound beam with diminishing energy causing decreases in lateral resolution
(or sharpness); less divergence occurs with high-frequency, large-diameter transducers
Focused transducers can change the field interface, i.e., focal zone, being the area of greatest image resolution
Reflection
Each interface (from various acoustic impedances) within the tissue reflects sound waves back to the emitting transducer; good contour
definition thus results between different tissues
Fluids allow perfect sound transmission, with no echoes, and result in a black image; tissues attenuate and disperse sound waves, resulting in
homogeneous or heterogeneous appearances
30 M.L. Noga et al.
3.3.1 Speed of Sound 3.3.4 Resolution
• The speed of ultrasound through tissue depends on the • Spatial resolution describes the ability to discriminate two
properties of the tissue. adjacent objects on the display.
• Gases have the slowest propagation speed (e.g., There are two types:
air = 330 m/s); liquids have an intermediate speed (e.g., – Axial resolution: the ability to distinguish objects that are
water = 1,480 m/s); solids have a high propagation speed located parallel to each other along the beam axis or at
(e.g., bone = 3,400 m/s). different depths. This depends on the pulse length, which
is a function of the wavelength and the number of cycles
in the pulse. The higher the frequency or shorter the pulse
3.3.2 Reflection length, the better the axial resolution is produced. This is
particularly important for the pediatric population, as
• When an ultrasound wave arrives at the interface between their structures are smaller than in adults.
two different types of tissue, it is partially reflected and – Lateral resolution: the ability to distinguish objects
partially transmitted. located beside each other. This depends on the beam
• The intensity of the echo depends on the acoustic imped- width and the number of transducer elements per cen-
ance of the two tissues. Acoustic impedance is determined timeter (line density).
by the density and stiffness of the tissue.
• The acoustic impedance of soft tissues ranges between
1.3 and 1.7 × 106 kg · m/s; air = 430 kg · m/s; 3.3.5 Refraction
bone = 6.47 × 106 kg · m/s. The greater the difference in
the acoustic impedance of two tissues, the more the reflec- • A sound wave meeting a boundary layer at an angle will
tion there is (e.g., soft tissue-air interface or soft tissue- change direction as it enters the next medium; this
bone interface). There will be little transmission beyond depends on the change of velocity of propagation.
these boundaries; therefore, imaging beyond these bound- • If the velocity is greater in the first medium, refraction
aries is usually impossible. occurs toward the perpendicular and vice versa.
• The subsequent subsection of this chapter will cover the
ultrasonographic appearance of different tissues in more
detail. 3.3.6 Absorption
• Absorption is the main cause of energy loss as ultrasound

3.3.3 Scattering propagates through the tissue.
• When sound waves enter a body, friction causes kinetic
• For interfaces whose dimensions are very small, such as energy to be converted to heat energy, and the energy lost
blood vessels, reflections are known as scattering. cannot be used to construct an image.
• Scattered waves spread in all directions and distort the • Absorption depends on the tissue and the frequencies
resulting image. employed. High absorption occurs in the bone; hence, an
• Different types of tissues cause different degrees of acoustic shadow is cast. The higher the frequency, the
scattering; hence, it is more important as a diagnostic greater the damping and the less the maximum depth of
tool. penetration.
3.4 Optimization of Image Quality: 3.4.5 Focal Zone

Knobology
• There are three parts to the ultrasound energy as it propa-
3.4.1 Frequency gates the tissue:
– Near field (Fresnel region)
• Selection of a transducer with a frequency appropriate to This is adjacent to the transducer surface and is a non-
the depth of the target nerve being examined is the first diverging portion of the ultrasound beam.
step in obtaining a good ultrasound image. Its width is the same as that of the transducer.
• With each transducer, there is a range of frequency, and a Its length is a function of the transducer frequency and
more precise frequency can be selected by choosing the width.
type of examination to be performed, for example, the – Focal zone
Resolution (or nerve examination), General, or Penetration At this point, the sound cone is at its narrowest and is
(or abdomen examination) buttons on the ultrasound at the end of the near field and before the far field.
machine. This area has the best lateral resolution.
Some ultrasound machines allow the focal zone to be
selected, and it should lie where the target nerve is.
3.4.2 Depth – Far field (Fraunhofer region)
This is where the ultrasound beam begins to diverge and
• It is important to select the appropriate depth since too diminish in energy since it is absorbed by the tissue.
much depth results in a smaller target and too shallow Lateral resolution decreases as this diverging beam
produces an inadequate image which may exclude impor- progresses.
tant neighboring structures necessary to perform a nerve
block safely.
3.4.6 Doppler Ultrasound
3.4.3 Gain • Doppler ultrasound uses continuous (rather than pulsed)

ultrasound beams to detect the presence and measure the
• By increasing the gain, the amplitude of the echoes is velocity of moving interfaces.
increased, and the image will appear brighter. • It detects frequency shift in echoes from moving subjects.
• This function serves to improve the signal-to-noise ratio As a moving object approaches, the received frequency is
such that weak echoes can be detected (Fig. 3.2). higher than the emitted frequency and is lower as it moves
away. This change in frequency is known as Doppler shift.
• It is useful since it can detect the presence of vessels
3.4.4 Time Gain Compensation which can be landmarks to aid identification of the tar-
geted nerve.
• This function offers adjustment of gain in various image • It also highlights the location of vessels adjacent to the
depths. targeted nerve such that the trajectory of the needle can be
• This is important since the amplitude of ultrasound planned to avoid the vessels. This is particularly impor-
decreases as it propagates the tissue; therefore, by adjust- tant in the supraclavicular region since aberrant vessels
ing gain at different depths of the image enables a uni- such as transverse cervical artery and suprascapular artery
form display of the signal throughout the image. can be present in the field of the needle trajectory.
32 M.L. Noga et al.
Fig. 3.2 Gain adjustments and focal zone depth. Increasing the gain in artifactual images and poor resolution between structures. The focal
will increase the amplitude of echoes and improve the signal-to-noise zone (area of greatest image resolution) is adjusted by effectively
ratio. Gain settings that are either too high (a) or too low (b) will result reducing the beam diameter (compare c and d)
3.5 Anisotropy and Artifacts There are various forms of artifacts:
3.5.1 Anisotropy Acoustic shadowing

• Any structure with a high attenuation coefficient (e.g.,
• Anisotropy is the property of tendons, nerves, and muscles to bone) diminishes the penetration of the ultrasound
vary in their ultrasound appearance depending on the angle beam resulting in minimal or no transmission through
of incidence between the ultrasound beam and the structure. the structure (Fig. 3.3).
• This is important since these three structures are our land- • Some artifacts may form important landmarks in iden-
marks or objects to be differentiated when performing a tifying the target nerve (e.g., the radial nerve “rolling”
nerve block. This becomes more challenging when the on the humerus).
structures are small, as in children.
• The loss of a 90° angle of incidence between the transducer Acoustic enhancement
and the structure being imaged can produce a peculiar • When the ultrasound beam propagates from a tissue
image in nerves, for example, in the supraclavicular region with low attenuation to that with a high attenuation, a
when the contact between the transducer and the skin is hyperechoic area may be seen just below the interface
lost. This can be overcome by using an SLA “hockey stick” (Fig. 3.4).
probe in small children or C11 curved array probe for older • This can be minimized by reducing the overall gain or
children when the brachial plexus is not too superficial. decreasing the far gain.
• This effect is also commonly seen when imaging the
femoral nerve in the inguinal region. Reverberation artifact
• This is caused by ultrasound passing through two
adjacent structures with markedly different acous-
3.5.2 Artifacts tic properties (Fig. 3.5).
An artifact is an image attribute which does not reflect the orig-

inal structures being scanned. This can be a result of the opera-
tor or the interaction of ultrasound with the adjacent tissue.
Fig. 3.4 Example of acoustic enhancement. The bright white area

indicated by the arrow is acoustic enhancement which is reflected onto
Fig. 3.3 Example of acoustic shadowing. Bone (arrows) prevents pen- the tissue
etration of the ultrasound beam, leading to reflection of the beam and
shadowing underneath
34 M.L. Noga et al.
Fig. 3.5 Example of reverberation artifact (multiple hyperechoic lines

deep to the needle).
3.6 Echogenic Appearance of Various There are two common views for ultrasound tissue
Tissues imaging in regional anesthesia:
Different tissues have their own ultrasonographic appear- • Cross-sectional view when the ultrasound image gives a
ance (Table 3.2). Transducers with a high frequency and view of a “cut across the structure.” This is also known as
bandwidth are necessary to differentiate between the the short axis or transverse view.
fascicular appearance of the nerves and the fibrillar • Longitudinal view is when the ultrasound images the
characteristics of tendons. This is particularly challenging in structure by following its course. This is otherwise called
areas where the nerves and tendons are close together, such the long axis view.
as those at the wrist or ankle.
Table 3.2 Ultrasonographic characteristics of various tissues

Tissue/cavity Sonographic appearance
Nerves Fascicular appearance
Long axis Hyperechoic (bright) tubular connective tissue with dispersed elongated hyperechoic fascicles
Short axis Round/elliptical hypoechoic (dark) fascicles in hyperechoic homogeneous background
Plexus level Long axis view more hypoechoic than in the periphery
Tendons Fibrillar appearance
Long axis Fine, highly linear parallel hyperechoic lines separated by fine hypoechoic lines
Short axis Alternating hyper- and hypoechoic longitudinal areas; no round fascicular appearance
Muscle
Long axis Pennate or feather-like
Short axis “Starry night” with uniform hypoechoic pattern; more hypoechoic than nerves and tendons
Bone Linear hyperechoic bone density with hypoechoic shadow
Blood vessels Hypo- or anechoic circular structures on short axis viewing. Arteries can be distinguished from veins by their darker,
more defined circular structure, as well as their lack of easy compressibility
Fat Generally hypoechoic, may contain pathological hyperechoic connective tissue
Fascia Hyperechoic marking well-defined boundary
Pleura and air Pleura appears hyperechoic with either anechoic fluid-filled cavity or diffuse hyperechoic air cavity (e.g., aerated lung)
36 M.L. Noga et al.
Nerves and tendons • Nerve roots, such as those seen in the cervical region
• Long axis view of the nerves in the peripheral appears during interscalene blocks, appear monofascicular.
as hyperechoic (bright) tubular structures from the The trunks and cords of the brachial plexus have an
connective tissues with elongated and well-defined even better defined fascicular pattern owing to the
hypoechoic (dark) spaces within this tubule, which are hyperechoic thick epineurium. This fascicular pattern
neuronal fascicles (Fig. 3.6). is more difficult to appreciate at the cord level since it
• Short axis view of a nerve in the periphery shows small is deeper.
elliptical or round hypoechoic structures which are • With a longitudinal view, the brachial plexus is
fascicles, each surrounded by a homogeneous hyper- hypoechoic compared to the nerves in the periphery
echoic connective tissue, giving a honeycomb appear- due to the increased amount of connective tissues
ance to the nerve. The nerve can also be “traced back” accompanying the nerves in the periphery.
using the traceback approach (see Sect. 4.4.2) since it • It may be difficult to differentiate between a nerve and
is a continuous structure and is usually adjacent to the a tendon with ultrasound although there are certain dif-
vessel(s) (Fig. 3.7). ferences, as shown in Table 3.3.
Fig. 3.6 Long axis view of peripheral nerves shows hyperechoic tubu- Fig. 3.7 Short axis view of a peripheral nerve (yellow arrow) shows
lar structures (yellow arrow). Elongated and well-defined hypoechoic small elliptical or round hypoechoic structures which are fascicles, each
spaces within this tubule are neuronal fascicles surrounded by a homogeneous hyperechoic connective tissue, giving a
honeycomb-like appearance to the nerve. Red arrow indicates artery;
green arrows indicate tendon
Table 3.3 Differences in ultrasonographic appearance of nerves and tendons

Nerves Tendons
General appearance Fascicular Fibrillar
Long axis view (at 90° Less pronounced and fewer hyperechoic lines, Numerous fine, parallel, hyperechoic lines
incidence angle) but these lines are thicker (fibrillar pattern) separated by hypoechoic lines
Transverse view No specific patterns to hyper- or hypoechoic areas Alternating hyper-, hypoechoic longitudinal areas
Honeycomb-like appearance, especially the periphery
Consistency in shape Fairly consistent in shape Profile changes abruptly
Longitudinal view with active Stationary among the surrounding mobile tissue Mobile
or passive movement
Muscle Pleura and air

• In a short axis (cross-sectional) view, there is a • The pleura has a hyperechoic linear appearance, and,
uniform, hypoechoic “starry night” pattern; on beyond the pleura, the reverberation artifact creates
longitudinal scanning (long axis view), there is a specular reflectors which “move” on breathing
typical pennate or feather-like appearance (Fig. 3.8). (Fig. 3.5).
• The hyperechoic lines within the muscle are separated by • The air within the lung forms a “comet tail” acoustic
wider spaces of hypoechoicity compared to the nerves. shadow deep from the pleura.
Bone
• The bone has a linear, hyperechoic appearance which
casts a hypoechoic shadow beneath (acoustic shadow-
ing) (Fig. 3.3).
• This striking appearance is ideal for providing
landmarks for nerve blocks, such as the greater trochan-
ter of the femur as a landmark for subgluteal approach
to the sciatic nerve or the radial groove/deltoid tuberos-
ity, medial epicondyle, and lateral epicondyle for radial,
median, and ulnar nerve locations, respectively.
Vascular structure
• Blood vessels appear as anechoic structures on cross-
sectional view.
• Arteries are typically circular and pulsatile; the latter
characteristic is enhanced upon external compression
by the transducer on the skin.
• Veins are compressible, so care must be taken when
performing nerve blocks since pressure exerted on the
transducer during scanning may occlude the veins,
making them invisible on the image. This is particu-
larly true when the vessels are small, such as those in
children.
Fat
• Fatty tissue is slightly hypoechoic relative to the skin,
although abnormalities such as tumors may result in
hyperechoic reflection.
Fig. 3.8 Short (top) and long (bottom) axis view of muscle. Note the
uniform, hypoechoic “starry night” pattern in the short axis view and
Fascial tissue the pennate or feather-like appearance in the long axis view. Yellow
• The fascia appears as a well-defined hyperechoic line. arrows indicate nerve; green arrows indicate muscle
38 M.L. Noga et al.
3.7 Equipment Selection click” cameras, which are simple to use and can capture
reasonably good pictures. In contrast, the larger, cart-
• The necessary equipment allowing performance of based systems are akin to complex manual cameras
ultrasound-guided regional anesthesia is, of course, an favored by the professional photographer.
ultrasound machine. The portable laptop machines cur- • For most blocks performed in children, a SonoSite
rently available offer a good-quality, high-resolution M-Turbo machine is adequate. However, for imaging
image, comparable to those of the larger, more cumber- neuraxial structures, the large, cart-based systems are
some (and more expensive) cart-based systems. Portable superior due to higher resolution and sensitivity, which
machines are more practical and allow ultrasound-guided produce remarkable images and enable greater precision.
nerve blocks to be performed at the bedside. • The most crucial piece of equipment is the transducer. As
• The machine should have the basic functions for optimiz- mentioned previously in this chapter, high-frequency lin-
ing image quality, such as gain control, color flow ear transducers (13–6 MHz) that allow high spatial reso-
Doppler, and zoom. lution are ideal for superficial structures in children during
• The machine should allow images and short video clips to both peripheral nerve blocks and neuraxial blocks.
be captured and stored. There should be a hard disk with • A smaller footprint, as with the SLA “hockey stick” trans-
high capacity for storage of the images and film sequence ducer (25 mm), is practical for performing nerve blocks in
as well as an ability to export these to a Universal Serial small children. Transducers with a larger surface area
Bus (USB) memory stick or compact disc (CD). The footprint (38 mm) are more suitable for older children and
images in this book were captured with the SonoSite provide an increased overview.
M-Turbo (Bothell, WA, USA), unless stated otherwise. • For neuraxial blocks, a 38 mm footprint high-frequency
• A good machine should be simple to use and with the probe (13–6 MHz) is usually used.
commonly used function buttons clearly visible.
• Ultrasound machines are almost like cameras. Portable Preferred needle and probe options for various block
units are analogous to current automatic, “point-and- locations are listed in Table 3.4.
Table 3.4 Needle and probe Block location Needlea Probea

selection for peripheral block
Upper extremity
locations
Interscalene 3–5 cm, 22G HFL38, C11
Supraclavicular 3.75 cm, 22G SLA, C11
Infraclavicular 10 cm, 22G HFL38, C11
Axillary 1.25–2 cm, 22G HFL38
Radial (spiral groove) 1.25–2 cm, 22G HFL38
Musculocutaneous (coracobrachialis) 1.25–2 cm, 22G HFL38
Median (antecubital) 3.75 cm, 22G HFL38
Ulnar (mid-forearm) 3.75 cm, 22G SLA, HFL38
Lower extremity
Lumbar plexus 15 cm, 22G C60
Femoral 3–4 cm, 22G HFL38
Sciatic – anterior/posterior 10 cm, 22G C60
Popliteal – posterior 5–6 cm, 22G HFL38
Popliteal – lateral 10 cm, 20G HFL38
Ankle 2.5 cm, 24G SLA, HFL38
Trunk
Intercostal 3.75 cm, 22G HFL38
Paravertebral 8.75 cm, 22G HFL38, C60
a
Selection based on commonly available needle length and SonoSite probes (see Fig. 3.1b)
3.8 Current Advances for Future 3.8.4 Sonix GPS (Ultrasonix Medical Corp,
Developments Richmond, BC, Canada)
Advancements in technology enable constant improvement Sonix GPS is an electromagnetic needle tracking system
of the quality of ultrasound images. The areas of important with a sensor housed within the needle for real-time
development are: ultrasound-guided needle insertion. The current and pre-
dicted needle positions are displayed on the ultrasound
screen, and, as the needle is advanced, the needle trajectory
3.8.1 Compound Imaging and ultrasound beam are aligned in real time, allowing the
user to aim the needle accurately toward the final target
Speckle is a 2D noise in ultrasonographic images resulting location.
from scattering media. To overcome speckle, multiple image
planes are captured from different beam angles and broad
bandwidth frequencies simultaneously and are then averaged 3.8.5 Power Doppler
to construct a speckle-reduced single image. This process is
known as compounding. This technique can detect lower flow vessels which would
not show up in normal color Doppler, such as those with a
low diastolic velocity from a perpendicular Doppler angle.
3.8.2 Single-Crystal Transducers Instead of estimating the frequency shift in Doppler signals,
power Doppler estimates the integral of the power spectrum.
These are sizable monocrystals produced by techniques that The color in the power Doppler image indicates that blood
are similar to those employed in growing silicon. They may flow is present but does not provide any information on flow
produce increased bandwidth, sensitivity, and high energy velocity.
density for remarkable performance.
3.8.6 Robot-Assisted Regional Anesthesia

3.8.3 Capacitive Micromachined Ultrasound
Transducers (CMUT) Recently, the multipurpose da Vinci Surgical System Type
S (DVS) (Intuitive Surgical, Sunnyvale, CA) was demon-
The conversion from acoustic to electrical energy and vice strated to place a single-injection nerve block and peri-
versa is obtained through an electric field stored in a multi- neural catheter into an ultrasound phantom under real-time
tude of microscopic capacitors obtained from a silicon wafer ultrasound guidance. The limitation with this technique is,
by means of micromachining. These transducers have excel- first and foremost, the cost, and there is a need for
lent bandwidth and impedance matching to the human body. increased manpower (two engineers, an anesthesiologist,
These properties produce higher-resolution images and and a urologist, in this simulation) to perform this proce-
enable optimal tissue harmonic imaging which captures the dure using this equipment. This is, however, an exciting
higher-frequency echoes with less scatter and artifacts. This experiment that proves the benefits of the twenty-first-
application is important for real-time 3D imaging. century technology.
40 M.L. Noga et al.
Suggested Reading Oakley CG, Zipparo MJ. Single-crystal piezoelectrics: a revolutionary

development for transducers. Ultrason Symp 2000 IEEE. 2000;2:
1157–67.
Bhargava R, Noga M, Lou L. Ultrasound basics. In: Tsui BC, editor.
Oralkan O, Ergun S, Johnson JA, et al. Capacitive micromachined
Atlas of ultrasound and nerve stimulation-guided regional anesthe-
ultrasonic transducers: next-generation arrays for acoustic
sia. New York: Springer; 2007. p. 19–33.
imaging. IEEE Trans Ultrason Ferroelectr Freq Control. 2002;49:
Connolly DJA, Berman L, McNally EG. The use of beam angulation to
1596–610.
overcome anisotropy when viewing human tendon with high fre-
Park SE, Hackenberger W. High performance single crystal piezoelec-
quency linear array ultrasound. Br J Radiol. 2001;7(4):183–5.
trics: applications and issues. Curr Opin Solid State Mater Sci.
Gray AT. Ultrasound-guided regional anesthesia. Anesthesiology.
2002;6:11–8.
2006;104:368–73.
Polaner DM, Suresh S, Cote CJ. Regional anesthesia. In: Cote CJ,
Hemmerling TM, Taddei R, Wehbe M, et al. First robotic ultrasound-
Lerman J, Todres ID, editors. A practice of anesthesia for infants
guided nerve blocks in humans using the Magellan system. Anesth
and children. 4th ed. Philadelphia: WB Saunders; 2009. p. 873–4.
Analg. 2013;116:491–4.
Rapp H, Folger A, Grau T. Ultrasound-guided epidural catheter inser-
Karmakar MK, Kwok WH. Ultrasound-guided regional anesthesia. In:
tion in children. Anesth Analg. 2005;101:333–9.
Cote CJ, Lerman J, Todres ID, editors. A practice of anesthesia for
Rubin K, Sullivan D, Sadhasivam S. Are peripheral and neuraxial
infants and children. 4th ed. Philadelphia: WB Saunders; 2009.
blocks with ultrasound guidance more effective and safe in chil-
p. 911–24.
dren? Pediatr Anesth. 2009;19:92–6.
Kelsey CA. Essentials of radiology physics. St. Louis: Warren H. Green;
Sites BD, Brull R, Chan VW, et al. Artifacts and pitfall errors associated
1985.
with ultrasound-guided regional anesthesia. Part I: understanding
Lemoigne Y, Caner A, Rahal G, editors. Physics for medical imaging
the basic principles of ultrasound physics and machine operations.
applications. Dordrecht: Springer; 2007.
Reg Anesth Pain Med. 2007;32:412–8.
Marhofer P, Frickey N. Ultrasonographic guidance in pediatric regional
Tighe PJ, Badiyan SJ, Luria I, et al. Robot-assisted regional anesthesia:
anesthesia. Part 1: theoretical background. Pediatr Anesth. 2006;16:
a simulated demonstration. Anesth Analg. 2010;111(3):813–6.
1008–18.
Clinical and Practical Aspects
of Ultrasound Use 4
Contents
4.1 Image Acquisition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.2 Probe Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4.3 Image Optimization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.3.1 Probe Alignment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.3.2 Practical Approach: Traceback Method. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.4 Control of Needle Trajectory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.4.1 Visibility of Needles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.4.2 Hand-Eye Coordination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.4.3 Needling Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
M.L. Noga, MD, FRCPC (*)

Department of Radiology and Diagnostic Imaging,
University of Alberta, 2A2.41 Walter Mackenzie Centre,
8440-112 Street, Edmonton, AB T6G 2B7, Canada
University of Alberta Hospital, 2-150 Clinical Sciences Building,
B.C.H. Tsui, Dip Eng, BSc (Math), B Pharm, MSc, MD, FRCPC

DOI 10.1007/978-0-387-79964-3_4
42 M.L. Noga et al.
4.1 Image Acquisition 4.2 Probe Preparation
Basic Concepts • Both the probe and the patient’s skin should be prepared
• It is advisable to perform the block in a stress-free for maximum sterility and optimal imaging.
environment with minimal time restraints. • Water-soluble conductivity gel is always used to remove
• The target area should be surveyed (scanned) using a the air-skin interface and to allow good reflection of
generous amount of ultrasound gel prior to sterile
ultrasound waves.
preparation. One of the most common reasons for poor • Probe sterility is paramount in performing real-time, or
visualization is lack of sufficient gel for skin-probe dynamic, ultrasound-guided nerve block. This can be
contact. maintained by standard sleeve covers, although these can
• Upon location of a suitable puncture site, the probe posi- be expensive and cumbersome.
tion is marked on the skin with a sterile marker. • When using a probe with the standard long covers, it is
• The images used in this book are those from our everyday important to avoid air tracking between the probe and
practice and are achievable by any newcomer to cover, as well as between the cover and the skin, which
ultrasound-guided regional anesthesia. We have been can obscure the ultrasound image.
mindful not to concentrate on presenting anatomically • For single-shot blocks, we find it practical to use a trans-
perfect ultrasound images, which are obtained occasion- parent dressing without the full cover of a sterile sleeve:
ally; shown are images that are representative of what you –– A sterile transparent dressing (Tegaderm™; 3M Health
will encounter in an average day. Care, St. Paul, MN, USA) can be used effectively, but
• In order to facilitate learning in identification of the sono- to maintain a smooth surface, it must be stretched
anatomy, unlabelled ultrasound images are placed next to before it is adhered to the surface of the probe. The
identical but well-labeled images. Our colleagues have IV3000 dressing (Smith & Nephew Medical Limited,
found this layout to be the most effective for familiarizing Hull, UK) is marketed for this purpose, but we have
themselves with realistic clinical images as there is no observed that, when placed over the probe surface,
distraction from multiple labels, yet at the same time, they multiple small adhesive wells trap air underneath the
benefit from side-by-side reference to the same image that dressing, leading to poor imaging and a limited ability
has been labeled. to use the Doppler effect (Fig. 4.1) [1].
• More importantly, the labeling system indicates what –– We also use individual sterile packs of gel.
structures are normally visualized as well as the • For continuous blocks:
expected locations of any clinically relevant and impor- –– Complete sterile preparation is required; a complete ster-
tant structures which may not be immediately obvious. ile cover is used for the ultrasound probe. A mask, sterile
Hopefully, this will reduce frustration and failure from gown, and gloves should be worn by the operator.
unrealistic expectation in an attempt to visualize every • After completion of the procedure, the probe and related
structure. equipment (including all surfaces and cables) should be
thoroughly cleaned.
4 Clinical and Practical Aspects of Ultrasound Use 43
Fig. 4.1 Effects of sterile transparent dressing on image quality and dressing, leading to poor imaging and limited ability to use Doppler.
ability to use Doppler ultrasound with curved probes. The Tegaderm A complete commercial sterile cover (right) would be necessary if
dressing maintains image quality and ability to use Doppler as long performing catheter insertion for continuous anesthesia/analgesia

as it is stretched (left). The IV3000 dressing can be used (middle), (Adapted from Tsui et al. [1]. With permission from Wolters Kluwer
but multiple small adhesive wells containing air may form under the Health)
44 M.L. Noga et al.
4.3 Image Optimization in this situation, and artifacts such as anisotropy (Chap. 3,
Sect. 3.6) will be minimized.
• One of the most important factors in ultrasound-guided • To obtain the best short-axis view in a coronal plane, such
localization is patient positioning. The patient should be as scanning the supraclavicular region, follow these
placed in a position such that the target area is well important steps for probe handling (Fig. 4.2):
exposed. In the subsequent clinical chapters, patient –– Scan across the relevant area to obtain a transverse
positioning will be described for each individual block view of the vascular structure (e.g., subclavian artery)
prior to discussing the ultrasound imaging technique. or nerve since it is easier to capture these structures
• The operator position should be optimized to enable both with an ultrasound beam “transecting” in a short axis
a good view of the ultrasound screen and comfortable rather than obtaining a longitudinal view.
hand positioning for needle insertion. –– The image can be refined by rotating the probe (turn
• The reader is referred to Chap. 3 to choose the appropri- slightly clockwise or anticlockwise) or tilting the probe
ate frequency of transducer at each peripheral block forward and backward to achieve a perpendicular beam
location; the frequency will partly determine the type of through the target structure in order to sharpen the image.
array (linear versus curved) that will be suitable. Often, • Adjust the time gain compensation (TGC) so that the
a high-frequency linear array transducer (10 MHz or visualized area is of uniform echotexture. Always adjust
more) is the most appropriate for the pediatric popula- the TGC to the center when changing transducers during
tion. If the area of interest is relatively deep, such as the a study.
gluteal region in teenagers, a lower-frequency trans- • Appropriate depth should be adjusted such that the target
ducer (5–7 MHz) may be advantageous with greater nerve is in the center of the screen with other relevant
penetration. Whether the probe array is curved or linear structures in view (e.g., in supraclavicular block, one
depends on the region and field of view required (e.g., should be able to visualize the subclavian artery, the first
blocks in the lumbar region benefit from larger fields of rib, and the pleura).
view and lower frequencies, which curved array probes • The focal point should be adjusted to the where the target
offer). nerve is.
• A systematic approach allows the best image to be
obtained in a timely fashion, increasing the success rate of
4.3.1 Probe Alignment ultrasound-guided peripheral nerve blocks.
• Most neural structures are accompanied by blood vessels
• The probe will have a marker or groove to show which (pulsatile arteries or compressible veins) or bony land-
way is “up.” The marker corresponds to the top of the marks, which are readily identifiable using ultrasound.
ultrasound image, and if you slide the probe toward the Color Doppler is useful in this situation to identify blood
marker, the image will move in the direction that the vessels. The color convention is for red to represent blood
probe is moved. Similarly, if you slide the probe away flowing toward the transducer and blue to represent blood
from the marker side, the image will move in the direction flowing away from the transducer. Therefore, the knowl-
opposite the marker. edge of anatomy is always important to identify nerves
• In most circumstances, and particularly with transverse around these landmarks.
planes of viewing, the plane of the transducer beam • The “traceback” approach (see below) also aids the identi-
should intersect the axis of the nerve structures at a per- fication of a nerve, especially when differentiating between
pendicular position. The lateral resolution will be optimal similar-looking structures such as tendons or artifacts.
Fig. 4.2 Probe handling during supraclavicular blockade with the probe (clockwise or anticlockwise) or tilt the probe forward and
landmark identification of the subclavian artery. Scan across the
backward to achieve a perpendicular beam through the target structure
relevant area to obtain a transverse view of the vascular structure (bottom)
(in this case the subclavian artery; top). To sharpen the image, rotate
46 M.L. Noga et al.
4.3.2 Practical Approach: Traceback Method probe moves, whereas the appearance of the target
nerve does not change in any significant manner and is
As with the conventional “blind” approach, knowledge of traceable.
anatomy is of upmost importance when performing periph- • In this way, we can more easily and reliably identify the
eral nerve blocks under ultrasound guidance. The spatial corresponding nerve or plexus.
appreciation in relation to the surrounding structures is also
relevant. In our experience, neural structures are not always For illustration purposes, see Fig. 4.3, which describes a
easy to identify under ultrasound; they can appear hyper- or traceback practice for facilitating identification of the sciatic
hypoechoic and are sometimes confused with artifacts. nerve at the popliteal fossa (using vascular landmark identi-
Nerves are continuous structures, which lend themselves to fication). This approach allows the operator to gain confi-
be “traced” proximally and distally. This enables the differ- dence in their ability to recognize and locate the nerves.
entiation from structures with similar appearance (e.g., ten- During the training process, we found that the traceback
dons). In this section, we will describe a systematic approach is an easy and reliable way to become proficient at
“traceback” approach [2] to help identify the target nerves identifying neural structures prior to performing regional
(within various regions) of commonly used nerve blocks. anesthesia. However, the traceback approach may not be
necessary in some locations where the larger nerves are more
• Instead of immediately focusing on locating the target easily identifiable, for example, the median nerve in the
nerve at the commonly used block site, the goal of this axilla and antecubital fossa and the femoral nerve in the
exercise is to obtain a clear image of an obvious anatomic inguinal region.
landmark (i.e., a blood vessel or bony landmark) not too We strongly recommend that the initial step in performing
far removed from one point along the target nerve’s path. ultrasound-assisted regional anesthesia is identification of
• If suitable, it is generally preferred to perform the block at obvious landmarks (usually blood vessels or bony land-
this location due to the dependable anatomical relations. marks) in the vicinity of the target nerve. Table 4.1 lists the
• Otherwise, the operator focuses on the nerve (often in numerous nerve blocks that can benefit from identification of
short axis by adjusting the transducer as described above highly visible and dependable structures (i.e., blood vessels
in probe alignment) and “traces” it toward the block target (especially with color Doppler) and bone) for accurate nerve
area by moving the ultrasound probe in a proximal or dis- identification. Nonetheless, the traceback technique is useful
tal direction along the nerve. for popliteal nerve for identification of the bifurcation, iden-
• The appearance of surrounding structures (e.g., muscle tifying the brachial plexus at the interscalene region, or for
and other soft tissues) changes consistently as the revealing anatomic anomalies.
Sciatic nerve in the

posterior thigh
Scanned region
S
Medial Lateral
Ultrasound probe scans proximally from the popliteal crease
T P
Identify the tibial (T) nerve lateral to the popliteal artery; scan proximally
to view its convergence with the common peroneal (P) nerve to become
the sciatic (S) nerve.
Fig. 4.3 Traceback approach in the posterior thigh for identification of the sciatic nerve at the popliteal fossa (Adapted from Tsui and Finucane
[2]. With permission from Wolters Kluwer Health)
48 M.L. Noga et al.
Table 4.1 Useful landmarks for identification of nerves using ultrasound; many can be used in “traceback” approaches
Block Ultrasound landmark Comments
Interscalene Subclavian artery Trace nerve proximally from the distal supraclavicular location where the
artery lies medial to the nerve
Supraclavicular Subclavian artery Brachial plexus lies lateral and often superior to the artery
Infraclavicular Subclavian artery and vein Brachial plexus cords surround the artery
Axillary Axillary artery Terminal nerves surround the artery
Peripheral nerves
Median at antecubital fossa Brachial artery Nerve lies immediately medial to the artery
Radial at posterior elbow Humerus at spiral groove Groove is found on posterolateral surface of humerus inferior to the deltoid
insertion, and the nerve can be located (also adjacent to the deep brachial
artery) and traced to the anterior elbow
Ulnar at medial forearm Ulnar artery The nerve lies medial and adjacent to the artery at the midpoint of the forearm
Lumbar plexus Transverse process Lies between and just deep to the lateral tips of the processes
Femoral Femoral artery Nerve lies lateral to artery (vein most medial). Insert needle above the
bifurcation of the deep femoral artery
Sciatic
Labat Ischial bone Nerve lies lateral to the ischial bone
Subgluteal Greater trochanter and Nerve lies between the two bone structures
ischial tuberosity
Popliteal Popliteal artery Trace back from the popliteal crease where the tibial nerve is adjacent to the
artery. Scanning proximally to the sciatic bifurcation, the artery becomes
deeper and at a greater distance from the tibial nerve where it is joined by the
peroneal nerve
Ankle
Tibial (posterior tibial) Posterior tibial artery Nerve lies posterior to the artery
Deep peroneal Anterior tibial artery Nerve lies lateral to the artery
4.4 Control of Needle Trajectory • Manufacturers are constantly improving needles for visi-
bility, and echogenic needles are commercially available
4.4.1 Visibility of Needles (Chap. 1).
• It is important to be able to visualize the tip of the needle.
• Common small-bore, 22G insulated block needles are Tilting (Fig. 4.4a), rotating (Fig. 4.4b), and manipulating
adequate to perform ultrasound-guided blocks in the transducer alignment (Fig. 4.4c) is necessary to ensure
children. that the image of the needle includes the tip. This is par-
• Since neural structures are superficial in children, there is ticularly important for the out-of-plane approach, since
generally good needle visibility since the increased angles the image of the needle is a hyperechoic dot which could
of penetration tend to reduce visibility. be interpreted as either the shaft or the tip of the needle on
• A larger-gauge needle, such as the 17G–20G Tuohy nee- the screen (see below).
dles used in peripheral nerve block catheterization, can
also improve visibility.
50 M.L. Noga et al.
Fig. 4.4 Tilting (a), rotating (b), and manipulating (c) the alignment of the ultrasound probe is necessary to visualize the tip of the needle. The
line on the paper indicates the original axis of the probe
4.4.2 Hand-Eye Coordination population illustrates this point by focusing on the

onscreen action rather than on the controller when play-
One of the most common errors of the beginner learning ing a video game (Fig. 4.5). Similarly, an experienced
ultrasound-guided regional anesthesia is to focus their laparoscopic surgeon may look directly at their instru-
attention on the needle in their hand, instead of observing ments upon initial insertion but will transfer their focus to
the needle position changes on the screen. This is a cardi- the screen for all subsequent instrument manipulation.
nal error, as important information relating to the needle Although it sounds trivial to stress good hand-eye coordi-
position and the corresponding image will be missed by nation, mastering it has been extremely helpful for staff at
concentrating on the actual needle. Today’s teenage our institution.
Fig. 4.5 Children demonstrating hand-eye coordination focusing on

the video game screen rather than their hand movements on the control-
ler (Reprinted from Tsui BC, Dillane D. Practical and clinical aspects
of ultrasound and nerve stimulation-guided peripheral nerve blocks. In:
Tsui BC, editor. Atlas of ultrasound and nerve stimulation-guided
regional anesthesia. New York: Springer; 2007. p. 35–48. With permis-
sion from Springer Verlag)
52 M.L. Noga et al.
4.4.3 Needling Technique • Most commercial needle-guiding tools involve physical

fixation of the needle aligned in-plane with respect to the
4.4.3.1 In-Plane Technique (Fig. 4.6) ultrasound beam; such an apparatus is not only expensive
and cumbersome to use but often limits fine adjustment of
• Aligning the needle to the ultrasound plane is an impor- needle placement and requires extra long needles (Fig. 4.7).
tant concept to grasp and practice. • A GPS needle tracking device is available which provides
• In-plane (IP, long-axis, longitudinal, or axial) needling real-time information of where the needle should be
approaches with the needle parallel to the ultrasound maneuvered for the target area (Chap. 3).
scanning plane have the advantage of allowing continu- • In contrast, the freehand technique requires excellent
ous control of the needle trajectory due to clear visualiza- coordination to align and maintain the needle in plane to
tion of both needle tip and shaft. the ultrasound beam in order to visually track the advance-
• The nerve structure is often placed at the edge of the ultra- ment of the needle toward the target in real time; accord-
sound screen to ensure shallow insertion angle of the ingly, the freehand technique often requires a steep
needle and, therefore, a better visualization. learning curve.
• Good alignment of the needle shaft and scanning plane is • Tsui [3] developed a method of needle-probe alignment
required and can be attained by paying close attention using a laser attachment for the probe (Fig. 4.8); the laser
when viewing the needle and probe from above or in an line will project onto both the needle shaft and the midline
axial view. of the probe, indicating an in-plane position. Alternatively,
• For practical reasons, it is often advisable to use a small a commercially available laser attachment for the needle
footprint linear (e.g., hockey stick) probe or curved array (SonoGuide, Pajunk, Geisingen, Germany) is also avail-
probe (e.g., C11) in compact areas, such as the supracla- able and operates with a similar concept (Fig. 4.9).
vicular fossa. It is critical to use in-plane technique at this • It should be noted that the in-plane approach can be per-
location (to adequately view the needle to prevent pleural formed as a single shot or catheter insertion when the tar-
puncture), and smaller probes will be beneficial for more get nerve is scanned both in a short-axis (cross-sectional
space to maneuver the needle. view) or a long-axis (longitudinal view).
Fig. 4.6 Needle (green arrow), including tip and shaft during an in-
plane approach
Fig. 4.7 Commercial biopsy needle attachment. The fixed needle has a
limited trajectory and has to be extra long (Reprinted from Tsui BC,
Dillane D. Practical and clinical aspects of ultrasound and nerve
stimulation-guided peripheral nerve blocks. In: Tsui BC, editor. Atlas
of ultrasound and nerve stimulation-guided regional anesthesia.
New York: Springer; 2007. p. 35–48. With permission from Springer
Verlag)
Fig. 4.8 Alignment of the block needle and ultrasound beam using a
laser line (Reprinted from Tsui [3]. With permission from Wolters
Kluwer Health)
Fig. 4.9 Commercially available laser attachment for block needle

54 M.L. Noga et al.
4.4.3.2 Out-of-Plane Technique: greater than 2 cm away from the probe since there will be
Walkdown Approach a relatively large “blind” needling area. In this situation,
the needle should be inserted almost perpendicularly (i.e.,
• Out-of-plane (OOP; tangential, short-axis) alignment of the needle placed just adjacent to the probe which means
the needle to the scanning plane can be useful in several that in reality, it will be 0.5 cm away from the ultrasound
block locations (e.g., popliteal, terminal nerves of the beam). Again, applying the principles of trigonometry, a
forearm, ankle blocks), but the separation between the distance ≤1 cm between the needle and the ultrasound
needle tip and proximal shaft can be poorly defined. beam becomes negligible as the target depth increases,
• OOP needling can be difficult since the needle shaft can and the needle insertion depth becomes comparable to the
easily be mistaken for the needle tip (Fig. 4.10). target depth (Fig. 4.12). For instance, the difference
• Needle tip imaging can be improved by using shallow ini- between the depth of needle insertion and the actual depth
tial puncture angles since the tip appears as a bright dot at of the target is minimal when the needle is directly adja-
these angles. cent to the transducer with a maximum distance of 1 cm
• An approach that can improve needle tip visibility when away from the ultrasound beam:
using OOP approaches with linear probes involves calcu-
lating the required depth of puncture (with measurement
to the related neural structure recorded using ultrasound
(( 2cm target depth ) 2
+ (1cm insertion distance )
2
)
= 2.2 cm needle length required
prior to the block) and using trigonometry with the shaft
angle and length to calculate a “reasonable” distance to Therefore, this approach helps clinicians to determine if
place the initial needle puncture site (Fig. 4.11) [4]. the hyperechoic dot on the ultrasound image is the needle
• The initial shallow puncture will be easily seen, and the tip by correlating it to the length of the needle inserted.
needle tip can be followed as it is walked down to the final • The nerve structure is often placed in the center of the
calculated depth. For example, if the final depth of pene- screen to guarantee that aligning the needle puncture with
tration for the block is 2 cm, the needle will ultimately the center of the probe will ensure close needle tip-nerve
obtain a 45° angle if the initial puncture site is 2 cm from alignment.
the probe and the needle is incrementally angled to this • The choice of probe, whether linear or curved, can be
level [5]. This approach works best for structures that are altered depending on the anatomical situation.
≤2 cm deep. • The OOP approach usually works well when the target
• For target nerves deeper than 2 cm, a long needle is nerve is scanned in a short-axis (cross-sectional view) for
required. It is impractical to have the needle insertion site both single shot and catheter insertion.
a b
Fig. 4.10 Needle tip (a) and shaft (b) in an out-of-plane approach. Green arrows indicate needle position
Fig. 4.11 Walkdown approach to

optimize out-of-plane needle
s
visibility and tracking. The steep

gree
angles (left) often used limit the
s
ee
p de
visibility of needle tips, while
gr
Probe Probe
de
shallower angles (right) improve
Stee
45
visibility. Incremental needle
angulation (with two to three
insertion angles from shallow to final Distance rees
45°) can improve needle tracking. deg
ow
The trigonometric relationship, using S hall
an ultrasound-measured target depth,
will allow an estimate of the target
Depth
Depth
needle insertion site, directing the

needle to the target location at a final
angle of 45° (Adapted from Tsui and
Dillane [4]. With permission from
Wolters Kluwer Health) Distance = depth
when needle inserted
at 45 degrees
56 M.L. Noga et al.
a c
a c
Fig. 4.12 Method to determine needle tip location by correlating it to beam becomes negligible as the target depth increases. The needle
the length of the needle inserted for target nerves deeper than 2 cm with insertion depth therefore becomes comparable to the target depth. The
an out-of-plane approach. The needle is placed just adjacent to the hyperechoic dot on the ultrasound image can be distinguished as the
probe and inserted almost perpendicularly. According to principles of needle tip (a) or the shaft (b) (Adapted from Tsui [5]. With permission
trigonometry, a distance ≤1 cm between the needle and the ultrasound from Springer Verlag)
References Grau T. Ultrasound in the current practice of regional anesthesia. Best

Pract Res Clin Anaesth. 2005;19:175–200.
Gray AT. Ultrasound-guided regional anesthesia. Current state of the
1. Tsui BC, Twomey C, Finucane BT. Visualization of the brachial
art. Anesthesiology. 2006;104:368–73.
plexus in the supraclavicular region using a curved ultrasound probe
with a sterile transparent dressing. Reg Anesth Pain Med.
Cote CJ, Lerman J, Todres ID, editors. A practice of anesthesia for
2006;31:182–4.
infants and children. 4th ed. Philadelphia: WB Saunders; 2009.
2. Tsui BC, Finucane BT. The importance of ultrasound landmarks: a
p. 911–8.
“traceback” approach using the popliteal blood vessels for identifi-
Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional
cation of the sciatic nerve. Reg Anesth Pain Med. 2006;31:481–2.
anesthesia. Br J Anaesth. 2005;94:7–17.
3. Tsui BC. Facilitating needle alignment in-plane to an ultrasound
Schafhalter-Zoppoth I, McColluch CE, Gray AT. Ultrasound visibility
beam using a portable laser unit. Reg Anesth Pain Med. 2007;
of needles used for regional nerve block: an in vitro study. Reg
32(1):84–8.
Anesth Pain Med. 2004;29:480–8.
4. Tsui BC, Dillane D. Needle puncture site and a “walkdown”
Tsui BC, Dillane D. Practical and clinical aspects of ultrasound and
approach for short-axis alignment during ultrasound-guided blocks.
nerve stimulation-guided peripheral nerve blocks. In: Tsui BC,
Reg Anesth Pain Med. 2006;31(6):586–7.
editor. Atlas of ultrasound and nerve stimulation-guided regional
5. Tsui B. A trigonometric method to confirm needle tip position
anesthesia. New York: Springer; 2007. p. 35–48.
during out-of-plane ultrasound-guided regional blockade. Can

Tsui BC, Finucane BT. Practical recommendations for improving
J Anesth. 2012;59:501–2.
needle-tip visibility under ultrasound guidance? Reg Anesth Pain
Med. 2005;30:596–7.
Suggested Reading
Chan VW. The use of ultrasound for peripheral nerve block. In: Boezaart
AP, editor. Anesthesia and orthopaedic surgery. New York: McGraw-
Hill; 2006. p. 283–90.
Regional Block Catheter Insertion Using
Ultrasonography and Stimulating 5
Catheters
Contents
5.1 Indications, Contraindications, and Safety of Peripheral Nerve Catheter Placement . . . . . . . 60
5.2 Equipment and Injectates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.2.1 Equipment Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.2.2 Sterile Transducer Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5.2.3 Choice of Injectates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.3.1 Confirming Catheter Tip Location with Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.3.2 Confirming Catheter Tip Location with Nerve Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.3.3 Catheter-Over-Needle Assembly Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.3.4 Securing the Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
5.4 Examples of Common Peripheral Nerve Catheterization Procedures Used in Children . . . . . 69
5.4.1 Infraclavicular Nerve Block Catheterization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
5.4.2 Femoral Nerve Block Catheterization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
5.4.3 Sciatic Nerve Block Catheterization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
5.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
V.H.Y. Ip, MB ChB, MRCP, FRCA (*)

Department of Anesthesia and Pain Medicine,
University of Alberta Hospital,

DOI 10.1007/978-0-387-79964-3_5
5.1 Indications, Contraindications, space, Pajunk has designed a peripheral continuous catheter
and Safety of Peripheral Nerve (SonoLong Curl Continuous kit, Pajunk, Geisingen,
Catheter Placement Germany) which curls immediately after exiting the needle
(Fig. 5.1), allowing the tip to remain near the position of the
Prior to performing any procedure, the risk should be needle tip.
balanced against the benefit. This is particularly true in the
pediatric population, where data on the efficacy and safety of 2. Stimulating Catheters
peripheral nerve catheters is scarce. In general, peripheral Although it is still unclear as to whether stimulating cath-
catheters are used in children undergoing procedures that are eters are more effective than non-stimulating catheters at
associated with significant and prolonged postoperative positioning the catheter tip in proximity to the nerve, stimu-
pain, such as major orthopedic procedures, traction of lating catheters can aid in the verification of catheter tip
femoral fractures, operations on congenital malformations localization. When motor response is present at a reasonable
of upper or lower limbs, and amputation, or to facilitate threshold (0.5 mA), this usually signifies the correct place-
postoperative physiotherapy. Peripheral catheters can also be ment of a stimulating catheter. Some stimulating needle and
used in children to improve peripheral perfusion following catheter sets, for example, the StimuCath® (Arrow
microvascular surgery and to help manage chronic pain International, Reading, PA, USA) with a 5 mm bare tip, may
conditions. need a higher stimulation current, such as 1 mA; it should
One of the main considerations of peripheral nerve cath- also be noted that nerve stimulation is not sensitive enough
eter placement is when there is a high risk of neurovascular to detect intraneural placement of the catheter. Therefore, it
injury from either the injury or surgery, for example, condy- is our recommendation that the spread of local anesthetic
lar or supracondylar fractures of the elbow. Physicians through the catheter tip be observed with ultrasound.
should exercise caution since there is a lack of safety data Ultrasound-guided perineural catheter insertion can be tech-
with regard to regional anesthesia in patients with preexist- nically challenging and requires a sound knowledge of sono-
ing neurological disorders. Another consideration is that anatomy, good hand-eye coordination, and a competent
there is continued debate regarding performing regional assistant. High success rates can be obtained once these
anesthesia in anesthetized adults. Such practice is well skills are acquired.
accepted in pediatric patients as it reduces the risk of a “mov- Catheters that are used in continuous peripheral nerve
ing target” and because children are often unable to commu- blocks in children are similar to those used in adults. There
nicate and differentiate between paresthesia, pain at injection are four commercial varieties of catheters available with dif-
site, or pressure from the injectate. ferent lengths of needles required for various blocks and to
accommodate the child’s habitus/size. Several manufacturers
now provide Tuohy needle/catheter sets specifically tailored
5.2 Equipment and Injectates for pediatric use.
5.2.1 Equipment Required Arrow® StimuCath (Arrow International, Reading, PA,

USA)
5.2.1.1 Types of Catheters • The insulated needle is 17G and 18G Tuohy-tipped with
centimeter markings available in 4 and 8 cm (Fig. 5.2).
1. Non-stimulating Catheters • The 60-cm-long catheter comes in 19G and 20G which is
The principle behind these types of catheters is the made more rigid by a steel stylet.
catheter-through-needle technique, in which the catheter is • The catheter has a female adaptor to accommodate the
introduced within the larger-bore Tuohy needle which has stimulating cable from the nerve stimulator.
been placed in proximity to the nerve. The Tuohy needle will • The catheter has a SnapLockTM adaptor.
be removed at the end of the procedure leaving the catheter • The hub of the catheter is a stimulating cable that stimu-
in situ. Despite the concurrent use of ultrasound, catheter lates the catheter
threading is performed essentially blind due to its small • The stylet has to be removed before liquid can be injected
diameter. The catheter tip position is often difficult to ascer- through the catheter as it is advanced for hydrodissection
tain since needle withdrawal is inevitably accompanied by (see below).
simultaneous compensating advancement of the catheter. In • The catheter can kink if resistance is encountered during
order to facilitate threading of the catheter into the perineural insertion.
5 Regional Block Catheter Insertion Using Ultrasonography and Stimulating Catheters 61
Fig. 5.1 Pajunk® SonoLong Curl Fig. 5.2 Arrow® StimuCath

Pajunk® StimuLong Sono (Pajunk, Geisingen, Germany) This ensures atraumatic manipulation of the catheter
• The insulated Tuohy needles are available in 50, 100, and tip.
110 mm lengths. – Similar to the StimuLong Sono catheters, fluid can be
• The stimulating catheter has a gold-plated, atraumatic injected through the catheter during advancement for
rounded tip with a high conductivity (Fig. 5.3). hydrodissection.
• The catheter does not have a stylet, enabling fluid to be
injected as the catheter is advanced. ContiStim® Catheters (B.Braun, Melsungen, Germany)
• The metal coil of the catheter provides radiopacity and • Life-Tech has incorporated smaller catheters (21G–24G;
prevents kinking of the catheter as it meets resistance. Prolong Micro) for pediatric use.
• The 18G, 19G, and 20G insulated Tuohy needles are
Pajunk® StimuLong Sono-Tsui Set (Pajunk, Geisingen, available in variable lengths of 50, 100, and 150 mm.
Germany) • It has an atraumatic ball tip to reduce tissue damage and
• The insulated Tuohy needles have lengths of 50 and create a 360° outflow pattern.
100 mm (Fig. 5.4). • The catheters are said to be kink resistant.
• The catheter design incorporates the characteristics of the • The fluid path/giving set connector is attached to a port
StimuLong Sono catheter with two distinct features: for stimulation of the catheter.
– The stiffness of the catheter tip can be regulated by • It features an EzTwistTM closure for the fluid path connec-
pushing the steel stylet forward and backward and can tor which indicates that the catheter has been securely
be locked in place by tightening or loosening a valve. connected.
Fig. 5.3 Stimulating catheter (Pajunk® StimuLong Sono) featuring a Fig. 5.4 Pajunk® StimuLong Sono-Tsui Set. Catheter tip with steel
gold-plated, atraumatic rounded tip with a high conductivity stylet to adjust stiffness. Stylet can be pushed forward or backward and
can be locked in place with a valve
3. Catheter-over-needle assembly Several advantages of this design include:
• There are a few variations on this design marketed by dif- • Simple to use with the insertion technique comparable to
ferent brands: that of a single-shot nerve block
– Pajunk, whose feature design is its two components, • Less risk of leakage from the catheter insertion site, which
the outer catheter sheath and the flexible, non-kink- is particularly important in shoulder surgery where the
able inner catheter (Figs. 5.5 and 5.6). This assembly patient is in a sitting position with a potential for surgical
was initially designed and modified by Dr. Ban Tsui. field contamination
The inner catheter is introduced within the outer cath- • Less risk of dressing adhesive disruption
eter and is Luer-locked in place for injection • Less risk of dislodgement
(Fig. 5.7). • Less cumbersome steps
– B.Braun, with the catheter-over-needle as a sole com- • Easy visualization of the catheter, especially the catheter tip
ponent (Fig. 5.8)
– Arrow, with a catheter-over-needle with a blunt needle A preassembled peripheral catheter pack is an efficient
and a sharp injection needle for the initial puncture of way of bringing together all the essential equipment to per-
the skin (Fig. 5.9). form a peripheral nerve catheter. If such a pack is not avail-
• To position the distal end of the outer catheter in proxim- able, a cart/trolley with all the necessary equipment should
ity to the target nerve, a 21G needle is inserted within the be prepared. The equipment required includes:
outer catheter with its distal end protruding for its electri-
cally conductive property. • Sterilizing solution.
• The insertion of this catheter/needle unit is under real- • Sponges/gauze.
time ultrasound guidance and nerve stimulation. The lat- • Drapes.
ter is used mainly to monitor for the absence of motor • Lidocaine in a small syringe and 23G hypodermic needle
response to prevent intraneural injection. for skin infiltration if necessary.
• The distal end of the outer catheter is tapered and thin for • Sterile ultrasound transducer cover, sterile gel, and elastic
smooth advancement within the tissue. The second com- bands for transducer preparation (see below).
ponent of the inner catheter is inserted into the outer cath- • Appropriately sized (gauge and length) Tuohy needle and
eter after the needle has been withdrawn. extension tubing, nerve block catheter, or catheter-
• The main difference between this catheter-over-needle over-needle.
assembly and the traditional catheter-through-needle • 5 % dextrose in water (D5W) and appropriate syringes for
assembly is the position of the needle in relation to the hydrodissection.
catheter. In the traditional assembly, the catheter is intro- • Micro-filter or giving set attachment for the injecting into
duced within the Tuohy needle; therefore, upon removal the catheter.
of the Tuohy needle, a gap is left between the skin and the • Appropriate dressings.
catheter. In contrast, the needle in the catheter-over-needle • Sterile gowns and gloves (it is recommended that full
assembly is within the outer catheter which remains in sterile procedure should be observed for peripheral cath-
situ at the end of the procedure. This enables a tight fit eter insertion, including a face mask, hat, sterile gown,
between the skin and the catheter. Moreover, the inner and gloves).
catheter literally replaces the needle, which was initially • Ultrasound machine with appropriate settings.
placed in proximity to the nerve before its withdrawal. • The nerve stimulator should be set up and ready to use for
This enables the tip of the inner catheter to be in proxim- the initial placement of the needle and/or if a stimulating
ity to the nerve. catheter is to be used.
Fig. 5.5 Pajunk® catheter-over-needle assembly Fig. 5.8 B.Braun® catheter-over-needle assembly
Fig. 5.6 Detail of Pajunk® catheter-over-needle components Fig. 5.9 Blunt and sharp needles from Arrow® catheter-over-needle
assembly
Fig. 5.7 Luer-lock holding together the inner and outer catheter
5.2.2 Sterile Transducer Preparation space; however, the use of local anesthetics or conducting
solution, such as normal saline, will abolish the capacity to
For peripheral nerve catheter insertion, it is important to have stimulate. This is particularly important when stimulating
an appropriate sterile cover for the ultrasound transducer as catheters are used.
well as for the cord so it does not contaminate the sterile field Hydrodissection using D5W, a nonconducting fluid, is
while scanning (see Chap. 4, Sect. 4.3). The following useful for “dissecting” or “opening” of the perineural space.
describes how to prepare a sterile transducer probe: This facilitates catheter advancement while maintaining the
ability to stimulate and may enhance the contrast at the tissue
• Open the sterile sheath by placing two thumbs inside the interface, potentially allowing for better visibility of both the
sheath, and roll the length of the sheath up so that the needle and the catheter under ultrasound. Overaggressive
sheath bunches up in the hand. hydrodissection is not advised since it may hinder electrical
• Ensure plenty of sterile gel is applied on the inside of the stimulation of the nerve by creating a potential mechanical
sheath where the surface of the transducer is to be placed. barrier.
• Cover the transducer inside the sheath, and push the
length of the sheath to cover the cord of the transducer Local Anesthetics
(take care to avoid desterilizing the gloves). Unlike in adults, the dose of local anesthetics is weight
• Pull an elastic band over the cord to hold the sheath on the dependent in infants and children. In pediatric patients,
cord. after an initial bolus, the dosage recommended for continu-
• Stretch the surface of the sheath covering the transducer ous infusion is 0.1–0.2 mL/kg/h of either bupivacaine or
to avoid any air bubbles or creases before pulling an elas- levobupivacaine (0.125–0.25 %) or ropivacaine (0.15–
tic band over the transducer to hold it in place. This will 0.2 %). The lower rates are generally used for upper extrem-
also minimize any sliding between the sheath and the ity catheters and the higher rates for lower extremity
transducer while scanning. catheters. If necessary, the infusion rate may be adjusted up
to a maximum of 0.2 mg/kg/h for infants of less than
6 months and 0.4 mg/kg/h in children of more than
5.2.3 Choice of Injectates 6 months.
5.2.3.1 During Catheter Insertion

To facilitate advancement of the catheter, a solution is
injected through the Tuohy needle to expand the perineural
5.3 Technique • The Tuohy needle is attached to the extension tubing and
flushed with D5W.
When inserting peripheral nerve catheters, aseptic technique • Sterile gel is applied to the skin.
should always be observed in order to reduce the risk of • The ultrasound probe is used to identify the target nerve.
infection. All the equipment should be ready as described in • If the patient is sedated, local anesthetics can be injected
Chap. 1. to raise a skin wheal at the site of planned needle entry.
The key practical techniques for insertion of peripheral • The Tuohy needle can be inserted in plane or out of plane
nerve catheters are as follows: with respect to the probe axis.
– When an in-plane approach is used, there is a good
• An assistant who is trained in regional anesthesia with view of the advancement of the needle. If the nerve
experience in monitoring pediatric patients under sedation runs perpendicular to the needle insertion, the tip of
or general anesthesia should be present. This is important the catheter should be placed underneath or above the
not only for monitoring the child during catheter insertion nerve rather than parallel to the nerve.
but to assist with the nerve stimulator and the injectate. – When an out-of-plane approach is used, tissue move-
• Routine monitoring such as electrocardiography, nonin- ment can be appreciated as the needle is advanced. On
vasive blood pressure, pulse oximetry, capnography, and sliding the probe proximally and distally from the nee-
end-tidal gas monitoring (especially for those in whom dle insertion site, the cross section of the tip of the
anesthesia is maintained on volatile agents) is applied. needle can be appreciated when the hyperechoic dot
• Emergency drugs such as atropine, ephedrine, and succi- disappears and reappears as the probe is slid proxi-
nylcholine are drawn up, and resuscitation drugs such as mally and distally. An out-of-plane technique allows
epinephrine and Intralipid are available if needed. the catheter to be placed parallel to the nerve if the
• There should be oxygen supply and an Ambu® bag (or nerve runs parallel to the direction of needle insertion.
Bagger) available. • For both in-plane and out-of-plane techniques, D5W can
• Intravenous access should be established. be used to hydrodissect the tissue plane to confirm the
• The child should either be sedated with titrated doses of position of the needle tip, provide a space for the advance-
midazolam and/or fentanyl or induced under general ment of the catheter, and create a better contrast medium
anesthetic. If nerve stimulation is used for identifying the for visualization of the needle.
target nerve or for the stimulating catheter, use of muscle
relaxants should be avoided. Methods used to confirm the catheter tip location differ
• Patient is placed in a suitable position for peripheral nerve between the non-stimulating and the stimulating nerve block
catheter placement. catheters. Ultrasound can be used to help ascertain the non-
• The height of the bed and the position of the ultrasound stimulating catheter tip, whereas both nerve stimulation and
machine should be placed in an ergonomically friendly ultrasound can be used to determine the stimulating catheter
fashion. tip in relation to the nerve.
• Pre-procedure scanning is helpful to determine the opti-
mal ultrasound machine settings such as gain, depth,
scanning mode, and focus range. Scanning can also iden- 5.3.1 Confirming Catheter Tip Location
tify any abnormal anatomy in advance. with Ultrasonography
• Ensure all the equipment is gathered and prepared as out-
lined earlier in this chapter. When using ultrasound to determine the location of the cath-
• The skin should be cleaned with a sterile solution and the eter tip, the transducer may be placed along the length of the
area draped. catheter as it is aspirated, allowing movement of the column
• The probe is covered with sterile gel which is then covered of fluid within the catheter to be observed. Injecting D5W
with the long sterile probe sleeve. An elastic band can be through the catheter to expand the hypoechoic area may also
applied to minimize slipping of the sheath against the help to locate the catheter tip.
transducer and to prevent air bubbles from accumulating. If the movement of the fluid column in the catheter can be
observed on aspiration but no spread of the injectate is in
Traditional non-stimulating nerve block catheter and view, the catheter may be too deep into the tissue and may
stimulating nerve block catheter insertion techniques need to be pulled back. One can also use the markings along
the catheter to note the depth of the catheter in the tissue.
• The catheter is prepared, kept in a sterile towel, and placed Doppler color flow is another useful method to determine
on the sterile field. It must be within easy reach of the tissue movement upon injection of agitated D5W through the
operator during the procedure. catheter.
As previously mentioned, it is always good practice to • Both the catheter-over-needle assembly and the inner
observe the spread of the injectate delivered via the periph- catheter should each be primed with 10 mL of D5W.
eral nerve catheter to visually confirm the position of the • Sterile gel is applied to the skin.
catheter tip. This practice should be employed whether a • Ultrasound probe is used to identify the target nerve.
stimulating catheter is used or not. • Local anesthetic is used to raise a skin wheal at the site of
planned needle entry.
• 21G catheter-over-needle (of the chosen length) can be
5.3.2 Confirming Catheter Tip Location inserted in plane or out of plane.
with Nerve Stimulation • Nerve stimulator at a current of 0.2 mA can be attached to
monitor for the absence of motor response. This will help
• Since the stimulating catheter is to be inserted beyond the to prevent intraneural needle insertion.
tip of the needle, the length of the needle and the exten- • As the tip of the needle is in the desired position, injection
sion tubing should be noted to ensure an accurate stimula- of D5W can be used to ascertain the spread.
tion response elicited by the catheter independent from Hydrodissection with D5W or local anesthetic can be
the needle. used.
• The nerve stimulator should be set at 0.5 mA since a • The needle is removed while the outer catheter remains in
higher current not only causes discomfort to the patient situ.
but can also cause muscle twitches which displace the • The inner catheter is introduced within the outer catheter
probe and the needle. and is Luer-locked in place (Fig. 5.7).
• When the tip of the needle is at the desired position, negative • The spread of the injectate via the inner catheter tip can be
aspiration for blood should be confirmed and a small amount confirmed under ultrasound. This is relatively easy to do
of D5W should be injected. It is important to observe the since the ultrasound probe can be held at all times during
spread of the solution since it provides information on the the catheter insertion (with a single operator) and the
location of the needle tip. If hydrodissection is not observed, inner catheter is inserted the same place as the needle
the needle tip may be in an intravascular position. which has been removed.
• The injection of D5W should amplify the motor response.
• The extension tubing is then removed and the nerve stim-
ulator is disconnected from the Tuohy needle.
• The catheter, with the stimulation port attached to the
nerve stimulator, is inserted through the Tuohy needle. Clinical Pearls
• The catheter should be advanced beyond the tip of the Catheter insertion can be performed using in-plane or
Tuohy needle and the subsequent motor response observed. out-of-plane approach (see Chap. 4) with the nerve
• In order to place the nerve block catheter tip in proximity imaged in a short axis (cross-sectional view) or long
to the nerve, the specific motor response pertaining to the axis (longitudinal view). However, if the nerve is
sensory distribution of the nerve should be observed. imaged in short axis and an in-plane approach is
• It is possible for the catheter to be advanced too far, caus- used, the catheter should not be threaded too far
ing it to coil. This can be seen by an increase in the motor beyond the Tuohy needle tip when using the tradi-
response on further advancement of the catheter. If this is tional catheter insertion technique. Note that this is
noted, the catheter should be pulled back until ideal motor not an issue if the catheter-over-needle approach is
stimulation is achieved. used.
It seems logical to scan the nerve in a long axis and
use an in-plane approach such that the catheter travels
5.3.3 Catheter-Over-Needle Assembly parallel to the nerve. However, it is not always easy to
Insertion scan the nerve in a long axis since the course of the
nerve may not be straight or it may become more
• An appropriate length catheter-over-needle assembly is superficial or deep. Therefore, it is important to apply
the key to success. Therefore, it is useful to perform a pre- the knowledge of anatomy when selecting the most
scan to estimate the distance between skin puncture and appropriate plane to scan the nerve.
the nerve.
5.3.4 Securing the Catheter
It is important to secure the peripheral nerve catheter in place

both for inpatient and ambulatory care. This can be done in
several ways:
• Applying cyanoacrylate (e.g., Dermabond®) at the

entrance site of the catheter.
• Subcutaneous tunneling before fixation with occlusive
dressing.
• Securing the dressing more effectively (e.g., with
TegadermTM) by removing all of the gel before applying
skin glue, such as Mastisol or cyanoacrylate glue.
• The catheter-over-needle can be secured with a normal IV
dressing and a caution label, such that the catheter is
clearly marked as a peripheral nerve block catheter Fig. 5.10 Catheter-over-needle secured with IV dressing and clearly
(Fig. 5.10). marked as a peripheral nerve block catheter
5.4 Examples of Common Peripheral long-term positive outcome in a 9-year-old with traumatic
Nerve Catheterization Procedures amputation of the hand [2].
Used in Children
5.4.1 Infraclavicular Nerve Block 5.4.2 Femoral Nerve Block Catheterization

Catheterization
5.4.2.1 Position
5.4.1.1 Position Supine
Supine with arm adducted, elbow flexed, and forearm placed
on the abdomen 5.4.2.2 Transducer Selection
Linear probe (38 mm, 13–6 MHz) or SLA “hockey stick”
5.4.1.2 Transducer (25 mm, 13–6 MHz), depending on the size of the child
SLA “hockey stick” (25 mm, 13–6 MHz) for smaller chil-
dren or linear probe (38 mm, 13–6 MHz) for older/larger 5.4.2.3 Surface Landmark
children Inguinal crease
5.4.1.3 Surface Landmark 5.4.2.4 Sonoanatomy

Coracoid process and clavicle Identify the femoral artery. If the profunda femoris artery is
in view, scan proximally until only one artery is present. The
5.4.1.4 Sonoanatomy hyperechoic femoral nerve is lateral to the femoral artery,
The axillary artery is deep to the pectoralis major and minor superficial to the iliopsoas muscle, and just deep to the
muscles. The lateral cord of the brachial plexus lies superior hyperechoic line of the fascia iliaca.
to the artery, the posterior cord lies posterior to the artery,
and the medial cord lies posterior and medial to the artery. 5.4.2.5 In-Plane Approach
The axillary vein lies just caudad to the artery. Place the transducer just below the inguinal crease. Insert an
appropriately sized insulated Tuohy needle (e.g., 5 cm,
5.4.1.5 In-Plane Approach 18G–20G) lateral to the femoral nerve. The needle shaft and
Place the transducer just medial to the coracoid process, cau- tip should be in view. Aim to place the catheter just deep to
dad to the clavicle, in a longitudinal or parasagittal position. the femoral nerve on its medial aspect.
Insert a 5 cm, 18G–20G insulated Tuohy needle in a
cephalad-to-caudad direction. Aim to position the catheter 5.4.2.6 Out-of-Plane Approach
just next to the posterior cord and posterior to the artery. As with the in-plane technique, place the transducer just
Beware of the pleura medially to the transducer. below the inguinal crease. Insert an appropriately sized insu-
lated Tuohy needle perpendicular to the transducer. Only the
5.4.1.6 Motor Response to Nerve Stimulation cross section of the needle shaft can be seen. Aim to place the
Flexion or extension of wrist or fingers needle tip just deep to the fascia iliaca. Hydrodissection will
help to confirm that the injectate is introduced at the correct
tissue layer and will also help to open up the space. Advance
Clinical Pearl the catheter 1–3 cm beyond the needle tip, depending on the
Sometimes the arm can be abducted 90° at the shoul- age and size of the child, so that it lies parallel to the nerve.
der and elbow to increase visibility of the cords.
5.4.2.7 Motor Response to Nerve Stimulation
Sartorius and midline “dancing of the patella” (quadriceps)
5.4.1.7 Clinical Evidence twitches are both accepted.
Continuous infraclavicular brachial plexus block was
described for pain control in two pediatric patients undergo- Clinical Pearl
ing orthopedic procedures [1]. Another case report used If two branches of the femoral nerve are observed after
ultrasound-guided continuous infraclavicular block to pro- hydrodissection, aim for the deeper branch.
duce sympathectomy of extended duration, resulting in a
5.4.2.8 Clinical Evidence 5.4.3.2 Popliteal Approach

The evidence supporting the use of femoral nerve catheter in
children is limited. There is a recent case report on its use in Position
intractable pain from a chronic dislocated hip in a 12-year- Lateral
old girl [3].
Transducer
Linear probe (38 mm, 13–6 MHz)
5.4.3 Sciatic Nerve Block Catheterization
Surface Landmark
5.4.3.1 Subgluteal Approach Knee crease
Position Sonoanatomy
Lateral The sciatic nerve at the popliteal region is just medial to the
biceps femoris muscle. Be aware of the popliteal vessels just
Transducer medial and anterior to the sciatic nerve. Scan proximally and
Linear probe (38 mm, 13–6 MHz) distally to identify where the sciatic nerve divides into the
tibial nerve and the common peroneal nerve.
Surface Landmark
Greater trochanter and ischial tuberosity Out-of-Plane Approach
Place the transducer just above the knee crease; the sciatic
Sonoanatomy nerve is usually divided at this point. Scan proximally until
Identify the acoustic shadows cast by the greater trochanter the sciatic nerve has just divided. Insert an appropriately
and the ischial tuberosity. The sciatic nerve is in cross sec- sized insulated Tuohy needle (e.g., 5 cm, 18G–20G) perpen-
tion lateral to the long head of the biceps femoris muscle. dicular to the probe and aim to place the needle tip at a point
when the sciatic nerve just split. The catheter can then be
In-Plane Approach advanced 1–3 cm beyond the needle tip, depending on the
Place the transducer with one end on the greater trochanter age and size of the child.
and the other end on the ischial tuberosity. Insert an appro-
priately sized insulated Tuohy needle (e.g., 5 cm, 18G–20G) Motor Response
perpendicular to the probe. Aim to place the needle tip just Plantar flexion or dorsiflexion of the foot
above the sciatic nerve, and advance the catheter 1–3 cm
beyond the needle tip, depending on the age and size of the
child. Clinical Pearl
It is better to direct the catheter cephalad to enable its
Motor Response to Nerve Stimulation proximal placement along the sciatic nerve.
Plantar flexion or dorsiflexion of the foot
Clinical Evidence
Clinical Pearls
There are prospective studies and case reports demonstrat-
The current of the nerve stimulator needs to be
ing the efficacy of continuous popliteal sciatic nerve
increased as the catheter is advanced.
blocks [6–9]. One study also demonstrated reduced
Rotating the Tuohy needle 90° sometimes allows
adverse effects compared to epidural analgesia [10]. A
for better advancement of the catheter.
recent study evaluating the adverse effects of continuous
peripheral nerve block found a significant association of
Clinical Evidence persistent insensate extremity with continuous popliteal
Compared with other blocks, there are more clinical studies nerve block [11]; however, this could be secondary to the
and case reports on continuous subgluteal sciatic nerve volume and concentration of local anesthetic used in this
blocks in children for correction of congenital defects, ortho- confined perineural space. Ilfeld et al. [12] reported a
pedic oncology surgery, osteotomy, and amputation [4, 5]. lower incidence of insensate extremity in adults with a
Each has demonstrated successful results with minimal side lower infusion rate of local anesthetic, such as 4 mL/h of
effects. 0.4 % ropivacaine.
5.5 Summary stimulating catheters use the principles of physics to guide

their placement. The catheter-over-needle technique
Continuous peripheral nerve catheters have been shown to increases the precision of catheter tip placement without the
help aid in pain control, especially in managing challenging need for over-feeding the catheter. With these recent techno-
cases in the pediatric population. Ultrasonography enables logical advancements, the risk of peripheral nerve catheter
visualization of the spread of injectate in real time, while placement in anesthetized children is relatively low.
References ER. The effects of varying local anesthetic concentration and

volume on continuous popliteal sciatic nerve blocks: a dual-center,
randomized, controlled study. Anesth Analg. 2008;107:701–7.
1. Dadure C, Raux O, Troncin R, Rochette A, Capdevila X. Continuous
infraclavicular brachial plexus block for acute pain management in
children. Anesth Analg. 2003;97:691–3.
2. Loland VJ, Ilfeld BM, Abrams RA, Mariano ER. Ultrasound-
guided perineural catheter and local anesthetic infusion in the Suggested Reading
perioperative management of pediatric limb salvage: a case report.
Pediatr Anesth. 2009;19:905–7. Bosenberg AT. New developments in paediatric regional anaesthesia.
3. Nayak S, Roberts S, Cunliffe M. Management of intractable pain South Afr J Anaesth Analg. 2008;14:81–3.
from a chronic dislocated hip in an adolescent. Pediatr Anesth. Dhir S, Ganapathy S. Use of ultrasound guidance and contrast enhance-
2008;18:357–8. ment: a study of continuous infraclavicular brachial plexus
4. van Geffen GJ, Gielen M. Ultrasound-guided subgluteal sciatic approach. Acta Anaesthesiol Scand. 2008;52:338–42.
nerve blocks with stimulating catheters in children: a descriptive Ecoffey C, Lacroix F. Pediatric regional anesthesia update: results in a
study. Anesth Analg. 2006;103:328–33. French survey. In: Rawal N, Ivani G, editors. Highlights in regional
5. van Geffen GJ, Pirotte T, Gielen MJ, Scheffer G, Bruhn J. anesthesia and pain therapy XVII. Geneva: Kenes International;
Ultrasound-guided proximal and distal sciatic nerve blocks in 2008. p. 162–3.
children. J Clin Anesth. 2010;22:241–5. Ganapathy S. Regional block catheter insertion using ultrasonography
6. Dadure C, Pirat P, Raux O, Troncin R, Rochette A, Ricard C, and stimulating catheters. In: Tsui BC, editor. Atlas of ultrasound
Capdevila X. Perioperative continuous peripheral nerve blocks with and nerve stimulation-guided regional anesthesia. New York:
disposable infusion pumps in children: a prospective descriptive Springer; 2007. p. 215–23.
study. Anesth Analg. 2003;97:687–90. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of
7. Dadure C, Acosta C, Capdevila X. Perioperative pain management regional anesthesia in children: a one-year prospective survey of the
of a complex orthopedic surgical procedure with double continuous French-language society of pediatric anesthesiologists. Anesth
nerve blocks in a burned child. Anesth Analg. 2004;98:1653–5. Analg. 1996;83:904–12.
8. Dadure C, Bringuier S, Raux O, Rochette A, Troncin R, Canaud N, Ivani G, Codipietro L, Gagliardi F, et al. A long term infusion via a
Lubrano-Lavadera JF, Capdevila X. Continuous peripheral nerve sciatic catheter in a 3-years-old-boy. Pediatr Anesth. 2003;13:
blocks for postoperative analgesia in children: feasibility and side 718–21.
effects in a cohort study of 339 catheters. Can J Anesth. 2009;56: Ivani G, Mossetti V. Continuous central and perineural infusions for
843–50. postoperative pain control in children. Curr Opin Anesthesiol.
9. Ludot H, Berger J, Pichenot V, Belouadah M, Madi K, Malinovsky 2010;23:637–42.
JM. Continuous peripheral nerve block for postoperative pain Koscielniak-Nielsen ZJ, Rasmussen H, Hesselbjerg L. Long-axis
control at home: a prospective feasibility study in children. Reg ultrasound imaging of the nerves and advancement of perineural
Anesth Pain Med. 2008;33:52–6. catheters under direct vision: a preliminary report of four cases. Reg
10. Dadure C, Bringuier S, Nicolas F, Bromilow L, Raux O, Rochette A, Anesth Pain Med. 2008;33:477–82.
Capdevila X. Continuous epidural block versus continuous Lonnqvist PA, Morton NS. Postoperative analgesia in infants and
popliteal nerve block for postoperative pain relief after major children. Br J Anaesth. 2005;95:59–68.
podiatric surgery in children: a prospective, comparative random- Tsui BCH, Kropelin B, Ganapathy S, Finucane B. Dextrose 5% in
ized study. Anesth Analg. 2006;102:744–9. water: fluid medium for maintaining electrical stimulation of
11. Saporito A, Sturini E, Petri J, Borgeat A, Aguirre JA. Case report: peripheral nerves during stimulating catheter placement. Acta
unusual complication during outpatient continuous regional popli- Anaesthesiol Scand. 2005;49:1562–5.
teal analgesia. Can J Anesth. 2012;59:958–62. Tsui BC, Wagner A, Finucane B. Electrophysiologic effect of injectates
12. Ilfeld BM, Loland VJ, Gerancher JC, Wadhwa AN, Renehan EM, on peripheral nerve stimulation. Reg Anesth Pain Med. 2004;29:
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Part II
Considerations in Pediatric Regional Anesthesia
Pain Assessment in Children
Undergoing Regional Anesthesia 6
Bruce D. Dick, Kathy Reid, Michelle J. Verrier,
and Alex Baloukov
Contents
6.1 Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.2 Principles of Pain Assessment in Infants and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.3 Assessing Pain in Neonates and Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.3.1 The Premature Infant Pain Profile (PIPP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.3.2 Neonatal Pain Agitation and Sedation Scale (N-PASS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.3.3 CRIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.3.4 Assessing Postoperative Pain in Infants and Young Children . . . . . . . . . . . . . . . . . . . . . . . . 81
6.4 Assessing Pain in Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.1 Faces Pain Scale-Revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.2 Numeric Rating Scales (NRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.3 Oucher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.4 Pieces of Hurt/Poker Chip Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.5 Wong-Baker FACES Pain Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.6 Visual Analogue Scale (VAS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.4.7 Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) . . . . . . . . . . . . . . . . . . . . . . . 83
6.5 Assessing Postoperative Pain in Critically Ill Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.6 Assessing Postoperative Pain in Children with Cognitive Impairments . . . . . . . . . . . . . . . . . . . 86
6.7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
6.8 Developmental, Familial, and Psychological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
6.8.1 Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
6.8.2 Developmental Delays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
6.8.3 Psychological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6.8.4 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
6.8.5 Cultural Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
B.D. Dick, PhD, R Psych (*)

Division of Pain Medicine, Department of Anesthesiology M.J. Verrier, BA
and Pain Medicine, Stollery Children’s Hospital, Department of Anesthesiology and Pain Medicine,
University of Alberta, 2-150 Clinical Sciences Building, University of Alberta, 2-150 Clinical Sciences Building,
Edmonton, AB T6G 2B7, Canada Edmonton, AB T6G 2G3, Canada
e-mail: [email protected] e-mail: [email protected]
K. Reid, RN, MN, NP A. Baloukov, MPH
Pediatric Anesthesia, Stollery Children’s Hospital, Faculty of Health Sciences, Simon Fraser University,
8440 – 112 St, Room 1C3.09, Edmonton, AB T6G2B7, Canada Burnaby, BC, Canada
e-mail: [email protected] e-mail: [email protected]

DOI 10.1007/978-0-387-79964-3_6
76 B.D. Dick et al.
6.1 Background In considering how to effectively assess pain in a clini-

cal setting, there are many factors to be aware of and a
Effective pain management is a key objective of proper variety of dimensions of pain that could potentially be
patient care. Adequate pain management has the potential to assessed. Current pain theory falls within the widely vali-
improve health, facilitate healing, and reduce long-term neg- dated biopsychosocial model. This chapter will discuss a
ative results of pain after hospitalization [1]; poor pain man- number of important aspects of pain assessment in children
agement is inhumane and unethical. Inherent to good pain undergoing medical procedures. An outline of validated
management is skilled pain assessment, and practice stan- measures is included along with practical guidelines for
dards have been developed mandating effective pain assess- their use, and the importance of these guidelines for assess-
ment and management across the life span [2]. For example, ing biological, psychological, and social factors will be
effective pain assessment and management and staff educa- reviewed. These factors have the potential to impact a
tion on these topics are now required for institutional accred- child’s pain and the resulting response to pain in the clini-
itation in the United States [3]. cal setting as well as following post-hospital discharge.
Children are a particularly vulnerable clinical population The best practice standards based on current guidelines
who are at risk for poor pain management for a variety of will also be reviewed and will be discussed with a particu-
reasons. A child’s developmental level and ability to com- lar focus on pain assessment relevant to regional anesthesia
municate play important roles in pain assessment and man- practice.
agement [4]. The medical history of the child can also play
an important role in pain assessment. Previous experience
with medical procedures, particularly painful medical proce- 6.2 Principles of Pain Assessment
dures, can markedly affect a child’s response to pain, pain in Infants and Children
behaviors, and potentially even the child’s perception of pain
[5]. Assessing pain in pediatric patients is often challenging due
Sadly, not only are children vulnerable to undertreatment to the subjective personal nature of pain and the difficulty
of pain, they are also especially at risk for experiencing nega- that children can have in verbally reporting pain. Pain is a
tive consequences resulting from poor pain control. For multidimensional phenomenon, and pain measurement tools
example, neonates who experience less analgesia following need to capture the many important aspects of pain. It is
painful procedures are more likely to experience augmented important to note that measurements of pain intensity, often
pain and increased behavioral changes during and following used in acute care settings, are only one part of a comprehen-
subsequent painful stimuli [6–8]. It has been found that these sive pain assessment [14]. Pain assessment tools should be
changes result from alterations in the central nervous system reliable, valid, developmentally appropriate, clinically use-
through processes such as central sensitization, windup, ful, and practical to use [15]. Utilizing multiple measures,
receptive field alteration, and even altered gene expression such as behavioral and physiological data, may result in a
[9, 10]. Pain-related stress responses also affect hormonal more accurate assessment [16]. Several reliable and valid
responses, homeostatic function, immune function, infection measures exist to assist in assessing pain in pediatric patients
rates, disease progression, and mortality rates [11, 12]. In undergoing procedures, including self-reporting, behavioral
addition, children often have less control over their environ- observations, and physiological measures. The pain assess-
ments and can be strongly affected by their parents’ behav- ment tools included in the following section have been vali-
iors, including parental responses to medical settings and dated for use in pediatric patients experiencing acute
medical procedures [13]. postoperative pain.
6 Pain Assessment in Children Undergoing Regional Anesthesia 77
6.3 Assessing Pain in Neonates Facial Coding System (NFCS) [22] and the Neonatal Infant
and Infants Pain Scale (NIPS) [23] are useful for the assessment of
short-term acute pain involved in medical procedures, such
Neonates and infants under the age of 1 month often as venipunctures, but their usefulness for painful experi-
undergo painful interventions, including surgical proce- ences of longer duration such as postoperative pain is lim-
dures, venipunctures, and heel lances [17]. Assessing pain ited [18]. Tools with demonstrated validity in assessing
in this vulnerable population requires multidimensional postoperative pain in neonates and infants include the
measures, as infants are preverbal and cannot communi- Premature Infant Pain Profile (PIPP), the Neonatal Pain
cate their pain with words [18]. Recent reviews have shown Agitation and Sedation Scale (N-PASS), and CRIES
that while over 40 tools have been developed for assessing (Table 6.1). These tools will be described below, including
pain in these children, no one tool has been identified as information about their development, content, validation,
ideal [19–21]. Many of the tools such as the Neonatal and reliability.
Table 6.1 Pain assessment tools for neonates

Clinical
indications for
Tool Reference Age range use Guidelines for use Advantages and disadvantages
PIPP Stevens et al. [24]; 28–40 weeks Procedural pain, Score ranges from 0 to 3 in Includes cutoff scores for mild,
McNair et al. [25] gestational age postoperative each indicator, scores can moderate, and severe pain
pain range from 0 to 21 in infants Multidimensional; 7 indicators,
less than 36 weeks gestation, including two physiological, three
maximum score 21 in infants behavioral, and two contextual
over 36 weeks gestation
N-PASS Hummel et al. [26] 0–100 days old; Ventilated and/or Scoring determines whether Multidimensional; 5 indicators,
23 weeks gestation postoperative infant is sedated or in pain including four behavioral and one
and above infants physiological. Measures sedation and
pain on a continuum. Includes
scoring criteria for corrected age. Has
been validated in ventilated infants
CRIES Krechel and Bildner 32–60 weeks Postoperative Scoring ranges from 0 to 2 in Multidimensional; 5 indicators,
[27] gestational age infants each of the 5 indicators for a including two physiological and three
total score of 0–10 behavioral
78 B.D. Dick et al.
6.3.1 The Premature Infant Pain Profile and nasolabial furrows. Initial reliability and validity testing
(PIPP) involved procedural pain such as heel lance, circumcision,
and venipuncture. Research on the PIPP has demonstrated
This tool consists of a seven-item, 4-point scale that mea- construct validity of the tool as a measure of prolonged post-
sures behavioral, physiological, and contextual indicators operative pain in premature infants who underwent surgical
[24] (Fig. 6.1). These measures include gestational age, procedures [25].
behavioral state, oxygen saturation, brow bulge, eye squeeze,
Infant Study Number:

Date/time:
Event:
Process Indicator 0 1 2 3 Score
Chart Gestational age 36 weeks and 32–35 weeks, 6 28–31 weeks, 6 less than 28
more days days weeks
Observe infant Behavioral state active/awake quiet/awake active/sleep quiet/sleep
15 s eyes open eyes open eyes closed eyes closed
facial no facial facial no facial
movements movements movements movements
Observe baseline
Heart rate
Oxygen
saturation
Observe infant Heart rate 0–4 beats/min 5–14 beats/min 15–24 beats/min 25 beats/min or
30 s Max increase increase increase more increase
Oxygen 0–2.4 % decrease 2.5–4.9 % decrease 5.0–7.4 % decrease 7.5 % or more
saturation decrease
Min
Brow bulge None Minimum Moderate Maximum
0–9 % of time 10–39 % of time 40–69 % of time 70 % of time or
More
Eye squeeze None Minimum Moderate Maximum
More
Nasolabial furrow None Minimum Moderate Maximum
More
Total
score
Fig. 6.1 Scoring method for the premature infant pain profile (PIPP) (Adapted from Stevens et al. [24]. With permission from Wolters Kluwer
Health)
6.3.2 Neonatal Pain Agitation and Sedation neonatal intensive care unit who had received surgical proce-
Scale (N-PASS) dures [26]. The infants ranged in postnatal age from 0 to
100 days, and gestational age ranged from 23 to 40 weeks.
The N-PASS [26] consists of five indicators that have dem- Convergent validity, assessed by correlation with the PIPP,
onstrated reliability and validity as pain measures in various was 0.83 at high pain scores and 0.61 at low pain scores.
neonatal pain assessment scales (Fig. 6.2). These indicators Inter-rater reliability was high (0.85–0.95). The N-PASS is
are cry/irritability, behavior state, facial expression, extremi- validated up to 3 years of age.
ties/tone, and vital signs. The tool was tested on infants in the
Fig. 6.2 N-PASS assessment table. Used with permission

80 B.D. Dick et al.
6.3.3 CRIES between 32 and 60 weeks gestational age who underwent

surgical procedures, including insertion of ventriculoperito-
CRIES [27] is a tool that measures five physiological and neal shunts and thoracotomies. Construct validity was estab-
behavioral variables: C-crying, R-requires increased oxygen lished by comparing scores pre- and post-analgesia
administration, I-increased vital signs, E-expression, and administration. Inter-rater reliability was found to be accept-
S-sleepiness (Fig. 6.3). The tool was tested on infants able (r = 0.72).
Date/time
Crying - Chracteristic cry of pain is high pitched.
0 – No cry or cry that is not high-pitched
1 – Cry high pitched but baby is easily consolable
2 – Cry high pitched but baby is inconsolable
Requires O2 for SaO2 <95 % - Babies experiencing pain
manifest decreased oxygenation. Consider other cause of hypoxemia,
e.g., oversedation, atelectasis, pneumothorax)
0 – No oxygen required
1 – <30 % oxygen required
2 – >30 % oxygen required
Increased vital signs (BP* and HR*) - Take BP last as this
may awaken child making other assessments difficult
0 – Both HR and BP unchanged or less than baseline
1 – HR or BP increased but increase in <20 % of baseline
2 – HR or BP is increased >20 % over baseline.
Expression - The facial expression most often associated
with pain is a grimace. A grimace may be characterized by
brow lowering, eyes squeezed shut, deepening naso-labial furrow,
or open lips and mouth.
0 – No grimace present
1 – Grimace alone is present
2 – Grimace and non-cry vocalization grunt is present
Sleepless - Scored based upon the infant’s state
during the hour preceding this recorded score.
0 – Child has been continuously asleep
1 – Child has awakened at frequent intervals
2 – Child has been awake constantly
Total score
Fig. 6.3 CRIES neonatal pain assessment tool. Used with permission
6.3.4 Assessing Postoperative Pain in Infants testing of the tool involved assessment of children between
and Young Children 2 months and 7 years of age who had undergone surgical
procedures in the postanesthesia care unit. Inter-rater
Although most children over the age of 18 months are verbal, reliability was found to be high using simultaneous indepen-
their ability to communicate pain may still be limited to cry- dent evaluations (r = 0.94). Validity testing has demonstrated
ing or to providing information only about the presence or that FLACC scores decrease with analgesia administration in
absence of pain. Assessing pain in infants and preschool age children under the age of 3 years [30].
children is best accomplished by measures that include
behavioral manifestations of pain. Tools that have shown 6.3.4.2 Parents’ Postoperative Pain Measure
reliability and validity in assessing postoperative pain in (PPPM)
infants and young children include the Faces, Limb, Activity, The Parents’ Postoperative Pain Measure [31] has been vali-
Cry, and Consolability (FLACC) scale for hospital use and dated as a measure for home use in children who are
the Parents’ Postoperative Pain Measure (PPPM) for use at discharged to home following day surgery procedures. This
home [28]. 15-item tool includes cutoff scores which show excellent
sensitivity and specificity (>80 %) in determining clinically
6.3.4.1 FLACC (Faces, Limb, Activity, Cry, meaningful pain scores. The initial validation of this tool was
and Consolability) completed on children ages 7–12 years undergoing proce-
The FLACC [29] has been shown to be a reliable tool for dures which were ranked by experts into three classes –
measuring postoperative pain in young children (Fig. 6.4). highly painful (e.g., tonsillectomies), moderately painful
The acronym FLACC incorporates the different domains of (e.g., sinus surgeries), or little or no pain (e.g., myringoto-
the assessment – Facial expression, Leg movement, Activity mies). Further validation of the PPPM [32] demonstrated
level, Cry, and Consolability. Each domain receives a score that the tool is a reliable valid measure for home use on chil-
between 0 and 2 for a total score of between 0 and 10. Initial dren between the ages of 2 and 6 years.
Scoring
Categories
0 1 2
Occasional grimace or Frequent to constant
No particular
Face frown, withdrawn, quivering chin,
expression or smile
disinterested clenched jaw
Normal position or Kicking, or legs drawn
Legs Uneasy, restless, tense
relaxed up
Lying quietly, normal Squirming, shifting

Activity Arched, rigid or jerking
position, moves easily back and forth, tense
Crying steadily,
No cry (awake or Moans or whimpers;
Cry screams or sobs,
asleep) occasional complaint
frequent complaints
Reassured by
occasional touching, Difficult to console or
Consolability Content, relaxed
hugging or being talked comfort
to, distractable
Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored
from 0-2, which results in a total score between zero and ten.
Fig. 6.4 FLACC pain assessment tool (Based on data from Ref. [29])
82 B.D. Dick et al.
6.4 Assessing Pain in Children 6.4.3 Oucher

and Adolescents
The Oucher [37] consists of a numeric rating scale combined
Children over the age of 3 years can often provide reliable with six photographs of children’s faces. Caucasian, African-
information about the intensity or severity of their pain American, Hispanic, First Nations (boy/girl), and Asian (boy/
using validated self-report scales. Much of the research girl) versions are available. Using this scale, the child chooses
related to pain assessment tools for this population has the face that best reflects the pain level. The picture selection
focused on the use of the scales in clinical trials rather than is then converted to a number between 0 and 10. The scale
in clinical practice. The Pediatric Initiative on Methods, must be printed in color in order for the child to accurately
Measurement, and Pain Assessment in Clinical Trials (Ped- see the faces, making it a more expensive tool to use.
IMMPACT) by Stinson et al. [33] reviewed 34 self-report
tools and found that while no single tool was optimal for all
types of pain, six were shown to be reliable and valid for 6.4.4 Pieces of Hurt/Poker Chip Scale
acute pain (Table 6.3). The Faces Pain Scale [34] and Faces
Pain Scale-Revised [35] have both been shown to be reli- The Pieces of Hurt, or Poker Chip Scale [38], consists of four
able, valid, simple, easy to use, and require minimal instruc- chips or pieces of hurt. The child chooses how many pieces
tion. Other recommended pain scales include the Oucher, of hurt they are experiencing. The tool is difficult to use in
the Pieces of Hurt, the Wong-Baker FACES Pain Scale, and postoperative care in hospitals because of infection control
the Visual analogue scale. Numeric rating scales are fre- concerns and availability of poker chips on the unit.
quently used in clinic practice. Each of these scales is dis-
cussed below.
6.4.5 Wong-Baker FACES Pain Scale
6.4.1 Faces Pain Scale-Revised The Wong-Baker FACES Pain Scale [39] is a reliable and
valid tool for assessing pain in children over 3 years of age.
The Faces Pain Scale-Revised [35] has been translated into It is similar to the Faces Pain Scale-Revised in that it consists
more than 40 languages and can be obtained free of charge of a series of six cartoon faces depicting “no hurt” to “hurts
for use in clinical practice. Obviously, it is important when worst.” The child then chooses the face that best describes
using pain assessment tools with young verbal children to his/her pain. Recent research [40, 41] has found that chil-
communicate in a language that they understand whenever dren’s pain ratings are influenced by the pictorial anchors, as
possible. These pictorial scales with accompanying instruc- the “no pain” face has a smile and the “most pain” face has
tions have a series of six faces that the child points to, indi- tears. These findings suggest that the faces in this scale may
cating how much they hurt or how sore they feel. This scale measure pain affect rather than pain intensity.
has strong psychometric properties and is widely used in
research and clinical practice internationally.
6.4.6 Visual Analogue Scale (VAS)
6.4.2 Numeric Rating Scales (NRS) The visual analogue scale (VAS) [42], which has several
forms, is composed of a line with the words “no pain” and
Older children are often asked to rate their pain using these “worst” or “most pain” as anchors (Fig. 6.6). The line can be
scales (Fig. 6.5). The NRS is generally composed of an vertical or horizontal. The child is asked to mark a point on
11-point numeric rating scale, with anchors of 0 (No Pain) the line to indicate pain intensity. The VAS has been used
and 10 (Worst Pain Imaginable). A recent publication by von extensively in research studies. It is not as clinically useful as
Baeyer et al. [36] reviewed the use of the numeric rating a tool as it may be difficult to interpret and difficult to include
scale to define age limits for which it would be appropriate in a chart document and requires careful explanation to the
and concluded that the scale is supported for use in children child. Debate continues as to optimal line length and the
over the age of 8 years. choice of anchor words.
6.4.7 Children’s Hospital of Eastern Ontario based on the following criteria: 0 is behavior that is the
Pain Scale (CHEOPS) antithesis of pain; 1 is behavior not indicative of pain, and
not the antithesis of pain; 2 is behavior indication of mild or
The Children’s Hospital of Eastern Ontario Pain Scale [43] is moderate pain; and 3 is behavior indicative of severe pain.
a time-sampling behavioral pain scale. It looks for behaviors Therefore, the total score can be from 4 to 13 for each time
related to six items: cry, facial, child verbal, torso, touch, and period sampled. It showed good inter-rater reliability, with
legs. Each behavior listed under each item is given a numeri- average percentage of agreement by patients ranging from
cal score and definition. The numerical scores are assigned 90 to 99.5 %.
Fig. 6.6 Visual analogue scale (VAS). A 10-cm scale is recommended;

the child marks a point along the scale that corresponds with his/her
Fig. 6.5 Numeric rating scale (NRS) pain. A ruler is then used to determine the score by measuring the dis-
tance between the “no pain” anchor and the mark
84 B.D. Dick et al.
6.5 Assessing Postoperative Pain 45] (Fig. 6.7) was developed to assess distress in critically ill
in Critically Ill Children children. In many critically ill children, pain may be a con-
tributor to the distress. The COMFORT scale consists of
Assessing postoperative pain in critically ill children in an behavioral and physiological indicators. The tool requires
intensive care unit requires multidimensional tools. If a criti- extensive training of clinical staff but is one of the few tools
cally ill child is not sedated, a self-report should be obtained validated for use in this population. The modified FLACC
where possible. However, for many of these children, seda- [46] is valid in measuring postoperative pain in intubated
tion is a required part of their care, making valid assessment children. The Cry section is modified to reflect the facial
by self-reporting more difficult. The COMFORT scale [44, expression associated with crying.
Patient Sticker
Date Time
Observer
Alertness • Deeply asleep (eyes closed, no response to changes in the environment) 1

• Lightly asleep (eyes mostly closed, occasional responses) 2
• Drowsy (child closes his or her eyes frequently, loss respansive to the environment) 3
• Awake and alert (child responsive to the environment) 4
• Awake and hyperalert (exaggerated responses to the environmental stimuli) 5
Calmness–Agitation • Calm (child appears serene and franquil) 1

• Slightly anxious (child shows slight anxiety) 2
• Anxious (child appers agilated but remains in control) 3
• Very anxious (child appears very agilated, just able to control) 4
• Panicky (child appears severely distressed, with loss of control) 5
Respiratory response • No spontaneous respiration 1

(score only in mechanically • Spontaneous and ventilator respiration 2
ventilated children) • Restlessness or resistance to ventilator 3
• Active breathing against ventilator or regular coughing 4
• Fighting against ventilator 5
Crying • Quiet breathing, no crying sounds 1

(score only in childran • Occasional sobbing or moaning 2
breathing spontaneously)
• Whining (monotone) 3
• Crying 4
• Screaming or shricking 5
Physical movement • No movement 1

• Occasional (3 or fewer) slight movements 2
• Frequent (more than 3) slight movements 3
• Vigorous movements limited to extremities 4
• Vigorous movements including lorso and head 5
Muscle tone • Muscles totally relaxed, no muscle tone 1

• Reduced muscle tone, less resistance than normal 2
• Normal muscle tone 3
• Increased muscle tone and flexion of fingers and loes 4
• Extreme muscle rigidity and flexion of fingers and loes 5
Facial tension • Facial muscles totally relaxed 1

• Normal facial tone 2
• Tension evident in some facial muscles (not sustained) 3
• Tension evident throughout facial muscles (sustained) 4
• Facial muscle contorted and grimacing 5
Total Score
VAS (Visual Analogue Scale)
Put a mark on the line below to indicate how much pain you think the child has at this very moment.
no pain worst pain VAS Score
Treatment datails
Datails of child’s condition
Assessments made
(before or after medication or standard assessment)
Fig. 6.7 COMFORT scale for pain assessment in critically ill children (Reprinted from van Dijk et al. [45]. With permission from Wolters Kluwer
Health)
86 B.D. Dick et al.
6.6 Assessing Postoperative Pain strated good inter-rater reliability and included cutoff scores
in Children with Cognitive to determine mild or moderate to severe pain. The tool
Impairments requires a 10-min observation of behaviors in six domains –
vocal, social, facial, activity, body and limbs, and physiolog-
Assessing postoperative pain in children with cognitive ical. The FLACC has also shown reliability and validity in
impairments requires the use of multidimensional tools and assessing postoperative pain in children with cognitive
parental input. It can be difficult to determine which behav- impairments. Malviya et al. [48] utilized the FLACC as well
iors are pain related in this population. The Non- as individualized behaviors identified by the parent for each
Communicating Children’s Pain Checklist-Postoperative child in assessing pain postoperatively in children aged
Version (NCCPC-PV) by Breau et al. [47] (Fig. 6.8) demon- 4–19 years with cognitive impairments.
Non-communicating Children’s Pain Checklist – Postoperative Version

(NCCPC-PV)
NAME: UNIT/FILE #: DATE: (dd/mm/yy)
OBSERVER: START TIME: AM/PM STOP TIME: AM/PM
How ofetn has this child shown these behaviours in the last 10 minutes? Please circle a number for each behaviour. If an
item does not apply to this child (for example, this child cannot reach with his/her hands), then indicate “not applicable”
for that item.
0 = NOT AT ALL 1 = JUST A LITTLE 2 = FAIRLY OFTEN 3 = VERY OFTEN NA = NOT APPLICABLE
I. Vocal
1. Moaning, whining, whimpering (fairly soft)............................................................. 0 1 2 3 NA
2. Crying (moderately loud)........................................................................................ 0 1 2 3 NA
3. Screaming/yelling (very loud)................................................................................. 0 1 2 3 NA
4. A specific sound or word for pain (e.g., a word, cry or type of laugh).................... 0 1 2 3 NA
II. Social
5. Not cooperating, cranky, irritable, unhappy............................................................ 0 1 2 3 NA
6. Less interaction with others, withdrawn................................................................. 0 1 2 3 NA
7. Seeking comfort or physical closeness................................................................. 0 1 2 3 NA
8. Being difficult to distract, not able to satisfy or pacify............................................ 0 1 2 3 NA
III. Facial
9. A furrowed brow...................................................................................................... 0 1 2 3 NA
10. A change in eyes, including: squinching of eyes, eyes opened wide, eyes frowing 0 1 2 3 NA
11. Turning down of mouth, not smiling...................................................................... 0 1 2 3 NA
12. Lips puckering up, tight, pouting, or quivering...................................................... 0 1 2 3 NA
13. Clenching or grinding teeth, chewing or thrusting tongue out.............................. 0 1 2 3 NA
IV. Activity
14. Not moving, less active, quiet................................................................................ 0 1 2 3 NA
15. Jumping around, agitated, fidgety.......................................................................... 0 1 2 3 NA
V. Body and Limbs

16. Floppy.................................................................................................................... 0 1 2 3 NA
17. Stiff, spastic, tense, rigid....................................................................................... 0 1 2 3 NA
18. Gesturing to or touching part of the body that hurts............................................. 0 1 2 3 NA
19. Protecting, favoring or guarding part of the body that hurts.................................. 0 1 2 3 NA
20. Flinching or moving the body part away, being sensitive to touch......................... 0 1 2 3 NA
21. Moving the body in a specific way to show pain
(e.g. head back, arms down, curls up, etc.)........................................................... 0 1 2 3 NA
VI. Physiological
22. Shivering............................................................................................................... 0 1 2 3 NA
23. Change in color, pallor.......................................................................................... 0 1 2 3 NA
24. Sweating, perspiring............................................................................................. 0 1 2 3 NA
25. Tears..................................................................................................................... 0 1 2 3 NA
26. Sharp intake of breath, gasping........................................................................... 0 1 2 3 NA
27. Breath holding....................................................................................................... 0 1 2 3 NA
SCORE SUMMARY:
Category: I II III IV V VI TOTAL
Score:
Fig. 6.8 The Non-Communicating Children’s Pain Checklist-Postoperative Version (NCCPC-PV). Used with permission
88 B.D. Dick et al.
6.7 Summary and the following tables summarize current tools for
assessing pain in children of different age groups.
In summary, there are many tools available for assessing Table 6.1 addresses tools for use in neonates, Table 6.2
postoperative pain in children. Clinicians need to use addresses behavioral tools, and Table 6.3 addresses self-
tools that are reliable, valid, and easy to use. Many of the report tools. Whichever tool is chosen for use, it must be
tools are designed to capture pain intensity, which is only used regularly to effectively manage postoperative pain in
one part of a comprehensive pain assessment. Figure 6.9 children.
PIPP : Age 28–40 weeks

Neonates and
N-PASS: Age 23 weeks gestation-100 days
premature infants
CRIES: Age 32–60 weeks gestation
FLACC: Age 2 mos-7 years, 4–19 years in children

Preverbal children
with cognitive impairments
FLACC: Age 2 mos-7 years, 4–19 years in children with

cognitive impairments
Non-verbal children Comfort: Age 0–18 years intubated, sedated
NCCPC-PV: Age 3–18 years, including children with
cognitive impairments
FACES pain scale revised: Age 4–18 years

Wong Baker FACES pain scale: Age 3 years and up
Verbal children
Oucher: Age 3–18 years
Pieces of hurt: Age 3–18 years
FACES pain scale revised: Age 4–18 years

Older verbal children Numeric rating scale: Age 8 years and up
Visual Analogue scale: Age 8 years and up
Fig. 6.9 Appropriate pain assessment scales for children of different age groups (See text for details)
Table 6.2 Behavioral pain assessment tools

Clinical
indications for
Tool Reference Age range use Guidelines for use Advantages and disadvantages
FLACC Merkel et al. [29] 2 months–7 years; Postoperative Scoring ranges from 0 to 2 in Child needs to be observed for a
ages 4–19 years pain each of the 5 indicators for a minimum of 2 min while awake,
for children with total score of 0–10 5 min while asleep. Five
cognitive behavioral indicators
impairments
COMFORT Ambuel et al. [44] 0–18 years Postoperative 8 categories with scores for Multidimensional; 8 indicators,
pain each of 1–5. Scoring between including six behavioral and two
8 and 40. Score determines physiological. Requires extensive
optimal sedation in child training. Only tool validated for
use in intubated sedated children
NCCPC-PV Breau et al. [47] Children ages Postoperative 6 categories with indicators Requires a 10-min observation
3–18 years who pain for a total of 27 indicators. time. More comprehensive than
are able to provide Scores 0–3 or not applicable FLACC in that it includes five
a verbal report for each indicator scores are behavioral indicators and one
including children tabulated. A score of 11 or physiological. Includes cutoff
with cognitive more is indicative of scores
impairments moderate to severe pain; a
score of 6–10 is indicative of
mild pain
Table 6.3 Self-reporting pain assessment tools

Clinical indications
Tool Reference Age range for use Guidelines for use Advantages and disadvantages
Faces Pain Hicks et al. [35] 4–18 years Postoperative pain, Series of 6 faces depicting Simple, easy to use and
Scale-Revised acute procedural “no pain” to “most pain explain. Translated into 32
pain possible.” Scoring 0–10 languages and available on the
Internet, although not all
translations have been
validated
Wong-Baker Wong and Baker [39] 3 years and Postoperative pain, Series of six faces ranging Simple, easy to use, and
FACES Pain older procedural pain from smiling to crying. readily available. Children
Scale Scoring 0–5 have demonstrated a tendency
to choose the anchors; may
measure pain affect rather than
pain intensity
Numeric rating von Baeyer et al. [36] 8–18 years Postoperative pain, 11-point scale with 0 = no Easy and quick to use. Does
scale procedural pain pain and 10 = most pain not require tools. Can be
explained verbally
Visual Huskisson [42] 8 years and Procedural pain Premeasured horizontal or Easy and quick to use. Limited
analogue scale older vertical line, usually 100 mm clinical utility: difficult to
in length. Child indicates interpret and document;
pain intensity by marking a requires careful explanation.
point along the line Variability in length of line,
use of marking, and choice of
anchor words
Oucher Beyer and Aradine [37] 3–18 years Postoperative pain, Two scales; a series of 6 Expensive (must be printed in
procedural pain photographic faces and a color). Children should be
0–100-mm vertical numeric screened to determine their
scale ability to use the numeric
rating scale
Pieces of Hurt Hester [38] 3–18 years Procedural pain Four red plastic poker chips Need to have poker chips.
representing “little hurt” to Infection control (cannot be
“most hurt you could have.” used between patients); need
Child chooses the chip that to store chips at the bedside
represents his/her pain
intensity. Scoring 0–4
90 B.D. Dick et al.
6.8 Developmental, Familial, as new skills are acquired in cognitive, motor, and social
and Psychological Factors domains, new abilities emerge. Along with these abilities
come unique response tendencies that correspond with a
6.8.1 Age child’s developmental stage. For example, it has been found
that younger children tend to assign higher intensity scores
Historically, some have been tempted to erroneously concep- to pain descriptors than older children [54]. It has also been
tualize children as “mini-adults” when it came to formulat- noted that as cognitive skills such as seriation, classification,
ing practice guidelines. It is now clear that many aspects of matching, and estimation develop, children are able to more
children’s behavior are unique and dissimilar to correspond- reliably produce valid pain scores. The younger a child is,
ing behavior in adults. Age-related developmental changes the greater the tendency that a child will be more egocentric
interact with many factors that influence pain assessment. and concrete and focus excessively on perceptually salient
The effects of age in the context of pain assessment have aspects of a scale [55]. Younger children such as those in the
been increasingly studied over the past 20 years. Some of 3–4-year age range have been found to be more likely to
these effects are clear and some are more subtle. choose endpoints of visual analogue or categorical scales
One of the most obvious and pertinent factors relevant to [56]. It is also important to note that a child’s ability to attend
assessing a child’s pain is the level of the child’s ability to to and complete tasks such as pain ratings is affected by
communicate the experience of pain. While self-report is the stressors [57]. This is particularly pertinent given the stress-
gold standard for pain assessment [49], this is often difficult ful nature of pain. As well, there also appears to be a strong
or impossible for young children or for children with devel- developmental trend with regard to a child’s ability to use
opmental delays. Further, as pain is by nature a subjective words that label one’s emotional state [58]. As a child’s lan-
experience, reporting something as complex as one’s pain guage skills become more sophisticated, his/her ability to
experience is inherently challenging [50]. In addition to pos- provide valid and reliable pain reports also increases.
sible limitations in communicating information about pain
being experienced, what a developing child understands School-Age Children
when questioned about pain or the child’s understanding of As with the previously described age groups, as children in
how to respond using pain assessment tools can be limited or this age category develop, they become increasingly able to
qualitatively different from what the assessing adult under- use language and conceptual thinking to more skillfully pro-
stands. These differences can be a result of a number of fac- vide information related to pain assessment. It is during this
tors including the child’s level of communication developmental stage that children show increasing abilities
sophistication, past pain experiences, and culture. to use many self-report scales. During this stage, children
Furthermore, a child who is ill and/or in pain may have more tend to use more complex conceptualizations and report
difficulty engaging effectively in tasks, particularly if those more abstract and affective aspects of pain [4]. This ability
tasks are complex. can be noted between ages 7 and 10 years, becoming more
established by the age of 11 years [59]. A wider range of
Neonates and Infants self-report measures can be reliably used to obtain valid pain
There is considerable evidence from biological measures measures in this age range.
that newborns and infants experience pain at the same level
of intensity as adults [51]. There is strong evidence from the Adolescence
use of physiological and behavioral measures that infants Adolescents show an increasing ability to describe and focus
show enhanced acute pain responses [52]. It has long been on the psychological and social impact of pain. Adolescents
known that as the number of painful procedures that a neo- generally demonstrate increased cognitive flexibility, abstract
nate or infant experiences increases, there can be a corre- thinking, and a broader vocabulary available to describe their
sponding increase in anticipatory fear reactions related to experiences. They also tend to show increased concern about
cues for an upcoming medical procedure [53]. Obviously, the personal and future relevance of a current pain experi-
given the very limited ability of an infant to communicate, ence as it pertains to disability and disfigurement [4].
physiological, biological, and observational measures must
be relied upon to assess pain in very young children. In many
cases, parents can provide valuable information based on 6.8.2 Developmental Delays
behavioral observations of an infant that can be valid and
reliable estimates of pain and distress. Relevant to the discussion of a child’s ability to report pain
and an observer’s ability to rate a child’s pain is a discussion
Preschoolers on unique challenges that exist when assessing pain in chil-
Preschool age children present with some remarkable dren with developmental delays or other forms of physical or
abilities but also experience considerable challenges in many mental impairment. Individuals with developmental disabili-
cases when trying to rate their pain. As children develop and ties are at risk of having their pain underestimated and under-
treated due to their difficulties in verbal communication, ful stimulus have been found to be associated with later pain
cognitive impairment, and even motor skill deficits [60]. ratings following a painful episode [72]. A subsequent study
Malviya and colleagues found that few developmentally found that children who expected to have more pain postop-
delayed children with postoperative pain were assessed for eratively tended to report higher pain levels [73]. Of note, it
pain, and those who were assessed tended to receive fewer has also been found that health-care providers can uninten-
doses of analgesic medication [61]. This bias may be rooted tionally affect an individual’s perception of pain by doing
in an incorrect belief that developmentally disabled children such things as communicating personal expectations [74].
experience less pain or have higher pain tolerances [62]. This highlights the importance of the care provider’s
Strong evidence exists that it is more likely that differences approach to pain assessment and management while inter-
in apparent pain tolerance or pain behaviors are a result of acting with a child.
differences in behavioral expression of pain [63]. This is
especially pertinent as children in this population can be Anxiety, Fear of Pain, and Catastrophizing
more likely to experience more frequent and particularly Effective pain assessment includes an understanding of fac-
painful medical procedures due to other physical conditions tors related to procedural and pain-related anxiety and fear.
[64, 65]. Pain-related fear and anxiety are natural and understandable
As is the case with very young children, parents and other consequences of pain and anticipating a painful procedure. It
caregivers who are familiar with a child with developmental is important to understand that it can be difficult for children
disabilities have the potential to provide valuable and valid to separate their reactions to pain from their reactions to fear
estimates of the child’s pain experience. This information and anxiety [18]. However, this should not be used by clini-
may simply not be measurable using existing pain assess- cians as an excuse to deny appropriate analgesia due to a
ment tools available in most hospital settings [64]. However, supposition that reported pain is psychosomatic or merely a
even caregiver reports have been found to be inconsistent manifestation of fear.
and underestimate pain in this population [66, 67]. Anxiety has been established as a factor that can amplify
Fortunately, there is a growing body of research that has one’s pain experience [75]. Tsao and colleagues found that
examined pain measurement in the developmentally dis- anxiety symptoms, anticipatory anxiety, and anxiety sensi-
abled. There is evidence that observers, even those unfamil- tivity accounted for 62 % of the variance when predicting a
iar with a developmentally delayed child, can reliably assess child’s pain response to experimental pain [76]. Another
pain in these children when provided with adequate informa- study also found that pain catastrophizing predicts children’s
tion about the child in conjunction with the use of validated pain ratings for experimental pain [77]. An interesting study
assessment measures [64]. of postoperative pain in adolescents found that preoperative
anxiety and anticipated pain levels predicted postoperative
pain ratings and analgesic use [78]. These studies highlight
6.8.3 Psychological Factors some of the effects of pain-related anxiety and pain catastro-
phizing on pain. They emphasize the impact of anxiety and
fear of pain on a child’s perception of pain and should not be
Expectations misinterpreted to suggest that appropriate analgesia should
Assessing both a child’s and parents’ expectations with not be provided. Perception is reality for anyone experienc-
regard to the anticipated procedure can be a helpful aspect of ing pain, and assessing pain and pain-related anxiety effec-
pain assessment. An important part of understanding a tively enables health-care providers to better understand and
child’s expectations of pain is obtaining a history of the adequately manage pain.
child’s experience with previous painful procedures.
Children who have experienced multiple previous painful Social and Family Factors
procedures, particularly those who have received poor anal- Understanding a child’s family context is an obvious key
gesia during those procedures, are at increased risk of devel- factor in understanding a child’s pain experience [79].
oping higher levels of procedure- and pain-related anxiety Children can be at risk for inaccurate assessment and poor
[68]. This can lead to a vicious cycle where pain and anxiety pain management due to social and family factors. Accurate
amplify each other and thereby lead to heightened pain expe- parental reports can play an important role in a child’s care,
rience and pain behavior. putting a child at risk if those reports are not valid. Potential
The impact of expectations on pain perception has been barriers include a parent’s inability to accurately assess pain,
broadly established [69]. Cheng et al. reported that pain parental fears regarding negative side effects of treatment,
expectation, previous pain experience, and acceptance of and inaccurate beliefs about the risk of addiction to analge-
pain accounted for 55 % of the variance in children’s overall sics [80, 81].
pain levels [70]. It has been found that children are prone to Palermo and Chambers have written an excellent review on
having difficulty in accurately estimating the amount of pain important family variables relevant to pain assessment to take
that they will experience [71]. Expectations related to a pain- into account at the levels of the individual child, dyadic fac-
92 B.D. Dick et al.
tors, and the family itself [13]. Working collaboratively with and gender (psychosocial factors) in children. Several stud-
family members while using validated pain assessment tools ies aimed at measuring relationships between sex and pain
has been found to result in effective pain assessment [47]. reactions have failed to observe any differences between
Schecter and colleagues found that parents’ prediction of boys and girls [90–92]. Other findings suggest that there are
a child’s pain response was the best predictor of distress dur- biological differences in ways males and females react to
ing immunization, highlighting the potential value of paren- pain across the life span. For example, several researchers
tal input during pain assessment [82]. In addition, parents conclude that females have lower pain threshold and toler-
generally expect that their children’s procedural pain be ances than males [93–95]. Sex differences in pain responses
appropriately managed [83] and are therefore often highly in adults have also been attributed to various biological dif-
motivated to assist health-care providers as needed during ferences in pain mechanisms, such as brain chemistry,
pain assessment. metabolism, physical structures, and hormonal variations
affecting pain transmission, pain sensitivity, and pain per-
Biases in Health-Care Providers ception [94, 96]. Unfortunately, these findings are inconsis-
There is a rich collection of literature that clearly demon- tent in the pediatric population [97].
strates humans’ inherent tendency to individual bias. For Further research on this subject has investigated gender-
example, a dated but relevant study found that physicians related differences, including pain behavior and characteris-
were biased to overestimate a child’s cognitive level if the tics influenced by sociocultural factors such as femininity
child is well dressed and does not have dysmorphic features and masculinity [98]. In these studies, females have com-
[84]. There are a number of important issues that are worth monly been found to report more severe levels of pain, more
noting for individuals involved in the medical care of chil- frequent pain, and pain of longer duration than males [96, 99,
dren who experience pain due to disease and/or medical 100]. In addition, girls of various ages have been found to
procedures. rate a greater difference between their ratings of unpleasant-
A primary ongoing issue in pediatric pain assessment and ness of pain and pain intensity scores in comparison to boys,
management is the reluctance of some health-care providers indicating that females may have a greater ability to discrim-
to use analgesics (particularly opioids) to manage pain. inate different pain stimuli [101–103]. When analyzing these
Some of these biases result from misinformation based on findings, it is essential to consider that differences in pain
outdated or biased perceptions [85]. Such biases can lead responses between genders could be attributed to differences
care providers to minimize pain when assessing it and attri- in pain reporting styles. In multiple studies, girls consistently
bute pain to other factors such as anxiety or other psycho- select more words to describe their pain than boys [54],
logical factors. While it has been well established that stress which corresponds with findings suggesting greater verbal
and anxiety can exacerbate pain perception and pain behav- fluency and emotional expressiveness in girls.
ior and impede pain coping [86, 87], a reluctance to use opi- While increased pain reactions and behaviors may be
oids or other analgesics according to established guidelines observed in females, this does not necessarily imply that they
is unethical and inhumane. are experiencing more pain. It is possible that they could
In a survey of physicians across a variety of subspecial- simply be more verbally expressive about their pain than
ties, it was found that pediatricians tended to report a belief males, which can be attributable to psychosocial factors
that pain was experienced at an earlier age than surgeons and [104]. Stereotypically, males in many cultures are expected
family practitioners and were more likely to prescribe anal- to hold back on reporting pain. As a result there may be a
gesics for pain than these other groups [88]. That same study greater social cost to openly express their experience of pain.
also found that physicians tended to rate other subspecialty This may teach boys to minimize pain responses, which in
procedures as more painful than procedures from their own turn can lead society to expect less pain response from them.
specialty. Another research found that physicians were far In some cultures, females are perceived to be weaker and to
more likely to prescribe appropriate analgesics for the same tolerate less pain, which invites them to express their pain
medical problem in older patients compared to toddlers [89]. more freely [105]. In a recent study on sex differences in par-
While these studies highlight physician bias in practice, these ent and child pain ratings, researchers found that, although
biases exist across specialties and disciplines. Awareness of subjects of both genders correspondingly responded to pain
one’s own personal biases must be a priority for all care pro- in the presence of both parents, fathers were inclined to rate
viders when assessing and managing a child’s pain. a higher pain score to their sons than daughters [106], which
illustrates a societal expectation that may falsely contribute
to differences observed in gender reactions to pain. Due to
6.8.4 Gender the inconsistency in the literature, it is important to consider
the many factors that may influence pain responses and the
There have been a number of studies investigating the differ- various ways these can be interpreted when assessing a
ences in pain response related to sex (physiological factors) child’s pain.
6.8.5 Cultural Factors To maximize accurate assessment of children’s pain that

is also culturally sensitive, recent pediatric literature high-
It is important to be aware of cultural factors and possible lights the benefit of self-report measures [111, 112]. The
cultural stereotypes that can exist when assessing procedural researchers from these studies took Westernized self-report
pain in children. It is also important to note that subjective assessment tools, such as the Wong-Baker FACES Scale and
experience and coping strategies in response to pain in chil- Oucher Scale, and created new ethnic versions of these tools
dren can be unique across cultures. As well, some cultures for a variety of cultures (African-American, Hispanic, and
conceptualize pain as positive, character building, or cleans- Lebanese). It is also worth noting that some original Western
ing and welcome painful experiences for these and other self-report assessment tools, including the Wong-Baker
reasons. FACES Scale and Poker Chip Scale, were found to be reli-
Studies that have examined pain in children from differ- able and appropriate for Jordanian-Muslim children between
ent cultures have shown some consistent findings. For exam- the ages of 3 and 14 [110]. In general, the new ethnic ver-
ple, differences have been found between children from sions of each assessment tool achieved good correlations
cultural groups in their pain control and pain behaviors, but with existing reliable measures of pain, providing support
not in self-reported pain scores [107, 108]. Pfefferbaum and for the use of these scales. As well, it was suggested that
colleagues (1990) have noted that these differences may these culturally sensitive self-report measures foster a sense
reflect biased descriptors included in observational instru- of respect between the medical team and patient’s family,
ments, which fail to capture pain behaviors unique to certain opening further communication that may help break down
cultures [109]. Other findings suggest that self-report mea- stereotypical barriers.
sures can accurately assess a child’s level of pain regardless
of his/her cultural background [110]. Gharaibeh and Abu- Conclusion
Saad (2002) argue that children have their own separate sub- This chapter has reviewed current practice standards in
culture mediated by common norms of growth and assessing pain in children with a focus on practice rele-
development, natural feelings and instinct, and common vant to regional anesthesia. Great progress has been made
styles of nonverbal communication [110]. This line of in the past 25 years in the field of pain assessment in chil-
thought supports the universal pain experience in children as dren. However, it is also clear that a dearth of information
mediated more by developmental maturation than by exists on pain assessment specifically relevant to regional
culture. anesthesia.
94 B.D. Dick et al.
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Pediatric Pharmacological
Considerations 7
Derek Dillane
Contents
7.1 Introduction 98
7.2 Structure and Physiochemical Properties 98
7.2.1 Onset of Action, Potency, and Duration 99
7.2.2 Sodium Channel 100
7.2.3 Physiological Considerations 101
7.3 Pharmacokinetics 102
7.3.1 Absorption 102
7.3.2 Absorption from Epidural Space 102
7.3.3 Absorption from Other Routes of Administration 102
7.3.4 Distribution 103
7.3.5 Plasma Protein Binding 103
7.3.6 Hepatic Metabolism 104
7.4 Toxicity 105
7.4.1 Central Nervous System Toxicity 106
7.4.2 Cardiac Toxicity 106
7.4.3 Treatment of Toxicity 107
7.4.4 Prevention of Toxicity 108
7.5 Dosing 108
References 108
Suggested Reading 110
D. Dillane, MB BCh BAO, MMedSci, FCARCSI

University of Alberta, 2-150 Clinical Sciences Building,
Edmonton, AB, Canada

DOI 10.1007/978-0-387-79964-3_7
98 D. Dillane
7.1 Introduction 7.2 Structure and Physiochemical

Properties
The first amino-amide local anesthetic was developed by
Swedish chemists Löfgren and Lundquist in 1943, and this All local anesthetics are weak bases. They have a molecular
xylidine derivative, which they called lidocaine, was first weight ranging from 220 to 288 Da [4]. Their formula con-
marketed in 1948 [1]. Lidocaine has been in clinical use for sists of a lipophilic aromatic ring connected to a hydrophilic
almost 60 years, is the most widely used local anesthetic residue by a hydrocarbon chain. They are clinically classified
worldwide, and remains one of the safest and most effica- as amino-esters or amino-amides depending on the link
cious local anesthetic agents ever manufactured. One of its between the lipophilic ring and the hydrophilic tertiary
main drawbacks, however, is a short duration of action. The amine (Fig. 7.1). Amino-ester local anesthetics are hydro-
longer acting amino-amide, bupivacaine, was synthesized by lyzed in the plasma by cholinesterases, whereas the amides
Bo af Ekenstam in 1957 and introduced into clinical practice are metabolized in the liver by the cytochrome P450 enzyme
10 years later [2]. It would take a further 10 years of clinical system. The amino-amide group is most commonly used for
use before serious cardiac toxicity was reported, and this pediatric regional anesthesia and, as such, will be the focus
important safety issue led to the continuing search for a long- of this chapter.
acting and safe agent. In the 1980s, the development of new,
long-acting amides took advantage of the fact that most of
these molecules have a chiral center. These three-dimensional
stereoisomers have an identical chemical composition but
differ in spatial orientation [3]. This led to the development
of the single stereoisomers levobupivacaine and ropivacaine,
first approved for clinical use in 1996.
O CH3
O
Cocaine (1884)
H3 C N O
ESTERS AMIDES
CH3
NH2 N CH3
HN O Lidocaine (1944)
CH3 Procaine (1905)
H3C CH3
H 3C N
O O
H3C CH3
N
H3C N H 3C N N
O O H3 C
HN O HN O HN O
H3 C CH3 H 3C CH3
Tetracaine (1930) H3C CH3
NH
Bupivacaine Levobupivacaine Ropivacaine
(1963) (1996) (1996)
CH3
Fig. 7.1 Derivation of ester- and amide-class local anesthetics from cocaine. Shown are chemical structures and years in which each drug was
first used
7 Pediatric Pharmacological Considerations 99
7.2.1 Onset of Action, Potency, and Duration membranes. This explains why lidocaine has a faster onset
of action than ropivacaine or bupivacaine. Moderately lipo-
Being weak bases, local anesthetics exist in solution as both philic drugs are most effective clinically due to the drug hav-
ionized (water soluble) and non-ionized (lipid soluble) mol- ing to cross several membranes to reach its target site. At
ecules. Local anesthetics traverse phospholipid membranes physiological pH, a significant fraction of the drug is in a
in their non-ionized form. The degree of drug ionization is non-ionized form and readily crosses the membrane to the
determined by the dissociation constant (pKa) and the pH of cytosolic side of the nerve cell. Excessively lipophilic drugs
the surrounding fluid. The pKa of a molecule represents the remain in the first membrane encountered [6]. For the drug
pH at which 50 % of the molecules exist in a lipid-soluble to effectively block the sodium channel, it must become re-
form and 50 % in a water-soluble form. Local anesthetic ionized on the cytosolic side of the membrane.
molecules with a pKa that approaches physiologic pH have Potency is directly related to lipid solubility which is
a higher concentration of the non-ionized lipid-soluble form. expressed as lipid/water partition coefficient. Drugs with low
As the pKa of a drug increases, a greater proportion exists in lipid solubility need higher concentrations to produce a
the ionized hydrophilic form at physiological pH. Commonly block of similar intensity to that produced by local anesthet-
used local anesthetics have a pKa between 7.8 (lidocaine) ics with higher lipid solubility (e.g., 2 % lidocaine (partition
and 8.1 (ropivacaine and bupivacaine) (Table 7.1). Drugs coefficient 43) vs. 0.5 % bupivacaine (partition coefficient
with a lower pKa (e.g., lidocaine) exist to a greater degree 346)). Duration of action is largely determined by the degree
in a non-ionized form and diffuse more easily across cell of plasma protein binding.
Table 7.1 Comparative physicochemical properties of local anesthetics

Agent Potency pKa Molecular weight (Da) Toxic plasma concentration (μg/mL) % protein binding
Lidocaine 1 7.8 234 >5 70
Prilocaine 1 7.8 220 >5 55
Mepivacaine 1 7.6 246 >5 77
Bupivacaine 4 8.1 288 >3 95
Levobupivacaine 4 8.1 288 >97
Ropivacaine 4 8.1 274 >4 94
Agent % ionized at pH 7.4 Partition coefficient with h-octanol/buffer Volume of distribution (L) Clearance (L/min)
Lidocaine 25 43 91 0.95
Prilocaine 24 25 191
Mepivacaine 39 21 84 9.78
Bupivacaine 17 346 73 0.47
Levobupivacaine 17 346 55
Ropivacaine 17 115 59 0.44
100 D. Dillane
7.2.2 Sodium Channel The voltage-gated sodium channel is a large, multimeric

complex comprised of an α subunit and one or more smaller
Voltage-dependent Na+ channels in nerves contribute to the β subunits. The α subunit contains all the features necessary
control of membrane excitability and are responsible for for a functional ion channel including voltage sensor, activa-
action potential generation. When the cell membrane is tion/inactivation gates, and ion pore. The β subunits play a
depolarized by a few millivolts, sodium channels activate role in membrane localization of the channel as well as mod-
and inactivate within milliseconds (Fig. 7.2). Influx of ulation of channel gating [8]. Na+ channels exist in a closed,
sodium ions through the channel depolarizes the membrane open, and inactivated state [7]. Local anesthetics bind more
further and initiates the action potential. Local anesthetics tightly to the Na+ channel during the open and inactivated
prevent neural excitation and subsequent propagation of state than the closed state. In effect, this means that they
action potential by inhibiting passage of Na+ ions through show high affinity for their site of action during high-
these channels. The drug may access the Na+ channel through frequency action potentials, such as those that occur during
the hydrophilic inner pore or traverse the hydrophobic cell sensory transmission or motor activity [9]. This is a phenom-
membrane when the channel is closed [7]. The local anes- enon known as frequency-dependent or use-dependent
thetic must be re-ionized to prevent passage of Na+ ions. An blockade.
equilibrium exists between the ionized and unionized forms
in the Na+ channel.
Fig. 7.2 Schematic diagram of a sodium channel in a neuron cell mem- phospholipid membrane in their non-ionized form. Drugs with a low
brane. Left, the deactivated form is impermeable to sodium ions; middle, pKa (e.g., lidocaine) exist to a greater degree in a non-ionized form and
the activated form allows sodium ions to flow into the cell; right, the more readily cross the cell membrane. The drug must become re-ionized
channel is blocked by local anesthetic. Local anesthetics traverse the in the intracellular environment to effectively block the sodium channel
7.2.3 Physiological Considerations diameter are blocked before those of larger size with recov-
ery from blockade occurring in the reverse order) [10].
The diameter and degree of myelination of a nerve fiber Clinically, it is more likely that the action of local anesthetic
determines the nature of impulse conduction and the effec- on nerve fibers is multifactorial (e.g., peripheral versus core
tiveness of local anesthetic drugs. There are three major ana- nerve fiber, state of activation of the nerve, length of nerve
tomical categories: myelinated somatic nerves (A fibers), exposed to local anesthetic, and degree of myelination in
myelinated preganglionic autonomic nerves (B fibers), and addition to nerve diameter).
unmyelinated axons (C fibers). The A fibers are subdivided Myelination is not complete before the age of 12 years.
into four groups according to decreasing speed of impulse The relative absence of a myelin sheath coupled with the
conduction and diameter (Table 7.2). The thinnest A fibers, smaller nerve fiber diameter may explain why infants and
the Aδ group, are responsible for pain and cold temperature children are subject to prolonged motor blocks with local
transmission. Aγ fibers are responsible for muscle tone. C anesthetic solutions of lower concentration [4]. In addition,
fibers are thinner than myelinated axons, have a much lower the endoneurium of developing nerves is loose and easily
conduction velocity, and are also responsible for the trans- penetrated by local anesthetic molecules in both directions.
mission of pain signals. Aδ fibers are responsible for fast This may account for both the shorter onset and shorter dura-
pain transmission, whereas C fibers are responsible for section of effect of local anesthetic action in younger age groups.
ond or slow pain transmission [6]. Differential nerve block- Beyond infancy, the endoneurium contains more connective
ade has been demonstrated in animal studies after tissue, making it more difficult for the local anesthetic to tra-
administration of local anesthetic (i.e., fibers of smaller verse [9].
Table 7.2 Classification and properties of peripheral nerve fibers

Nerve class Aα Aβ Aγ Aδ B C
Function Motor Pressure/touch Proprioception/motor tone Pain/temperature Preganglionic autonomic Pain/temperature
Diameter (μm) 12–20 5–12 1–4 1–4 1–3 0.5–1
Conduction speed (m/s) 70–120 30–70 10–30 12–30 10–15 0.5–1.2
Local anesthetic ++ ++ +++ +++ +++ +
sensitivity (+++ most
susceptible)
102 D. Dillane
7.3 Pharmacokinetics 7.3.2 Absorption from Epidural Space
Pharmacologists and anesthesiologists share a common The main component of the epidural space is fat, which is an
interest in pharmacokinetics, but rather than being con- important determinant of local anesthetic systemic uptake.
cerned with volumes of distribution and total body clear- More lipophilic local anesthetic molecules will be retained to
ance, the pediatric anesthesiologist wants to know how a greater degree by epidural fat leading to subsequent delayed
much local anesthetic can be safely administered to pro- absorption. It has been demonstrated in adults that after a sin-
duce an effective nerve block in a timely fashion. However, gle-shot epidural injection, 30 % of a dose of lidocaine and
these empirical and abstract concepts are not mutually 50 % of a dose of bupivacaine remained in the epidural space
exclusive. for 3 h after injection [12]. The time to maximum peak plasma
Unlike other therapeutic agents administered to infants concentration (Tmax) in infants for lidocaine and bupivacaine is
and children, local anesthetics can be delivered directly to 30 min after caudal or lumbar epidural injection [13].
their site of action. Traditionally, a large volume and high Ropivacaine Tmax is longer in infants than in children and lon-
concentration of local anesthetic has been injected to ensure ger in children compared to adults. In children aged 1–2 years,
adequate anesthesia and analgesia. This was, in part, due to ropivacaine Tmax is 115 min, whereas in children aged
the relatively small number of local anesthetic molecules 5–8 years, ropivacaine Tmax is closer to the adult value of 30
thought to reach the target nerves. The nerve sheath or peri- [14]. The vasoconstrictive properties of ropivacaine may con-
neurium is a very effective diffusion barrier. A large fraction tribute to its prolonged absorption from the epidural space.
of the delivered agent is absorbed by the surrounding tissue After Tmax has been achieved, the rate of absorption slows
or is removed by the systemic circulation. Direct measure- down significantly so that it becomes longer than that of elimi-
ment in an animal model demonstrates that <2–3 % of an nation, leading to a flip-flop effect in plasma drug concentra-
injected dose enters the target nerve. In addition, more than tion [4]. This continuous, protracted systemic absorption
90 % of an injected dose is taken up by the systemic circula- during the elimination phase, in combination with the buffer-
tion within 30 min of injection [11]. Ultrasound guidance ing effect of plasma protein binding, limits the plasma concen-
may allow for more accurate deposition, necessitating a tration of unbound drug and is protective against toxicity.
smaller volume and dose of local anesthetic.
Neonates and infants present significant pharmacokinetic
peculiarities possibly leading to an increased risk of toxicity. 7.3.3 Absorption from Other Routes
Immature hepatic metabolism and marked differences in of Administration
serum protein binding serve to increase serum concentra-
tions of unbound amide local anesthetic. Absorption rates at different block sites are directly related to
local blood flow and inversely related to local tissue binding
[15]. As a consequence, plasma uptake is faster from the more
7.3.1 Absorption vascular intercostal space or the axilla than from the caudal
space. Vascular uptake of local anesthetic after intercostal
Regional anesthesia in the pediatric population involves the nerve block occurs more rapidly than with any other regional
injection of a relatively large volume of a concentrated technique [16]. Despite recently published epidemiologic data
local anesthetic solution into a compact anatomical space. indicating up to a fivefold increase in the utilization of periph-
The rate of absorption into the bloodstream is a major eral nerve blockade in the pediatric population, specific phar-
determinant of systemic toxicity. This has been studied pre- macokinetic data are lacking [17]. Ilioinguinal-iliohypogastric
dominantly for epidural/caudal anesthesia. Explicit detail nerve blockade is the only peripheral block whose kinetics
on the kinetics of other routes of administration is lacking have been reported with any degree of regularity. Significantly
for this population. What is evident, though, for both cen- higher plasma concentrations of both bupivacaine and ropiva-
tral and peripheral blocks, is the more rapid rate of absorp- caine have been reported in one study following ilioinguinal-
tion from the cephalic parts of the body [4]; for example, a iliohypogastric nerve block as compared to caudal blockade
cervical epidural leads to higher plasma levels of local [18]. Times to peak plasma concentration were much faster for
anesthetic than a caudal epidural. Similarly, absorption both drugs following ilioinguinal-iliohypogastric nerve block.
decreases from head to foot for peripheral conduction and The narrow inter-fascial space at this block location may facil-
infiltration blocks due to the relative difference in vascular- itate absorption. This, coupled with greater uptake of local
ity between these areas. anesthetic into epidural fat, may account for the lower plasma
levels seen after caudal injection.
7.3.4 Distribution 7.3.5 Plasma Protein Binding
Local anesthetics are distributed to the tissues and body fluid Local anesthetics bind tightly to serum proteins, greatly lim-
compartments after systemic absorption to the plasma. Volume iting the free fraction of available drug. This is clinically rel-
of distribution (Vd) is a mathematical expression which depicts evant as it is only the free or unbound fraction that is bioactive
the distribution characteristics of a drug in the body. It is a mea- (i.e., readily available to cross cell membranes to become
sure of the degree to which a drug is delivered by the plasma to active at the sodium channel). Volume of distribution (see
the organs and tissues of the body. Drugs with a small calculated above) is inversely related to protein binding. Drugs which
Vd have a high concentration of drug in the plasma, have a con- are highly protein-bound have limited passage into tissues
comitant low tissue concentration, and are more likely to accu- resulting in a high drug plasma concentration and a low Vd.
mulate to toxic levels. Drugs with a larger Vd are subject to In adults, lidocaine is up to 70 % protein bound while bupi-
slower elimination. Vd is influenced by degree of ionization/ vacaine, levobupivacaine, and ropivacaine are over 90 % pro-
lipophilicity, plasma protein binding, and molecular size [19]. tein bound [19].
Since local anesthetics are weak bases that have dissociation Three principal blood components are involved in local
constants (pKa values) above physiological pH, more than 75 % anesthetic binding: the plasma proteins alpha-1-acid glyco-
of the commonly used amide local anesthetic drugs exist in a protein (AAG), human serum albumin (HSA), and erythro-
hydrophilic ionized form at physiological pH (Table 7.1). cytes. Like most weak bases, local anesthetics bind mainly to
Hence, they are highly water-soluble molecules but are less AAG. AAG has a greater affinity for binding local anesthetic
likely to cross lipid cell membranes. As a result of the delayed by an order of magnitude of 5,000–10,000 compared to albu-
systemic absorption of local anesthetic drugs, it is impossible to min [26]. Capacity for binding is relatively low, however,
calculate a volume of distribution with any accuracy. One study and saturation occurs at clinically relevant concentrations.
found bupivacaine to have a higher Vd in neonates and infants Even though albumin is the most abundant plasma protein
[20], which may be related to the higher fraction of unbound (50–80 times more abundant than AAG), it has a low affinity
drug to plasma protein (see next section). Following adult epi- for amide local anesthetic drugs [4]. By virtue of its enor-
dural anesthesia, ropivacaine appears to have a smaller Vd than mous binding capacity (it is almost unsaturable), together
bupivacaine [21, 22], and indirect evidence points to a similarly with its abundance, the role of HSA becomes significant
reduced Vd in infants. Following single-shot caudal anesthesia, when AAG is saturated.
peak concentration of ropivacaine is higher than bupivacaine AAG concentration is very low at birth (less than 30 % of
[23]. Two further studies have demonstrated that Vd of ropiva- the adult concentration) and progressively increases to adult
caine appears slightly smaller before the age of four [14, 24]. levels during the first year of life [5]. The unbound fraction
Local anesthetic is distributed to organs according to their of local anesthetic is higher during infancy which increases
vascular density. The local anesthetic is taken up within each susceptibility to toxicity. Conversely, a consequence of this
organ according to the tissue-plasma partition coefficient high free drug concentration is a greater hepatic clearance
(Table 7.3). The lungs play an important buffering role by than would be expected with immature hepatic microsomal
taking the full impact of drug-laden venous blood. A variety metabolism.
of investigational techniques, including autoradiography, AAG is a major acute-phase protein, and its concentration
scintillation counts, and tissue assays, confirm the lung’s rapidly increases in the first 24–48 h after surgery. The result-
ability to quickly extract local anesthetic [25], although this ing AAG level in infants remains lower than that which is
buffering action of the lung is saturable. present in children and adults, but the subsequent decrease in
free drug concentration may provide some protection against
Table 7.3 Tissue-blood partition coefficients (lidocaine) toxicity in the early postoperative period. This elevation in
Organ Tissue-plasma λ Tissue-blood λ AAG levels may diminish on the third postoperative day,
Spleen 3.5 – leading to a sudden rise in the unbound fraction, which can
Lung 3.1 5.4 precipitate toxicity. A total cessation or reduction in the infu-
Kidney 2.8 – sion dose of local anesthetic has been recommended in the
Stomach 2.4 – neonatal age group beyond 48 h [9].
Fat 2.0 2.9 Affinity for red blood cells is low and not saturable. This
Brain 1.2 1.7 may be considered as a buffer system when toxic concentra-
Heart 1.0 – tions occur. It is especially relevant in infants with a low
Muscle 0.7 0.9 AAG concentration. It is important to remember that infants
Liver 0.6 2.9 have a physiologic anemia which reduces storage capacity
Skin 0.6 – and favors increased fraction of unbound drug [26].
Bone 0.4–0.9 –
Based on data from de Jong [59]
104 D. Dillane
7.3.6 Hepatic Metabolism

LA injection
Local anesthetics undergo extensive hepatic biotransforma-

tion prior to renal excretion. Clearance is low at birth and LA >90% bound to
does not reach adult levels until 6–9 months [27, 28]. The Blood albumin or
terminal half-life of amide local anesthetics is three to eight alpha-1-acid
glycoprotein
times longer in neonates when compared to adults [4]. Amide
local anesthetics are metabolized in the liver by oxidative
pathways involving the cytochrome P450 enzyme superfam-
ily (Fig. 7.3). Lidocaine and bupivacaine are metabolized Na+ channel
Heart blockade by
mainly by CYP3A4, an enzyme system which is not fully unbound LA
mature at birth. However, most biotransformation activities
are achieved by CYP3A7, an enzyme which is present only
in the fetus and during the first months of life [29]. First major capillary
Ropivacaine is metabolized by CYP1A2, which is not bed reached
fully functional before the age of 3 years. Consequently, it is 'cushions' impact
Lungs
on the brain;
reasonable to assume that bupivacaine clearance should be at amide-linked LA
or near normal adult levels from birth and that ropivacaine metabolized
clearance should be markedly deficient; however, this is not
the case. Clearance of bupivacaine is markedly deficient at
birth and increases slightly in the first year of life. Conversely, Toxic CNS effects
Brain by unbound LA
ropivacaine clearance is not very low at birth; however, it
does not fully reach adult values before the age of 5 years
[14]. This enzymatic immaturity is clinically relevant to a
Cytochrome P450
limited extent but does not preclude the use of local anesthet-
Liver enzymes metabolize
ics in neonates and infants. LA from non-polar
Only a small fraction of unmetabolized amide local anes- to polar metabolites
thetic is excreted in the urine. Thus, renal dysfunction affects
local anesthetic clearance less than hepatic failure, notwith-
standing the accumulation of potentially harmful metabolites Excretion of water
Kidney
soluble metabolites
[25]. The clearance of one of the main metabolites of ropiva-
caine, 2,6-pipecoloxylidide (PPX), is decreased in uremic
patients. Its cardiotoxicity in rat studies is reported as half Reabsorption of lipid
that of bupivacaine. soluble metabolites
Fig. 7.3 Sites of local anesthetic action and metabolism following

plasma absorption. Local anesthetic molecules are bound to plasma
proteins, and this limits the free fraction of available drug. The unbound
fraction is metabolized in the liver by the cytochrome p450 enzyme
superfamily
7.4 Toxicity pediatric population. Early signs of cerebral toxicity are subjec-
tive (dizziness, drowsiness, tinnitus). These will not be related
Local anesthetics have the same toxic effects in infants and chil- by the young or anesthetized child (and most pediatric blocks
dren as those seen in adults. The major toxic effects are on the are performed under anesthesia or heavy sedation). Moreover,
cardiovascular and central nervous systems. In the adult patient, general anesthesia itself raises the cerebral toxicity threshold,
neurologic toxicity occurs at lower concentrations followed by and neuromuscular blockade will preclude the onset of general-
cardiac toxicity at higher concentrations. This is not always true ized tonic-clonic seizures. Consequently, the first manifestation
for bupivacaine, an assumption which may be broadened to of an accidental intravascular injection or rapid absorption may
include the entire spectrum of local anesthetic toxicity in the be cardiovascular collapse (Table 7.4) [9].
Table 7.4 Dosage recommendations for regional blocks in pediatric patients

Route of administration Recommended agent Maximum dose single shot Maximum dose reinjection Maximum dose continuous
Caudal epidural Bupivacainea 2 mg/kg Not recommended
Bupivacaine with epinephrine 2.5 mg/kg
Lumbar epidural Bupivacaine with epinephrine 1.25–1.75 mg/kg 0.75–1 mg/kg Infants 1 month–1 year:
Bupivacaine 0.2–0.25 mg/kg/h
1–4 years old:
0.25–0.35 mg/kg/h
4 years:
0.25–0.4 mg/kg/h
Peripheral blocks Lidocaine 6 mg/kg As for lumbar epidural
Lidocaine with epinephrine 7 mg/kg
a
Use bupivacaine-equivalent doses (i.e., 1:1) for ropivacaine and levobupivacaine
106 D. Dillane
7.4.1 Central Nervous System Toxicity quently be followed by ventricular fibrillation. Alternatively,
profound bradycardia may ensue, followed by asystole [4].
Local anesthetics readily cross the blood-brain barrier to dis- Because of their higher heart rate, neonates and infants may
rupt cerebral function. The central toxic response is specifi- be more susceptible to the use-dependent blockade of sodium
cally related to plasma levels of local anesthetic in the central channels produced by bupivacaine. These electrophysiologi-
nervous system (CNS) and their effect on the complex inter- cal effects are compounded by a direct negative inotropic
play between excitatory and inhibitory pathways that facili- effect of local anesthetic drugs. A number of the reported
tate neurotransmission. Initially, there is a generalized fatalities due to cardiovascular toxicity resulting from the
excitatory phase, as manifested by seizure activity. This ini- use of bupivacaine in caudal anesthesia were associated with
tial phase appears to be the result of blocking inhibitory doses in excess of the recommended therapeutic range [38,
pathways in the amygdala which allow excitatory neurons to 39]. Nevertheless, there have been reports of cardiovascular
function unopposed. When levels of local anesthetic in the collapse requiring resuscitation in infants who received cau-
CNS increase further, both inhibitory and excitatory path- dally administered bupivacaine within the recommended
ways (being more resistant to the effects of local anesthetic dose range [40, 41].
toxicity) are inhibited, leading to CNS depression, a reduced The levorotatory isomer (S-) of bupivacaine has less
level of consciousness, and eventually coma. potential for cardiac toxicity than the dextrorotatory one (R+)
The reported incidence of cerebral toxicity is low. Two or racemic mixture of both [25]. This led to the development
large surveys (each greater than 20,000 regional anesthesia of the single stereoisomers levobupivacaine and ropivacaine.
procedures in the pediatric population) indicate that the inci- It has been purported that lidocaine blocks sodium channels
dence of seizures is <0.01–0.05 % [30, 31]. There have been in a “fast-in/fast-out” fashion, whereas bupivacaine blocks
several case reports of children experiencing seizures after a these channels in either a “slow-in/slow-out” manner in low
regional anesthesia procedure, most of which involved con- concentrations or a “fast-in/slow-out” manner at higher con-
tinuous lumbar or caudal epidural anesthesia with bupiva- centrations [42]. Ropivacaine, on the other hand, has been
caine [32–35]. Bupivacaine is associated with seizures at shown to block sodium channels in a “fast-in/medium-out”
blood levels as low as 4.5–5.5 μg/mL. Rather alarmingly on fashion [43]. The dissociation constant (between ligand and
occasion, these toxic blood levels were reached even after receptor) for bupivacaine is almost ten times longer than that
adhering to the recommended therapeutic range [32, 34]. of lidocaine, resulting in a prolonged and near irreversible
Cerebral toxicity is associated with lidocaine, prilocaine, and cardiac depressant effect [42]. There is a positive correlation
mepivacaine at blood levels of 5–10 μg/mL. between local anesthetic lipid solubility and inhibition of car-
diac contractility – further evidence for the clinically relevant
finding that ropivacaine is less toxic than racemic bupivacaine
7.4.2 Cardiac Toxicity [44]. In vitro studies appear to concur with animal studies
which have demonstrated that bupivacaine has the most
The potentially devastating sequelae of cardiovascular toxic- potent myocardial depressant effect, followed by ropivacaine
ity may be the first manifestation of local anesthetic toxicity and lidocaine [45].
in infants and children, although the overall incidence in this The true equipotency ratio between the enantiomeric
population is remarkably low. Several large series of regional agents has been the subject of much conjecture. Results
anesthesia procedures in infants and children report no cases from a number of animal and clinical studies would suggest
of cardiovascular toxicity [32, 35–37]. A prospective study a rank order of potency of ropivacaine < levobupivacaine <
of more than 24,000 regional anesthesia procedures reported bupivacaine [3]. This suggests that any theoretical cardio-
four patients who developed a cardiac arrhythmia, and none protective benefit derived from ropivacaine would be
of these progressed to cardiac arrest or collapse [31]. negated by the clinical need for higher doses due to its lower
For obvious ethical reasons, most available information potency. The difference in potency does not appear to be
on this subject comes from animal studies and case reports. clinically relevant for surgical blocks (both peripheral and
The principal mechanism relates to the blockade of myocar- epidural) when the newer agents are used at concentrations
dial voltage-dependent sodium channels leading to an of 0.5–0.75 %, with the clinical profile of the nerve block
increase in the PR interval and QRS duration, provoking a being similar to that obtained with racemic bupivacaine.
dose-dependent prolongation of conduction time and even- However, the lower potency of ropivacaine becomes rele-
tual depression of spontaneous pacemaker activity. Persistent vant when used for postoperative analgesia with both epi-
sodium channel blockade predisposes to reentrant arrhyth- dural and continuous peripheral nerve blockade. For this
mias. Subtle T-wave changes on the electrocardiogram may application, 0.2 % ropivacaine appears to be as effective as
progress to ventricular arrhythmias, the most malignant 0.125–0.15 % levobupivacaine, which in turn is identical to
being torsades de pointes. These arrhythmias may subse- racemic bupivacaine [3].
7.4.3 Treatment of Toxicity treatment of a 13-year-old child when administered for

ropivacaine- and lidocaine-induced ventricular arrhythmia
Immediate intervention at the earliest sign of toxicity is of following posterior lumbar plexus blockade [57].
prime importance and improves the chances of successful Intralipid 20 % should be administered as a bolus of
treatment. General supportive measures are warranted, 1.5 mL/kg over 1 min followed immediately by an infusion
including Advanced Life Support Guidelines (ACLS) and at a rate of 0.25 mL/kg/min. It is important that chest com-
more specific measures directed at local anesthetic toxicity. pressions continue to allow the lipid to circulate. Two further
All patients subject to a regional anesthesia procedure must boluses of 1.5 mL/kg with 5 min between boluses may be
have electrocardiography, pulse oximetry, and blood pres- considered if the initial response is inadequate. The infusion
sure monitoring. Acute morbidity from seizure activity is may be continued until hemodynamic stability is restored.
due in large part to airway complications. Hypoxia, hyper- The rate may be increased to 0.5 mL/kg if blood pressure
carbia, and acidosis all worsen prognosis. Consequently, air- remains low (Fig. 7.4).
way control must be achieved prior to management of seizure In light of the current evidence, it would appear prudent to
activity. Seizure control can be achieved with midazolam ensure immediate availability of Intralipid 20 % in areas
(0.05–0.2 mg/kg) or small doses of propofol if there are no where regional anesthesia is performed. For patients in car-
signs of cardiovascular instability. The approach to cardio- diac arrest due to local anesthetic toxicity and who are being
vascular collapse must be similarly methodical and must pri- resuscitated following current ACLS guidelines, it is appro-
oritize oxygenation and ventilation. Increasing the heart rate priate to administer lipid emulsion. It is equally justifiable to
may be imperative in infants especially in the presence of administer lipid emulsion to patients displaying overt neuro-
profound intraventricular block. Though contentious as to its logic toxicity in an attempt to preempt cardiac toxicity.
effect on long-term survival, epinephrine has been recom-
mended for the treatment of cardiac toxicity [4, 46]; how-
ever, careful titration is required with individual boluses of
less than 1 μg/kg in order to avoid ventricular fibrillation or
tachycardia. Vasopressin is contraindicated for the treatment
of local anesthetic-induced cardiovascular collapse.
Experimental animal studies and clinical case reports
suggest that lipid emulsion is effective in the reversal of local
anesthetic toxicity [47–49]. Intralipid® 20 % is a Food and
Drug Administration-approved hyperalimentation source
comprised of soybean oil, glycerol, and egg phospholipids.
The mechanism of action of lipid emulsion in the reversal of
local anesthetic toxicity has not been fully elucidated but
may act as a circulating lipid sink extracting lipophilic local
anesthetic from plasma or tissues [50]. Alternatively, it may
facilitate the reversal of local anesthetic inhibition of myo-
cardial fatty acid oxidation, thereby restoring the myocardial
adenosine triphosphate (ATP) supply [51]. Lipid emulsion
may act as a direct inotrope by increasing intracellular myo-
cardial calcium [52]. Weinberg et al. conducted the original
research involving the successful resuscitation of rats in
whom cardiovascular collapse was induced with intravenous
bupivacaine [47], and these findings were successfully
repeated in a canine model of bupivacaine toxicity [50]. It
would take a further 8 years after publication of the original
animal studies before the appearance of the first clinical case
report of the successful use of lipid emulsion in the treatment
of bupivacaine-induced cardiac toxicity [48]. Its successful
use has subsequently been reported for the treatment of tox-
icity induced by ropivacaine [53], levobupivacaine [54], and Fig. 7.4 Pathway for use of Intralipid® in treating local anesthetic
mepivacaine [55, 56]. It has had a favorable outcome in the toxicity
108 D. Dillane
7.4.4 Prevention of Toxicity • In children over 30 kg, regardless of age, dose should be
reduced to adult dose.
Unintentionally high blood levels of local anesthetic lead • Local anesthetic doses need to be modified in the pres-
to a spectrum of neurological and cardiac complications ence of pathology which affects drug clearance (e.g., liver
with potentially devastating effect. This usually results or cardiac disease).
from unintentional intravascular injection and may be pre-
vented by careful observation of a number of safety steps.
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2013. p. 835–879.
Complications of Regional Anesthesia
in the Pediatric Population 8
Adam M. Dryden and Ban C.H. Tsui
Contents
8.1 General Principles 112
8.2 Adverse Events Related to Local Anesthetics 115
8.2.1 Allergic Reactions 115
8.2.2 Systemic Toxic Reactions 115
8.3 Complications Related to Regional Anesthesia Equipment 119
8.3.1 Introduction 119
8.3.2 Adverse Events Caused by Needles 119
8.3.3 Adverse Events Caused by Nerve Stimulators 124
8.3.4 Adverse Events Caused by Ultrasound Probes 124
8.3.5 Summary 124
8.4 Block Complications 125
8.4.1 Introduction 125
8.4.2 Complications of Peripheral Nerve Blocks 125
8.4.3 Complications of Neuraxial Blocks 126
8.4.4 Summary 127
Conclusion 127
References 129
A.M. Dryden, MD, FRCPC


DOI 10.1007/978-0-387-79964-3_8
112 A.M. Dryden and B.C.H. Tsui
8.1 General Principles for the procedure being done in the operating room or in a
dedicated block area. Again, the patient must have complete
An adverse event rarely occurs as a result of a single factor cardiopulmonary monitoring throughout all stages of the
(Fig. 8.1). Rather, complications occur as a result of an accu- block. Resuscitation equipment and drugs must be readily
mulation of factors spanning multiple domains. Thus, it is available wherever regional anesthesia is being performed.
critical that all steps be taken to mitigate risk as best as pos- Monitoring by well-trained staff must also be available in the
sible to decrease the likelihood of an adverse event. The most postanesthetic recovery unit. The nursing staff must be
important factors for prevention are the patient, the practitio- familiar with the blocks being performed and know when
ner, the place, the procedure, and, finally, proper consent and who to call for assistance. They must be able to reassure
(Table 8.1). the child who wakes up with inability to move or with numb-
Not all patients are ideal candidates for regional anes- ness from a block placed for postoperative analgesia. Finally,
thesia, and one needs to select their patient carefully staff should be able to recognize an adverse event as early as
(Table 8.2). A complete anesthetic history must be sought possible since early recognition and diagnosis will facilitate
prior to deciding which anesthetic options to offer the the best outcomes for the child.
patient and their family. Patient-specific contraindications The safest and least invasive procedure should be chosen
to regional anesthesia have been covered in other chapters. to accomplish a given task. As a general rule, distal blocks
In short, extra consideration must be given to patients with tend to produce fewer and less severe adverse outcomes than
respiratory difficulties, hemodynamic disturbances, cardiac proximal or central blocks. Regional anesthesia should be
abnormalities, clotting disorders, or preexisting neurologi- induced with as few needle passes as possible. To facilitate
cal conditions prior to offering a regional technique. One this, we always recommend the use of nerve stimulators and
must be prepared to detail the extraordinary risks of per- appropriate ultrasound probes (as detailed in each of the
forming a block in a patient who may have relative contra- block chapters) when possible. There has been much discus-
indications to a particular technique and to communicate sion in the literature attempting to characterize the additional
these risks to the family in a relevant manner. Preexisting level of safety offered by these technological advances,
deficits must be documented prior to undertaking a proce- although there is still insufficient evidence to support this
dure. Careful consideration must be given to the behavioral conclusion [1]. Despite this, block placement based solely
tendencies of a child when regional anesthesia is offered as on landmarks, paresthesia, and loss of resistance is difficult
the sole modality of anesthesia, and the practitioner must to endorse when these technological modalities have revolu-
be prepared to induce general anesthesia at any point should tionized the practice of regional anesthesia [2].
the child become uncooperative during the procedure. Finally, consent should be discussed with the patient and
When an awake block is placed in a pediatric patient, the the parents, and this discussion should be documented.
patient and parents should be given the option of having the Serious complications such as convulsions, cardiac toxicity,
parents present for reassurance and guidance during the spinal cord/nerve injury leading to paralysis or neurologic
procedure. Additionally, patients who are unable to tolerate deficit, pneumothorax, hematoma, infection, cardiac arrest,
a likely adverse event should not be offered a particular and death must be disclosed, although less than half of anes-
procedure (e.g., an interscalene block in a patient with poor thetists routinely disclose these risks prior to a neuraxial or
respiratory reserve). peripheral nerve block [3]. Less serious, but common, adverse
Prior to performing a block, the anesthetist should be effects (e.g., nausea, pruritus, urinary retention) should also
highly skilled in regional technique or be under the direct be disclosed. Pediatric patients should be as involved in the
guidance of a well-trained regional anesthetist. Familiarity discussion and decision as appropriately possible. The steps
with the equipment and the drugs alone are not enough to involved in performing a block must be explained in age-
facilitate a safe block. When performing a block, there are appropriate language; this is especially true should the block
always many possible outcomes, and the practitioner should be performed in an awake child. The decision to accept the
have the requisite skill to anticipate and manage each and risks of a regional anesthesia procedure ultimately lie with the
every one of the outcomes. Anesthetists performing regional parents and the child, and their views must be respected.
anesthesia in a pediatric patient should know how to use the Although time is often extremely limited, establishing good
technology and tools at hand to decrease the chances of an patient rapport is critical. This is especially true should an
adverse outcome. adverse event occur. Litigation often occurs with an adverse
Blocks must be placed in the safest environment possible. event in the setting of poor communication. Should an adverse
The majority of pediatric blocks are placed under general event occur, disclosure should be as immediate, thorough,
anesthesia, and as such the standard monitors must be placed and truthful as possible. The management plan for the com-
prior to the initiation of any block. For those regional tech- plication should be outlined with assurance that the best inter-
niques performed in the awake pediatric patient, we advocate ests of the child are paramount.
8 Complications of Regional Anesthesia in the Pediatric Population 113
Preparation for all regional techniques

• All equipment must be prepared and tested
• Adequate assistance should be available
• Provider must be familiar with the relevant anatomy and the technique being used
• Provider must be familiar with relevant practice, guidelines (e.g., ASRA anti-coagulant practice guideline)
• Patient must be appropriately monitored during initiation, maintenance, and recovery of technique
Technique considerations
• Currently, no evidence of superiority of ultrasound, peripheral nerve stimulation, or
monitoring injection pressures
• Consider a combined approach
Pediatric considerations
• Sedated or anesthetized during block performance
• Need to balance the risk of movement of an uncooperative and moving child with the loss of ability
of the child to report paresthesia
• Many children will not be able to report paresthesia regardless of alertness
• An inability to report and detect early CNS signs of toxicity
• Need to carefully watch cardiac signs of local toxicity
Congenital and pre-existing disease
Peripheral Neuropathy CNS Mass Lesions Previous Spinal Surgery

• e.g., diabetes, multiple sclerosis, peripheral • e.g., hematoma, abscess, tumor, spinal • Previous fusion injuries may make spinal
vascular disease stenosis, etc. anesthesia technically easier than placing an
• May have increased risk of worsening condition • High anesthetic volumes may increase mass epidural
due to PNB-induced injury effect • Ensure imaging is reviewed prior to initiation
• Carefully consider risks and benefits • Reported to have a higher risk of spinal cord
injury with neuraxial techniques Congenital Spinal Abnormality
CNS Disorders • Scoliosis, spina bifida, tethered spinal cord,
• e.g., multiple sclerosis, post-polio syndrome • Consider other perioperative anesthetic/
• Ensure imaging is reviewed prior to initiation
• Insufficient evidence of altered risk analgesic technique if feasible
• Carefully consider risks and benefits
Fig. 8.1 General principles for performing regional anesthesia in pediatric patients
Table 8.1 Maintaining a standard of care during regional anesthesia

practice
Maintaining standard of care
• Preoperative patient selection
• Appropriate parental and parent consent
• Using appropriate equipment and technique
• Monitoring regional anesthesia practice
• Accurate and meticulous anesthesia documentation
• Postoperative communication and follow-up visit
Table 8.2 Patient selection factors

Factors involved in patient
selection Relative contraindications Absolute contraindications
Patient cooperation Consider safety of maintaining catheter Parental and patient refusal
postoperatively when using a
continuous catheter technique
Anatomic and physiologic Anatomical anomalies; technical
considerations challenges: small structures
Anesthetic considerations Lack of experience and skills; lack of appropriate equipment for
performing the block (e.g., nerve stimulator, ultrasound, proper
size of needle); lack of appropriate equipment for resuscitation
and monitoring (e.g., oxygen, mask, drugs, etc.)
Coexisting diseases Preexisting progressive neurological Infection at the site of injection; allergy to local anesthetics;
disease; comatose states; sepsis; coagulopathy [although an International Normalized Ratio (INR)
coagulopathy of <2 is acceptable for ophthalmic procedures]
Surgical procedures Lengthy procedures that outlast the
duration of action of the local anesthetic
(single injection techniques – should
consider performing block at the end of
the procedure)
8.2 Adverse Events Related to Local and particular attention should be made to ventilator pres-
Anesthetics sures (in the ventilated child), as bronchospasm can occur
prior to hemodynamic alterations.
8.2.1 Allergic Reactions
8.2.1.3 Management
8.2.1.1 Introduction The management of an allergic reaction should be tailored to
True allergic reactions to local anesthetics are, thankfully, the presentation. For mild local reactions (e.g., pruritus, ery-
rare. The full spectrum of allergic signs and symptoms rang- thema), an antihistamine is often sufficient in children who
ing from skin irritation to anaphylaxis are indeed possible, cannot tolerate the symptoms. When the symptoms remain
though reports are scarce [4, 5]. The likelihood of an allergic mild but become systemic (e.g., nausea, vomiting), then one
reaction is higher with local anesthetics belonging to the should consider the addition of a corticosteroid to systemic
amino-ester class. Reactions to preservatives (e.g., methyl- and complete (i.e., H1 and H2 receptors) antihistamine
paraben, metabisulfite) are also possible [6]. blockade. Finally, true anaphylaxis (e.g., hypotension, bron-
chospasm) should be managed as per Pediatric Advanced
8.2.1.2 Prevention Life Support guidelines with maintenance of a patent airway,
Preventing a de novo allergic reaction is not possible. One supplemental oxygenation, and cardiovascular support, bear-
must, however, ensure that a detailed history is taken from ing in mind that anaphylaxis requires epinephrine (0.01 mg/
the patient and parents detailing previous exposures to local kg s.c. or i.m.) for successful treatment.
anesthetics (e.g., dentist’s appointments, emergency room
visits) and that the chart is reviewed for documented aller-
gies. When a family history of an allergic reaction to a local 8.2.2 Systemic Toxic Reactions
anesthetic is provided, the anesthetist should fully character-
ize the incident, including the offending agent and the conse- 8.2.2.1 Introduction
quence thereof. A positive family history does not preclude As with allergic reactions, severe systemic toxic reactions to
the use of a particular agent but should increase the level of local anesthetics are so exceedingly rare that quantification
vigilance in monitoring for a possible adverse event. of the risks of such a reaction is virtually impossible. In three
One can, however, prevent a mild local reaction from studies that attempted quantification, each with an excess of
transforming into an anaphylactic reaction with careful mon- 20,000 patients, the occurrence of such events was estimated
itoring and early intervention. As the majority of blocks are at less than 0.05 % [7–9]. The specific presentations included
performed in the deeply sedated or anesthetized child, care- in this category include cardiovascular disturbances (both
ful monitoring of the site of injection is required for early electrical and hemodynamic) as well as neural insults (sei-
recognition of local reactions. Continuous cardiopulmonary zures and neurotoxicity).
monitoring is required during the initial stages of a block,
8.2.2.2 Prevention
The pattern of systemic toxic reactions is no different in chil-
dren than it is in adults, but the presentation can be vastly
different. One of the major reasons for this is that when a
child is heavily sedated or anesthetized, initial irritability and
seizures will not be evident when performing initial blocks.
The first signs may in fact be dysrhythmias, hypotension, or Baseline ECG
even cardiac arrest. The ability to detect inadvertent intravas-
cular injection of local anesthetics is also altered in the pedi-
atric population. Resting heart rates in neonates and infants
are so high that a bolus dose of a local anesthetic with epi-
nephrine does not increase the heart rate to a reliably detect-
able level [10, 11]. Some advocate for vagolysis with atropine
prior to injection of epinephrine containing local anesthetic
to increase the sensitivity of intravascular injection, while Marked increase in T wave height after intravascular
others advocate for the use of isoproterenol [12, 13]. injection of bupivacaine with epinephrine
Monitoring T wave height may also provide an early warn-
ing system for a systemic toxic reaction (Fig. 8.2). Indeed, Fig. 8.2 Representative ECG readings showing normal baseline ECG
(top) and ECG after intravascular injection of local anesthetic (bottom).
detecting an increase in impedance with a nerve stimulator Monitoring T wave height can help warn of systemic local anesthetic
following an injection of D5W prior to the administration of toxicity
a local anesthetic can be used to rule out intravascular injec-
tion [14, 15]. At the very least, one must carefully aspirate
prior to the injection of a local anesthetic and repeat the aspi- Table 8.3 Signs of early accidental intravascular injection during con-
ration after any change in needle position. tinuous local anesthetic infusion
In any event, it is important for the clinician to recognize Early signsa Late signs
the early CNS indicators of inadvertent intravascular injec- • Light-headedness • Muscle twitching
tion, as they may occur during continuous anesthetic infu- • Tinnitus • Drowsiness
sion via peripheral or epidural catheters (Table 8.3). • Blurred vision • Generalized tonic-clonic convulsions
• Perioral numbness
a
Detection of these signs can be challenging due to communication bar-
riers with pediatric patients
8.2.2.3 Nervous System Toxicity 8.2.2.4 Cardiovascular Toxicity and Management

and Management Cardiovascular toxicity of local anesthetics is the final step in
The toxicity to the nervous system from local anesthetics the presentation of local anesthetic toxicity and, as such, is
comes in two forms: CNS toxicity (seizures) and local neural one of the rarest manifestations. In a prospective study per-
toxicity. Fortunately, the incidence of each remains rare. In formed by Giaufre et al. [9] of over 24,000 infants and chil-
two large studies, the incidence of seizures or convulsions dren, only four dysrhythmias (0.017 %) were reported, which
following any regional anesthesia in infants and children was is within the same order of magnitude reported by a previous
estimated at 0.01–0.05 % [9]. Case reports, however, are retrospective study [23].
present in the literature. In one of the first accounts of the use Local anesthetics exert their effect by blocking sodium
of a caudal block in children with lidocaine, convulsions channels. A portion of this block is a use-dependent block –
were reported in two children [16]. Seizures caused by bupi- the faster the sodium channels cycle through open, closed,
vacaine have been also reported in association with continu- and inactivated conformations, the higher the probability
ous infusions [17, 18] and after a top up [19]. that they will be blocked by the anesthetic. It is this same
The management of seizures induced by local anesthetics mechanism that contributes to the dysrhythmias induced by
remains unclear. There has been a case report of the success- local anesthetics. In case reports, the predominant pattern of
ful halting of a bupivacaine-induced seizure with a dose of presentation of cardiac toxicity in infants and children is
phenytoin [20]. Since the incidence is so low, it is difficult to ST-segment elevation followed by elevation of T waves and
devise standardized management recommendations. One subsequent bradycardia and ventricular dysrhythmias [11,
must always be guided by basic resuscitation principles (i.e., 24, 25]. Complete cardiovascular collapse follows [26].
circulation, airway, breathing). The particular agent used to The initial steps to managing a patient in which local
halt seizure activity will be guided by local practice patterns anesthetic systemic toxicity is suspected are no different than
and personal comfort – there is no conclusive evidence for any other resuscitation. Airway, respiratory, and
the use of phenytoin compared to benzodiazepines. There are cardiovascular support as outlined by Pediatric Advanced
early reports that the use of lipid emulsions may halt seizure Life Support should be followed. A helpful mnemonic,
activity in an adult patient [21], although this has not yet SAVED (Stop injection, Airway, Ventilation, Evaluate circu-
been reported in the pediatric population. This treatment lation, Drugs; Fig. 8.3), was published in the adult literature
modality has the advantage of possibly aborting the syn- and is also relevant in the pediatric population [27]. Once the
drome of local anesthetic systemic toxicity and preventing patient’s airway is appropriately controlled and the respira-
the development of life-threatening cardiovascular conse- tory status has been optimized, the next step is management
quences. Nevertheless, insufficient evidence exists for this of the cardiovascular toxicity. As the child presenting with
method to be uniformly recommended. cardiovascular toxicity is often bradycardic and hypotensive,
Local anesthetics are also directly toxic to neural struc- appropriate support in the form of fluid boluses (10–20 mL/
tures and can result in an irreversible blockade if used at high kg of an isotonic crystalloid), epinephrine (0.01 mg/kg), and
enough concentrations [22]. Reports suggestive of direct chest compressions should be provided.
local anesthetic toxicity are difficult to tease out of the litera- One of the more novel methods of treating cardiovascular
ture, and neurological injuries reported are more likely due toxicity is the use of a lipid emulsion such as Intralipid® (see
to direct injury by needles or ischemia from embolized air as Chap. 7). Recent studies demonstrate improved hemody-
a result of a loss of resistance technique. Some have sug- namics and survival in animal models of bupivacaine toxicity
gested that the young pediatric patient may, theoretically, be with the administration of intravenous lipid emulsion [28,
at a higher risk for neural toxicity as myelination is not com- 29]. There are two proposed mechanisms of action. One is
plete until at least two years of age. In children, there is that the lipid emulsions function to remove local anesthetic
always the possibility that our ability to detect neural injury molecules from binding sites responsible for cardiovascular
is lower since we must rely solely on clinical exams and depression [30], effectively acting as a “sink” for the anes-
parental history for detection. Furthermore, the plasticity of thetic drug. Evidence also exists that lipid emulsions act by
the nervous system is so great in these patients that the insult reversing the local anesthetic inhibition on myocardial fatty
may be fully recovered before it was ever detected. acid oxidation [31]. By doing this, they restore myocardial
Regardless, long-term morbidity is not evident from direct adenosine triphosphate supplies, allowing the cardiomyo-
toxicity from local anesthetics. cytes to regain normal electrical and mechanical function. In
the adult population, the use of lipid emulsions has been

reported to treat local anesthetic-induced cardiac arrest due Stop injection
to bupivacaine, levobupivacaine, ropivacaine, and mepiva-
caine [32–34]. The use of lipid emulsions in pediatrics has
only recently been reported. The first report of the use of
Airway
lipid emulsions in a pediatric patient was in a 13-year-old
girl by Ludot et al. [35]. Fifteen minutes after placing a pos-
terior lumbar plexus block with lidocaine and ropivacaine Airway inadequate
under general anesthesia, a wide, complex tachycardia was Likely to remain patent
noted and attributed to the use of local anesthetics. A 20 % or invasive airway
secure Provide airway (e.g.
lipid emulsion was administered at a dose of 3 mL/kg result- Intubation, LMA)
ing in the restoration of normal hemodynamic parameters
and a normalization of the electrocardiogram. Since then,
Shah et al. [36] have reported the successful use of a 20 % Ventilation
lipid emulsion at a dose of 2 mL/kg to reverse hypotension
and tachycardia attributed to the use of bupivacaine, which
was not responsive to two doses of epinephrine (0.02 mg/kg) Oxygenation and
ventilation inadequate
in a 40-day-old male infant. Currently, the upper limit of safe
dosing is unclear, and whether ideal dosing varies among Oxygenation and
ventilation adequate
neonates, infants, and children is still unclear. Moreover, Provide supplemental
whether doses need to be adjusted in those with comorbidi- oxygen (e.g. NC, NIPPV,
invasive ventilation)
ties has also not been elucidated. At this time, the recom-
mended dosing for Intralipid® 20 % is a bolus of 1.5 mL/kg
i.v. over 1 min, followed by infusion of 0.25 mL/kg/min. Evaluate Circulation
Compressions should be maintained to circulate the lipid.
Bolus doses can be administered every 3–5 min to a total of
3 mL/kg. Lipid emulsions should be administered (during Poor hemodynamic
resuscitation) to patients in cardiac arrest due to local anes- parameters
thetic toxicity and perhaps even preemptively to those exhib- Hemodynamics adequate
iting neurologic toxicity. Suport circulation (e.g.
compressions, fluid,
vasopressors)
Drugs
Use medications as appropriate:

• Lipid emulsion (administer early)
• Bolus of 1.5 ml *kg–1 iv over one minute
• Infusion of 0.25 mL*kg–1* min–1
• Repeat bolus q3-5 min to a total of 3 mL*kg–1
• Bronchospasm/Edema → antihistamines, corticosteroids,
bronchodilators
• Hypotension → fluid, epinephrine (10–100μg aliquots)
• Seizures → midazolam (0.05–0.1 mg*kg–1), propofol(0.5–
1.5 mg*kg–1), barbiturates (thiopentone [1–2 mg*kg–1])
• Ventricular arrythmias → amiodorone (300 mg initially,
followed by repeat 150 mg bolus 3–5 minutes later)
Fig. 8.3 The SAVED pathway for management of local anesthetic

systemic toxicity
8.2.2.5 Summary 8.3 Complications Related to Regional

Serious adverse events resulting from the use of local anes- Anesthesia Equipment
thetics remain quite rare. Management guidelines are as
scarce as the case reports which support them. That being 8.3.1 Introduction
said, when faced with a case of local anesthetic systemic tox-
icity or an allergic reaction, the consequences are dire and are Ideally, any piece of equipment introduced into our reper-
true anesthetic emergencies. Basic principles in the manage- toire will function to decrease the overall morbidity and mor-
ment of adverse events from local anesthetics include [37]: tality of performing any procedure. While many of the tools
used in regional anesthesia are designed to do just that, there
• Bronchodilators, antihistamines, and corticosteroids are are always new and sometimes unexpected complications
often required in the treatment of allergic reactions. introduced with every new piece of technology. We also can-
• Endotracheal intubation and ventilation are required to not ignore the fact that the basic instrument of regional anes-
correct acidosis and prevent hypoxia and hypercarbia, thesia, the hollow needle, is a fundamentally risky device.
which can further worsen the child’s condition. The reports of harm to children from the equipment routinely
• Profound hypotension can occur in both allergic reactions used to perform blocks are exceedingly rare, and the large
and systemic toxicity and can respond to fluid boluses and safety studies done to date in this patient population reveal
vasopressors (e.g., epinephrine). an excellent safety record.
• Decreased cardiac contractility is a core feature and can
be improved with epinephrine.
• Chest compressions and defibrillation are often required 8.3.2 Adverse Events Caused by Needles
to restore organ perfusion and should be instituted as
necessary. 8.3.2.1 Needle Trauma to the Peripheral Nerve
• Effective resuscitation in this setting is difficult, and atrio- In a prospective study of over 24,000 patients, not one
ventricular pacing and cardiopulmonary bypass are addi- permanent peripheral neural injury was reported as a result
tional options in refractory cases. of needle penetration [9]. In an adult population, Auroy et al.
• Lipid emulsion therapy can be lifesaving and can be con- [39] reported an incidence of permanent nerve injury caused
sidered early. Lipid emulsions should be available in loca- by peripheral nerve blocks to be about 0.02 %, and this find-
tions where local anesthetics are used in potentially toxic ing has been validated in a smaller, more recent study [40].
doses, regardless of the age of the patient [38]. Assuming that the incidence is similar in the pediatric popu-
• Seizures can be managed with benzodiazepines, propofol, lation, one would have expected that perhaps five to ten pedi-
barbiturates, or phenytoin. Lipid emulsions are an emerg- atric patients in large safety studies would have experienced
ing therapy for seizure treatment in this context. permanent neural injury, but this has not been the case. There
are several possible reasons for this. Perhaps our ability to
detect neural injury is diminished in the young child, as his-
tory may prove less reliable and is not available in the infant
or neonate. In the adult patient, neural injury is almost always
accompanied with paresthesia or pain upon injection of local
anesthetic, which raises suspicion of intraneural injection
and neural trauma. This reporting is not possible in the
sedated or anesthetized child and is perhaps unreliable in the
immature child; as a result, we do not go looking for tran-
sient or permanent neural injuries. In the adult patient, how-
ever, there is insubstantial evidence that performing nerve
blocks in awake patients results in less neural injury than
performing them in anesthetized patients [41]. It is also pos-
sible that the child’s immature nervous system is able to
adapt to a neural insult and recover function before it is
detectable.
Our ability to prevent peripheral neural trauma may
account for the low incidence. Needle selection is one par-
ticular method of prevention (Table 8.4). Common sense dic-
tates that damage caused by a small-gauge needle is less than
that caused by a larger-gauge one. The recommendation for
the use of blunt needles in regional anesthesia was made by be considered. Patient positioning, surgical trauma, and tour-
Selander et al. [42] in 1977. It was thought that blunt needles niquet application are all possible causes and must be con-
were less likely to penetrate neural structures and that resul- sidered. Neural injury caused by the needle may not
tant intraneural injections would be less likely. Although necessarily be due to laceration, but rather to high-pressure
there are no clinical trials supporting recommendations as to injections which may cause mechanical destruction of the
what type of needle is best for regional anesthesia proce- neural fascicular architecture, damage, and subsequent scar-
dures in any age range, small-gauge, short, blunt needles are ring [45]. As indicated previously in this chapter, the sub-
recommended if possible. The likelihood of neural damage stance being injected is also a potential source of injury.
can also be decreased with low injection pressures. Even if Thus, when a neurologic injury is suspected, a thorough
the needle is placed within the nerve sheath, the majority of history must be taken, a complete physical examination must
trauma may be related to the pressure of injection. Rapid, be performed and documented, and all stages of the operative
high-pressure injections should be avoided. A practical way period scrutinized. Consultation should be sought with neu-
to do this is to aspirate air above the injectate in a syringe and rological specialists to determine the best and quickest way
to monitor the volume of the air during injection using a to achieve a diagnosis. During this time, disclosure to the
compressed air injection technique (CAIT) (Chap. 1, Fig. patient and parents must be timely and thorough. Oftentimes,
1.9). Injection pressure should be decreased if the volume of imaging in the form of an MRI is the primary modality of
air decreases to less than half of its original volume [43]. diagnosis. The anesthesiologist, neurologist, neurosurgeon,
Finally, one would assume that one of the primary modalities and radiologist must work as a team to arrive at a diagnosis
of preventing neural injury would be to use either nerve before permanent injury occurs. Electrodiagnostic tech-
stimulation or ultrasound to rule out intraneural injection. niques (such as nerve conduction studies, electromyography
While we recommend the use of both of these technologies and evoked potentials) can also be useful under the guidance
(as described elsewhere in this book), it remains difficult to of a neurologist. Experience from the adult population sug-
prove that they in fact decrease intraneural injection and neu- gests that should a neurological deficit persist at the time of
ral trauma from needles [37, 44]. Neural damage as a result discharge, most will resolve in 4–6 weeks, and the majority
of peripheral nerve blocks is rare, and as such, demonstrating (>99 %) are resolved within one year. The paucity of reports
the safest approach will prove difficult. from the pediatric literature suggests that permanent periph-
As discussed in Chap. 2, recent literature has suggested eral nerve injury is almost unheard of.
that by measuring differences in electrical impedance of tis-
sues, it may be possible to distinguish between extraneural Table 8.4 Suggested methods/equipment for reducing nerve injuries
and intraneural injection during administration of peripheral when performing regional anesthesia
nerve blocks. This difference in impedance is thought to Methods/equipment for reducing the risk of nerve injuries
relate to the different tissue compositions and water contents • Needle type: small gauge, short beveled
of extraneural and intraneural tissue. However, further • Patient: awake with appropriate level of sedation
research is needed to determine whether this technique can • Nerve stimulation: use accurate nerve stimulators and insulated
be utilized in peripheral nerve blocks in humans as a method nerve needles (current ≥0.2 mA)
to avoid intraneural injection. • Ultrasound: direct visualization of nerves and surrounding
Regardless of the safety record of needles with respect to structures by using high-resolution ultrasound equipment if
available
the peripheral nerve, when neurological sequelae are present
• Paresthesia: injection should be stopped and needle repositioned if
in a child who has undergone a regional anesthesia proce- persistent
dure, it is the duty of the anesthesiologist to rule out iatro- • High injection pressure: avoid rapid and high-pressure injections
genic neural injury. Neural symptoms can include motor, (pressure <20 psi)
sensory, and autonomic dysfunction in a specific neural ter- • Local anesthetic: avoid high concentrations (i.e., lidocaine 2 % or
ritory. When these symptoms are found, other causes must bupivacaine 0.75 %)
8.3.2.2 Needle Trauma to the Spinal Cord anatomy involved for performance of a particular block.
Spinal cord injury following a peripheral or neuraxial block Even with technological aids, placing needles without the
is a feared complication. In the adult literature, there are prerequisite knowledge is tempting fate. Although difficult
multiple examples of permanent spinal cord injuries follow- to prove from the literature, techniques involving nerve stim-
ing peripheral nerve blocks [46–48]. There are, however, no ulation and ultrasound for monitoring needle tip placement
such case reports in the pediatric literature. In the 2010 are useful tools. As described in other chapters, both tech-
ADARPEF study, complications from over 30,000 regional niques can be used for a variety of peripheral and neuraxial
anesthesia procedures were reported over a 1-year period, procedures and have the potential to decrease the likelihood
and not one permanent spinal cord injury was reported [8]. of a devastating spinal cord injury.
This is in contrast to the reporting of one permanent neuro- Should it occur, there is no specific treatment for primary
logical deficit in a 3-month-old child in a study following needle damage to the spinal cord. When suspected, the initial
over 10,000 epidurals over a 5-year period [49]. step in the management of spinal cord injury is the recogni-
Prevention of needle trauma to the spinal cord is critical. tion and identification of neural dysfunction. It is important
In adults, most cases of permanent neuraxial injury involve to rule out acute and reversible causes of spinal cord injury
deviations from recommended practice. As such, when devi- (Fig. 8.4). This includes nerve compression from hemato-
ating from the standard practice, the anesthetist should con- mas, as they must be identified and dealt with early (within
sider it carefully and document the justification for doing so. 6–8 h) to avoid the development of permanent paraplegia or
One of the key ways of preventing neuraxial injury is to quadriplegia. All causes of neural injury must be investi-
increase the distance of the needle from the spinal cord by gated, including surgical causes (ligation of spinal cord ves-
performing a peripheral block. There are already reports [8] sels during abdominal or thoracic surgery, injury to the
of a large shift away from neuraxial techniques in favor of femoral nerve during pelvic surgery, injury to the lateral
peripheral blocks in pediatric regional anesthesia. One par- cutaneous nerve of the thigh during retraction near the ingui-
ticular institution reported a decrease in the use of neuraxial nal ligament, and fibular head pressure causing neurapraxia
anesthesia in pediatric patients from 97 to 24.9 % of cases of the lateral popliteal nerve), patient positioning, preexist-
over the past 17 years [50]. Although placement of epidurals ing conditions, and the regional anesthesia procedure. As
in anesthetized adults remains controversial [41, 51–53], it with peripheral nerve injuries, neurology and radiology spe-
seems quite clear that this practice is the accepted – and cialists must be consulted immediately and a team approach
safe – standard in the pediatric population. The reason for used to arrive at the correct diagnosis. Each of these special-
this disparity remains unclear. ties has a very useful body of knowledge when dealing with
Knowing the position of the needle tip at all times is key these situations. An emergent MRI is often used to arrive at
to the prevention of spinal cord injury. This begins with a the correct diagnosis, and management is often guided by the
well-studied technique and a detailed understanding of the consultant neurologist and neurosurgeon.
Fig. 8.4 Decision tree for

management of neural dysfunction Recognize and identify the neural
and possible spinal cord injury dysfunction
Perform and document a thorough

history and physical examination
Compare neurological status with

preoperative examination
Spinal cord process suspected?

Yes
No
Is the deficit improving? Urgent imaging (e.g. MRI)

Is the deficit mild?
Yes
No
Neurology or
Observe Consult neurology and image neurosurgery
consultation
Is the deficit progressing?

Yes
No
Observe for 2–3 weeks Consider exploratory

arrange follow-up EMG surgery
Is there significant axonal loss?

Yes
No
Physical therapy and Refer to peripheral nerve

rehabilitation for 3–5 months surgeon
No
Does the patient have acceptable
clinical recovery?
Yes
Observe
8.3.2.3 Needle Trauma to Pleura a

Regional techniques involving needles moving towards the
lung, particularly the supraclavicular approach, involve the
risk of pneumothorax. The risk of pneumothorax in the pedi-
atric population is difficult to quantify, and it is even difficult
to glean from the adult literature, with some studies report-
ing incidences in the range of 5 % and others quoting posi-
tive radiologic evidence in up to 25 % of patients [54, 55].
Other approaches to the brachial plexus are often sought for
this very reason. With the advent of ultrasound, there is
renewed interest in the supraclavicular block. In a series [56]
of 40 children (>5 years old), 40 ultrasound-guided supracla-
vicular blocks were placed without a clinically significant
pneumothorax, and Pande et al. [57] reported the successful
use of ultrasound in performing nearly 200 supraclavicular
blocks without incidence of pneumothorax. These studies
are too small to detect the true incidence but provide evi-
dence that the practice of supraclavicular blocks is being
revisited with some success. b
As always, a detailed understanding of the anatomy can
help prevent a pneumothorax. Simultaneously visualizing
the pleura and the needle moving towards the target can
decrease the likelihood of a pneumothorax. These blocks
should never be placed bilaterally. When performing high
risk blocks on patients scheduled for same-day surgery, the
signs and symptoms of pneumothorax (sudden onset chest
pain, shortness of breath) should be clearly conveyed to the
patient and parents, and they should be instructed to present
to their nearest emergency department should these symp-
toms occur. Using ultrasound to detect pneumothorax has
been well described in the adult population, but there is no
data for such use in the pediatric literature (Fig. 8.5).
In the event of a pneumothorax, the patient should be
placed on 100 % oxygen until stabilized, and positive pres-
sure ventilation should be halted as soon as feasible.
Continuous monitoring is required in the initial stages to rule
Fig. 8.5 Ultrasound images of lung sliding to assess for pneumotho-
out the presence of a tension pneumothorax leading to car- rax. Normal lung sliding (a) can be visualized on ultrasound; in the case
diovascular collapse. N2O should also be avoided as it can of needle trauma to the pleura, lung sliding can no longer be visualized
result in an increase in pneumothorax size. A chest tube or (b), suggesting possible pneumothorax
pleural catheter is often required if the lung has lost approxi-
mately one-fourth of its volume. Needle decompression may
be required in the event of a tension pneumothorax while
thoracostomy supplies are being prepared.
8.3.3 Adverse Events Caused by Nerve waves have the potential to transfer energy by increasing the
Stimulators rate of vibration of the substrate being examined. In fact, this
is a common therapeutic tool in physiotherapy. At the wave-
Patients undergoing a regional anesthesia procedure can lengths and powers typically used in regional anesthetic
describe the sensation from nerve stimulators in a variety of practice, this effect is negligible and there are no reports of
ways. Words such as “funny,” “tingly,” “tapping,” and some- an ultrasound-induced burn.
times even “pain” are used. Both patients and parents will Ultrasound probes may incite a false sense of security
often ask if the electricity from the nerve stimulator is harm- when placing an unfamiliar block, leading to unnecessary
ful in any way. There are no published reports of any harm risk. We advocate for the use of ultrasound whenever possi-
caused by nerve stimulators in any population. Nerve stimu- ble, but only in the hands of a practitioner who also has the
lators have the ability to malfunction, but there are no requisite anatomic and procedural knowledge coupled with
instances of electricity-induced burns or neurapraxia the experience (or under the guidance of an anesthetist with
reported. Nerve stimulators can therefore be considered a the experience) to place the block in the safest way possible
piece of equipment that only adds to the safety of the regional and to manage potential complications. Ultrasound probes
anesthetic procedure being performed. can also act as a fomite. We recommend following manufac-
turers’ guidelines to sterilize ultrasound probes between
patients and to always cover the ultrasound probe in a sterile
8.3.4 Adverse Events Caused by Ultrasound fashion when placing blocks (see Chap. 4).
Probes
Whenever an imaging modality is suggested, the potential 8.3.5 Summary

harm from ionizing radiation that has been publicized springs
to mind. This is especially true in the minds of parents look- Much of the potential harm in regional anesthesia arises
ing to prevent long-term sequelae from medical procedures. from the fundamental instrument, the needle. Until such time
As detailed in Chap. 3, ultrasound probes do not produce that we are able to deliver local anesthetics to target tissues
ionizing radiation; rather, they use high-frequency sound without tissue penetration, we must accept this risk and make
waves to generate echoes and subsequent images. Ultrasound every effort to mitigate it.
8.4 Block Complications techniques are described elsewhere in this book as an

accepted method of delivering local anesthetics. Preventing
8.4.1 Introduction vessel penetration is done with anatomical understanding
and visualization techniques (ultrasound). Prior to block
The use of regional anesthesia in pediatrics has been increas- placement, a history ruling out clotting disorders must also
ing dramatically over the past 20 years; as a result, we are be elicited, as regional anesthesia is relatively contraindi-
likely to see a higher number of complications. This is an cated in this patient group. In the event of a vascular punc-
emerging area of study. As it currently stands, there are a ture, the needle should be removed (oftentimes, the block
limited number of high-quality studies of significant enough can still be placed safely and effectively). Pressure should be
power to detect infrequent minor and major complications, applied to the site until bleeding ceases and the hematoma
and developing management guidelines is difficult. We must stops expanding. The site should be continuously monitored
draw on the experiences of our adult regional anesthesia col- throughout the case and in the postanesthetic care unit.
leagues and translate it to our patient group while continuing Pulses and compartment pressures should also be monitored
to build a body of literature to guide future actions. clinically distal to the site of hematoma to rule out compart-
ment syndrome (Table 8.5). Should compartment syndrome
be suspected, orthopedic surgery and plastic surgery should
8.4.2 Complications of Peripheral Nerve be consulted for diagnosis and management. In the case of
Blocks admitted patients, an order should also be left for the nursing
unit to continue intermittent monitoring of limb pulses, pain,
8.4.2.1 Phrenic Nerve Paralysis and Paresis pressure, and paresthesia as the block fades. For same-day
These complications have gone unreported in the pediatric surgery patients, these same instructions should be given to
literature despite the overwhelming incidence in the adult the caregivers of the child.
literature. Estimates of temporary hemidiaphragmatic pare- Serious complications arising from peripheral hemato-
sis following supraclavicular and interscalene blocks range mas are rare. The only significant reporting of hematomas
in the order of 50–100 % [58]. A permanent phrenic nerve in the pediatric population following peripheral nerve
palsy has even been reported as a result of an interscalene blocks are those following dorsal penile nerve blocks. The
block [59]. The difference in patient and block selection most recent Cochrane Review of dorsal penile nerve blocks
likely explains the absence of reports in pediatric patients. revealed that there were no serious sequelae as a result of
There were an insufficient number of blocks above the clav- hematomas [62]. There has also been a report of a bowel
icle in a group of over 2,000 pediatric patients to even report wall hematoma following an ilioinguinal-iliohypogastric
[8]. Should these blocks be performed, some evidence exists nerve block in a 6-year-old girl without serious conse-
that using low volumes of local anesthetics, coupled with quences [63].
ultrasound guidance, can decrease the risk of hemidiaphrag-
matic paralysis [60]. Bilateral blocks above the clavicle are
contraindicated. Recently, it was demonstrated that a bolus
injection of normal saline through an interscalene catheter Table 8.5 Causes of compartment syndrome
originally used for a brachial plexus block was sufficient to Causes of compartment syndrome
resolve inadvertent phrenic nerve palsy and restore diaphrag- • Excessive tourniquet pressures
matic function [61]. • Allergic reactions
• Undiagnosed Raynaud’s disease
8.4.2.2 Hematoma and Subsequent Sequelae • Sickle cell disease
Inadvertent puncture of blood vessels while performing • Intra-arterial injection
peripheral nerve blocks is relatively common. Transarterial • Drug administration error
8.4.2.3 Bacterial Infection surgical consultation is recommended for consideration of

Any time the skin is penetrated with a foreign object, there is abscess drainage. While the overall infection rate associated
the potential for the introduction of an infection. Preventing with caudal epidural catheters is quite low, fixing the catheter
bacterial infection is done by ensuring the block is placed in with an occlusive dressing in a cephalad direction is recom-
a clean environment (either an operating room or a dedicated mended to reduce the risk of contamination by stool and
block room). Sterile technique must be used at all times with urine [68, 69].
the patient and tools draped and covered appropriately.
Patients and their parents should be warned of the potential 8.4.3.3 Total Spinal Anesthesia
for infection and should report to a medical caregiver should An excessive dose of local anesthetic injected into the sub-
the child develop localized erythema, pain around the punc- arachnoid space results in total spinal anesthesia. Typically,
ture site, fevers, chills, or purulent discharge. Infections can this is the result of an unintentional injection of a dose of
be treated as per local antibiotic guidelines with drainage of local anesthetic intended for the epidural space. It may also
abscesses as required. The actual risk of infection in the set- be seen when a small epidural dose or a large spinal dose of
ting of sterile technique and peripheral nerve blocks in pedi- local anesthetic enters the subarachnoid space. Minimizing
atric patients has yet to be quantified. this adverse event is possible with the use of ultrasound as
well as nerve stimulation (Chap. 2, Table 2.2) [70]. In adult
patients, total spinal anesthesia is seen in 0.2 % of patients
8.4.3 Complications of Neuraxial Blocks undergoing epidural anesthesia [71]. Out of 1,100 pediatric
epidurals, one child experienced a total spinal anesthetic [8].
8.4.3.1 Hematoma This was recognized in the recovery room as the child did
Epidural hematoma following neuraxial anesthesia is rare. The not initiate spontaneous breathing and was treated success-
incidence is estimated to be less than 1 in 150,000 cases of neur- fully with 4 h of monitored ventilation. Inability to breathe,
axial anesthesia in adult patients [64]. Although specifically tai- combined with possible hemodynamic instability, is the typi-
lored for the adult population, guidance from the American cal presentation pattern. Resuscitation with endotracheal
Society of Regional Anesthesia is available [64]. In the pediatric intubation, mechanical ventilation, and vasopressor therapy
literature, reports are scarce and none of the large pediatric stud- may be required. Recovery may take between 30 min and
ies have demonstrated this risk, although they are likely insuf- 6 h, depending on the agent used and the dose administered.
ficiently powered if the incidence is in the range of 0.0007 %, as Cerebrospinal fluid lavage via an epidural catheter has been
in the adult population. Should the child experience bilateral used to successfully treat a total spinal in a 14-year-old child
lower limb weakness with back pain, consideration should be [72]. In this case, the patient recovered within 30 min.
given to a centrally compression lesion. MRI is the primary
modality of diagnosis and early neurology and neurosurgical 8.4.3.4 Subdural Injections
consultation is advised, lest the deficit become permanent. The subdural space is a potential space between the dura and
the arachnoid that extends from the level of the second sacral
8.4.3.2 Infection vertebra up to the floor of the third ventricle. The subdural
Epidural abscesses are a rare but potentially devastating space differs from the epidural space in that it is both extra-
complication. In the adult literature, the incidence has been and intracranial. This space envelops the cranial and spinal
estimated at between 0 and 0.005 % [65, 66]. Large studies nerves for a short distance and is widest in the cervical area.
in the pediatric population have failed to show any cases of The incidence of subdural injections of local anesthetic drugs
epidural abscesses [8]. There were, however, two reports of is reported to range from 0.1 to 0.8 % [73], although it is
epidural abscesses in the UK audit of over 10,000 epidurals infrequently reported in the pediatric population. The epi-
[49]. Presentation is variable, but one should be suspicious if dural stimulation test can provide information about the loca-
a child complains of back pain with localized tenderness and tion of the needle or catheter in the subdural space [74, 75].
fever developing days after the puncture. Leukocytosis can When suspected a radiopaque dye can be used to diagnose
also be present. The consequences of an unrecognized subdural catheter placement. The progression of the block in
abscess are dire; progressive weakness and paraplegia can a subdural injection is variable and can present as a “patchy”
develop if untreated. Meningitis may also develop, a case of block with a slow onset of motor and sensory blockade.
which was also reported in the UK study [49]. Antibiotic Respiratory insufficiency is possible and supportive ventila-
regimes should be tailored to local guidelines. When the tips tion and sedation can be required until the block subsides.
of caudal catheters were cultured, Gram-negative bacteria
were present, with Staphylococcus epidermidis being the 8.4.3.5 Post-Dural-Puncture Headache
most common microorganism colonized on the skin and Post-dural-puncture headache (PDPH) is a relatively com-
catheters of lumbar and caudal epidurals [67]. Prompt mon phenomenon in the adult population. It was previously
thought that PDPH did not occur in the pediatric population lumbar punctures for chemotherapy [88]. A lumbar EBP has
[76]. Possible explanations previously offered included been performed in a 7-year-old child [85]. Furthermore,
lower CSF pressure, lower hydrostatic pressure when there has been one case reported of cervical dural puncture
upright, and differences in the elasticity of the dural matter in treated successfully with a lumbar EBP [89]. A CSF leak of
these different age groups. This, however, has proven untrue. 5 weeks’ duration in a 3-year-old child was quickly and suc-
In fact, the incidence of PDPH in children is quoted between cessfully treated with an EBP after repair was attempted with
2 and 15 % [77]. invasive techniques [90]. When performed successfully, pain
The symptoms of PDPH remain the same in the pediatric dissipates within 10–15 min. This procedure is not without
population. The International Headache Society defines a risk, and side effects such as transient bradycardia, lumbo-
PDPH as a headache occurring within 7 days of a lumbar vertebral syndrome, and facial palsy have been reported
puncture and resolving within 14 days and is worse in the [91–94].
upright position [78]. Other symptoms may include nausea,
vomiting, and various optical and auditory phenomena. The 8.4.3.6 Hypotension
primary difference between the two populations is the ability Hypotension following neuraxial blockade in young pediat-
to verbalize these symptoms. Children may exhibit a wide ric patients is almost unheard of [95]. This is likely due to the
range of behaviors instead of vocalizing and describing their immaturity of the autonomic nervous system and decreased
symptoms. Thus, children should be questioned routinely reliance on sympathetic tone to maintain blood pressure. As
following dural puncture, and caregivers should be provided such, hypotension following neuraxial blockade should
information on possible manifestations of PDPH. prompt the practitioner to consider other such causes, includ-
Prevention of PDPH is possible with knowledge of the ing those related to surgery and other unrecognized bleeding,
factors that influence the incidence of PDPH. In pediatrics, local anesthetic toxicity, anaphylaxis, and total spinal anes-
links have been demonstrated between headaches and needle thesia. In the older adolescent, a decrease in blood pressure
gauge, bevel design, and orientation. The importance of can be seen following a neuraxial block and should be treated
bevel orientation was demonstrated following dural penetra- as it is in adults, with fluids, positioning (Trendelenburg),
tion with an epidural needle and confirmed in a study show- and sympathomimetics.
ing no difference in the incidence of PDPH when comparing
22G and 25G needles, as long as the bevel was oriented ver-
tically [79, 80]. Needle design is also a factor in the develop- 8.4.4 Summary
ment of PDPH; blunt-pointed needles (e.g., Sprotte,
Whitacre) are linked to a reduced incidence of PDPH as Complications from neuraxial blocks in pediatric patients
opposed to sharp, cutting-point needles (e.g., Quincke). This are surprisingly rare, and there are almost no reports of mor-
has been demonstrated in the pediatric population [77]. tality as sequelae. However, the recent ADARPEF study
Initial treatment is to utilize conservative measures such indicates that the complication rate of central blocks is six
as bed rest and oral hydration, despite little evidence to sup- times higher than that of peripheral blocks [8]. Given this
port them. Analgesics (acetaminophen, nonsteroidal anti- fact, peripheral blocks must always be considered for anes-
inflammatories) can also be used for symptomatic treatment. thesia. Management of the majority of these complications
Caffeine can also be used and has been shown to be effective remains supportive, and in the event of a space-occupying
in the adult population, although there is some controversy lesion (abscess or hematoma), consultation with neurology
[81, 82]. Autologous epidural blood patching (EBP), intro- and neurosurgical specialists should be considered early.
duced by Gormley in 1960, remains one of the most effective
treatments for PDPH [83]. Success rates for EBPs are Conclusion
approximately 85 % and rise to 98 % after a second patch. It A review of the potential complications of pediatric
has suggested that the blood acts as a sealant, plugging the regional anesthesia is provided. In this relatively under-
hole created by the needle, thus preventing further CSF leak- studied group, new complications will emerge as sample
age. Another possibility is the counterpressure theory sizes increase and more patients are offered regional anes-
whereby the injected blood increases the epidural pressure thesia. In the interim, we must take some of our guidance
increasing CSF pressure. from our adult regional anesthesia colleagues. Fortunately,
EBPs are not commonly reported in the pediatric popula- the practice of regional anesthesia in pediatrics is quite
tion. Case reports have suggested the use of between 3 and safe. Reports of adverse events are few and far between,
8.5 mL, and a small series in adolescents suggested using a and those that do exist are rarely associated with long-
volume of 0.2–0.3 mL/kg [84–87]. A caudal blood patch has term consequences. Every effort must be made to main-
been reported by Kowbel in a 4-year-old child who devel- tain this excellent safety record. We can prevent
oped a subarachnoid cutaneous fistula following repeated complications by carefully selecting our patients, ensur-
ing that practitioners are well trained, that areas in which by both the patient and caregivers. Management and
blocks are performed are the safest possible, that the saf- assessment must be carried out promptly whenever any
est procedure is chosen, and that proper consent is given complication is suspected (Table 8.6).
Table 8.6 Suggested steps for evaluating neurological injury

Suggested steps involved in evaluating neurological injury
• Recognize and identify the neural dysfunction
• The history of any new or intensifying neural dysfunction in the absence of further anesthetic injection must be considered as a warning sign
of possible neural injury
• When neural damage is suspected, a careful history assessment and a physical examination must be carried out promptly
• The sequence and onset of the symptoms must be determined
• The nature of pain, motor weakness, sensory deficit, and sphincter control should be compared to information obtained preoperatively about
the patient’s baseline neurologic status; such information may provide clues to the cause of injury and appropriate management
• Symptoms/signs of spinal cord compression must be dealt with urgently (within 6–12 h); otherwise, permanent paraplegia or quadriplegia
may occur
• A thorough postoperative follow-up should be completed, even if a neurologic injury is not suspected
• Consider surgical causes:
◦ Surgical trauma to neural structures from retractors, a scalpel blade, or tension within the surgical site may not have been mentioned to
the anesthesiologist
◦ Long-acting local anesthetics may have been injected by the surgeon
◦ Compartment syndrome resulting from edema or bleeding around the wound caused by dressings or casts can compromise neural function
◦ Vascular injury during the surgery could result in nerve injury (e.g., spinal cord injury after thoracic aneurysm repair). Because of this, it
is probably desirable to let the block subside after aortic surgery
◦ Patient positioning must be reviewed to rule out direct pressure (e.g., peroneal nerve at the fibular head) or tension on nerves (e.g., traction
on the brachial plexus from hyperextension of the shoulder during thoracotomy); improper patient positioning may produce nerve injury
that might otherwise be attributed to a regional anesthetic mishap
• Consider anesthetic causes:
◦ The details of anesthesia management should be thoroughly reviewed, especially if portions of the anesthetic care were delivered by other
anesthesiologists
◦ Drug choice, dose, and last time of administration should be recorded
◦ Duration of nerve blockade should be noted; a long duration of blockade can result in neural injury
◦ High concentrations of agents probably increase the risk of neural complications
◦ Multiple nerve-blocking attempts can increase the risk of injury
◦ In awake patients, the presence of paresthesia during needle insertion and the subsequent injection of local anesthetic can be a warning
sign indicating neural injury
◦ For cooperative teenagers, the level of sedation must be appropriate without compromising the ability to observe a paresthesia. In younger
patients, regional anesthesia often needs to be performed under general anesthetic
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Part III
Clinical Anatomy
Clinical Anatomy of the Head and Neck
9
Glenn Merritt, Anil H. Walji, and Ban C.H. Tsui
Contents
9.1 Clinical Anatomy of Trigeminal Nerve 136
9.1.1 Ophthalmic Nerve (V1 Division of the Trigeminal Nerve, Pure Sensory) 138
9.1.2 Maxillary Nerve (V2 Division of the Trigeminal Nerve, Pure Sensory) 140
9.1.3 Mandibular Nerve (V3 Division of the Trigeminal Nerve, Sensory and Motor
to Muscles of Mastication) 142
9.2 Clinical Anatomy of the Cervical Plexus 142
9.3 Clinical Anatomy of Occipital Nerves 145
9.3.1 Lesser Occipital Nerve (C2) 145
9.3.2 Greater Occipital Nerve (C2) 146
9.4 Clinical Anatomy of the Nerve of Arnold 146
G. Merritt, MD
Department of Anesthesiology, University of Colorado Hospital
and Children’s Hospital Colorado, Aurora, CO, USA
A.H. Walji, MD, PhD
Division of Anatomy, Department of Surgery,
Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, AB, USA
2-150 Clinical Sciences Building, Edmonton,
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_9
136 G. Merritt et al.
9.1 Clinical Anatomy of Trigeminal Nerve exiting the skull through the foramen rotundum, the max-
illary nerve courses anteriorly over the pterygopalatine
• The trigeminal nerve (cranial nerve V), the largest of the fossa and enters the floor of the orbit through the infraor-
cranial nerves, is fundamentally the sensory nerve of the bital fissure as the infraorbital nerve; the infraorbital
head and supplies sensory innervation to the entire face nerve courses in the infraorbital canal, and descending
all the way from the lambdoidal suture on the vertex of branches include the greater palatine, lesser palatine, and
the skull to the bottom of the chin. Of its three major divi- nasopalatine and superior alveolar nerves. The mandibu-
sions, the ophthalmic and maxillary nerves are purely lar nerve courses into the infratemporal fossa through the
sensory, while the mandibular nerve is a mixed sensory foramen ovale and divides into its two major branches,
and motor nerve, the motor fibers being distributed pri- the lingual nerve and inferior alveolar nerve. The termi-
marily to the muscles of mastication. In addition, the tri- nal branches of these three divisions, destined for the
geminal nerve acts as a conduit for postganglionic face, namely, the supraorbital, infraorbital, and mental
parasympathetic fibers from the ciliary, pterygopalatine, nerves, exit the skull through the supraorbital, infraor-
mandibular, and otic ganglia in the head. The pregangli- bital, and mental foramina, respectively, and usually lie
onic fibers destined for these ganglia arise from the ocu- vertically in-line with each other in the plane of the pupil
lomotor nerve (for the ciliary ganglion), facial nerve (for (neonate, Fig. 9.2a; adolescent, Fig. 9.2b). The greater
the pterygopalatine and submandibular ganglia), and palatine, lesser palatine, and nasopalatine nerves exit the
glossopharyngeal nerve (for the otic ganglion). palate through corresponding foramina of the posterior
• The sensory and motor roots of the trigeminal nerve arise aspect of the secondary palate and anterior aspect of the
from the ventral aspect of the base of the pons. Sensory primary palate. Although the terminal branches are the
branches are sent to the large semilunar (trigeminal, semi- nerves that we focus on for many common regional anes-
lunar, or Gasserian) ganglion, which lies in a shallow thesia blocks, it is important to remember that each of the
depression, recess, or cleft in the meningeal layer of dura trigeminal divisions send branches internally to supply
(trigeminal or Meckel’s cave; trigeminal fossa) in the the oral and nasal mucosa as well as the mucosa of the
middle cranial fossa on the dorsal surface of the petrous paranasal sinuses external branches to supply the lateral
temporal bone near its tip or apex. The ganglion’s anterior aspect of the face.
aspect gives rise to three main divisions: the ophthalmic
(V1), maxillary (V2), and mandibular (V3) nerves
(Fig. 9.1).
• A smaller motor root lies underneath the main trigeminal
ganglion and supplies motor fibers to the mandibular
nerve. These motor fibers supply mostly the muscles of
mastication, namely, the masseter, temporalis, medial and Ophthalmic n.
lateral pterygoids, as well as the anterior belly of the

digastric, mylohyoid, tensor tympani, and tensor veli
palatini muscles.
• The three major divisions of the trigeminal nerve exit the
Maxillary n.
cranium through three distinct foramina – the ophthalmic Gasserian
ganglion
nerve enters the orbit through the superior orbital fissure,
where it divides into its three main branches, the frontal, Mandibular n.
lacrimal and nasociliary nerves. The maxillary nerve
passes through the foramen rotundum to cross over the Fig. 9.1 Major branches of the trigeminal nerve: ophthalmic, maxil-
top of the pterygopalatine fossa and then enters the floor lary, and mandibular nerves. The roots of the trigeminal nerve arise
of the orbit through the inferior orbital fissure. After from the base of the pons and form the Gasserian ganglion
9 Clinical Anatomy of the Head and Neck 137
a b
Fig. 9.2 Neonate (a) and adolescent (b) skull models depicting three through the supraorbital foramen (SO), infraorbital foramen (IO), and
distinct foramina, through which branches of the trigeminal nerve exit mental foramen (M), respectively
the cranium. The ophthalmic, maxillary, and mandibular nerves exit
9.1.1 Ophthalmic Nerve (V1 Division • The supratrochlear nerve traverses the orbit along the
of the Trigeminal Nerve, Pure Sensory) same plane as the supraorbital nerve but just medial to it,
passes over the trochlea, and enters the front of the face
• The uppermost ophthalmic branch of the trigeminal nerve via the frontal notch (or just medial to the supraorbital
is a pure sensory nerve and passes through the superior foramen or notch). It then courses superiorly into the fore-
orbital fissure (sphenoidal fissure) into the orbit. head. As it passes through the orbit, the nerve sends a
• The nerve divides into three main branches – lacrimal, branch to join the infratrochlear branch of the nasociliary
frontal, and nasociliary – just prior to entering the orbit nerve. This nerve supplies sensation to the medial part of
through the superior orbital fissure. the upper eyelid, the conjunctiva, and the lower-middle
• The lacrimal nerve is the smallest of the three divisions. It forehead (Fig. 9.4).
enters the orbit through the superior orbital fissure and • The nasociliary nerve is the intermediate branch (in
communicates with the zygomaticotemporal branch of terms of size) of the frontal nerve and passes obliquely
the maxillary nerve. It courses through the lateral aspect through the orbit to reach its medial aspect. Its anterior
of the orbit over the lateral rectus muscle. The lacrimal and posterior ethmoidal branches pass through the eth-
nerve then enters the lacrimal gland and innervates it with moidal foramina to enter the cranium. The nerve then
parasympathetic secretomotor fibers (from the zygomati- travels on the upper surface of the cribriform plate of the
cotemporal nerve) and the adjoining conjunctiva with ethmoid bone underneath the dura mater and descends
sensory fibers. The nerve eventually pierces the orbital through a slitlike opening in the crista galli to enter the
septum to innervate the skin of the lateral aspect of the nasal cavity. The nasociliary nerve supplies two internal
upper eyelid, joining with filaments from the facial nerve. nasal branches that innervate the lateral wall of the nasal
• The division’s largest branch, the frontal nerve, courses cavity and the mucous membrane of the front part of the
anteriorly through the orbit along the upper surface of the nasal septum.
levator palpebrae superioris muscle and bifurcates into its • The ethmoidal branches also supply the mucosa lining
terminal sensory branches, the larger supraorbital nerve the ethmoid air cells. The posterior branch leaves the orbit
laterally and the smaller supratrochlear nerve medially. through the posterior ethmoidal foramen and innervates
• The supraorbital nerve courses anteriorly between the the sphenoidal sinus. The nasociliary nerve terminates in
levator palpebrae superioris and the periosteum of the the infratrochlear and anterior ethmoidal branches; the
orbital roof, continues anteromedially towards the troch- former supplies the conjunctiva and skin of the medial
lea, exits the orbit through the supraorbital foramen (or aspect of the upper eyelid, while the latter supplies the
notch in some cases), and finally curves superiorly into anterior and middle ethmoid cells and then sends two
the forehead before branching into its medial and lateral internal branches that innervate the mucous membranes
branches. Anesthesia of the supraorbital nerve blocks the of the front part of the nasal septum and lateral nasal wall.
conjunctiva and skin of the upper eyelid as well as the The anterior ethmoidal branch eventually exits the face as
ipsilateral upper forehead as far back as the lambdoidal the external nasal nerve, which innervates the skin of the
suture (Figs. 9.3 and 9.4). It also supplies sensory fibers to nasal ala and apex of the nose.
the mucous membrane of the frontal air sinuses.
Fig. 9.3 Cutaneous innervation

by the trigeminal nerve and cervi-
cal plexus
Fig. 9.4 Cutaneous innervation

by the trigeminal nerve, cervical
plexus, and dorsal nerve roots
9.1.2 Maxillary Nerve (V2 Division maxilla to course under the mucous membrane of the
of the Trigeminal Nerve, Pure Sensory) maxillary sinus which it supplies. The posterior, anterior,
and middle superior alveolar (dental) nerves form the
• The maxillary nerve, like the ophthalmic, also contains superior dental plexus, which innervates the maxillary
purely sensory fibers. It exits the skull through the teeth and gingivae. Together with the infraorbital nerve,
foramen rotundum, courses beneath the skull base anteri- these superior alveolar nerves also supply sensory inner-
orly, and crosses over the upper part of the pterygopala- vation to the mucosa lining the maxillary sinus.
tine (sphenopalatine) fossa (medial to the lateral pterygoid • The palatine nerves (Fig. 9.6), the greater (anterior) and
plate on each side) before entering the orbit through the lesser (middle and posterior), are the terminal sensory
inferior orbital fissure as the infraorbital nerve (Fig. 9.5). endings of the maxillary nerve and emerge as branches
• Suspended from the nerve as it courses over the pterygo- from the pterygopalatine ganglion. The sensory fibers
palatine fossa is the parasympathetic pterygopalatine, or within them pass through the ganglion without synapsing.
more commonly called sphenopalatine ganglion, which They are distributed to the roof of the mouth, the soft pal-
lies within the fossa. Several branches of the maxillary ate, the palatine tonsil, and the mucous membrane lining
nerve appear to arise from the pterygopalatine ganglion; the nasal cavity. The branches descend through the ptery-
however, the nerve fibers within them simply pass through gopalatine (greater palatine) canal and emerge on the hard
the sphenopalatine ganglion without synapsing. Although palate; the anterior branch emerges through the greater
they seem to be branches of the ganglion, they are in real- palatine foramen (Fig. 9.6), while the middle/posterior
ity branches of the maxillary nerve just coursing through branches emerge via a minor/lesser palatine foramen (an
the ganglion and very intimately associated with it. opening behind the greater palatine foramen). The sen-
• During its course through the infraorbital groove and/or sory supply of the greater branch includes the gums and
canal in the floor of the orbit, the maxillary nerve gives off the mucosa and glands of the hard palate; the sensory sup-
two superior alveolar (dental) branches (the middle and ply of the lesser branches includes the uvula, the tonsils,
anterior superior alveolar nerves) that supply the maxil- and the soft palate.
lary teeth and gingivae before terminating as the infraor- • Nasal branches (also arising from the ganglion) enter the
bital nerve, which surfaces onto the face through the nasal cavity through the sphenopalatine foramen to be
infraorbital foramen (Fig. 9.5). distributed in lateral and medial groups to the posterior
• The middle and anterior superior alveolar (dental) nerves aspects of the superior and middle nasal conchae laterally
arise from the main trunk of the nerve as it passes through and the posterior part of the roof of the nasal septum
the infraorbital groove and/or canal, while the posterior medially. The largest of these nerves is the nasopalatine
superior alveolar nerve is given off just before it enters (long sphenopalatine) nerve which courses anteroinferi-
the floor of the orbit. The nerve pierces the infratemporal orly on the nasal septum and then descends through the
surface of the maxilla to run under the mucous membrane incisive foramen in the anterior aspect of the hard palate
of the maxillary sinus, which it supplies. It then breaks up to be distributed to the roof of the mouth (Fig. 9.6).
into small branches to form the posterior part of the • The pharyngeal nerve arises from the posterior aspect of
superior dental plexus to supply the maxillary molars. the pterygopalatine ganglion and courses through the pal-
Branches given off from within the pterygopalatine fossa atovaginal canal to supply the mucosa of the nasopharynx
include the zygomatic nerve to the orbit (with its zygo- just posterior to the opening of the Eustachian (auditory,
maticotemporal and zygomaticofacial branches), the pharyngotympanic) tube.
short sphenopalatine (pterygopalatine) nerves, and the • The terminal infraorbital nerve passes through the infe-
posterior superior alveolar (dental) nerve (Fig. 9.5). rior orbital fissure into the floor of the orbit, where it
• The zygomaticofacial nerve passes along the infero- courses through the infraorbital groove and/or canal
lateral aspect of the orbit and exits through a foramen in (just below the eye and lateral to the nose), and reaches
the zygoma to supply the skin on the cheek. The zygo- the facial surface of the maxilla. It then divides into the
maticofacial nerve merges with nerve fibers from the pal- inferior palpebral nerves (lower eyelid), external and
pebral branches of the maxillary nerve and zygomatic internal nasal nerves (wings or ala of the nose), and
branches from the facial nerve to form a plexus. The zygo- medial and lateral branches of the superior labial nerve
maticotemporal nerve sends a branch to join the lacrimal (upper lip).
nerve, providing parasympathetic, secretomotor innerva- • The infraorbital nerve innervates the lower eyelid and
tion to the lacrimal gland. The posterior superior alveolar upper lip, including the philtrum, the lateral portion of the
nerve also arises high in the pterygopalatine fossa before nasal cavity and the skin of the cheek. Blockade of the
the maxillary nerve enters the infraorbital groove. The infraorbital nerve produces anesthesia of the middle third
nerve then pierces the infratemporal surface of the of the ipsilateral face (Fig. 9.5).
Fig. 9.5 Anatomy of the

maxillary and mandibular nerves Inferior orbital fissure
Maxillary n. Zygomatic n.
Mandibular n.
Inferior palpebral n.
Infraorbital n.
Nasal n.
Auriculotemporal n.
Superior labial n.
Pterygopalatine fossa
Posterior superior
Inferior alveolar (dental) n. alveolar (dental) n.
Short sphenopalatine
Mylohyoid n. (pterygopalatine) n.
Incisive foramen Nasopalatine n.
Nasopalatine n.
Anterior and middle
superior alveolar
branches
Greater palatine n.
Greater palatine n.
Posterior superior
Greater palatine alveolar branches
Fig. 9.6 Left side: the greater and foramen
lesser palatine nerves emerge on the
hard palate from the greater and
lesser palatine foramen,
respectively. The nasopalatine nerve
emerges from the incisive foramen. Lesser palatine foramen
Right side: sensory innervation of Lesser palatine n.
the hard palate Lesser palatine n.
9.1.3 Mandibular Nerve (V3 Division 9.2 Clinical Anatomy of the Cervical
of the Trigeminal Nerve, Sensory Plexus
and Motor to Muscles of Mastication)
• The cervical plexus is a mixed spinal nerve plexus in the

• The mandibular nerve is the third and largest branch of neck formed from the anterior (ventral) rami of the first
the trigeminal and the only mixed nerve (i.e., with both a four cervical nerves.
sensory and a motor component). It exits the skull poste- • Sensory and motor fibers supplying the neck and poste-
rior to the maxillary nerve (Fig. 9.5) through the foramen rior scalp arise from these four cervical (C1–C4) spinal
ovale, enters the infratemporal fossa, and forms a short, nerves (Fig. 9.7). The cervical plexus is unique in that it
thick trunk, which divides quickly into a small, mainly divides early into cutaneous branches (penetrating the
motor, anterior trunk and a large, mainly sensory, poste- cervical fascia to supply the skin and subcutaneous tis-
rior trunk. sues of the neck) and muscular branches (deeper branches
• The main sensory posterior (mandibular) trunk receives a which innervate the neck muscles, the diaphragm and
few filaments from the motor root, and its branches are joints of the cervical spine), which can be blocked sepa-
the auriculotemporal, lingual, and inferior alveolar (den- rately. The branches of the plexus provide sensory inner-
tal) nerves. vation to the skin and subcutaneous tissues of the anterior
• The anterior trunk of the mandibular nerve gives rise to and lateral aspects of the neck; part of the posterior scalp;
the buccal nerve (sensory) and the masseteric, deep tem- the skin inside, above, and posterior to the external ear;
poral, and lateral pterygoid nerves (motor). and the posterior aspect and lower third of the auricle or
• The main branch (posterior trunk) continues as the infe- pinna of the ear (Fig. 9.4). The cervical plexus lies deep to
rior alveolar (dental) nerve medial to the ramus of the the sternocleidomastoid muscle (Fig. 9.8) and internal
mandible. After giving off the nerve to the mylohyoid, the jugular vein, but is anterior to the scalenus medius and
inferior alveolar nerve enters the mandibular canal levator scapulae muscles.
through the mandibular foramen, which is guarded by a • Each ramus (except the first) divides into ascending and
tongue-shaped process of bone called the lingula (used as descending parts that unite in communicating loops; the
a landmark for locating the nerve during an inferior alveo- first or C2 and C3 loop supplies superficial sensory
lar nerve block) (Fig. 9.5). Within the mandibular canal branches to the head and neck; the second or C3 and C4
the nerve courses inferiorly and anteriorly to innervate the loop gives rise to cutaneous nerves supplying the shoulder
mandibular teeth and gingivae. The nerve then curves region and upper thorax as well as muscular (motor)
anteriorly to follow the body and anterior aspect of the branches which go deep to supply the muscles. C3, C4,
mandible and exits through the mental foramen, located and C5 anterior rami form the phrenic nerve which sup-
on the mental process of the mandible, giving off the inci- plies the diaphragm (its sole motor supply), as well as the
sive nerve and its terminal branch – the mental nerve. fibrous pericardium, mediastinal pleura and diaphrag-
• Other terminal nerves of the posterior trunk include the matic pleura and peritoneum with sensory fibers.
lingual nerve (lying under the lingual mucosa and supply- • Motor branches innervating the strap muscles of the neck
ing the mucosa of the floor of the mouth, mandibular gin- (sternohyoid, sternothyroid, and omohyoid) emerge from
givae, and general sensation to the anterior two-thirds of the ansa cervicalis, a neural loop formed from the joining
tongue) and the auriculotemporal nerve (dividing into of the descendens hypoglossi (C1) and descendens cervi-
superficial temporal branches behind the temporoman- calis (C2 and C3) which form the ansa cervicalis usually
dibular joint to supply the joint, the external acoustic embedded within the anterior aspect of the carotid sheath
meatus and auricle of the ear, and the scalp over the tem- deep to the sternocleidomastoid.
ple). The auriculotemporal nerve usually has two roots • Classic cervical plexus anesthesia can be achieved by
encircling the middle meningeal artery within the infra- injecting along the tubercles of the transverse processes of
temporal fossa. the cervical vertebrae, producing both motor and sensory
• The mental nerve, with its three branches (one ascending blockade. The transverse processes of the cervical verte-
to reach the chin and two descending to innervate the skin brae form peculiar elongated troughs for the emergence of
and mucous membrane of the lower lip), is the primary the cervical spinal nerve roots (Fig. 9.9). These troughs lie
target of anesthesia. immediately lateral to an aperture for the cephalad passage
• The mandibular nerve also supplies the skin of the tempo- of the vertebral artery, the foramen transversarium. At the
ral region, lower jaw, and chin (Figs. 9.4 and 9.5); the lateral end of the transverse process, the trough is guarded
mandibular gingival and labial mucosae; and the menin- by an anterior and a posterior tubercle, the anterior of
ges of the middle cranial fossa. which can often easily be palpated.
• These tubercles also serve as the attachment sites for the continue laterally to emerge superficially under the poste-
anterior and middle scalene muscles, which form a compart- rior border (clavicular head) of the sternocleidomastoid
ment for the cervical plexus as well as the brachial plexus muscle at about its midpoint (Erb’s point). The branches,
immediately below. The compartment at this level is less including the lesser occipital nerve, great auricular nerve,
developed than the one formed around the brachial plexus. transverse cervical nerve, and supraclavicular nerves
• The deep muscular branches curl anteriorly around the (medial, intermediate and lateral [posterior] branches),
lateral border of the scalenus anterior and proceed cau- innervate the skin on the anterior and posterior aspects of
dally and medially. Many branches serve the deep ante- the neck and shoulder (Fig. 9.8).
rior neck muscles; other branches include the superior • After arising from the second and third cervical nerve
root of the ansa cervicalis, the trapezius branch of the roots, the great auricular nerve ascends up to the angle of
plexus, and the phrenic nerve. These deep muscular the mandible and gives off anterior and posterior branches
branches also supply the sternocleidomastoid muscle as to supply the skin over the parotid gland and the mastoid
they pass behind it. process (Fig. 9.8).
• The sensory fibers emerge from behind the scalenus ante-
rior muscle but are separate from the motor branches and
Fig. 9.7 Schematic of the cervical Anterior

plexus, which arises from the rami of Great
anterior primary rami of C1–C4 auricular n.
(C2, 3)
C1
Hypoglossal n. Lesser
(XII) occipital n.
(C2)
C2
nerves to
Geniohyoid &
Thyrohyoid mm
C3 Spinal accesory n.
Transverse (C1 - 5)
cervical n. (C2, 3)
Ansa
cervicalis
(C1 - 3)
C4
Phrenic n.
(C3 - 5)
C5
Posterior Medial Anterior

Supraclavicular n.
(C3, 4)
Fig. 9.8 Cutaneous innervation by

the superficial cervical plexus
Lesser occipital n.
Great
auricular n.
Supraclavicular n.
Transverse
cervical n.
Vertebral artery Lateral

in transverse foramen atlantoaxial joint
C1 spinal n.
C1 Atlas
C2 Axis
Vertebral
artery
Uncinate
process
Transverse
process
Spinal n.
in sulcus
C7 spinal n.
Fig. 9.9 Nerve roots of the cervical
plexus emerging from the troughs formed
by the transverse processes, posterior and
lateral to the vertebral artery C7 vertebral body
9.3 Clinical Anatomy of Occipital Nerves 9.3.1 Lesser Occipital Nerve (C2)
The posterior scalp over the occipital region is innervated by • This nerve arises from the second (sometimes also the third)
sensory fibers of the greater and lesser occipital nerves. anterior cervical ramus and is a superficial (cutaneous)
nerve. It traverses cephalad from the posterior edge of the
sternocleidomastoid muscle towards the top of the head,
where it pierces the deep fascia and ascends the scalp behind
the auricle, dividing into several branches (Fig. 9.10).
Fig. 9.10 Greater and lesser occipital nerve

distributions. Sites of needle insertion are
marked with X
Superior
nuchal line
Greater occipital n.
X
X
Lesser occipital n.
Great auricular n.
posterior branch
9.3.2 Greater Occipital Nerve (C2) 9.4 Clinical Anatomy of the Nerve
of Arnold
• The greater occipital nerve arises from the posterior
ramus of the second cervical spinal nerve as its medial • The Nerve of Arnold is the sensory auricular branch of
branch (the cervical plexus arises from the anterior rami) the vagus nerve. It arises from the jugular (superior) gan-
and travels in a cranial direction, medial to the occipital glion of the vagus nerve. Soon after its origin, it is joined
artery (Fig. 9.10), to reach the skin at a location within the by a filament from the petrous (inferior) ganglion of the
aponeurosis of the trapezius muscle just inferior to the glossopharyngeal nerve, after which it passes behind the
superior nuchal line. At this point, it provides branches internal jugular vein and enters the mastoid canaliculus
medially to supply the head and laterally to supply the on the lateral wall of the jugular fossa. Passing through
skin of the scalp in the area behind the auricle (post- the substance of the temporal bone, it crosses the facial
auricular area). It supplies motor fibers to the semispinalis canal about 4 mm (in adult) above the stylomastoid fora-
capitis muscle. The lateral branch supplies the splenius, men, where it gives off an ascending branch which joins
longissimus, and semispinalis capitis muscles. the facial nerve. The nerve then passes through the tympa-
nomastoid fissure between the mastoid process and the
temporal bone, becomes superficial, and divides into two
branches. One branch joins the posterior auricular nerve,
while the other travels to the skin of the posterior auricu-
lar area and to the posterior wall and floor of the external
acoustic meatus which it supplies with sensory innerva-
tion (Fig. 9.11). The nerve also provides sensory innerva-
tion to the inferior portion of the outer aspect of the
tympanic membrane.
Fig. 9.11 Sensory distribution of the Nerve of Arnold, indicated by

green-shaded area
Suggested Reading
Chapter 28: Neck. In: Standring S, editor. Gray’s anatomy. 40th ed.
London: Churchill Livingstone; 2008. p. 455–62.
Chapter 29: Face and scalp. In: Standring S, editor. Gray’s anatomy.
40th ed. London: Churchill Livingstone; 2008. p. 492–5.
Clinical Anatomy of the Brachial Plexus
10
Contents
10.1 Brachial Plexus: Overview 150
10.2 Branches of the Brachial Plexus 153
10.2.1 Branches from the Roots (Ventral Rami) 153
10.2.2 Branches from the Trunks 153
10.2.3 Branches from the Cords 154
10.2.4 Terminal Nerves 154
A.H. Walji, MD, PhD

Faculty of Medicine and Dentistry,
University of Alberta, Edmonton, AB, Canada
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_10
150 A.H. Walji and B.C.H. Tsui
10.1 Brachial Plexus: Overview hiatus) before forming the trunks and entering the floor of
the posterior triangle of the neck (supraclavicular fossa). In
The brachial plexus is a spinal nerve plexus in the neck, the posterior triangle, the plexus is covered only by platysma,
shoulder, and axilla that provides innervation to the skin, deep fascia, and skin and is palpable, especially in thin indi-
subcutaneous tissues, and muscles of the entire upper limb viduals. The anterior and middle scalene muscles lie imme-
from the shoulder to the fingers, as well as articular inner- diately anterior and posterior respectively to the plexus in the
vation to the shoulder, elbow, and wrist joints. It is one of interscalene region, forming the so-called interscalene
the largest somatic plexuses in the body, and its compo- groove or triangle. The plexus at this level consists of upper
nents, namely, the roots, trunks, divisions, cords, and termi- (superior), middle, and lower (inferior) trunks and is enclosed
nal nerves, are arranged proximo-distally in a regional within the interscalene fascial sheath. Most commonly, the
fashion; the roots are paravertebral in location, the trunks upper trunk is formed by the convergence of C5 and C6,
by and large interscalene, the divisions subclavian, the while C7 becomes the middle trunk, and C8 and T1 converge
cords axillary, and the nerves brachial. Surgical anesthesia to make the lower trunk. The trunks are crossed by the exter-
and postoperative analgesia can be achieved from local nal jugular vein, the superficial (transverse) cervical and
anesthetic blockade of the brachial plexus at any point suprascapular arteries (branches of the thyrocervical trunk
along its course. that can function as external collaterals of the subclavian
The interscalene and periclavicular block approaches artery), the inferior belly of the omohyoid, and the supracla-
(e.g., supraclavicular, intersternocleidomastoid, and subcla- vicular nerves as they course inferolaterally.
vian perivascular) target the brachial plexus at the root and At and above the level of the interscalene groove (C6), the
trunk levels, while the infraclavicular, axillary, and periph- plexus lies posterolateral to the internal jugular vein and
eral approaches target the cords and terminal nerves of the common carotid artery. As the plexus emerges between the
brachial plexus. scalene muscles, its proximal part is cephalad to the third
This chapter highlights the clinical anatomy of the bra- part of the subclavian artery and its lower trunk posterior to
chial plexus itself, while the anatomy and distribution of the it. The plexus then courses behind the medial two thirds of
peripheral nerves are discussed at length in a subsequent the clavicle where it is also posterior to the subclavius mus-
chapter (Chap. 14). Chapter 14 also provides an overview cle and suprascapular vessels. Near the midpoint of the clav-
and detailed description of the clinically relevant anatomy of icle, the plexus and the subclavian artery are separated from
the brachial plexus as well as that of the dermatomes, myo- the subclavian vein by the tendinous insertion of the anterior
tomes, osteotomes, and innervation of major joints of the scalene muscle (Fig. 10.2).
upper extremity. Coursing distally, each of the three trunks then branches
The five roots of the brachial plexus arise in a paraverte- into anterior and posterior divisions deep to the clavicle (sub-
bral location from the anterior (primary) rami of C5–T1 spi- clavian location), following which the divisions reunite to
nal nerves and exit from the intervertebral foramina, above form three cords in the axilla (axillary location) and five
the transverse processes of the corresponding cervical verte- major terminal nerves in the upper arm (brachial location)
brae (Fig. 10.1). The plexus may receive variable contribu- (Fig. 10.3). The three cords of the plexus, namely, lateral,
tions from C4 and T2. When C4 makes a large contribution, medial, and posterior, are named for their relationship to the
T1 is reduced, forming a prefixed brachial plexus (C4 to C8); second part of the axillary artery. Within the axilla, the bra-
however, in some cases, the contribution from C5 may be chial plexus is enclosed together with the first part of the
reduced and that from T2 increased, leading to a postfixed axillary artery and axillary vein within the fibrous axillary
plexus (C6 to T2). sheath, a continuation of the prevertebral layer of deep
After exiting the intervertebral foramina, the roots tra- cervical fascia. The major terminal nerves and their branches
verse through the interscalene groove or triangle (scalene can been seen in Fig. 10.4.
10 Clinical Anatomy of the Brachial Plexus 151
Fig. 10.1 Anatomy of the Middle

brachial plexus scalene m.
Upper, middle,
and lower
Anterior and trunks
posterior
divisions
C5-C8, T1 roots
Lateral
and posterior
C6
cords
C7
Peripheral Nerve
Nerves T1
C8
T1
Brachial Anterior
artery scalene m.
Clavicle
Musculocutaneous n. Medial 1st Rib

Axillary n. cord Phrenic n.
Medial pectoral n.
Radial n.
Medial brachial cutaneous n.
Median n.
Ulnar n.
Upper, middle and

lower trunks C5
Anterior and
Posterior division C6
r
pe
Up
ior
ter C7
An
r
rio
dle
te
Mid
s
Po
Lateral, Posterior and

medial cords Anterior
rd r C8
rio r
lC
o
s te Lowe
er
a Po
Lat te rior
Pos ior T1
n. rd
n ter
u s
r Co A
eo
ad
rio
an te
l he
ut s rd
oc Po Co
era
l
cu ial
Lat
us ed
M M
n.
i an Medial head
ed
M
.
rn
na
Ul
.
ln
dia
Axillary n.
Ra
Fig. 10.2 Course of the brachial plexus at the interscalene groove and
under the clavicle
Paravertebral Interscalene Subclavian Axillary Brachial

Roots Trunks Divisions Cords Nerves
Dorsal Scapular
Root: C5 Suprascapular Lateral Pectoral Musculocutaneous nerve
Supplies: Levator Scapulae Root: C5, 6, 7 Root: C5–T1
Root: C5, 6
and Rhomboids (motor only) Supplies: Supraspinatus, Supplies: Pectoralis Major Supplies: Flexor compartment
infraspinatus (motor only) and Minor (motor only) of the arm (Biceps, brachialis,
C5 coracobrachialis)
Superior Anterior Superior Lateral

Po Medium
st Root: C5–T1
Supplies: Supplies all flexor muscles
er
io
of the forearm (except 1½),
rS
and has an important
up
motor distribution in the hand
C6
erio
(thumb muscles and lateral 2 lumbrieals)
and the skin over the lateral palm and
r
lateral 3½ digits including nail beds
id d le
Upper Subscapular
Root: C5, 6 Radial
rM
Supplies: Subscapularis Root: C5–T1
(motor only) Supplies: all extensor muscles
rio
of arm and forearm
te
and posterior skin of
C7 Middle An Posterior arm, forearm and hand
r
io
er
Lower Subscapular
Thoracodorsal
nf Root: C5, 6 Axillary
rI Root: C6, 7, 8
rio Supplies: Latissimus
Supplies: Subscapularis Root: C5, 6
oste dorsi (motor only)
and Teres Major Supplies: deltoid and teres minor
P (motor only) and skin over the
C8 Inferior Anterior Inferior Medial
lower part of deltoid
Ulnar
Root: C8, T1
Anterior divisions supply: Medial Pectoral Medial cutaneous nerve of forearm Supplies: 1½ flexors of the
- muscle of the anterior wall of axilla Root: C8, T1 forearm and
Root: C8, T1
- flexor muscles of the limb Supplies: Pectoralis Supplies: Skin (sensory only) supplies majority
T1 - Skin overlying those muscles
Posterior divisions supply:
Major and Minor (motor only) of the intrinsic muscles
in the hand and
- muscles of the posterior wall of the axilla the skin over the palm
Long Thoracic - extensor muscles and medial 1½ digits
Root: C5, 6, 7 - skin overlying those muscles Medial cutaneous nerve of arm
Supplies: Serratus Anterior (motor only) Root: C8, T1
Supplies: Skin (sensory only)
Interscalene Supraclavicular Infraclavicular
Fig. 10.3 Schematic diagram of the brachial plexus
Fig. 10.4 A “map” of the brachial

plexus showing sensory and motor
supply, terminal nerves, and targets
of interscalene, supraclavicular, and
Scalenus medius
infraclavicular blocks C5
Scalenus anterior
C6
C7
Common carotid artery
Internal jugular vein
Subclavian artery
Subclavian vein
10.2 Branches of the Brachial Plexus block. The phrenic nerve arises from the anterior rami of
spinal nerves C3, C4, and C5 (C3, C4 and C5 keep the dia-
From proximal to distal, the plexus is distributed regionally phragm alive!) and normally descends in a superolateral to
and consists of five roots (paravertebral), three trunks (inter- inferomedial direction on the anterior surface of the scale-
scalene), two divisions per trunk (subclavian), three cords nus anterior muscle (subject to anatomic variation) deep to
(axillary), and five major terminal nerves (brachial) the prevertebral fascia, before passing under the clavicle and
(Figs. 10.3 and 10.4). through the superior thoracic aperture into the superior
Branches arising from the roots and trunks of the brachial mediastinum, passing just medial to and in front of the inter-
plexus are generally classified as “supraclavicular” branches, nal thoracic (mammary) artery. Once within the thoracic
while those arising from the cords are referred to as “infra- cavity, both right and left phrenic nerves descend anterior to
clavicular” branches. the pulmonary hila together with the pericardiophrenic ves-
sels (branches of the internal thoracic or mammary vessels)
• Root branches (supraclavicular): in the plane between the fibrous pericardium medially and
– Nerve to longus cervicis muscle (C5–C8) the mediastinal pleura laterally on their way to the dia-
– Nerve to longus colli and scalene muscles (C5–C8) phragm which they pierce to supply. The right phrenic
– Contribution to phrenic nerve (C5) pierces the diaphragm’s central tendon near the caval orifice,
– Dorsal scapular nerve [nerve to rhomboids] (C5) while the left phrenic traverses the muscular portion of the
• Trunk branches (supraclavicular): left hemidiaphragm and lies somewhat more anterior than
– Nerve to subclavius (superior trunk, C5, C6) the right.
– Suprascapular nerve (superior trunk, C5, C6)
– Long thoracic nerve [posterior thoracic nerve] Innervation Motor: diaphragm (the phrenic is the sole motor
supply to the diaphragm)
(C5–C7)
Sensory: fibrous pericardium, parietal layer of serous
• Cord branches (infraclavicular): pericardium, mediastinal parietal pleura,
– Lateral cord diaphragmatic parietal pleura, and diaphragmatic
• Lateral pectoral nerve (C5–C7); musculocutaneous parietal peritoneum
nerve (C5–C7); lateral root (head) of median nerve
(C5–C6, C7)
– Medial cord 10.2.1.2 Dorsal Scapular Nerve
• Medial pectoral nerve (C8, T1); medial cutaneous Originating from the ventral ramus of C5, this nerve passes
nerve of arm (medial brachial cutaneous nerve, C8, through the scalenus medius and courses behind the levator
T1); medial cutaneous nerve of forearm (medial scapulae before running with the deep branch of the dorsal
antebrachial cutaneous nerve, C8, T1); medial root scapular artery to terminate in the rhomboids, which it
(head) of median nerve (C8, T1); ulnar nerve (C7– supplies.
C8, T1)
– Posterior cord Innervation Motor: rhomboid major, rhomboid minor, levator
scapulae (occasionally)
• Upper subscapular nerve (C5, C6); thoracodorsal
Sensory: none
nerve (C6–C8); lower subscapular nerve (C5, C6);
axillary nerve (C5, C6); radial nerve (C5–C8, T1)
Selective clinically relevant nerves will be described in 10.2.2 Branches from the Trunks
more detail below with respect to their origins, course, and
function as related to clinical practice. 10.2.2.1 Long Thoracic Nerve
This nerve has contributions from the roots of C5–C7.
Contributions from C5 and C6 pierce the scalenus medius
10.2.1 Branches from the Roots (Ventral Rami) and join within or lateral to the muscle; the nerve then
descends dorsal (posterior) to the brachial plexus and first
10.2.1.1 Phrenic Nerve part of the axillary artery. The C7 contribution, when pres-
Strictly speaking, the phrenic nerve is not part of the bra- ent, emerges between the scalenus medius and scalenus ante-
chial plexus; however, due to its close relationship to the rior muscles before joining with the C5 and C6 contributions
plexus, the nerve has to be considered from a clinical per- near the superior border of the serratus anterior muscle. The
spective since it plays an important role and has significant nerve then crosses the superior border of the serratus anterior
clinical implications when performing brachial plexus to reach its lateral surface before descending on the muscle
to supply each of its digitations and to terminate at its lower 10.2.3.2 Medial Pectoral Nerve
border. Arising from the medial cord, with contributions from C8
and T1, this nerve travels from its origin posterior to the
Innervation Motor: serratus anterior axillary artery and then swings anteriorly between the axil-
Sensory: none lary artery and vein to join with the filament from the lateral
pectoral nerve anterior to the axillary artery. It enters the
10.2.2.2 Nerve to the Subclavius deep surface of the pectoralis minor and supplies it; usually
Small but deserving of mention is the nerve to the subclavius. some branches will travel around the inferior border of the
Arising from where the ventral rami of C5 and C6 join, this pectoralis minor to terminate in the pectoralis major.
small filament travels anterior to the main plexus, passing ante-
rior to the third part of the subclavian artery, and is usually Innervation Motor: pectoralis minor, some to pectoralis major
connected in some capacity to the phrenic nerve before passing Sensory: none
above the subclavian vein to supply the subclavius muscle.
10.2.3.3 Upper and Lower Subscapular Nerves
Innervation Motor – subclavius The upper (superior) subscapular nerve (C5 and C6) arises
Sensory – none from the posterior cord and usually enters the subscapularis
quite high to supply it; frequently it may be double.
10.2.2.3 Suprascapular Nerve The lower (inferior) subscapular nerve (C5 and C6) arises
A large branch of the superior trunk, this nerve arises from the further down, also from the posterior cord, and is the larger
anterior rami of C5 and C6; travels laterally, deep to the trape- of the two nerves. It supplies the inferior portion of the sub-
zius and omohyoid muscles; and enters the supraspinous fossa scapularis and terminates in the teres major which it also
through the suprascapular notch beneath the superior trans- supplies.
verse scapular ligament. Coursing deep to the supraspinatus
and supplying it, the nerve then curves around the lateral bor- Innervation Motor: subscapularis, usually also the teres major
der of the spine of the scapula (spinoglenoid notch) and, with Sensory: none
the supraclavicular artery, reaches the infraspinous fossa,
where it supplies the infraspinatus and provides articular 10.2.3.4 Thoracodorsal Nerve
branches to the capsule of the glenohumeral (shoulder) and Arising from the posterior cord between the subscapular
acromioclavicular joints. A cutaneous branch, though rare, nerves, the thoracodorsal nerve has contributions from C6 to
may pierce the deltoid close to the tip of the acromion and C8. It travels initially with the subscapular artery then with
become superficial to supply the skin of the shoulder and the thoracodorsal artery along the posterior wall of the axilla
upper arm within the region supplied by the axillary nerve. to the deep surface of the latissimus dorsi, which it supplies
before terminating at the muscle’s lower border.
Innervation Motor: supraspinatus, infraspinatus
Sensory: when present, supplies skin on lateral aspect Innervation Motor: latissimus dorsi
of shoulder, proximal third of arm; articular Sensory: none
innervation to shoulder and acromioclavicular joints
10.2.4 Terminal Nerves

10.2.3 Branches from the Cords
10.2.4.1 Axillary Nerve
10.2.3.1 Lateral Pectoral Nerve The axillary nerve (C5, C6), also known as the circumflex
With contributions from the C5 to C7 anterior rami, the lat- humeral nerve, arises from the posterior cord of the brachial
eral pectoral nerve can either arise from the anterior divi- plexus and initially lies posterior to the axillary artery,
sions of the upper and middle trunks or have a single origin lateral to the radial nerve, and anterior to the subscapularis
from the lateral cord. It passes anterior to the axillary artery (Figs. 10.5, 10.6, and 10.7). The nerve then courses inferi-
and vein before piercing the clavipectoral fascia and termi- orly to the lower border of the subscapularis where it winds
nating on the deep surface of the pectoralis major muscle, posteriorly through the quadrangular space, underneath the
which it supplies. A filament from the nerve loops in front of capsule of the shoulder joint, together with the posterior
the axillary artery (ansa pectoralis) and joins with the medial circumflex humeral vessels to reach the back of the shoul-
pectoral nerve to send fibers to the pectoralis minor muscle. der and deltoid region. The quadrangular intermuscular
space is bounded laterally by the neck of the humerus,
Innervation Motor: pectoralis major, some to pectoralis minor medially by the long head of the triceps, and superiorly and
Sensory: none inferiorly by the teres minor and major muscles,
respectively. Here, the nerve divides into anterior, poste- upper (superior) lateral cutaneous nerve of the arm, which
rior, and collateral branches. pierces the deep fascia on the lower aspect of the posterior
The anterior branch travels around the surgical neck of border of the deltoid and sends cutaneous branches to the
the humerus with the posterior circumflex humeral vessels, overlying skin. Although this nerve usually supplies the pos-
deep to the deltoid, and as far as the anterior border of this terior aspect of the deltoid, the deltoid can also be supplied
muscle. It supplies the deltoid and also gives off several by the anterior branch. The main trunk of the axillary nerve
small cutaneous branches which travel through the deltoid to supplies an articular branch to the capsule of the shoulder
the skin overlying its lower part on the lateral aspect of the joint just below the subscapularis. The collateral branch to
shoulder. the long head of the triceps arises just prior to the termination
The posterior branch supplies the posterior aspect of the of the posterior cord.
deltoid and teres minor. It usually lies medial to the anterior
branch in the quadrangular space. It travels posteromedially Innervation Motor: deltoid, teres minor, and long head
of the triceps
along the attachment of the lateral head of the triceps, gener-
Sensory: articular innervation to the shoulder joint,
ally inferior to the rim of the glenoid cavity. It then gives a cutaneous innervation to the skin of the shoulder over
branch to the teres minor, which enters the muscle through the lower portion of deltoid and upper portion of the
its inferior surface. The posterior branch also gives rise to the long head of the triceps
Fig. 10.5 Peripheral nerves and Pectoralis

vessels of the upper extremity major m. (cut) Axillary Axillary
artery vein
Musculocutaneous n.
Coracobrachialis m.
Biceps brachii m.
Brachial
artery
Triceps brachii m.
Median n.
Teres major m.
Ulnar n.
Latissimus dorsi m.
Lateral and
Musculocutaneous n. medial cords of
brachial plexus
Median n.
Ulnar n. Medial cutaneous
Axillary n.
nerves of forearm
and arm
Posterior Radial n.
Lateral cutaneous and lower lateral
nerve of forearm cutaneous
nerves of arm
Posterior cutaneous
nerve of forearm
Anterior
interosseus n.
Deep branch Superficial branch

of radial n.
Palmar (cutaneous)
branch of medican n.
Deep and
Dorsal digital nerves
superficial
branches
of ulnar n.
Showing medial and lateral cords only
Fig. 10.6 Peripheral nerves of the upper extremity: medial and lateral Showing posterior cord only
cords
Fig. 10.7 Peripheral nerves of the upper extremity: posterior cords
10.2.4.2 Musculocutaneous Nerve 10.2.4.4 Medial Cutaneous Nerve of the Arm

Arising from the lateral cord of the brachial plexus opposite Arising from the medial cord of the brachial plexus (C8 and
the lower border of the pectoralis minor and derived from the T1), this nerve passes through the axilla close to the axillary
anterior rami of C5 to C7, this nerve usually pierces the cora- vein and communicates with the intercostobrachial nerve
cobrachialis and passes obliquely between the biceps brachii (Fig. 10.6). It then descends medial to the brachial artery and
and the brachialis to the lateral aspect of the arm (Figs. 10.6 basilic vein, piercing the deep fascia at the mid-upper arm to
and 10.7). It supplies the coracobrachialis, biceps brachii, and supply the skin on the lower third of the medial aspect of the
most of brachialis (a small lateral portion of the muscle is arm and terminate in cutaneous branches around the elbow,
supplied by the radial nerve [C7]). At about the level of the some reaching as far as the olecranon.
elbow, it pierces the deep fascia lateral to the tendon of the
biceps brachii and continues as the lateral cutaneous nerve Innervation Motor: none
of the forearm. The branch to the coracobrachialis usually Sensory: skin on the lower third of the medial aspect
of the arm, skin over the medial epicondyle
comes off before the nerve enters the muscle; these fibers and olecranon
may also arise directly from the lateral cord. The branch to
the brachialis gives off an articular branch to the capsule of
the elbow joint. It also supplies a small branch to the perios- 10.2.4.5 Medial Cutaneous Nerve of the Forearm
teum of the humerus which courses with the nutrient artery. Similar to the medial cutaneous nerve of the arm, this nerve
also arises from the medial cord (C8 and T1). It courses
Innervation Motor: coracobrachialis, biceps brachii, most of between the axillary artery and vein, and as it leaves the
brachialis, occasionally pronator teres
axilla, it sends a branch that pierces the deep fascia to supply
Sensory: skin of lateral forearm, articular innervation
to the elbow, small branch to humerus the skin over the biceps brachii nearly as far as the elbow.
From its origin, the nerve courses downwards medial to the
brachial artery before piercing the deep fascia together with
10.2.4.3 Lateral Cutaneous Nerve of the Forearm the basilic vein midway down the arm and dividing into ante-
A continuation of the musculocutaneous nerve after it has sup- rior and posterior branches. The anterior branch generally
plied the muscles in the anterior arm, this nerve pierces the passes in front of the median cubital vein, traveling antero-
deep fascia lateral to the biceps brachii tendon and descends medially in the forearm and connecting with the palmar cuta-
along the radial (lateral) border of the forearm deep to the neous branch of the ulnar nerve. The posterior branch travels
median cubital and cephalic veins to reach the wrist (Fig. 10.6). across the forearm medial to the basilic vein, anterior to the
It supplies sensory innervation to the skin and subcutaneous medial epicondyle, and curves to the back of the forearm to
tissues of the anterolateral forearm up to the lateral aspect of descend along its medial (ulnar) border to the wrist. It termi-
the wrist, with communicating branches around the radial bor- nates by communicating with the medial cutaneous nerve of
der of the forearm to the posterior cutaneous nerve of the fore- the arm, the posterior cutaneous nerve of the forearm, and
arm (from the radial nerve) and the superficial terminal branch the dorsal branch of the ulnar nerve.
of the radial nerve. At the wrist, the lateral cutaneous nerve of
the forearm lies anterior to the radial artery, courses to the base Innervation Motor: none
of the thenar eminence, and ends in cutaneous branches with Sensory: skin on medial aspect of lower third of arm
and forearm
communications to the palmar cutaneous branch of the median
nerve and terminal branches of the radial nerve.
Innervation Motor: none

Sensory: skin of anterolateral forearm up to lateral
aspect of wrist
10.2.4.6 Median Nerve profundus (which provides tendons to the index (second) and
The median nerve is formed from the lateral and medial middle (third) fingers). The palmar cutaneous branch arises
cords of the brachial plexus via the lateral (C5–C7) and just proximal to the flexor retinaculum (thus, it is usually
medial (C8 and T1) roots of the median nerve respectively spared in carpal tunnel syndrome) and either pierces it or the
(Figs. 10.5, 10.6, 10.8, and 10.9). These roots surround the deep fascia before branching into lateral and medial divisions.
third part of the axillary artery, generally uniting in front of The lateral divisions connect with the lateral cutaneous nerve
it. The median nerve then enters the upper arm lateral to the of the forearm and innervate the thenar skin, while the medial
brachial artery, crossing over the artery anteriorly at the level branches innervate the palmar skin in the center of the palm
of the insertion of the coracobrachialis. From there, it courses and connect with palmar cutaneous branches of the ulnar
down the arm medial to the artery into the cubital fossa, at nerve. It is important to note that many possible communicat-
which point it lies deep to the bicipital aponeurosis and ing branches can exist simultaneously, even from the anterior
superficial to the brachialis, which separates it from the interosseous nerve, which helps to explain anomalous inner-
elbow joint capsule. vation commonly found within the hand.
During its course in the arm, the median nerve gives off The median nerve then passes deep to the flexor retinacu-
vascular vasomotor (sympathetic) branches to the brachial lum, within the carpal tunnel, into the palm, where it divides
artery, articular branches to the elbow, and proximal radio- into five or six branches which are variable in number and
ulnar joints and muscular branches (usually given off proxi- position. The nerve may get compressed in carpal tunnel
mally near the elbow) to the superficial flexor muscles in the syndrome (an entrapment neuropathy) leading to pain, tin-
anterior compartment of the forearm (except flexor carpi gling and numbness along its distribution in the hand, with
ulnaris). It usually sends a branch to the pronator teres a vari- atrophy of the thenar muscles if long-standing. The recurrent
able distance proximal to the elbow. The median nerve then (motor) branch comes off the lateral side of the nerve and
leaves the cubital fossa and courses between the two heads of may be the first palmar branch or a terminal branch unto
the pronator teres to enter the forearm, which it does by pass- itself. The recurrent motor branch is extremely important as
ing underneath a tendinous arch between the radial and it supplies the muscles of the thenar eminence, responsible
humero-ulnar heads of the flexor digitorum superficialis for moving the thumb. Its terminal portion may give a branch
(FDS) muscle. Here it may get compressed between the two to the first dorsal interosseous muscle, which may be its only
heads of pronator teres (pronator syndrome) leading to weak- supply or shared with that from the ulnar nerve. The nerve
ness of wrist and digit flexors and pronation. From there, it continues as the common and proper palmar digital branches,
travels distally adherent to the deep surface of the FDS but providing cutaneous innervation to the first three and a half
superficial to the flexor digitorum profundus muscle. Near the digits anteriorly and the second through fourth digits dor-
wrist it emerges approximately 5 cm proximal to the flexor sally from their tips to the distal interphalangeal joints. In
retinaculum just lateral to the tendons of the flexor digitorum addition, the median nerve also sends motor branches to first,
superficialis and between them and the tendon of flexor carpi second, and occasionally third lumbricals.
radialis. When present, the tendon of palmaris longus lies just
medial to the nerve at the wrist, the median nerve peeking out Innervation Motor (median nerve): pronator teres, flexor carpi
laterally from behind it. radialis, palmaris longus (when present), flexor
digitorum superficialis
In the forearm, the median nerve gives off two branches;
Anterior interosseous nerve: lateral half of flexor
the anterior interosseous nerve and the palmar cutaneous digitorum profundus, flexor pollicis longus,
branch. The anterior interosseous branch forms posteriorly as pronator quadratus
the nerve traverses between the two heads of the pronator teres Median nerve in the hand: opponens pollicis, abductor
(where it may also be compressed in pronator syndrome) and pollicis brevis, flexor pollicis brevis, and lumbricals
travels deep along the anterior aspect of the interosseous mem- (1, 2, and occasionally 3)
brane (hence the name) together with the anterior interosseous Sensory: articular innervation to capsule of elbow
joint, skin on radial side of the wrist anteriorly
artery. It terminates at the level of the pronator quadratus, and palm, palmar surface of the thumb and index
which it supplies, and also innervates the remaining two mus- and middle fingers and radial side of ring finger, skin
cles of the deep anterior compartment of the forearm, namely, distal to DIP joints of thumb, index, middle, and radial
the flexor pollicis longus and the lateral half of flexor digitorum side of ring fingers dorsally. Vascular to brachial artery
Fig. 10.8 Cross section of the Anterior

arm showing positions of major
muscles, blood vessels, and Lateral antebrachial
Brachial artery
nerves. BR brachioradialis, ECRL cutaneous n.
extensor carpi radialis longus (from musculocutaneous n.) Brachial vein
muscle
Median n.
Biceps brachii Basilic vein
Cephalic vein
Brachlalls
BR
ECRL
Triceps brachii Ulnar n.
Radial n.
Lateral and medial

Lateral intermuscular septa Medial
Anterior
Ulnar artery
Median n.
Radial artery
Ulnar n.
Superficial
branch
radial n. Flexor digitorum
superficialis m.
Flexor carpi
Cephalic
ulnaris m.
vein
FPL Flexor digitorum
profundus m.
Radius
Ulna
Basilic
vein
Fig. 10.9 Cross section of the
distal forearm showing location of
ulnar nerve with respect to ulnar Interosseous membrane and
artery. FPL flexor pollicis longus related nerves and vessels
muscle Lateral Medial
10.2.4.7 Ulnar Nerve pisiform bone and posteromedial to the ulnar artery. The
The ulnar nerve arises from the medial cord of the brachial ulnar nerve then passes under the superficial part of the flexor
plexus from C8 and T1 and an occasional contribution from retinaculum (within Guyon’s canal) with the ulnar artery and
C7 (Figs. 10.6, 10.9, and 10.10). Initially, the nerve courses divides into its superficial and deep terminal branches. The
between the axillary artery and vein and then lies along the ulnar artery lies anterolateral to the nerve at the wrist.
medial aspect of the brachial artery up to the midpoint of the The dorsal branch continues distally and posteriorly
humerus, where it pierces the medial intermuscular septum, beneath the flexor carpi ulnaris before piercing the deep fas-
passes posteriorly, and then descends along the anterior sur- cia and dividing into two, often three dorsal digital branches
face of the medial head of the triceps brachii muscle. It then along the medial aspect of the back of the wrist and hand.
passes behind the medial epicondyle of the humerus (in the The superficial terminal branch supplies the palmaris bre-
condylar groove) where it is very superficial and can be vis and skin on the medial aspect of the palm and divides into
rolled against the bone. If jarred against the epicondyle, two palmar digital nerves; one supplying the medial side of
characteristic tingling sensations result (“funny bone”). It the fifth (little) finger and the other supplying the adjoining
has no branches in the arm. Just beyond the medial epicon- sides of the fifth (little) and fourth (ring) fingers through a
dyle, the nerve enters the forearm between the two heads of common digital nerve.
the flexor carpi ulnaris which it supplies. Here, the nerve lies The deep terminal branch courses with the deep branch of
medial to the elbow joint, superficial to the fibrous joint cap- the ulnar artery as it passes between the abductor digiti min-
sule and the ulnar collateral ligament. The nerve may also imi and flexor digiti minimi, perforating the opponens digiti
get compressed in the osseofibrous tunnel formed by the ten- minimi to follow the deep palmar arch deep to the long flexor
dinous arch connecting the ulnar and humeral heads of the tendons. It supplies the muscles of the hypothenar eminence
flexor carpi ulnaris (cubital tunnel syndrome) leading to controlling the fifth finger, and as it crosses the hand from
numbness and tingling along its distribution in the hand. medial to lateral, it sends branches to the interossei and to the
The nerve then descends through the medial aspect of third and fourth lumbricals. The nerve terminates by supply-
forearm, coursing somewhat anteriorly and coming to lie ing the adductor pollicis, the first palmar interosseous and
deep to and between the flexor carpi ulnaris and flexor digi- flexor pollicis brevis (usually). It sends articular twigs to the
torum superficialis muscles. As it courses through the middle wrist joint capsule and to intercarpal, carpometacarpal, and
of the forearm between these muscles, it approaches the metacarpophalangeal joints. It also sends vasomotor (sympa-
ulnar artery on its lateral aspect; the artery, distant from it in thetic) branches to the ulnar and palmar arteries.
the upper third of the forearm, comes to lie close to the nerve
and just lateral to it in the lower half to two thirds of the fore- Innervation Motor: flexor carpi ulnaris, medial half of flexor
arm (Fig. 10.9). The nerve and artery lie directly anterior to digitorum profundus, lumbricals 3 and 4, opponens
the ulna at the junction of the lower third and upper two digiti minimi, flexor digiti minimi, abductor digiti
thirds of the forearm (Fig. 10.10). In the forearm, the ulnar minimi, all the interossei, adductor pollicis, flexor
pollicis brevis (usually)
nerve supplies the flexor carpi ulnaris and the medial half of
Sensory: cutaneous innervation to fifth digit
flexor digitorum profundus which provides tendons to the and medial half of fourth, extending to just
ring (fourth) and little (fifth) fingers. Approximately 5 cm proximal to the wrist, both dorsal and ventral.
proximal to the wrist the ulnar nerve gives off its dorsal cuta- Articular branches to wrist joint, intercarpal,
neous branch which continues distally into the hand after carpometacarpal, and interphalangeal joints
Vasomotor: to ulnar and palmar arteries
passing anterior to the flexor retinaculum, just lateral to the
Fig. 10.10 Median and ulnar nerve pathways in

the anterior forearm
Median n.
Radial artery
Ulnar n.
Ulnar artery
Flexor carpi
radialis tendon Flexor digitorum
profundus
Flexor pollicis muscle and tendon
longus tendon
Flexor carpi
ulnaris tendon
Flexor
retinaculum
Lateral Medial
10.2.4.8 Radial Nerve passing through the supinator muscle between its two heads
The radial nerve is the largest branch of the brachial plexus and supplying it. Emerging from the supinator, the deep
and arises from the posterior cord (C5–C8) (Figs. 10.7 and branch courses between the deep and superficial forearm
10.11). It emerges from the posterior aspect of the plexus and extensors inferiorly, which it supplies (except extensor carpi
lies posterior to the third part of the axillary artery and the radialis longus which is supplied by the main radial nerve).
proximal portion of the brachial artery. The nerve descends At the distal border of the extensor pollicis brevis, the nerve
within the axilla (where it gives rise to the posterior cutane- travels deep to descend along the interosseous membrane
ous nerve of the arm), coursing across the subscapularis and and terminate at the dorsal aspect of the carpus, supplying
the tendons of teres major and latissimus dorsi (it lies on the articular innervation to the wrist and hand.
insertion of this latter muscle). It then passes between the
medial and lateral heads of the triceps brachii muscle through Innervation Motor (main radial nerve): triceps brachii, anconeus,
brachioradialis, extensor carpi radialis longus
the triangular interval together with the profunda brachii
Posterior interosseous nerve: extensor carpi radialis
artery (deep brachial artery), giving rise to the posterior cuta- brevis, supinator, extensor carpi ulnaris, extensor digiti
neous nerve of the forearm and the lower (inferior) lateral minimi, extensor digitorum, extensor indicis, extensor
cutaneous nerve of the arm. Here, lying posteromedial to the pollicis brevis, abductor pollicis longus, extensor
profunda brachii artery, it descends obliquely across the pos- pollicis longus
Sensory: skin of posterior arm and forearm, posterior
terior aspect of the humerus along the radial (spiral) groove
hand laterally near the base of the thumb, and the
at the level of the insertion of the deltoid muscle. Here it may dorsal aspect of the index finger and the lateral half
be compressed by badly fitted crutches and plaster casts, pro- of the ring finger up to the distal interphalangeal crease
longed resting of the arm on the back rest of a chair or over Articular: elbow, wrist, distal radio-ulnar, some
the edge of the operating table if the arm is not positioned intercarpal and carpometacarpal joints
correctly. It may also get injured in mid-shaft fractures of the
humerus. Compression of the radial nerve in the radial
groove results in wrist drop due to weakness or paralysis of
wrist and digit extensors (“Saturday night palsy”). The nerve
then reaches the lateral margin of the humerus above the Deltoid muscle
elbow, pierces through the lateral intermuscular septum, and

Infraspinatus
crosses over the lateral epicondyle of the humerus to enter muscle
the anterior compartment of the arm in a deep groove Teres minor
between the brachialis and brachioradialis muscles proxi- muscle
mally and the extensor carpi radialis longus muscle distally
(Fig. 10.11). Muscular branches of the radial nerve supply
Deltoid
the triceps brachii, anconeus, brachioradialis, and extensor tuberosity
carpi radialis longus muscles. Articular branches supply the
capsule of the elbow joint. Deep brachial
In front of the lateral epicondyle of humerus, the nerve (profunda brachii)
divides into its two terminal branches, the superficial termi- artery
Teres major
nal or radial (sensory) and the deep terminal or posterior muscle Radial n.
interosseous (motor) nerves. The superficial terminal branch (lying over
travels inferiorly beneath the brachioradialis and lateral to spiral groove)
the radial artery and curves around the lateral side of the Triceps Triceps
brachii brachii
radius before eventually piercing the deep fascia dorsally at (long head) (lateral head)
approximately the level of the wrist. From here, it divides
into four or five dorsal digital nerves, often communicating
with posterior and lateral cutaneous nerves of the forearm. Fig. 10.11 Route of the radial nerve between the medial and lateral
The posterior interosseous nerve travels to the posterior heads of the triceps brachii muscle. The nerve travels deep to the bra-
aspect of the forearm around the lateral aspect of the radius, chial artery and then follows the path of the spiral groove beyond the
deltoid tuberosity
Suggested Reading
Chapter 45. Pectoral girdle and upper limb: overview and surface anat-
omy. In: Standring S, Johnson D, editors. Gray’s anatomy, 40th ed.
London: Churchill Livingstone; 2008. p. 780–90.
Chapter 45. Pectoral girdle, shoulder region and axilla. In: Standring S,
Johnson D, editors. Gray’s anatomy, 40th ed. London: Churchill
Livingstone; 2008. p. 818–22.
Schuenke M, Schulte E, Schumacher U. The brachial plexus. In: Ross
LM, Lamperti ED, editors. Thieme atlas of anatomy: general anat-
omy and musculoskeletal system. Stuttgart: Georg Thieme Verlag;
2006. p. 314–27.
Clinical Anatomy of the Lumbar Plexus
11
Contents
11.1 Lumbar Plexus 166
11.1.1 Branches of the Lumbar Plexus 168
11.1.2 Iliohypogastric Nerve 169
11.1.3 Ilioinguinal Nerve 170
11.1.4 Genitofemoral Nerve 170
11.1.5 Lateral Femoral Cutaneous Nerve (Lateral Cutaneous Nerve of Thigh) 170
11.1.6 Femoral Nerve 171
11.1.7 Obturator Nerve 173
A.H. Walji, MD, PhD

Faculty of Medicine and Dentistry, University of Alberta,
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_11
11.1 Lumbar Plexus lumbar region, the psoas major has posterior attachments to
the transverse processes and anterior attachments to the lips
The lumbar plexus (Fig. 11.1) lies on the posterior abdomi- of the vertebral bodies, intervertebral discs, and intervening
nal wall in the retroperitoneum and is formed within the sub- tendinous arches. The lumbar plexus lies between these two
stance of the psoas major muscle from the union of the masses and is thus contained within the “psoas compart-
anterior primary rami of L1–L3 and most of L4 spinal nerves ment” and lies in the same coronal (frontal) plane as the
(Fig. 11.2). In some cases the plexus also receives a small intervertebral foramina.
branch from T12 (termed “pre-fixed” plexus) or a contribu- The nerves of the lumbar plexus are responsible for sup-
tion from L5 (termed “post-fixed” plexus). The first lumbar plying motor innervation to the transversus abdominis and
nerve emerges between the first and second lumbar verte- internal oblique muscles, the cremaster muscle in the male,
brae; the last (L5) emerges between the fifth lumbar vertebra muscles making up the posterior abdominal wall, and mus-
and the base of the sacrum (body of the first sacral vertebra) cles in the anterior and medial compartments of the thigh. In
(Fig. 11.3). The lumbar spinal nerves (anterior rami) usually addition, they provide sensory innervation to the skin of the
lie within the substance of the psoas major muscle immedi- posterolateral gluteal and suprapubic regions, anterior and
ately after exiting the intervertebral foramina (Fig. 11.4). In medial thigh, and the external genitalia.
some cases, the plexus may lie posterior to the muscle. In the
Lateral view T12
L1
Lumbar plexus
Subcostal n
Iliohypogastric n.
Sacral plexus Iliohypogastric n

Ilioinguinal n. L2
Obturator n. Ilioinguinal n
Genitofemoral n
Femoral n.
L3
Lateral femoral
cutaneous n. Lateral femoral
cutaneous n
Sciatic n.
L4
Saphenous n.
Femoral n
Tibial n. To lumbosacral trunk
Common
perneal n.
Obturator n
Deep peroneal (fibular) n.

Fig. 11.2 Schematic diagram of the lumbar plexus
Superficial peroneal n.
Medial and lateral

plantar n.
Fig. 11.1 Nerves of the lower extremity

11 Clinical Anatomy of the Lumbar Plexus 167
L2
L3
Lateral femoral
cutaneous n. L4
L5
Femoral n.
Inguinal ligament
Obturator n.
Fig. 11.4 Major branches of the lumbar plexus
Sciatic n.
Fig. 11.3 Lumbar and sacral plexuses within the skeleton

11.1.1 Branches of the Lumbar Plexus (L2 to L4), psoas minor (L1), and iliacus (L2, L3) muscles as
well as six major terminal nerves, as described below
The plexus gives rise to direct muscular branches which sup- (Figs. 11.4 and 11.5).
ply the quadratus lumborum (T12; L1 to L4), psoas major
Fig. 11.5 Branches of the lumbar

plexus in the upper thigh (anterior view).
VL vastus lateralis, VI vastus
intermedius, RF rectus femoris, VM
vastus medialis, S sartorius, P pectineus,
AB adductor brevis, AL adductor longus,
AM adductor magnus, G gracilis
Femoral n. and
muscular branches
Sciatic n. and
muscular
branches
Obturator n. and
Saphenous n. anterior and
posterior branches
AM
AB
VL Vl P G
VM AL
RF S
Lateral femoral
cutaneous n.
11.1.2 Iliohypogastric Nerve
A branch of the L1 nerve root (anterior ramus), the iliohypo-

gastric nerve (Fig. 11.6), emerges from behind the upper part
of the psoas major and courses laterally along the posterior
abdominal wall underneath the subcostal nerve (T12). It Intercostal
crosses posterior to the inferior pole of the kidney obliquely, neurovascular
sandwiched between it and the anterior surface of the quadra- bundle
tus lumborum muscle. The nerve then pierces the posterior
Kidney
aspect of the transversus abdominis to run anteriorly along
the iliac crest in the plane between the transversus abdominis
and the internal oblique, dividing into its lateral and anterior
cutaneous branches. The lateral branch pierces the internal
and external oblique muscles above the iliac crest to be dis- Iliohypogastric n.
tributed to the posterolateral skin of the gluteal region. The Ilioinguinal n.
anterior branch continues between the transversus abdominis
and the internal oblique muscles and supplies them, coursing Transverse process
above and parallel to the inguinal ligament. It then pierces the
internal oblique just medial to the anterior superior iliac spine Psoas major m.
and exits through the aponeurosis of the external oblique
above the superficial inguinal ring to become cutaneous and
supply the skin of the suprapubic region. The iliohypogastric
nerve often has communicating branches with the subcostal
(T12) and ilioinguinal (L1) nerves.
Fig. 11.6 Psoas major muscle compartment, highlighting the ilioin-
Innervation Motor: transversus abdominis and internal oblique, guinal and iliohypogastric nerves
including the conjoint tendon
Sensory: posterolateral gluteal skin, suprapubic skin
11.1.3 Ilioinguinal Nerve and passes behind the inguinal ligament before entering the
femoral sheath lateral to the femoral artery. It supplies vaso-
Another branch of the L1 nerve root, the ilioinguinal nerve motor filaments to the femoral artery and then pierces the
(Fig. 11.6), is smaller than the iliohypogastric nerve. The anterior lamina of the femoral sheath and fascia lata (deep
nerve emerges from beneath the lateral border of the upper fascia of the thigh) to supply the skin over the proximal part
part of the psoas major with or just below the iliohypogastric of the femoral triangle, where it terminates.
nerve (the two may arise as a common trunk and split more
distally at a variable distance) and crosses the inferior pole of Innervation Motor: cremaster muscle in males
the kidney obliquely just below the iliohypogastric nerve Sensory: scrotum in males, skin over mons pubis
and labia majora in females, skin of anteromedial
anterior to the quadratus lumborum. It then pierces the trans- thigh/proximal, skin over proximal, lateral aspect
versus abdominis near the anterior aspect of the iliac crest of femoral triangle
and enters the internal oblique, supplying it, after which it Vascular: vasomotor branches to femoral artery
travels through the inguinal canal below the spermatic cord.
The nerve emerges from the canal, lying inferior to the cord,
through the superficial inguinal ring to be distributed to the 11.1.5 Lateral Femoral Cutaneous Nerve
skin on the proximal medial aspect of the thigh and the exter- (Lateral Cutaneous Nerve of Thigh)
nal genitalia. The nerve occasionally joins the iliohypogas-
tric nerve as it enters the transversus abdominis, or it may be This nerve is formed from the posterior branches of L2 and L3
absent altogether, in which case the iliohypogastric nerve anterior rami. The nerve emerges from behind or through the
takes over supply to the associated areas. lateral border of the psoas major muscle and courses subperi-
toneally towards the anterior superior iliac spine, crossing the
Innervation Motor: internal oblique, transversus abdominis iliacus muscle obliquely on its anterior surface under the fas-
Sensory: skin over the pubic symphysis, skin on cia iliaca. As it does so, it supplies the parietal peritoneum
proximal medial thigh, and upper part of scrotum/skin
over the base of the penis (in males) or the mons pubis overlying the iliacus muscle. The nerve then enters the thigh
and lateral aspects of the labia majora (in females) through or below the inguinal ligament, approximately 1 cm
medial to the anterior superior iliac spine (depending on the
size and age of the subject). Here, it may be compressed by
waistbands of tight clothing, tight belts, or abdominal obesity,
11.1.4 Genitofemoral Nerve leading to pain and/or paresthesias along the lateral aspect of
the thigh (meralgia paresthetica). On the right side of the
The genitofemoral nerve, with contributions from the L1 and body, the nerve passes posterolateral to the cecum, and on the
L2 nerve roots, originates within the substance of the psoas left, it traverses behind the lower part of the descending colon.
major muscle. The nerve pierces through the muscle approxi- The nerve then either pierces or lies on top of the sartorius
mately at the level of L3/L4 and travels retroperitoneally along muscle before dividing into its anterior and posterior branches.
the muscle’s anterior surface before dividing into its genital The anterior branch becomes subcutaneous about
and femoral branches at the level of L5 or S1. It can also divide 8–10 cm distal to the anterior superior iliac spine (in the
within the psoas major, emerging as two distinct nerves. average adult) and supplies the skin of the anterolateral thigh
The genital branch crosses the external iliac artery and as far down as the knee. The posterior branch pierces the
enters the inguinal canal through its deep ring and, in males, fascia lata more proximally than the anterior and courses
travels within the spermatic cord where it supplies the cre- posterolaterally to supply the skin over the posterolateral
master muscle; it then courses towards the scrotum to supply aspect of the thigh extending from the greater trochanter to
the scrotal skin. In females, the nerve travels within the mid-thigh, sometimes also including the skin over the gluteal
inguinal canal and follows the round ligament of the uterus region.
to the labia majora. The nerve ends in cutaneous branches to
the skin over the mons pubis and labia majora. The femoral Innervation Motor :none
branch travels along the anterior surface of the lower part of Sensory: skin on anterior and lateral thigh as far as the
knee, skin on posterolateral thigh, sometimes skin
the psoas major, courses lateral to the external iliac artery, over gluteal region
11.1.6 Femoral Nerve vastus lateralis, intermedius (including the articularis genu, a
small muscle attaching to the top of the suprapatellar bursa
The femoral nerve, with contributions from the posterior and sometimes fused with the vastus intermedius), and medi-
divisions of L2, L3, and L4 anterior rami, is the largest alis muscles, as well articular innervation to the hip and knee
branch of the lumbar plexus. It descends through the sub- joints. It also gives rise to the saphenous nerve (Fig. 11.9),
stance of the psoas major muscle and emerges from its lower the largest terminal cutaneous branch of the femoral nerve.
lateral border, coursing inferiorly between the psoas major The saphenous nerve arises within the femoral triangle and
medially and the iliacus laterally, deep to the iliac fascia. It travels inferiorly deep to the sartorius muscle within the sub-
then courses downwards behind the inguinal ligament some- sartorial (adductor, Hunter’s) canal to the medial aspect of
what deep and lateral to the femoral artery (Figs. 11.5, 11.7, the knee, where it pierces the fascia lata between the tendons
and 11.8) to enter the femoral triangle in the proximal por- of sartorius and gracilis to become subcutaneous. Here it
tion of the thigh. At the level of the femoral triangle and just supplies the skin of the pre- and peripatellar regions of the
below the inguinal ligament, one can use the mnemonic knee. The nerve then continues inferiorly along the medial
N-A-V-E-L from lateral to medial (nerve-artery-vein-empty aspect of the leg together with the long (great) saphenous
space [femoral canal]-lymphatics) to determine the location vein, supplies the skin along the medial aspect of the leg up
of the various structures therein. Posterior to the inguinal to the ankle, and terminates in two branches; one along the
ligament, the nerve is outside the femoral sheath and sepa- medial aspect of the ankle, and the other passing anterior to
rated from the artery by a portion of the psoas major. While the ankle and along the medial side of the foot ending just
still within the abdomen, the nerve supplies muscular proximal to the big (great) toe; these branches supply the
branches to the iliacus and pectineus muscles, as well as a skin on the medial aspects of the ankle and foot up to the first
small vascular (vasomotor) branch to the proximal part of the metatarsophalangeal (MP) joint. The saphenous nerve has
femoral artery. The nerve to the pectineus usually arises from communicating branches with the lateral, intermediate, and
the medial aspect of the femoral nerve near the inguinal liga- medial cutaneous nerves of the thigh and the prepatellar
ment and runs behind the femoral sheath to enter the muscle plexus.
through its anterior surface. Vascular (vasomotor) branches of the femoral nerve sup-
The femoral nerve divides right after passing beneath the ply the femoral artery and its branches.
inguinal ligament, remaining as a single nerve trunk only for
a short distance. In the proximal thigh, the femoral nerve Innervation Motor: iliacus, pectineus, sartorius, quadriceps
femoris, articularis genu
bifurcates into anterior and posterior divisions around the
Sensory: skin of anterior and medial thigh, pre- and
lateral circumflex femoral artery. The anterior division gives peripatellar skin, skin on medial aspect of lower leg,
rise to the medial and intermediate cutaneous nerves of the medial aspect of ankle and foot up to 1st MP joint.
thigh, supplying the skin on the anteromedial thigh, and pro- Articular innervation to the hip and knee joints
vides motor branches to the sartorius muscle. The posterior Vascular: vasomotor filaments to proximal femoral
artery and its branches
division supplies motor innervation to the rectus femoris and
Fig. 11.7 Relationship between the

femoral nerve, artery, and vein deep to
the inguinal ligament
Femoral n.
Femoral
Iliopsoas m. artery
Femoral
vein
Deep femoral
(profunda
femoris) Spermatic
artery cord
Pectineus m.
Rectus
femoris m.
Sartorius m.
Adductor
longus m.
Gracilis m.
Vastus Adductor
medialis m. magnus m.
Fascia lata
Femoral vein
Skin and
Femoral Femoral artery superficial
sheath
Femoral n. fascia
Pectineus m.
Fascia iliaca
Psoas major m. Iliacus m. Sartorius m.
Lateral
Fig. 11.8 Cross section at the block location below the inguinal crease.
The femoral nerve lies deep to the fascia lata and fascia iliaca (iliopec-
tineal fascia) and is separated from the artery and vein(s) by the latter
11.1.7 Obturator Nerve nus muscle through its anterior surface, supplies it, and then
courses behind the adductor brevis muscle to descend on the
The obturator nerve arises from the anterior divisions of L2, anterior aspect of the adductor magnus muscle (medial to
L3, and L4 anterior rami (Figs. 11.4 and 11.5). The nerve the anterior branch). It supplies the adductor magnus and the
emerges from the medial border of the psoas major muscle at adductor brevis, when the brevis is not innervated by the
the pelvic brim and courses behind the common iliac vessels anterior division. It usually sends an articular branch to
and lateral to the internal iliac vessels. It then descends ante- the knee joint which either perforates through the distal
riorly along the pelvic side wall on the obturator internus portion of the adductor magnus or traverses the adductor hia-
muscle, anterosuperior to the obturator vessels, towards the tus with the femoral artery. It then traverses the adductor
obturator canal, through which it enters the upper part of the canal with the femoral artery (and vein) to enter the popliteal
medial aspect of the thigh. It divides into its anterior and fossa. Here the nerve courses with the popliteal artery (with
posterior branches near the obturator foramen, just lateral to vascular filaments to it) along the back of the knee and termi-
the pubic tubercle. Proximally, these branches are separated nates as an articular branch that pierces the oblique popliteal
by the obturator externus, more distally by the adductor ligament to supply the posterior capsule of the knee joint.
brevis. The posterior branch is not thought to provide any cutaneous
The anterior branch passes into the thigh anterior to the innervation.
obturator externus and descends in front of the adductor bre- The obturator nerve and its branches can be quite variable
vis but behind the pectineus and adductor longus muscles, in their course and distribution; occasionally, a small acces-
alongside the femoral artery, which it may supply with vaso- sory obturator nerve, arising from the anterior rami of L3
motor branches (Figs. 11.5 and 11.9). Near the obturator and L4, may be present, supplying the pectineus and articu-
foramen, it sends an articular branch to the hip joint. As it lar branches to the hip joint.
courses behind the pectineus, it supplies it (often), the
adductor longus, brevis (usually), and gracilis muscles. Its Innervation Motor: obturator externus, adductors longus, brevis,
and magnus, pectineus (usually), and gracilis
terminal cutaneous branches emerge at the lower border of
Sensory: skin on medial distal thigh, articular
adductor longus to supply the skin on the medial aspect of innervation to the hip and knee joints
the thigh. The posterior branch pierces the obturator exter- Vascular: vasomotor to popliteal artery
Fig. 11.9 Location of major vessels

and nerves within the thigh Adductor longus m.
Branch of
Saphenous n.
femoral n.
Gracilis m.
Adductor magnus m.
Femoral vein
Vastus
intermedius m. Femoral artery
Obturator n.
Vastus (cutaneous
lateralis m. branch)
Rectus Vastoadductor
femoris m. membrane
Vastus
medialis m.
Sartorius m.
Saphenous branch
of descending
genicular artery
Saphenous n.
Suggested Reading Mahadevan V. Pelvic girdle, gluteal region and thigh. In: Standring S,
editor. Gray’s anatomy. 40th ed. London: Churchill Livingstone;
2008. p. 1382–3.
Borley NR. Posterior abdominal wall and retroperitoneum. In:
Schuenke M, Schulte E, Schumacher U. The nerves of the lumbar
Standring S, editor. Gray’s anatomy. 40th ed. London: Churchill
plexus. In: Ross LM, Lamperti ED, editors. Thieme atlas of anat-
Livingstone; 2008. p. 1078–81.
omy: general anatomy and musculoskeletal system. Stuttgart: Georg
Mahadevan V. Pelvic girdle and lower limb: overview and surface anat-
Thieme Verlag; 2006. p. 472–5.
omy. In: Standring S, editor. Gray’s anatomy. 40th ed. London:
Churchill Livingstone; 2008. p. 1336–40.
Clinical Anatomy of the Sacral Plexus
12
Contents
12.1 Sacral Plexus 178
12.2 Direct Muscular Branches of the Sacral Plexus 179
12.2.1 Nerve to the Piriformis 179
12.2.2 Nerve to Obturator Internus and Gemellus Superior 179
12.2.3 Nerve to Quadratus Femoris and Gemellus Inferior 179
12.3 Major Terminal Nerves of the Sacral Plexus 179
12.3.1 Superior Gluteal Nerve 179
12.3.2 Inferior Gluteal Nerve 179
12.3.3 Posterior Femoral Cutaneous Nerve 179
12.3.4 Sciatic Nerve 180
12.3.5 Tibial Nerve 182
12.3.6 Common Peroneal (Fibular) Nerve 183
12.3.7 Pudendal Nerve 184
12.3.8 Pelvic Splanchnic Nerves 185
A.H. Walji, MD, PhD

AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_12
12.1 Sacral Plexus pudendal vessels course from the greater to the lesser sciatic
foramina, crossing the sacrospinous ligament posteriorly
The sacral plexus (Fig. 12.1) provides innervation to the near its attachment to the ischial spine. As they transit
skin, subcutaneous tissues, and muscles of the gluteal region, through the gluteal region on their way into the perineum,
posterior thigh, leg, and foot, as well as articular innervation they lie superficial to the sacrospinous ligament but deep to
to the hip, knee, and ankle joints. The plexus is located the sacrotuberous ligament. Finally, the plexus gives off sev-
within the pelvis and is formed from the fusion of the lumbo- eral direct muscular branches, including nerves to the
sacral trunk (L4 and L5) with the anterior (primary) rami of piriformis, obturator internus, superior and inferior gamelli,
sacral spinal nerves S1 to S3 and part of S4 (Fig. 12.1). The and quadratus femoris muscles.
lumbosacral trunk is formed from the union of a branch of
L4 with the anterior ramus of L5 and courses along the L4
medial border of the psoas major muscle. The trunk passes
over the pelvic brim, crosses anterior to the sacroiliac joint, Lumbosacral trunk
and joins with the anterior ramus of S1. The anterior primary
rami of S1–S3, after exiting through the anterior sacral L5
foramina, join the lumbosacral trunk to form the sciatic
nerve, the largest nerve of the sacral plexus and the widest
Superior gluteal n S1
nerve in the body. The anterior rami of sacral nerves S2 (par- (L4, 5, S1)
tial), S3, and S4 join to form the pudendal nerve, the other
terminal nerve of the plexus. Other branches of the plexus
include the superior and inferior gluteal nerves, posterior Inferior gluteal n
S2
femoral cutaneous nerve, and direct muscular branches. (L5, S1, 2)
These rami lie on the anterior aspect of the piriformis muscle N to quadratus
femoris
and converge toward the greater sciatic foramen, through (L4, 5, S1)
which they exit as nerves to enter the gluteal region,
perineum, and posterior thigh. S3
The sacral plexus itself lies anterior to the piriformis and Posterior
cutaneous n.
between it and the endopelvic fascia (thus, it is extraperito- of thigh
neal). Anterior to the plexus are the internal iliac vessels, the N to obturator (S1, 2, 3)
internus S4
ureters, and the sigmoid colon on the left and distal ileal loops (L5, S1, 2) Perforating
on the right. The superior gluteal vessels pass between the cutaneous n.
Sciatic n
(S2 & 3)
lumbosacral trunk (L4, L5) and S1 or between the S1 and S2 S5
roots. The inferior gluteal vessels pass either between the roots
Pudendal n.
of S1 and S2 or between S2 and S3 (the gluteal vessels gener- (S2, 3, 4)
Co
ally follow the course of the sacral nerves in the frontal plane).
The sciatic nerve exits through the greater sciatic foramen
to enter the gluteal region on its way to the posterior com- Fig. 12.1 Schematic diagram of the lumbosacral trunk and the sacral
plexus
partment of the thigh. The pudendal nerve and internal
12 Clinical Anatomy of the Sacral Plexus 179
12.2 Direct Muscular Branches 12.3 Major Terminal Nerves of the Sacral
of the Sacral Plexus Plexus
12.2.1 Nerve to the Piriformis 12.3.1 Superior Gluteal Nerve
The nerve to the piriformis usually arises from the posterior The superior gluteal nerve is formed from the posterior
branches of S1 and S2 anterior rami (occasionally only S2) (dorsal) branches of L4, L5, and S1 anterior rami. The nerve
and enters the muscle through its anterior surface to leaves the pelvis via the greater sciatic foramen above the
supply it. piriformis along with the superior gluteal artery and vein to
enter the gluteal region, where it splits into superior and infe-
rior branches. The superior branch travels with the upper
12.2.2 Nerve to Obturator Internus ramus of the deep branch of the superior gluteal artery to
and Gemellus Superior supply the gluteus medius and sometimes the gluteus mini-
mus. The inferior branch travels with the lower ramus of the
Arising from the anterior branches of L5, S1, and S2 anterior deep branch of the superior gluteal artery across the gluteus
rami, this nerve leaves the pelvis through the greater sciatic minimus, supplying it and the gluteus medius and terminat-
foramen below the piriformis, supplies a branch to the ing in the tensor fasciae latae, which it also supplies.
gemellus superior, crosses the ischial spine, re-enters the pel-
vis (perineum) through the lesser sciatic foramen, and sup- Innervation Motor – gluteus medius and minimus, tensor fasciae
latae
plies the obturator internus by piercing it through its pelvic
Sensory – none
surface.
12.2.3 Nerve to Quadratus Femoris 12.3.2 Inferior Gluteal Nerve

and Gemellus Inferior
The inferior gluteal nerve arises from the posterior branches
This nerve arises from the anterior branches of L4, L5, and of L5, S1, and S2 anterior rami. The nerve leaves the pelvis
S1 anterior rami, exits the pelvis via the greater sciatic fora- through the greater sciatic foramen below the piriformis
men below the piriformis, crosses the ischial tuberosity deep muscle and enters the gluteal region, where it divides into
to the sciatic nerve, and supplies branches to the gemellus several branches that enter the gluteus maximus through its
inferior and quadratus femoris as well as an articular branch deep surface to supply it.
to the capsule of the hip joint.
Innervation Motor – gluteus maximus
Sensory – none
12.3.3 Posterior Femoral Cutaneous Nerve
Arising from the posterior branches of S1 and S2 and ante-

rior branches of S2 and S3 anterior rami, the posterior femo-
ral cutaneous nerve leaves the pelvis via the greater sciatic
foramen below the piriformis and courses inferiorly deep to
the gluteus maximus with the inferior gluteal artery, lying
either medial or posterior to the sciatic nerve. The nerve
continues down the posterior aspect of the thigh deep to the
fascia lata but superficial to the long head of the biceps
femoris. When the nerve reaches the posterior aspect of the
knee, it pierces the deep fascia and travels with the small
(short) saphenous vein to the mid-calf where its terminal
branches communicate with the sural nerve. This is a purely
cutaneous (sensory) nerve supplying the skin over the gluteal
region, perineum, posterior thigh, and upper leg.
As the nerve crosses the lower border of the gluteus maxi- Muscular branches are distributed to the hamstrings
mus, three or four gluteal branches (also known as the inferior (biceps femoris, semimembranosus, and semitendinosus
clunial nerves) wind around the muscle’s inferior border to sup- muscles) and the hamstring (ischial) part of the adductor
ply the skin over its lower lateral aspect. The perineal branch magnus muscle, mostly through its tibial division (see
supplies the skin on the upper medial aspect of the thigh, crosses below). Articular branches arise from the proximal portion
the ischial tuberosity, pierces the fascia lata, and terminates in of the nerve (sometimes directly from the sacral plexus) and
cutaneous branches to the skin of the scrotum and labia majora. are distributed to the posterior aspect of the hip joint capsule.
Cutaneous branches arise mostly from the tibial and com-
Innervation Motor – none mon peroneal (fibular) divisions and supply the skin on the
Sensory – cutaneous innervation to the gluteal region, posterior and lateral aspects of the leg and lateral and plantar
perineum, back of thigh, and back of proximal leg
aspects of the foot (see below).
Innervation Motor – biceps femoris, semimembranosus,

12.3.4 Sciatic Nerve semitendinosus, ischial (hamstring) portion of
adductor magnus, muscles of the entire leg and foot
The sciatic nerve is formed within the pelvis from the fusion through its tibial and common peroneal (fibular)
of the lumbosacral trunk (L4–L5) with the anterior rami of divisions
S1–S3. A flattened oval shape in cross section, the sciatic Sensory – articular innervation to the hip, cutaneous
innervation to the skin of the entire lower leg and foot
nerve is the widest, thickest, and largest peripheral nerve in (with exception of the medial aspect supplied by the
the human body and at least 2 cm wide at its origin in the saphenous branch of the femoral nerve)
average adult. The sciatic nerve, although appearing as one
nerve, is really two nerves, the tibial and common peroneal
(fibular) nerves, enclosed within a common epineural sheath.
The nerve leaves the pelvis through the greater sciatic Posterior superior
foramen below the piriformis (generally) and descends just iliac spine (PSIS)
medial to the midpoint of an imaginary line drawn between
the greater trochanter of the femur and the ischial tuberosity
along the back of the thigh (Fig. 12.2). It is accompanied
medially by the posterior femoral cutaneous nerve and the
inferior gluteal vessels. Proximally, the nerve lies deep to
the gluteus maximus, resting first on the posterior surface of
the ischium and then coursing inferiorly posterior to the
Piriformis m. Greater
obturator internus, gamelli, and quadratus femoris muscles
to enter the back of the thigh, where it divides. Inferior to the trochanter
of femur
lower border of the gluteus maximus, the nerve is relatively
Superior gamellus,
superficial, after which it lies on the posterior aspect of the
obturator internus,
adductor magnus under the cover of the long head of the and inferior
biceps femoris muscle (Fig. 12.3). gamellus mm.
The nerve generally divides into the tibial nerve medially Quadratus
Ischial spine
and the common peroneal (fibular) nerve laterally near the apex femoris m.
(under
of the popliteal fossa (approximately two thirds of the way sacrotuberous
down the thigh) (Fig. 12.4). The point where it divides, how- ligament)
ever, is variable and can be at a more proximal location or any- Ischial
where between the piriformis muscle and the popliteal fossa or, tuberosity
occasionally, even more distally. In about 2 % of the popula-
tion, the nerve pierces the piriformis. Its surface projection on Sciatic nerve
the back of the thigh is along an imaginary line drawn from just
medial to the midpoint between the greater trochanter and
ischial tuberosity to the superior apex of the popliteal fossa. Fig. 12.2 Initial course of the sciatic nerve
Fig. 12.3 Cross section of the Quadriceps femoris

thigh showing position of the
Vastus Vastus Rectus Vastus
sciatic nerve with respect to major medialis m. intermedius m. femoris m. lateralis m.
muscles, vessels, and femur
Medial intermuscular septum
Femoral artery
Femoral vein
Sartorium m. Femur
Adductor longus m.
Iliotibial
tract
Gracilis m.
Adductor brevis m.
Lateral intermuscular
septum
Adductor magnus m.
Semimembranosus m. Biceps femoris m.

short head and
Semitendinosus m. long head
Sciatic n.
Gluteus
maximus m.
Biceps femoris m.
(long head)
Semitendinosus m.
Sciatic n.
Semimembranosus m.
Biceps
Popliteal femoris m.
artery (short head)
and vein
Tibial n.
Common
peroneal n.
Gastrocnemuis m.
(medial and lateral heads)
Fig. 12.4 Course and division of the sciatic nerve in the posterior thigh
12.3.5 Tibial Nerve deep (anterior) to the tendinous arch of the soleus with the
popliteal artery to enter the posterior compartment of the leg,
The tibial (medial popliteal) nerve is the larger of the two through which it continues inferiorly with the posterior tibial
divisions of the sciatic nerve and arises from the anterior vessels. In the leg, the nerve lies deep to the soleus muscle
branches of the anterior rami of the fourth and fifth lumbar and, for most of its course, on the surface of the tibialis pos-
and first to third sacral nerves (L4, L5, S1, S2, and S3). It terior; however, in the lower third of the leg, it comes to lie
splits off from the sciatic generally near the apex (proximal against the posterior surface of the tibial shaft and becomes
aspect) of the popliteal fossa, about two thirds of the way quite superficial, being covered only by the skin and fasciae
down the thigh, although the split may occur anywhere and occasionally overlapped by the flexor hallucis longus. Its
between the piriformis and the popliteal fossa. The nerve surface marking is a vertical line drawn down the midline of
courses inferiorly through the posterior compartment of the the leg from the inferior angle of the popliteal fossa to the
thigh and popliteal fossa to the lower border of the popliteus midpoint between the calcaneal tendon and medial malleo-
muscle, after which it passes deep (anterior) to the tendinous lus. At the medial aspect of the ankle, the relationship of the
arch of the soleus with the popliteal artery to enter the poste- nerve to the posterior tibial vessels and flexor tendons can be
rior compartment of the leg. In the back of the thigh, the remembered by the mnemonic “Tom, Dick And Very Nervous
nerve is overlapped proximally by the semimembranosus Harry,” which stands for, from anterior to posterior, Tibialis
and semitendinosus muscles medially and the biceps femoris posterior, flexor Digitorum longus, posterior tibial Artery
muscle laterally. Within the popliteal fossa, the nerve and Vein, tibial Nerve, and flexor Hallucis longus. The nerve
becomes more superficial, while lower down, near the base terminates between the medial malleolus and the calcaneal
(distal aspect) of the fossa, it is covered by both heads of the tuberosity (heel) deep to the flexor retinaculum, by dividing
gastrocnemius muscle. Within the popliteal fossa, the nerve into its terminal branches – the medial and lateral plantar
courses lateral to the popliteal vessels, becoming superficial nerves.
to them at the level of the knee joint, and crosses to the The medial plantar nerve, the larger terminal branch of
medial side of the popliteal artery near the base of the fossa. the tibial nerve, originates deep to the flexor retinaculum and
Branches given off within the fossa include muscular lies lateral to the medial plantar artery. The nerve travels
branches, articular branches, and the cutaneous sural nerve. deep to the abductor hallucis and then passes between it and
Muscular branches in the popliteal fossa supply the gas- the flexor digitorum brevis before giving off a medial proper
trocnemius, plantaris, soleus and popliteus muscles; in the digital nerve to the big toe (hallux) and dividing into three
leg they supply the soleus, tibialis posterior, flexor digitorum common plantar digital nerves. Cutaneous branches pierce
longus and flexor hallucis longus muscls. Articular branches the plantar aponeurosis to supply the skin on the medial
accompany the superior and inferior medial and middle aspect of the sole of the foot. Muscular branches supply the
genicular vessels to supply the posteromedial capsule of the abductor hallucis, flexor hallucis brevis, flexor digitorum
knee joint including the oblique popliteal ligament. brevis, and the first lumbrical. Articular twigs supply the tar-
The sural nerve travels inferiorly between the heads of sal and metatarsal joints. The common plantar digital nerves
the gastrocnemius, piercing the deep fascia in the leg proxi- further split into proper digital nerves, supplying the skin on
mally where it is usually joined (the point of union is vari- the adjacent sides of the medial three and a half toes (similar
able) by a sural communicating branch from the common to the distribution of the median nerve in the hand except for
peroneal (fibular) nerve. Some sources term this the lateral the second lumbrical).
sural cutaneous nerve and the main trunk from the tibial the The lateral plantar nerve travels forward and laterally
medial sural cutaneous nerve. From here, the sural nerve from its origin beneath the flexor retinaculum, crossing the
descends subcutaneously close to the small (short) saphe- sole of the foot obliquely and lying medial to the lateral plan-
nous vein, lateral to the calcaneal tendon, toward the space tar artery. The nerve then courses anteriorly toward the base
between the lateral malleolus and the calcaneus. It then trav- of the fifth metatarsal, between the flexor digitorum brevis
els around the lateral malleolus inferiorly and along the lat- and the flexor digitorum accessorius (quadratus plantae), ter-
eral aspect of the foot, ending as the lateral dorsal cutaneous minating between the flexor digitorum brevis and abductor
nerve. The sural nerve supplies cutaneous innervation to the digiti minimi by splitting into its deep and superficial
skin on the posterior and lateral aspects of the distal third of branches. Before dividing, it supplies the flexor digitorum
the leg and the skin on the lateral aspect of the foot up to the accessorius and abductor digiti minimi and gives cutaneous
little toe. It communicates with the posterior femoral cutane- branches that pierce the plantar fascia to supply the skin on
ous nerve in the leg and with the superficial peroneal (fibu- the lateral aspect of the sole of the foot. The superficial
lar) nerve on the dorsum of the foot. branch further divides into two common plantar digital
The tibial nerve leaves the popliteal fossa under cover of nerves which supply the flexor digiti minimi brevis and the
the two heads of the gastrocnemius muscle and then courses two interossei in the fourth intermetatarsal space as well as
the skin on the plantar aspect of the little toe and lateral half courses inferiorly along the anterior aspect of the lower third
of the fourth toe. The deep branch accompanies the lateral of tibia just lateral to the anterior tibial artery (between the
plantar artery (as it swings medially to form the deep plantar tibialis anterior medially and extensor hallucis longus later-
arch) deep to the long flexor tendons and adductor hallucis, ally) before crossing the ankle under the extensor retinacu-
supplying the latter muscle as well as the second to fourth lum and terminating as medial (cutaneous) and lateral
lumbricals and all the interossei (except those in the fourth (motor) branches. It supplies muscular branches to the tibia-
intermetatarsal space supplied by the superficial branch). Its lis anterior, extensor hallucis longus, and extensor digitorum
distribution is similar to that of the ulnar nerve in the hand, in longus (including the peroneus tertius) and an articular
that it supplies the majority of the intrinsic muscles of the branch to the capsule of the ankle joint. The medial terminal
foot. branch runs along the dorsum of the foot, lateral to the dor-
salis pedis artery, and connects with the medial branch of the
Innervation Motor – popliteus, gastrocnemius, soleus, plantaris, superficial peroneal (fibular) nerve, terminating as dorsal
tibialis posterior, flexor digitorum longus and brevis,
flexor hallucis longus and brevis, abductor hallucis, digital nerves to adjacent sides of the hallux (big toe) and
lumbricals, flexor accessorius (quadratus plantae), second toe (first web space). Its interosseous branch supplies
flexor digiti minimi, adductor hallucis, interossei, the first dorsal interosseous muscle and the metatarsophalan-
abductor digiti minimi geal joint of the big toe. The lateral terminal branch crosses
Sensory – cutaneous to skin on posterior and lateral the tarsus obliquely laterally deep to the extensor digitorum
aspects of distal leg and sole of foot. Articular
innervation to knee joint and joints of the foot brevis, which it supplies. Its tiny interosseous branches sup-
ply the second dorsal interosseous muscle and the tarsal and
metatarsophalangeal joints of the middle three toes.
The superficial peroneal (fibular, musculocutaneous)
12.3.6 Common Peroneal (Fibular) Nerve nerve also arises from the common peroneal bifurcation and
descends along the anterior intermuscular septum. At first
The common peroneal (fibular or lateral popliteal) nerve is deep to the peroneus longus, it then courses anteroinferiorly
about half the size of the tibial nerve and arises from the between the peroneal (fibular) muscles (lateral compartment)
posterior branches of the anterior rami of the fourth and fifth and the extensor digitorum longus (anterior compartment) to
lumbar and first and second sacral nerves (L4, L5, S1, and pierce the deep fascia in the leg’s distal third. Here, it becomes
S2). After splitting off from the sciatic nerve (tibial compo- superficial and divides into medial and lateral branches. As it
nent), it descends obliquely along the lateral border of the lies on the intermuscular septum between the lateral and ante-
popliteal fossa toward the fibular head, medial to the biceps rior compartments, it sends muscular branches to the pero-
femoris, and between its tendon and the lateral head of the neus longus and brevis muscles (the peroneus tertius is
gastrocnemius. The nerve winds around the lateral aspect of supplied by the deep peroneal nerve) and cutaneous branches
the fibular neck (where it is very superficial and may easily to the skin on the lateral aspect of the lower leg. The medial
be injured) deep to the peroneus longus muscle and gives off branch (medial dorsal cutaneous nerve) travels anterior to the
articular and cutaneous branches before dividing into its ter- ankle before dividing into two dorsal digital nerves, one sup-
minal superficial and deep peroneal nerves (Fig. 12.5). plying the skin on the medial aspect of the hallux (big, great
Of the three articular branches, two course with the toe) and the other the skin on the adjacent sides of the second
superior and inferior lateral genicular arteries to supply the and third toes (skin on the adjacent sides of the hallux and
posterolateral capsule of the knee joint, while the third second toe is supplied by the deep peroneal nerve). It com-
(recurrent articular nerve) arises a little lower and runs with municates with branches of the saphenous nerve and deep
the anterior recurrent tibial artery to supply the anterolat- peroneal (fibular) nerves. The smaller lateral branch (inter-
eral capsule of the knee joint and the proximal tibiofibular mediate dorsal cutaneous nerve) travels laterally across the
joint. The cutaneous branches, in the form of the sural com- dorsum of the foot and supplies the skin on the lateral aspect
municating nerve (joins with the sural nerve from the tibial of the ankle before terminating as dorsal digital nerves sup-
nerve) and the lateral sural nerve (lateral cutaneous nerve plying the skin on adjacent sides of the third, fourth, and fifth
of the calf), supply the skin on the anterolateral and poste- toes and communicating with the sural nerve.
rior aspects of the proximal leg.
The deep peroneal (fibular, anterior tibial) nerve arises Innervation Motor – tibialis anterior, extensor hallucis longus,
extensor digitorum longus and brevis,
from the common peroneal division between the fibular neck peroneus longus, brevis and tertius
and the proximal portion of the peroneus longus and passes Sensory – articular innervation to the knee, ankle,
deep to the extensor digitorum longus to descend on the ante- and joints of the foot. Cutaneous to skin on upper
rior aspect of the interosseous membrane, reaching the ante- anterolateral leg and dorsum of foot, dorsum and
rior tibial artery in the upper third of the leg. The nerve then adjacent sides of all toes (except first web space)
Lateral view 12.3.7 Pudendal Nerve

Saphenous n.
The pudendal nerve is formed from the union of the anterior
divisions of the second, third, and fourth anterior sacral rami
Tibial n. (S2, S3, and S4) at the upper border of the sacrotuberous liga-
ment. The nerve leaves the pelvic cavity together with the
Common
perneal n.
internal pudendal artery and vein through the greater sciatic
foramen below the piriformis and between it and the coccyg-
eus to enter the gluteal region. As the nerve transits through
the gluteal region, it crosses the sacrospinous ligament poste-
Deep peroneal (fibular) n.
riorly near its attachment to the ischial spine, lying superficial
to the sacrospinous ligament but deep to the sacrotuberous
Superficial peroneal n.
ligament (an important landmark for the pudendal nerve
block). At the level of the ischial spine, the internal pudendal
Medial and lateral vessels lie medial to the pudendal nerve. After crossing the
plantar n.
sacrospinous ligament, the pudendal nerve (with the internal
pudendal vessels) re-enters the pelvis (perineum) through the
Fig. 12.5 Lower extremity nerves entering the leg. Terminal branches lesser sciatic foramen and courses anteriorly within the
of the common peroneal nerve (deep and superficial peroneal nerves)
pudendal (Alcock’s) canal on the medial aspect of the obtura-
enter the leg just distal to the fibular neck
tor internus along the lateral wall of the ischiorectal fossa (the
pudendal canal is formed from a split in the deep fascia over
the obturator internus). In the posterior part of the canal, it
gives rise to the inferior rectal and perineal nerves and termi-
nates anteriorly as the dorsal nerve of the penis (or clitoris).
The inferior rectal nerve pierces through the medial
aspect of the pudendal canal and crosses the ischiorectal
fossa obliquely from lateral to medial with the inferior rectal
vessels to supply the external anal sphincter, the skin lining
the lower part of the anal canal, and the skin around the anal
verge. In females, it may supply sensory branches to the
lower part of the vagina. It may sometimes arise directly
from the sacral plexus. Its territory of supply overlaps with
that of the perineal branch of the posterior femoral cutaneous
and posterior scrotal (labial) nerves (see below).
The perineal nerve is the inferior and larger of the termi-
nal branches of the pudendal nerve and arises from it in the
posterior aspect of the pudendal canal. The nerve then
courses forward beneath the internal pudendal artery in com-
pany with the perineal artery and divides into posterior scro-
tal (labial) and muscular branches. The posterior scrotal
(labial) nerves pierce the perineal membrane (formerly
called the inferior fascia of the urogenital diaphragm), course
anteriorly in the lateral aspect of the urogenital triangle and
supply the skin of the scrotum or labia majora, overlapping
the territory of the perineal branch of the posterior femoral
cutaneous and inferior rectal nerves. The posterior labial
branches of the perineal nerve may also supply sensory
innervation to the lower part of the vagina. The muscular
branches are distributed to the adjacent superficial muscles
of the perineum (e.g., superficial transverse perineal muscle)
and the external anal sphincter. Direct muscular branches
arising from the pudendal nerve itself supply the levator ani
(pelvic diaphragm), external anal sphincter, superficial and
deep transverse perineal muscles, sphincter urethrae, and the Suggested Reading
bulbospongiosus and ischiocavernosus muscles.
The dorsal nerve of the penis (clitoris), the terminal con- Chapter 63: True pelvis, pelvic floor and perineum. In: Standring S,
editor. Gray’s anatomy. 40th ed. London: Churchill Livingstone;
tinuation of the pudendal nerve in males, courses forward
2008. p. 1091–2.
above the internal pudendal artery along the medial aspect of Chapter 79: Pelvic girdle and lower limb: overview and surface anat-
the ischiopubic ramus deep to the perineal membrane. It sup- omy. In: Standring S, editor. Gray’s anatomy. 40th ed. London:
plies the corpus cavernosum, passes through the hiatus Churchill Livingstone; 2008. p. 1336–40.
Chapter 80: Pelvic girdle, gluteal region and thigh. In: Standring S, edi-
between the anterior aspect of the perineal membrane and
tor. Gray’s anatomy. 40th ed. London: Churchill Livingstone; 2008.
pubic symphysis in company with the dorsal artery of the p. 1384–5.
penis, and traverses through the suspensory ligament to enter Schuenke M, Schulte E, Schumacher U. The nerves of the sacral plexus.
the dorsal surface of the penis. The nerve ends in sensory In: Ross LM, Lamperti ED, editors. Thieme atlas of anatomy: gen-
eral anatomy and musculoskeletal system. Stuttgart: Georg Thieme
branches in the glans penis. The corresponding nerve in
Verlag; 2006. p. 476–83.
females, the dorsal nerve of the clitoris, takes a similar
course and ends in sensory branches in the glans clitoris
although it is much smaller than in males.
12.3.8 Pelvic Splanchnic Nerves
Visceral branches of the sacral plexus, the pelvic splanchnic

nerves (also known as the nervi erigentes), arise from the
anterior rami of S2, S3, and S4 to provide parasympathetic
innervation to the pelvic viscera via the superior and inferior
hypogastric plexuses. In males, the pelvic splanchnic nerves
play a critical role in maintaining erectile function, and dam-
age to them (e.g., during prostatectomy or rectal surgery)
may render the patient impotent.
Clinical Anatomy of the Trunk
and Central Neuraxis 13
Contents
13.1 Spinal Nerves and the Vertebral Column 188
13.1.1 Origin of Spinal Nerves 188
13.1.2 Vertebral Column 188
13.2 Development of the Vertebral Column 190
13.2.1 Developmental Anatomy of the Thoracic and Lumbar Vertebral Column (Spine) 191
13.2.2 Developmental Anatomy of the Sacrum 193
13.3 Costovertebral Articulations 194
13.4 Paravertebral Space 196
13.5 Thoracic Spinal Nerves and Intercostal Nerves 196
13.6 Vertebral (Spinal) Canal 201
13.6.1 Vertebral Levels, Spinal Nerve Roots, and Spinal Cord Segments 201
13.6.2 Spinal Nerves Above the Sacrum 202
13.6.3 Termination of the Spinal Cord and Dural Sac 203
13.6.4 CSF Volume 204
Reference 204
A.H. Walji, MD, PhD

Division of Anatomy, Department of Surgery, Faculty of Medicine
and Dentistry, University of Alberta, Edmonton, AB, Canada
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_13
13.1 Spinal Nerves and the Vertebral root ganglia with their peripheral processes passing through
Column the sympathetic trunk via the rami communicantes without
synapsing (without synapsing) and ending in the thoracic
13.1.1 Origin of Spinal Nerves and abdominal viscera.
Soon after exiting the intervertebral (spinal) foramina,
Spinal nerves arise from the spinal cord and are part of the each spinal nerve in turn divides into a larger ventral and a
peripheral nervous system, along with the cranial and auto- smaller dorsal (primary) ramus (Fig. 13.1). The ventral rami
nomic nerves and their ganglia. Spinal nerves supply somatic course laterally and anteriorly to supply the muscles, subcu-
or body wall structures, in other words, structures derived taneous tissues (superficial fascia), and skin of the neck,
embryologically from somites and somatic mesoderm. They trunk, and upper and lower extremities. The dorsal rami
also supply parietal membranes, namely, the parietal pleura, course posteriorly and supply the paravertebral muscles,
pericardium, and peritoneum, as well as the periosteum. subcutaneous tissues, and skin of the back close to the mid-
There are 31 pairs of spinal nerves − 8 cervical (C1–C8), 12 line. All dorsal rami are arranged and distributed segmen-
thoracic (T1–12), 5 lumbar (L1–L5), 5 sacral (S1–S5), and 1 tally, from C1 all the way down to coccyx 1 (Co1). The only
coccygeal (Co1). These spinal nerves are formed by the ventral rami that are arranged and distributed segmentally
union of the ventral (anterior) and dorsal (posterior) spinal are those of spinal nerves T1–T12. The ventral rami of T1–
roots, each made up of smaller rootlets. The rootlets either T11 are called the intercostal nerves, while the ventral ramus
converge to form the roots as they exit the cord if they are of T12 is the subcostal nerve. The intercostal nerves course
motor (efferent; ventral) or diverge from the roots as they through the 11 intercostal spaces beneath the intercostal ves-
enter the cord if they are sensory (afferent; dorsal). The dor- sels between the innermost and internal intercostal muscles,
sal roots bear sensory ganglia (dorsal root ganglia) contain- while the subcostal nerve runs along the posterior abdominal
ing the cell bodies of somatic and visceral sensory neurons. wall underneath the 12th pair of ribs. Ventral rami not
Each typical spinal nerve is a mixed nerve containing arranged segmentally (C1 to C8 and L1 to Co1) fuse to form
somatic and visceral fibers, both efferent and afferent. The nerve plexuses. Thus, the neck, lower abdomen, pelvis, and
motor (somatic efferent) fibers supply skeletal muscle, extremities are supplied by nerve plexuses (cervical, bra-
while sensory (somatic afferent) fibers innervate skin and chial, lumbar, and sacral plexuses), while the thoracic and
superficial fascia (subcutaneous tissues). The sensory fibers upper three quarters of the abdominal wall are supplied by
also supply receptors in joint capsules and ligaments, fas- the segmentally organized intercostal nerves.
ciae, and skeletal muscle (e.g., muscle spindles and Golgi It is important to realize that the first cervical (C1) nerve
tendon organs). In addition, all spinal nerves contain sym- leaves the spinal cord and courses above the atlas (C1 verte-
pathetic (visceral efferent) fibers for supplying blood ves- bra); hence, the cervical nerves are numbered corresponding
sels, smooth muscle, and glands in the skin and blood to the vertebrae inferior to them (e.g., the C6 nerve exits
vessels in skeletal muscle. The preganglionic sympathetic below C5 and above C6 vertebra; C8 nerve exits below C7
neurons arise from the lateral horn of the spinal gray matter and above T1). From this point on, all the spinal nerves are
(intermediolateral cell column) in the thoracic and upper named corresponding to the vertebral level above. For exam-
two or three lumbar segments and synapse with postgangli- ple, T3 and L4 spinal nerves exit below the T3 and L4 verte-
onic neurons in the sympathetic trunk (chain) at corre- brae, respectively.
sponding levels or track up and down the trunk to be
distributed with spinal nerves at all levels. Some synapse
with the postganglionics at higher or lower levels in the 13.1.2 Vertebral Column
trunk to get into spinal nerves above T1 and below L2/3.
Those destined for the head synapse mostly in the superior This section reviews the developmental anatomy and growth
cervical ganglion. Finally, sacral spinal nerves from cord of the vertebral column (spinal column or spine) and pro-
segments S2, S3, and S4 contain preganglionic parasympa- vides a basis for appreciating the improved visibility ren-
thetic fibers, which leave via the ventral rami of the sacral dered when imaging the spine using ultrasound on the
nerves and are destined for the pelvic viscera via pelvic pediatric patient. It begins with the development of the verte-
plexuses and ganglia. These parasympathetic nerves are brae and vertebral column as a whole, followed by the growth
called the pelvic splanchnic nerves or the nervi erigentes. and curves of the vertebral column and finally a brief descrip-
Visceral afferent fibers, carrying visceral sensation pain tion of the developmental anatomy of the thoracic and lum-
from the viscera, have their cell bodies in the spinal dorsal bar spine and sacrum.
13 Clinical Anatomy of the Trunk and Central Neuraxis 189
Fig. 13.1 Cross section of a thoracic Vertebral body

vertebral segment with a simplified Sympathetic
spinal nerve and paravertebral space ganglion Pleura
shown (right side only). DRG dorsal
root ganglion Intervertebral foramen Paravertebral
Ventral root space
Spinal nerve
Dorsal root (with DRG)
Ventral ramus
Transverse process
(intercostal nerve)
Dorsal ramus
Superior
costotransverse
ligament Rib
Erector spinae
muscle Spinous process Medial and lateral branches
13.2 Development of the Vertebral processes fuse with those in the centrum to form a
Column cartilaginous model of the vertebra. The spinous and
transverse processes arise from proliferation of chondrifi-
As with most of the other bones of the human body, the cation centers in the vertebral neural arch and lateral pro-
development of the human vertebral column goes through cess, respectively.
three stages: mesenchymal (precartilaginous), chondrifica- 3. Ossification (bony) stage
tion (cartilaginous), and ossification (bony). Ossification of the developing vertebrae commences dur-
ing the embryonic period around the eighth to ninth
1. Mesenchymal (precartilaginous) stage weeks of IUL and is usually complete by the 25th year.
During the fourth week of intrauterine life (IUL), sclero- Three primary ossification centers appear, one for the
tomic mesenchymal cells of the somites (derived from the centrum and one for each half of the vertebral neural arch,
paraxial mesoderm) start to migrate toward the notochord followed by five secondary (epiphyseal) ossification cen-
which represents the primitive axial supporting structure. ters. Centers for the vertebral arches appear classically
At this stage, the developing neural tube, notochord, and first in the upper cervical vertebrae during the ninth to
endoderm of the yolk sac are in close contact and are tenth weeks of IUL and then in successively lower verte-
flanked by the paired dorsal aortae from which the inter- brae, reaching the lumbar vertebrae at around 12 weeks.
segmental arteries branch off and course between the Thus, at birth, each vertebra consists of three bony parts
somites. In the thorax, these intersegmental arteries connected by cartilage. The vertebral neural arches usu-
become the intercostal arteries; in the abdomen, they ally fuse during the first 3–5 years of life, commencing in
become the lumbar arteries. The mesenchymal tissue sur- the lumbar region and progressing cranially. The verte-
rounding the notochord is subdivided by the intersegmen- bral arches articulate with the centrum at the cartilaginous
tal vessels into sclerotomic segments. The mesenchymal neurocentral junctions (joints) or synchondroses, which
cells within the sclerotome become characterized by permit the vertebral arches to grow and the vertebral canal
alternating regions of densely packed and loosely to expand as the spinal cord enlarges. These neurocentral
arranged cells between which an intervertebral fissure junctions disappear when the vertebral arches fuse with
appears. This new segment forms the primitive vertebra the centrum beginning in the cervical region during the
consisting of a dense cranial zone separated by a loose third to sixth years of life. Until puberty, the superior and
caudal zone of cells by the intersegmental vessels. inferior surfaces of the bodies and tips of transverse and
From the dense zone, three processes arise and extend spinous processes are cartilaginous. Five secondary cen-
dorsally, ventrally, and laterally. The dorsal extension is ters of ossification appear at the epiphyses of the vertebra
called the neural process and will form the vertebral neural around puberty: one for the tip of the spinous process, one
arch. The ventral process will form the centrum (vertebral each for the tips of the transverse processes and two annu-
body), while the lateral process is related to the develop- lar ring-like epiphyses, one on the superior and one on the
ment of the vertebral transverse process and the attachment inferior rim of the vertebral body. The vertebral body is
of the ribs. Therefore, the primordia of the definitive verte- thus made up of two annular epiphyses with the mass of
brae are not formed from the mesenchymal cells of one bone in between them which is derived from the centrum.
somite but the recombination of the lesser and more con- It is important to point out that the adult vertebral body is
densed zones of mesenchyme derived from two adjacent not coextensive with the developmental centrum.
somites. The intervertebral fissures fill with mesenchymal Although the centrum will form the majority of the verte-
cells that migrate from the dense zone to form the annulus bral body, in the adult, the body includes parts of the neu-
fibrosus of the intervertebral (IV) disk, whereas the noto- ral arches posterolaterally. These secondary centers fuse
chord and inner cells of the annulus fibrosus degenerate to with the rest of the vertebra around 25 years of age to
form the nucleus pulposus. form the definitive vertebra and the vertebral column. The
2. Chondrification (cartilaginous) stage atlas (C1), axis (C2), C7, sacrum, and coccyx are excep-
During the sixth to seventh weeks of IUL, a pair of chon- tions to this typical ossification pattern.
drification centers appears in each vertebral body fol- The majority of people have 7 cervical, 12 thoracic, 5
lowed by separate centers in each neural and transverse lumbar, 5 sacral (fused), and usually 4 (3 to 5) coccygeal
processes. The two centers in each vertebral body fuse at (fused) vertebrae; however, about 2–3 % have one fewer or
the end of the embryonic period (~9 weeks of IUL) to one or two additional vertebrae. When this occurs, there may
form a cartilaginous centrum or body. At the same time, be regional compensation (e.g., 11 thoracic and 6 lumbar
the chondrification centers in the neural and transverse
vertebrae), so when determining the number of vertebrae, it posture, the center of gravity is at about the level of the
is important to examine the entire vertebral column. xiphoid process and remains above the umbilicus throughout
early childhood. At about 5–6 years, it is just below the
Growth and Curves of the Vertebral Column umbilicus, and at around 13 years, it shifts to the level of the
The increase in length of the vertebral column is determined iliac crest. In the adult, the center of gravity lies at the level
by the growth of its vertebral components. The various of the sacral promontory (the most forward projecting aspect
regions of the column and different parts of the vertebrae of the upper edge of the first sacral vertebra).
have differential rates of growth. The growth of the vertebral
bodies begins in the thoracic and lumbar regions and extends
craniocaudally. The lower part of the column grows faster 13.2.1 Developmental Anatomy
than the upper as a functional prerequisite for providing bet- of the Thoracic and Lumbar Vertebral
ter support. There are two periods of accelerated growth: the Column (Spine)
first between 2 and 7 years of age and the second between 9
and 15 years of age. The curves of the vertebral column • At birth, the vertebrae of the thoracic and lumbar spine
become evident during the third month of IUL life. At first, consist of three bony masses: a centrum anteriorly and
there is only a slight curve, concave anteriorly, followed in two vertebral neural arches posteriorly, united by
the fifth month by the appearance of the sacrovertebral angle. cartilage.
Radiographic studies have shown, however, that 83 % of • Development of the thoracic spine:
fetuses aged between 8 and 23 weeks already possess a cer- – The laminae typically unite in a caudo-cranial
vical curve. (upwards, T12 through T1) fashion, usually by the end
At birth, this embryonic anterior curvature is preserved in of the first or beginning of the second year of life.
the thoracic and sacral regions. These areas of the column, – The centrum (body) fuses with the neural arches (neu-
concave anteriorly, are therefore referred to as the primary rocentral fusion), also in a caudal to cranial manner,
curves. The cervical curve is also present at birth although it generally by the end of the fifth year of life.
becomes more accentuated when the baby starts supporting – The transverse processes are present and prominent at
its head (around 3–4 months of life) and sitting upright birth; however, their tips, like the tips of the transverse
(around 9 months of life). The lumbar curves appear later in processes, remain cartilaginous until puberty.
response to the baby adopting the upright walking posture – The three facets for articulation with the ribs at the
and walking unassisted (around 12 months of life). These are costovertebral and costotransverse joints are present at
termed secondary or compensatory curves since they develop birth.
in response to biomechanical demands placed on the column – The neurocentral and posterior synchondroses are not
and are convex anteriorly. Thus, the adult has four anteropos- fused at birth; the posterior ones fuse within 2–3 months
terior curves: cervical (secondary), thoracic (primary), lum- of postnatal life, and the neurocentral synchondroses
bar (secondary), and sacrococcygeal or pelvic (primary), close after 5–6 years of life.
while the newborn has only three, cervical, thoracic, and • Development of the lumbar spine:
sacral, the latter demarcated by the sacrovertebral angle. – Fusion of the laminae of L1 through L4 occurs during
Between 3 and 9 months of life, the cervical curve becomes the first year of life, with those of L5 fusing by 5 years
more marked in response to the biomechanical demands of age.
placed on it from the baby supporting its head and sitting – Neurocentral fusion is generally complete by age 4.
upright, while after the first year, one sees the appearance of – Transverse processes begin to develop after the first
the lumbar curve in response to the need for supporting the year of life; however, their tips, like the tips of the spi-
baby’s weight. nous processes, are cartilaginous until puberty.
The cervical and lumbar curves in the adult are due mainly – The lumbar secondary compensatory curve (through
to the shapes of the intervertebral disks, while the thoracic intervertebral disk modification) does not begin to
curve is related more to the shapes of the thoracic vertebrae, develop until 6 or 8 months of age when the infant
which have a greater depth posteriorly. During intrauterine begins sitting upright and supporting its weight and
life, the vertebral column represents about three quarters of becomes more apparent after the first year of life when
total body length, whereas at birth, it is reduced to two fifths the infant is able to adopt the upright posture and walk
due to the relatively rapid development of the lumbosacral unassisted.
region and lower extremities. This variation in the propor- • The vertebral canal in young infants is quite small, with
tions of the vertebral column, head, trunk, and extremities the thickness of the epidural space being as little as
causes the center of gravity of the body to shift caudally as 1–2 mm.
the infant grows. In the newborn held in the upright erect
• Secondary ossification centers in vertebral bodies and

arches do not fuse with the rest of the vertebra until the Spinal
early twenties, allowing continuing growth and develop- nerve
ment of the vertebral structures.
• In children, most vertebrae contain five secondary ossifi-
cation centers (in the transverse and spinous processes as
well as on the superior and inferior surfaces or rims of the
vertebral bodies), which allow continual growth and
remodeling of the vertebral column.
• In adults (early 20s), the vertebral column is essentially
complete with the exception of fusion between the bodies
of S1 and S2.
• In adults:
– The thoracic vertebral bodies are of medium size and
heart shaped (Fig. 13.1); vertebral (spinal) canals are
small and nearly circular in shape; laminae are rela-
tively small; spinous processes are long and oriented Transverse
process
obliquely inferiorly (Figs. 13.2 and 13.3). Spinous pro-
cesses overlap from T5–T8, the latter being the longest
and most oblique, and their obliquity increases from
T1–T9 then decreases in T10–T12. The transverse pro-
cesses are relatively broad and robust for articulation
with the ribs and generally face posterolaterally. The
thoracic vertebrae are adapted mostly for articulation
with the ribs and their role in movements of the chest Thoracic spinuous
wall during respiration; however, they also play a sec- processes
ondary role in supporting and transmitting the weight Fig. 13.2 Vertebrae of the thoracic spine, illustrating inferiorly ori-
of the head and neck and the thorax to the lumbar seg- ented spinous processes
ment of the column.
– The lumbar vertebral bodies are large and kidney
shaped; vertebral (spinal) canals are triangular in
Thoracic
shape; laminae are thick; spinous processes are short
spine
and stout with a posterior (horizontal) orientation
(Fig. 13.3); intervertebral disks are thickest with
respect to the rest of the spine; within the lumbar spine
itself, the disks are thicker anteriorly, contributing to
Long and
the anterior lumbar curvature (lumbar lordosis). The inferiorly orientated
transverse processes are long, slender, and directed lat- spinous procceses
erally and are mostly for muscular attachments. The

lumbar vertebrae are designed primarily for weight
bearing and transmission, as reflected in the large size
and robustness of their bodies, laminae, and IV disks.
Lumbar
spine
Thick and
horizontal spinous
procceses
Fig. 13.3 Spinal column showing the thoracic and lumbar regions
13.2.2 Developmental Anatomy of the Sacrum • Sacral vertebrae are oriented vertically until weight bear-
ing around age 1.
• In infancy and childhood, the sacrum is highly variable • Beyond puberty, the sacral hiatus is an inferiorly placed
with respect to its shape and ossification and therefore opening into the caudal epidural space, below the fifth
also its visibility on ultrasound imaging (Fig. 13.4): sacral vertebra and between it and its inferior “horns” or
– Like the lumbar spine, neonatal sacral vertebrae are cornua (this is because the S5 laminae fail to fuse)
composed of two half neural arches posteriorly and a (Fig. 13.4). In young infants, the sacral hiatus is generally
centrum anteriorly. lower, below the fifth sacral vertebra, and since there is
– S1 and S2 vertebrae contain lateral elements that will much less ossification of the sacrum, ultrasound imaging
form the articular surfaces of the sacroiliac joints. in infants is generally rendered easier and generates supe-
– Compared to the lumbar spine, fusion and ossification rior image quality.
are delayed in the sacrum; neurocentral fusion occurs • The posterior sacrococcygeal ligament (membrane) has
between ages 2 and 6, and fusion of the neural arches superficial and deep laminae and covers the sacral hiatus
to form spinous processes continues until age 15. externally; this ligament requires penetration by the nee-
– Ossification is a continual process that carries on until dle for epidural needle entry (see Fig. 13.5).
puberty with ventral fusion of S1–S2 occurring in the
early 20s.
Incomplete fusion
of vertebral bodies
and neural arches Pelvic surface
Complete fusion
with median
sacral crest and Dorsal
2 cornuae (horns) surface
Caudal
Epidural
epidural space space
Lateral elements
to form articular
surfaces of sacrum
Sacral
hiatus
Fig. 13.4 Posterior view of infant (left) and adolescent (right) sacra, illustrating incomplete fusion of the sacral neural arches. Also shown is the
incorporation of lateral elements which form the articular surfaces to form the sacroiliac joints
13.3 Costovertebral Articulations
The costovertebral articulations (Fig. 13.6) are relevant pri-

marily for paravertebral and intercostal blockades, although
practitioners will encounter these joints during ultrasound-
guided epidurals as the imaging technique will incorporate
these structures. The ribs articulate with the vertebral column
through two synovial joints, one for the head of the rib (cos-
tovertebral) and the other for the tubercle (costotransverse):
• Costovertebral joint: the head of the rib articulates

through a synovial joint with demi-facets on adjacent tho-
racic vertebral bodies and the corresponding interverte-
bral disk of the upper vertebral joint, e.g., 7th rib with
bodies of T6, T7, and T6–T7 disk (except for the 1st and
10th–12th ribs, which articulate with a single vertebral
facet through a simple synovial joint). The synovial joint
cavities of the remaining costovertebral joints are bisected
by an intra-articular ligament resulting in double synovial
compartments. The joints are enclosed in fibrous capsules
lined on the inside with synovial membrane and rein-
Posterior
sacrococygeal forced by capsular, radiate, and intra-articular ligaments.
ligament • Costotransverse joint: articular facets on the tubercles of
the ribs articulate through synovial joints with the trans-
verse processes of the corresponding thoracic vertebrae
(the 11th and 12th ribs lack this articulation since they do
not possess tubercles). The joints are enclosed in thin
Fig. 13.5 The caudal epidural space. When performing epidural entry fibrous capsules lined with synovial membrane and rein-
in this location, puncture of the posterior sacrococcygeal ligament min- forced by ligaments. The ligaments are the superior and
imizes the risk of potential needle trauma to the spinal cord lateral costotransverse and the costotransverse ligament,
the latter filling the interosseous gap (costotransverse
foramen) between the neck of the rib and its adjacent ver-
tebral transverse process. The primary purpose of these
articulations is to facilitate movements of the ribs for
respiratory excursions of the thorax.
Fig. 13.6 Costovertebral articulations. Costal articular (demi)

Left side: costovertebral and Radiate ligament facet of vertebral body
costotransverse synovial joints,
illustrating exterior surfaces with
ligamentous coverings; right side: Costovertebral synovial joint
section through the synovial joints
Head of rib
Costotransverse ligament
Neck of rib
Tubercle of rib
Transverse process
Lateral costotransverse ligament
Costotransverse synovial joint

13.4 Paravertebral Space 13.5 Thoracic Spinal Nerves

and Intercostal Nerves
The paravertebral space is a bilateral wedge-shaped space on
either side of the vertebral column and between the individ-
ual vertebrae, extending the column’s entire length, through • There are 12 pairs of thoracic spinal nerves: T1–T12.
which the spinal nerves course after exiting from the inter- • The intercostal nerves are the ventral primary rami of
vertebral foramina. In the thoracic region, its boundaries are thoracic spinal nerves T1–T11.
as follows (Fig. 13.1): • The ventral primary ramus of thoracic spinal nerve T12 is
called the subcostal nerve, which courses beneath the
• Medially: vertebral body, intervertebral disk and foramen, 12th rib along the posterior abdominal wall.
and spinous process • The thoracic spinal nerves arise from the thoracic seg-
• Anterolaterally: parietal pleura ments of the cord from the union of dorsal and ventral
• Posteriorly: costotransverse joint and the adjacent parts of roots and emerge from the intervertebral (spinal) foram-
the transverse process and the rib, approximately 2.5 cm ina to course through the paravertebral space en route to
(for adolescents) from the tip of the transverse process, the structures they supply in the thoracic and abdominal
often in a slightly caudal orientation walls.
• The intervertebral foramina are found between adjoining
The paravertebral space communicates medially with the neural arches near their junctions with the vertebral bod-
intervertebral foramen throughout the length of the column ies, where adjacent vertebral notches on the pedicles of
with the exception of the sacrum and coccyx. In the thoracic the vertebra above and below contribute to the formation
region, it is continuous laterally with the intercostal space, of the foramen.
and adjacent levels of the paravertebral space communicate • As they course through the intervertebral foramina, the
with each other. In the lumbar region, however, the paraver- spinal nerves have clinically important relations with the
tebral space is divided into segments by the attachments of boundaries of the foramina.
the psoas major muscle. • Forming the complete perimeter of an intervertebral fora-
men, these boundaries are, superiorly and inferiorly, the
vertebral notches of the pedicles of adjoining vertebrae;
anteriorly, the posterolateral aspects of the adjacent ver-
tebral bodies and intervening IV disk; and, posteriorly,
the fibrous capsule of the synovial facet (zygapophyseal)
joint between the superior and inferior articular processes
of the vertebrae.
• Each spinal nerve, together with its spinal artery, a small
venous plexus, and its own meningeal branch(es), tra-
verses the intervertebral foramen.
• After exiting through the intervertebral foramen, each spi-
nal nerve quickly divides into a small dorsal (primary)
ramus (branch) to supply the paravertebral (paraspinal)
muscles and skin of the back and a larger ventral (pri-
mary) ramus that swings around from posterolateral to
anteromedial along the chest wall to supply the intercostal
spaces, the adjacent thoracic wall, and the anterior
abdominal wall (Fig. 13.1).
• The ventral (primary) rami of thoracic spinal nerves T1–
T11 form the 11 pairs of intercostal nerves for the 11
intercostal spaces (see Fig. 11.6) and the subcostal nerve
(T12), which courses just underneath the 12th rib.
• The intercostal nerves give off cutaneous branches at the
lateral and anterior aspects of the thoracic and abdominal
walls that supply the skin and superficial fascia (subcuta-
neous tissues) in these regions.
• Thoracic spinal nerves T2 through T12 (intercostal nerves
and subcostal nerve) and lumbar spinal nerve L1
(iliohypogastric and ilioinguinal nerves) can be blocked abdominal wall, they course in the plane between the trans-
for surgical intervention (Fig. 13.7). versus abdominis and internal oblique muscles, which cor-
responds to the plane between the innermost and internal
Initially, the intercostal nerves course through the poste- intercostal muscles in the thorax. The tenth intercostal nerve,
rior aspects of the intercostal spaces, between the intercostal for example, the cutaneous branches of which supply the
membrane and the parietal pleura, and then course laterally periumbilical skin, travels laterally between the transverse
past the angles of their respective ribs between the innermost abdominis and internal oblique muscles; courses anteriorly
and internal intercostal muscles. Laterally, they give off both and then medially around the abdominal wall; pierces the
collateral branches (running adjacent to the nerve within the posterior rectus sheath; pierces through the rectus abdomi-
intercostal space) and lateral cutaneous branches, the latter nis, supplying it; and then pierces the anterior rectus sheath
of which divide into ventral and dorsal rami. The first inter- to become the anterior cutaneous branch (Figs. 13.8, 13.9,
costal nerve branches into two nerves; the first of which and 13.10). Intercostal nerves T7 to T9 and T11 take a simi-
leaves the thorax near the neck of the first rib and contributes lar course through the anterior abdominal wall. They supply
to the brachial plexus, while the second travels a path similar the muscles, skin, and subcutaneous tissues of the anterolat-
to those below it within the intercostal space. The lateral eral abdominal walls, as well as the parietal peritoneum lin-
cutaneous branch of the second intercostal nerve is the inter- ing the abdominal walls. Cutaneous innervation to the
costobrachial nerve, which pierces the second intercostal anterolateral thoracic and abdominal walls by cutaneous
space and crosses the axilla to reach the medial and posterior branches of the intercostal nerves and subcostal nerve is
aspects of the arm where it supplies the skin and subcutane- organized segmentally (Fig. 13.7). Landmark dermatomes
ous tissues. on the anterior thoracic and abdominal walls in the adult are
As the intercostal nerves travel laterally, anteriorly, and the sternal angle (of Louis), T2; nipple, T4; xiphoid process,
then medially to reach the anterior aspect of the thoracic T7; umbilicus, T10; and suprapubic region, L1.
wall, they contact the parietal pleura again before giving off
the anterior cutaneous nerves of the thorax. The first to sixth Innervation: Motor: rectus abdominis; transversus abdominis;
internal and external oblique; innermost, internal,
intercostal nerves (T1–T6) proceed in their intercostal spaces and external intercostals; subcostales; transversus
between the innermost and internal intercostal muscles and thoracis; serratus posterior (superior and inferior);
beneath the intercostal vessels until they approach the ster- and levatores costarum
num where they end as the anterior cutaneous nerves of the Sensory: skin and subcutaneous tissues on anterior
thorax. Intercostal nerves 7 (T7) through 11 (T11) and the and posterior thoracic and abdominal walls, parietal
pleura, parietal peritoneum, skin and subcutaneous
subcostal nerve (T12) continue from their intercostal and tissues on medial and posterior aspects of the arm
subcostal spaces into the anterior abdominal wall, in which (via brachial plexus and intercostobrachial nerve),
they supply and end as the anterior cutaneous nerves of the and peripheral portions of the diaphragm
abdomen (T7–T12). As these nerves enter the anterolateral
Fig. 13.7 Cutaneous innervation of

the anterior trunk
C2
C3
C4
Supraclavicular nerves
T2
C5 T3 C5
Intercostal nerves
T4
T5
anterior and
T6
lateral cutaneous branches
C6
T7 C6
T1
T8 T1
T9
C7 T10
C8
C7
T11 C8 Iliohypogastric n.
T12 lateral and
L1 anterior branch
L2 S2
L2
Ilioinguinal nerve
S3
Genitofemoral nerve
L3 L3 Lateral femoral
cutaneous nerve
Medial crural cutaneous
L4 L4 branches of saphenous
branch of femoral nerve
S1 L5 S1 S1 L5 S1
Fig. 13.8 Anterior view of the Rectus abdominis m.

abdomen
Intercostal
nerves
Transversus
abdominis m.
Internal oblique m.
External oblique m.
Iliohypogastric n.
Ilioinguinal n.
Anterior superior
iliac spine (ASIS)
a
Rectus Linea Rectus sheath
External oblique abdominis m. alba (anterior layer) Superficial fascia
aponeurosis (membranous layer)
Internal oblique
aponeurosis Superficial fascia
Transversus (fatty layer)
abdominis aponeurosis
Skin
External
oblique m. Rectus sheath Parietal
(posterior layer) peritoneum Transversalis
fasica
Internal Transversus
oblique m. abdominis m.
b
Superficial Rectus Linea Rectus sheath
abdominal fascia abdominis alba (anterior layer) Skin
Subcutaneous
External oblique tissue
aponeurosis Transversus
abdominis
Internal oblique Internal
aponeurosis oblique
External
oblique
Transversalis fascia and
parietal peritoneum
Transversus abdominis
aponeurosis
Fig. 13.9 Transverse view of the abdomen above (a) and below (b) the arcuate line of the abdomen (Douglas’ line)
Abdominal Inferior
Renal fascia
aorta vena cava Lateral abdominal
(anterior layer)
wall muscles
Perirenal fat
L3 vertebral
Psoas body
major m.
Kidney Renal fascia
(posterior layer)
Costal
process
Latissimus
Vertebral dorsi m.
(neural)
arch
Serratus posterior
Spinuous inferior m.
process
Quadratus
lumborum m.
Intrinsic back Superficial and deep layers

muscles of thoracolumbar fascia
Fig. 13.10 Transverse view of the lumbar torso (L3 level)

13.6 Vertebral (Spinal) Canal From superficial to deep, the three meninges surrounding
the spinal cord are:
In order to safely and proficiently administer a spinal anesthetic
in children, it is crucial to understand the anatomy of the verte- 1. The dura mater (pachymeninx) which is the outermost
bral (spinal) canal, including the level of termination of the spi- fibrous and toughest layer of the meninges. Between the
nal cord and dural sac, the relationship between vertebral levels dura and the walls of the vertebral canal is the spinal epi-
and spinal cord segments, as well as the age-dependent varia- dural space, a real space containing epidural fat within
tion in the volume of cerebrospinal fluid (CSF). This section loose connective tissue, lymphatics, small arterial vessels,
reviews the gross and developmental anatomy of the vertebral and the internal vertebral venous plexus (see below).
column in order to provide a basis for appreciating the improved 2. The arachnoid mater, a much thinner and more delicate,
visibility when imaging the spine in the pediatric patient, fol- mostly translucent spider web-like membrane which lines
lowed by a brief segment explaining the relationship between the inside of the dura and is separated from the next deep
vertebral levels and spinal cord segments. layer, the pia mater, by a real space, the subarachnoid
The spinal cord and its nerve roots lie within the bony space, through which it sends delicate trabeculae down to
central canal of the vertebral column. The vertebral column the pia mater. The spinal subarachnoid space contains
consists of 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 cerebrospinal fluid (CSF) and the anterior and posterior
(3 to 5) coccygeal vertebrae. The developmental anatomy of spinal vessels. There is a potential subdural space within
the lumbar and sacral regions is of particular relevance to the vertebral canal since the dura and arachnoid are
spinal anesthesia in infants and children. closely applied; however, accidental subdural penetration
may occur during epidural injections.
• The vertebral (spinal) canal is the longitudinal, cylindrical 3. The pia mater, the transparent innermost single-cell lay-
space within the vertebral column created by successive ered membrane tightly adherent to the surface of the spinal
vertebral foramina superimposed upon one another and cord and inseparable from it. The pia mater intimately fol-
extends from C1 vertebra to the bottom of the sacrum lows and dips into all the grooves and fissures on the sur-
(sacral canal). Superiorly, it is continuous with the fora- face of the cord. The arachnoid and pia together are
men magnum which transmits the spinomedullary junc- sometimes referred to as the leptomeninges. Deep to the
tion. The vertebral canal houses the spinal cord with its pia is a thick subpial collagenous layer which is continu-
blood vessels and surrounding meninges; the proximal ous with the collagenous core of the denticulate ligaments.
portions of the spinal nerves within their dural sheaths, The latter, which are flat, triangular fibrous sheets on either
epidural fat, loose connective tissue, lymphatics, and side of the cord between the ventral and dorsal roots anchor
small arterial branches; and the internal vertebral venous the cord via their apices to the inside of the dura mater at
plexus. The latter five structures are found within the epi- regular intervals and provide it with structural support.
dural space, a real space between the dura and the bony
margins of the vertebral canal. Intermediate layer: In addition to the three classically
• The vertebral canal’s anterior border is formed by poste- described layers of meninges surrounding the cord, there is
rior aspects of the vertebral bodies and the posterior lon- an additional so-called intermediate layer of leptomeninges
gitudinal ligament; laterally, it is bordered by the pedicles, found just deep to the arachnoid but superficial to the pia and
while posterolaterally and posteriorly, its boundaries are concentrated mostly around the posterior and anterior
formed by the laminae, the ligamenta flava, and the poste- regions of the cord. This layer is perforated and lacelike in
rior aspects of the vertebral neural arches, respectively. appearance and thickened focally to form the posterior, pos-
• The lumbar segment of the vertebral (spinal) canal has been terolateral, and anterior ligaments of the cord and provide it
described as having a shape similar to that of an hourglass, with additional support to that provided by the denticulate
with narrowing at the third and fourth lumbar levels. This ligaments. Structurally, it is similar to the trabeculae crossing
feature is already present at age 3. Furthermore, the sagittal the cranial subarachnoid space and may play a role in damp-
(anteroposterior) diameter of the vertebral canal does not ening fluid waves in the CSF within the subarachnoid space.
differ significantly between the ages of 3–14 inclusive.
• The major structure within the vertebral canal is the spinal
cord with its blood vessels, its cerebrospinal fluid, and its 13.6.1 Vertebral Levels, Spinal Nerve Roots,
three meningeal coverings. The meninges are three con- and Spinal Cord Segments
centric membranes surrounding the brain and spinal cord
and providing support and protection to these delicate An appreciation of the clinical anatomy of the spinal cord as
structures. The cranial and spinal meninges are continu- it relates to the vertebral column and the relationship between
ous at the foramen magnum. spinal cord segments and vertebral levels is important for the
anesthesiologist. Since, due to differential growth rates, the the arachnoid mater. The dural/arachnoid sleeve extends
spinal cord is shorter than the vertebral column, the more onto the spinal nerves for a short distance before blending
caudal spinal roots descend almost vertically for varying dis- with the epineurium surrounding the nerves.
tances beyond the termination of the cord (conus medullaris) • The spinal epidural space (Fig. 13.11) is a “real” space
to reach their corresponding intervertebral foramina. As they between the dura mater and the periosteum lining the ver-
do so, they form a divergent bundle of spinal roots resem- tebral (spinal) canal. This space is richly vascularized
bling a horse’s tail, the cauda equina, beyond the conus (internal vertebral venous plexus, small arterial branches,
medullaris and surrounding the filum terminale. This sheaf and lymphatics) and filled with epidural fat and loose con-
of nerve roots is suspended within the cerebrospinal fluid in nective tissue which surrounds the dura mater. It is bor-
an expanded subarachnoid space, the lumbar cistern, the pre- dered posteriorly by the ligamentum flavum (interlaminar
ferred site for performing a lumbar puncture. ligament), laterally by the pedicles, and anteriorly by the
With regard to the relationship between spinal cord seg- posterior longitudinal ligament which lies on posterior
ments and vertebral levels, the following estimation is help- aspects of the vertebral bodies within the vertebral canal.
ful: at the cervical level, the tip of the vertebral spinous • Gray and white rami communicantes (Fig. 13.1) connect
process corresponds to the succeeding spinal cord segment the spinal nerves to the sympathetic trunk (chain) ganglia
(i.e., the tip of the fifth cervical spine is opposite the sixth to allow preganglionic sympathetic fibers leaving the spi-
cervical spinal cord segment). At upper thoracic levels, this nal cord (T1–L2/3) to enter the trunk and leave it again to
difference corresponds to two cord segments (i.e., the tip of be distributed with spinal nerves at all levels.
the third thoracic spine is opposite the fifth thoracic cord seg- • The spinal nerves divide into ventral and dorsal (primary)
ment); in the lower thoracic region, this difference increases rami (Figs. 13.1 and 13.11); the dorsal rami supply the
to three segments (i.e., the tenth thoracic spine is opposite paravertebral muscles and skin near the midline of the
the first lumbar cord segment); the 12th thoracic spine lies back; the ventral rami of the thoracic spinal nerves form
opposite the first sacral cord segment; thus, there is a pro- the intercostal and subcostal nerves (T1–T12) (Sect. 13.5)
gressively increasing discrepancy between spinal cord seg- which supply the walls of the thorax and abdomen
ments and vertebral levels craniocaudally. (including the parietal pleura and peritoneum). The
The adult spinal cord terminates in most cases at the level remaining ventral rami (C1–T1 and L1–S3) form the cer-
of the intervertebral disk between the first and second lumbar vical, brachial, lumbar, and sacral plexuses, which supply
vertebrae (L1 and L2); however, there is some variation (see the muscles, skin, and subcutaneous tissues of the neck,
also Sect. 13.2.2). The neonatal spinal cord extends to the lower trunk, and extremities.
upper border of the third lumbar vertebra (L3), this level ris-
ing during the first 2 months after birth. There is marked
variation however; the cord may terminate between L1–L3/4 Epidural
Psoas major m. space Dura mater
at birth and between L1–L3 in children between the ages of
3 months to 15 years [1].
13.6.2 Spinal Nerves Above the Sacrum

Spinal n.
• The ventral and dorsal roots (dorsal roots containing the

dorsal root ganglia at this location) of the spinal nerves
join as they leave the spinal cord, forming the mixed spi- Ventral rami
nal nerve, which exits the vertebral canal through the
intervertebral (spinal, neural) foramen. Dorsal rami
• The ventral and dorsal roots as well as the proximal por-
Ligamentum flavum
tions of the spinal nerves are enclosed within a sleeve of Erector spinae m.
dura mater, which is an extension of the dura from that
surrounding the cord. Deep to this sheath of dura mater is Fig. 13.11 The spinal epidural space
13.6.3 Termination of the Spinal Cord site for obtaining a sample of CSF through a lumbar
and Dural Sac puncture.
• Despite the above classical description, a recent study
suggests that the conus medullaris terminates most com-
• The spinal cord occupies the upper two thirds of the ver- monly at the level of the L1–L2 disk space and, in the
tebral canal. It begins at the superior border of the atlas absence of tethering, virtually never ends below the mid-
vertebra (C1) and, in the average adult, ends at the conus body of L2.
medullaris, approximately at the level of the IV disk – The spinal cord and dural sac were traditionally
between the first and second lumbar vertebrae. Its level of thought to terminate at a more caudal level in neonates;
termination varies somewhat between individuals and however, ultrasonography and MRI scans have demon-
with posture, especially vertebral flexion, during which strated that the location of the caudal displacement of
its position rises slightly. It may end as high as T12 or in the conus medullaris in tethered cord syndrome is sim-
some cases as low as the L2–L3 IV disk. There is some ilar in term infants and adults.
correlation between its level of termination and the length – The dural sac in neonates and infants terminates more
of the trunk, especially in females. The spinal cord caudally at the level of S3 as compared to adults in
appears to “decrease” in length significantly throughout whom it ends at S2.
prenatal and antenatal development, with the cord reach-
ing as far down as S1 or 2 in the last few intrauterine
months and as low as L2 or 3 at birth (Fig. 13.12). This
apparent “decrease” is really the result of the greater rate
of growth of the vertebral (spinal) column as compared to
the cord and elongation of the lumbosacral region.
• The dural sac extends beyond this level, to approximately
the second sacral vertebral level (S2); within the sac, the Conus medullaris
nerves forming the cauda equina run vertically from the (end of spinal cord)
conus medullaris in the lumbar section of the vertebral

canal and within the sacral canal (between the posterior L1
surface of the sacrum and the fused pedicles [interverte-
bral foramina in infants]) > 1 year old
• The nerves forming the cauda equina are suspended L2
within the cerebrospinal fluid occupying the subarach-
noid lumbar cistern, which is the subarachnoid space
below the conus medullaris and between it and the termi- L3 At birth
nation of the dural sac at S2. The arachnoid mater, lining
the inside of the dura mater, also terminates at around the
S2 before extending inferiorly with the filum terminale. L4
• The filum terminale is a filament of connective tissue
about 20 cm long in the average adult that extends from
the tip of the conus medullaris to the sacrum and coccyx. L5
Its proximal or upper 15 cm or so, termed the filum termi-
nale internum (internal filum terminale), is surrounded by
extensions of the dura and arachnoid and reaches down to
the posterior aspect of the second sacral vertebra (S2). Its
Month 4 of
distal or final 5 cm or so, termed the filum terminale exter- intrauterine life
num (external filum terminale), fuses with the investing
dura mater and attaches to the posterior aspect of the first
coccygeal vertebral segment. The filum is continuous
above with the pia lining the spinal cord. The central
canal of the spinal cord continues into the filum terminale
for a short distance (3 to 5 cm) although its patency is
variable. The subarachnoid space surrounding the filum Fig. 13.12 Development of the spinal cord. The spinal cord appears to
terminale internum is expanded to form the lumbar cis- decrease in length significantly throughout early development due to
tern, which contains the cauda equina and is the preferred the relatively faster growth of the vertebral column
13.6.4 CSF Volume Reference

1. Barson AJ. The vertebral level of termination of the spinal cord dur-
ing normal and abnormal development. J Anat. 1970;106:489–97.
• CSF is produced from arterial blood by the choroid plex-
uses of the lateral, third, and fourth ventricles through a
combined process of diffusion, pinocytosis, and active
transfer. Suggested Reading
• It is in a state of constant circulation through continuous
production and reabsorption into the venous system, pri- Cramer GD, Darby SA, editors. Clinical anatomy of the spine, spinal
cord, and ANS. 3rd ed. St. Louis: Mosby; 2014.
marily through the arachnoid granulations in the superior
Newell RLM. Spinal cord and spinal nerves: gross. In: Standring S,
sagittal sinus. editor. Gray’s anatomy. 40th ed. London: Churchill Livingstone,
• While diffusion and the pressure gradient created within 2008; p. 749–61.
the CSF by virtue of its constant production and reabsorp-
tion are perhaps the major force causing the CSF to circu-
late, particularly around the cerebral hemispheres, its flow
around the spinal cord is not that active and probably
regulated to some extent by changes in body posture.
• Infants and neonates have a larger volume of CSF circu-
lating on an ml/kg basis (neonates = 10 mL/kg; infants
under 15 kg = 4 mL/kg; young children = 3 mL/kg) com-
pared to adults (2 mL/kg). This fact may account for the
higher dose of local anesthetic required per kilogram of
body weight and shorter duration of action of spinal anes-
thesia in infants owing to the larger CSF volume in
children.
Clinical Anatomy of the Dermatomes
and Innervation of the Joints 14
Contents
14.1 Introduction 206
14.1.1 Dermatomes 206
14.1.2 Myotomes 206
14.1.3 Osteotomes 207
14.2 Innervation of the Upper Extremity 207
14.2.1 Dermatomes and Cutaneous Distribution of the Peripheral Nerves 207
14.2.2 Myotomes 209
14.2.4 Innervation of the Major Joints of the Upper Extremity 211
14.3 Innervation of the Lower Extremity 215
14.3.1 Dermatomes and Cutaneous Distribution of the Peripheral Nerves 215
14.3.2 Myotomes 216
14.3.4 Innervation of the Major Joints 219
A.H. Walji, MD, PhD

Edmonton, AB Canada
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_14
14.1 Introduction 14.1.2 Myotomes
14.1.1 Dermatomes The ventral (motor) roots of the spinal cord provide motor
innervation to the skeletal muscles by providing motor nerve
With the exception of C1 (which does not have a sensory fibers to the spinal nerves. A myotome is a block of skeletal
component), sensory fibers from the dorsal roots of the spi- muscle that is supplied segmentally by the ventral roots of a
nal nerves supply a specific segment or band of skin. This spinal nerve; movements of the extremities and trunk that are
skin segment is termed a dermatome. For example, the created by these myotomes can thus be classified segmen-
C5-T1 spinal nerves provide cutaneous innervation to the tally (see segmental motor responses associated with nerve
upper extremity. There is considerable overlap between con- stimulation). In general, segmental innervation of the mus-
tiguous dermatomes, and adjacent dermatomes are generally cles can be fairly well differentiated. In addition to segmen-
arranged as consecutive horizontal bands on the surface of tal (myotomal) distribution of innervation, there is also
the axial skeleton and more or less vertical projections on the specific muscular distribution that is derived from the termi-
extremities. Anatomical knowledge of the respective derma- nal nerves. Knowledge of this terminal nerve innervation
tomes will help to block the appropriate skin segment during becomes extremely important when blocking the brachial
peripheral nerve blockade. Dermatomes are important par- plexus branches at sites beyond the root level (e.g., during
ticularly for peripheral nerve blockade. Clinically, fairly spe- axillary block, it would be useful to use radial nerve motor
cific areas of regional anesthesia can be achieved based on responses to confirm posterior cord localization). Table 14.1
the cutaneous innervation provided by the terminal nerves in summarizes the origin of each terminal nerve and its objec-
that part of the body. tive movement upon electrical stimulation.
Table 14.1 Upper extremity (brachial plexus terminal motor nerves): origins and motor responses to nerve stimulation
Motion Nerve Cord Division Trunk Root
Arm abduction Suprascapulara Upper C5, C6
Arm abduction Axillary Posterior Posterior Upper C5, C6
Elbow flexion Musculocutaneousb Lateral Posterior Upper C5, C6
Anterior
Extension (dorsiflexion) of the elbow, wrist, hand, and fingers Radial Posterior Posterior Upper C5, C6
Posterior Middle C7
Latissimus dorsi twitch (shoulder shrug) Thoracodorsal Posterior Posterior Middle C7
Forearm pronation and wrist flexion Median (lateral head) Lateral Anterior Upper C5, C6
Medial Anterior and posterior Middle C7
Anterior Lower C8, T1
Thumb flexion and opposition (flexion middle and ring finger) Median Medial Anterior Lower C8, T1
Thumb flexion and opposition Anterior interosseous Medial Anterior Lower C8, T1
Fifth finger flexion and opposition, ulnar deviation of the wrist Ulnar Medial Anterior Lower C8, T1
a
The suprascapular nerve may not be blocked during supraclavicular block if the needle is placed at the level of the divisions rather than the trunks.
Also, infraclavicular block will not target the suprascapular nerve since this nerve leaves the plexus at the trunks
b
The targets of brachial plexus block using the axillary approach are the terminal nerves of the upper extremity and branches at the cord level of
the plexus. The musculocutaneous nerve may not be blocked if the injection fails to spread to the proximal location where it branches
14 Clinical Anatomy of the Dermatomes and Innervation of the Joints 207
14.1.3 Osteotomes 14.2 Innervation of the Upper Extremity
Osteotomes refer to specific regions of the bones throughout 14.2.1 Dermatomes and Cutaneous
the extremities that are innerved by the terminal nerves Distribution of the Peripheral Nerves
(rather than by spinal segments as with dermatomes). The (Figs. 14.1, 14.2, 14.3, and 14.4)
innervation of bones can be significantly different from that
of the muscles and skin. A good knowledge of joint innerva-
tion is important for orthopedic surgery as well as other sur- Segmental Cutaneous Innervation of the Upper Extremity
gical specialties and neurology. • C3 and 4: upper shoulder region (supraclavicular nerves)
• C5: deltoid and lateral aspect of the arm
• C6: lateral arm, forearm, and thumb
• C7: the hand and middle three fingers
• C8: fifth finger and medial side of both the hand and lower
forearm
• T1: medial side of the lower arm and upper forearm
• T2: medial side of the upper arm (intercostobrachial
nerve)
Fig. 14.1 Dermatomes; anterior view

Fig. 14.4 Cutaneous distribution of the peripheral nerves of the upper

extremity; posterior view
Fig. 14.2 Dermatomes; posterior view
Fig. 14.3 Cutaneous distribution of the peripheral nerves of the upper

extremity; anterior view
14.2.2 Myotomes
For clinical practice, it is important to understand that there

is a specific distribution of innervation to skeletal muscles
that is derived from the terminal nerves (Figs. 14.5 and 14.6).
Table 14.1 summarizes the origin of each terminal nerve and
its objective movement upon electrical stimulation.
Segmental Motor Responses Associated with Nerve

Stimulation
• C5: lateral rotation and abduction of the arm at the shoul-
der joint
• C6: pronation and supination of the forearm
• C5 and 6: elbow flexion
• C6-8: medial rotation and adduction of the arm at the
shoulder
• C6 and 7: elbow extension
• C6 and 7: wrist flexion and extension (long flexor and
extensor muscles of the wrist)
• C7 and 8: digit flexion and extension (long flexors and
extensors of the fingers), opposition of the thumb
• T1: intrinsic movements of the hand
Muscular Distribution of the Spinal Segments

• C5: rhomboids, supraspinatus, infraspinatus, anterior por- Fig. 14.5 Distribution of muscular innervations by the terminal nerves
tion of deltoid, long head of biceps of the upper extremity; anterior view
• C6: teres major and minor, middle and posterior deltoid,
short head of biceps, coracobrachialis, brachialis, bra-
chioradialis, extensor carpi radialis longus and brevis,
supinator, pronator teres
• C7: triceps, anconeus, extensor digitorum, extensor digiti
minimi, extensor carpi ulnaris, abductor pollicis longus,
extensor pollicis longus and brevis, extensor indicis,
flexor carpi radialis
• C8: flexor digitorum superficialis and profundus, flexor
carpi ulnaris, flexor pollicis longus, pronator quadratus,
abductor and flexor pollicis brevis, opponens pollicis
• T1: flexor digitorum superficialis, abductor digiti minimi,
adductor pollicis, flexor digiti minimi brevis, opponens
digiti minimi, palmar and dorsal interossei, lumbricals
Fig. 14.6 Distribution of muscular innervations by the terminal nerves

of the upper extremity; posterior view
14.2.3 Osteotomes
Terminal nerves, rather than spinal cord segments, distribute

sensory innervation to specific regions of bones throughout
the extremities. These terminal nerves also send articular
branches to specific joints in the extremity. These regions of
the bones, each supplied by a specific branch of a terminal
nerve, are termed osteotomes; those for the upper extremity
are summarized in Figs. 14.7 and 14.8.
Fig. 14.8 Osteomes of the upper extremity; posterior view
Fig. 14.7 Osteomes of the upper extremity; anterior view

14.2.4 Innervation of the Major Joints Table 14.2 outlines the innervation of the joints of the
of the Upper Extremity upper extremity joint innervation and associated motor
responses associated with nerve stimulation during nerve
In general, the nerve supplying a joint also supplies the mus- block procedures.
cles which move the joint and the skin covering the articular
attachments of those muscles (Hilton’s law).
Table 14.2 Innervation of the joints of the upper extremity joint innervation and motor responses associated with nerve stimulation
Joint Nerve Root Motion
Shoulder
Anterior and posterior Suprascapular C5, C6 Arm abduction
Axillary C5, C6 Arm abduction
Elbow
Anterior Musculocutaneous C5, C6 Elbow flexion
Radial C5–C7 Extension of the elbow, wrist, and fingers
Median C5–T1 Thumb flexion and forearm pronation
Posterior Radial C5–C7 Extension of the elbow, wrist, and fingers
Ulnar C8, T1 Fifth finger flexion and opposition
Wrist Radial (superficial) C5–C7 Extension of the elbow, wrist, and fingers
Median C5–T1 Thumb flexion and forearm pronation
Ulnar C8, T1 Fifth finger flexion and opposition
14.2.4.1 Innervation of the Shoulder • Lateral pectoral nerve: articular branches arise mainly
The nerve supply to shoulder joint nerve supply is derived from the lateral pectoral nerve.
from the axillary, suprascapular, and lateral pectoral nerves, – Articular branch travels superior to the coracoid pro-
from branches arising from the posterior cord of the brachial cess to reach the acromioclavicular joint, with its ter-
plexus, possibly the radial nerve. Sympathetic innervation is minal portion supplying the anterosuperior region of
derived directly from the stellate and perhaps from other the shoulder joint capsule, as well as synovial tissue.
lower cervical and/or upper thoracic sympathetic ganglia – Sympathetic fibers which innervate the joint arise from
(Table 14.2). Recommended block(s) is/are shown in both the stellate ganglion and the sympathetic trunk
Fig. 14.9. just superior to the stellate ganglion.
• Fibers descend within the adventitia of the subcla-
• Axillary nerve (articular branch): after leaving the poste- vian and axillary arteries to the point where the
rior cord of the brachial plexus and descending laterally arteries enter the vascular area of the joint.
across the subscapularis muscle, the articular branch of • Fibers anastomose with the branch from the poste-
the axillary nerve innervates mainly the inferior aspect of rior cord of the brachial plexus.
the joint capsule • Fibers also reach the region supplied by the lateral
– A portion of the articular branch innervates the bicipi- pectoral nerve.
tal sulcus and forms anastomoses with fiber bundles • Suprascapular nerve: “upper” articular branch arises from
from the posterior cord. the nerve as it courses through the supraspinous fossa,
– The branch leaves the plexus in proximity to where the runs laterally to supply the periosteum of the coracoid
axillary nerve forms and courses obliquely across the process, the coracoacromial ligament, and the acromio-
subscapularis muscle to reach the bicipital sulcus and clavicular joint, and finally reaches the superior aspect of
inferior and superior aspects of the anterior surface of the shoulder joint capsule.
the joint capsule. – After branching, fibers continue anteriorly to overlap
– Terminal twigs course superiorly from the inferior with the areas supplied by the articular branch of the
aspect of the capsule to reach the anterior and posterior lateral pectoral nerve.
surfaces of the capsule. • Suprascapular nerve: “lower” articular branch leaves the
• Nerve fibers largely penetrate the fibrous layer of nerve before its entrance into the infraspinous fossa and
the capsule, while there is some penetration into the travels laterally to reach the posteroinferior region of the
synovial layer and adjacent portions of the humerus. capsule deep to the infraspinatus and teres minor
• Fibers which reach the posterior capsule join the muscles.
lower articular branch of the suprascapular nerve; – Some fibers run inferiorly to reach the region inner-
those coursing toward the anterior capsular surface vated by the ascending fibers of the articular branch of
jointly innervate this area with the branch from the the axillary nerve.
posterior cord of the plexus.
Shoulder Joint
*Interscalene
*supraclavicular
+ superficial
cervical plexus
Elbow Joint
*supraclavicular
*infraclavicular
Wrist Joint
*supraclavicular
*infraclavicular
*median
Hip Joint + radial
*lumbar plexus + ulnar
*femoral
+ lateral femoral
cutaneous
+ obturator
+ sciatic
Knee Joint
*femoral
+ obturator
+ sciatic
Ankle Joint
*femoral
+ sciatic
Fig. 14.9 Innervation of the major joints

14.2.4.2 Innervation of the Elbow 14.2.4.3 Innervation of the Wrist and Hand
The elbow joint is supplied by the musculocutaneous, median, While some joints of the wrist and hand receive sole innerva-
ulnar, and radial nerves; some of the articular branches tion from one nerve, many receive innervation from multiple
course some distance within the upper arm musculature, nerves, generally from those supplying the muscles that
while some are formed close to the elbow joint (Table 14.2; move that particular joint (Table 14.2; Fig. 14.9).
Fig. 14.9).
• Ulnar nerve: it supplies the wrist and hand through
• Musculocutaneous nerve: articular branch arises from the branches from the main nerve as well as through the digi-
nerve to the brachialis muscle. tal nerves.
– After running along the medial aspect of this muscle, – The dorsal branch of the ulnar nerve (before giving off
the nerve dives deep to supply the periosteum of the digital branches) gives off branches which innervate
humerus and reach the anterior aspect of the joint the dorsal aspect of the joint between the triquetrum
capsule. and pisiform, the lunate and hamate, the triquetrum
– Nerve fibers run medially and laterally in the fibrous and hamate, and the hamate and fourth metacarpal.
layer of the capsule; some reach the synovial tissue. – The deep branch of the ulnar nerve supplies the joints
– There may be anastomoses with the median (medially) between the capitate and hamate, the capitate and sec-
and radial (laterally) nerves’ articular branches. ond metacarpal, the capitate and third metacarpal, the
• Median nerve: articular branches generally arise before the hamate and fourth metacarpal, and the hamate and fifth
nerve passes between the heads of the pronator teres muscle metacarpal.
and course somewhat recurrently to innervate the region of • After innervating these joints at the bases of the
capsule near the medial epicondyle of the humerus. metacarpals, long filaments are sent off to reach the
– A small branch of the nerve innervates the anterior metacarpophalangeal joints of the second, third,
capsule after coursing along the medial surface of the and fourth fingers.
brachialis muscle; this branch anastomoses with a twig • The digital nerve branches supply the joint between
of the articular branch of the musculocutaneous nerve. the hamate and fifth metacarpal, the interphalangeal
• Ulnar nerve: articular branches represented mainly by joints of the little finger on both medial and lateral
filaments forming as the nerve passes behind the medial sides, and the metacarpophalangeal joint of the
epicondyle of the humerus. fourth finger.
– Fibers supply the ulnar collateral ligament and reach • The dorsal and palmar digital nerves supply the
the posteromedial region of the capsule; some ramify metacarpophalangeal and interphalangeal joints of
in the tissue forming the superior extension of the joint the fifth finger on medial and lateral sides and of the
capsule. medial side of the fourth finger on the medial side.
• Radial nerve • Median nerve: articular supply includes innervation from
– The muscular branch supplying the anconeus muscle, branches from the main nerve as well as through the digi-
formed proximally in the radial groove, runs within the tal nerves and the anterior interosseous nerve.
lateral head of the triceps brachii muscle and provides – Before branching, the nerve supplies the radioscaph-
filaments to the capsule lining the olecranon fossa (and oid joint and the joints between the scaphoid and capi-
perhaps to the posterolateral region of the capsule). tate and between the capitate and trapezoid.
– The ulnar collateral nerve (a branch of the radial nerve) – The digital nerves innervate both sides of all joints of
also provides filaments to the capsule proximal to the the first, second, and third fingers, as well as the lateral
olecranon process. side of the joints of the fourth finger.
– Fibers leaving the nerve after its entrance into the lat- – The anterior interosseous nerve supplies the distal
eral intermuscular septum innervate the anterolateral radioulnar joint and sends branches to the radioscaph-
region of the capsule (and radial collateral and annular oid, radiolunate, and scaphoid-lunate joints.
ligaments). • Radial nerve: superficial branch courses over the back
– As the nerve courses anterior to the elbow joint, a branch of the hand and gives off many branches, including
to the anterior region of the capsule anastomoses with those to the radioscaphoid joint and to joints between
articular fibers from the musculocutaneous nerve. the scaphoid and trapezium, the scaphoid and trapezoid,
the trapezium and first metacarpal, the trapezium and 14.3 Innervation of the Lower Extremity
second metacarpal, and the trapezoid and second
metacarpal. 14.3.1 Dermatomes and Cutaneous
– The dorsal digital nerves supply both sides of both Distribution of the Peripheral Nerves
joints of the thumb, both sides of the (Figs. 14.1, 14.2, 14.10, and 14.11)
metacarpophalangeal and proximal interphalangeal
joints of the second finger, and the lateral side of the Segmental Sensory Innervation (Dermatomes) of the
metacarpophalangeal joint of the third finger. Lower Limb
– The dorsal digital nerve to the index finger provides a • L1: pelvic region (anterior) and upper medial thigh
branch which runs deep to innervate the first and sec- • L2: upper and lateral aspects of the thigh
ond metacarpals and has recurrent twigs which supply • L3: lower anterior medial aspect of the thigh and knee
many of the carpal joints. • L4: anteromedial aspect of the leg and medial ankle
– The posterior interosseous nerve supplies the back of • L5: anterolateral aspect of the leg, medial aspect of the
the carpus widely on its middle and medial aspects. foot, medial aspect of the distal plantar surface of the foot,
upper surface of the first to second/third toes
Innervation of the radiocarpal joint is provided by the • S1: lateral side of the foot and sole and lateral three toes
anterior interosseous nerve (a branch of the median nerve) • S2: posterior surface of the thigh and leg
and posterior interosseous nerve (a branch of the radial • S3 and 4: the gluteal and perianal (posterior pelvic) region
nerve) interosseous nerves. Additional contributions are
made by the median, radial, and ulnar nerves.
Fig. 14.10 Cutaneous distribution of the peripheral nerves of the

lower extremity; anterior view
14.3.2 Myotomes
For clinical practice, it is important to understand that there

is a specific distribution of innervation to skeletal muscles
that is derived from the terminal nerves (Figs. 14.12 and
14.13). Tables 14.3 and 14.4 summarize the origin of each
terminal motor nerve and its related movement; the segmen-
tal innervation of the lower extremity is depicted indirectly,
through the origin of the terminal nerves.
Segmental Motor Responses Associated with Nerve

Stimulation
• L2 and 3: flexion, adduction, and medial rotation of
the hip
• L3 and 4: extension of the knee
• L4: foot inversion
• L4 and 5: dorsiflexion of the foot
• L5 and S1: extension, abduction, and lateral rotation of
the hip and flexion of the knee
• L5 and S1: foot eversion
• S1 and 2: plantar flexion of the foot
Muscular Distribution of the Spinal Segments

• L2: psoas major, iliacus, gracilis, sartorius
• L3: adductor longus and brevis, rectus femoris
Fig. 14.11 Cutaneous distribution of the peripheral nerves of the • L4: vastus lateralis and medialis, adductor magnus, tibia-
lower extremity; posterior view lis anterior
• L5: tibialis anterior, extensor digitorum longus, extensor
hallucis longus, peroneus (fibularis) tertius, extensor digi-
torum brevis, tibialis posterior, flexor digitorum longus,
semimembranosus, semitendinosus, short head biceps
femoris, tensor fasciae latae, gluteus medius, and
minimus
• S1: peroneus (fibularis) longus and brevis, medial and lat-
eral heads of gastrocnemius, soleus, biceps femoris, glu-
teus maximus, piriformis
• S2: abductor hallucis, abductor digiti minimi (quinti),
interossei
• S2–4: external anal sphincter
• S4: bulbospongiosus (bulbocavernosus)
Fig. 14.12 Distribution of muscular innervations by the terminal Fig. 14.13 Distribution of muscular innervations by the terminal
nerves of the lower extremity; anterior view nerves of the lower extremity; posterior view
Table 14.3 Lower extremity (lumbar plexus terminal motor nerves): origin and motor responses associated with nerve stimulation
Motion Nerve Division Root
Adduction and flexion of the thigh Obturator Anterior L2, L3, L4
Patellar twitch and knee extension Femoral (main nerve and its posterior Posterior L2, L3, L4
branch)
Thigh adduction only (pectineus) Femoral (anterior branch below inguinal Posterior L2, L3, L4
ligament)
Table 14.4 Lower extremity (sacral plexus terminal motor nerves): origin and motor responses associated with nerve stimulation
Motion Nerve Root
Anal sphincter Pudendala S2, S3, S4
Gluteal twitch/thigh abduction (gluteus minimus and medius) Superior gluteala L4, L5, S1
Gluteal twitch/thigh extension (gluteus maximus) Inferior glutealb L5, S1, S2
Knee flexion and ankle plantar flexion Tibial (above and below sciatic bifurcation) L4, L5, S1, S2, S3
Ankle dorsiflexion Common peroneal (fibular) L4, L5, S1, S2
Ankle and toe extension Deep peroneal (fibular) L5, S1
Foot eversion (peroneus longus and brevis) Superficial peroneal (fibular) L5, S1
First toe abduction Medial plantar S1, S2
Fifth toe abduction Lateral plantar S1, S2, S3
a
The pudendal and superior gluteal nerves will not be blocked with sciatic nerve block
b
Only the posterior gluteal approach to sciatic nerve block will block the inferior gluteal nerve
14.3.3 Osteotomes
Terminal nerves, rather than spinal cord segments, distribute

sensory innervation to specific regions of the bones through-
out the extremities. These terminal nerves also send articular
branches to specific joints in the extremity. These regions of
the bones (osteotomes), each supplied by a specific branch of
a terminal nerve, are summarized in Figs. 14.14 and 14.15.
Fig. 14.15 Osteomes of the lower extremity; posterior view
Fig. 14.14 Osteomes of the lower extremity; anterior view

14.3.4 Innervation of the Major Joints
Table 14.5 outlines the innervation of the joints of the lower

extremity and associated motor responses resulting from
nerve stimulation during nerve block procedures.
Table 14.5 Innervation of the joints of the lower extremity and motor responses associated with nerve stimulation
Joint Nerve Root Motion
Hip
Anterior Femoral (nerve to rectus femoris) L2–L4 Patellar twitch (thigh adduction if posterior division only)
Obturator (anterior division) L2–L4 Thigh adduction
Posterior Sciatic (nerve to quadratus femoris) L4, L5, S1 Gluteal twitch (quadratus femoris)
Knee
Anterior Femoral (articular branches) L2–L4 Patellar twitch
Tibial (articular branches) L4, L5, S1, S2, S3 Knee and ankle flexion
Common peroneal (fibular) L4, L5, S1, S2 Ankle dorsiflexion
Obturator L2–L4 Thigh adduction
Posterior Common peroneal (fibular) L4, L5, S1, S2 Ankle dorsiflexion
Tibial L4, L5, S1, S2, S3 Knee and ankle flexion
Ankle Tibial (above and below sciatic bifurcation) L4, L5, S1, S2, S3 Knee flexion and ankle plantar flexion
Common peroneal (fibular) L4, L5, S1, S2 Ankle dorsiflexion
Deep peroneal (fibular) L5, S1 Ankle and toe extension
Superficial peroneal (fibular) L5, S1 Foot eversion (peroneus longus and brevis)
Medial plantar S1, S2 First toe abduction
Lateral plantar S1, S2, S3 Fifth toe abduction
14.3.4.1 Innervation of the Hip 14.3.4.2 Innervation of the Knee

Innervation of the hip is provided through articular branches Innervation of the knee joint is derived from the femoral,
from the femoral, obturator (and accessory obturator when obturator, and sciatic (tibial, common peroneal [fibular], and
present), and superior gluteal nerves, from the nerve to the recurrent peroneal [fibular]) nerves (Hilton’s law)
quadratus femoris (the latter two from the sacral plexus) and (Table 14.5; Fig. 14.9).
possibly from the lumbar sympathetic ganglia (sympathetic
supply) (Table 14.5; Fig. 14.9). Multiple blocks are needed • Femoral nerve supplies the knee through articular
(Fig. 14.9). branches of its saphenous branch as well as articular
branches of its muscular branches to the vastus medialis,
• Femoral nerve: articular branches arise from the common vastus intermedius, and vastus lateralis muscles.
trunk of the nerve and/or from its muscular branches – Saphenous nerve: articular division arises at variable
(nerves to rectus femoris, to vastus lateralis, and to locations, often either from within the femoral triangle
pectineus). or just after the femoral artery passes through the
– When there are multiple articular branches, these often adductor magnus muscle through the adductor hiatus,
anastomose before reaching the joint capsule. usually anastomoses with the articular fibers of the
• Femoral nerve: terminal branches supply the iliofemoral obturator nerve and nerve to the vastus medialis
ligament and the neighboring portion of the femur (along muscle.
the intertrochanteric line). • Branch travels vertically, anterior to the tendon of
– The fibers which reach the capsule ramify in the fibrous the adductor magnus, and courses toward the
layer, particularly the portion of the capsule which anteromedial aspect of the joint capsule.
attaches to the femur. – Articular branches from the femoral nerve supply the
– Some of the terminal branches course posteriorly and suprapatellar bursa, the patellar and femoral perios-
superiorly. teum (via nerves to the vastus intermedius muscle), the
• Nerve to the pectineus: articular branch courses along the anteromedial (saphenous nerve and nerve to vastus
medial edge of the iliopsoas muscle, then enters the medialis) and anterolateral (nerve to vastus lateralis)
anteromedial aspect of the capsule, and also innervates aspects of the joint capsule, and the infrapatellar fat
the neighboring region of the femur. pad. Vascular branches supply the femoral artery and
– This region (including the pubofemoral ligament) is its branches.
supplied by the nerve to the pectineus via an articular • Tibial nerve: it is usually in the form of a large branch
branch and, when present, also by a branch from the (although as many as five branches may exist), which
accessory obturator nerve. arises either from the tibial portion of the sciatic nerve in
• Obturator nerve: articular branches are given off within the thigh (following closely with the sciatic nerve in its
the obturator canal or distally from the anterior or poste- sheath) or from the tibial nerve within the popliteal fossa
rior division of the obturator nerve; these branches travel – The tibial nerve has several branches which form a
laterally to supply the medial portion of the capsule and dense plexus, with some fibers entering the adventitia
ramify in the fibrous layer of the capsule. of the popliteal vessels, some following the genicular
– Some fibers reach the synovial tissue, and some course vessels both medially and laterally, and most entering
along the ligamentum teres (ligament of the head of the fibrous layer of the joint capsule posteriorly and
the femur) to the acetabulum and femur. eventually the synovial tissue.
• Nerve to the quadratus femoris descends on the ischium – Branches or continuations of the nerve accompany the
anterior to the sciatic nerve and innervates the superior medial and inferior medial genicular arteries
ischiofemoral (ischiocapsular) ligament through one or and bear the same names as the arteries. The superior
two fine twigs. medial genicular nerve supplies the periosteum and
• Superior gluteal nerve via the nerve’s branch to the glu- medial epicondyle while the inferior medial genicular
teus minimus muscle: twigs first innervate the fibrous nerve supplies the anterior portion of the capsule and
layer of the superolateral region of the capsule then course the tibial periosteum.
anteriorly and inferiorly to reach the region supplied by – Articular branches of the tibial nerve supply the poste-
the femoral nerve. rior, medial, and lateral regions of the capsule, the
– Sympathetic fibers from the lumbar ganglia may reach infrapatellar fat pad, the tibial and perhaps fibular peri-
the capsule by accompanying the articular vessels. osteum, and the superior tibiofibular joint.
• Common peroneal (fibular) nerve: articular branch arises – Superficial peroneal (fibular) nerve
either from the common peroneal portion of the sciatic • Branches from the common peroneal (fibular) nerve
nerve within the posterior mid-thigh or from the common and supplies the skin on the anterior aspect of the
peroneal (fibular) nerve within the popliteal fossa. ankle
– The branch joins either, or both, the superior or infe- – Sural nerve
rior lateral genicular arteries, is named accordingly, • Branches from the common peroneal (fibular) nerve
and supplies the anterolateral or lateral portions of the and supplies skin on the lateral aspect of the ankle
capsule, respectively. • Deep nerves at the ankle:
– The common peroneal (fibular) nerve supplies the – Deep peroneal (fibular) (L5, S1): lies anterior to the
anterolateral portion of the capsule, the infrapatellar tibia and interosseous membrane and lateral to the
fat pad, and the tibial periosteum. anterior tibial artery and vein at the ankle and is deep
• The anterolateral portion of the capsule is supplied jointly to and between the tendons of the extensor hallucis
by the nerve to vastus medialis and common peroneal longus and extensor digitorum longus muscles, and
(fibular) nerve, with varying contributions depending on beyond the extensor retinaculum, it branches into
the distribution of each nerve. medial and lateral terminal branches.
– The recurrent common peroneal (fibular) nerve sup- • The medial branch passes over the dorsum of the
plies the anterolateral surface of the tibial periosteum, foot and supplies the first web space through two
the tibial tuberosity, the infrapatellar fat pad, and the terminal digital branches.
superior tibiofibular joint. • The lateral branch traverses laterally and terminates
• Obturator nerve: anterior division frequently anastomo- as the second, third, and fourth dorsal interosseous
ses with the articular branch of the saphenous nerve. nerves that supply the tarsal and metatarsophalan-
– The division gives small twigs to the superior medial geal joints of the middle three toes.
genicular artery (naming the terminal fibers as such), – Tibial nerve (often called the posterior tibial nerve)
thus serving the same anteromedial aspect of the cap- (S1–3): on the posterior aspect of the knee joint, it
sule as the saphenous and nerve to vastus medialis, joins the posterior tibial artery and then runs deep until
before terminating by anastomosing with the branches the lower third of the leg, where it emerges at the
of the tibial nerve thus forming the popliteal plexus medial border of the calcaneal tendon (Achilles
and innervating the superior part of the posteromedial tendon).
capsule. • Behind the medial malleolus, it lies beneath several
– Articular branches of the obturator nerve supply the layers of fascia and is separated from the Achilles
superior part of the posteromedial capsule (as a portion tendon only by the tendon of the flexor hallucis lon-
of the popliteal plexus), the anteromedial portion of gus muscle; the nerve is posteromedial to the poste-
the capsule (as the superior medial genicular nerve, rior tibial artery and vein, which in turn are
together with the saphenous nerve), and the infrapatel- posteromedial to the tendons of the flexor digito-
lar fat pad. rum longus and tibialis posterior muscles.
• Just below the medial malleolus, the nerve divides
into the lateral and medial plantar nerves.
14.3.4.3 Innervation of the Ankle (Table 14.5; • The nerve innervates the ankle joint through its
Fig. 14.9) articular branches and, through its cutaneous
branches, the skin over the medial malleolus, the
• Superficial nerves at the ankle: inner aspect of the heel (including the skin over the
– Saphenous nerve Achilles tendon), and the dorsum of the foot
• The longest cutaneous branch from the femoral (through the medial and lateral plantar nerves).
nerve which innervates the medial skin of the ankle
Suggested Reading Gardner E. The innervation of the knee joint. Anat Rec. 1948b;
101:109–30.
Garner E. The innervation of the hip joint. Anat Rec. 1948;
Bo WJ, Meschan I, Krueger WA. Basic atlas of cross-sectional anat-
101:353–71.
omy: a clinical approach. Philadelphia: WB Saunders; 1980.
Gray DJ, Gardner E. The innervation of the joints of the wrist and hand.
Ellis H, Feldman S, Harrop-Griffiths W, editors. Anatomy for anaesthe-
Anat Rec. 1965;151:261–6.
tists. 8th ed. Hoboken: Wiley-Blackwell; 2004.
Lee B. Atlas of surgical and sectional anatomy. Norwalk: Appleton-
Gardner E. The innervation of the elbow joint. Anat Rec.
Century-Crofts; 1983.
1948a;102:161–74.
Netter FH. Atlas of human anatomy. Summit: CIBA-GEIGY Corp.;
1989.
Part IV
Nerve Blocks of the Head and Neck
Trigeminal Nerve Blocks
15
Glenn Merritt and Ban C.H. Tsui
Contents
15.1 Indications 226
15.2 Block Techniques 226
15.2.1 Superficial Transcutaneous Approach to Trigeminal Nerve Blocks:
Supraorbital, Infraorbital, and Mental Nerve Block 226
15.2.2 Intraoral Approach to Trigeminal Nerve Blocks: Infraorbital, Mental,
and Greater Palatine Nerves 233
15.2.3 Deep Trigeminal Nerve Blocks 237
15.3 Current Literature in Ultrasound-Guided Approaches 239
15.4 Case Study 239
References 239
G. Merritt, MD
Department of Anesthesiology,
University of Colorado Hospital and Children’s Hospital Colorado,
13123 East 16th Ave., Aurora, CO 80045, USA

DOI 10.1007/978-0-387-79964-3_15
226 G. Merritt and B.C.H. Tsui
15.1 Indications 15.2 Block Techniques
Blockade of the trigeminal nerve – the fifth cranial nerve – The most comprehensive blockade of the trigeminal nerve
targets its three major branches (Fig. 9.1), the ophthalmic targets the central ganglion. This block is usually performed
(V1, sensory), the maxillary (V2, sensory), and the mandibu- by neurosurgeons under fluoroscopic guidance to treat dis-
lar (V3, sensory and motor to the muscles of mastication), abling trigeminal neuralgia. Few anesthesiologists perform
and provides anesthesia to the anterior portion of the scalp, this technically difficult block, and it will not be described in
face, and much of the oral cavity. Some common clinical detail here.
uses of trigeminal nerve block include (for a more compre-
hensive list, see Table 15.1):
15.2.1 Superficial Transcutaneous
• Ophthalmic nerve block (V1: supraorbital, Approach to Trigeminal Nerve Blocks:
supratrochlear): Supraorbital, Infraorbital, and Mental
– Frontal craniotomies Nerve Block
– Excision of scalp nevus
• Maxillary nerve block (V2: infraorbital, greater The trigeminal block can be easily performed by injection of
palatine): the three individual terminal superficial branches through a
– Cleft palate surgery (maxillary, greater palatine, lesser landmark-based approach using palpation of their respective
palatine, nasopalatine) foramina (Fig. 15.1). These bony landmarks are usually suf-
– Cleft lip surgery (infraorbital) ficient themselves for routine anesthetic purposes although
– Nasal septum repair (infraorbital) ultrasound imaging may prove useful for locating them in
– Endoscopic sinus surgery (infraorbital) some cases. An additional block of the supratrochlear nerve
– Surgical repair of soft tissue injury of the face (terminal nerve of ophthalmic branch) is required if the field
(infraorbital) of anesthesia is to cross the midline of the forehead.
• Mandibular nerve block (V3: mental)
– Lower lip repair (mental)
Table 15.1 Indications for trigeminal nerve blocks in children

Nerve to be blocked Indications
V1: Ophthalmic division Frontal craniotomies
Ventriculo-peritoneal shunt
Dermoid cyst excision
Pigmented nevus excision
Ommaya reservoir placements in
neonates
Scalp lesions
V2: Maxillary division, Cleft lip/palate repair
including greater palatine Endoscopic sinus surgery
nerve (GPN) Rhinoplasty
Pulse dye laser for port wine stain
removal
Mole removal
Transsphenoidal hypophysectomy
Nasal tip reconstruction
V3: Mandibular division Surgery involving the lower lip (e.g.
hemangioma) Fig. 15.1 Patient positioning and surface landmarks for superficial tri-
Surgery involving the skin of the chin geminal nerve blocks in a 4-year-old child
Trigeminal neuralgia in V3
Temporomandibular joint dysfunction
15 Trigeminal Nerve Blocks 227
15.2.1.1 Patient Positioning unless one is attempting to enter the foramen while
performing the nerve block, this should not affect clin-
• The patient is positioned lying supine. ical practice.
• The patient’s head may be placed to rest on a donut. – The supraorbital nerve enters the facial skeleton
through the supraorbital foramen, which is located in
the midsagittal plane at the level of the pupil. The
15.2.1.2 Landmarks and Surface Anatomy supratrochlear nerve is located medial to the supraor-
bital foramen and can be found closer to the midfacial
• Each nerve is closely associated with a readily palpable sagittal plane (Fig. 15.3a). The supraorbital notch is
foramen. Figure 15.2 illustrates the cross-sectional anat- easily palpated at the medial upper angle of the orbit.
omy of each respective foramen, captured by Visible Palpate the roof of the orbital rim starting from the
Human Visualization Software (VHVS) and MRI. midline. The more medial supratrochlear nerve is
• The nerves are too superficial to visualize well with ultra- located at the upper internal angle of the orbital rim.
sound. However, ultrasound can be used to identify the Eipe et al. [5] describe their point of needle insertion as
foramina by scanning sagittally in the medial to lateral the intersection of a vertical line through the pupil of
direction [1]. The foramina create discontinuity in the the eye and a horizontal line through the ala of the nose
hyperechoic line of the bone. The absence of hyperecho- in their study of twenty children above 12 years of age.
genic bony structure indicates the position of the foramen – The infraorbital notch (Fig. 15.3b) can be palpated
(Fig. 15.3). Using this method, the foramina can be land- easily along the floor of the orbital rim in children but
marked and marked on the skin to facilitate easier identi- can be difficult in the neonate due to the developing
fication of the needle insertion site. Color Doppler can craniofacial skeletal configurations. If the foramen that
also be used to verify the locations of the foramina by exists inferior to the orbital rim cannot be palpated
imaging the blood vessels associated with each foramen; directly, it can be sought by gently probing with a
however, these vessels are small and are often difficult to small-gauge needle or found using surface landmarks
visualize. as a guide. Alternatively, a simple mathematical for-
– All branches of the trigeminal nerve have been reported mula can be utilized (distance from the midline =
to lie in the same sagittal plane on each side of the face 21 mm + 0.5 × age (in years)) [2].
for adolescent and adult patients at a distance of – The mental nerve emerges from the mental foramen
approximately 2.5 cm lateral to the midsagittal line (Fig. 15.3c), which lies inferior to the outer lip at the
passing through the pupil [2]. Some reports indicate level of the first premolar, midway between the upper
that accessory or double foramina may exist [3, 4], but and lower borders of the mandible [6].
Fig. 15.2 VHVS and MRI of (a) supraorbital, (b) infraorbital, and (c) mental foramina
Fig. 15.3 Ultrasound images with color Doppler demonstrating dis- by blue bars in the center panel: “1” represents starting position and “2”
continuity in the hyperechogenic line at the supraorbital (a), infraorbital represents final position over the foramen
(b), and mental (c) foramina. Ultrasound probe positioning is indicated
15.2.1.3 Considerations and Needle Insertion the injection and confirm where both the needle and
Technique (Infraorbital Nerve Block) local anesthesia are being placed.
– The intraoral approach has been reported to be less
• Generally, short, 25G–30G hypodermic needles will be painful for the patient [7]. In our opinion, the ability to
suitable for these blocks, provided that one is not trying to supervise accurate needle placement and exact area of
enter the foramen directly since this may require a larger local anesthetic placement may be limited to the indi-
needle for accurate placement. Longer needles are essen- vidual performing the block, particularly in small
tial for: infants with cleft lip and palate defects.
– Intraoral approaches to the infraorbital nerve in older • Before the needle is introduced, the location and anatomic
children and adolescents (the infraorbital foramen may characteristics of the infraorbital foramen and the course
be located 2–3 cm away from the gingival sulcus) of the exiting nerve branches should be studied.
– Suprazygomatic maxillary nerve blocks in children of Understanding the shape and course of the foramen will
any age (depth of the pterygopalatine fossa from the help the practitioner decide how best to enter or, in most
superior junction of the zygoma and posterior orbital cases, avoid entering the foramen.
rim has been reported to be approximately 4 cm even – The infraorbital nerve travels from the foramen rotun-
in infants and young children) dum through the infraorbital canal and exits the facial
– Any approach to the pterygopalatine fossa from intra- skeleton through the infraorbital foramen. When
or extraoral routes in children of all ages examining the skull in the anterior plane, the infraor-
• Most exiting foramina communicate directly with the bital canal runs in a nasal-to-temporal direction; this
inferior orbital fissure. Thus, when using techniques that directional information will help to plan entry or
require injection of local anesthetic into the foramen avoidance of the foramen.
itself, orbital contents may be injured inadvertently if one – If one plans on entering the foramen, then a nasal-
is not conscious of the depths and anatomic characteris- temporal needle direction is recommended. For novice
tics of the various canals where the nerves exit the facial practitioners, a temporal-nasal needle direction will
skeleton. make it impossible to enter the canal. Any sagittally
• Intraforaminal approaches are popular in many countries, directed needle risks entering the foramen and should
but they have been reported to result in a higher incidence be avoided.
of paresthesia. Careful attention to injection pressure is – In infants, the infraorbital foramen will lie at the level
critically important if the needle has entered the infraor- of the nasal ala. The needle insertion point and loca-
bital canal itself. When placing the needle in these small tion of the infraorbital foramen have been reported to
foramina, the injection pressure must not be excessive, be at the midpoint of a line drawn from the lateral
thereby minimizing trauma to the nerve. Intraforaminal orbital rim to the lateral corner of the mouth [8]. Due
approaches are not recommended for beginners since the to the development of the craniofacial skeleton, a bet-
basic approaches, when performed correctly, will provide ter surface landmark in older children is the intersec-
excellent anesthesia and eliminate any risk of major tion of a line drawn from the lateral orbital canthus to
complications. the nasal ala and another line passing sagittally through
• When determining the optimal technique for infraorbital the medial edge (limbus) of the iris [9]. The foramen
nerve block, the choice of an extraoral percutaneous route represents the initial point at which the infraorbital
or an intraoral route (see below) must be made. While nerve starts to branch into its peripheral divisions.
many practitioners advocate one technique over the other, • The branches of the infraorbital nerve include the inferior
either approach is appropriate, provided that the practitio- palpebral, external nasal, internal nasal, and superior
ner understands the benefits and limitations of the various labial branch (which has a medial and lateral division).
approaches: Only 40 % of the time do the nerves exit as separate
– The extraoral percutaneous approach is relatively sim- branches [10]; the other 60 % of the time, the nerves exit
ple, and a supervisor and surgical team can visualize as a network. Regardless, it is critical to remember that all
the nerves travel in a lateral-to-medial direction toward • Many authors describe backing the needle off the bone at
the nasal ala. Successful nerve blockade is achieved when this point. This is unnecessary but can be done if desired
the local anesthesia spread matches these branching pat- to decrease the risk of nerve injury. After aspiration of the
terns. By understanding this principle, one can use visual- syringe, inject enough local anesthetic to ensure spread to
ization to determine when an adequate dose is achieved. the nasal ala rim, thereby covering all nerve branching
patterns. If local anesthetic tracks in any other direction,
the block may not be accurate, and the needle should be
15.2.1.4 Needle Insertion Techniques: repositioned.
Infraorbital Nerve and Branches
Advanced Approaches
• Mark the skin with landmarks: the easiest landmark to • Advanced extraoral approaches include modifying the
identify in almost all ages is a point at the intersection of above technique and using a needle insertion point
a line passing through the orbit at the vertical level of the either at the infraorbital rim in the area of the infraor-
limbic sagittal line and a line drawn from the lateral edge bital notch itself or entry of the infraorbital foramen
of the orbit to the nasal ala rim. At this point, the infraor- directly. These superiorly based techniques are best
bital foramen may be palpated. performed in older children or adolescents undergoing
• Mark the foramen’s location, and place the index finger of awake surgery and allow the block to be performed rel-
the hand contralateral to the side to be blocked on the atively rapidly using small volumes of local anesthetic.
superior aspect of the eyelid of the side to be blocked This approach can be performed with a smaller volume
(e.g., left index finger on the child’s right eyelid). This of a more concentrated local anesthetic solution and
will enable the practitioner to hold the syringe like a pen- may work at volumes of 0.25–1 mL per side to achieve
cil and perform accurate needle placement. Injection with adequate anesthesia. By moving the needle to the area
the non-dominant hand requires practice but is worth the immediately below the foramen, the needle tip can be
effort to improve accuracy. placed directly under the fascia surrounding the infraor-
• With the free hand’s index finger, the patient’s eye can be bital nerve as it exits the foramen while using the max-
examined for abnormalities and to confirm that stage 2 illa as a backstop. When done accurately, local
anesthesia is not present. Following this, place the index anesthetic will be injected at the under-surface of the
finger below the orbit in the area of the infraorbital notch. foramen, providing consistent and reliable anesthesia.
Take care not to push the eye as this may cause a brady- An added benefit is that a gentle and quick injection can
cardiac response. gain a scared awake child’s confidence.
• Lowering the eyelid and placing the finger on the inferior • Entering the infraorbital foramen is another advanced
orbital rim can prevent local anesthetic from spreading in technique and is best performed if one remembers to
a superior direction, which is not necessary unless block- change the needle direction to nasal-temporal. The fora-
ade of the inferior palpebral branch is needed for surgery. men is located 7–8 mm below the orbital rim in adults
This will also help to prevent spread of local anesthetic to and older children. When entering from a percutaneous
the loose soft tissues of the eye, which may lead to bruis- nasal ala approach, a longer needle may be required.
ing and a black eye. Zide [11] suggests to place the needle in the center of an
• The needle is inserted in a temporal-to-nasal direction, imaginary triangle formed by the nasal labial fold, the
directly superior and lateral to the marked infraorbital nasal ala fold, and the foramen. Using this technique,
foramen. Entering a small distance away from this mark block success was 100 % in adults when 1 mL local
will help ensure needle contact with the bone in the area of anesthetic was placed directly in the foramen, and no
the foramen itself. The goal is to not enter the infraorbital cases of nerve injury were found. To date, no studies
foramen directly but to place the needle in proximity to the have been done in pediatric patients using this
infraorbital foramen when contact with the maxilla occurs. technique.
15.2.1.5 V1: Ophthalmic Branches – Typically, 0.5–1 mL is deposited in a superficial area at

this superior nasal area using a small-gauge needle. In
• The supraorbital and supratrochlear nerves are the termi- the case of bilateral cleft lip repair, it is important to
nal branches of V1 and can be blocked using one needle place additional local anesthesia at the base of the
insertion with redirection (Fig. 15.4). After blocking the nasal septum to ensure coverage of the prolabial fold.
supraorbital nerve, the needle is withdrawn and redirected Typically, this area is covered by infraorbital nerve
medially toward the supratrochlear foramen, where the block via a branch of the internal nasal branch.
supratrochlear nerve can be blocked. However, this branch may not exist secondary to the
• The external nasal branch of the anterior ethmoid nerve bilateral cleft palate. This block is extremely painful
and infratrochlear nerve innervates portions of the nasal for the awake patient and should be performed follow-
bridge and the skin of the nasal ala, apex, and vestibule of ing all other blocks.
the nose. These terminal branches of V1 can be blocked • The mental canal angles medially and inferiorly; there-
by insertion of a needle at the junction of the cartilaginous fore, if the mental foramen cannot be palpated, subcuta-
and bony portion of the nose on both lateral edges. neous injection can be performed above and lateral to the
– This block is typically required for surgeries such as anticipated location of the mental foramen. This block
nasal fracture repair, rhinoplasty, and any cleft repair can be performed intraorally or extraorally; anecdotal evi-
that involves the surgeon working on the tip of the dence suggests better success with the former approach,
nasal area. but no studies have been performed to confirm this.
Fig. 15.4 Needle insertion for transcutaneous supraorbital nerve block

15.2.1.6 Local Anesthetic Application

• Intravascular injection is a rare but possible compli-
• The choice of local anesthetic will depend on the purpose cation. Epinephrine (1:200,000) is a useful adjuvant
of the block and the duration of anesthesia required (e.g., that may help identify intravascular injection.
0.5–1 % lidocaine, 0.5–1 % mepivacaine for shorter proce- Remember that the infraorbital artery lies in the
dures, and 0.2–0.5 % ropivacaine or bupivacaine for longer middle of the nerve plexus, so aspiration of blood
procedures). Textbooks will often quote the following indicates that you are in the middle of the nerves.
doses for surgical anesthesia: 0.5–1.5 mL for infants, Repositioning the needle should lead to a successful
2–3 mL for children, and 3–5 mL for adolescents. However, block.
these volumes may be excessive, and in our experience, • With infraorbital blocks, the child may bite their lip
1 mL or less is sufficient to block any infraorbital nerve due to numbness. Thus, parents need to be warned
provided the local anesthetic is placed accurately and one is of this effect and that feeding may be affected.
attentive to adequate spread during block performance. • Skull nerve blocks can be used for craniotomy pro-
Due to the vascularity of the face, epinephrine should cedures and are also recommended to attenuate
always be used as an adjuvant to the local anesthetic to postoperative pain [12, 13]. The nerves blocked to
prolong duration of action. For diagnostic or therapeutic achieve successful anesthesia for craniotomy
purposes, smaller volumes (0.5–1 mL) are recommended. include the supraorbital and supratrochlear nerves,
• After needle insertion, the appropriate local anesthetic the greater and lesser occipital nerves, the auriculo-
dose (e.g., 1–2 mL of 0.5–1 % lidocaine, or 0.5–1 mL of temporal nerves, and the greater auricular nerves.
0.125–0.25 % bupivacaine, or 0.2 % ropivacaine with epi- They can also be used for providing pain relief fol-
nephrine (1:200,000)) is injected slowly after aspiration. lowing minor surgical procedures on the forehead
• Injection directly into the canals should be performed and scalp [14].
carefully to reduce the risk of neural injury. • Supraorbital nerve blocks have been associated
• Ensure that the local anesthetic reaches all the relevant with a high requirement for supplementation, per-
branches in order to achieve adequate anesthesia. While haps due to the anatomic variation of the nerve. The
many practitioners commonly think that they are blocking nerve may exit the skull undivided or its medial and
the infraorbital nerve directly, it is important to remember lateral branches may exit separately.
that the nerve branches as soon as it exits the skull.
• Inaccurate placement of local anesthesia necessitates
injection of larger volumes, which can be painful for 15.2.2 Intraoral Approach to Trigeminal Nerve
awake and nonsedated patients. Inaccurate injection may Blocks: Infraorbital, Mental,
also lead to partial blockade of maxillary nerve branches, and Greater Palatine Nerves
which may fail to provide (1) adequate anesthesia to
awake patients or (2) analgesia in the recovery room upon Trigeminal nerves can also be blocked via the intraoral
emergence. approach.
15.2.2.1 Patient Positioning

Clinical Pearls
• Supine with head resting on a donut.
• The blocks should be followed by local compres- • Greater palatine nerve: to keep the mouth open during
sion to prevent hematoma formation. blockade of the greater palatine nerve, a bite block or,
more appropriate, a Dingman mouth retractor is required.
15.2.2.2 Landmarks and Surface Anatomy represents the level at which the greater palatine nerve
exits the foramen and can be located consistently at this
• Infraorbital foramen: intraorally, locate the subsulcal level. When palpating the medial bone edge, care must be
groove at the level of the canine or first premolar taken to recognize the correct structures. Moving the fin-
(Fig. 15.5). ger randomly posterior risks palpating the hook of the
• Mental foramen: the buccal mucosa of the first premolar hamulus rather than the true medial edge of the bone,
is identified (Fig. 15.6). which represents the level of the greater palatine foramen.
• Greater palatine foramen: in the intact palate, locate the Palpation of the hamulus will be too posterior, and injec-
greater palatine foramen medial and anterior to the first tion here will result in ineffective anesthesia. To correct
premolar in infants (Fig. 15.7) and second molar in ado- this, the finger should be moved toward the lateral edge of
lescents. The nerve runs anterior to the foramen on the the palate, and a depression or groove will be felt, repre-
floor of the hard palate. In a patient with cleft palate, senting the foramen. This is the exit for the nerve and vas-
locate the greater palatine foramen by palpating the cular pedicle that accompanies the nerve and supplies
medial edge of the cleft palate. The end of the hard palate blood supply to the palatal tissues.
Fig. 15.5 Surface anatomy and needle insertion for intraoral infraor- Fig. 15.7 Surface anatomy and needle direction for greater palatine
bital nerve block nerve block
Fig. 15.6 Surface anatomy and needle direction for intraoral mental
nerve block
15.2.2.3 Needle Insertion Technique both the practitioner and surgeon to have a full view of
needle placement and prevent injury to the vascular
• Intraoral infraorbital nerve: evert the upper lip and, using pedicle.
a ≥45° angle, insert a 23G–27G needle into the buccal – After locating the greater palatine foramen, the injec-
mucosa in the subsulcal groove (Fig. 15.5). A longer nee- tion is performed in a cross-mouth technique, which
dle is needed to reach the level of the foramen. External will allow everyone involved in the operation to view
palpation at the foramen will help to prevent the needle needle insertion and local anesthetic spread.
from entering the globe of the eye. – Use of epinephrine as an adjunct is critical so that the
– Lateral needle placement or local anesthetic spread blanching of mucosa can help determine optimum
risks partial blockade. Placing local anesthetic too far local anesthetic spread.
laterally on the maxilla may result in blockade of the – Performing the injection at the beginning of surgery
middle or anterior superior alveolar nerves; in this allows local anesthetic spread to be followed without
case, only dental – not surgical – anesthesia may be any confusion from the surgical injection, which is
achieved. typically performed for palate hemostasis and dissec-
– Inaccurate needle direction may make location of the tion of soft tissues. Ideally, the injection is performed
foramen difficult since the needle is traveling in a sag- in a gentle, single-shot technique without hunting for
ittal or nasal-to-temporal direction from the buccal the foramen directly.
sulcus. – Ideally, the needle will contact the bone of the palate
• Mental nerve: Evert the lower lip and insert a 25G–27G in a periforaminal location. Typically, 0.5–1 mL local
needle into the buccal mucosa between the canine and the anesthesia is injected. Spread in the hard palate only
first premolar (Fig. 15.6). indicates successful injection; if the soft palate tissues
• Greater palatine nerve: for patients with an intact palate, begin to dissect, then the needle may be too far poste-
insert a 25G–27G needle into the mucosa anterior to the rior and may need to be repositioned slightly
greater palatine foramen (Fig. 15.7). For cleft palate anterior.
repairs, several separate blocks will be needed since the – After the greater palatine nerve is surrounded by local
greater palatine nerve is only one of the nerves that anesthetic, the needle is inserted in a posterior direc-
innervate the cleft palate. The nasopalatine nerve, which tion about 3–5 mm posterior from the original injec-
is a terminal branch of the maxillary nerve, innervates tion position. The soft tissues that make up the soft
the anterior or primary palate and the front four teeth palate pedicle are expanded by an additional 0.5–1 mL
and will need to be blocked separately. The soft palate, of local anesthetic. The lesser palatine foramen is too
which is supplied by the lesser palatine nerve and a difficult to locate clinically since it is very lateral on
plexus of nerves that arise from the glossopharyngeal the palate and extremely small (Fig. 15.8). Since a
plexus in the oral cavity, also requires a separate plexus of nerves innervates the soft palate, spreading
injection. the local anesthetic through the soft palate tissues will
– When blocking these nerves, it is critical that the ensure posterior spread to reach the lesser palatine
mouth be opened as widely as possible with the assis- foramen. Medial spread will help anesthetize the glos-
tance of some type of mouth retractor such as a sopharyngeal components and help to ensure complete
Dingman retractor. Having a wide open view allows palate anesthesia.
• The last nerve to block for palate anesthesia is the naso- to inject on both anterior surfaces of the palate to per-
palatine nerve (Fig. 15.8). It exits the nasopalatine fora- form so-called partial palatal injections, which will
men, which is located under the nasopalatine papilla in the anesthetize the anterior palate.
front of the hard palate. The foramen is the entrance to a – In some palate repairs, the vomer will also be used for
canal that travels in the direction of the tooth roots at a 45° the repair; additional local anesthesia should be placed
angle. here to ensure complete anesthesia of the surgical
– A 25G–27G needle may be placed in this foramen; area.
however, it is not uncommon to encounter difficulty
entering the foramen, and some force may be required
upon injection to ensure local anesthetic spread 15.2.2.4 Local Anesthetic Application
through the foramen. After aspiration, the appropriate local anesthetic dose (e.g.,
– If the cleft palate extends through the foramen, any 1–2 mL of 0.5–1 % lidocaine, or 0.5–1 mL of 0.125–0.25 %
injected local anesthesia will drip into the nasal vault bupivacaine, or 0.2 % ropivacaine with epinephrine
and will not be effective. In this situation, it is possible 1:200,000) is slowly injected after aspiration.
Fig. 15.8 Surface anatomy and needle direction for nasopalatine nerve
block
15.2.3 Deep Trigeminal Nerve Blocks formed by a lateral approach to enter the sphenopalatine
fissure. This can be achieved by approaching either
Deep trigeminal nerve blocks are not commonly performed above or below the zygomatic arch. Novice practitio-
in the pediatric population; however, it is worth discussing ners should exercise caution with this block since
the suprazygomatic maxillary nerve block, which has accurate needle placement requires insertion 3–4 cm
recently become popular for cleft palate repairs. These deep into the skull base in a blind fashion. The recom-
blocks have not been commonly performed, even in the adult mended insertion point is at the junction of the supe-
population, most likely because of the deep insertion required rior zygoma and posterior orbit. The needle is inserted
to perform accurate nerve blockade and the potential perpendicularly to contact the greater wing of the
for harm. sphenoid at a depth of 2 cm. After bony contact, the
needle is redirected 9° inferior and 20° anterior in the
• Deep trigeminal blocks are required when the superficial direction of the plane of the philtrum and is advanced
block of the infraorbital nerve does not produce adequate 3–4 cm further to enter the pterygopalatine fossa
anesthesia or when complete maxillary or mandibular (Fig. 15.9). A dose of 0.15 mL/kg is recommended
anesthesia is required. after negative aspiration. The block is then repeated on
• Maxillary nerve block (often but not completely accu- the opposite side for complete maxillary nerve
rately referred to as sphenopalatine block) can be per- anesthesia.
1 2
3 4
Fig. 15.9 Surface anatomy and needle direction for maxillary nerve block. (1) The needle is inserted perpendicularly to contact sphenoid; (2) the
needle is redirected 9° inferior and then (3) 20° anterior; (4) the needle/syringe can hold its own position once the needle has entered the pterygo-
palatine fossa
The mandibular nerve can be blocked at the point where it should be advanced no further than the depth of the ptery-
leaves the cranium through the foramen ovale. The block can goid plate. While no pediatric studies exist to recommend
be done with an intraoral or extraoral approach through the accurate dosing, 1–3 mL of local anesthetic should
intercondylar mandibular notch. achieve adequate anesthesia since the needle is close to
the foramen ovale and skull base.
• When using an extraoral approach, place the needle
through the notch in a perpendicular fashion, and contact Due to the depth of these blocks (see Figs. 15.10 and
the pterygoid plate. Measure the depth and move the nee- 15.11), they should be performed by practitioners with
dle posterior to walk off the pterygoid plate. The needle related and adequate experience.
Fig. 15.10 VHVS and MRI images capturing the maxillary nerve during its course through the infraorbital groove and canal. This will be the
location of a maxillary nerve block
Fig. 15.11 VHVS and MRI of the mandibular nerve showing its position posterior to the maxillary nerve yet remaining medial to lateral ptery-
goid plate
15.3 Current Literature in Ultrasound- 15.4 Case Study

Guided Approaches
It has been reported that failure to achieve full anesthesia Greater Palatine Nerve Block (Provided by S. Suresh)
using traditional blocks of the trigeminal nerve is in the
region of 22 % [15]. In pediatric patients, one reason for this A 5-month-old female infant, 6.5 kg in weight, with a
may be that landmarks used to perform superficial trigeminal past medical history of cleft lip and cleft palate and
nerve blocks (particularly infraorbital) are absent or difficult mother with cleft lip, presented for cleft palate surgery.
to palpate in the neonate. Facial foramina can be localized Hemoglobin was measured at 9.8 g%. No preadmis-
accurately and reliably using ultrasound [1, 16], and this may sion medications were given. A greater palatine nerve
provide an opportunity to improve success in these blocks. block was administered; briefly, the mouth gag was
Tsui [1] described an ultrasound approach to locate the placed by the surgeon, after which the greater palatine
supraorbital, infraorbital, and mental foramina (see above). foramen was identified in the hard palate (this usually
Identification of each foramen can be achieved using a high- corresponds to the second molar in an older patient
resolution, short-footprint linear transducer; a disruption in with dentition), and 0.5 mL 0.25 % bupivacaine was
the continuity of the bone will appear as scanning proceeds injected with a 27G needle into the area anterior to the
in a medial-to-lateral direction at the level of the foramina greater palatine foramen bilaterally (cf. Fig. 15.7).
(Fig. 15.3). Color Doppler will prove useful to locate the Duration of surgery was 2 h, 35 min; block duration
respective artery within the foramen. was 8–10 h. No ultrasound imaging considerations
The effectiveness of trigeminal nerve block has been dem- were necessary, and no additional opioid was needed
onstrated in various studies. Ahuja et al. [17] showed a sig- in recovery. Patient outcome was excellent and resulted
nificant improvement in pain score in the infraorbital block in early discharge from PACU.
group compared to normal saline infiltration in children
scheduled for cleft lip repair. A double-blinded, randomized
study also demonstrated a significant reduction in analgesia
requirement and pain score in children who had an infraor-
bital nerve block compared to the conventional peri-incisional References
infiltration by the surgeon [18]. Recently, Mesnil et al. [19]
1. Tsui BC. Ultrasound imaging to localize foramina for superficial
observed the effectiveness of bilateral maxillary nerve blocks trigeminal nerve block. Can J Anesth. 2009;56:704–6.
using a suprazygomatic approach, finding improved pain 2. Suresh S, Voronov P, Curran J. Infraorbital nerve block in children:
relief and a reduction in opioid consumption following cleft a computerized tomographic measurement of the location of the
palate repair in infants. Furthermore, this approach minimizes infraorbital foramen. Reg Anesth Pain Med. 2006;31:211–4.
3. Canan S, Asim OM, Okan B, Ozek C, Alper M. Anatomic varia-
the likelihood of entering the orbit and reduces the risk of tions of the infraorbital foramen. Ann Plast Surg. 1999;43:613–7.
vascular injury as the needle enters the infratemporal fossa 4. Thakur G, Thomas S, Thayil SC, Nair PP. Accessory mental fora-
and ultimately the sphenopalatine fossa in a superior-to-infe- men: a rare anatomical finding. BMJ Case Rep. 2011; 2011;
rior direction. No significant difference was found in man- bcr0920103326.
5. Eipe N, Choudhrie A, Pillai AD, Choudhrie R. Regional anesthesia
dibular infiltration anesthesia and mandibular block for dental for cleft lip repair: a preliminary study. Cleft Palate Craniofac
surgery in children [20]; however, in this study, mixed surgi- J. 2006;43:138–41.
cal cases with a relatively small sample size were investi- 6. Voronov P, Suresh S. Head and neck blocks in children. Curr Opin
gated, which could introduce confounding factors. Anaesthesiol. 2008;21:317–22.
7. Lynch MT, Syverud SA, Schwab RA, Jenkins JM, Edlich
The effectiveness of bilateral maxillary nerve blocks R. Comparison of intraoral and percutaneous approaches for infra-
using a suprazygomatic approach with nerve stimulation orbital nerve block. Acad Emerg Med. 1994;1:514–9.
[19] and ultrasound [21] has been reported. Using electrical 8. Bosenberg AT, Kimble FW. Infraorbital nerve block in neonates for
stimulation, Mesnil et al. [19] showed that the disappear- cleft lip repair: anatomical study and clinical application. Br J
Anaesth. 1995;74:506–8.
ance of the temporal muscle twitch coincided with the nee- 9. Wilhelmi BJ, Mowlavi A, Neumeister MW, Blackwell SJ. Facial
dle’s tip in the pterygopalatine fossa where local anesthetic fracture approaches with landmark ratios to predict the location of
was injected. More recently, this group successfully pub- the infraorbital and supraorbital nerves: an anatomic study.
lished a randomized, double-blind study evaluating an J Craniofac Surg. 2003;14:473–7.
10. Hu KS, Kwak HH, Song WC, Kang HJ, Kim HC, Fontaine C,
ultrasound-guided suprazygomatic maxillary nerve block Kim HJ. Branching patterns of the infraorbital nerve and topogra-
[21]. They used a linear array probe located in the infrazy- phy within the infraorbital space. J Craniofac Surg.
gomatic area to allow out-of-plane visualization of the nee- 2006;17:1111–5.
dle tip and local anesthetic spread in the pterygopalatine 11. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr
Surg. 1998;101:840–51.
fossa. Both these approaches allowed improved pain relief 12. Suresh S, Bellig G. Regional anesthesia in a very low-birth-weight
and a reduction in opioid consumption following cleft pal- neonate for a neurosurgical procedure. Reg Anesth Pain Med.
ate repair in infants. 2004;29:58–9.
13. Uejima T, Suresh S. Ommaya and McComb reservoir placement in 20. Yassen GH. Evaluation of mandibular infiltration versus mandibu-
infants: can this be done with regional anesthesia? Pediatr Anesth. lar block anaesthesia in treating primary canines in children. Int J
2008;18:909–11. Paediatr Dent. 2010;20:43–9.
14. Suresh S, Wagner AM. Scalp excisions: getting “ahead” of pain. 21. Sola C, Raux O, Savath L, Macq C, Capdevila X, Dadure
Pediatr Dermatol. 2001;18:74–6. C. Ultrasound guidance characteristics and efficiency of suprazy-
15. Pascal J, Charier D, Perret D, Navez M, Auboyer C, Molliex gomatic maxillary nerve blocks in infants: a descriptive prospective
S. Peripheral blocks of trigeminal nerve for facial soft-tissue sur- study. Pediatr Anesth. 2012;22:841–6.
gery: learning from failures. Eur J Anaesthesiol. 2005;22:480–2.
16. Hannan L, Reader A, Nist R, Beck M, Meyers WJ. The use of ultra-
sound for guiding needle placement for inferior alveolar nerve
blocks. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
Suggested Reading
1999;87:658–65.
17. Ahuja S, Datta A, Krishna A, Bhattacharya A. Infra-orbital nerve Belvis D, Voronov P, Suresh S. Head and neck blocks in children. Tech
block for relief of postoperative pain following cleft lip surgery in Reg Anesth Pain Manag. 2007;11(4):208–14.
infants. Anaesthesia. 1994;49:441–4. Dalens B. Blocks of the head, neck, and face. In: Dalens B, editor.
18. Prabhu KP, Wig J, Grewal S. Bilateral infraorbital nerve block is Regional anesthesia in infants, children, and adolescents.
superior to peri-incisional infiltration for analgesia after repair of Philadelphia: Lippincott Williams & Wilkins; 1995. p. 398–401.
cleft lip. Scand J Plast Reconstr Surg Hand Surg. 1999;33:83–7. Suresh S, Polaner DM, Cote CJ. Regional Anesthesia. In: Cote CJ,
19. Mesnil M, Dadure C, Captier G, Raux O, Rochette A, Canaud N, Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
Sauter M, Capdevila X. A new approach for peri-operative analge- 2013. p. 835–79.
sia of cleft palate repair in infants: the bilateral suprazygomatic Suresh S, Voronov P. Head and neck blocks in infants, children, adoles-
maxillary nerve block. Pediatr Anesth. 2010;20:343–9. cents. Pediatr Anesth. 2012;22:81–7.
Cervical Plexus Blocks
16
Ban C.H. Tsui
Contents
16.1 Indications for Cervical Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
16.1.1 Indications for Superficial Cervical Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
16.1.2 Indications for Combined Superficial and Deep Cervical Plexus Block . . . . . . . . . . . . . . 242
16.2 Classic (Deep) Cervical Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
16.2.1 Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
16.2.2 Landmarks and Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
16.2.3 Needle Insertion Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
16.2.4 Nerve Localization and Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
16.2.5 Current Literature for Deep Cervical Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
16.3 Ultrasound-Guided Superficial Cervical Plexus Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
16.3.3 Scanning Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
16.3.4 Sonographic Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
16.3.6 Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
16.3.7 Current Literature for Superficial Cervical Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
16.4 Great Auricular Nerve Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
16.4.4 Nerve Localization and Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
16.4.5 Current Literature for Great Auricular Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
16.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_16
242 B.C.H. Tsui
16.1 Indications for Cervical Plexus Block 16.2 Classic (Deep) Cervical Plexus Block
16.1.1 Indications for Superficial Cervical This block is not commonly used in young children. In addi-
Plexus Block tion to the depth of the block, it also has the potential for
inadvertent phrenic nerve blockade, especially in young chil-
dren, which may compromise their respiratory function. For
• Carotid endarterectomy (with a deep cervical plexus this reason, bilateral deep cervical plexus block is considered
block or infiltration) contraindicated. Furthermore, the proximity of the deep cer-
• Surgical excision of lesions in the neck or “cape region” vical plexus to the vertebral and carotid arteries increases the
of the shoulder risks of inadvertent vascular puncture and systemic absorp-
• Surgical fixation of fractured clavicle tion of local anesthetic (Fig. 16.1). A risk of spinal anesthe-
• To facilitate tunneling of interscalene brachial plexus sia is also present; therefore, high volumes of local anesthetic
catheters and as an adjunct to this block for total shoulder and high injection pressure should be avoided.
replacement
C1 spinal n.
16.1.2 Indications for Combined Superficial C1

and Deep Cervical Plexus Block
C2
• Tympanomastoid surgery
• Otoplasty
C3
• Cochlear implant
• Thyroidectomy Posterior tubercle
of transverse
C4
• Vocal cord surgery process
C5 Transverse
process
C7 spinal n.
Fig. 16.1 Deep cervical plexus anatomy

16 Cervical Plexus Blocks 243
16.2.1 Patient Positioning of C6. Each transverse process of C2–C5 is marked

approximately 0.5–1 cm behind the line. The transverse
• Supine with a small towel or pillow under the head, which process of C2 lies about 1–1.5 cm inferior to the mastoid
is turned 45° to the contralateral side with slight neck process, depending on the age and size of the patient.
extension Deep cervical plexus block is a variation of cervical para-
vertebral nerve block of C2–C4.
16.2.2 Landmarks and Surface

Anatomy (Fig. 16.2) 16.2.3 Needle Insertion Technique
• Landmarks include the posterior edge of the sternocleido- • Three injections using a 22G–24G needle at the level of
mastoid muscle, the caudal portion of the mastoid process C2–C4 perpendicular to the horizontal plane and advanced
(see Clinical Pearls), the angle of the jaw, and the trans- slightly caudally and posteriorly (it is very important to
verse processes of cervical vertebrae C2–C5. avoid inadvertent intrathecal or epidural injection into the
• If no transverse processes can be palpated, the transverse vertebral artery). The needle will typically contact the
process of C6 can be located at the level of the cricoid posterior tubercle of the transverse process (Fig. 16.1),
cartilage. A line is drawn from the mastoid process along upon which, the needle is withdrawn slightly, and the
the sternocleidomastoid muscle to the transverse process local anesthetic is injected after negative aspiration.
Fig. 16.2 Patient positioning and surface landmarks for a deep cervi-
cal plexus block. SCM sternocleidomastoid muscle
244 B.C.H. Tsui
16.2.4 Nerve Localization and Local the groove between the longus capitis and scalenus
Anesthetic Application medius.
– After confirming contact with the transverse process, the
• A nerve stimulator attached to an insulated needle can be needle is withdrawn slightly and a syringe is connected.
used to localize the mixed spinal nerves. Correct position – The dose of local anesthetic should be considered
of the needle tip is confirmed when current intensity of carefully, especially when multiple injections are per-
0.5 mA elicits a local neck muscle response [1]. formed. A dilute solution (0.5–1.0 % lidocaine [maxi-
• Concurrent use of ultrasound guidance is recom- mum dose 7 mg/kg] or 0.125–0.25 % bupivacaine
mended to improve safety and efficacy of this block. [maximum dose 2 mg/kg]) with epinephrine (1:200,000
The ultrasound image with corresponding MRI and or 1:400,000) to detect inadvertent intravenous injec-
VHVS images is shown in Figs. 16.3 and 16.4, where tion should be used. Generally, 1–3 mL of the solution
a selective deep cervical plexus block is performed in is used at each injection site.
Fig. 16.3 VHVS and MRI images of the deep cervical plexus
Fig. 16.4 Ultrasound image of the deep cervical plexus

Clinical Pearls are possible if the needle is advanced too far medi-
• At birth, the mastoid process only represents a small ally into the vertebral foramen. This is more likely in
portion of the temporal bone. The mastoid width and the cervical region because of the longer dural
depth increases rapidly up to the age of 7 years with sleeves that accompany these nerve branches.
no apparent gender dimorphism. The maximum size Careful monitoring of the patient should continue for
is apparent between years 11 and 19. This should be 60 min after the block has been performed.
considered when palpating the attachment of the ster- • Phrenic nerve palsy leading to hemidiaphragmatic
nocleidomastoid muscle as a landmark for these paresis is a common occurrence with this block; there-
blocks. fore, care must be taken in young children. Bilateral
• The deep block may be performed by single injection blocks are not recommended. Minimizing the volume
at C3 or C4 as originally described by Winnie or by a of local anesthetic may limit blockade of the phrenic
standard three-injection technique. nerve.
• There are several life-threatening complications that • Other well-described side effects include Horner’s
may arise from deep cervical plexus block. A cau- syndrome (if the superior cervical or cervicothoracic
dally directed needle is imperative; otherwise, injec- ganglion is blocked), stellate ganglion block, and
tion into the vertebral artery (Fig. 16.5) may occur, hoarseness due to recurrent laryngeal nerve block.
potentially leading to convulsions, unconsciousness, • The authors did not recommend performing the deep
and blindness. Subarachnoid or epidural injections cervical plexus block unless it is strongly indicated.
Fig. 16.5 Ultrasound image highlighting the close proximity of the vertebral artery to the deep cervical plexus
246 B.C.H. Tsui
16.2.5 Current Literature for Deep Cervical between the sternocleidomastoid and levator of the scap-
Plexus Block ula muscles; after which, the needle was advanced to a
position between the levator of the scapula and cervical
Zeidan described a nerve stimulator-guided deep cervical transverse process, where another injection of 15 mL ropi-
plexus block for carotid endarterectomy [1]. The transverse vacaine 0.75 % was done. All blocks were successful with
process is identified 1 cm posterior to the posterior border of no need for supplementary analgesics in the 24 h post-
the sternocleidomastoid. With a block needle connected to a block period. Obviously, this dosage is too high for the
nerve stimulator, the needle is inserted perpendicular to the pediatric population.
skin, aiming slightly caudal at C2 level to elicit neck muscle There have been reports of successful cervical plexus
contraction at a current intensity of 0.5 mA. Excellent results blocks to provide surgical anesthesia for lymph node biopsy
were reported with this technique; however, there was no and excision of thyroid nodules in adolescents using a single
description of the specific type of muscle response elicited to injection at the level of C3 [3]. When reviewing the literature
confirm correct placement of the needle versus direct muscle describing ultrasound imaging techniques of deep cervical
contraction from the stimulating needle itself. Data on pedi- block in adults, the two most useful sonographic landmarks
atric patients are lacking. appear to be the groove between the longus capitis and sca-
A recent case series by Perisanidis et al. [2] assessed lenus medius [4] and the sulcus between the anterior and
combined deep and intermediate cervical plexus block for posterior tubercles of the transverse processes and posterior
oral and maxillofacial surgery in adults. Under ultrasound to the vertebral artery [5, 6].
guidance, the authors injected 15 mL ropivacaine 0.75 %
16.3 Ultrasound-Guided Superficial nerve, and the supraclavicular nerve (Fig. 16.6). These are all
Cervical Plexus Block branches from the anterior primary rami of the C1–C4 nerve
roots. Superficial cervical plexus block provides anesthesia
This block aims to anesthetize the four branches of the super- to the ipsilateral occipital region, some of the ear, the ante-
ficial cervical plexus, namely, the lesser occipital nerve, the rior and posterior triangles of the neck, and the upper back,
great auricular nerve, the anterior or transverse cervical shoulder, and upper pectoral regions.
Lesser occipital n.
Great
auricular n.
Supraclavicular n.
Transverse
cervical n.
Fig. 16.6 Superficial cervical plexus

anatomy
248 B.C.H. Tsui
16.3.1 Patient Positioning
• The patient may be supine with the head turned 45° to the
opposite side or lateral decubitus with the side to be
blocked uppermost. Alternatively, the patient may be
more comfortable with the head of the bed raised to 30°
with the head turned or semilateral.
16.3.2 Landmarks and Surface Anatomy

(Fig. 16.7)
• A horizontal line is drawn laterally from the cricoid carti-

lage (at the level of C6) to bisect a line drawn along the
posterior border of the clavicular head of the sternoclei-
domastoid muscle (generally, this intersection is at the Fig. 16.7 Patient positioning and surface landmarks for a superficial
lower-third to midpoint of this muscle). cervical plexus block. SCM sternocleidomastoid muscle
16.3.3 Scanning Technique • The target for injection is the fascial plane between the
superficial cervical fascia on the deep surface of the ster-
• A linear (6–15 MHz) transducer is placed in a transverse nocleidomastoid muscle and the deep cervical fascia on
location at the midpoint of the posterior border of the ster- the superficial surface of the anterior and middle scalene
nocleidomastoid muscle. muscles (Figs. 16.8, 16.9, and 16.10).
• The required depth is usually 2–4 cm for adolescents. • The interscalene brachial plexus lies deep to the deep cer-
• Identify the fascial plane between the superficial cervical vical fascia at this point.
fascia, which invests the sternocleidomastoid muscle, and • The phrenic nerve can be difficult to visualize and lies
the deep cervical fascia, which invests the scalene mus- deep cervical fascia on the surface of the anterior scalene
cles, deep cervical muscles, and the phrenic nerve. muscle.
• The carotid sheath containing the carotid artery, internal
jugular vein, and vagus nerve may also be visible deeper
16.3.4 Sonographic Appearance in the image.
• The nerve fibers may be visible with careful scanning and

will be easier to see following local anesthetic injection;
however, it is not necessary to identify them.
Trachea Visceral fascia

Esophagus Thyroid gland
Infrahyoid muscles
Longus colli m.
Cervical fascia
Common Pretracheal layer
carotid artery Superficial layer
Prevertebral layer
Internal jugular vein
Carotid sheath
Sternocleidomastoid m.
Vagus n.
C6 vertebra Scalene muscles
Sympathetic trunk
Brachial plexus
Spinal
cord
C6
vertebra
Levator scapulae m.
Superficial and
deep layers of
nuchal fascia
Intrinsic back muscles Trapezius m.
Fig. 16.8 Cross-section at C6 showing location of cervical fasciae

250 B.C.H. Tsui
Fig. 16.9 VHVS and MRI images of the superficial cervical plexus
Fig. 16.10 Ultrasound image of the superficial cervical plexus

16.3.5 Needle Insertion Technique (Fig. 16.11) the needle, especially the tip, due to the superficial nature
of the block and the flat angle of the needle.
• An injection of 1 mL lidocaine at the block needle • A “pop” may be felt as the needle penetrates the superfi-
insertion site will aid patient comfort when performed cial cervical fascia.
awake. • The tip of the needle should be just below and 0.5 cm
• Use a 2–3 cm, 22–27G bevel-tipped nerve block needle. medial to the middle of the posterior border of the sterno-
• An in-plane (IP) approach from lateral to medial should cleidomastoid muscle and deep to the superficial cervical
allow continuous visualization of the complete length of fascia during local anesthetic injection.
Fig. 16.11 Needle insertion for superficial cervical plexus block

252 B.C.H. Tsui
16.3.6 Local Anesthetic Application 16.4 Great Auricular Nerve Blocks
• Performing a test dose with D5W is recommended prior Blocking the great auricular nerve can provide postoperative
to local anesthetic application to visualize the spread and analgesia facilitating early discharge or omitting the need for
confirm needle tip localization. hospital admissions. This is a superficial block, and ultra-
• 0.1–0.2 mL/kg of local anesthetic (e.g., 0.25 % bupiva- sound is not usually indicated. However, risks such as intra-
caine) should provide adequate spread. vascular injection, hematoma, and injecting too far into the
• Correct needle position will separate the sternocleido- deep cervical plexus or vascular structures should be
mastoid and scalene muscles as well as ensure spreading recognized.
of local anesthetic superiorly and inferiorly.
• After some space has been created by hydrodissection, Indications This is a branch of the superficial cervical
the needle can be advanced slightly medially to enhance plexus (Fig. 16.6) providing sensory innervations to the
the local anesthetic spread. pinna and the postauricular region. Common indications of
• If intramuscular injection into the sternocleidomastoid or great auricular nerve block include:
scalene muscles occurs, the needle will need to be reposi-
tioned into the correct plane. • Tympanomastoid surgery
• Cochlear implant
• Craniotomies
16.3.7 Current Literature for Superficial • Otoplasty (with lesser occipital nerve)
Cervical Block
Less common indications:
There is a paucity of evidence on the use of superficial cervi-
cal plexus blocks in children. Brownlow et al. [6] reported • Brachial cleft cyst excision
the use of a superficial cervical plexus block combined with • Thyroidectomy
mild sedation in a child with an anterior mediastinal mass • Parathyroidectomy
who successfully underwent a diagnostic cervical node • Clavicular fracture reduction
biopsy. • Thyroplasty
Clinical Pearls 16.4.1 Patient Positioning

• Complications associated with the superficial cervi-
cal plexus block include phrenic nerve paralysis • Supine with head turned to the contralateral side.
leading to diaphragmatic dysfunction, vagus nerve
block with resultant recurrent nerve paralysis, inad-
vertent intravascular injection, or inadvertent deep
cervical plexus block.
• Hematoma and deep plexus block, with associated
Horner’s syndrome, are also possible following
superficial cervical plexus block.
16.4.2 Landmarks and Surface external jugular vein may cross the neck at the point in
Anatomy (Fig. 16.12) which the cervical plexus wraps around the belly of the
sternocleidomastoid muscle. Landmarks include the cri-
• The cricoid cartilage (C6) is identified, and a line is drawn coid cartilage (level of C6), the posterior border of the
from it to the posterior border of the sternal head of ster- sternocleidomastoid muscle, and in some children, the
nocleidomastoid muscle (Fig. 16.6). In some patients, the external jugular vein.
Fig. 16.12 Patient positioning and surface landmarks for great auricu-
lar nerve blocks. SCM sternocleidomastoid muscle
254 B.C.H. Tsui
16.4.3 Needle Insertion Technique References
• Using an acute angle to facilitate a superficial subcutane- 1. Zeidan A, Hayek F. Correspondence: nerve stimulator-guided cervi-
cal plexus block for carotid endarterectomy. Anesthesia. 2007;62:
ous insertion, a 27G needle is advanced cephalad along
299–300.
the posterior border of the sternocleidomastoid muscle. 2. Perisanidis C, Saranteas T, Kostopanagiotou G. Ultrasound-guided
combined intermediate and deep cervical plexus nerve block for
regional anesthesia in oral and maxillofacial surgery.
Dentomaxillofac Radiol. 2013;42:29945724.
16.4.4 Nerve Localization and Local 3. Tobias JD. Cervical plexus block in adolescents. J Clin Anesth.
Anesthetic Application 1999;11:606–8.
4. Soeding P, Eizenberg N. Review article: anatomical considerations
• After negative aspiration, local anesthetic (e.g., 2–3 mL for ultrasound guidance for regional anesthesia of the neck and
upper limb. Can J Anesth. 2009;56:518–33.
of 0.25 % bupivacaine with 1:200,000 of epinephrine) is
5. Sandeman DJ, Griffiths MJ, Lennox AF. Ultrasound guided deep
injected in incremental doses to form a small subcutane- cervical plexus block. Anaesth Intensive Care. 2006;34:240–4.
ous wheal. 6. Brownlow RC, Berman J, Brown Jr RE. Superficial cervical block
for cervical node biopsy in a child with a large mediastinal mass. J
Ark Med Soc. 1994;90:378–9.
7. Suresh S, Barcelona SL, Young NM, et al. Postoperative pain relief
16.4.5 Current Literature for Great Auricular in children undergoing tympanomastoid surgery: is a regional block
Nerve Block better than opioids? Anesth Analg. 2002;94:859–62.
8. Suresh S, Barcelona SL, Young NM, et al. Does a preemptive block
of the great auricular nerve improve postoperative analgesia in chil-
Two randomized, double-blinded studies have demonstrated
dren undergoing tympanomastoid surgery? Anesth Analg. 2004;98:
that the great auricular nerve block provides the same degree 330–3.
of pain relief as intravenous morphine with lower incidence
of vomiting [7, 8]. However, the use of this block as a pre-
emptive analgesic measure did not show any benefit in terms
of quality or duration of postoperative analgesia in children Suggested Reading
undergoing tympanomastoid surgery [8].
Belvis D, Voronov P, Suresh S. Head and neck blocks in children. Tech
Reg Anesth Pain Manag. 2007;11(4):208–14.
Clinical Pearls Dalens B. Blocks of nerves supplying the head and neck. In: Dalens B,
editor. Pediatric regional anesthesia. Boca Raton: CRC; 1990.
• Care should be taken to avoid intravascular injec- p. 465–8.
tion and deep cervical nerve block. Dalens B. Blocks of the head, face, and neck. In: Dalens B, editor.
Regional anesthesia in infants, children, and adolescents.
• There is also a potential for phrenic nerve blockade.
Philadelphia: Lippincott Williams & Wilkins; 1995. p. 440–5.
Suresh S, Voronov P. Head and neck blocks in infants, children,
adolescents. Pediatr Anesth. 2012;22(1):81–7.
16.5 Case Study
Superficial Cervical Plexus Block (Provided by S. Suresh)

A 12-year-old male, 17.5 kg in weight, presented for
cochlear implant placement. The patient had under-
gone a hearing test and had a past history of sensori-
neural deafness. A tympanomastoidectomy, lasting
3 h, 25 min, was performed. A landmark-based super-
ficial cervical plexus block was performed at the pos-
terior border of the sternocleidomastoid and at the
level of the cricoid cartilage (see Fig. 16.11). A subcu-
taneous injection was completed with the needle
pointed cephalad. A 27G needle was used, and 2 mL
0.25 % bupivacaine was injected; duration of the block
was 12 h. An additional 0.5 mg of morphine was given
for pain and postoperative recovery was excellent with
no PONV.
Occipital Nerve Blocks
17
Ban C.H. Tsui
Contents
17.2 Block Techniques 256
17.2.1 Patient Positioning 256
17.2.2 Landmarks and Surface Anatomy 258
17.2.3 Needle Insertion Technique 258
17.2.4 Local Anesthetic Application 259
17.4 Case Study 259
References 259
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_17
256 B.C.H. Tsui
17.1 Indications 17.2 Block Techniques
Anesthetizing the greater occipital nerve provides analgesia The greater occipital nerve lies medial to the occipital artery
for: which forms a reference point [1] for both ultrasound guid-
ance (not shown here) and the landmark technique when per-
• Occipital craniotomy forming these blocks (Figs. 17.1 and 17.2). Since the nerve
• Shunt revision can be relatively easily located medially to the palpable
• Diagnosis and treatment of occipital neuralgia and cervi- occipital artery along the superior nuchal line, a simple land-
cogenic headaches. mark approach with careful and frequent aspiration between
injections is often sufficient. However, an ultrasound-guided
Combined lesser occipital and great auricular nerve approach has been described [2].
blocks are indicated for postoperative analgesia for:
• Otoplasty 17.2.1 Patient Positioning
• Supine with head turned to the contralateral direction.

• The head can be tilted forward slightly to expose the
prominent nuchal ridge of bone at the posterior base of
the skull.
• Can be completed with the patient prone in preparation
for surgical position.
Fig. 17.1 Occipital nerve anatomy
Superior
nuchal line
Greater occipital n.
A
B
Lesser occipital n.
Great auricular n.
(posterior branch)
A = Greater occipital n. block location

B = Lesser occipital n. block location
17 Occipital Nerve Blocks 257
Fig. 17.2 VHVS and MRI images capturing the expected location of the greater occipital nerve
258 B.C.H. Tsui
17.2.2 Landmarks and Surface Anatomy 17.2.3 Needle Insertion Technique

(Fig. 17.3) (Figs. 17.4 and 17.5)
• Greater occipital nerve: The nerve is typically located lat- • A short, fine intradermal needle (e.g., 2–3 cm, 25G–27G)
eral (1–2 cm) and inferior (1–2 cm) to the external occipi- is introduced with a slight cranial angulation at each mark
tal protuberance. In adults, it is found one-third of the to the depth of the skull itself. Generally, the greater
distance from the external occipital protuberance to the occipital nerve is the primary target, but if more anterior
mastoid process [1], which will typically locate the lateral anesthesia of the scalp is required, the lesser occipital
border of the insertion of the erector muscles of the neck. nerve branches are also blocked by advancing the needle
Alternatively, the nerve can be located directly medial to subcutaneously from this point in an anterior direction
the easily palpated occipital artery. toward the mastoid process.
• Lesser occipital nerve: This nerve is located lateral to the
greater occipital nerve (approximately 2.5 cm in adoles-
cent patients), along the inferior nuchal line.
Fig. 17.4 Surface anatomy and needle insertion for greater occipital
nerve block
Fig. 17.3 Surface landmarks for greater and lesser occipital nerve
blocks. SCM sternocleidomastoid muscle
Fig. 17.5 Surface anatomy and needle direction for lesser occipital
nerve block
17 Occipital Nerve Blocks 259
17.2.4 Local Anesthetic Application 17.4 Case Study
• After slight withdrawal after bone contact, local anes- Occipital Nerve Block (Provided by A. Sawardekar)
thetic is injected (e.g., 0.5–1 mL of 0.5–1 % lidocaine for A previously healthy 34-month-old boy, 16 kg in weight,
diagnostic procedures or 2–3 mL of 0.125–0.25 % bupi- presented to the emergency room with new onset of
vacaine with epinephrine 1:400,000 for therapeutic pro- headache and blurred vision. A CT scan and MRI of the
cedures) after aspiration. brain revealed a posterior fossa tumor. A posterior fossa
• A fanlike injection can be used, with gentle massage of craniotomy and tumor resection (glioma) was sched-
the area to allow adequate spread of local anesthetic. uled. A bilateral occipital nerve block was administered
• For lesser occipital nerve anesthesia, a band of anesthetic using a landmark approach with 22G needle and 3 mL
solution can be deposited along the line between skin 0.25 % bupivacaine injected into each side. Duration of
entry and the mastoid process using 2–3 mL of local the surgery was 280 min, and block duration was 12 h.
anesthetic. No additional analgesics were needed. The patient
received two additional doses of oral acetaminophen
during the 24-h period following surgery.
Clinical Pearl
Complications with this technique are rare. Care must
be taken not to advance the needle anteriorly under the
References
skull, as the foramen magnum might be entered unin-
tentionally with a long needle. Local hematoma may 1. Becser N, Bovim G, Sjaastad O. Extracranial nerves in the posterior
be produced with superficial injection, but this is only part of the head. Anatomic variations and their possible clinical sig-
a temporary problem. nificance. Spine. 1998;23:1435–41.
2. Greher M, Moriggl B, Curatolo M, et al. Sonographic visualization
and ultrasound-guided blockade of the greater occipital nerve: a
comparison of two selective techniques confirmed by anatomical
dissection. Br J Anaesth. 2010;104:637–42.
17.3 Current Literature in Ultrasound-

Guided Approaches
Suggested Reading
A recent cadaveric study compared two techniques of ultra-
sound guidance for greater occipital nerve block, using both Belvis D, Voronov P, Suresh S. Head and neck blocks in children. Tech
the traditional block site and a selective approach at a proxi-
mal location where the nerve curls around the lower border Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
of the obliquus capitis inferior muscle after emerging below 2013. p. 835–79.
the posterior arch of the atlas [2]. A transverse midline orien- Suresh S, Voronov P. Head and neck blocks in infants, children, adoles-
tation is initially used to identify the external occipital protu- cents. Pediatr Anesth. 2012;22(1):81–7.
berance. A caudal scan is used to identify the spinous process
of C2 by its bifid appearance. A lateral rotation of the trans-
ducer is used to locate the obliquus capitis inferior muscle.
The nerve is identified during its cranial course where it lies
superficial to the muscle. Reported success of the simulated
block, defined by spread of dye to the nerve, was 80 % using
the traditional landmarks compared to 100 % with the new
selective technique. The selectivity of this block may be
important in certain circumstances, for instance, in diagnos-
ing occipital neuralgia. However, for most anesthesia pur-
poses, the traditional block site is suitable.
Blockade of the Auricular Branch
of the Vagus Nerve (Nerve of Arnold) 18
Ban C.H. Tsui
Contents
18.2 Block Technique 262
18.2.3 Needle Insertion Technique 263
18.4 Case Study 264
Reference 264
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_18
262 B.C.H. Tsui
18.1 Indications 18.2.1 Patient Positioning
Blockade of the nerve of Arnold can be used in children • Supine with the head turned to the contralateral side.
undergoing myringotomy and tube placement, tympanos-
tomy, and paper patch myringoplasty.
18.2.2 Landmarks and Surface Anatomy

18.2 Block Technique (Figs. 18.1 and 18.2)
Since the nerve can be easy to block at the tragus of the ear • The tragus of the ear is identified and pulled forward.
and the injection is superficial in nature, a simple landmark-
based approach is commonly used and is described here.
Fig. 18.1 VHVS and MRI images of the expected location of the auricular branch of the vagus nerve (nerve of Arnold)
Fig. 18.2 Patient positioning and surface landmarks for nerve of

Arnold block
18 Blockade of the Auricular Branch of the Vagus Nerve (Nerve of Arnold) 263
18.2.3 Needle Insertion Technique 18.3 Current Literature in Ultrasound-

Guided Approaches
• A 30G needle is inserted into the posterior tragus, approx-
imately 45° to the horizontal (Fig. 18.3). This novel regional technique was investigated in a random-
ized, double-blinded study comparing children receiving the
nerve of Arnold block or intranasal fentanyl for myringot-
18.2.4 Local Anesthetic Application omy. No difference was found in postoperative pain relief,
amount of rescue analgesics used, nausea and vomiting, or
• Inject local anesthetic solution (e.g., 0.2–0.3 mL of time to discharge between groups [1].
0.25 % bupivacaine with epinephrine 1: 200,000 or 0.2–
0.3 mL of 2 % lidocaine with epinephrine 1: 200,000)
after aspiration.
Fig. 18.3 Surface anatomy and needle direction for nerve of Arnold
block
264 B.C.H. Tsui
18.4 Case Study Reference

1. Voronov P, Tobin MJ, Billings K, et al. Postoperative pain relief in
infants undergoing myringotomy and tube placement: comparison
Nerve of Arnold Block (Provided by S. Suresh) of a novel regional anesthetic block to intranasal fentanyl-a pilot
A 16-year-old male, weighing 59.3 kg, with a past analysis. Ped Anesth. 2008;18:1196–201.
medical history of hearing loss, was diagnosed with
bilateral otitis media and long-standing bilateral tym-
panic membrane perforations based on an audiogram
and binocular microscopy. The patient was scheduled Suggested Reading
for tympanoplasty. A nerve of Arnold block was per-
formed with a 27G needle and an injection of 0.3 mL Belvis D, Voronov P, Suresh S. Head and neck blocks in children. Tech
2 % lidocaine (see Fig. 18.3). Surgery lasted two and a Suresh S, Voronov P. Head and neck blocks in infants, children, adoles-
half hours; block duration was 3.5 h. The patient rated cents. Pediatr Anesth. 2012;22(1):86–7.
his pain as 3/10 20 min postoperatively and 0/10 at
discharge. Ketorolac (Toradol) injection (30 mg) was
provided for postoperative analgesia.
Part V
Nerve Blocks Above the Clavicle
Interscalene Brachial Plexus Block
19
Ban C.H. Tsui
Contents
19.2 Surface Anatomy 268
19.3 Nerve Stimulation Technique 269
19.3.1 Needle Insertion 270
19.3.2 Current Application and Appropriate Responses 271
19.3.3 Modifications to Inappropriate Responses 272
19.4 Ultrasound-Guided Technique 273
19.4.1 Preparing the Site 275
19.4.2 Scanning Technique 275
19.4.3 Sonographic Appearance 277
19.5 Local Anesthetic Application 279
19.5.1 Clinical Pearls: Interscalene Block 279
19.7 Case Study 280
References 281
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_19
268 B.C.H. Tsui
19.1 Indications 19.2 Surface Anatomy (Fig. 19.1)
The interscalene approach to brachial plexus blockade tar- 19.2.1 Patient Positioning
gets the roots and proximal trunks of the plexus between the
anterior and middle scalene muscles at the level of the sixth The patient lies supine with the head rotated approximately
cervical vertebra (C6) (see Figs. 10.1 and 10.2) and provides 45° to the nonoperative side after general anesthesia has
anesthesia to the upper arm including the shoulder. While the been induced. Surface landmarks include:
interscalene approach may fail to anesthetize the distal roots
of the plexus, it consistently anesthetizes the axillary and • Clavicular head of the sternocleidomastoid muscle:
musculocutaneous nerves, which are frequently missed – The lateral border of the sternocleidomastoid muscle
when performing an axillary block. marks the location of the anterior scalene muscle. This
portion of the sternocleidomastoid muscle can be
Indications accentuated by asking the child to reach in the direc-
tion of the ipsilateral knee before induction of general
• Shoulder and humerus surgery
anesthesia.
• Interscalene groove:
– The groove is located between the anterior and middle
scalene muscles approximately 1 cm above the separa-
tion of the sternal and clavicular heads of the sterno-
cleidomastoid muscle. The anterior scalene muscle
lies immediately behind the lateral border of the cla-
vicular head of the sternocleidomastoid muscle at the
level of the cricoid cartilage (C6). The groove is made
more pronounced by asking older children to raise the
head or take a deep breath while awake.
• Chassaignac’s tubercle:
– The anterior tubercle on the C6 vertebra is located at
the intersection of the interscalene groove with the
transverse plane of the cricoid cartilage. This landmark
is more applicable in adolescents (whose vertebrae are
better developed).
Fig. 19.1 Patient positioning and surface landmarks for interscalene
brachial plexus block When using the interscalene approach, the point of needle
insertion is at the level of C6 within the interscalene groove.
For the parascalene approach, a line is drawn between the
midpoint of the clavicle and the transverse process of C6.
The needle insertion site is two-thirds of the way down this
line, near the external jugular vein.
19 Interscalene Brachial Plexus Block 269
19.3 Nerve Stimulation Technique

(Tables 14.1 and 19.1)
Table 19.1 Responses and recommended needle adjustments for use during nerve stimulation at the interscalene level
Correct response to nerve stimulation
Twitches elicited from the upper and middle trunks (pectoralis, deltoid, biceps brachii muscles) and middle and lower trunks (triceps,
forearm or hand muscles) with current intensity of at least 0.4 mA (0.1–0.3 ms) verify stimulation of the brachial plexus
Other common responses and needle adjustments
Muscle twitch from electrical stimulation
Neck (anterior scalene or sternocleidomastoid)
Explanation: needle usually anteromedial to plexus
Needle adjustment: withdraw needle to subcutaneous tissue and reinsert in a 10–20° more posterior angle
Diaphragm (phrenic nerve)
Explanation: needle plane is too anterior
Needle adjustment: withdraw needle to subcutaneous tissue and reinsert in a 15° more posterior angle
Scapula (thoracodorsal nerve to serratus anterior muscle)
Explanation: needle tip is too posterior and deep to brachial plexus
Needle adjustment: withdraw to subcutaneous tissue and reinsert in a more anterior plane
Trapezius (accessory nerve)
Explanation: needle tip too posterior to plexus
Needle adjustment: withdraw to subcutaneous tissue and reinsert in a more anterior plane
Bone contact
Needle stops a depth of 1–2 cm (transverse process of cervical vertebrae or first rib), without twitches
Explanation: needle shaft angle is too posterior and touching anterior tubercles
Needle adjustment: withdraw to subcutaneous tissue and reinsert in a 15° more anterior angle
Vascular puncture
Most commonly carotid artery puncture; seen as arterial blood aspiration
Explanation: needle angle and tip anterior to plexus
Needle adjustment: withdraw completely for pressure treatment and reinsert tip 1–2 cm posterior
Alternative explanation: vertebral artery puncture. Especially a risk in OOP technique or when there is difficulty with needle tip
visualization in either plane
Needle adjustment: needle tip is too medial, must be withdrawn and reinserted laterally
270 B.C.H. Tsui
19.3.1 Needle Insertion angle relative to the skin surface and directed medially,
posteriorly, and caudally.
A flowchart illustrating the needle insertion site and proce- • In children, the compact arrangement of anatomical struc-
dures is shown in Fig. 19.2. tures within the neck may warrant a modified, angled needle
insertion (as compared to the perpendicular orientation
• A 22G–25G, 30–35 mm (depending on the age and size often used in adults) in order to prevent inadvertent puncture
of the child), short-beveled needle is inserted at an acute of the vertebral artery or epidural/subarachnoid space [1].
Fig. 19.2 Flowchart of needle

insertion and procedures for an
interscalene brachial plexus block Brachial Plexus Block
lnterscalene Approach
Recommend Concurrent Use of Nerve

Stimulation
Position: Supine, Head Rotated 45° to

Non-Operative Side
Site: lnterscalene Groove at Level of C6
Needle Insertion: 60° to Skin Surface in a Medial,

Caudal, Dorsal direction
Arterial Blood
Transverse Process Contacted
Withdraw Needle, Apply Pressure for

Hemostasis
Withdraw and Reinsert Slightly
Anteriorly
Needle Inserted to Appropriate Depth (see text)

without Adverse Event
Aspirate and Inject Local Anesthetic

19.3.2 Current Application and Appropriate

Clinical Pearl Responses
• Needle insertion below C6 has been described
(including the parascalene approach described by Figure 19.3 illustrates the procedure for employing nerve
Dalens et al. [2]); both approaches are successful. stimulation techniques for interscalene brachial plexus
• For the parascalene approach, a line is drawn block.
between the midpoint of the clavicle and the trans-
verse process of C6 (Chassaignac’s tubercle). The • Applying an initial current of 0.8–1.0 mA (2 Hz, 0.1–
needle is inserted perpendicular to the skin two- 0.3 msec) is sufficient for stimulation of the plexus.
thirds of the way down this line near the external • After obtaining the appropriate motor response, the cur-
jugular vein. rent is reduced to aim for a threshold current of 0.4 mA
(0.1–0.2 msec).
• Motor response cessation at currents less than 0.2 mA
indicates the needle is probably intraneural.
• Twitches elicited from the upper and middle trunks (pec-
toralis, deltoid, biceps brachii muscles) and lower trunks
(triceps, forearm, and hand muscles) verify stimulation of
the brachial plexus.
Fig. 19.3 Flowchart of procedure

for employing nerve stimulation
techniques for interscalene Nerve Stimulation
Brachial Plexus Block
brachial plexus block
lnterscalene Approach
Use 0.8 rnA at 2 Hz Initially
Reduce Current to 0.4 rnA as Roots are Localized
Stimulation at less than 0.4 mA Other Response to Nerve Stimulation
Withdraw Needle until Stimulation See figure 19.3

Disappears at
> 0.4mA
Upper, Middle, or Lower Trunk Stimulation

272 B.C.H. Tsui
19.3.3 Modifications to Inappropriate

Responses
An algorithm of modifications to inappropriate responses to

nerve stimulation is shown in Fig. 19.4.
Common Responses to Nerve

Stimulation during lnterscalene Block
Anterior Scalene
Sternocleidomastoid Diaphragm Serratus Anterior Trapezius
(Direct Stimulation) (Phrenic n.) (Thoracodorsal n.) (Accessory n.)
Needle is anterior-medial Needle plane is anterior Needle plane is posterior Needle is posterior to
to plexus to plexus and plexus plexus
Reinsert and angle Reinsert and angle Reinsert in a more Reinsert and angle
slightly posteriorly slightly posteriorly anterior plane slightly anteriorly
Upper or Middle Trunks:

•Pectoralis
•Deltoid
•Biceps Brachii
Lower Trunks:
•Triceps
•Forearm
•Hand
Aspirate and Inject Local

Anesthetic
Fig. 19.4 Flowchart of modifications to inappropriate responses to nerve stimulation during interscalene block
19.4 Ultrasound-Guided Technique Table 19.2 summarizes particular imaging considerations in

pediatric populations. Patient positioning and anatomical
For a summary of ultrasound-guided interscalene block tech- landmarks are the same for ultrasound techniques as they are
niques, see Fig. 19.5. Major anatomical structures in the bra- for landmark and nerve stimulation techniques. If nerve
chial plexus as captured by MRI and VHVS images are stimulation is employed in conjunction with ultrasound
shown with the corresponding ultrasound image in Fig. 19.6. imaging, the previous section can be referred to for appropri-
The roots of the plexus are clearly visible in the ultra- ate responses and modifications.
sound image with corresponding cadaveric and MRI images.
Ultrasound Technique
Brachial Plexus Block
Cricoid Approach Traceback Approach
Position Probe in Axial Oblique Plane

Position Probe in Coronal Oblique Plane
Place Probe over Carotid Artery at C6

Place Probe in Lateral Upper Border of
Clavicle
Slide probe laterally toward the

interscalene groove
Scan Medially
Scan Distally and Proximally

Identify Subclavian Artery and Center
View
Identify Hypoechoic Nerve Roots

Identify Trunks and Divisions
(Honeycomb)
Traceback to lnterscalene Groove Where

Roots are Most Visible
Insert Needle Using OOP or IP

Technique
Consider Nerve Stimulation for Confirmation
Fig. 19.5 Flowchart of ultrasound-guided techniques in interscalene blocks

274 B.C.H. Tsui
Fig. 19.6 (a) VHVS and MRI images of anatomical structures in the brachial plexus. (b) Ultrasound image of the brachial plexus at the intersca-
lene groove
Table 19.2 Anatomical and imaging considerations for interscalene block

Pediatric patients Adult patients
• The proximity of vascular structures and the brachial plexus • There is a relatively greater distance between the vascular and neural
increases the risk of vascular puncture, especially of the vertebral structures
artery
• The interscalene groove is not always at the lateral border of the • The interscalene groove is usually located at the lateral border of the
sternocleidomastoid muscle; it can be situated medially or sternocleidomastoid muscle
laterally. Therefore, the “traceback” technique is recommended
for localization (see text)
• All roots of the brachial plexus can be visualized with • C5 to C7 roots can be easily identified using ultrasonography,
ultrasonography, especially in small children whereas C8 to T1 roots are rarely visible
• Roots of the brachial plexus are situated relatively superficially at • Roots of the brachial plexus are situated relatively deeply
the level of the interscalene block; in very young children, these
roots may be only a few millimeters beneath the skin
• A parascalene approach to the brachial plexus has been • The parascalene approach can also be used safely in adults.
described, which may reduce the risk of vascular injection and However, with ultrasound guidance, pertinent structures could be
sparing the adjacent nerves (i.e., phrenic), pleura, epidural/spinal avoided and a smaller volume of local anesthetic can be used. This
spaces, and spinal cord in pediatric patients when compared to may spare the phrenic nerve
the landmark technique of interscalene and supraclavicular block
19.4.1 Preparing the Site 19.4.2.2 Traceback Approach (Fig. 19.7)
Prepare the needle insertion site and skin surface with an • The probe is positioned in a coronal oblique plane at the
antiseptic solution. midpoint to medial aspect of the upper border of the
Prepare the ultrasound probe surface by applying a sterile clavicle.
adhesive dressing to it prior to needling as discussed in Chap. 4. • The pulsating subclavian artery becomes visible. (The
probe may have to be moved laterally while maintaining
contact with the clavicle.) Doppler ultrasound can greatly
19.4.2 Scanning Technique assist with identification of this structure.
• The probe is adjusted to place the subclavian artery in the
A high-frequency (10–5 MHz) hockey stick or linear trans- center of the image. The brachial plexus (trunks/divi-
ducer (13–6 MHz) is recommended to delineate the complex sions) can be seen in short axis as a tightly enclosed clus-
arrangements of the superficial structures in this region. ter (i.e., a honeycomb-like arrangement), superior and
lateral to the subclavian artery.
• The use of color Doppler ultrasound can be of great assis- • The image can be optimized by tilting the probe anteri-
tance to confirm the location of the carotid artery and orly or posteriorly.
internal jugular vein (for the cricoid cartilage approach) • The scanning angle is maintained as the plexus is traced
or the subclavian artery (for the traceback approach). in a cephalad direction along the interscalene groove to
the level of the cricoid cartilage (C6) to reveal a trans-
Two scanning techniques for interscalene brachial plexus verse view of the neural structures located deep to the
imaging are described below: sternocleidomastoid muscle between the anterior and
middle scalene muscles.
19.4.2.1 Cricoid Cartilage Approach
• With the probe in an axial oblique plane, begin the scan in

the interscalene groove at the level of the cricoid cartilage
(C6), and move the probe proximally and distally.
• Note the apparent change in size of the anterior scalene
muscle, from smaller proximally above C6 to larger dis-
tally. Also note the hypoechoic nerve roots as they emerge
from the intervertebral foramina.
• It may be difficult to visualize the neural structures in
young children using this approach due to the variability
of the location of the brachial plexus. It may be beneficial
to scan the neck inferiorly to the supraclavicular region to
identify the nerve structures, which appear as a cluster of
hypoechoic structures and resemble a “bunch of grapes”
(see traceback approach below).
276 B.C.H. Tsui
Fig. 19.7 Ultrasound traceback approach for interscalene block

19.4.3 Sonographic Appearance posterolaterally, the middle and posterior scalene mus-
cles appear as a single mass.
• At the level of the cricoid cartilage and deep to the sterno- – In a sagittal oblique section, brachial plexus roots
cleidomastoid muscle: and/or trunks are visualized most commonly as three
– The common carotid artery is the pulsatile structure (this number varies depending on the scan level) round
which appears circular while the internal jugular vein, or oval-shaped hypoechoic structures, sometimes with
superior and lateral to the artery, appears flatter in internal punctate echoes.
shape and is easily compressible; both are anechoic – Scanning proximally and distally to capture a view of
structures. the most distal structures (C8/T1 roots or lower trunk)
– The nerve/plexus structures are located posterolateral is useful since it will improve the chance of providing
to the vessels. blockade of the entire plexus.
• At the interscalene groove in the short-axis view – If the ultrasound field of view is large:
(Fig. 19.6): • The hypoechoic C6 transverse process may be seen
– If using a traceback approach, the cluster or “honey- with an acoustic shadow effect beyond the level of
comb” image will become multiple distinct round or the common carotid artery and directly medial to
oval hypoechoic structures as the probe is traced the middle scalene muscle (if visible at this high
cephalad. position in the neck).
– The sternocleidomastoid muscle is triangular and • The vertebral artery and vein may be seen deep to
superficial overlying the internal jugular vein and com- the plexus and anterior to the C6 transverse process.
mon carotid artery. The structures are clearly discern- Occasionally, the vertebral vessels may only be
ible; the anechoic vessels appear dark and the artery seen at the C7 level, as they are located inside the
appears pulsatile. transverse process at and above C6.
– Lateral to the vessels and posterior to the sternocleido-
mastoid muscle lies the anterior scalene muscle. More
278 B.C.H. Tsui
19.4.4 Needle Insertion – Angle the needle incrementally in a stepwise fashion

as follows:
• Begin with local anesthetic infiltration of the skin. • Start with an angle of 10° to localize the needle tip
• Use a 22G–25G, 30–35 mm short-beveled insulated block as a bright dot on the ultrasound display. Withdraw
needle. the needle to the point where the needle tip disap-
• In-plane (IP; long axis) approach (Fig. 19.8): pears from view
– With the probe aligned to view the plexus in short axis, • Reinsert the needle caudally in a “walk-down”
the needle is inserted from lateral to medial through manner until the required depth is achieved and the
the middle scalene muscle into the interscalene groove. needle tip is seen in proximity to the nerves.
• Out-of-plane (OOP; short axis) approach (Fig. 19.9): • If the initial puncture site is the same distance from
– Although the OOP approach is described here, the IP the probe as the nerve target is from the skin, the
approach is preferred to reduce the risk of complica- approximate final angle of insertion (as calculated
tions with this block technique. with simple trigonometry) will be 45°.
– The probe should be placed with the brachial plexus • For both IP and OOP approaches, scanning prior to nee-
centered in the middle of the ultrasound screen to dling will determine the angle, required trajectory dis-
ensure that needle insertion at the probe’s midline will tance, and vertical depth of needle penetration.
result in accurate needle placement. • A maximum depth should be less than 1–2 cm, even in
– With the clinician standing cephalad or caudad to the mature teenage adolescents. A report described the roots
probe, determine the needle puncture site at a location of the brachial plexus as 0.4 cm deep in a 7-year-old child
cranial to the probe (in short axis to the plexus) and at under ultrasound imaging [3].
a distance equal to the depth of the middle root.
Fig. 19.8 In-plane needling technique for ultrasound-guided intersca- Fig. 19.9 Out-of-plane needling technique for ultrasound-guided
lene block. Blue rectangle indicates ultrasound probe footprint interscalene block. Blue rectangle indicates ultrasound probe footprint
19.5 Local Anesthetic Application 19.6 Current Literature in Ultrasound-

Guided Approaches
• The authors typically use a 0.25 % bupivacaine solution at
a 0.2–0.3 mL/kg without exceeding the maximum dose of A recent recommendation by the ASRA Practice Advisory on
2 mg/kg. Neurologic Complications in Regional Anesthesia and Pain
• Different duration times of analgesic block were shown to Medicine stated that interscalene block should not be performed
be independent of the type and concentration of local anes- in anesthetized or deeply sedated patients [5]. However, as DeVera
thetic used (0.125–0.25 % bupivacaine or 0.1–0.2 % ropi- et al. [6] stated in their correspondence, there is minimal advan-
vacaine) in children who underwent shoulder arthroscopy. tage to performing interscalene blocks in children, who are unable
The duration of sensory block averaged 15 ± 4.5 h [4]. to provide feedback of paresthesia. It is safer to perform intersca-
• Epinephrine may be added at 1:200,000, although it is lene blocks (and other peripheral nerve blocks) in anesthetized or
recommended to also note changes in the ST segment or deeply sedated children since they will not be a moving target.
T wave on the ECG for reliable indication of intravascular DeVera et al. reported their record of safety during the first 5 years,
injection. in which 1,657 upper- and lower-extremity peripheral nerve
blocks were performed in children under general anesthesia as
young as 2 months of age. Furthemore, a recent report from the
19.5.1 Clinical Pearls: Interscalene Block Pediatric Regional Anesthesia Network (PRAN) concluded that
placement of interscalene blocks in children under general anes-
thesia is no less safe than placement in awake adults [7].
There has been a paucity of literature on ultrasound-guided
• Nerve stimulation is recommended to confirm the interscalene blocks. van Geffen et al. [3] reported an interest-
identity of the nerve structures prior to the injection ing case of a 7-year-old child with femur-fibula-ulna (FFU)
of local anesthetic. syndrome with hypoplasia of the humerus. She had undergone
• Performing a test dose with D5W is recommended a fistula resection of the proximal rudiment of the humerus at
prior to local anesthetic application to visual- 3 years of age. She was scheduled for resection of a painful
ize the spread and confirm nerve localization. exostosis on the 2-cm-long humerus rudiment. Interscalene
Flush the syringe and injection tubing adequately block under ultrasound guidance was performed using a high-
prior to this test, as residual air bubbles will cause frequency (10–5 MHz) linear probe. The roots of the brachial
sonographic artifacts that may reduce the image plexus were identified and 8 mL of 0.75 % ropivacaine was
quality for subsequent local anesthetic injection. used, which provided 20 h of analgesia postoperatively. This
Deposit local anesthetic in the midst of the neural case demonstrated the importance of ultrasound imaging for a
structures so that it spreads to surround the nerves peripheral nerve block, especially where nerve localization
circumferentially. would have been difficult due to the absence of the muscula-
• Local anesthetic distention in this compartment is ture for motor response from nerve stimulation.
seen as a hypoechoic fluid expansion resulting in Recently, Fredrickson et al. [8] reported a case of an 11-year-
separation of the brachial plexus from its sheath. old child with Erb’s palsy who underwent extensive derotation
• It is important to confirm a negative aspiration of humeral osteotomy for severe contracture deformity that was
blood and CSF prior to injection of local anesthetic limiting external shoulder rotation. An interscalene catheter was
since the brachial plexus at this location is in prox- inserted using ultrasound guidance as well as nerve stimulation
imity to the vessels and subarachnoid space. (the stimulation threshold was 0.46 mA) with an OOP approach
• In adults, it has been shown that a bolus injection of under general anesthesia. A bolus of 8 mL of 0.5 % ropivacaine
normal saline through an already-sited interscalene was injected via the catheter, followed postoperatively by ropi-
catheter is sufficient to reverse inadvertent phrenic vacaine 0.2 % at 2 mL/h with on-demand boluses of 4 mL every
nerve block and restore diaphragm function (see 30 min to a maximum of 30 mL per 4 h. The child reported
Sect. 8.4.2.1). excellent postoperative analgesia without any opioid require-
ment, and the catheter was removed on postoperative day 2.
Another recent case report described the use of ultrasound-
guided interscalene block for repair of a fractured lateral
humeral condyle [9]. The patient, a 17-month-old child, was
a poor candidate for general anesthesia due to an upper respi-
ratory infection and drug-induced hepatitis. Together with
20 μg fentanyl and 50 mg thiopental sodium, the interscalene
block – performed with a 25 mm, 24G needle and 1.5 mL
0.5 % ropivacaine – was sufficient for surgical anesthesia.
No additional sedative or analgesic was needed, and the
patient’s postoperative pain was well-controlled.
280 B.C.H. Tsui
19.7 Case Study
Interscalene Brachial Plexus Block (Contributed by

A. Sawardekar)
A 13-year-old male, 65 kg, presented with a 6-week
history of left upper arm pain. An MRI of the left arm
revealed a mass of the left proximal humerus. An open
biopsy and curettage of the mass was scheduled, and
the patient received an ultrasound-guided interscalene
brachial plexus block for the procedure. The block was
administered in plane with a 22G needle and a 13–6 MHz
linear high-frequency probe (see Fig. 19.10); 13 mL of
0.25 % bupivacaine was injected. Surgery lasted 120 min,
and block duration was 8 h. No additional analgesics
were required. The patient was discharged home after
2 h in the recovery room and was given instructions to
take oral hydrocodone once sensation had returned to the
operative extremity. Fig. 19.10 Ultrasound-guided interscalene block. MSM middle
scalene muscle, ASM anterior scalene muscle. See Case Study for
details
References tice? A report from the Pediatric Regional Anesthesia Network

(PRAN). Reg Anesth Pain Med 2014;39:502–5.
8. Fredrickson MJ. Ultrasound-assisted interscalene catheter place-
1. Marhofer P. Upper extremity peripheral blocks. Tech Reg Anesth
ment in a child. Anaesth Intensive Care. 2007;35:807–8.
Pain Manag. 2007;11:215–21.
9. Lee JH, Kim YR, Yu HK, et al. Ultrasound-guided interscalene
2. Dalens B, Vanneuville G, Tanguy A. A new parascalene approach to
brachial plexus block in a pediatric patient with acute hepatitis -a
the brachial plexus in children: comparison with the supraclavicular
case report-. Korean J Anesthesiol. 2012;62:568–70.
approach. Anesth Analg. 1987;66:1264–71.
3. van Geffen GJ, Tielens L, Gielen M. Ultrasound-guided intersca-
lene brachial plexus block in a child with femur fibula ulna
syndrome. Pediatr Anesth. 2006;16:330–2.
4. Ganesh A, Wells L, Ganley T, et al. Interscalene brachial plexus Suggested Reading
block for post-operative analgesia following shoulder arthroscopy
in children and adolescents. Acta Anaesthesiol Scand. 2008;52: Neal JM, Gerancher JC, Hebl JR, Ilfeld BM, McCartney CJ, Franco
162–3. CD, Hogan QH. Upper extremity regional anesthesia: essentials of
5. Neal JM, Bernards CM, Hadzic A, et al. ASRA practice advisory on our current understanding. Reg Anesth Pain Med. 2009;34:134–70.
neurologic complications in regional anesthesia and pain medicine. Suresh S, Polaner DM, Cote CJ. Regional Anesthesia. In: Cote CJ,
Reg Anesth Pain Med. 2008;33:404–15. Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
6. Devera HV, Furukawa KT, Scavone JA, et al. Interscalene blocks in 2013. p. 835–79.
anesthetized pediatric patients. Reg Anesth Pain Med. 2009; Tsui BC. Interscalene block. In: Tsui BC, editor. Atlas of ultrasound
34:603–4. and nerve stimulation-guided regional anesthesia. New York:
7. Taenzer A, Walker BJ, Bosenberg AT, et al. Interscalene brachial Springer; 2007. p. 63–74.
plexus blocks under general anesthesia in children: is this safe prac-
Supraclavicular Brachial Plexus Block
20
Ban C.H. Tsui
Contents
20.3.2 Current Application and Appropriate Responses 287
20.7 Case Study 294
References 295
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_20
284 B.C.H. Tsui
The supraclavicular approach to brachial plexus blockade The patient is positioned supine with the head turned approx-
targets the trunks and/or divisions of the brachial plexus imately 45° to the contralateral side after general anesthesia
where they lay cephaloposterior to the subclavian artery has been induced. The operative arm extends down the
above the mid-clavicle and first rib (see Figs. 10.1 and 10.2). patient’s side, parallel to the body. If necessary, the arm can
be pulled down gently towards the knee. A comfortable ergo-
Indications nomic position should be planned to improve block perfor-
• Hand, forearm, and elbow surgery mance. The block may be completed while positioned lateral
to the side to be blocked at the level of the upper arm or at the
head of the table looking towards the patient’s feet. Surface
landmarks include:
• Clavicle: the needle insertion site is approximately at the

midpoint of the clavicle.
• Subclavian artery pulsation: this serves as the principal
landmark; the plexus is located immediately posterolat-
eral to the subclavian artery.
Fig. 20.1 Patient positioning and surface landmarks for supraclavicu-

lar block of the brachial plexus
20 Supraclavicular Brachial Plexus Block 285
20.3 Nerve Stimulation Technique pneumothorax and vascular puncture during supraclavicu-
(Tables 14.1 and 20.1) lar blockade, the authors strongly recommend an
ultrasound-guided approach. See “Ultrasound-Guided
Nerve stimulation responses can be useful to minimize the Technique” below for a description of anatomical land-
risk of intraneural injection and to confirm proximity of mark identification, patient positioning, and needle inser-
the needle to the target trunk. Because of the high risk of tion technique.
Table 20.1 Responses and needle adjustments for use with nerve stimulation at the supraclavicular level
Correct response to nerve stimulation
The correct responses are similar to those observed when using the interscalene approach. At this location, the brachial plexus is starting to
divide from trunks into anterior and posterior divisions. Twitches of pectoralis, deltoid, biceps (upper trunk), triceps (upper/middle trunk),
forearm (upper/middle trunk), and hand (lower trunk) muscles with current intensity of 0.4 mA (0.1–0.3 ms) are acceptable. Distal responses
(hand or wrist flexion or extension) are best to confirm needle placement within the fascia
Muscle twitch from electrical stimulation
Diaphragm (phrenic nerve)
Explanation: unlikely as the needle plane is too anterior
Needle adjustment: withdraw needle to the subcutaneous tissue and reinsert in a 15° more posterior angle
Vascular puncture
Subclavian artery puncture: indicated with arterial blood withdrawal
Explanation: needle tip is deep to the plexus
Needle adjustment: withdraw completely for pressure treatment and reinsert carefully while observing the needle tip at all times using
in-plane approach
Bone contact
Needle stops at a depth of 3 cm (first rib)
Explanation: needle is inserted too deep and well beyond the plexus. However, this scenario is unlikely with ultrasound guidance, unless
tip of the needle is not visualized (needle not properly aligned with the ultrasound beam)
Needle adjustment: withdraw to subcutaneous tissue and reinsert
Pleural contact
Needle tip seen beyond the white line (first rib) and a pocket is observed to form beyond the bright line
Explanation: needle is inserted too deep, traversed the plexus and subclavian artery, and has entered the pleural space. However, it is
unlikely with US-guided technique
Needle adjustment: withdraw needle to subcutaneous tissue and reinsert if there is a strong clinical indication
286 B.C.H. Tsui
20.3.1 Needle Insertion weight, the depth of insertion increases 3 mm until the child
reaches 50 kg. After that, advance 1 mm for every 10 kg
Depth of insertion depends on age and weight of the patient. increase in weight. The maximum depth should not exceed
It is a nonlinear relationship, i.e., for a 10 kg child, the depth 35 mm (see Table 20.2).
of insertion is about 10 mm. For every 10 kg increase in
Table 20.2 Weight-dependent depth of needle insertion for supracla-

vicular brachial plexus block
Recommended depth
Patient weight (kg) of needle insertion (mm)
10 10
20 13
30 16
40 19
50 22
60 23
70 24
20.3.2 Current Application and Appropriate • As the trunks of the brachial plexus begin to divide at
Responses this block location, twitches of the pectoralis deltoid,
biceps (upper trunk), triceps (upper/middle trunk),
Figure 20.2 illustrates the procedure for employing nerve forearm (upper middle trunk), and hand (lower trunk)
stimulation techniques for supraclavicular nerve block. muscles may be elicited, depending on the needle
location.
• An initial current of 0.8 mA (2 Hz, 0.1–0.3 ms) is suffi- • Obtaining a distal response in the hand or wrist indicates
cient for stimulation of the plexus. After obtaining the optimal needle placement for a successful block.
appropriate motor response, the current is reduced to aim • In children, the spread of anesthetic solution may be
for a threshold current of 0.4 mA (0.1–0.2 ms). Motor greater than for adults since the fascia is less adherent to
response cessation at currents greater than 0.4 mA or less the nerve trunks. This increases the likelihood of a suc-
than or equal to 0.2 mA indicates that the needle may cessful block with any motor response.
either be too distant from the nerve or may have breached
the epineurium, respectively.
Fig. 20.2 Flowchart of the

procedure for employing nerve
stimulation techniques for Nerve stimulation
supraclavicular nerve block Brachial plexus block
Supraclavicular approach
Use 0.8 mA at 2 Hz initially
Reduce current to 0.4 mA as trunks are localized
Stimulation at less than 0.4 mA Other Response to nerve stimulation
Withdraw needle until stimulation See figure 20.2

Disappears at
< 0.4 mA
Upper, middle, or lower trunk stimulation
Aspirate and inject local anesthetic

288 B.C.H. Tsui
20.3.3 Modifications to Inappropriate 20.4 Ultrasound-Guided Technique

Responses
For a summary of ultrasound guidance techniques in supra-
An algorithm of modifications to inappropriate responses to clavicular blocks, see Fig. 20.4.
nerve stimulation is shown in Fig. 20.3. Major anatomical structures in the brachial plexus as cap-
tured by MRI and VHVS images are shown with the corre-
sponding ultrasound image in Fig. 20.5a.
Prepare the needle insertion site and skin surface with an
Common responses to nerve antiseptic solution. Prepare the ultrasound probe surface by
Stimulation during the
supraclavicular block applying a sterile adhesive dressing to it prior to needling, as
discussed in Chap. 4.
Diaphragm Ultrasound approach

(Phrenic n.) Brachial plexus block
supraclavicular approach
Needle plane is
anterior to plexus
Position probe in
coronal oblique
plane
Reinsert and angle
slightly posteriorly
Place probe in
lateral upper
Upper or middle trunks: Border of clavicle
• Pectoralis
• Deltoid
• Biceps brachii
Scan medially
Lower trunks: Rotate or tilt as
• Triceps necessary
• Forearm
• Hand
Identify subclavian
artery and center
Aspirate and Inject view
local anesthetic
“
Fig. 20.3 Flowchart of modifications to inappropriate responses to
Identify plexus
nerve stimulation during supraclavicular brachial plexus block
(“Cluster of
Grapes”)
Insert needle using

IP technique
Consider nerve stimulation

for confirmation
Aspirate and inject

local anesthetic
Fig. 20.4 Flowchart of ultrasound-guided techniques in supraclavicu-

lar blocks
Fig. 20.5 (a) VHVS and MRI images of anatomical structures in the brachial plexus at a supraclavicular section. (b) Ultrasound image of the
brachial plexus at the supraclavicular level
290 B.C.H. Tsui
20.4.1 Scanning Technique • Generally, the nerve structures are most visible when the
angle of incidence is 90° to the ultrasound beam.
The required depth of penetration is usually less than 1 cm • Failure to maintain either good skin-probe contact or a
for children and 1–2 cm for teenagers. 90° beam-to-nerve incidence angle can result in an anisot-
ropy effect and alter the appearance of the plexus (see
• The major challenge with ultrasound imaging in this Chap. 3).
region is the presence of a bony prominence (clavicle) • The probe is first placed in a coronal oblique plane at the
and curved soft tissue contour that can interfere with lateral end of the upper border of the clavicle. It is then
imaging of the brachial plexus in short-axis view. moved medially until an image of the subclavian artery
• Typically, a high-frequency hockey stick probe is used for appears on screen. The subclavian artery is characterized
small children. A curved array probe with a small foot- by its pulsatile property and can be confirmed with color
print is extremely useful in compact areas and for patients Doppler (Fig. 20.5b). Some dorsal and ventral rotation of
in whom the brachial plexus is at a greater depth (older the probe may be necessary to improve image clarity.
and/or obese children). The small footprint allows unre- This scanning technique is illustrated in Fig. 20.6.
strained needle movement around the probe, and the low • With the subclavian artery in the middle of the screen, the
to moderate frequency improves visualization of deeper plexus can be viewed superior and lateral to the artery
structures. above the first rib.
Fig. 20.6 Scanning technique for supraclavicular brachial plexus

block
20.4.2 Sonographic Appearance • The fascicular linings/sheaths of the brachial plexus trunks
are hyperechoic, outlining the “grape-like” structures.
Figure 20.5b illustrates the sonographic anatomy of a young • The first rib lies deep to the artery and appears as a hyper-
child. Table 20.3 summarizes imaging considerations in the echoic linear structure with a hypoechoic bony shadow
pediatric population. underneath.
• The lung pleura appear as a hyperechoic line accompa-
• The subclavian artery is anechoic, hypodense, pulsatile, nied by a hyperechoic shadow due to air artifacts
and round; its identity can be confirmed by color Doppler. underneath.
• The trunks/divisions of the brachial plexus can be found • Inferomedial to the smaller subclavian artery is the
superior and lateral to the subclavian artery in the ultra- anechoic, oval-to-round subclavian vein; the anterior sca-
sound image plane. They appear as a cluster of at least lene muscle lies between the artery and vein.
three (more as the probe is traced distally) hypoechoic
structures similar to a “bunch of grapes.”
Table 20.3 Anatomical and imaging considerations for supraclavicular block

Pediatric patients Adult patients
• The trunks of the brachial plexus can become divisions at this • The trunks of the brachial plexus can also become divisions at this
level, but the tight space makes neural ultrasound imaging and level; however, more available space allows for clear visualization
needling more challenging of neural structures using ultrasonography
• The brachial plexus at the level of the supraclavicular block is • The roots of the brachial plexus are situated more deeply, and there
situated superficially and in proximity to the pleura. This increases is a greater distance between the roots and the pleura
the risk of pleural puncture and pneumothorax
292 B.C.H. Tsui
20.4.3 Needle Insertion 20.5 Local Anesthetic Application
• Infiltrate the skin with local anesthetic.

• A 30 mm, 21G–23G insulated needle is suitable for this • Blockade at this level can be achieved with volumes of
block. local anesthetic as low as 0.15–0.2 mL/kg. Recommended
• We consider the out-of-plane technique dangerous for local anesthetics are 0.25 % bupivacaine, 0.5 % bupiva-
supraclavicular block and do not recommend this caine, 0.2 % ropivacaine, or 2 % lidocaine.
approach. • Ultrasound Considerations:
• Perform an in-plane (IP) needling technique using a small – Performing a test dose with D5W is recommended
footprint curved (Fig. 20.7) or hockey stick probe: prior to local anesthetic application to visualize the
– The needle is inserted immediately above the clavicle spread and confirm nerve localization.
in a lateral-to-medial direction and with a slightly – In our experience, it is best to deposit local anesthetic
cephalad angulation to avoid the lung. The authors find next to the nerve structures in the supraclavicular win-
that a medial-to-lateral direction is often limited by the dow immediately lateral to the subclavian artery on top
compact space. of the first rib. Injection in this location will often lift
– Visualization of the needle tip at all times using an IP the nerve structures superiorly and away from the first
approach can minimize the occurrence of pneumo- rib and subclavian artery.
thorax and vascular puncture. The IP approach with – The hypoechoic spread of local anesthetic appears to
lateral-to-medial needle insertion ensures needle-nerve surround the nerves on the ultrasound screen.
contact before the subclavian artery is approached, – If the spread of anesthetic seems inadequate for the
thereby reducing the risk of inadvertent vascular whole plexus, reposition the needle prior to further
puncture. injection.
– Directing the needle towards the thorax during this
approach increases the risk of pleural puncture.
Vigilant identification of the pleura is required through-
out the procedure in addition to constant visualization
and awareness of the needle tip.
Fig. 20.7 In-plane needling technique for supraclavicular block. Blue

rectangle indicates ultrasound probe footprint
20.6 Current Literature in Ultrasound- of general anesthesia for humeral osteotomy and pinning.
Guided Approaches This approach facilitated postoperative testing of the periph-
eral nerves prior to injection of local anesthetic (5 mL of
Ultrasound-guided supraclavicular block has been described 0.25 % bupivacaine) for postoperative analgesia.
primarily in the adult literature, although there have been A unique case of bilateral supraclavicular block com-
several reports published in the pediatric literature. Using a bined with caudal anesthesia was described by Vermeylen
technique similar to the one described for adults, De Jose et al. [4]. In this case, a 2-year-old boy required amputation
Maria and colleagues randomized 80 children to receive of all four extremities following pneumococcal sepsis. After
supraclavicular or infraclavicular brachial plexus blocks administering the caudal block, ultrasound-guided supracla-
[1]. Supraclavicular blocks used a needle (short beveled, vicular blocks were performed on each side using 2.5 mL
22G–25G, 35–50 mm) aligned IP to a high-frequency probe ropivacaine (5 mg/mL) per side. The ability to visualize
placed in the coronal oblique plane once the brachial plexus spread of the local anesthetic allowed the authors to use a
trunks/divisions (forming a cluster of hypoechoic nodules) minimal dose, avoiding toxicity. Postoperative pain relief
were visualized lateral to the subclavian artery (hypoechoic was excellent.
and pulsatile) and close to the underlying first rib (hyper- Yang et al. [5] described a series of four cases in which
echoic and curvilinear). The authors directed the needle from pediatric patients received supraclavicular brachial plexus
lateral to medial in order to approach the plexus lateral to blocks for upper extremity surgery. In all cases, the block
the artery and prevent direct contact of the plexus. A lin- was successful and provided adequate anesthesia and analge-
ear probe with a 35 mm footprint was used, although other sia. Two of the patients received perineural catheters to man-
smaller footprint linear or curvilinear probes may be appro- age postoperative pain; no adverse events involving the
priate for some cases due to the reduced contact area and catheters were reported.
array characteristics [2]. Visualization of the needle tip and its relation to the
In the report described above, De Jose Maria et al. [1] plexus should reduce associated complications and increase
compared the success rate, complications, and block perfor- significantly the use of supraclavicular block. Indeed, the
mance times of the blocks in children scheduled for upper rapid onset of this block offers the most reliable blockade of
limb surgery. Light general anesthesia was provided to all the brachial plexus for analgesia and anesthesia of the entire
patients. In addition to the above outcomes, the block dura- upper extremity, to the degree that it is referred to as a “spi-
tion and volumes of ropivacaine 0.5 % used were recorded nal for the upper extremity” at our facility.
for the supraclavicular approach. Both block approaches
were effective (with failure defined as any amount of supple-
mental analgesia required during surgery or within the first Clinical Pearls: Supraclavicular Block
4 h after the block), and neither was associated with compli- • If anesthesia of the lower trunk is needed for hand
cations. Patients requiring supplemental analgesia intraop- surgery, it is advisable to inject local anesthetic
eratively had block failure of the radial (one with immediately next to the inferior portion of the nerve
infraclavicular block) and ulnar (two from both groups) cluster, close to the first rib.
nerves. Two patients receiving infraclavicular block had • Some experts recommend deferring this block until
accidental puncture of their axillary artery. The supraclavic- the operator reaches reasonable competency in
ular block was faster to perform (9 versus 13 min; 95 % con- other ultrasound-guided nerve blocks. In practice,
fidence interval for this difference was 2–6 min and was we often find it easier to perform a low interscalene
statistically significant). The sensory and motor blocks using block instead of a true supraclavicular block, with a
the supraclavicular approach lasted 6.5 and 5 h, respectively. similar clinical result.
Approximately 6 mL of ropivacaine was used. • The risk of pneumothorax may be reduced by
Steinfeldt et al. [3] described a case where a supraclavicu- avoiding overinflation of the lung or by temporarily
lar brachial plexus AngiocathTM (BD Medical, Sandy, UT, reducing positive pressure ventilation if the patient
USA) was inserted under ultrasound guidance. This proce- is intubated.
dure was performed in a 7-year-old child prior to emergence
294 B.C.H. Tsui
20.7 Case Study
Supraclavicular Brachial Plexus Block (Provided by

S. Suresh)
A 5-year-old female patient, 20.4 kg, presented for closed
reduction percutaneous pinning of the left elbow. After
induction of general anesthesia, the patient received an
elbow X-ray and X-ray with fluoroscopy in the OR. An
ultrasound-guided supraclavicular nerve block was
administered with a 20G needle (see Fig. 20.8); 3.5 mL
0.25 % bupivacaine with epinephrine 1:200,000 was
given for postoperative analgesia. Block duration was
6–12 h, and surgery lasted for 2 h and 8 min. Pain report-
ing following surgery was 0/10 (FLACC scale) at PACU
admission and 0/10 (FLACC scale) at PACU discharge.
Fig. 20.8 Ultrasound-guided supraclavicular brachial plexus

block. BP brachial plexus, DSA dorsal scapular artery, ScA subcla-
vian artery (See Case Study for details)
References Suggested Reading

1. De Jose MB, Banus E, Navarro EM, et al. Ultrasound-guided supra- Karmakar MK, Kwok WH. Ultrasound-guided regional anesthesia. In:
clavicular vs infraclavicular brachial plexus blocks in children. Cote CJ, Lerman J, Todres ID, editors. A practice of anesthesia for
Pediatr Anesth. 2008;18:838–44. infants and children. 4th ed. Philadelphia: WB Saunders; 2009.
2. Tsui BC, Twomey C, Finucane BT. Visualization of the brachial p. 924.
plexus in the supraclavicular region using a curved ultrasound probe Neal JM, Gerancher JC, Hebl JR, Ilfeld BM, McCartney CJ, Franco
with a sterile transparent dressing. Reg Anesth Pain Med. 2006;31: CD, Hogan QH. Upper extremity regional anesthesia: essentials of
182–4. our current understanding. Reg Anesth Pain Med. 2009;34:
3. Steinfeldt J, Robison T, Przybylo HJ. Placement of an US-guided 134–70.
supraclavicular block postoperatively in children: can we make this Tsui BC. Supraclavicular block. In: Tsui BC, editor. Atlas of ultrasound
easy? Pediatr Anesth. 2010;20:780–1. and nerve stimulation-guided regional anesthesia. New York:
4. Vermeylen K, Berghmans J, Van de Velde M. Ultrasound as guid- Springer; 2007. p. 75–85.
ance for a combined bilateral supraclavicular and caudal block, in
order to reduce the total anaesthetic dose in a two year old child
after a pneumococcal sepsis. Acta Anaesthesiol Belg. 2011;62:
151–5.
5. Yang CW, Cho CK, Kwon HU, et al. Ultrasound-guided supracla-
vicular brachial plexus block in pediatric patients -a report of four
cases. Korean J Anesthesiol. 2010;59(Suppl):S90–4.
Part VI
Nerve Blocks Below the Clavicle
Infraclavicular Brachial Plexus Block
21
Ban C.H. Tsui
Contents
21.4.1 Preparing the Site 306
21.7 Case Study 309
References 310
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_21
300 B.C.H. Tsui
Infraclavicular nerve blocks target the cords of the brachial Preferably, the patient is positioned supine with a pillow
plexus where they surround the axillary artery (see Fig. under the shoulder. The arm is adducted and the elbow flexed
10.1). These blocks are suitable for upper arm, elbow, fore- at 90° with the hand resting on the abdomen. If the patient is
arm, and hand surgery. Blocks in awake or mildly sedated awake, the arm may rest at the patient’s side if this will avoid
children have been described, although the practice of under- discomfort. Surface landmarks include:
taking this block once the child is anesthetized is more
common. • Cephalad
– Clavicle
Indications • Medially
• Surgery of the upper arm including the proximal humerus, – Sternal notch and sternoclavicular joint
elbow, forearm, and hand. – Medial end of the clavicle
• Laterally
– Anterior aspect of the acromion: palpate the clavicle
and move laterally to the acromioclavicular joint. The
acromion can be differentiated from the humerus
through passive movement of the arm.
– Coracoid process: medial and inferior to the acromio-
clavicular joint, which can be palpated just medial to
the head of the humerus.
Fig. 21.1 Patient positioning and surface landmarks for infraclavicular

brachial plexus block
21 Infraclavicular Brachial Plexus Block 301
21.3 Nerve Stimulation Technique subcutaneous tissue and reinsert. See Table 21.1 for
(Table 14.1) responses and recommended needle adjustments when
using nerve stimulation for infraclavicular block.
21.3.1 Needle Insertion (Figs. 21.2 and 21.3) • Blood aspiration indicates axillary artery/vein puncture.
If this occurs, carefully reinsert the needle after complete
• Clean the skin with antiseptic solution, and drape the withdrawal.
patient to ensure sterility. • An initial current of 0.8 mA (frequency 2 Hz, pulse width
• Infiltrate the skin with local anesthetic (e.g., 0.5 mL of 0.1 msec) is sufficient for stimulation of the plexus. The
1 % lidocaine). current is then reduced to aim for a threshold current of
• The point of needle insertion depends on the age of the 0.4 mA while maintaining the appropriate motor response.
patient, but is approximately 0.5–1 cm inferior to the cor- • A distal motor response of hand or wrist flexion or exten-
acoid process. sion is ideal.
• Insert a 30–50 mm, 21–24G insulated needle in a vertical • Ultrasound guidance will help reduce the incidence of
direction while applying nerve stimulation. both bone contact and vessel puncture.
• If the needle encounters a bone (rib), the needle has been
placed too deep to the plexus. Withdraw the needle to the
Nerve stimulation
Brachial plexus block
Infraclavicular approach
Infraclavicular technique
Strongly recommend Use 0.8 mA at 2 Hz initially

Concurrent use of nerve
Stimulation and
Ultrasound guidance
Reduce current to 0.4 mA
as plexus is localized
Position: supine, arm

adducted, elbow flexed
90°, hand on abdomen Stimulation at less Other response to
than 0.4 mA nerve stimulation
Site: inferior and medial to

the coracoid process Withdraw needle See figure 21.3
until stimulation
disappears at
< 0.4 mA
Needle insertion: inserted
in vertical direction
Avoid angled insertion
Avoid placing too medially Distal Motor response of
hand, wrist flexion or
extension
Fig. 21.2 Flow chart of the procedures and needle insertion site for an
infraclavicular block of the brachial plexus
Aspirate and inject
local anesthetic
Fig. 21.3 Flowchart of the procedure for employing nerve stimulation

techniques for infraclavicular nerve block
302 B.C.H. Tsui
Table 21.1 Responses and recommended needle adjustments for use during nerve stimulation at the infraclavicular location
Correct response from nerve stimulation
Distal responses (hand or wrist flexion or extension) are best for surgery of the elbow and below
Muscle twitches from electrical stimulation
Pectoralis (adduction of arm)
Explanation: needle tip is too shallow
Needle adjustment: advance needle deeper
Deltoid (axillary nerve stimulation)
Explanation: needle tip is too inferior
Needle adjustment: withdraw needle to subcutaneous tissue and reinsert slightly more superiorly
Biceps (musculocutaneous nerve)
Explanation: needle tip is too superior
Needle adjustment: withdraw needle to subcutaneous tissue and reinsert slightly more inferiorly
Vascular puncture
Cephalic vein (seen as blood withdrawal when needle appears to be placed superficially)
Explanation: cephalic vein is superficial to the plexus and the subclavian artery and vein
Needle adjustment: withdraw needle and redirect carefully while observing the needle tip at all times using in-plane approach
Subclavian or axillary artery/vein puncture (seen as blood aspiration)a
Explanation: artery and vein are next to the plexus
Needle adjustment: withdraw needle completely for pressure treatment and reinsert carefully while observing the needle tip at all times
using in-plane approach; if the blood is venous, the needle tip is likely too caudal
Bone contact
Needle stops at rib
Explanation: needle is inserted too deep and has passed the plexus and subclavian artery. However, it is unlikely with ultrasound-guided
technique
Needle adjustment: withdraw needle to subcutaneous tissue and reinsert
Pleural – more risk with medial locations of needle insertion
Needle observed to pass beyond the white line (rib), with a pocket forming
Explanation: needle is inserted too deep, has passed the plexus and subclavian artery, and is entering into the pleural space. However, it
is unlikely with US-guided technique
Needle adjustment: withdraw to subcutaneous tissue and reinsert
a
Subclavian vessels when needle insertion is at a more medial location; axillary vessels when block is performed at a more lateral location
21.3.2 Modifications to Inappropriate

Responses
See Fig. 21.4.
Common responses to nerve

Stimulation during
infraclavicular block
Subscapularis Pectoralis Deltoid Biceps

(direct stimulation) (direct stimulation) (axillary n.) (musculocut. n.)
Needle is still
Needle is inferior to Needle is superior
Needle is too deep superficial to
plexus to plexus
plexus
Reinsert more Continue to Reinsert slightly Reinsert directed

superficially advance needle more superiorly more caudally
Distal responses:
• Hand or wrist flexion
or extension
Fig. 21.4 Flowchart of
modifications to inappropriate
responses to nerve stimulation Aspirate and inject
during infraclavicular brachial local anesthetic
plexus block
304 B.C.H. Tsui
21.4 Ultrasound-Guided Technique

(Fig. 21.5) Ultrasound technique
Infraclavicular approach
It is common to perform an infraclavicular brachial plexus
block with the patient’s elbow flexed and the hand resting on
the abdomen or with the arm resting at the patient’s side. Position probe in
However, it may be more advantageous to position the parasagittal plane
patient with the elbow flexed and the arm abducted and
externally rotated when completing the block under ultra-
sound guidance. This maneuver can render the cords taut and Place probe below
and medial to the
bring them to a more superficial location, thus accentuating coracoid process
their ultrasonographic appearance. Stretching the cords also
brings the nerves closer around the axillary artery, which
may facilitate local anesthetic spread around the nerves. Scan medially
The location of the needle puncture will be where the bra- and laterally
chial plexus cords, axillary vessels, and pleura are visualized
best. It is ideal to make small probe adjustments (i.e.,
Capture short axis
superior-inferior or medial-lateral) with the goal to have a view of nerves,
well-defined cross section of the axillary artery. Blocks axillary vessels
below the clavicle are associated with complications
(Table 21.2); therefore, knowledge of the anatomical details
of this region is crucial to perform this block correctly Identify pleura and
maintain view
(Fig. 21.6a) and to avoid adverse events. Similar to the nerve
stimulation technique, a lateral approach decreases the risk
of pleural puncture, although a more medial location will
Insert needle using
allow higher resolution of the structures (Fig. 21.6b). If using OOP or IP
a medial puncture site, ensure to maintain a view of the technique
pleura and needle tip on the ultrasound screen at all times.

For confirmation
Aspirate and inject

local anesthetic
Fig. 21.5 Flowchart of ultrasound-guided techniques for infraclavicu-

lar nerve block
Table 21.2 Complications of nerve blocks below the clavicle

1. Hematoma
Intravascular injection: arterial or venous
Avoid multiple needle insertions
Apply form pressure over the needle insertion site after needle
withdrawal
2. Pneumothorax
Needle too medial, near the cupola of the lung
Pay attention to the site and angle of needle insertion
If using ultrasound, keep the lungs in view to avoid trauma to the
pleura
3. Nerve injury
From intraneural injections
Use a nerve stimulator to confirm needle position. Withdraw
needle when there is nerve stimulation at <0.4 mA to avoid
intraneural injection
Avoid high pressure during administration of injectates. See Chap.
1 for compressed air injection technique
Fig. 21.6 (a) VHVS and MRI images of anatomical structures in the tion. (c) Ultrasound image of the brachial plexus at the infraclavicular
brachial plexus at an infraclavicular section. (b) Ultrasound image of level at a medial scanning location
the brachial plexus at the infraclavicular level at a lateral scanning loca-
306 B.C.H. Tsui
21.4.1 Preparing the Site • The coracoid process is the most cephalad structure and
appears hypoechoic with an associated hypoechoic bony
Prepare the needle insertion site and skin surface with an shadow.
antiseptic solution. A sterile adhesive dressing should be • The pectoralis major and minor muscles are separated by
applied to the ultrasound probe prior to needling. a hyperechoic lining, which is the perimysium.
• The pectoralis minor muscle is superficial to the axillary
neurovascular bundle. Within this bundle the large axil-
21.4.2 Scanning Technique (Fig. 21.5) lary vein lies medial and caudad to the artery and the
cords of the plexus surround the artery (lateral cord ceph-
A small footprint linear array transducer (7–13 MHz fre- alad, posterior cord deep, and medial cord caudad).
quency) will provide good visualization in young children. A • The lateral and posterior cords of the plexus are often
curved array transducer (7–4 MHz frequency) will provide a readily visualized as hyperechoic oval structures.
wider field of view and improved definition to allow better • The medial cord may not be readily identified because it
imaging of the neurovascular structures in older or larger lies between the axillary artery and vein and can some-
children when the plexus is found at a depth >4 cm. times be posterior or even slightly cephalad to the axillary
The required depth of penetration is usually within artery.
2–3 cm at a lateral location inferior to the coracoid process. • The pleura will appear as a hypoechoic cavity outlined by
This can be shallower or deeper depending on the size of the a sloping hyperechoic line and is often located in very
pectoralis muscle layers. close proximity to the neurovascular structures.
Below and slightly medial to the coracoid process, posi- • The deep aspect of the image may show an underlying rib
tion the probe in a parasagittal plane, and move the probe (2nd or 3rd).
medially and laterally to capture the best possible short axis
view of the nerve structures and axillary vessels. The artery In the parasagittal plane at a more medial location – the
is often the first identifiable structure. midpoint of the line between anterior acromion and jugular
When the neurovascular structures are poorly visualized, notch (Fig. 21.6c):
the probe can be directed medially towards the midpoint of
the clavicle. At this level, the cords can be found posterolat- • The cords of the plexus are seen as round hypoechoic
eral to the subclavian artery. It is important to identify the nodules, lying cephalad and lateral to the subclavian
pleural cavity and maintain it within view throughout the artery.
procedure especially with a more medial block approach. • The subclavian vein lies anteromedial, and the cephalic
As vascular puncture and pneumothorax are the most vein lies superficial to subclavian artery. The veins may
likely complications of this block, it is advisable to use color be hard to visualize or may appear irregularly shaped and
Doppler to identify the axillary artery and vein and the less hypoechoic than the artery.
cephalic vein, particularly if the neural structure is in doubt. • The pleural cavity is found inferior and posterior to the
hyperechoic first rib. The pleural cavity may appear
hyperechoic due to an air artifact.
21.4.3 Sonographic Appearance • Because the plexus and vessels are superficial and imme-
diately anterior to the pleura, it is important to maintain a
In the parasagittal plane at the lateral coracoid infraclavicu- good view of the pleura and needle tip throughout the
lar region (immediately medial and inferior to the coracoid procedure.
process), using a linear probe (Fig. 21.6b):
21.4.4 Needle Insertion posterior cord. Local anesthetic infiltration at this point
will often create a U-shaped spread around the axillary
• A 30–50 mm, 21G–24G insulated needle should be used artery. However, pulling the needle tip back and complet-
if performing nerve stimulation. Both in-plane (IP) and ing a second injection anterior to the axillary artery will
out-of-plane (OOP) approaches are appropriate for usually ensure a good distribution of local anesthetic sur-
ultrasound-guided infraclavicular block. If a more medial rounding all three cords.
block location is used, an IP technique is preferable. This • For an OOP approach (Fig. 21.8), insert the needle at the
will allow the needle tip to be tracked continually to help midpoint of the probe, angling it from medial to lateral.
avoid pleural puncture. Conversely, OOP needling has a The distance from the probe that the needle is inserted
reduced needle path length which may reduce the discom- will depend on the insertion angle of the needle and the
fort if the block is being performed on a conscious child. distance from the probe to the target structure. We recom-
• When using an IP approach (Fig. 21.7), introduce the mend using a 45° angle of insertion so that the insertion
block needle cephalad to the probe and advance it cau- point of the needle will be the same distance from the
dally at approximately a 45–60° angle to the skin. At the probe as the depth of the plexus, forming a right-angled
lateral block location, after passing through the pectoral triangle with the plexus, probe, and needle insertion point.
muscles, the needle will first contact the lateral cord. It is Additionally, the use of an incremental needling tech-
best to advance the needle deeper so that it is posterior to nique, such as the “walk down” approach, will enable
the axillary artery and therefore able to contact the careful tracking of the needle tip position.
Fig. 21.7 In-plane needling technique for ultrasound-guided infracla-

vicular brachial plexus block. Blue rectangle indicates probe footprint Fig. 21.8 Out-of-plane needling technique for ultrasound-guided
infraclavicular brachial plexus block. Blue rectangle indicates probe
footprint
308 B.C.H. Tsui
21.5 Local Anesthetic Application in any of the patients. There was no difference in the VAS
30 min after the block or during surgery.
We recommend using nerve stimulation for confirmation De Jose Maria et al. [3] recently compared the efficacy
prior to local anesthetic injection. Injecting an initial test of ultrasound-guided infraclavicular and supraclavicular
dose of D5W is recommended prior to local anesthetic appli- blocks. For the infraclavicular block, these authors placed
cation to visualize the spread and confirm nerve localization. the probe below the clavicle, either parallel to the clavicle
For an infraclavicular block, 0.5 mL/kg of 0.2–0.5 % rop- or using a slightly parasagittal plane, depending on the vis-
ivacaine or 0.25–0.5 % bupivacaine can be used, although in ibility of the plexus. A medium frequency probe (thus
very small children, the concentration may need to be allowing greater visualization of deeper structures) was
adjusted to obtain an adequate volume to achieve the block used in some of the older children in order to improve the
(minimum of 5 mL). visibility of the pleura and vessels. In contrast to Marhofer
A hypoechoic fluid collection is often observed, accentu- et al. [1], the needle was placed immediately cephalad to
ating the imaging of adjacent nerve structures. the probe and the probe was held in a transverse orienta-
Local anesthetic deposited posterior to the axillary artery tion, therefore effectively using an OOP approach. Both
with cephalad and caudad spreading seems to result in con- groups used a fairly steep angle of needle insertion. The
sistent surgical anesthesia in the hand when performing the needle was redirected when necessary to ensure the cords
block in the lateral position. If local anesthetic does not sur- were adequately surrounded by local anesthetic solution,
round all the cords, stop halfway through and reposition the and the spread of local anesthetic was monitored during
needle prior to applying the remaining injectate. If a circum- performance of the block.
ferential spread is not achieved despite repositioning, con- It is important to note that there is a great deal of indi-
sider pulling the needle tip back and completing a second vidual anatomical variation in the location of the cords
injection anterior to the axillary artery as described above. around the artery. At this location, the nerve structures appear
hyperechoic, rather than hypoechoic as seen in a more ceph-
alad position, probably due to an increase in the number of
21.6 Current Literature in Ultrasound- fascicles and amount of hyperechoic connective tissue. The
Guided Approaches cervical pleura is situated closest to the brachial plexus cords
at medial locations within the infraclavicular fossa; thus,
Marhofer et al. [1] described their use of ultrasound-guided when performing an infraclavicular block on children, a more
lateral infraclavicular block for surgical anesthesia in chil- lateral puncture site is recommended. Ultrasound imaging
dren. The patients were placed supine with their arm offers visualization of the related anatomy and the approach-
adducted, elbow flexed, and forearm placed on their abdo- ing needle. This is particularly useful in children to help avoid
men. A linear probe was placed transversely below the clav- multiple punctures and because some anatomical landmarks
icle to capture an image of the brachial plexus. The authors (i.e., the coracoid process) are underdeveloped, making land-
reported successful visualization of the plexus in all 40 mark-based techniques difficult in children. Similar to the
patients studied. The needle was inserted OOP, 1 cm from supraclavicular approach, an IP needle alignment may pro-
the inferior aspect of the probe, and directed slightly crani- vide superior outcomes with this block, since viewing the
ally towards the lateral border of the plexus. Local anesthetic needle tip and shaft at all times will help to ensure that the
spread was viewed surrounding the plexus. Compared to the vessels and cervical pleura are not punctured.
conventional nerve stimulation technique, the authors found The advantages of continuous infusions using an infracla-
ultrasound to be superior in terms of (1) visual analogue vicular approach over an axillary or supraclavicular approach
scores (VAS) during block performance, (2) sensory onset in children and adults have been described in the literature.
times (mean onset times were 9 versus 15 min), (3) longer Advantages cited include the ease of placing, stabilizing, and
duration of sensory block (384 versus 310 min), and (4) bet- securing a catheter that passes through major and minor pec-
ter sensory and motor block scores 10 min after block inser- toralis muscles [4, 5].
tion in patients that were assessed. Ultrasound guidance also Loland et al. [6] reported the successful use of brachial
improves success rates for infraclavicular block in pediatric plexus perineural infusion when caring for pediatric patients
patients, as demonstrated in a recent clinical trial comparing following near-amputation of the dominant hand. An
two groups of patients receiving either an ultrasound-guided ultrasound-guided infraclavicular brachial plexus catheter
block or a nerve stimulation-guided block [2]. was installed in the recovery room after reconstructive sur-
The faster onset and longer duration of the blocks has gery, and a continuous infusion of 0.2 % ropivacaine was
been attributed to ultrasound aiding in more accurate deposi- maintained for 24 days. The authors concluded that in pedi-
tion of the local anesthetic to the brachial plexus. At 30 min, atric upper extremity limb salvage, perineural local anes-
all blocks, whether placed by ultrasound or nerve stimula- thetic infusion prolonged the benefits of brachial plexus
tion, were successful, and general anesthesia was not required blockade further into the postoperative period.
21.7 Case Study

Clinical Pearls: Infraclavicular Block
• Place the linear probe medial to the coracoid pro-
Infraclavicular Block (Provided by S. Suresh)
cess and inferior to the clavicle.
An 8-year-old female patient, 50.3 kg, with no medical
• After recognizing the axillary artery, look for the
or relevant family history presented for open reduction
cords of the brachial plexus surrounding the artery.
and fixation of the right small finger following proxi-
• Place the needle using an IP approach, with the tip
mal phalanx and distal intraarticular fracture based on
of the needle aimed towards the posterior cord.
X-ray of the finger 4 days prior to surgery. The patient
• In small children, it can be difficult to undertake an
received an ultrasound-guided infraclavicular block,
IP approach from above the ultrasound probe as
performed with a 22G needle and 10 mL 0.25 % bupi-
there is often not enough space between the clavicle
vacaine with 1:200,000 epinephrine (see Fig. 21.9).
and the probe. In this case, either an OOP approach
Block duration was 6–12 h; duration of surgery was
or the approach described by Marhofer et al. [1],
1 h and 42 min. Pain reporting in recovery was 5/10
with the needle insertion caudad to the ultrasound
(FACES) 10 min following surgery and 0/10 (FACES)
sound probe, is appropriate.
1 h following surgery. Postoperative analgesia con-
• Avoid using a medially positioned ultrasound probe
sisted of ketorolac injection (24 mg) and morphine
and needling technique due to proximity to the
(Duramorph) injection 1 mg with a total of three doses
pleura.
given.
Fig. 21.9 Ultrasound-guided infraclavicular brachial plexus

block. Pec major pectoralis major, pec minor pectoralis minor,
LC lateral cord of brachial plexus, MC medial cord, PC poste-
rior cord, ScA subclavian artery. See Case Study for details
310 B.C.H. Tsui

1. Marhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance Karmakar MK, Kwok WH. Ultrasound-guided regional anesthesia. In:
for infraclavicular brachial plexus anesthesia in children. Cote CJ, Lerman J, Todres ID, editors. A practice of anesthesia for
Anaesthesia. 2004;59:642–6. infants and children. 4th ed. Philadelphia: WB Saunders; 2009.
2. Ponde VC, Diwan S. Does ultrasound guidance improve the success p. 924–5.
rate of infraclavicular brachial plexus block when compared with Neal J, Gerancher JC, Hebl J, Ilfeld B, McCartney C, Franco C, Hogan
nerve stimulation in children with radial club hands? Anesth Analg. Q. Upper extremity regional anesthesia: essentials of our current
2009;108:1967–70. understanding. Reg Anesth Pain Med. 2009;34:134–70.
3. De Jose MB, Banus E, Navarro EM, et al. Ultrasound-guided supra- Tsui BC. Infraclavicular block. In: Tsui BC, editor. Atlas of ultrasound
clavicular vs infraclavicular brachial plexus blocks in children. and nerve stimulation-guided regional anesthesia. New York:
Pediatr Anesth. 2008;18:838–44. Springer; 2007. p. 87–98.
4. Dadure C, Raux O, Troncin R, et al. Continuous infraclavicular bra-
chial plexus block for acute pain management in children. Anesth
Analg. 2003;97:691–3.
5. Ponde VC. Continuous infraclavicular brachial plexus block: a
modified technique to better secure catheter position in infants and
children. Anesth Analg. 2008;106:94–6, table.
6. Loland VJ, Ilfeld BM, Abrams RA, Mariano ER. Ultrasound-
guided perineural catheter and local anesthetic infusion in the
perioperative management of pediatric limb salvage: a case report.
Axillary Block of the Brachial Plexus
22
Ban C.H. Tsui
Contents
22.1 Indications ....................................................................................................................................... 312
22.2 Surface Anatomy............................................................................................................................. 312
22.3 Nerve Stimulation Technique ......................................................................................................... 312
22.3.1 Modifications to Inappropriate Responses .......................................................................... 314
22.4 Ultrasound-Guided Technique....................................................................................................... 315
22.4.1 Preparing the Site ................................................................................................................ 315
22.4.2 Scanning Technique ............................................................................................................ 317
22.4.3 Sonographic Appearance .................................................................................................... 317
22.4.4 Needle Insertion .................................................................................................................. 318
22.5 Local Anesthetic Application ......................................................................................................... 319
22.6 Current Literature in Ultrasound-Guided Approaches .............................................................. 319
22.7 Case Study ....................................................................................................................................... 320
References ................................................................................................................................................... 320
Suggested Reading ..................................................................................................................................... 320
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_22
312 B.C.H. Tsui
22.1 Indications 22.3 Nerve Stimulation Technique

(Figs. 22.2 and 22.3; Tables 14.1
The ulnar, median, radial, and musculocutaneous nerves are and 22.1)
the primary targets of an axillary block. The ulnar, median,
and radial nerves surround and follow the axillary artery • A 30–50 mm, 22–24G insulated needle is typically intro-
from the apex of the axilla along the humerus. The musculo- duced at the upper border of the axillary artery in a direc-
cutaneous nerve often leaves the plexus via the lateral cord, tion towards the midpoint of the clavicle using
proximal to the axillary apex, and needs to be blocked approximately a 45° angle to the skin and directing the
separately. needle medially, dorsally, and caudally. A perpendicular
needle direction may also be used, with the needle
Indications directed towards the upper border of the artery and the
• Surgery of the elbow, forearm, wrist, or hand humerus.
• A “pop,” indicating loss of resistance, is felt as the needle
penetrates the axillary sheath surrounding the plexus.
22.2 Surface Anatomy (Fig. 22.1) • Applying an initial current of 0.8–1.0 mA (2 Hz, 0.1 ms)
is sufficient for stimulation of the plexus. The current is
The patient is positioned supine with the arm abducted 70–80° reduced to aim for a threshold current of 0.4 mA (0.1 ms)
and externally rotated, the elbow flexed at 90°, and the dorsum while obtaining the appropriate motor response.
of the hand facing the table. Surface landmarks include: • A distal motor response in the hand is ideal, although
forearm twitches may be used.
• Anterior axillary fold • Bone contact indicates that the needle has advanced to the
– Formed by the pectoralis major muscle humerus and that the needle should be withdrawn.
– Palpating the axillary artery just deep to the insertion of • Arterial blood in the tubing indicates axillary artery punc-
this muscle will identify the optimal site of needle inser- ture, and the needle should be withdrawn slightly; venous
tion if attempting to block the musculocutaneous nerve. blood (axillary vein) necessitates withdrawing and redi-
• Posterior axillary fold recting the needle more laterally or superiorly.
– Formed by the latissimus dorsi and teres major muscles. • For the separate block of the musculocutaneous nerve,
– The lower part of the axillary artery can be palpated elbow flexion is the desired motor response.
anterior to this fold on the medial side of the arm; trace • The musculocutaneous nerve is usually found between
this pulse to a proximal location for an optimal block the biceps and coracobrachialis muscles (Fig. 22.6a). In
for targeting all the nerves. order to block the nerve, a separate needle puncture within
• Bicipital sulcus or groove the belly of the coracobrachialis muscle is performed.
– A groove between the tendons of the biceps and triceps After grasping the belly of the muscle, use the same nee-
brachii muscles dle insertion site as for the axillary block, and direct the
needle towards the interior of the muscle.
• If a tourniquet is required for the surgery, the intercosto-
brachial nerve should be anesthetized using a small ring
of local anesthetic at the upper aspect of the arm.
Alternatively, a small amount of local anesthetic solution
can be injected during the withdrawal of the needle.
Fig. 22.1 Patient positioning and surface landmarks for axillary block
of the brachial plexus
22 Axillary Block of the Brachial Plexus 313
Axillary block Nerve stimulation

Axillary nerve block
Strongly recommend
Concurrent use of nerve
Stimulation and
ultrasound guidance Use 0.8 mA at 2 Hz initially
Position: supine, arm

abducted and externally
rotated with elbow
as plexus is localized
flexion and forearm
supination
Site: upper border of Stimulation at less Other response to

axillary artery than 0.4 mA Nerve stimulation
Needle insertion: towards

Midpoint of clavicle, 45° to Withdraw needle
skin directed medially, See figure 22.3
until stimulation
dorsally and caudally disappears at
< 0.4 mA
Blood in tubing Bony contact

(humerus)
Transarterial
approach Needle too deep Distal motor response of
hand is ideal
Wrist flexion or extension
Advance Through is acceptable
artery Reinsert needle
Angled inferiorly
or slightly
superficially
Aspirate and inject
2/3 of the local Aspirate and inject
anesthetic local anesthetic
Withdraw until Fig. 22.3 Flowchart of the procedure for employing nerve stimulation
anterior to artery techniques for axillary brachial plexus block
Aspirate and inject

1/3 of the local
anesthetic
Maintain pressure
for hemostasis
Fig. 22.2 Flowchart of procedures and needle insertion site for axil-
lary brachial plexus block
314 B.C.H. Tsui
Table 22.1 Responses and recommended needle adjustments for 22.3.1 Modifications to Inappropriate
nerve stimulation-guided axillary brachial plexus block Responses
Hand twitch with approximately 0.4 mA (median, radial or ulnar See Fig. 22.4
nerve)
For a higher success rate, multiple injections at each nerve are
recommended:
Median nerve (C5–C8, T1; flexion of middle, index fingers, Common responses to nerve
and thumb and pronation and flexion of wrist), ulnar nerve Stimulation during axillary
(C7–8,T1; flexion of ring and little fingers and ulnar deviation block
of wrist), radial nerve (C5–8, T1; extension of fingers and
wrist)
Upper arm (local twitches from biceps or triceps) Biceps Triceps
(local stimulation) (local stimulation)
Explanation: needle angle is too superior or inferior
Needle adjustment: withdraw completely and redirect
accordingly
Vascular puncture
Needle is superior Needle is inferior to
Axillary artery with arterial blood in tubing to desired plane desired plane
Explanation: needle in lumen of axillary artery
Needle adjustment: inject 2/3 of the local anesthetic posterior
to the artery and 1/3 anterior to the artery
Axillary venous blood in tubing
Reinsert inferiorly Reinsert superiorly
Explanation: needle in lumen of axillary vein
Needle adjustment: redirect slightly more laterally or superiorly
Paresthesia without motor response
Needle has contacted brachial plexus
Explanation: stimulator, needle, or electrode malfunctioning Inject at each nerve for
Needle adjustment: none if typical distribution of paresthesia higher success rate
(inject); reinsert if atypical
Bone contact Median nerve (CS-8, T1)
Humerus (2–3 cm deep) •Flexion- middle, index
Explanation: needle has advanced beyond plexus, too deep fingers, thumb and wrist
Needle adjustment: withdraw to subcutaneous tissue and • Pronation-wrist
reinsert with an angle 20–30° more superior or inferior Ulnar nerve (C7 -8, T1)
•Flexion- ring, little
fingers
•Ulnar deviation -wrist
Radial nerve (CS-8, T1)
•Extension- fingers,
wrist
Aspirate and inject

local anesthetic

nerve stimulation during axillary brachial plexus block

(Fig. 22.5)
Ultrasound technique
Axillary nerve block
The terminal nerves of the brachial plexus at the axillary
level are shown in the MRI image and ultrasound image
(Fig. 22.6).
Position probe
Perpendicular to
22.4.1 Preparing the Site anterior axillary
fold
• Prepare the needle insertion site and skin surface with an
antiseptic solution.
• Prepare the ultrasound probe surface by applying a sterile Place probe at the
adhesive dressing to it prior to needling. bicipital sulcus at
the axillary pulse
Capture short axis

view of neuro-
vascular bundles
May scan distally

and traceback to
Identify each nerve
(See text)
Insert needle using

OOP or IP
technique

for confirmation
Aspirate and inject

local anesthetic
Fig. 22.5 Flowchart of ultrasound-guided techniques in axillary bra-

chial plexus block
316 B.C.H. Tsui
Fig. 22.6 (a) VHVS and MRI images of anatomical structures in the brachial plexus at the axilla. (b) Ultrasound image of the brachial plexus at
the axilla
22.4.2 Scanning Technique 22.4.3 Sonographic Appearance
• The patient is positioned with the arm abducted at 80–90°, • In a transverse cross section, using a high-frequency,
externally rotated and flexed at the elbow. small footprint (“hockey stick”) probe (Fig. 22.6b), cora-
• High-frequency (10–15 MHz) linear probes are generally cobrachialis muscles are seen on the right superior aspect.
recommended for imaging as the nerves are found super- The deeper teres major muscle is seen inferior to the neu-
ficially (1–2 cm) below the skin. rovascular bundle.
• Small footprint probes are most useful for young or small • The anechoic and circular axillary artery lies in the mid-
children. dle and is adjacent to both the biceps and coracobrachialis
• The probe is positioned in a transverse plane perpendicu- muscles.
lar to the axis of the humerus at the level of the bicipital • The compressible anechoic axillary vein (two may be
sulcus and over the location of the palpable axillary artery. present) lies superficial (although there are many vari-
This should offer a transverse or short-axis view of the ants) between the median and ulnar nerves.
neurovascular bundle (Fig. 22.6b). • The axillary artery runs deep to the vein and is surrounded
• An initial scan should identify the axillary artery and by the nerves.
vein. Subsequent adjustments should be made to view all • The nerves appear round to oval in short axis with a
the terminal nerves. honeycomb-like appearance of hypoechoic neutral struc-
• Distal scanning along the course of each nerve is sug- tures surrounded by hyperechoic connective tissue (epi-
gested to accurately identify each terminal nerve: neurium) rims.
– The radial nerve starts its course posterior to the axil- • The median nerve is often located superior to the artery,
lary artery and travels deeper to the posterior aspect of lying between the artery and biceps brachii muscle.
the humerus towards the radial groove of the humerus • The ulnar nerve is usually located inferior and superficial
(adjacent to the deltoid tuberosity). to the artery.
– The median nerve lies superior (lateral in the image) to • The radial nerve lies deep/posterior to the artery at the
the axillary artery in the axilla. The nerve, while mov- midline.
ing to the medial aspect, follows closely the axillary/ • Clockwise around the axillary artery, the nerves are
brachial artery towards the cubital fossa. arranged median, ulnar, and radial, but there are many
– The ulnar nerve lies medial and inferior (superficial variations.
and medial in the image) to the axillary artery in the • The musculocutaneous nerve is commonly located in the
axilla and travels medially in the arm to reach the ulnar hyperechoic plane between the biceps and coracobrachia-
nerve sulcus behind the medial epicondyle of the lis muscles (see above) and varies significantly in its
humerus. appearance: proximally, it may appear round-oval, and
• Color Doppler should be used to confirm the location of distally, it may be triangular. Occasionally, it may also
the artery and is able to distinguish the artery from small appear flat.
nerves that appear to be pulsating on ultrasound.
• The most proximal location at the apex of the axilla may
be the best for viewing all the terminal branches of the
brachial plexus.
318 B.C.H. Tsui
22.4.4 Needle Insertion direction (Fig. 22.8). The block needle is initially
directed posteriorly and deep to the median nerve and
While a single-injection technique has been shown to be suc- axillary artery to locate the radial nerve. We recom-
cessful in children (perhaps due to minimal septae within the mend the initial injection of local anesthetic at this
sheath), the use of ultrasound may improve success if injections location to minimize distortion of the image from the
are performed after the needle is directed towards each nerve. spread of hypoechoic local anesthetic solution. Next,
The technique used will depend on the state of the patient (level retract the needle and inject local anesthetic around the
of sedation and comfort) and visibility of the nerves. median nerve, followed by injection around the ulnar
nerve which is most superficial. It is important to note
• Use a 30–50 mm, 22–24G insulated needle if using nerve that the relative location of the nerves can be variable.
stimulation. • For intercostobrachial and medial cutaneous nerve blocks,
• Both in-plane (IP) and out-of-plane (OOP) needle subcutaneous injections should be performed on the
approaches can be used for axillary block. medial surface of the upper arm all the way from the
• An OOP approach is similar to the traditional blind proce- biceps brachii to the triceps brachii muscles.
dure with the needle distal and perpendicular to the probe • For musculocutaneous nerve blocks, often the best
placed in transverse axis to the nerves (Fig. 22.7). Place results will be from infraclavicular blockade; however,
the needle 1 cm from the probe at a 30–45° angle from the the nerve may also be blocked in a separate injection
skin and align the needle insertion site with the neurovas- during the axillary approach, either above the artery
cular bundle target. into the body of the coracobrachialis (with elbow flex-
• The IP approach involves inserting the needle at an ion as nerve stimulation response) or at a mid-humeral
acute angle (20–30°) to the skin in a superior-to-inferior location.
Fig. 22.7 Out-of-plane needling technique for ultrasound-guided axil- Fig. 22.8 In-plane needling technique for ultrasound-guided axillary
lary brachial plexus block. Blue rectangle indicates probe footprint brachial plexus block. Blue rectangle indicates probe footprint
22.5 Local Anesthetic Application nerves, in that order, with 3 mL mepivacaine 1 % and 2 mL
bupivacaine 0.18 % using a 24G SonoPlex NanoLine needle.
• Tracing the nerves distally or proximally along their General anesthesia was not given, and pain control was
known path may be adequate in some cases to identify the effective during and after surgery.
individual nerve branch (see “Scanning”). Nevertheless, it Boschin et al. [3] performed bilateral axillary brachial
is recommended to identify each nerve separately through plexus block in a 3-year-old who presented for surgery to
the use of electrical stimulation to improve block repair pseudosyndactyly of all fingers. Both hands were
performance. repaired during the same surgery, and the axillary blocks
• Performing a test dose with D5W is recommended prior were administered before each side was operated on. Blocks
to local anesthetic application to visualize the spread and were performed under ultrasound guidance; a 24G needle
confirm nerve localization. was inserted using an in-plane approach, and 7.5 mL ropiva-
• The dose of local anesthetic is 0.2–0.3 mL/kg 0.25–0.5 % caine 0.25 % was injected in each side. There were no issues
bupivacaine, ropivacaine, or levobupivacaine. For the with pain control following surgery.
musculocutaneous nerve, inject 0.5–1 mL of local anes- A recent study by Elnour et al. [4] compared ultrasound-
thetic solution deep to the fascia. and nerve stimulation-guided axillary block in patients
• A proper injection is indicated by fluid spread completely undergoing forearm and hand surgery. They demonstrated
around the nerve structure and nerve movement away higher (but not significantly) block success, shorter block
from the needle tip. Improper injection (e.g., injection performance time, and increased block duration in the ultra-
outside the sheath) is indicated by a partial asymmetrical sound group.
fluid expansion not immediately adjacent to the nerve Three expert reviews have been recently published which
structure. describe axillary block as performed by the respective authors
• Nerve visualization often becomes more difficult after [5–7]. This block should be performed with a similar tech-
local anesthetic injection. nique to that used in adults, using IP needle alignment with a
high-frequency probe placed transversely to the humerus and
using multiple injections to surround all the terminal nerves
22.6 Current Literature in Ultrasound- of the plexus. Multiple punctures may be necessary to anes-
Guided Approaches thetize all the relevant nerves for many surgical procedures
(i.e., brachial cutaneous, medial antebrachial, and possibly
In adults, while multiple-injection techniques seem to be musculocutaneous nerves will require separate blockade).
superior to those using single or double injections, the suc-
cess rate of axillary block using single-injection technique in
children seems to be similar to that of the multiple-injection
technique. Nevertheless, rates of success are still moderate at Clinical Pearls: Axillary Block
70–80 % [1], and to ensure adequate circumferential spread • Place a hockey stick probe or a linear small foot-
of local anesthetic around each of the individual nerves, mul- print probe in the axilla as proximal as possible.
tiple injections and needle redirections are commonly • The needle is directed from superior to inferior
required. Various strategies have been used to improve suc- using an in-plane approach.
cess rates (e.g., pressure applied distally and/or transarterial • The structures are superficial and can usually be
approaches to more effectively block the posterior cord), easily identified. The radial nerve is occasionally
although they appear to have limited benefits in children. challenging to locate.
Two case reports describe the use of axillary block for • Color Doppler can be used to recognize the vascu-
anesthesia for pseudosyndactyly repair in recessive dystro- lar structures.
phic epidermolysis bullosa patients. Englbrecht et al. [2] • Local anesthetic should be injected to surround
administered an ultrasound-guided axillary block by target- each of the terminal nerves.
ing each of the ulnar, median, radial, and musculocutaneous
320 B.C.H. Tsui
22.7 Case Study References

1. Carre P, Joly A, Cluzel FB, et al. Axillary block in children: single
or multiple injection? Pediatr Anesth. 2000;10:35–9.
Axillary Block (Provided by S. Suresh) 2. Englbrecht JS, Langer M, Hahnenkamp K, Ellger B. Ultrasound-
A female infant with Apert syndrome, 15 months of guided axillary plexus block in a child with dystrophic epidermoly-
age and weighing 11.9 kg, was presented for right-hand sis bullosa. Anaesth Intensive Care. 2010;38:1101–5.
3. Boschin M, Ellger B, van den Heuvel I, et al. Bilateral ultrasound-
thumb-index and middle-ring complex syndactyly guided axillary plexus anesthesia in a child with dystrophic epider-
reconstruction with a full-thickness skin graft from the molysis bullosa. Pediatr Anesth. 2012;22:504–6.
right antecubital fossa, as well as endoscopic release of 4. Elnour HA, Hana MG, Rizk SN, Soaaida S. Ultrasound guided axil-
bilateral coronal sutures, bilateral supraorbital release, lary brachial plexus block in pediatric surgical patients. Egypt J
Anesth. 2009;25:281–90.
and craniofacial reconstruction. Diagnosis was based 5. Marhofer P. Upper extremity peripheral blocks. Tech Reg Anesth
on bilateral X-rays of the hands (two views) and CT/ Pain Manag. 2007;11:215–21.
CTA with contrast of the bilateral upper extremity. For 6. Rapp H, Grau T. Ultrasound-guided regional anesthesia in pediatric
syndactyly repair, an ultrasound-guided, in-plane axil- patients. Tech Reg Anesth Pain Manag. 2004;8:179–98.
7. Roberts S. Ultrasonographic guidance in pediatric regional anesthe-
lary block was performed using a 22G needle and 6 mL sia. Part 2: techniques. Pediatr Anesth. 2006;16:1112–24.
0.25% bupivacaine (see Fig. 22.9). Block duration was
6–12 h. Postoperative analgesia consisted of hydroco-
done-acetaminophen (Lortab) 2.5–167 mg/5 mL solu-
tion 1.2 mg, given 5 h after surgery. Suggested Reading
Dalens B. Infraclavicular brachial plexus blocks. In: Dalens BJ, editor.
Pediatric regional anesthesia. Boca Raton: CRC Press; 1990.
p. 247–51.
Karmakar MK, Kwok WH. Ultrasound-Guided Regional Anesthesia.
In: Cote CJ, Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB
Saunders; 2013. p. 880–908.
Mather SJ. Upper limb blocks. In: Peutrell JM, Mather SJ, editors.
Regional anaesthesia for babies and children. Oxford: Oxford
University Press; 1997. p. 101–5.
Tsui BC. Axillary block. In: Tsui BC, editor. Atlas of ultrasound and
nerve stimulation-guided regional anesthesia. New York: Springer;
2007. p. 99–107.
Fig. 22.9 Ultrasound-guided axillary brachial plexus block. Mc

musculocutaneous nerve, MN median nerve, RN radial nerve,
UN ulnar nerve, AA axillary artery, AV axillary vein. See “Case
Study” for details
Terminal Nerve Blocks of the Upper
Extremity 23
Ban C.H. Tsui
Contents
23.1 Median Nerve Block 322
23.1.1 Surface Anatomy 322
23.1.2 Nerve Stimulation Technique 323
23.1.3 Ultrasound-Guided Technique 323
23.1.5 Case Study 325
23.2 Radial Nerve Block 326
23.3 Ulnar Nerve Block 330
Reference 334

DOI 10.1007/978-0-387-79964-3_23
322 B.C.H. Tsui
23.1 Median Nerve Block • The median nerve supplies the thenar muscles, the lateral
two lumbricals, and all the muscles in the anterior com-
• The median nerve innervates muscles which produce partment of the forearm except the flexor carpi ulnaris and
flexion and opposition of the thumb, middle, and index the medial half of the flexor digitorum profundus, which
fingers, as well as pronation and flexion of the wrist. The are supplied by the ulnar nerve.
nerve carries fibers from all roots and trunks of the bra-
chial plexus.
• At the level of the axilla, the nerve initially lies superior to
the axillary artery and then descends along the medial 23.1.1 Surface Anatomy (Fig. 23.1)
aspect of the arm, lateral to the brachial artery (continua-
tion of the axillary artery). It then crosses the artery, usu- The patient is placed supine with the arm abducted slightly,
ally anteriorly, at the midpoint of the humerus at the the elbow flexed approximately 30°, and the forearm resting
insertion of the coracobrachialis muscle. on an arm board. Surface landmarks include:
• The nerve crosses the elbow, lying medially on the bra-
chialis muscle and just medial to the brachial artery and • Medial
vein (all of these medial to the biceps brachii tendon). The – Medial epicondyle of the humerus
cross-sectional view at the antecubital fossa seen in Fig. • Lateral
10.8 illustrates its relationship to the artery, vein, and – Brachial artery pulse: immediately medial to the biceps
adjacent musculature. brachii tendon.
• Passing deep to the bicipital aponeurosis and median – Biceps brachii tendon: lateral to the brachial artery and
cubital vein, the nerve divides between the two heads of median nerve, it may be best palpated with slight
the pronator teres muscle, giving off the anterior interos- elbow flexion.
seous nerve, which supplies the flexor pollicis longus and
pronator quadratus muscles and the lateral half of the
flexor digitorum profundus muscle.
• Distal to the antecubital fossa, cutaneous sensory branches
emerge and supply the palm, the palmar aspects of the
first three digits, and the lateral half of the fourth digit
(there may be some variation in overlap of cutaneous
innervation from the ulnar nerve of the medial one and a
half digits).
• At the most distal skin crease of the wrist, the median
nerve lies near the midline, passes deep to the flexor
retinaculum, and divides into medial and lateral
branches.
• Through its innervation of the lateral two lumbricals, it
mediates flexion of the metacarpophalangeal joints and
extension of the interphalangeal joints of digits two and
three.
Fig. 23.1 Surface anatomy and landmarks for median nerve block
23 Terminal Nerve Blocks of the Upper Extremity 323
23.1.2 Nerve Stimulation Technique 23.1.3.1 Scanning Technique

(Table 14.1) • High-frequency (10+ MHz) probes should be used for
visualizing the median nerve in children.
• The median nerve is superficially located at the elbow, • Place the probe in the axial plane with the center of the
and a short needle (3–4 cm at most) with a short bevel probe just medial to the biceps tendon in order to capture
should be used for the blocks. a transverse view of the nerve (medially) and adjacent
• Complete elbow extension should be avoided to reduce brachial artery (laterally).
the chance of elbow joint penetration. • Both the nerve and artery lie quite superficial, and the
• Insert the needle perpendicular to the skin immediately nerve can be larger than the artery at this location.
medial to the pulse of the brachial artery. • Color Doppler may be used to confirm the identity of the
• Twitches will be seen in the lateral three digits (flexion of artery and of the nerve on its medial aspect.
the thumb, index, or middle finger), although wrist flexion
or forearm pronation can also indicate adequate nerve
localization. 23.1.3.2 Sonographic Appearance
The nerve appears oval/peanut-shaped and lies medial to the
artery, which is often circular and smaller than the nerve
23.1.3 Ultrasound-Guided Technique (Fig. 23.2b).
Refer to the VHVS and ultrasound images for the relevant

anatomy (Fig. 23.2).
Fig. 23.2 (a) VHVS and MRI images at the antecubital fossa. (b) Ultrasound image of the median nerve at the antecubital fossa
324 B.C.H. Tsui
23.1.3.3 Needle Insertion 23.1.4 Local Anesthetic Application

• An in-plane (IP) or out-of-plane (OOP) approach may be
used to block the median nerve at the level of the elbow. • The median nerve can be blocked using a 3–4 cm needle,
• For the IP approach (Fig. 23.3), insert the needle medial insulated if using nerve stimulation, with 2–3 mL of
to the median nerve in order to avoid the brachial artery. 0.25–0.5 % ropivacaine.
The needle will be perpendicular to the median nerve, and • Performing a test dose with D5W is recommended prior
the goal will be to inject local anesthetic around the nerve. to local anesthetic application to visualize the spread and
This approach may cause more discomfort in an awake confirm nerve localization.
patient due to a longer needle path compared to the OOP • Aim to spread approximately 1–3 mL of local anesthetic
technique. around the nerve in a circular fashion in order to avoid
• For the OOP approach (Fig. 23.4), position the nerve at nerve contact but obtain a complete block.
the center of the ultrasound screen, and insert the needle • The local anesthetic injection will appear as an expansion
in cross section to the transversely placed probe in a ceph- of hypoechogenicity surrounding the nerve.
alad direction.
• Place the needle initially at a small distance (e.g., 1 cm)
from the probe in order to view the needle tip once the
needle has reached the nerve.
Fig. 23.3 In-plane needling approach for ultrasound-guided median

nerve block. Blue rectangle indicates probe footprint
Fig. 23.4 Out-of-plane needling approach for ultrasound-guided

median nerve block. Blue rectangle indicates probe footprint
23.1.5 Case Study
Median Nerve Block at the Elbow

(Contributed by A. Spencer)
A 12-year-old girl, 44 kg in weight, presented for hand
surgery. An X-ray showed a mildly displaced intra-
articular fracture of the distal portion of the proximal
phalanx of the left thumb without involvement of the
epiphyseal growth plate. The patient required an open
reduction and internal fixation of the proximal phalanx
and underwent a general anesthetic combined with an
ultrasound-guided median nerve and radial nerve block
at the elbow. Both blocks were performed with a
40 mm, 22G needle using an in-plane approach (see
Figs. 23.5 and 23.10). Four mL of 0.5 % bupivacaine
was used for each block; block duration was 6–12 and
8–12 h for the median and radial nerve blocks, respec-
tively. The duration of surgery was 1 h, 10 min. Pain Fig. 23.5 Ultrasound-guided median nerve block. M median nerve, BA
reporting was 0/10 at both 30 and 60 min post-op with brachial artery, arrowheads indicate needle position (see Case Study for
sensory block noted in the median and radial territories. details)
Postoperative analgesia consisted of acetaminophen
500 mg po q4h prn and ibuprofen 400 mg po q6h prn.
326 B.C.H. Tsui
23.2 Radial Nerve Block 23.2.1 Surface Anatomy (Fig. 23.6)
• The radial nerve innervates muscles which produce exten- The patient is placed supine with the arm abducted slightly,
sion (dorsiflexion) of the wrist and digits. The nerve car- the elbow flexed approximately 30°, and the forearm resting
ries fibers from the upper and middle trunks, the posterior on an arm board. Surface landmarks include:
division, and the posterior cord of the brachial plexus and
emerges from the posterior aspect of the plexus. • Deltoid tuberosity: internal rotation of the arm accentu-
• The nerve’s origin lies posterior to the second and third ates the posterior deltoid region and enables the deltoid
parts of the axillary artery, and it descends within the muscle to be traced to its point of insertion on the tuberos-
axilla across the subscapularis, teres major, and latissimus ity. The spiral groove lies just distal to the tuberosity.
dorsi muscles (the nerve lies on the insertion of this latter • Lateral epicondyle of the humerus: palpate from proximal
muscle). to distal along the lateral aspect of the humerus toward the
• It then passes between the medial and lateral heads of the elbow, and feel the curvature of the lateral supracondylar
triceps brachii muscle and descends obliquely across the crest proximal to the epicondyle.
posterior aspect of the humerus along the spiral (radial) • Biceps brachii muscle: palpate the lateral border of the
groove at the level of the deltoid muscle insertion (Fig. distal muscle belly. The radial nerve lies deep and lateral
10.11). It travels posterior and medial to the deep brachial to this portion of the muscle.
artery of the arm at this location.
• The nerve reaches the lateral margin of the humerus above
the elbow before crossing over the lateral epicondyle and
entering the anterior compartment of the arm in a deep
groove between the brachialis and brachioradialis mus-
cles proximally and the extensor carpi radialis longus
muscle distally.
• In front of the lateral epicondyle of the humerus, the nerve
divides and continues as the superficial radial (sensory)
and the deep posterior interosseous (motor) nerves.
• The radial nerve supplies the posterior compartments of
the arm and forearm, including the skin and subcutane-
ous tissues. It also supplies the skin on the posterior
aspect of the hand laterally near the base of the thumb
and the dorsal aspect of the index finger and the lateral
half of the ring finger up to the distal interphalangeal
crease.
Fig. 23.6 Surface anatomy and landmarks for radial nerve block
23.2.2 Nerve Stimulation Technique the brachioradialis muscle. Locate the round radial nerve
before its division to deep and superficial branches. To
• The nerves are all superficially located at the elbow, and a confirm the nerve’s identity, it can be traced distally to
short needle (3–4 cm) with a short bevel should be used and past the elbow, where the branches appear as two
for all blocks. adjacent hyperechoic “bubbles.”
• Complete elbow extension should be avoided to reduce • Alternatively, the nerve can be traced proximally to where
the chance of elbow joint penetration. it descends obliquely across the posterior aspect of the
• The point of puncture is on a line joining the epicondyles, humerus along the spiral (radial) groove at the level of the
at the location between the biceps brachii tendon and the deltoid insertion. The nerve lies posteromedial to the deep
brachioradialis muscle. Insert the needle using a 30–60° brachial artery at the posterior humeral location. Color
angle horizontally, directed cephalad. Doppler can be valuable in localizing the nerve (Fig. 23.7).
• Needle contact to the humerus indicates that the needle is • It may be useful to first locate the nerve at the posterior
too deep, while deep insertion without bone contact indi- humeral location with subsequent tracing laterally and
cates that the needle has passed the anterior aspect of the anterior to the elbow location.
arm, lateral to the humerus, without contacting the nerve.
• Twitches will appear on the radial aspect of the operative
hand; extension (dorsiflexion) of the wrist and digits is the 23.2.3.2 Sonographic Appearance
specific motor response. • The nerve lies sandwiched between the brachialis and
brachioradialis muscles, near the lateral curvature of the
rectangular-appearing humerus.
23.2.3 Ultrasound-Guided Technique • Above the elbow, the nerve is usually oval-round, while at
its point of division, it becomes flattened, containing two
23.2.3.1 Scanning Technique hypoechoic areas.
• High-frequency (10–15 MHz) probes should be used in • At the posterior humeral location, the deep brachial artery
children due to the short distance from the skin to the nerve. (of similar size to the nerve) lies anterolateral to the oval
• Place the probe in the axial plane at the lateral aspect of nerve; both appear to rest on the oval-shaped humerus
the distal upper arm (1–2 cm above the elbow joint at the (Fig. 23.7b).
level of the supracondylar ridge of the humerus), lateral • Note that most experts prefer to place the block at a more
to the biceps tendon, and medial to the upper aspect of distal location (i.e., antecubital) (Figs. 23.7c & d).
328 B.C.H. Tsui
Fig. 23.7 (a) VHVS and MRI images of the location of the radial nerve at the level of the humerus. (b) Ultrasound image of the location of the radial
nerve at the humerus. The dashed arrow indicates that the probe is moved distally from this position to the antecubital fossa. (c) VHVS and MRI images
of the location of the radial nerve at the level of the antecubital fossa. (d) Ultrasound image of the radial nerve at the block location (antecubital fossa)
23.2.3.3 Needle Insertion (e.g., 1 cm) from the probe in order to view the needle tip
• An OOP technique for needle insertion is a good approach once the needle has reached the nerve.
due to the short distance to the nerve (Fig. 23.8). • For the IP approach, on the posterior aspect of the mid-
Alternatively, an IP technique (see below) using an upper arm, slide the probe caudally looking for the hyper-
anterior-to-posterior approach will provide constant visu- echoic nerve that will eventually run anteriorly along the
alization of the needle shaft and tip and may help avoid distal part of the humerus. Move the image of the nerve
puncture of the deep brachial artery which may be adja- to the most lateral edge of the screen during IP advance-
cent to the radial nerve. However, an IP technique may ment. The needle is inserted in plane with the ultrasound
cause more discomfort in an awake patient. transducer in a lateral-to-medial or medial-to-lateral
• For the OOP approach, position the nerve at the center of direction (Fig. 23.9). The needle shaft and tip should be
the ultrasound screen, and insert the needle in cross visualized in real time as it tracks toward the radial nerve.
section to the transversely placed probe in a cephalad Injecting local anesthetic anteriorly and posteriorly to the
direction. Place the needle initially at a small distance nerve may be required to completely surround the nerve.
Fig. 23.8 Out-of-plane needling technique for ultrasound-guided Fig. 23.9 In-plane needling approach for ultrasound-guided radial
radial nerve block. Blue rectangle indicates probe footprint nerve block. Blue rectangle indicates probe footprint
330 B.C.H. Tsui
23.2.4 Local Anesthetic Application 23.3 Ulnar Nerve Block
• The radial nerve can be blocked using a 30–40 mm nee- • In the forearm, the ulnar nerve innervates muscles that
dle, insulated if using nerve stimulation, with 2–3 mL of produce flexion of the ring (fourth) and little (fifth) fingers
0.5 % ropivacaine. and ulnar deviation of the wrist. The ulnar nerve is the
• Performing a test dose with D5W is recommended prior continuation of the medial cord from the anterior division
to local anesthetic application to visualize the spread and of the lower trunk of the brachial plexus.
confirm nerve localization. This may not be necessary • Initially, the nerve courses between the axillary artery and
using the IP technique with good needle tip visualization vein and then along the medial aspect of the brachial
(see Chap. 4 box on test dose with D5W prior to local artery to the midpoint of the humerus before passing pos-
anesthetic injection). teriorly and following the anterior surface of the medial
• Aim to spread approximately 2–3 mL of local anesthetic head of the triceps brachii muscle (Fig. 10.6).
(e.g., ropivacaine 0.25–0.5 %) around the nerve in a circu- • It then passes behind the medial epicondyle of the
lar fashion in order to avoid nerve contact but obtain a humerus (in the condylar groove), divides between the
complete block. humeral and ulnar heads of the flexor carpi ulnaris mus-
• The local anesthetic injection will appear as an expansion cle, and lies on the medial aspect of the elbow joint.
of hypoechogenicity surrounding the nerve. • During its descent through the forearm, the nerve courses
anteriorly, coming to lie deep to and between the flexor
carpi ulnaris and flexor digitorum superficialis muscles,
23.2.5 Case Study approaching the ulnar artery near the midline of the fore-
arm at its midpoint (Fig. 10.9). The nerve and artery lie
See Sect. 23.1.5 for details on nerve block procedure. Figure directly anterior to the ulna at the junction of the lower
23.10 shows the radial nerve block with a medial-to-lateral third and upper two thirds of the forearm.
approach.. • At the wrist, the nerve crosses superficial to the flexor
retinaculum immediately lateral to the pisiform bone
(medial to the hook of the hamate bone) and divides into
superficial and deep branches; the ulnar artery lies antero-
lateral to the nerve at the wrist.
• The nerve supplies all the intrinsic muscles of the hand
except those supplied by the median nerve (i.e., all the
interossei, the medial two lumbricals, the hypothenar
muscles, the adductor pollicis, and the deep head of flexor
pollicis brevis).
• Through its innervation of the interossei and medial two
lumbricals, the nerve mediates flexion of the metacarpo-
phalangeal joints and extension of the interphalangeal
joints of digits four and five.
• Dorsal and palmar cutaneous branches of the nerve branch
5–10 cm proximal to the wrist and generally supply the
medial half of the fourth and the entire fifth digit (there
may be some variation in overlap with the cutaneous
Fig. 23.10 Ultrasound-guided radial nerve block (see median nerve branches of the median nerve supplying the lateral three
Case Study (Sect. 23.1.5) for details) and a half digits).
23.3.1 Surface Anatomy (Fig. 23.11)
The patient’s arm is flexed at the elbow with the shoulder

externally rotated and the forearm supinated and resting on
an arm board. Surface landmarks include:
• Ulna: palpate the bone at the junction of the middle and

lower thirds of the forearm.
• Ulnar artery pulse: may be difficult to palpate in many
individuals.
If using the nerve stimulation technique:
• The needle insertion point is the ulnar groove, which lies

between the medial epicondyle of the humerus and the
olecranon process. Fig. 23.11 Surface anatomy and landmarks for ulnar nerve block
332 B.C.H. Tsui
23.3.2 Nerve Stimulation Technique 23.3.3 Ultrasound-Guided Technique
• The ulnar nerve is located superficially at the elbow as it Refer to Fig. 23.12 for the VHVS and ultrasound anatomy of
passes through the condylar groove. this region, respectively.
• With the arm flexed at the elbow, a short-beveled nee-
dle (3–5 cm) should be inserted 1–3 cm distal to and in 23.3.3.1 Scanning Technique
line with the condylar groove. Alternatively, the block The aim is to view the ulnar nerve in short axis as it
may be completed 2–3 cm proximal to the condylar approaches the ulnar artery:
groove.
• Insert the needle in the direction of the ulnar groove using • Place the probe above the ulna and belly of the flexor
a 45° angle directed proximally and medially. carpi ulnaris muscle, on the anterior surface of the fore-
• Twitches will appear in the ulnar aspect of the hand – arm, rather than medially to contact the bone. Scan down-
motor responses are flexion of the ring and little fingers ward slowly until the pulsatile artery and nerve are viewed
and ulnar deviation of the wrist. adjacent to each other (Doppler may be valuable here).
• Blood withdrawal on aspiration suggests ulnar artery • Confirm the identity of the nerve by dynamically scan-
puncture. In this case, the needle should be reinserted ning proximally and distally to confirm that it is separate
after pressure treatment; contact with the ulna indicates from the artery proximally and that it converges to join
that the needle is too deep. the artery at the mid-forearm distally (Fig. 23.12b).
• The block location will be where the nerve and artery are
viewed in the same image but remain at sufficient distance
apart to avoid arterial puncture during needle insertion.
Fig. 23.12 (a) VHVS and MRI images of the ulnar nerve in the forearm. (b) Ultrasound image of the ulnar nerve in the forearm
23.3.3.2 Sonographic Appearance

• The nerve in short axis at a proximal location is viewed as
a honeycomb-like, oval-shaped structure, including
hypoechoic fascicular structures surrounded significantly
by hyperechoic tissue.
• More distally, the nerve appears to take a rounded shape.
The adjacent ulnar artery appears anechoic and roughly
similar in size to the nerve and lateral to it.
• If able to demarcate the muscles, they are located as fol-
lows: the flexor carpi ulnaris is superficial below the skin
and subcutaneous layers and has a distinctive linear fas-
cial plane within; the flexor digitorum superficialis is
superolateral to the nerve and artery; the flexor digitorum
profundus is medial and deep to the nerve and artery (see
Fig. 10.9).
• If visible, the deep hyperechoic ulna will have a bony Fig. 23.13 In-plane needling approach for ultrasound-guided ulnar
shadow underneath. The median nerve may be seen at the nerve block. Blue rectangle indicates probe footprint
lateral edge of the image and appears similar to the ulnar
nerve in size and shape.
23.3.3.3 Needle Insertion

• Our recommended technique is an IP approach to the
ulnar nerve at the mid-forearm.
• Position the image of the nerve to the most lateral edge of
the screen for good visibility of the needle shaft during IP
advancement. Insert the needle above the ulna but below
the probe by 0.5–1 cm, in line with the probe’s axis
(Fig. 23.13).
• An OOP technique can be used, with the needle inserted
a small distance from the caudad surface of the probe. For
this technique, the nerve should be placed in the center of
the image prior to needling (Fig. 23.14).
Fig. 23.14 Out-of-plane needling approach for ultrasound-guided

ulnar nerve block. Blue rectangle indicates probe footprint
334 B.C.H. Tsui
23.3.4 Local Anesthetic Application visualization of both nerves in one image. Following this,
0.2 mL/kg per nerve of levobupivacaine 0.25 % was injected
• The ulnar nerve can be blocked using a 3–5 cm needle, under ultrasound and nerve stimulation guidance.
insulated if using nerve stimulation, with 1–3 mL of Postoperative pain control was excellent with no need for
0.25–0.5 % ropivacaine or bupivacaine. opioid analgesics.
• Performing a test dose with D5W to visualize the spread
and confirm nerve localization is recommended prior to
local anesthetic application.
Reference
• Aim to spread approximately 1–3 mL of local anesthetic
around the nerve in a circular fashion in order to avoid 1. Mottard N, James I, Duflo F. Interest of ultrasound guidance for
nerve contact but obtain a complete block. ulnar and median nerve block in the mid forearm in children. Ann
• The local anesthetic injection will appear as an expansion Fr Anesth Reanim. 2010;29:406–7.
of hypoechogenicity surrounding the nerve.
Suggested Reading
23.3.5 Case Study
Dalens BJ. Distal conduction blocks. In: Dalens BJ, editor. Pediatric
regional anesthesia. Boca Raton: CRC Press; 1990. p. 261–5.
In the adult population, ulnar nerve block is typically per-
formed as a rescue block in cases of insufficient anesthesia. Cote CJ, Lerman J, Todres ID, editors. A practice of anesthesia for
Blockade of the ulnar nerve is performed rarely as a sole infants and children. 4th ed. Philadelphia: WB Saunders; 2009.
block in the pediatric population. p. 926–8.
Mather SJ. Upper limb blocks. In: Peutrell JM, Mather SJ, editors.
Regional anaesthesia for babies and children. Oxford: Oxford
University Press; 1997. p. 105–8.
23.4 Current Literature in Ultrasound- Suresh S, Polaner DM, Cote CJ. Regional Anesthesia. In: Cote CJ,
Guided Approaches Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
2013. p. 835–879.
Tsui BC. Selective terminal nerve blocks of the upper extremity. In:
A recent letter describes ultrasound-guided blockade of the Tsui BC, editor. Atlas of ultrasound and nerve stimulation-guided
median and ulnar nerves in children aged 6 and 20 months regional anesthesia. New York: Springer; 2007. p. 109–36.
for syndactyly repair [1]. Pre-procedural scanning allowed
Part VII
Nerve Blocks of the Lumbar Plexus
Posterior Lumbar Plexus Block
24
Karen R. Boretsky and Ban C.H. Tsui
Contents
24.1 Indications ....................................................................................................................................... 338
24.2 Surface Anatomy............................................................................................................................. 338
24.3.2 Current Application and Appropriate Responses ............................................................... 340
24.3.3 Modifications to Inappropriate Responses .......................................................................... 340
24.5 Local Anesthetic Application ......................................................................................................... 351
24.7 Case Study ....................................................................................................................................... 352
References ................................................................................................................................................... 353
K.R. Boretsky, MD
Department of Anesthesia, Perioperative and Pain Medicine,
Harvard Medical School, Boston Children’s Hospital,
Boston, MA, USA
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_24
338 K.R. Boretsky and B.C.H. Tsui
24.1 Indications The site of needle insertion is approximately at the inter-

section of the two lines described above for Winnie’s tech-
• Unilateral procedures in the groin area, in the hip, and on the nique; however, ultrasound imaging may identify a slightly
upper and anterior aspect of the lower limb (e.g., femoral different needle insertion site.
osteotomy)
• Combined with a sciatic nerve block for complete surgi-
cal anesthesia to the lower extremity Clinical Pearl: Chayen’s Technique
• Situations where neuraxial block is contraindicated for • A more medial and caudal (L5 or below) needle
the patient puncture site may be used, following a technique
modification described by Chayen and colleagues
[1], which places the needle midway between the
24.2 Surface Anatomy (Fig. 24.1) L5 spinous process and the PSIS.
• Patients often experience bilateral blockade indic-
The patient lies in the lateral decubitus position with the ative of epidural spread. This block may be advan-
operative side up and both hips and knees flexed after general tageous in cases where epidural anesthesia is
anesthesia has been induced. Surface landmarks include: contraindicated, such as in patients with scoliosis.
• Redirections of the needle due to bone contact (iliac
• Horizontal line: bone or vertebral body) may be necessary.
– Intercristal line – a line connecting the upper border of • The plexus may be reached at a significantly greater
the iliac crests, corresponding to the level of the L4/L5 depth than when using Winnie’s approach.
intervertebral space • Motor responses to nerve stimulation may be pres-
• Vertical line: ent in both the thigh and lower leg (ankle and foot).
– A line perpendicular to the intercristal line and parallel • The volume of local anesthetic should likely be
to the spinous processes, crossing through the ipsilat- reduced to that recommended for epidural injections.
eral posterior superior iliac spines (PSIS)
Fig. 24.1 Surface anatomy and landmarks for posterior lumbar plexus
block
24 Posterior Lumbar Plexus Block 339
24.3 Nerve Stimulation Technique
The authors recommend combining nerve stimulation with Lumbar plexus block
ultrasound guidance for lumbar plexus blocks as the nerve
roots/plexus can be difficult to visualize, especially for older
children.
Reccommend use of nerve
stimulation
24.3.1 Needle Insertion
A flowchart illustrating the needle insertion site and proce- Position: lateral
dures is shown in Fig. 24.2. decubitus, operative side
up, hips and knees flexed
• Insert an insulated 22–25G, short-bevel needle perpen-

dicular to the skin.
• The needle will pass through the quadratus lumborum Site: L4-5 at the
muscle before reaching the psoas major muscle and perpendicular intersection
finally the lumbar plexus. The skin-plexus distance cor- of the intercristal line and
verticle line through PSIS
related strongly with children’s weight rather than age
and height in a study of children between the ages of 3
and 12 and ranged from 1.24 to 1.74 mm/kg depending on
age and the level at which the lumbar plexus was visual- Needle insertion:
perpendicular to skin
ized with ultrasound imaging (Table 24.1) [2].
• If the needle contacts the bone (transverse process) at a
moderate depth, the needle should be reinserted slightly Fig. 24.2 Flowchart of needle insertion and procedures for lumbar
cranial or caudad. This will occur more frequently if plexus blocks
using the needle puncture site described by Chayen et al.
[1] (see Clinical Pearl above).
Table 24.1 Distance of skin- Levels where lumbar

plexus at different ages at L3/L4 plexus is delineated >3–5 years old >5–8 years old >8–12 years old
and L4/L5
L3/4 1.68 mm/kg 1.55 mm/kg 1.24 mm/kg
L4/5 1.74 mm/kg 1.6 mm/kg 1.31 mm/kg
Based on data from Ref. [2]
24.3.2 Current Application and Appropriate 24.3.3 Modifications to Inappropriate

Responses Responses (Table 24.2)
Figure 24.3 illustrates the procedure for employing nerve An algorithm of modifications to inappropriate responses to
stimulation techniques for lumbar plexus block. nerve stimulation is shown in Fig. 24.4.
• Initially, set the nerve stimulator to apply 1–2 mA current Table 24.2 Responses and recommended needle adjustments for use
(2 Hz), and aim to elicit motor twitches of the quadriceps with nerve stimulation during lumbar plexus blocks
muscle at a current intensity threshold of 0.5 mA. See Correct response from nerve stimulation
Table 14.3 for expected motor responses during nerve Quadriceps muscle twitch (palpable or visual) at 0.5–1.0 mA
stimulation. intensity
Other common responses and needle adjustment
Paraspinal (local twitch from direct stimulation)
Explanation: needle tip too superficial
Nerve stimulation
lumbar plexus block Needle adjustment: advance needle tip
Hamstring (roots of sciatic nerve)
Explanation: needle inserted too caudally
Needle adjustment: withdraw completely and reinsert 3–5 cm
cranially
Thigh flexion (quite deep; psoas major muscle stimulation)
Use 2 mA at 2 Hz initially
Explanation: needle tip too deep (close to peritoneal cavity)
Needle adjustment: withdraw needle and follow protocol
Bone contact
Transverse process
Reduce current to 0.5 mA Explanation: close placement; angle slightly off
as plexus is localized Needle adjustment: withdraw to subcutaneous tissue and
reinsert with an angle of 5° more cranially or caudally
No response despite deep placement
Past transverse process and lumbar plexus
Stimulation at less Other response to Explanation: needle tip too deep
than 0.5 mA nerve stimulation Needle adjustment: withdraw completely and reinsert
according to protocol
Withdraw needle See Fig 24.4

until stimulation
disappears at
< 0.5 mA
Quadriceps muscle twitch
Aspirate and inject

local anesthetic
Fig. 24.3 Flowchart of nerve stimulation techniques for lumbar plexus

blocks

stimulation during
lumbar plexus block
Thigh Flexion Transverse process

Paraspinal Hamstring
(Psoas maj. contacted without
(Direct Stimulation) (Sciatic n. roots)
muscle) twitch
Needle is still Needle inserted too Needle is deep Needle directed

superficial to caudally (near peritoneal caudally or
plexus cavity) cranially
Withdraw needle
Continue to Reinsert slightly Redirect as
and reassess
advance needle cranially appropriate
landmark
Quadriceps m. Twitch
Aspirate and inject

local anesthetic
Fig. 24.4 Flowchart of modifications to inappropriate responses to nerve stimulation during lumbar plexus blocks

lumbar plexus block
For a summary of ultrasound guidance techniques in lumbar
plexus blocks, see Fig. 24.5.
Major anatomical structures in the lumbar plexus as cap- Infants and young Adolescents and
tured by MRI and VHVS images are shown with the corre- children children
sponding ultrasound image in Fig. 24.6.
antiseptic solution. Prepare the ultrasound probe surface by Position probe in a Position probe in a
applying a sterile adhesive dressing to it prior to needling as longitudinal plane transverse plane
discussed in Chap. 4.
Place probe just Place probe midline

lateral to spinous at level of L4/L5
process of lower spinous process
lumbar vertebrae
Rotate probe 90° to a

Identify transverse longitudinal plane
process of L5
Scan medial to
Scan cranially to L4- lateral
L5 interspace
Capture view of
Rotate probe 90° to a lateral border of
transverse plane transverse process
Locate Psoas m. Identify plexus

anterior to the within psoas m.
Erector Spinae and deep to the
Quadratus transverse process
Lumborum
Insert needle using

IP or OOP (higher
Identify plexus
risk) Technique
within psoas muscle
Insert needle using

IP or OOP (higher
risk) technique

for confirmation
Aspirate and inject

local anesthetic
Fig. 24.5 Flowchart of ultrasound-guided techniques in lumbar plexus

blocks
Fig. 24.6 (a) VHVS and MRI images of major anatomical structures in the lumbar plexus region. (b) Ultrasound image of major anatomical
structures in the lumbar plexus region. Blue rectangle indicates position of ultrasound probe
24.4.1 Scanning Technique process (the latter immediately above the intercristal
line) to capture an overview of the vertebrae. The more
Traditionally, the approach for the lumbar plexus block has superficial position of the L3/L4 interspace may allow
been at the L4–L5 level to avoid renal hematoma or other for better resolution of the structures.
complications at the level of the kidney (L2–L3). This low – Rotate the probe to the longitudinal plane and scan lat-
approach often results in absence of analgesia in the ilioin- erally from midline, capturing firstly the lamina, artic-
guinal/iliohypogastric nerves and occasionally the lateral ular, and then transverse processes as the probe is
femoral cutaneous nerve. In the future, ultrasound visualiza- moved laterally.
tion of the kidneys and vascular structures may allow needle – The cephalad end of the probe, positioned in the longi-
insertion at a more cephalad level (L1–L4) to provide more tudinal plane parallel to the spine, will be over the tip of
consistent blockade of these nerves. It must be noted that the the transverse processes of L2 or L3 (according to the
lower pole of the kidney can reach down even to the L4–L5 experience and judgment of the operator), viewing the
level in young children and infants (Fig. 24.6a). transverse processes of L2/3/4 or L3/4/5, respectively;
the transverse processes and the acoustic shadows cast
• In infants and young children: should be between the psoas muscle seen through the
– Place a 6–13 MHz “hockey stick” transducer in the acoustic window between the transverse processes.
posterior longitudinal (parasagittal) plane just lateral • Infants, children, and adolescents: alternate approach:
to the spinous processes, starting at a caudal level, to – Using a landmark-based technique or pre-scanning
view the hyperechoic line and corresponding bony with ultrasound, identify and mark the L3 spinous
shadowing from the cephalad portion of the sacrum. process.
– Identify the first transverse process (L5) and place the – Place a 2–6 MHz curved array probe (curvilinear) in
probe at the L4/L5 interspace. The L3/L4 interspace the transverse plane in the midaxillary line at the iden-
may allow higher resolution in some children. tified L3 level; this is usually immediately cephalad to
– Rotate the probe 90° to capture a transverse axis view the iliac crest. A curvilinear probe is preferred even for
(Fig. 24.7) in order to visualize (from medial to lateral) small infants due to the wide angle of visibility it pro-
the spinous process, the erector spinae muscles, and vides for deep, critical structures.
the quadratus lumborum muscle. Use these landmarks – This view positions the probe perpendicular to the
to identify the plexus within the deeper psoas major spine and allows the transverse process to be viewed
muscle. on end and exposes the psoas muscle in a position
– Alternate between the transverse and longitudinal immediately (anatomic) anterior to the transverse pro-
views to delineate the plexus. cess. (The psoas muscle is no longer hidden by/in the
• In adolescents and children with large amounts of subcu- acoustic shadow of the transverse process.)
taneous tissue: – Other landmarks that can be verified and identified
– Place a 5–8 MHz curved array probe (curvilinear) in include the vertebral body, the kidney, the erector spi-
the transverse plane at the level of the L4 or L5 spinous nae, and the quadratus lumborum. See Fig. 24.8.
Fig. 24.7 Transverse ultrasound view (from medial to lateral) of the spinous process, the erector spinae muscles, and the quadratus lumborum
muscle of infants and young children. Blue rectangle indicates position of ultrasound probe
Fig. 24.8 Ultrasound image showing subcutaneous landmarks in a transverse view at L3. Blue rectangle indicates position of ultrasound probe
24.4.2 Sonographic Appearance • If distinguishable, the psoas major muscle lies

superficial and lateral to the vertebral body. The
• In infants and young children (5–10 MHz “hockey stick” psoas major muscle also lies deep to and at the
probe): intersection of the other muscles (quadratus lumbo-
– Transversely, with the probe lateral to the spinous pro- rum and erector spinae) and appears largely
cess (Fig. 24.7), the plexus fascicles or fascicle groups hypoechoic with few hyperechoic speckles.
lie within the psoas major muscle and superficial (pos- • Plexus fascicles or fascicle groups lie adjacent to
terior) to the vertebral body; both the plexus fascicles both the psoas major muscle and the vertebral body,
and the psoas muscle appear hypoechoic. although it will likely not be seen in this
– A “starry night” appearance of the muscles is visible, population.
with hyperechoic divisions representing aponeurotic – Longitudinal/long-axis scan:
septae; the quadratus lumborum and erector spinae • A striated-appearing erector spinae muscle layer
muscles are superficial with the quadratus lumborum lies most superficial with the “fibrillar-appearing”
muscle deep and lateral to the erector spinae. psoas major muscle between the lumbar transverse
– The nerve fascicles appear as hypoechoic “dots” sur- processes.
rounded by hyperechoic connective tissue. • The transverse processes are located deep to the
– Longitudinally, the plexus appears fascicular with erector spinae muscles at roughly equal spacing and
hypoechoic parallel bands bordered by hyperechoic appear slightly tubular with bright reflections and
striations and lies embedded within the posterior one adjacent dark (hypoechoic) bony shadowing
third of the hypoechoic-appearing psoas major muscle, (Fig. 24.9).
deep to the tips of the lumbar transverse processes, and • Medial to the transverse processes are the “peak-
can be visualized in the ultrasound image between like” hyperechoic edges of the articular processes
hypoechoic acoustic bony shadows cast by the trans- with bony shadowings (Fig. 24.10). These acoustic
verse processes of adjacent spinal levels. shadowings are interspersed between the psoas
– The superficial erector spinae musculature appears major musculature. The spinous processes can be
highly hypoechoic and striated. captured sonographically and appear broad; like
• In adolescents or children with large amounts of subcuta- other bony structures, they cast a shadow beneath
neous tissue (5–8 MHz curved array probe): the bony edge where no other structure is visible
– The depth of the plexus in older children may limit (Fig. 24.11).
its visibility. Indeed, the transverse processes (which • Alternate method for all ages: transverse transducer in
are the primary landmarks) may be vaguely delin- midaxillary line (Fig. 24.12):
eated. Therefore, it is important to switch between – A “starry night” appearance of the muscles is evident
transverse and longitudinal scanning within the area with hyperechoic divisions representing septae, although
of the spinous processes and the tip of the transverse the individual muscles may not be discernible.
processes. – The transverse process appears as a fingerlike projec-
– Transverse/short-axis scan: tion in the middle of the screen anatomically anterior to
• A “starry night” appearance of the muscles is evi- the erector spinae (not always visualized) musculature.
dent, with hyperechoic divisions representing sep- – The rounded vertebral body is at the bottom of the
tae, although the individual muscles may not be image and has a hyperechoic outline with a dark acous-
discernible. tic shadow underneath.
• The articular and transverse processes are located – The distinct psoas muscle lies lateral to the vertebral
deep to the erector spinae musculature. body and anterior to the prominent transverse process
• The spinous processes appear hypoechoic (likely and has the “starry night” appearance.
due to dorsal shadowing effect) and extend – The kidney lies anterior to the psoas muscle and
superficially. appears more homogeneous and hypoechoic.
• The vertebral body, if visible, is at the deepest – The nerves of the lumbar plexus may sometimes appear
aspect of the image and will be dark due to consid- as a wafer. If not, the psoas muscle can be mentally
erable shadowing from the surrounding bony divided into quarters; aim the needle for the (anatomic)
structures. medial/posterior quarter of the psoas muscle.
Fig. 24.9 (a) VHVS and MRI images of lumbar transverse processes. (b) Ultrasound image of lumbar transverse processes. Blue rectangle indi-
cates position of ultrasound probe
Fig. 24.10 (a) VHVS and MRI images of lumbar articular processes. (b) Ultrasound image of lumbar articular processes. Blue rectangle indicates
position of ultrasound probe
Fig. 24.11 (a) VHVS and MRI images of lumbar spinous processes. (b) Ultrasound image of lumbar spinous processes. Blue rectangle indicates
position of ultrasound probe
Fig. 24.12 Transverse ultrasound view at the midaxillary line showing landmark structures. Blue rectangle indicates position of ultrasound probe
24.4.3 Needle Insertion – Nerve stimulation is recommended to confirm plexus

identification.
Both in-plane (IP) (Fig. 24.13) and out-of-plane (OOP) • “Supported” or “off-line” ultrasound imaging for pre-
(Fig. 24.14) techniques using “real-time” ultrasound imag- procedural identification of landmarks:
ing can be used. In young children, the plexus can be visual- – It is critical to use both transverse and longitudinal
ized and the needle trajectory controlled to a good degree. In scanning during off-line scanning to verify the identity
older children, however, we have found that ultrasound and location of the structures:
imaging is most useful for surveying the region and identify- • The medial border of the area of interest of the lum-
ing the location and depth of important bony and muscular bar plexus block is the tips of L4 and L5 transverse
anatomical landmarks before performing this block. This is processes and lateral border being the ipsilateral
“supported” or “off-line” scanning, often used before per- iliac crest.
forming ultrasound-guided epidurals (see the ultrasound sec- • Needling at more cephalad levels is possible; how-
tion in Chap. 1). ever, it is important to visualize the kidney, and the
operator should have adequate experience.
• “Real-time” technique using ultrasound imaging during – Mark the lateral edge of the transverse process and
the block to control the needle trajectory toward the plexus: record the skin-to-transverse process distance.
– An IP alignment to a longitudinal or transverse probe – After assessing the region and identifying landmarks
and an OOP alignment to a transverse probe are the with ultrasound, perform the needling.
recommended approaches used in real-time needling. – Insert the needle (e.g., 25G, 35 mm insulated needle)
A linear, short footprint probe or a curvilinear probe perpendicular to the skin, without any significant
can be used. The primary consideration for choosing medial or lateral angle, to a depth approximately 1 cm
an approach is the ability to view the needle tip in real beyond the recorded depth of the transverse process
time as it approaches the plexus. with ultrasound during the pre-procedural scan.
– For IP needling, the needle is inserted from the caudal or – It is highly recommended to use nerve stimulation to
anterior end of the probe and advanced to the posterior localize the plexus.
part of the psoas muscle. Both the needle tip and needle – If the needle contacts the transverse process, redirect
shaft can be seen in real time during this needling the needle caudally, and advance it until a “pop” is felt
approach; thus, it is the preferred method of the authors. as the needle enters the psoas major muscle compart-
– For OOP needling (advanced approach), place the ment or to the point indicated by nerve stimulation;
probe transversely at the point where a cross section of this caudal direction is used to avoid inadvertent
the plexus is seen at L4/5. kidney puncture.
• Insert the needle (e.g., 25G, 35 mm insulated)
approximately 1 cm caudad to the probe at an angle
of 45–60° to the skin. Clinical Pearls
• The needle tip will be seen as it approaches the • Ultrasound visualization of the plexus is often lim-
plexus through the psoas major muscle; aim to ited to young patients; thus, the real-time technique
place the needle immediately within the psoas may be limited to this population. In older patients,
compartment. it may be more practical to perform a pre-block
• Verify the needle tip position in both transverse and scan to mark the location and depth of the bony
longitudinal images where possible. landmarks (mainly the transverse processes).
– An OOP needling approach with a longitudinally • It is important to switch between transverse and
placed probe, or an IP needling approach with a trans- longitudinal planes when scanning between the
versely placed probe, may pose a higher risk of injur- spinous processes and the edge of the transverse
ing neighboring structures. Since it is difficult to track processes to survey the area.
the needle tip on ultrasound, the needle can easily be • The needle should be inserted in either a cephalad
angled either too medial (i.e., toward the intraforami- or caudad direction, rather than medially toward the
nal or spinal cord) or lateral (i.e., toward the abdominal spinal canal.
cavity or even pleura if too cephalad).
24.5 Local Anesthetic Application
• The amount and type of local anesthetic will depend on

the duration of the block desired and the age/weight of the
patient.
• Kirchmair et al. [2] used 0.3 mL/kg of 0.33 % ropivacaine
for blockade in their descriptive study of ultrasound-
guided lumbar plexus block in children between the ages
of 3 and 12 years and reported successful intra- and post-
operative analgesia.
• Generally, 0.2–0.5 mL/kg of 0.25 % bupivacaine or 0.2 %
ropivacaine is used. The dose of local anesthetic should
not exceed the maximum toxic dose.
Ultrasound Considerations
Fig. 24.13 In-plane needling technique for ultrasound-guided lumbar
• The hypoechoic spread of local anesthetic to the posterior
plexus block. Blue rectangle indicates probe footprint portion of the psoas major muscle may be visible.
Kirchmair et al. [2] report viewing a “flow-like” pattern
within the psoas compartment.
• It will be difficult to view any spread of the local anes-
thetic in larger patients where the resolution is poor.
Clinical Pearl
• Continuous lumbar plexus catheters provide good
analgesia for periacetabular osteotomy, triple
Bernese osteotomy, open reduction internal fixation
of the hip, femoral osteotomy, and high amputa-
tions in children as young as 8 months old.
Fig. 24.14 Out-of-plane needling technique for ultrasound-guided

lumbar plexus block. Blue rectangle indicates probe footprint

Guided Approaches
The lumbar plexus was primarily detected at the level of L3/ Lumbar Plexus Block (Contributed by K. Boretsky)
L4 and, to a lesser extent, L4/L5 in children older than A 6-year-old female, 22 kg, presenting with progres-
8 years old in one study using ultrasound [3]. The lumbar sive hip pain was diagnosed with developmental dys-
plexus was superficial enough for the use of a high-frequency plasia of the hip. She was scheduled for left femoral
hockey stick transducer at L4/L5 in patients under the age of derotational osteotomy. After induction of general
2 years. anesthesia, the patient was placed in the right lateral
Sonographic visualization of the lumbar paravertebral position for placement of a left lumbar plexus perineu-
region in children has been described in several studies. ral catheter. The L3–L4 spinous processes were pal-
Using a HDI 5000 ultrasound system (ATL/Philips, Bothell, pated at the intercristal line and marked. A curvilinear
WA) with a curved array probe (5–8 MHz, ATL/Philips), transducer (2–6 MHz) placed in a transverse orienta-
Kirchmair et al. [2] placed the probe in longitudinal and tion in the midaxillary line at the top of the iliac crest
transverse planes to view the lumbar plexus and measure the was used to identify the L3 transverse process, which
skin-to-plexus distance. The skin-to-plexus distances were appeared as a prominent hyperechoic fingerlike pro-
significantly correlated with the weight of the child (r = 0.68 jection (see Fig. 24.8). An 18G, 10 cm insulated block
at L3/4 and 0.64 at L4/5) (Table 24.1). Another study [4] needle was inserted 4 cm lateral to the midline and in
demonstrated a strong correlation between PSIS-intercristal plane with the transducer. The needle was advanced
line distance and lumbar plexus depth in 350 individuals until the tip was located in the posterior-medial quad-
aged 1 month to 24 years (mean age 10.4 ± 5.2 years). This is rant of the psoas muscle. Nerve stimulation of the
a particularly valuable tool to determine lumbar plexus depth quadriceps femoris confirmed placement near the
since it varies with age. lumbar plexus. Eleven milliliters (0.5 mL/kg with a
maximum of 30 mL) of ropivacaine 0.2 % was bolused
through the needle in 5 mL increments, and a 20G
Clinical Pearl single-orifice catheter was inserted 3 cm beyond the
• The lumbar plexus is situated deeply within the needle tip. An infusion of ropivacaine 0.1 % at
psoas muscle and is more visible in young children. 5.5 mL/h (0.25 mL/kg) was run throughout the case.
This is due to the greater contrast between the At the end of the case, ketorolac 11 mg IV was admin-
hypoechoic muscle tissue and the hyperechoic con- istered, and acetaminophen 330 mg po was given in
nective tissue of the nerve structures compared with PACU. The ropivacaine infusion and the ketorolac and
older children and adults [2]. acetaminophen were administered around the clock
• The needle tip and local anesthetic spread are chal- until postoperative day 2, when the patient was
lenging to visualize adequately for this block, even switched to oral oxycodone. Maximum NRS was
in young children. 3/10, and the patient was comfortable throughout her
• Nerve stimulation, needle puncture direction (rela- hospitalization.
tively lateral and cranial [5, 6]), and regular aspira-
tion during injection are techniques that will
increase the safety of lumbar plexus block.
• There must be a risk-benefit analysis when deciding
to use this block; although it will be the most suitable
block for achieving anesthesia of the entire lumbar
plexus, selective blocks of the separate nerves at
more peripheral sites or a caudal block may be more
appropriate depending on the procedure.

1. Chayen D, Nathan H, Chayen M. The psoas compartment block. Dalens B. Lumbar plexus blocks. In: Dalens B, editor. Regional anes-
Anesthesiology. 1976;45:95–9. thesia in infants, children, and adolescents. Philadelphia: Lippincott
2. Kirchmair L, Enna B, Mitterschiffthaler G, et al. Lumbar plexus in Williams & Wilkins; 1995. p. 313–20.
children. A sonographic study and its relevance to pediatric regional Karmakar MK, Kwok WH. Ultrasound-Guided Regional Anesthesia.
anesthesia. Anesthesiology. 2004;101:445–50. In: Cote CJ, Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB
3. Bosenberg AT. Lower limb nerve blocks in children using unsheathed Saunders; 2013. p. 880–908.
needles and a nerve stimulator. Anaesthesia. 1995;50:206–10. Tsui BC. Lumbar plexus/psoas compartment block. In: Tsui BC, editor.
4. Walker BJ, Flack SH, Bosenberg AT. Predicting lumbar plexus Atlas of ultrasound and nerve stimulation-guided regional anesthe-
depth in children and adolescents. Anesth Analg. 2011;112:661–5. sia. New York: Springer; 2007. p. 147–60.
5. Johr M. The right thing in the right place: lumbar plexus block in
children. Anesthesiology. 2005;102:865–6.
6. Schuepfer G, Johr M. Psoas compartment block in children: part I–
description of the technique. Pediatr Anesth. 2005;15:461–4.
Terminal Nerve Blocks of the Lower
Extremity 25
Ban C.H. Tsui
Contents
25.1 Femoral Nerve Block ...................................................................................................................... 356
25.1.1 Indications ........................................................................................................................... 356
25.1.2 Surface Anatomy ................................................................................................................ 356
25.1.3 Nerve Stimulation Technique.............................................................................................. 357
25.1.4 Ultrasound-Guided Technique ............................................................................................ 359
25.1.5 Local Anesthetic Application ............................................................................................. 363
25.1.6 Current Literature in Ultrasound-Guided Approaches ....................................................... 363
25.1.7 Case Study .......................................................................................................................... 364
25.2 Lateral Femoral Cutaneous Nerve Block ..................................................................................... 365
25.2.1 Indications ........................................................................................................................... 365
25.2.2 Surface Anatomy ................................................................................................................ 365
25.2.7 Case Study .......................................................................................................................... 369
25.3 Obturator Nerve Block ................................................................................................................... 369
25.3.1 Indications ........................................................................................................................... 369
25.3.2 Surface Anatomy ................................................................................................................ 370
25.3.6 Case Study .......................................................................................................................... 373
25.4 Saphenous Nerve Block .................................................................................................................. 374
25.4.1 Indications ........................................................................................................................... 374
25.4.2 Surface Anatomy ................................................................................................................ 374
25.4.6 Case Study .......................................................................................................................... 378
References ................................................................................................................................................... 379
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_25
356 B.C.H. Tsui
25.1 Femoral Nerve Block 25.1.2 Surface Anatomy (Fig. 25.1)
25.1.1 Indications The patient lies supine with the legs extended and the hip
slightly externally rotated after general anesthesia has been
Femoral nerve block provides surgical anesthesia and, pri- induced. Surface landmarks include:
marily, postoperative analgesia in the anterior thigh and
knee. Combined with a sciatic nerve block, complete anes- • Inguinal ligament:
thesia below the mid-thigh can be achieved. – Attached medially to the pubic tubercle (approximately
0.5–1 cm from midline on upper pubis border, depend-
Indications ing on the age and size of the child) and laterally to the
• Pain relief and muscle relaxation for femoral fractures, to anterior superior iliac spine (ASIS).
facilitate transport, physical exams, and clinical and • Femoral/inguinal crease:
radiological procedures in relation to the fractures. – Natural oblique skin fold parallel and 0.5–1 cm distal
• For mid-shaft fractures, this block is the best indication to the inguinal ligament (depending on the age and size
for sole femoral nerve anesthesia. Fractures in the upper of the child); the femoral artery is most superficial
and lower femoral shaft will benefit from complementary here.
sciatic and obturator nerve blocks, respectively. • Femoral artery pulse:
• Quadriceps tendon repair. – The femoral artery lies at the “mid-inguinal point,” at
• Knee surgery (in combination with sciatic nerve block). the junction between the medial third and lateral two
• Anesthesia during muscle biopsy and skin grafting proce- thirds of the inguinal ligament, although it is most
dures. The lateral femoral cutaneous nerve will also need superficial at the femoral crease.
to be blocked for surgical anesthesia if the lateral aspect – Located medial to the nerve.
of the thigh is within the surgical field. The needle is inserted at the inguinal crease: approxi-
mately 0.5–1 cm lateral to the femoral artery and approxi-
mately 0.5–1 cm below the inguinal ligament, depending on
the age and weight of the child. Ultrasound guidance may
identify a more optimal needle insertion site.
Fig. 25.1 Surface anatomy and landmarks for femoral nerve blocks
25 Terminal Nerve Blocks of the Lower Extremity 357
25.1.3 Nerve Stimulation Technique • As the needle advances, loss-of-resistance “pops” may be
felt upon penetration of the fascia lata and iliaca, although
25.1.3.1 Needle Insertion penetration of the fascia iliaca may sometimes be difficult
A flowchart illustrating the needle insertion site and proce- to feel. These “pops” may be more pronounced if using a
dures is shown in Fig. 25.2. lateral needle puncture point (see “Clinical Pearls”
below).
• Insert a 35–50 mm, 22G short-beveled, insulated needle • In the case of femoral arterial puncture, compress the
using an angle of approximately 30–45° in a cephalad artery for 5–10 min to prevent hematoma formation.
direction. Repeat the procedure in a more lateral direction with
• Aspirate the needle frequently since the femoral artery is care.
situated close to the nerve.
Femoral nerve block
Recommend use of nerve

stimulation
Position: supine, legs

Extended and hips
Externally rotated
Site: inguinal crease

Lateral to femoral artery
Needle insertion: 30–45°

Cephalad direction
Arterial or venous Bony contact

Blood (hip or superior
pubic ramus)
Withdraw needle,
apply pressure for Needle too deep
hemostasis
Reassess
Reinsert laterally landmark
Loss of resistance of fascia

Lata and iliaca at appropriate
depth (see text)
Aspirate and inject

local anesthetic
Fig. 25.2 Flowchart of needle insertion and procedures for femoral

nerve blocks
358 B.C.H. Tsui
25.1.3.2 Current Application and Appropriate 25.1.3.3 Modifications to Inappropriate

Responses Responses (Table 25.1)
Figure 25.3 illustrates the procedure for employing nerve stim- An algorithm of modifications in the case of inappropriate
ulation techniques for femoral nerve block. See Table 14.3 for responses to nerve stimulation is shown in Fig. 25.4.
expected motor responses during nerve stimulation.
• Using nerve stimulation at an initial current of 0.8–1 mA Clinical Pearls

(1 Hz, 0.1–0.2 ms), a quadriceps femoris muscle response • For a fascia iliaca block, loss-of-resistance tech-
(“patellar kick”) is sought. A current threshold of 0.5 mA nique is used instead of nerve stimulation since the
is used for accurate localization. needle is placed away from the nerve. The puncture
point is 0.5–1 cm below the inguinal ligament
(depending on the age and size of the child) at the
interception of one third lateral and two thirds
Nerve stimulation
Femoral nerve block medial of the inguinal ligament (pubic tubercle-
ASIS). The needle is introduced perpendicularly to
the skin plane. Two “pops” are felt when the needle
traverses the fascia lata and iliacus and enters the
Use 1 mA at 2 Hz initially iliopsoas muscle.
Reduce current to 0.5 mA Table 25.1 Responses and recommended needle adjustments for use
as Nerve is localized with nerve stimulation during femoral nerve block
Stimulation at less Other response to
The most reliable response is a visible or palpable ipsilateral femoral
than 0.4 mA Nerve stimulation muscle twitch (patella twitch) at 0.3–0.5 mA current, which
indicates that one is stimulating the posterior division of the nerve. If
twitches of the sartorius muscle occur, the needle may be outside the
nerve sheath, and one may be stimulating the proximal branch which
Withdraw needle See Fig 25.4 supplies the sartorius muscle
until stimulation
disappears at
< 0.4 mA Muscle twitches from electrical stimulation
Iliopsoas or pectineus (direct stimulation of muscle)
Explanation: too superior or deep needle tip placement
Patella twitch Needle adjustment: withdraw needle completely and reinsert
Sartorius (branches of femoral nerve to sartorius)
Explanation: needle tip too anteromedial to main femoral
Aspirate and inject nerve trunk
local Anesthetic Needle adjustment: redirect needle laterally and advance
1–3 mm deeper
Fig. 25.3 Flowchart of procedure for employing nerve stimulation Bone contact
techniques for femoral nerve blocks Hip or superior ramus of pubic bone
Explanation: needle tip too deep
Needle adjustment: withdraw needle to subcutaneous tissue
and reinsert
No response
Explanation: needle tip often too medial or lateral
Needle adjustment: withdraw completely and reinsert after
checking landmarks
Vascular puncture
Femoral artery or vein
Explanation: needle tip too medial
Needle adjustment: withdraw needle completely and reinsert
laterally
25.1.4 Ultrasound-Guided Technique

Stimulation during the
femoral nerve block For a summary of ultrasound-guided techniques in femoral
nerve blocks, see Fig. 25.5. Major anatomical structures sur-
Illiopsoas, rounding the femoral nerve as captured by MRI and VHVS
Sartorius No stimulation
pectineus
(sciatic n. Branch) images are shown with the corresponding ultrasound image
(direct stimulation)
in Fig. 25.6.
Needle is lateral, Needle is antero- Needle is too
medial or deep medial to femoral n. medial or lateral antiseptic solution. Prepare the ultrasound probe surface by
applying a sterile adhesive dressing to it prior to needling as
Withdraw discussed in Chap. 4.
Redirect laterally
completely and Reassess landmark
and slightly deeper
reinsert
Posterior division of femoral n. Ultrasound technique

• Patella twitch Femoral nerve block
Aspirate and Inject

local anesthetic
Position probe in a
transverse axis
nerve stimulation during femoral nerve blocks
Place probe inferior

to inguinal ligament
in inguinal crease
Identify femoral
vessels
Nerve is deep and

Lateral to femoral
artery
Insert needle using

OOP or IP
technique

for confirmation
Aspirate and inject

local anesthetic
Fig. 25.5 Flowchart of ultrasound-guided techniques in femoral nerve

blocks
360 B.C.H. Tsui
Fig. 25.6 (a) VHVS and MRI images of major anatomical structures surrounding the femoral nerve. (b) Ultrasound image of major anatomical
structures surrounding the femoral nerve
25.1.4.1 Scanning Technique • If the nerve is difficult to characterize, as in obese chil-

• A 5–10 MHz hockey stick probe can be used for most dren, a useful reference landmark is the profunda femoris
children and will allow good axial resolution of the nerve (deep femoral) artery (Fig. 25.7a). Scan distally to locate
in order to distinguish it from the surrounding structures the point where profunda femoris artery branches off
(vessels and muscles). deep to the femoral artery (Fig. 25.7b). Trace this artery
• Position the probe transverse to the nerve axis in the prox- proximally again to its convergence with the femoral
imal thigh, approximately 0.5–1 cm inferior to the ingui- artery; the femoral nerve will be located lateral to the
nal ligament and along the inguinal crease. The nerve artery.
should appear approximately 0.5–1 cm deep (depending • Tilting the probe from perpendicular usually helps to
on the size and age of the child) and just lateral to the improve the visualization of the femoral nerve (see
femoral artery. “Clinical Pearls” below).
• Color Doppler may be used to localize the femoral artery • Color Doppler may be used to localize the profunda fem-
and vein. oris artery (Fig. 25.7b).
Fig. 25.7 (a) VHVS and MRI images of the profunda femoris artery. (b) Ultrasound image with color Doppler used to localize the profunda
femoris artery
362 B.C.H. Tsui
25.1.4.2 Sonographic Appearance • For an OOP approach, the needle will be inserted caudad
• Short-axis plane below inguinal crease (Fig. 25.6b): to the probe in one of the following ways:
– The nerve lies lateral and deep to the large, circular, – After identifying the nerve, center the screen on the
and anechoic femoral artery. needle target area (just lateral to the nerve). At a dis-
– The fascia lata (most superficial) and iliaca (immedi- tance from the probe that is equal to the depth of the
ately adjacent to the nerve, separating the nerve from target area, insert the needle caudad to the probe at a
the artery) are superficial to the femoral nerve and 45° angle to the skin, and advance the needle until the
often appear bright and longitudinally angled. The fas- tip is visualized at the target location. The hypoechoic
cia may be better identified in contrast to the spread of a test dose of D5W is helpful to locate the
hypoechoic injectate after injection. needle tip.
– The femoral nerve often appears oval shaped, although – An OOP “walk down” approach with incremental,
it may be triangular and of variable size due to incon- stepwise angulation of the needle will provide imme-
sistencies in diameter throughout its course. For exam- diate localization of the needle tip as a bright dot,
ple, early division above the inguinal ligament can allowing the tip to be followed to the required depth.
increase the transverse diameter of the nerve. • Try to localize the needle tip beneath the fascia iliaca.
– The iliopsoas muscle may be seen deep to the nerve.
25.1.4.3 Needle Insertion Clinical Pearls

• Insert a 35–50 mm, 22G–25G needle either in-plane (IP) • It is important to ensure that the ultrasound beam is
(Fig. 25.8) or out of plane (OOP) (Fig. 25.9 to the trans- perpendicular to the nerve’s transverse axis to mini-
verse probe at the location identified by ultrasound mize anisotropic effects altering the echogenic
(approximately at the inguinal crease). properties of the structure. It has been shown that an
• For an IP approach, insert the needle in a lateral-to-medial approximate 10° cephalad or caudad tilt of the
direction from the lateral edge of the probe. This will help transducer can make the nerve isoechoic (similar
to ensure that the needle approaches the nerve before the appearing) to the underlying iliopsoas muscle.
artery or vein.
Fig. 25.8 In-plane needling technique for ultrasound-guided femoral Fig. 25.9 Out-of-plane needling technique for ultrasound-guided fem-
nerve block. Blue rectangle indicates probe footprint oral nerve block. Blue rectangle indicates probe footprint
25.1.5 Local Anesthetic Application and patella and open lateral release of the knee. After induc-
tion of general anesthesia, a linear transducer revealed a
• Inject 0.2–0.5 mL/kg of 0.25 % bupivacaine or 0.2 % nerve-like structure lateral to the femoral artery; stimulation
ropivacaine without exceeding the recommended toxic of this structure resulted in a motor response of the sartorius
dose of local anesthetic (2 mg/kg for bupivacaine and muscle. Stimulation of another hyperechoic structure poste-
3–4 mg/kg for ropivacaine without epinephrine). rior to the iliacus muscle elicited contraction of quadriceps
• Oberndorfer et al. [1] showed that a lower volume of local femoris muscle. Twenty milliliters of 0.2 % ropivacaine was
anesthetic is required when using ultrasound-guided tech- then injected through a stimulating nerve catheter.
nique as compared to the nerve stimulator approach in A recent case study [5] demonstrated the value of a femo-
children between the ages of 1 and 8 (0.2 mL/kg versus ral nerve block for rapid analgesia in an emergency setting: a
0.3 mL/kg of 0.5 % levobupivacaine). 3-month-old infant presented with a subtrochanteric femoral
• Farid et al. [2] described the use of 0.5 mL/kg of 0.2 % neck fracture due to non-accidental trauma. The patient
ropivacaine to a maximum volume of 40 mL in patients received one dose of morphine and two doses of fentanyl
aged 8–16 years (without US). prior to the block. Ultrasound was placed 1 cm distal to the
• Sethuraman et al. [3] used 0.2 mL/kg 0.5 % bupivacaine inguinal ligament of the limb in question, allowing visualiza-
with the total dose not exceeding 1–1.5 mg/kg in their tion of the femoral nerve and surrounding structures. Under
cohort of patients <10 years old undergoing muscle ultrasound guidance, a 27G needle was inserted in-plane and
biopsy (without ultrasound). used to inject 2 mL 0.25 % bupivacaine (1.25 mg/kg) to sur-
• Perform intermittent injection with interval aspiration. round the nerve. After 15 min, pain control was sufficient to
• If a sciatic nerve block will be administered in addition to place a Pavlik harness on the patient; only one dose of anal-
the femoral block, use less (e.g., two thirds) of the local gesic was required in the 18 h following the block.
anesthetic solution in order to avoid local anesthetic In a recent letter, Miller [6] described combined
toxicity. ultrasound-guided femoral and lateral femoral cutaneous
nerve block for pediatric patients undergoing surgical repair
Ultrasound Considerations of femur fractures. The femoral nerve was blocked first using
• Performing a test dose with D5W is recommended prior a 50 mm, 22G needle inserted in-plane in a lateral-to-medial
to local anesthetic application to visualize the hypoechoic direction, followed by injection of ropivacaine 0.2 % (0.2–
spread and confirm nerve localization. 0.5 mL/kg; max. volume 20 mL). The needle was withdrawn,
• Local anesthetic spread can be seen as an expanding and the ultrasound transducer was moved laterally along the
hypoechoic area; it should occur beneath the fascia iliaca inguinal ligament until its lateral aspect is in contact with the
and should surround the nerve. ASIS; the lateral femoral cutaneous nerve and local anes-
• The solution may displace the nerve medially toward or thetic from the previous injection was visualized. The same
laterally away from the artery, depending on the needle needle was inserted in-plane so that the needle tip was placed
approach. between the fascia lata and the fascia iliaca. Ropivacaine
0.2 % (0.05–0.2 mL/kg; max. volume 6 mL) was injected
and observed to surround the lateral femoral cutaneous
25.1.6 Current Literature in Ultrasound- nerve.
Guided Approaches Miller also provided the first report of ultrasound-guided
fascia iliaca compartment block in pediatric patients [7].
Oberndorfer et al. [1] compared ultrasound guidance to With the ultrasound probe positioned in the long axis and
nerve stimulator technique for sciatic and femoral nerve located mid-point over the inguinal ligament, lateral to the
blocks in a randomized study of 46 children. The primary border of the middle and lateral third of the ligament, the
outcome of the study was the duration of the nerve blockade. ilium, iliacus muscle, and fascia can be visualized. A
The study showed that ultrasound-guided blocks lasted lon- 100 mm, 21G or 50 mm, 22G needle was inserted in-plane
ger (508 vs. 335 min) and that a lower volume of local anes- approximately 1–2 cm below the inguinal ligament, directed
thetic (0.2 mL/kg vs. 0.3 mL/kg of levobupivacaine 0.5 %) cephalad, and advanced until the tip was just below the fascia
was required for an adequate analgesia compared to the iliaca and in the iliacus muscle. An appropriate volume of
nerve stimulator technique. ropivacaine 0.2 % was injected in this area achieving block-
Gurnaney et al. [4] reported a combined use of ultrasound ade of the femoral, obturator, and lateral femoral cutaneous
and nerve stimulation in the placement of a femoral perineu- nerves. Pain control was excellent in all three cases, with no
ral catheter in a pediatric patient with variant anatomy. requirement for narcotics in the recovery unit.
A 15-year-old presented to the operating room for an Ponde et al. [8] performed a randomized clinical trial to
arthroscopic chondroplasty of medial and lateral condyles examine success rates of combined femoral and sciatic block
364 B.C.H. Tsui
for pediatric patients suffering from arthrogryposis multi- 25.1.7 Case Study
plex congenital who were undergoing foot surgery. The
results demonstrated significantly higher block success rates
using ultrasound guidance compared to guidance by nerve Case Study: Femoral Nerve Block (Contributed
stimulation alone. Interestingly, post-surgery analgesia dura- by S. Suresh)
tion was extended by an hour in the ultrasound group, An 8-year-old male, 34.2 kg, with no past medical or
although the clinical significance of this finding is minimal. relevant family history was presented for physeal-
sparing left knee anterior cruciate ligament reconstruc-
tion with autogenous iliotibial band and lateral
Clinical Pearls meniscus repair based on MRI of the left knee without
• Although there is no direct evidence to prove that contrast. The patient received an in-plane, ultrasound-
ultrasound can reduce the risk of inadvertent vessel guided femoral nerve block with a 50 mm 20G needle
puncture, this has been the case in our experience. (10 mL 0.25 % bupivacaine) (see Fig. 25.10), followed
Prevention of intraneural local anesthetic injection by placement of a perineural catheter. Duration of sur-
or direct intravascular puncture may not be possible gery was 2 h, 53 min. Postoperative analgesia report-
in all cases (as in situations where the needle tip is ing was 0/10 (verbal) immediately following surgery
not clearly seen and the nerve may not be visible). and 7/10 (verbal) 30 min after surgery. Postoperatively,
However, precise placement of local anesthetic, the patient received a morphine injection (2 mg) and a
enabled by ultrasound imaging, may lessen the fre- continuous infusion of bupivacaine 0.1 % solution.
quency of injecting large volumes of local anes-
thetic to ensure adequate spread, as is often the case
when using blind techniques.
• Our preference is to use an IP technique, which
offers the ability to visualize the needle tip and the
needle shaft as it advances beneath the fascia iliaca.
Fig. 25.10 Ultrasound-guided femoral nerve block. FN femo-

ral nerve, FA femoral artery, FV femoral vein. See Case Study
for details
25.2 Lateral Femoral Cutaneous iliaca plays a key role in identifying the appropriate nerve
Nerve Block localization.
25.2.1 Indications • Inguinal ligament: the ligament is attached medially to

the pubic tubercle (approximately 0.5–1 cm from midline
The lateral cutaneous nerve (L2–L3) of the thigh is a on upper pubis border depending on the age and size of
small, subcutaneous sensory nerve that supplies the lat- the child) and laterally to the anterior superior iliac spine.
eral thigh. • ASIS: palpate this landmark by following the iliac crests
to their most anterior edge.
Indications
• Analgesia for: The needle puncture site lies approximately 0.5–1 cm
– Obtaining a skin graft from the lateral thigh caudad to the inguinal ligament and medial to the ASIS. The
– Muscle biopsy distance depends on the size and age of the child.
– Femoral neck pinning
– Plate placement or removal
• Supplementation of femoral and sciatic nerve blocks 25.2.3 Nerve Stimulation Technique
when tourniquets are used or when the surgical incision
lies within the lateral aspect of the upper thigh. The lateral femoral cutaneous nerve is purely sensory.
• Diagnosis of meralgia paresthetica. Therefore, nerve stimulation is not commonly used for this
block, as the elicitation of paresthesia is often difficult and
uncomfortable for children.
25.2.2 Surface Anatomy
The patient is placed supine with slight abduction and exter-
nal rotation of the leg after general anesthesia has been • A 35 mm, 22G–25G insulated needle (blunted) is inserted
induced. perpendicularly at the puncture site.
The lateral femoral cutaneous nerve is a small nerve; • A “pop” is felt as the needle is advanced beyond the fascia
therefore, its relationship with the fascia lata and fascia lata.
366 B.C.H. Tsui
25.2.4 Ultrasound-Guided Technique • The nerve should appear approximately 0.5–1 cm medial
and inferior to the ASIS, depending on the age and size of
Major anatomical structures surrounding the lateral femoral the child.
cutaneous nerve as captured by MRI and VHVS images • It can be difficult to identify this small nerve since it is
are shown with the corresponding ultrasound image in interposed between the fascia lata and iliaca.
Fig. 25.11a. • The nerve lies very superficial to the skin surface.
antiseptic solution. Prepare the ultrasound probe surface by 25.2.4.2 Sonographic Appearance (Fig. 25.11b)
applying a sterile adhesive dressing to it prior to needling as • The fascia lata (most superficial) and iliaca (immediately
discussed in Chap. 4. adjacent to the nerve) may be seen superficial to the sarto-
rius muscle and often appear bright and longitudinally
25.2.4.1 Scanning Technique angled.
• A 5–10 MHz hockey stick transducer can be used for • The lateral femoral cutaneous nerve often appears oval
most children and will allow good axial resolution of the shaped and hyperechoic and can be better identified after
nerve. injection of D5W or local anesthetic, which will surround
• Position the probe on the inguinal crease and scan proxi- the hyperechoic nerve with contrasting hypoechoic
mally until the lateral end of transducer lies over the ASIS. injectate.
Fig. 25.11 (a) VHVS and MRI images of major anatomical structures surrounding the lateral femoral cutaneous nerve. (b) Ultrasound image of
major anatomical structures surrounding the lateral femoral cutaneous nerve
25.2.4.3 Needle Insertion – Where possible, position the nerve in the middle of the
• Insert a 35 mm, 22G–25G needle IP (Fig. 25.12) or OOP screen, or visualize the fascia lata and fascia iliaca
(Fig. 25.13) to the transverse probe at the location identi- medial to the ASIS and inferior to the inguinal liga-
fied by ultrasound. ment. Aim the needle in between the fascial planes,
• For an IP approach: just inferior and medial to the ASIS.
– Insert the needle in either a lateral-to-medial or medial- – An OOP “walk down” approach with incremental,
to-lateral direction. stepwise angulation of the needle will provide
– Localize the needle tip beneath the fascia lata or just immediate localization of the needle tip as a bright
medial and inferior to the ASIS. dot; the needle tip can be followed to the required
• For an OOP approach, insert the needle approximately depth.
1 cm caudad to the probe and at a 45° angle to the skin.
Fig. 25.12 In-plane needling technique for ultrasound-guided lateral Fig. 25.13 Out-of-plane needling technique for ultrasound-guided lateral
femoral cutaneous nerve block. Blue rectangle indicates probe footprint femoral cutaneous nerve block. Blue rectangle indicates probe footprint
368 B.C.H. Tsui
25.2.5 Local Anesthetic Application 25.2.6 Current Literature in Ultrasound-

Guided Approaches
• If the lateral femoral cutaneous nerve can easily be identi-
fied on ultrasound, inject 1–3 mL of 0.25 % bupivacaine There is a paucity of literature on the use of ultrasound-
or 0.2 % ropivacaine (depending on the age and size of the guided lateral femoral cutaneous nerve block. Nonetheless,
child), between the fascia lata and fascia iliaca. the use of ultrasound guidance in lateral femoral cutaneous
• Prior to the advent of ultrasound-guided lateral femoral and 3-in-1 block allows real-time visualization of the spread
cutaneous nerve block, Maccani et al. [9] suggested a of local anesthetic deposited beneath the clearly identifiable
“blind” technique of injecting 6.8 mg/kg of lidocaine fascial layers [10]. This may help predict the success in cases
medial and inferior to the ASIS using a fanlike injection where the nerves may not be seen. There will likely be a
pattern. This method was shown to provide anesthesia (in reduced reliance on depositing a larger than necessary vol-
combination with femoral nerve block and sedation) in ume of local anesthetic in hopes of obtaining the block of all
children undergoing anterior thigh procedures such as related nerves.
muscle biopsy. A case report by Miller has been published which
describes combined femoral and lateral femoral cutaneous
Ultrasound Considerations nerve block (described in Sect. 25.1) [6].
• Performing a test dose with D5W is recommended prior
to local anesthetic application to visualize the solution
spread and confirm nerve localization. Clinical Pearls
• Local anesthetic spread should occur between the fascial • Although data on ultrasound-guided techniques for
space (fascia lata and fascia iliaca) surrounding the nerve. lateral femoral cutaneous block are lacking, ultra-
• A “donut” shape may appear as the hypoechoic local sound may improve target nerve localization or
anesthetic surrounding the nerve and the fascial plane identification within the plane of needle entry.
expands. Visual confirmation of local anesthetic spread
within the correct fascial plane will provide valu-
able information in cases where the nerve is not vis-
Clinical Pearls ible. The use of ultrasound may, therefore, result in
• It can be difficult to identify the lateral femoral smaller doses of local anesthetic being needed for
cutaneous nerve in children. Local anesthetic can effective blocks.
be deposited between the fascia lata and fascia ili-
aca, which are easier to identify with their hyper-
echoic appearance overlying the sartorius muscle.
• When performing this block with conjunction with
femoral nerve block, the space between the fascia
lata and fascia iliaca can be located easily by slowly
withdrawing and simultaneously injecting fluid
through the needle following completion of the
femoral nerve block.
25.2.7 Case Study 25.3 Obturator Nerve Block
25.3.1 Indications
Lateral Femoral Cutaneous Nerve Block (Contributed
by S. Suresh) • Prevent obturator reflex during transurethral bladder
A 4-year-old female, 19.7 kg, was scheduled for mus- tumor resections.
cle and skin biopsy and venous port insertion. The • Treatment of pain in the hip area.
patient had previously undergone a bilateral MRI of • Adductor spasm (as seen in multiple sclerosis patients).
the lower extremities without contrast and a frontal • Diagnostic tool for hip mobility.
fluoroscopic spot radiograph. Preadmission medica- • Knee surgery: improved analgesia has been shown when
tions included folic acid (1 mg tablet), Benadryl obturator nerve blockade is used in addition to femoral
6.25 mg, and Prilosec 10 mg. An ultrasound-guided block [11].
lateral femoral cutaneous nerve block was indicated,
which was performed with a 27G needle and 3 mL
0.25 % bupivacaine (see Fig. 25.14). Surgery lasted
1 h, 38 min; block duration was 12 h.
Fig. 25.14 Ultrasound-guided lateral femoral cutaneous nerve

(LFCN) block. See Case Study for details
370 B.C.H. Tsui
25.3.2 Surface Anatomy (Fig. 25.15) The needle puncture site is located approximately
0.5–1 cm (depending on the age and size of the child) beneath
The patient is positioned with the hip externally rotated and the inguinal ligament and equidistant laterally to the pubic
the knee slightly flexed to permit maximum exposure of the tubercle.
medial thigh.
The obturator nerve traverses the inguinal ligament medi-
ally and lies approximately 0.5–1 cm lateral to the pubic 25.3.3 Nerve Stimulation Technique
tubercle and 0.5–1 cm below the inguinal ligament (depend-
ing on the age and size of the child). Since the obturator nerve branches early after its descent
from the obturator canal, blocking this nerve before it
• Pubic tubercle: the tubercle lies approximately 1 cm lat- branches within the obturator canal near the superior pubic
eral to the midline. ramus is often indicated for blind techniques. However, in a
• ASIS: palpate this landmark by following the iliac crests small proportion of children, the obturator nerve divides
to their most anterior edge. either before or far from the obturator canal.
• Inguinal ligament: the ligament is attached medially to
the pubic tubercle and laterally to the anterior superior 25.3.3.1 Needle Insertion
iliac spine.
• Landmarks include: • Insert a 35–50 mm, 22G–25G insulated needle 0.5–1 cm
– Femoral/inguinal crease: a natural oblique skinfold caudad to the inguinal ligament and 0.5–1 cm lateral to
parallel and 0.5–1 cm distal to the inguinal ligament. the pubic tubercle, almost perpendicular to the skin, using
– Adductor longus muscle: the tendon of adductor lon- a slight (15°) lateral direction.
gus forms the medial border of the upper part of the • If contact with the pubic ramus occurs, “walk” the needle
thigh. The anterior division of the obturator nerve lies caudally off the pubic ramus and then advance the
immediately deep to the adductor longus muscle. needle.
25.3.3.2 Current Application and Appropriate

Responses
• Apply an initial current of 0.8–1 mA (1 Hz, 0.1–0.2 ms)

and aim to elicit muscle twitches in the adductor muscles
using a current of 0.5 mA. See Table 14.3 for expected
motor responses during nerve stimulation.
Fig. 25.15 Surface anatomy for obturator nerve block

25.3.3.3 Modifications to Inappropriate 25.3.4 Ultrasound-Guided Technique

Responses
• If no motor response occurs with a needle depth of one Major anatomical structures surrounding the obturator nerve
third of the anteroposterior diameter of the thigh, the as captured by MRI and VHVS images are shown with the
direction of the needle is incorrect, and the procedure corresponding ultrasound image in Fig. 25.16.
should be repeated after reassessing the landmark.
• Adduction of the adductor muscles can be obtained by
direct muscle stimulation at 1 mA. Decreasing the current
intensity to 0.5 mA will help with nerve localization.
Clinical Pearls
• Aspiration is essential when injecting near the
unbranched obturator nerve, as the obturator artery
lies adjacent to the nerve. Hemorrhage involving
this artery can be life-threatening [12].
Fig. 25.16 (a) VHVS and MRI images of major anatomical structures surrounding the anterior and posterior obturator nerves. (b) Ultrasound
image of major anatomical structures surrounding the anterior and posterior obturator nerves
372 B.C.H. Tsui
25.3.4.1 Scanning Technique 25.3.4.3 Needle Insertion

• A linear (6–15 MHz) transducer is placed in a transverse • Use a 35–50 cm, 22–25G insulated needle.
location over the anterior surface of the proximal thigh • An in-plane (IP) approach is used for ultrasound-guided
approximately 0.5–2 cm inferior to the inguinal ligament obturator nerve block (Fig. 25.17).
along the inguinal crease. • The block needle is advanced from lateral to medial. It is
• Depth of penetration is 1–4 cm from the skin surface. important not to puncture the femoral vessels using this
• The femoral vessels are identified using the Doppler func- approach. In addition, the medial circumflex artery and
tion if necessary. The femoral vein is medial to the artery. vein (arising from the profunda femoris vessels) may tra-
• The pectineus muscle can be found medial to the femoral verse between the obturator externus, adductor magnus,
vein. Further medial movement of the probe along the and adductor brevis muscles [3]. The needle is first
inguinal crease reveals the adductor longus, brevis, and directed into the fascial plane between the adductor lon-
magnus muscles. At this location, the anterior division of gus and adductor brevis. After injection of local anes-
the obturator nerve lies in the fascial plane between thetic at this location, the needle is redirected to the deeper
adductor longus and brevis, while the posterior division plane between the adductor brevis and adductor magnus.
lies between adductor brevis and magnus.
• If the transducer is moved cranially toward the inguinal
ligament until the superior pubic ramus is identified, the
fascia separating pectineus from obturator externus may
be visualized. At this location, the anterior division of
the nerve runs between the obturator externus and pec-
tineus, while the posterior division pierces the obturator
externus.

• The nerves may not be visible. In this case, the target for
injection is the intermuscular fascial plane in which the
nerves traverse.
• The adductor muscles – adductor longus, brevis, and
magnus – are arranged vertically from superficial to deep.
The pectineus muscle is located lateral to the adductor
muscles (Fig. 25.16b).
• A hyperechoic fascial plane separates the adductor mus-
cles from each other.
• The anterior division may be seen as a hyperechoic, elon-
gated oval structure between the adductor longus and bre-
vis muscles. The posterior division has a similar
appearance and lies between the adductor brevis and
magnus muscles.
Fig. 25.17 In-plane needling technique for ultrasound-guided obtura-

tor nerve block. Blue rectangle indicates probe footprint
25.3.4.4 Local Anesthetic Application 25.3.6 Case Study

to local anesthetic application to visualize the spread and
confirm needle tip localization. Obturator Nerve Block (Contributed by A. Spencer)
• 0.25 mL/kg (maximum 10 mL) of 0.25 % bupivacaine or An 8-year-old male, 25 kg, presented for obturator nerve
0.2 % ropivacaine is injected at each interfascial plane. block and multiple orthopedic procedures including per-
• Upon injection, one should visualize longitudinal spread cutaneous hip adductor tenotomy and botox injections,
of the hypoechoic-appearing local anesthetic within the bilateral medial release, and tibialis anterior tendon
interfascial plane. lengthening. The patient had a complex history, includ-
ing mixed cerebral palsy with spastic and dyskinetic
components. The patient was ex-premature and suffering
from intellectual disability and was also wheelchair
Clinical Pearls
bound. Clinically, the patient also suffered from adductor
• Performing a test dose with D5W is recommended
muscle spasm and contractures and required repeated
prior to local anesthetic application to visualize the
obturator nerve phenol blocks. Other history included
spread and confirm nerve localization.
central sleep-disordered breathing and mild obstructive
• Local anesthetic spread should appear as a
sleep apnea. The patient’s preadmission medications
hypoechoic expansion around the nerve between
included baclofen, Sinemet, and Prevacid.
the fascial planes of the muscles.
The patient underwent a general anesthetic with
• Locate the femoral artery as a single vessel first,
endotracheal intubation and lower lumbar epidural for
then scan medially to locate the femoral vein. The
perioperative pain control. Phenol blocks were com-
pectineus muscle can be found medial to the femo-
pleted prior to the scheduled orthopedic procedures;
ral vein; finally, locate the adductor muscles medial
the upper thighs and groin areas were prepped with
to pectineus muscle.
chlorhexidine solution, and the leg was externally
rotated and slightly flexed to provide good exposure
for ultrasound scanning. An 80 mm, 22G echogenic
needle and an in-plane approach was used for the
25.3.5 Current Literature in Ultrasound- blocks (see Fig. 25.18). Phenol 6 % solution ×1.5 mL
Guided Approaches was deposited bilaterally in the fascia containing the
anterior division of the obturator nerve. Duration of
To date, there have been no clinical reports in the pediatric surgery was 4 h. The patient was comfortable in the
literature describing ultrasound guidance for obturator nerve recovery area under epidural analgesia; postoperative
block. analgesia consisted of a continuous epidural infusion
of bupivacaine 0.08 % at 5 mL per hour for 48 h.
Acetaminophen 375 mg po q6h regular and ketorolac
8 mg IV q8h regular for 48 h were also used.
Fig. 25.18 Ultrasound-guided obturator nerve block. AL

adductor longus, AB adductor brevis, P pectineus. See Case
Study for details
374 B.C.H. Tsui
25.4 Saphenous Nerve Block 25.4.2 Surface Anatomy (Fig. 25.19)
25.4.1 Indications After general anesthesia has been induced, the patient is
placed supine with the hip slightly externally rotated and the
The saphenous nerve is a sensory nerve providing cutaneous knee slightly flexed. Surface landmarks include:
innervation to the medial side of the thigh and foot. A saphe-
nous nerve block is a useful adjunct to a sciatic nerve block • Femoral triangle
when complete sensory blockade of the lower leg and foot is – Formed by the inguinal ligament superiorly, sartorius
desired (e.g., following major foot and ankle surgery). laterally, and adductor longus medially.
• Vastus medialis
Indications – Part of the quadriceps muscle group. It is a prominent
• Surgical procedures of the medial aspect of the lower leg muscle on the medial side of the lower half of the
and ankle (in combination with sciatic nerve block). thigh.
• Tibial tuberosity
– Bony prominence on the anteromedial aspect of the
tibia and inferior to the patella. Useful when perform-
ing subcutaneous landmark-based block
The needle puncture site is located approximately distal
one third of the thigh above the medial aspect of the knee.
Clinical Pearls: Landmark-Based Technique

(Transsartorial Approach)
• After raising a skin wheal of local anesthetic over
the sartorius muscle at the level of one finger width
above the patella, advance a 20G Tuohy pediatric
epidural needle in a caudad (45°) and slightly pos-
terior direction into the sartorius muscle in the
medial aspect of the lower thigh.
• A loss of resistance should be felt as the needle pen-
etrates the fat pad underneath the sartorius muscle
(approximately 1–2 cm, depending on the age and
size of the child).
• This “blind” transsartorial block approach described
first by van der Wal et al. [13] has shown to be more
effective than those performed at other block loca-
tions for producing anesthesia to the medial aspect
of the foot. The approaches using needle insertion
below the knee may limit the efficacy of the block
(i.e., failure to provide complete anesthesia of the
medial ankle), due to the oftentimes significant
branching of the nerve once it passes the knee [14].
25.4.3 Nerve Stimulation Technique
The saphenous nerve is purely sensory, and elicitation of par-

esthesia, which is often difficult and uncomfortable for
children, remains the only means to confirm the appropriate
needle placement. Therefore, nerve stimulators are not com-
monly used in children to localize this nerve.
Major anatomical structures in the thigh as captured by MRI

and VHVS images are shown with the corresponding ultra-
sound image in Fig. 25.20a.
Ultrasound guidance has been used successfully at differ-
Fig. 25.19 Surface anatomy for saphenous nerve block ent locations, depending on the visibility of landmarks in the
vicinity of the nerve. Two techniques (transsartorius and
perifemoral approach) place the needle near the adductor
canal, and one uses a paravenous (saphenous vein) approach.
While each approach may be effective, disadvantages to the
paravenous approach include the limited visibility of the
nerve at this distal location and the fact that the nerve may
have already branched significantly at this point [15]. The
transsartorius perifemoral approach, which occurs at the
mid-lower thigh (adductor canal) level and uses the large
femoral artery instead of the more distal saphenous branch of
the descending genicular artery [16] as a primary visible
landmark (via color Doppler), may be a superior option and
is described below.
376 B.C.H. Tsui
Fig. 25.20 (a) VHVS and MRI images showing the saphenous nerve just above the medial aspect of the patella. (b) Ultrasound image showing
the saphenous nerve just above the medial aspect of the patella
25.4.4.1 Scanning Technique (Fig. 25.20b) 25.4.4.3 Needle Insertion

• A linear (6–15 MHz) transducer is placed in a transverse • Use a 5 cm, 22G needle. Nerve stimulation is unnecessary
location over the anteromedial surface of the mid-thigh. since the saphenous nerve is purely sensory.
• The femoral artery is identified here along with the over- • The needle is advanced using an in-plane (IP) technique
lying sartorius muscle. The vastus medialis is anterolat- until it is medial to the artery and between the artery and
eral to the sartorius muscle at this location. the sartorius muscle (Fig. 25.21).
• The probe is scanned distally to the point where the femo- • A distinct “pop” may be felt as the needle passes through
ral artery begins to move posteriorly. (The artery exits the the adductor membrane (between adductor magnus and
adductor canal through the adductor hiatus to become the vastus medialis).
popliteal artery.)
• At this point, the saphenous nerve begins to cross from
anterolateral to anteromedial along with the artery within Clinical Pearls
the adductor canal. • Only a small volume of local anesthetic is required
for an effective saphenous nerve block. Too much
25.4.4.2 Sonographic Appearance local anesthetic could result in nerve injury second-
• The saphenous nerve is occasionally too small to be visi- ary to increased pressure within the compartment.
ble (Fig. 25.20b). • The saphenous nerve is small and can be difficult to
• The sartorius, vastus medialis, and adductor magnus locate even with ultrasound. However, the nerve
muscles are viewed in transverse with overlying subcu- usually lies in the fascial plane between the sartorius
taneous fat. and the vastus medialis muscles. Local anesthetic
• The femoral artery lies deep to the sartorius and is can be deposited in this plane.
anechoic in appearance. • Locate and follow the sartorius muscle with the fem-
• The femoral vein is deep to the artery and is compressible. oral artery underneath.
Fig. 25.21 In-plane needling technique for ultrasound-guided saphe-

nous nerve block at the lower thigh
378 B.C.H. Tsui
25.4.4.4 Local Anesthetic Application 25.4.6 Case Study

to local anesthetic application to visualize the spread and Saphenous Nerve Block (Contributed by S. Suresh)
confirm needle tip localization. An 8-year-old male, 23 kg, was scheduled for a left
• 0.15–0.25 mL/kg (maximum 10 mL) of 0.25 % bupiva- calcaneal osteotomy following an X-ray of the left
caine or 0.2 % ropivacaine is injected. foot. A left calcaneal osteotomy and lengthening and
cuboid closing wedge osteotomy were performed fol-
lowing a sciatic nerve block. The block was performed
Clinical Pearls under ultrasound guidance using a 22G needle and
• During injection, expansion of the hypoechoic solu- 5 mL 0.25 % bupivacaine with 1:200,000 epinephrine
tion in the fascial plane between the sartorius mus- (see Fig. 25.22). Surgery lasted 2 h, 18 min; block
cle and the vastus medialis muscle can be observed. duration was 6–12 h. Pain reporting was 8/10 half an
hour following surgery and 0/10 1 h after surgery.
Postoperative analgesia consisted of a morphine
(Duramorph) injection, 1.2 mg 30 min after surgery.
25.4.5 Current Literature in Ultrasound-
Guided Approaches
There has been a limited amount of literature describing or

evaluating the efficacy of the saphenous nerve block and its
various approaches. A paravenous approach of the saphe-
nous nerve block under ultrasound guidance in children has
recently been described [17]. At the level of the proximal
tibia, the saphenous nerve usually lies posteromedial to the
saphenous vein (although this position can vary). The saphe-
nous nerve can also be identified at the level of the ankle
where the nerve is in close proximity to the saphenous vein
(paravenous approach). A tourniquet can be tied around the
lower leg to distend the saphenous vein just proximal to the
ankle. Color Doppler can be used to aid identification of the
saphenous vein. The nerve is adjacent to the vein in the sub- Fig. 25.22 Ultrasound-guided saphenous nerve block. SN
cutaneous tissue. saphenous nerve, SFA superficial femoral artery, FV femoral
An ultrasound-guided transsartorial perifemoral approach vein. See Case Study for details
has also been described in adults [18] and can also be adopted
in children. This is a more proximal approach in the mid-
thigh position using the easily identifiable femoral artery.
When the high frequency 5–10 MHz hockey stick probe is
placed transversely in the mid-thigh position, the femoral
artery can be identified lying deep to the sartorius muscle. By
scanning distally, the point where the femoral artery courses
deep to become the popliteal artery can be determined. Just
proximal to this location – deep to the sartorius muscle and
medial to the femoral artery – is where local anesthetic can
be deposited.
References surgery: a sequel of an unsuccessful obturator nerve block. Acta

Anaesthesiol Scand. 1999;43:784–8.
13. van der Wal M, Lang SA, Yip RW. Transsartorial approach for
1. Oberndorfer U, Marhofer P, Bosenberg A, et al. Ultrasonographic
saphenous nerve block. Can J Anaesth. 1993;40:542–6.
guidance for sciatic and femoral nerve blocks in children. Br J
14. Benzon HT, Sharma S, Calimaran A. Comparison of the dif-
Anaesth. 2007;98:797–801.
ferent approaches to saphenous nerve block. Anesthesiology.
2. Farid IS, Heiner EJ, Fleissner PR. Comparison of femoral nerve
2005;102:633–8.
block and fascia iliaca block for analgesia following reconstructive
15. Krombach J, Gray AT. Sonography for saphenous nerve block near
knee surgery in adolescents. J Clin Anesth. 2010;22:256–9.
the adductor canal. Reg Anesth Pain Med. 2007;32:369–70.
3. Sethuraman M, Neema PK, Rathod RC. Combined monitored anes-
16. Gray AT, Collins AB. Ultrasound-guided saphenous nerve block.
thesia care and femoral nerve block for muscle biopsy in children
Reg Anesth Pain Med. 2003;28:148.
with myopathies. Paediatr Anaesth. 2008;18:691.
17. Miller BR. Ultrasound-guided proximal tibial paravenous
4. Gurnaney H, Kraemer F, Ganesh A. Ultrasound and nerve stimu-
saphenous nerve block in pediatric patients. Paediatr Anaesth.
lation to identify an abnormal location of the femoral nerve. Reg
2010;20:1059–60.
Anesth Pain Med. 2009;34:615.
18. Tsui BC, Ozelsel T. Ultrasound-guided transsartorial perifemoral
5. Frenkel O, Mansour K, Fischer JW. Ultrasound-guided femoral
artery approach for saphenous nerve block. Reg Anesth Pain Med.
nerve block for pain control in an infant with a femur fracture due
2009;34:177–8.
to nonaccidental trauma. Pediatr Emerg Care. 2012;28:183–4.
6. Miller BR. Combined ultrasound-guided femoral and lateral femo-
ral cutaneous nerve blocks in pediatric patients requiring surgical
repair of femur fractures. Paediatr Anaesth. 2011;21:1163–4.
7. Miller BR. Ultrasound-guided fascia iliaca compartment block Suggested Reading
in pediatric patients using a long-axis, in-plane needle technique:
a report of three cases. Paediatr Anaesth. 2011;21:1261–4. Dalens BJ. Blocks of nerves of the lumbar plexus supplying the lower
8. Ponde V, Desai AP, Shah D. Comparison of success rate of extremities. In: Dalens BJ, editor. Pediatric regional anesthesia.
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lation in children with arthrogryposis multiplex congenita: a ran- Dalens B. Lumbar plexus blocks. In: Dalens B, editor. Regional anes-
domized clinical trial. Paediatr Anaesth. 2013;23:74–8. thesia in infants, children, and adolescents. Philadelphia: Lippincott
9. Maccani RM, Wedel DJ, Melton A, Gronert GA. Femoral and lat- Williams & Wilkins; 1995. p. 321–33.
eral femoral cutaneous nerve block for muscle biopsies in children. Karmakar MK, Kwok WH. Ultrasound-Guided Regional Anesthesia. In:
Paediatr Anaesth. 1995;5:223–7. Cote CJ, Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB
10. Simion C, Suresh S. Lower extremity peripheral nerve blocks in Saunders; 2013. p. 880–908.
children. Tech Reg Anesth Pain Manag. 2007;11:222–8. Suresh S, Polaner DM, Cote CJ. Regional Anesthesia. In: Cote CJ,
11. Macalou D, Trueck S, Meuret P, et al. Postoperative analgesia after Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
total knee replacement: the effect of an obturator nerve block added 2013. p. 835–879.
to the femoral 3-in-1 nerve block. Anesth Analg. 2004;99:251–4. Tsui BC. Femoral block. In: Tsui BC, editor. Atlas of ultrasound and
12. Akata T, Murakami J, Yoshinaga A. Life-threatening haemor- nerve stimulation-guided regional anesthesia. New York: Springer;
rhage following obturator artery injury during transurethral bladder 2007. p. 161–70.
Part VIII
Nerve Blocks of the Sacral Plexus
Sciatic and Popliteal Nerve Blocks
26
Heather Y.Z. Ting and Ban C.H. Tsui
Contents
26.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
26.2 Posterior Gluteal (Labat) Sciatic Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
26.2.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
26.2.2 Nerve Stimulation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
26.2.3 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
26.2.4 Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
26.3 Infragluteal/Subgluteal Sciatic Nerve Block Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
26.3.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
26.3.4 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
26.4 Anterior Sciatic Nerve Block Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
26.4.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
26.5 Popliteal or Mid-Thigh Sciatic Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
26.5.1 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
26.5.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
26.6 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
H.Y.Z. Ting, MD, FRCPC

University of Alberta Hospital, 8440-112 St NW, 2-150 Clinical
Sciences Building, Edmonton, AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_26
384 H.Y.Z. Ting and B.C.H. Tsui
26.1 Indications 26.2.1 Surface Anatomy (Figs. 26.1 and 26.2)
Indications The patient is placed in the lateral decubitus position with

• Sciatic nerve before bifurcation: the legs flexed at the hip and knee. Surface landmarks
– Knee surgery (with supplemental blockade of the fem- include:
oral nerve)
– Removal of leg implants • Greater trochanter of the femur
• Sciatic nerve after bifurcation (may require supplemental • Sacral hiatus
blockade of the saphenous nerve): • Posterior superior iliac spine
– Surgery on the lower limb
– Foot and ankle surgery The point of needle entry when using the landmark tech-
nique is where a perpendicular line drawn at the midpoint
between the greater trochanter and posterior superior iliac
26.2 Posterior Gluteal (Labat) Sciatic spine intercepts a line drawn between the greater trochanter
Nerve Block and the sacral hiatus.
The sciatic nerve at this location is deep compared to other

approaches described in the subsequent sections of this
chapter and can therefore be more challenging technically.
Fig. 26.2 Surface landmarks for posterior gluteal sciatic nerve block
Fig. 26.1 Skeletal model showing anatomical landmarks for posterior

gluteal sciatic nerve blockade
26 Sciatic and Popliteal Nerve Blocks 385
26.2.2 Nerve Stimulation Technique described above and advanced in the direction of the
ischium.
The approach described here is a modification of the • The sciatic nerve may be reached at a variable depth,
landmark-based approach described by Winnie [1] with sim- depending on the child’s size and adiposity, but the depth
plified landmarks and is typically easier to perform than the may be approximated as about 1 mm per kg of weight
lateral or anterior approach [2]. (especially between 20 and 40 kg) with relatively less
Nerve stimulation in conjunction with ultrasound guid- depth for younger children and greater depth for older
ance is recommended for enhanced nerve localization using children [2].
a posterior approach due to the depth of the sciatic nerve in • If there is bony contact, the needle may either be touching
the gluteal region. the iliac bone or the ischial spine. In these cases, the
needle tip has been placed too cephalad or too medial,
26.2.2.1 Needle Insertion respectively, or the needle is too deep.
A flowchart illustrating the needle insertion site and proce- • The inferior gluteal and internal pudendal vessels are at
dures is shown in Fig. 26.3. risk for puncture if the needle is directed too medially.
• With the operator facing the patient’s back, a 50–80 mm,

22G–25G needle (depending on the age and size of the
child) is inserted perpendicular to the skin at the landmark
Sciatic block
posterior gluteal approach
Strongly recommend
concurrent use of nerve
stimulation and
ultrasound guidance
Position:lateral decubitus
with flexion at knees and
hips
Site:Labat’s approach
(see Fig. 26.2)
Needle insertion:
Fig. 26.3 Flowchart of needle insertion and procedures for posterior

gluteal sciatic nerve block
26.2.2.2 Current Application and Appropriate success of complete block than plantar flexion. Foot
Responses eversion indicates stimulation of the superficial peroneal
Figure 26.4 illustrates the procedure for employing nerve nerves only and is associated with incomplete block [3].
stimulation techniques for lumbar plexus block. • See Table 14.4 for expected motor responses during nerve
stimulation.
• Initially, set the nerve stimulator to apply a current of
1–1.5 mA (2 Hz, 0.1–0.2 ms), and aim to elicit motor
twitches at a current intensity threshold of 0.4 mA (0.1– Clinical Pearl
0.2 ms) once the nerve is localized. Motor response cessa- A double-injection technique has been used for proxi-
tion at currents less than 0.2 mA indicates that the needle mal and popliteal sciatic nerve blocks in order to accu-
is probably at an intraneural location. rately localize the two components of the sciatic nerve
• Visible or palpable twitches of the hamstring, calf and thus provide greater block success (with shorter
muscles, foot, or toes verify stimulation of the sciatic latency) and allow lower total doses of local anesthetic.
nerve. However, this may increase the potential risk of nee-
• Inversion of the foot or plantar flexion is sought, with dling trauma.
inversion producing a more rapid onset and increased
Nerve stimulation
sciatic block

as nerve is localized

Withdraw needle See Fig 26.5

until stimulation
disappears at
<0.4 mA
Twitches of hamstring,
calf, foot or toes
foot inversion is ideal
Aspirate and inject

local anesthetic
Fig. 26.4 Flowchart for employing nerve stimulation technique for

posterior gluteal sciatic nerve block
26.2.2.3 Modifications to Inappropriate

Responses (Table 26.1)
An algorithm of modifications in case of inappropriate
responses to nerve stimulation is shown in Fig. 26.5.
Table 26.1 Responses and recommended needle adjustments for use with nerve stimulation during sciatic nerve block (posterior gluteal approach)
Visible or palpable twitches in any of the hamstring or calf muscles, foot, or toes, at 0.2–0.5 mA. Up to 1.0 mA may be required in some
patients (diabetic, peripheral vascular disease, sepsis)
Other common responses and needle adjustment
Gluteus maximus (local twitch from direct stimulation)
Needle adjustment: advance needle tip
Deep muscle layer (local twitch of inferior or superior gemellus, obturator internus, or quadratus femoris muscles)
Explanation: needle advanced too deep and beyond the nerve
Needle adjustment: withdraw needle to the skin and redirect slightly medially or laterally
Vascular puncture
Inferior gluteal or internal pudendal vessels puncture
Explanation: needle tip placed too medially
Needle adjustment: withdraw needle to skin and reinsert more laterally
Bone contact
Iliac bone (close to gluteus insertion)
Explanation: needle tip too superior
Needle adjustment: withdraw completely and reinsert according to protocol (check landmarks)
Ischial spine
Explanation: needle inserted at too medial position or angled in a medial direction
Needle adjustment: withdraw completely and reinsert in a more lateral direction
Common responses to nerve stimulation

during posterior gluteal sciatic block
IIiac bone contact without

Bony contact without sciatic Gluteus maximus Needle very deep without
local m. twitch close to gluteal
nerve twitch (direct stimulation) twitch
insertion
Needle is superficial & Needle is deep with

Too lateral (femur) or Needle is superficial
superior to target incorrect landmarks
medial (ischial bone)
Reassess landmarks and Reassess landmark and

Withdraw and redirect
redirect needle inferiorly Advance needle reinsert needle
needle appropriately
Sciatic nerve
• Hamstring
• Calf muscles
• Foot muscles
• Toes
Aspirate and inject local

anesthetic
Fig. 26.5 Flowchart of modifications to inappropriate responses to nerve stimulation during posterior gluteal sciatic nerve block
26.2.3 Ultrasound-Guided Technique The ischial tuberosity is very thin in children under 1 year of
age and may be more difficult to palpate or view sonographi-
For a summary of ultrasound guidance techniques for poste- cally [4]. Laterally, the medial aspect of the greater trochan-
rior gluteal sciatic nerve blocks, see Fig. 26.6. ter will appear largely hypoechoic, although its size will
Major anatomical structures of the sciatic nerve in the depend on the age of the child, and it will only become
gluteal region as captured by MRI and VHVS images are highly recognizable at 6–8 years of age [5]. The femoral con-
shown with the corresponding ultrasound image in Fig. 26.7a. dyles are cartilaginous between the first and third years of
Prepare the needle insertion site and skin surface with an life and do not ossify and develop their distinctive shape with
antiseptic solution. Prepare the ultrasound probe surface by visible sonographic appearance until 7–9 years of age; there-
applying a sterile adhesive dressing to it prior to needling as fore, the borders of the femur may not be as hyperechoic in
discussed in Chap. 4. young children.
There are some differences between adults and children
in terms of their anatomical landmarks and sonoanatomy.
sciatic block
Position probe in a
slightly oblique
transverse plane
Place probe in
gluteal region over
ischial bone
Scan cephalad and

caudally
Identify widest
portion of ischial
bone, with ischial
spine medially and
bony shadowing of
femur laterally
Identify inferior
gluteal artery and
adjacent sciatic
nerve between two
bony landmarks
Insert needle using

OOP or IP
technique

for confirmation
Aspirate and inject

local anesthetic
Fig. 26.6 Flowchart of ultrasound guidance technique for posterior

gluteal sciatic nerve block
Fig. 26.7 (a) VHVS and MRI images of anatomical structures surrounding the sciatic nerve in the posterior gluteal region. (b) Ultrasound image
of the posterior gluteal sciatic nerve block location
26.2.3.1 Scanning Technique 26.2.4 Local Anesthetic Application
• The choice of ultrasound probe for this block will depend • Ensure negative aspiration of blood prior to injection of
on the size of the patient. For young children, a high- local anesthetic.
frequency linear probe (10–5 MHz) can be used, although • Dalens et al. [2] described the use of four anesthetic solu-
in older or larger patients, a curved, lower-frequency tions, each with 1:200,000 epinephrine (15 patients in
(5–2 MHz) probe may be required for increased depth of each group): (1) 1 % lidocaine, (2) 0.5 % bupivacaine, (3)
penetration. a mixture of equal volumes of 0.5 % bupivacaine and 1 %
• The probe is moved cephalad and caudad in the gluteal lidocaine, and (4) a mixture of equal volumes of 0.5 %
region to examine the ischial bone (a hyperechoic line bupivacaine and 1 % etidocaine. The local anesthetic
with bony shadowing). Locate the widest portion of this solution was administered on a weight basis: 0.5 mL/kg in
bone that includes the ischial spine in the medial aspect. patients weighing less than 20 kg and 10 mL plus 0.25 mL/
• The gluteus maximus muscle will be visible superficial kg of patient’s weight exceeding 20 kg, up to 25 mL max-
and posterior to the sciatic nerve. imum injected volumes.
• Alternatively, the sciatic nerve can be first located in the • Small amounts of local anesthetic (0.3–0.5 mL/kg of
subgluteal region at approximately the midpoint between 0.5 % bupivacaine for single limb blocks and 0.3 mL/kg
the greater trochanter and ischial tuberosity and traced 0.25 % bupivacaine per side for bilateral blocks) have also
proximally. proven effective [6–8].
• Identification of the internal pudendal artery and vein • Ivani et al. [9] suggested a bolus dose of 0.4–0.6 mL/kg
adjacent to the ischial spine, as well as the inferior gluteal of 0.2 % ropivacaine for postoperative analgesia and a
artery immediately adjacent to the sciatic nerve, may be higher concentration of 0.5 % ropivacaine if intraopera-
facilitated with color Doppler. tive pain control is required. They also described the
use of clonidine 2 μg/kg in their local anesthetic
26.2.3.2 Sonographic Appearance mixture.
• The same group also suggested that ropivacaine and
• The sciatic nerve is hyperechoic and often appears wide levobupivacaine are probably the best choice for longer
and flat in short axis (Fig. 26.7b). operations when pain is more intense and long-lasting
• Overlying the sciatic nerve is the distinctive gluteus maxi- [10].
mus, which has a “starry night” pattern, and the inner • Due to the anatomy of the nerves in children (smaller
muscle layers (superior and inferior gemellus muscles diameter and shorter distance between the nodes of
and quadratus femoris muscle) are often indistinct. Ranvier), larger volumes with lower concentrations are
key to obtaining effective analgesia [11].
26.2.3.3 Needle Insertion • We recommend the use of ropivacaine 0.2 %, bupivacaine
0.25 %, or levobupivacaine 0.25 %, with a volume of
• Both in-plane (IP) and out-of-plane (OOP) approaches 0.25–0.5 mL/kg.
are appropriate for ultrasound-guided sciatic nerve block • As a guideline, lower concentrations should be used in
using the posterior gluteal approach. children below the age of 6 years. Based on clinical
• OOP approach (Fig. 26.8): the needle is inserted inferior experience, 6–12 h of analgesia can be expected [12].
to the probe in a cephalo-anterior direction. Since the • The dose of local anesthetic should not exceed the
nerve is deep at the gluteal region, needle insertion at a maximum toxic dose.
steep angle immediately next the transducer may increase
the visibility of the needle tip. Ultrasound Considerations
• IP approach (Fig. 26.9): the needle may be advanced in a • Performing a test dose with D5W is recommended prior
lateral-to-medial direction, penetrating the gluteus maxi- to local anesthetic application to visualize the spread and
mus muscle prior to reaching the sciatic nerve above the confirm nerve localization. Deposit the local anesthetic
ischial bone. solution over and around the sciatic nerve.
Fig. 26.8 Out-of-plane needling technique for ultrasound-guided pos- Fig. 26.9 In-plane needling technique for ultrasound-guided posterior
terior gluteal sciatic nerve block. Blue rectangle indicates probe gluteal sciatic nerve block. Blue rectangle indicates probe footprint
footprint
26.3 Infragluteal/Subgluteal Sciatic Nerve • Ischial tuberosity

Block Approach • Greater trochanter
In contrast to the Labat/gluteal sciatic nerve block, the infra- The needle is inserted at the midpoint of a line drawn
gluteal/subgluteal approach targets the sciatic nerve at a between the greater trochanter and the ischial tuberosity at
more superficial location. the level of the gluteal crease (Figs. 26.10 and 26.11).
26.3.1 Surface Anatomy (Fig. 26.10)
The patient can be placed in the lateral decubitus position

with the hip flexed and knee slightly extended, or they may
be positioned prone. Surface landmarks include:
Fig. 26.11 Surface landmarks for subgluteal approach to sciatic nerve

block
Fig. 26.10 Skeletal model showing anatomical landmarks for subglu-

teal sciatic nerve blockade

Landmark technique
The authors recommend combining nerve stimulation with sciatic black
subgluteal approach
ultrasound guidance for infragluteal/subgluteal sciatic blocks.

A flowchart illustrating the needle insertion site and proce- Recommend use of nerve
stimulation
dures is shown in Fig. 26.12.
• A 50–80 mm, 22G–25G needle (depending on the child’s

Position:lateral decubitus
age and size) is inserted perpendicularly to the skin until with flexed hip and
a loss of resistance is felt upon entrance to the common extended knee
sheath.
• The depth of the sciatic nerve will be variable and age
dependent.
Site:midpoint on line
• In situations of needle contact with bone: between the greater
– Touching the iliac bone: needle tip is placed too trochanter and ischial
cephalad. tuberosity
– Touching the hip joint: needle is located too deep and
lateral.
– Touching the ischium: needle is deep and medial. Needle insertion:
Bony contact
IIium Hip Ischium
Needle Needle
Needle
deep and deep and
superior
lateral medial
Reinsert and re-angle
Loss of resistance upon

entering common sheath at
appropriate depth (see text)
Aspirate and inject

local anesthetic
Fig. 26.12 Flowchart of needle insertion and procedures for subglu-

teal sciatic nerve block
26.3.2.2 Current Application and Appropriate • Visible or palpable twitches of the hamstring or calf
Responses muscles, foot, or toes verify stimulation of the sciatic
Figure 26.13 illustrates the procedure for employing nerve nerve.
stimulation techniques for subgluteal sciatic nerve block. • Twitches in the foot indicate stimulation of the tibial and
common peroneal nerves rather than the proximal
• Applying an initial current of 1–1.5 mA (2 Hz, 0.1– branches of the sciatic nerve and suggest optimal needle
0.2 ms) is sufficient for stimulation of the sciatic nerve. placement. Ideally, inversion of the foot, which is indic-
After obtaining the appropriate motor response, the cur- ative of tibial nerve stimulation, is sought [3].
rent is reduced to aim for a threshold current of 0.4 mA • See Table 14.4 for expected motor responses during nerve
(0.1–0.2 ms). Motor response cessation at currents less stimulation.
than 0.2 mA indicates that the needle is probably in an
intraneural location.
Nerve stimulation
sciatic block
subgluteal approach


Withdraw needle See Fig. 26.14

until stimulation
disappears at
<0.4 mA
Twitches of hamstring,
calf, foot or toes
foot inversion is ideal
Aspirate and inject

local anesthetic
Fig. 26.13 Procedure for employing nerve stimulation technique dur-

ing subgluteal sciatic nerve block

Table 26.2 Responses and recommended needle adjustments for use with nerve stimulation during sciatic nerve block (subgluteal approach)
Twitches (visible or palpable) in any of the hamstring or calf muscles, foot, or toes, at 0.2–0.5 mA. Up to 1.0 mA may be required in some
patients (diabetic, peripheral vascular disease, sepsis)
Gluteus maximus (local twitch from direct stimulation)
Needle adjustment: advance needle tip
Bone contact
Iliac bone (close to gluteus insertion)
Explanation: needle tip too superior
Needle adjustment: withdraw completely and reinsert according to protocol (check landmarks)
Ischial or hip joint
Explanation: needle missed the plane of the sciatic nerve and the tip is placed too far medially (ischial) or laterally (hip)
Needle adjustment: withdraw completely and reinsert with a 5–10° angle adjustment
Deep (10 cm) but no response; it is likely that the needle has been placed in the greater sciatic notch
Explanation: needle tip too inferior and medial
Needle adjustment: withdraw completely and reinsert slightly superiorly

stimulation during subgluteal
sciatic block
Gluteus maximus Deep muscle layer Vascular puncture

(inferior or superior IIiac bone (close to Ischial spine
(direct stimulation) (inferior gluteal or gluteus insertion)
gemellus;obturator internal pudendal
internus;quadratus vessels)
femoris)
Needle too Needle too superior Needle too medial
superficial
Needle advanced Needle too medial
too deep and
beyond nerve Withdraw needle Withdraw needle
Advance needle
and reinsert and reinsert more
Withdraw needle laterally
Withdraw needle and reinsert
and redirect
slightly medially or
laterally
Sciatic nerve
• Hamstring
• Calf muscles
• Foot muscles
• Toes
Aspirate and inject

local anesthetic
Fig. 26.14 Flowchart of modifications to inappropriate responses to nerve stimulation during subgluteal sciatic nerve block
26.3.3 Ultrasound-Guided Technique 26.3.3.1 Scanning Technique
For a summary of ultrasound guidance techniques in subglu- • A high-frequency (10–5 MHz) linear probe is appropriate
teal sciatic nerve blocks, see Fig. 26.15. for most children. Larger children and adolescents may
Major anatomical structures surrounding the sciatic nerve require the use of a curved, low-frequency (5–2 MHz)
using a subgluteal approach as captured by MRI and VHVS probe.
images are shown with the corresponding ultrasound image • Position the probe to obtain a short-axis view of the sci-
in Fig. 26.16. atic nerve, usually between the ischial tuberosity and the
Prepare the needle insertion site and skin surface with an greater trochanter of the femur.
antiseptic solution. Prepare the ultrasound probe surface by • Tilt and/or rotate the probe to optimize the ultrasound
applying a sterile adhesive dressing to it prior to needling as image of the sciatic nerve.
discussed in Chap. 4. • If the sciatic nerve is hard to localize at the subgluteal
region, it can be traced proximally from the bifurcation
point at or near the apex of the popliteal fossa
sciatic block
subgluteal approach
Position probe to
obtain short axis
view of sciatic n.
Place probe
between ischial
tuberosity and
greater trochanter
Tilt or rotate to
obtain clear view
Identify
hyperechoic and
often elliptical
sciatic nerve
between two bony
landmarks
Insert needle using

OOP or IP
technique

for confirmation
Aspirate and inject

local anesthetic
Fig. 26.15 Flowchart of ultrasound guidance technique for subgluteal

sciatic nerve block
Fig. 26.16 (a) VHVS and MRI images of anatomical structures surrounding the sciatic nerve in the subgluteal region. (b) Ultrasound image of
the subgluteal sciatic nerve block location
26.3.3.2 Sonographic Appearance 26.3.3.4 Local Anesthetic Application

See Sect. 26.2.4.
• On the lateral side, the greater trochanter appears round
with a hyperechoic edge and associated hypoechoic bony Ultrasound Considerations
shadowing. • Ultrasound guidance may allow for lower volumes of
• The sciatic nerve in the subgluteal region appears pre- local anesthetic compared to the nerve stimulation
dominantly hyperechoic and is often elliptical in a short- technique.
axis view (Fig. 26.16b). • Local anesthetic is injected following careful aspiration
and injection of a test dose of D5W to visualize the spread
and confirm nerve localization.
26.3.3.3 Needle Insertion • Deposit local anesthetic next to, but not directly within,
the sciatic nerve structure in the subgluteal region. A
• An OOP technique will result in the shortest possible hypoechoic local anesthetic fluid collection is often seen
needle path (Fig. 26.17). Since the nerve is deep, inserting around the hyperechoic nerve during injection.
the needle at a steep angle immediately next the trans-
ducer may increase the visibility of the needle tip.
• An IP alignment (Fig. 26.18) may allow for greater ease
of needle shaft and tip recognition than OOP alignment.
Use color Doppler to identify any blood vessels, such that
the needle trajectory can be modified to avoid vascular
puncture.
Fig. 26.17 Out-of-plane needling technique for ultrasound-guided Fig. 26.18 In-plane needling technique for ultrasound-guided subglu-
subgluteal sciatic nerve block. Blue rectangle indicates probe footprint teal sciatic nerve block. Blue rectangle indicates probe footprint
26.3.4 Case Study
Sciatic Nerve Block (Subgluteal Approach)

(Contributed by A. Sawardekar)
A 10-year-old girl, 40 kg, with no previous medical
history, presented with a left ankle fracture after falling
while playing basketball. The fracture was confirmed by
X-ray. Open reduction and internal fixation of the ankle
was scheduled, and a left sciatic nerve block was chosen
for pain control. An ultrasound-guided sciatic nerve
block with a subgluteal approach was administered. A
22G, 80 mm needle and a 13–6 MHz linear high-fre-
quency probe were used; the sciatic nerve was visualized
at the subgluteal-parabiceps area, medial to the femur
(Fig. 26.19). Ten mL 0.25 % bupivacaine was injected,
and the block lasted for 8 h. Duration of surgery was
120 min. No additional analgesics were needed in the
recovery room. The patient was discharged home after
2 h in the recovery room and was given instructions to
take oral hydrocodone once sensation had returned to the
operative extremity.
Note: As seen in the figure, the nerve appears to
expand following suspected injection into the epineurium
and encompasses the needle tip. Although no neurologic
sequelae were noted in this case, this practice is debat-
able, as some practitioners prefer to inject outside the
epineurium.
Fig. 26.19 Ultrasound-guided sciatic nerve block using a subglu-
teal approach. SN sciatic nerve, arrowheads indicate needle position
(see Case Study for details)
26.4 Anterior Sciatic Nerve Block from the sciatic nerve to facilitate easy nerve access
Approach (Fig. 26.20). Surface landmarks include:
Compared to the posterior approach, the anterior approach • Anterior superior iliac spine (ASIS)
is more difficult to perform due to the requirement of • Pubic tubercle
deeper needle insertion. In adults, it is a viable and impor- • Greater trochanter
tant alternative when the patient must be kept in a supine • Lesser trochanter
position. • Femoral crease
Three lines are drawn: (1) between the ASIS and the
26.4.1 Surface Anatomy pubic tubercle (inguinal ligament); (2) from the greater tro-
chanter towards the inner thigh, parallel to the inguinal liga-
The patient is placed in the supine position with the hip and ment; and (3) perpendicular to the first line, beginning at the
knee slightly flexed and the hip externally rotated. junction of its medial one-third and lateral two-thirds. The
Alternatively, the leg can be kept straight with slight internal needle insertion site is approximately at the intersection of
rotation. These approaches move the lesser trochanter away the latter two lines (Fig. 26.21).
Fig. 26.20 Skeletal model illustrating the appearance of the lesser trochanter with neutral, internal, and external rotation of the hip
Fig. 26.21 Surface landmarks for anterior sciatic nerve block

26.4.2 Nerve Stimulation Technique 26.4.2.2 Current Application and Appropriate

Responses
26.4.2.1 Needle Insertion Figure 26.23 illustrates the procedure for employing nerve
A flowchart illustrating the needle insertion site and proce- stimulation techniques for anterior sciatic nerve block.
• An initial current of 1–2 mA (2 Hz, 0.1–0.2 ms) is suffi-
• A 50–100 mm, 22G–25G insulated block needle (depends cient for stimulation of the sciatic nerve. After obtaining
on the age and size of the child) is inserted at the location the appropriate motor response, the current is reduced to
described above and advanced perpendicularly to the aim for a threshold current of 0.4 mA (0.1–0.2 ms). Motor
operating table until the bone (lesser trochanter) is response cessation less than 0.2 mA indicates that the
encountered. The needle is “walked off” the bone medi- needle is probably in an intraneural location.
ally and cephalad to enter the adductor magnus muscle. • Visible or palpable twitches in the leg, foot, or toes verify
• When the needle has penetrated the adductor magnus stimulation of the sciatic nerve.
muscle and entered the sciatic neurovascular compart- • See Table 14.4 for expected motor responses during nerve
ment, loss of resistance may be felt. stimulation.
• The depth of needle insertion will be at least twice that of
the posterior approach [2].
Nerve stimulation
Sciatic nerve block
sciatic nerve block
anterior approach
anterior approach
Recommend use of nerve

stimulation Use 1 mA at Hz initially
Position: supine, flexed Reduce current to 0.4 mA

hip and knee and as nerve is localized
externally rotated hip

Site: see Fig. 26.21 than 0.4 mA nerve stimulation
Needle insertion: Withdraw needle

See Fig. 26.24
perpendicular to table until stimulation
disappears at
<0.4 mA
Contact lesser trochanter
Twitches in toes,
“Walk off” bone medially foot, or calf
and cephalad
Aspirate and inject

local anesthetic
Loss of resistance upon
entering sciatic neuro-
vascular compartment
Fig. 26.23 Procedure for employing nerve stimulation technique for
anterior sciatic nerve block
Aspirate and inject

local anesthetic
Fig. 26.22 Flowchart of needle insertion and procedures for anterior

sciatic nerve block

Table 26.3 Responses and recommended needle adjustments for use with nerve stimulation during sciatic nerve block (anterior approach)
Twitches obtained (visible or palpable) from the calf, foot, or toe muscles at 0.2–0.5 mA current. Twitches of the quadriceps muscles will
likely occur during advancement
Quadriceps (patella twitch):
Explanation: needle placement too superficial
Needle adjustment: continue to advance the needle
Iliopsoas or pectineus (local twitch at femoral crease area):
Explanation: needle tip placement is too superior
Needle adjustment: withdraw needle completely and reinsert more inferiorly
Hamstrings (branches of the sciatic nerve or direct stimulation of muscles)
Explanation: needle possibly too inferior and caudally directed, although often this is not specific
Needle adjustment: withdraw needle completely and reinsert in a slightly more medial or lateral direction (5–10° in transverse plane)
Bone contact
Femur (usually lesser trochanter)
Explanation: needle tip directed too laterally or excessive lateral rotation of the femur
Needle adjustment: withdraw needle 2–3 cm and internally rotate the leg, then continue; if this fails withdraw the needle to the
subcutaneous tissue and reinsert it in a more medial direction
Deep needle advancement but no response
Explanation: needle tip is often too medial
Needle adjustment: withdraw completely and reinsert at a slightly more lateral position

stimulation during anterior
sciatic block
Hamstring (sciatic n. Iliopsoas or No bony contact

Quadriceps
branches or direct pectineus and
(femoral n.)
stimulation) (direct stimulation) no stimulation
Needle is too Needle plane is

Needle is shallow Needle is medial
medial or lateral superior
Continue Redirect laterally or

Reinsert inferiorly Reinsert laterally
advancing needle medially
Sciatic nerve
• Calf muscles
• Foot muscles
• Toes
Aspirate and inject

local anesthetic
Fig. 26.24 Flowchart of modifications to inappropriate responses to nerve stimulation during anterior sciatic nerve block

For a summary of ultrasound guidance techniques in anterior sciatic nerve block
sciatic nerve blocks, see Fig. 26.25. anterior approach
Anatomical details of the sciatic nerve in the anterior
aspect of the upper thigh as captured by MRI and VHVS
images are shown with the corresponding ultrasound image
Position probe in a
in Fig. 26.26. transverse axis
antiseptic solution. Prepare the ultrasound probe surface by
applying a sterile adhesive dressing to it prior to needling as
discussed in Chap. 4. Place probe distal to
femoral crease
Move probe medially

and laterally to
identify the femur
Preferred approach
Capture view of
hyperechoic sciatic
nerve medial to
femur
Rotrate probe 90˚ to a
longitudinal axis
Insert needle using

Identify nerve as
OOP or IP
hyperechoic cable
technique
Insert needle using

IP technique

for confirmation
Aspirate and inject

local anesthetic
Fig. 26.25 Flowchart of ultrasound guidance technique during ante-

rior sciatic nerve block
Fig. 26.26 (a) VHVS and MRI images of anatomical structures sur- nerve block location. (c) Ultrasound image showing a longitudinal view
rounding the sciatic nerve in the anterior aspect of the upper thigh. The of the sciatic nerve during the anterior approach. The nerve appears as
white box depicts ultrasound scanning from a lateral-to-medial direc- a hyperechoic “cable” when turning the transducer 90° relative to the
tion to improve visualization. (b) Ultrasound image of anterior sciatic transverse view
26.4.3.1 Scanning Technique needle in an anteromedial to posterolateral direction. An

OOP approach (Fig. 26.28) involves inserting the needle
• A curved, low-frequency (5–2 MHz) probe is suitable for at a steep angle, almost perpendicular, along the midline
scanning the sciatic nerve in the proximal thigh. of the probe. A steep angle is used since the nerve is deep,
• Place the probe over the proximal one-third of the thigh. and it may be easier to visualize the needle with this
• A transversely placed probe tends to be commonly used approach.
to view the sciatic nerve in the short axis, although the • If the probe is placed longitudinally (Fig. 26.29), the sci-
nerve may be best visualized by rotating the probe 90° to atic nerve appears as a long, linear “cable,” expanding the
view the nerve longitudinally. The nerve appears as a visible surface area of the nerve. Therefore, an IP approach
“cable,” which may aid in its identification and needle will be useful and will maximize the chance of success
placement [13]. since a “wider” target is presented.
• Moving in a lateral-to-medial direction may also aid in
nerve imaging with a longitudinally placed transducer. At
first, the femur, which casts a hypoechoic bony shadow, is
seen. As the probe is moved medially, a long, hyperechoic
cable-like structure can be seen.

As the sciatic nerve courses along the upper thigh, it is
mostly obscured by the femur when viewed from the anterior
aspect. The nerve is located deep to the adductor magnus
muscle within the posterior medial thigh compartment.
• In transverse axis, the sciatic nerve often appears oval or

round, predominantly hyperechoic, and is medial and
posterior to the lesser trochanter and deep to the adductor
magus muscle (Fig. 26.26b).
• The femoral neurovascular structures can be identified
using the Doppler and are visible superficial to the hyper-
echoic fascial tissue and lateral to the sciatic nerve. The
neurovascular structures are better visualized when the
leg is externally rotated. A longitudinal view captures a
broad, linear, and hyperechoic cable of fibers and may
allow for easier identification of the nerve [13]
(Fig. 26.26c).
• Color Doppler should be employed to identify any
branches of the femoral artery or inferior gluteal artery in
close proximity to the sciatic nerve or in the needle
trajectory.
• When using a probe positioned in transverse axis to the Fig. 26.27 Needling technique for anterior sciatic nerve block using
an in-plane needle approach with a transverse view. Blue rectangle indi-
nerve, an IP approach (Fig. 26.27) involves advancing the cates probe footprint
26.4.4 Local Anesthetic Application Ultrasound Considerations

• After careful aspiration and injection of a test dose of
See Sect. 26.2.4. D5W to visualize the anesthetic spread and confirm nerve
localization, inject the local anesthetic so that it spreads
over and around the sciatic nerve.
Fig. 26.28 Needling technique for anterior sciatic nerve block using Fig. 26.29 Needling technique for anterior sciatic nerve block using
an out-of-plane approach with a transverse view. Blue rectangle indian in-plane approach with a longitudinal view. Blue rectangle indicates
cates probe footprint probe footprint
26.5 Popliteal or Mid-Thigh Sciatic • Inferior triangle of the popliteal fossa: located below the
Nerve Block popliteal crease and bordered by the gastrocnemius; this
triangle is an inversion of the superior triangle.
Blocking the sciatic nerve in the popliteal fossa is a relatively
easy procedure, making it desirable for blocks at or below Typically, the point of needle insertion is within the
the knee. Due to the variable and oftentimes proximal divi- superior triangle of the popliteal fossa at the lower third of
sion of the sciatic nerve, a landmark-based approach to the the triangle, immediately medial to the biceps femoris ten-
popliteal block may result in blockade of the distinct (poste- don. This point will be lateral to the popliteal artery. The
rior) tibial or common peroneal nerves, rather than the com- knee can be flexed for palpation of the tendons, allowing
mon sciatic nerve. It is useful to place the needle proximal in the boundaries of the popliteal fossa to be marked. If the
the popliteal fossa in attempt to locate the sciatic nerve [14]. tendons are indistinguishable, it may be possible to palpate
Table 26.1 describes methods for locating the common sci- the apex of the triangle, where the muscle bellies of the
atic nerve when performing this block using the landmark/ semitendinosus (medial) and biceps femoris (lateral) mus-
blind technique. With the use of ultrasound, it is possible to cles join. Otherwise, tightening the posterior thigh muscu-
locate the bifurcation of the sciatic nerve, thus enabling lature by applying slight passive extension of the knee with
blockade of both branches at the popliteal fossa. the hip flexed may also be helpful for landmark identifica-
tion [15].
Indications The distance from the popliteal fold to the point of needle
• Foot and ankle surgery insertion can also be defined relative to patient weight. If the
• Other procedures involving the tibia and fibula, for exam- weight of the patient <10 kg, the distance from the popliteal
ple, amputation below the knee fold to the point of insertion is 1 cm. If the patient’s weight
is 10–20 kg, the point of insertion is 2 cm, 20–30 kg is 3 cm,
etc. [7].
26.5.1 Surface Anatomy
The patient may be placed in the lateral position with the Clinical Pearl
knee extended as much as possible or in the prone position. A lateral approach to the sciatic nerve at the popliteal
A supine position can be modified by elevating the child’s fossa may also be used. With this approach, the patient
leg with the hip and knee flexed. If nerve stimulation will be is positioned supine, and the leg and hip do not need to
used, the ankle should be extended off the end of the table. be flexed. The needle is inserted at a posterior angle
Surface landmarks include: (30° from the horizontal) at the junction of the tendon
of the biceps femoris and the vastus lateralis muscles.
• Superior triangle of the popliteal fossa: formed by the One drawback may be the need for double injection to
popliteal crease (base), biceps femoris tendon (lateral), block both divisions of the sciatic nerve [16].
and semimembranosus and semitendinosus tendons
(medial) (Fig. 26.30).
Fig. 26.30 Surface anatomy of the superior triangle of the popliteal fossa

Popliteal sciatic
A landmark-based technique, which relies on loss of resis- nerve block
tance as the needle enters the popliteal membrane, has shown
to be successful [15, 17]. However, with such a wide vari-
ability of the location of the sciatic nerve bifurcation, nerve
stimulation is useful to verify nerve localization, especially Recommend use of nerve
when blockade of either the tibial or common peroneal stimulation
nerves is desired. Furthermore, the use of nerve stimulation
together with ultrasound guidance (a method the authors rec-
ommend) enables more precise needle positioning and thus Position: prone or lateral
with knee extension
greater block success using lower local anesthetic volumes.
The nerve stimulation technique will rely upon the same
landmarks, needle insertion considerations, and local anes-
thetic application as the landmark-based techniques. Site: lower third of
superior triangle of
popliteal fossa
A flowchart illustrating the needle insertion site and proce-
Needle insertion: 45° in
cephalad direction
• A short-beveled or insulated block needle 30–40 mm,
22G–25G (depending on the age and size of the child) is
inserted in a cephalad direction at an angle of 45° to the
Arterial or venous Bony contact
skin. blood (femur)
• High in the popliteal fossa, the nerve is located at a mean
distance of 4.1 ± 0.8 cm in children under 8 years and at
5.8 ± 1.3 cm in those older than 8 years [18].
Withdraw needle, Needle too deep
• A distinct “pop” may be felt as the needle enters the pop- and medial
apply pressure for
liteal fossa membrane. hemostasis
• If blood is aspirated, the needle may have punctured one
of the popliteal vessels. This likely indicates that the nee- Redirect laterally
dle is positioned too medial and should be withdrawn; Reinsert laterally
pressure should be applied for 3 min on the puncture site
before needle reinsertion.
Loss of resistance with
entrance into popliteal fossa
membrane
Aspirate and inject

local anesthetic
Fig. 26.31 Flowchart of needle insertion and procedures for popliteal

sciatic nerve block
26.5.2.2 Current Application and Appropriate • There is no clear influence of age and depth of needle
Responses insertion on the elicitation of motor responses [17].
Figure 26.32 illustrates the procedure for employing nerve Obtaining a tibial nerve response (plantar flexion or foot
stimulation techniques for the sciatic nerve block. inversion) may be preferable to a common peroneal nerve
response (dorsiflexion or foot eversion), since local anes-
• Using an initial current of 1 mA, advance the needle until thetic injected around the common peroneal nerve may
a motor response is elicited in the foot and/or toes. Adjust not reach the tibial nerve.
the needle depth to obtain a minimal motor response at a • One study found that foot inversion was the best predictor
current of approximately 0.4 mA. Motor response cessa- of complete sensory blockade of the foot [19].
tion at currents less than 0.2 mA indicates that the needle • See Table 14.4 for expected motor responses during nerve
is probably in an intraneural location. stimulation.
Nerve stimulation
popliteal sciatic
nerve block


Withdraw needle See Fig. 26.33

until stimulation
disappears at
<0.4 mA
Dorisflexion, plantar
flexion, eversion or
inversion of foot
Aspirate and inject

local anesthetic
Fig. 26.32 Procedure for employing nerve stimulation technique for

popliteal sciatic nerve block

Responses (Tables 26.4 and 26.5)
Table 26.4 Responses and recommended needle adjustments for use with nerve stimulation during sciatic nerve block (posterior popliteal
approach)
Twitches (visible or palpable) in the foot or toes with 0.3–0.5 mA current. Either a common peroneal (fibular) or tibial nerve response may
result and both indicate correct needle positioning even slightly below the sciatic nerve bifurcation as the large volume of local anesthetic will
spread within the sheath. The common peroneal (fibular) response is ankle dorsiflexion and eversion; the tibia is ankle plantar flexion and
inversion. If eliciting a response is difficult in this current range, 0.7 mA may be used reliably with a tibial nerve response
Biceps femoris (local twitch)
Explanation: needle placement too lateral
Needle adjustment: withdraw needle completely and reinsert slightly more medial
Semimembranosus or semitendinosus (local twitch)
Explanation: needle placement too medial
Needle adjustment: withdraw needle completely and reinsert slightly more laterally
Calf muscles without foot or toe movement (muscular branches of sciatic nerve)
Explanation: needle probably too superficial
Needle adjustment: continue advancement
Bone contact
Femur
Explanation: needle tip advanced too deeply
Needle adjustment: withdraw needle to look for response at more superficial location; withdraw if not seen
Vascular puncture
Popliteal artery or vein
Explanation: needle tip too medial
Needle adjustment: withdraw completely and reinsert at slightly more lateral position
Table 26.5 Responses and recommended needle adjustments for use with nerve stimulation during sciatic nerve block (lateral popliteal approach)
Twitches (visible or palpable) in the foot or toes at 0.3–0.5 mA current
It is common to encounter a biceps femoris twitch at a location superficial to the sciatic nerve. Once this ceases, proceed slowly and the sciatic
response should be detected at about 2 cm beyond this location
With this approach, it is common to stimulate the common peroneal portion (i.e., dorsiflexion) of the sciatic nerve first
Biceps femoris (local twitch)
Explanation: needle placement too superficial
Needle adjustment: advance needle slowly, approximately 2 cm
Vastus lateralis (local twitch)
Explanation: needle placement too anterior
Needle adjustment: withdraw needle completely and reinsert slightly more posterior
Calf muscles without foot or toe movement (muscular branches of sciatic nerve)
Explanation: needle probably too superficial
Needle adjustment: continue advancement
Vascular puncture
Popliteal artery or vein
Explanation: needle tip too deep and anterior
Needle adjustment: withdraw completely and reinsert posteriorly with less depth
Bone contact
Femur
Explanation: needle tip too anterior and deep
Needle adjustment: withdraw completely and reinsert at slightly more posterior location

stimulation during popliteal
sciatic nerve block
Biceps femoris Semitendinosus Calf muscles Vastus lateralis

(direct stimulation) semimembranosus without foot or toe
(direct stimulation) movement
Needle is lateral or Needle is anterior

superficial Needle is medial Needle is superficial and lateral
Continue to
Reinsert medially Reinsert laterally Reassess landmark
advance
Responses in the foot

Common peroneal nerve
•Dorsiflexion
•Eversion
Tibial nerve
•Plantar flexion
•Inversion
Aspirate and inject

local anesthetic
Fig. 26.33 Flowchart of modifications to inappropriate responses to nerve stimulation during popliteal sciatic nerve block
26.5.3 Ultrasound-Guided Technique Prepare the needle insertion site and skin surface with an
antiseptic solution. Prepare the ultrasound probe surface by
For a summary of ultrasound guidance techniques in popli- applying a sterile adhesive dressing to it prior to needling as
teal sciatic nerve blocks, see Fig. 26.34. discussed in Chap. 4.
Major anatomical structures surrounding the branches of The bifurcation point of the sciatic nerve varies widely
the sciatic nerve at the popliteal fossa as captured by MRI between individuals (Table 26.6); thus, ultrasound imaging
and VHVS images are shown with the corresponding ultra- is highly valuable for accurate nerve localization. Placing the
sound image in Fig. 26.35. The schematic drawing in needle in close proximity to the nerve will maximize block
Fig. 26.36 depicts a posterior view showing the position of success with the need for minimal dosages of local
the sciatic nerve in the mid-thigh (prior to bifurcation) and anesthetic.
associated landmarks.
popliteal sciatic
nerve block
Position probe
transversely
Place probe in
popliteal crease
Capture tibial and

common peroneal
nerves lateral to
vessels
Scan proximally and

nerves will combine
as sciatic nerve
Insert needle just before

nerve bifurcation using OOP
technique

for confirmation
Aspirate and inject

local anesthetic
Fig. 26.34 Flowchart of ultrasound guidance technique during popli-

teal sciatic nerve block
Fig. 26.35 (a) VHVS and MRI images of anatomical structures surrounding the branches of the sciatic nerve at the popliteal fossa. (b) Ultrasound
image of the popliteal sciatic nerve block location
Popliteal
artery Femur
Vastus
Femoral vein medialis m.
Sartorius m. Rectus femoris m.

Adductor longus m.
Vastus
Gracilis m. intermedius m.
Adductor Vastus
magnus m. lateralis m.
Biceps femoris m.
Adductor brevis m.
(short head)
Semimembranosus m. Biceps femoris m.

(long head)
Semitendinosus m.
Deep artery
Sciatic n. of the thigh
Deep vein
of the thigh
Fig. 26.36 Posterior view of the thigh showing position of the sciatic nerve and major muscles and vessels
Table 26.6 Location of needle insertion for popliteal sciatic nerve block and position of sciatic nerve bifurcation
• A general guideline for determining the needle insertion distance is 1 cm from the popliteal crease for every 10 kg of the patient [7]
• Another method to determine a needle insertion point prior to sciatic nerve bifurcation is to use a ratio of femoral shaft lengths between
children (according to their age) and adults. This method assumes that the bifurcation is approximately 10 cm above the popliteal crease in
adults; the ratio is factored to this length of 10 cm to determine the needle location in the child [20]. Although Berniere et al. demonstrated
successful blocks using this method, block success and motor responses associated with either the tibial or common peroneal nerves were
used as endpoints. There was no verification using imaging
• Using MRI, Suresh et al. [21] found that the position of the sciatic nerve bifurcation correlated to age (R2 = 0.73) and created a formula
[27 + 4 × age (years) mm] to determine the point of bifurcation in children
• Ultrasound imaging has shown that, in the posterior thigh, the bifurcation point is highly variable (32–76 cm) [22]. This finding suggests
that ultrasound may be a superior method for performing the block when it is desirable to locate the sciatic nerve
26.5.3.1 Scanning Technique 26.5.3.2 Sonographic Appearance
• A linear or hockey stick, high-frequency (10–5 MHz) • At the level of the popliteal crease, the tibial and common
probe is commonly used for scanning the sciatic nerve peroneal nerves lie superficial and lateral to the popliteal
transversely in the popliteal fossa. A distal-to-proximal vessels. Both nerves appear round to oval and hyper-
traceback approach (Fig. 26.37a) can effectively locate echoic (Fig. 26.37a).
the sciatic nerve in the posterior popliteal fossa at the • The hyperechoic border of the femur (condyles) may be
bifurcation point. visible.
• At the popliteal crease, a transversely positioned probe • As the probe is moved more proximally, the common
captures the tibial and common peroneal nerves, with peroneal nerve appears to move towards the tibial nerve,
both nerves located posterior and superficial to the popli- merging to form the sciatic nerve.
teal vessels. Doppler can be valuable to visualize the pop- • More proximal in the thigh, the lip-shaped, hypoechoic
liteal vessels (see Fig. 26.37b). biceps femoris muscle lies superficial to the round hyper-
• As the probe is moved proximally from the crease, the echoic sciatic nerve (Fig. 26.37b).
tibial and common peroneal nerves approach each other
and finally join to form the sciatic nerve (Fig. 26.37b).
Fig. 26.37 Ultrasound image showing the distal-to-proximal scanning common peroneal and tibial nerves. (b) Ultrasound probe is moved
technique to locate the bifurcation of the sciatic nerve at the popliteal proximal to view the sciatic nerve. Doppler ultrasound highlights the
fossa. (a) Ultrasound probe is placed distally to visualize the separate popliteal vessels
26.5.3.3 Needle Insertion • There is a limited amount of literature on ultrasound-

guided popliteal blocks in the pediatric population. Ivani
• An OOP approach at the bifurcation of the sciatic nerve et al. [10] suggested that ropivacaine and levobupivacaine
(Fig. 26.38) is preferable, although the IP approach shown are probably the best choice for longer operations when
in Fig. 26.39 can also be used. pain is more intense and long-lasting.
• The OOP approach is a useful technique since the needle • Due to the anatomy of the nerves in children (smaller
can be seen piercing through the epineural sheath at the diameter and shorter distance between the nodes of
bifurcation between the two branches of the sciatic nerve. Ranvier), larger volumes with lower concentrations are
This approach also enables a catheter to be threaded ceph- key to obtaining effective analgesia [11].
alad along the sciatic nerve. • We recommend the use of ropivacaine 0.2 %, bupivacaine
• For the OOP approach, the probe is positioned directly 0.25 %, or levobupivacaine 0.25 %, with a volume of
above the sciatic nerve at its bifurcation point so that the 0.25–0.5 mL/kg.
nerve is placed in the center of the image. The needle • The dose of local anesthetic should not exceed the maxi-
should be inserted equidistant caudad or cephalad (cau- mum toxic dose, especially if a saphenous nerve block or
dad when inserting a catheter) to the probe at a 45° angle, femoral nerve block is required to provide anesthesia/
such that the tip of the needle can be visualized as it analgesia to the medial aspect of the leg and foot.
approaches the nerve.
Ultrasound Consideration
26.5.4 Local Anesthetic Application • The onset of anesthesia is more rapid if there is circumfer-
ential spread around both branches of the sciatic nerve.
• Ensure negative aspiration of the blood prior to injection Injection at the bifurcation or multiple injections may be
of local anesthetic. required for complete circumferential spread.
Fig. 26.38 Out-of-plane needling technique for ultrasound-guided Fig. 26.39 In-plane needling technique for ultrasound-guided popli-
popliteal sciatic nerve block. Blue rectangle indicates probe footprint teal sciatic nerve block. Blue rectangle indicates probe footprint
26.5.5 Case Study
Sciatic Nerve Block (Lateral Popliteal Approach) tibial nerve block with 20 mL 0.25 % bupivacaine in the
(Contributed by S. Suresh) popliteal fossa was used (Fig. 26.40). Pain control in
A 16-year-old male, 81.8 kg in weight, was diagnosed recovery was reported as 0/10 at PACU admission and
with a left knee ACL tear and left knee lateral meniscus 2/10 at PACU discharge. Postoperative analgesia
tear based on knee X-rays and MR with contrast. included morphine 2 mg injection, acetaminophen tab-
Preadmission medications included docusate (Colace) let 650 mg, hydrocodone-acetaminophen (Norco)
100 mg and hydrocodone-acetaminophen (Norco) 10 mg, and 400 mL/h 0.1 % bupivacaine (continuous
5–325 mg. Surgery lasted 3 h and 28 min and involved a nerve block).
left knee ACL reconstruction with patellar tendon auto- Note: This patient also received a femoral nerve block
graft and partial meniscectomy. An ultrasound-guided and femoral nerve catheter.
Fig. 26.40 Ultrasound-

guided lateral popliteal
sciatic nerve block. SN
sciatic nerve, PV popliteal
vein, PA popliteal artery,
arrowheads indicate
needle position (see Case
Study for details)
26.6 Current Literature in Ultrasound- of ultrasound techniques alone in sciatic nerve block in
Guided Approaches infants and toddlers [8, 27].
There is a paucity of literature on ultrasound-guided pop-
The first published case of sciatic nerve blockade under liteal nerve blocks in children. Nonetheless, popliteal
ultrasound in a child was in 2003 by Gray and colleagues approaches to the sciatic nerve have been used successfully
[23]. Several case reports have described ultrasound guid- in infants and children undergoing surgery of the ankle and
ance during continuous sciatic/popliteal blocks in chil- foot [7, 15, 20, 33, 34]. Blind techniques using either loss of
dren [18, 24–26], and Ponde et al. [27] showed that resistance or nerve stimulation (including surface nerve
successful continuous sciatic blocks can be achieved mapping [35]) have typically been used for sciatic nerve
when placing catheters under ultrasound guidance alone. localization in the posterior thigh. In an imaging study,
For sciatic (subgluteal and popliteal) and femoral nerve Schwemmer et al. [22] found that there was high variability
blocks in children, Oberndorfer et al. [7] found that ultra- (32–76 mm) in the point of sciatic nerve division in the
sound guidance prolongs the duration of sensory block popliteal fossa in children. These authors’ results indicate, in
(mean of 508 min vs. 335 min) compared to the nerve contrast to age-dependent formulas, that there was no consis-
stimulation technique, while allowing for reduced vol- tent age-related distance in their sample of patients, which is
umes of local anesthetic. A recent randomized controlled not surprising given the range of body habitus in children
study compared ultrasound- and nerve stimulation-guided today. Direct visualization may be the key to accurate local-
approaches to femoro-sciatic block in patients with arthro- ization on a case-by-case basis. Miller [36] described an
gryposis multiplex congenita. The results showed that alternative approach to ultrasound-guided popliteal sciatic
block success and duration of analgesia were increased block using the biceps femoris muscle, rather than the popli-
significantly in the ultrasound group. van Geffen et al. teal artery, as a landmark. The ultrasound transducer is
compared proximal, subgluteal, and distal approaches to placed distal to the bifurcation with the lateral aspect of the
sciatic nerve block and demonstrated that good pain con- transducer medial to the biceps femoris muscle. The com-
trol and good visualization of the sciatic nerve can be mon peroneal nerve may or may not be visible; however,
achieved using each technique. moving the transducer cephalad along the medial aspect of
A parasacral approach to sciatic nerve block has been the biceps femoris reveals the tibial nerve, whose path can be
used in adults and has been reported to block the entirety of traced back to the bifurcation point. This approach allows the
the sacral plexus at the exit of the greater sciatic notch [28– block to be performed with the patient in a prone or “near-
31]. A recent case series by Dillow et al. [32] studied the prone” position.
parasacral approach in pediatric patients undergoing lower Using nerve stimulation, elicitation of foot inversion has
limb surgery; both ultrasound and nerve stimulation were been shown to be the best predictor of complete sciatic nerve
used, and 0.5 mL/kg ropivacaine 0.2 % was injected. In all blockade [19]; however, Ponde et al. [8] demonstrated, in a
cases using the parasacral approach, block success was case series of infants and toddlers scheduled for congenital
100 %. Pain control was excellent, and mean block duration talipes equinovarus or vertical talus repair, that the success
was 17.3 ± 5.4 h. These results demonstrate that the parasa- rate of ultrasound-guided sciatic nerve block was unaffected
cral approach is effective for children as well as adults. by the ability to elicit a motor response with nerve stimula-
Ultrasound imaging may increase the use of the anterior tion. Nevertheless, it is our opinion that nerve stimulation,
approach to the sciatic nerve, which would be favorable when combined with ultrasound imaging, can both confirm
because the patient can remain in the supine position. the location of the nerve and act as an adjunct to monitoring,
Ultrasound guidance may also aid in the precise placement thus preventing intraneural injury. Therefore, we strongly
of local anesthetic around the sciatic (or other) nerve. This recommend the concurrent use of ultrasound and nerve stim-
concept has been promoted by two recent studies on the use ulation wherever possible.
References 22. Schwemmer U, Markus CK, Greim CA, et al. Sonographic imaging
of the sciatic nerve and its division in the popliteal fossa in children.
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in 180 pediatric patients. Anesth Analg. 1990;70:131–7.
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3. Sukhani R, Candido KD, Doty Jr R, et al. Infragluteal-parabiceps
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single-injection technique. Anesth Analg. 2003;96:868–73.
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Developmental juvenile osteology. London: Academic; 2000.
27. Ponde VC, Desai AP, Shah DM, Johari AN. Feasibility and efficacy
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of placement of continuous sciatic perineural catheters solely under
6. Bosenberg AT. Lower limb nerve blocks in children using
ultrasound guidance in children: a descriptive study. Pediatr Anesth.
unsheathed needles and a nerve stimulator. Anaesthesia. 1995;50:
2011;21:406–10.
206–10.
28. Ben-Ari AY, Joshi R, Uskova A, Chelly JE. Ultrasound localization
7. Oberndorfer U, Marhofer P, Bosenberg A, et al. Ultrasonographic
of the sacral plexus using a parasacral approach. Anesth Analg.
guidance for sciatic and femoral nerve blocks in children. Br J
2009;108:1977–80.
Anaesth. 2007;98:797–801.
29. Bendtsen TF, Lonnqvist PA, Jepsen KV, et al. Preliminary results of
8. Ponde VC, Desai AP, Dhir S. Ultrasound-guided sciatic nerve
a new ultrasound-guided approach to block the sacral plexus: the
block in infants and toddlers produces successful anesthesia regard-
parasacral parallel shift. Br J Anaesth. 2011;107:278–80.
less of the motor response. Pediatr Anesth. 2010;20:633–7.
30. Ripart J, Cuvillon P, Nouvellon E, et al. Parasacral approach to
9. Ivani G, Tonetti F. Postoperative analgesia in infants and children:
block the sciatic nerve: a 400-case survey. Reg Anesth Pain Med.
new developments. Minerva Anestesiol. 2004;70:399–403.
2005;30:193–7.
10. Ivani G, DeNegri P, Conio A, et al. Comparison of racemic
31. Taha AM. A simple and successful sonographic technique to iden-
bupivacaine, ropivacaine, and levo-bupivacaine for pediatric caudal
tify the sciatic nerve in the parasacral area. Can J Anesth. 2012;59:
anesthesia: effects on postoperative analgesia and motor block. Reg
263–7.
32. Dillow JM, Rosett RL, Petersen TR, et al. Ultrasound-guided para-
11. Bosenberg AT, Ivani G. Regional anaesthesia – children are
sacral approach to the sciatic nerve block in children. Pediatr
different. Pediatr Anesth. 1998;8:447–50.
Anesth. 2013;23:1042–7.
12. Eck JB, Ross AK. Paediatric regional anaesthesia – what makes a
33. Dadure C, Bringuier S, Nicolas F, et al. Continuous epidural block
difference? Best Pract Res Clin Anaesthesiol. 2002;16:159–74.
versus continuous popliteal nerve block for postoperative pain
13. Tsui BC, Ozelsel TJ. Ultrasound-guided anterior sciatic nerve
relief after major podiatric surgery in children: a prospective, com-
block using a longitudinal approach: “expanding the view”. Reg
parative randomized study. Anesth Analg. 2006;102:744–9.
34. Konrad C, Johr M. Blockade of the sciatic nerve in the popliteal
14. Singelyn FJ, Gouverneur JM, Gribomont BF. Popliteal sciatic nerve
fossa: a system for standardization in children. Anesth Analg.
block aided by a nerve stimulator: a reliable technique for foot and
1998;87:1256–8.
ankle surgery. Reg Anesth. 1991;16:278–81.
35. Bosenberg AT, Raw R, Boezaart AP. Surface mapping of peripheral
15. Tobias JD, Mencio GA. Popliteal fossa block for postoperative
nerves in children with a nerve stimulator. Pediatr Anesth. 2002;12:
analgesia after foot surgery in infants and children. J Pediatr
398–403.
Orthop. 1999;19:511–4.
36. Miller BR. The biceps femoris muscle as a landmark for perform-
16. Zetlaoui PJ, Bouaziz H. Lateral approach to the sciatic nerve in the
ing the popliteal sciatic nerve block using ultrasound guidance in
popliteal fossa. Anesth Analg. 1998;87:79–82.
pediatric patients. Pediatr Anesth. 2010;20:960–1.
17. Kempthorne PM, Brown TC. Nerve blocks around the knee in chil-
dren. Anaesth Intensive Care. 1984;12:14–7.
18. van Geffen GJ, Bruhn J, Gielen M. Ultrasound-guided continuous
sciatic nerve blocks in two children with venous malformations in
the lower limb. Can J Anesth. 2007;54:952–3. Suggested Reading
19. Benzon HT, Kim C, Benzon HP, et al. Correlation between evoked
motor response of the sciatic nerve and sensory blockade. Karmakar MK, Kwok WH. Ultrasound-Guided Regional Anesthesia.
Anesthesiology. 1997;87:547–52. In: Cote CJ, Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB
20. Berniere J, Schrayer S, Piana F, et al. A new formula of age-related Saunders; 2013. p. 880–908.
anatomical landmarks for blockade of the sciatic nerve in the pop- Suresh S, Polaner DM, Cote CJ. Regional Anesthesia. In: Cote CJ,
liteal fossa in children using the posterior approach. Pediatr Anesth. Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
2008;18:602–5. 2013. p. 835–79.
21. Suresh S, Simion C, Wyers M, et al. Anatomical location of the Tsui BC. Sciatic and popliteal blocks. In: Tsui BC, editor. Atlas of
bifurcation of the sciatic nerve in the posterior thigh in infants and ultrasound and nerve stimulation-guided regional anesthesia.
children: a formula derived from MRI imaging for nerve localiza- New York: Springer; 2007. p. 171–203.
tion. Reg Anesth Pain Med. 2007;32:351–3.
Part IX
Nerve Blocks at the Ankle
Ankle Blocks
27
Ban C.H. Tsui
Contents
27.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
27.2 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
27.3 Nerve Stimulation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
27.3.1 Needle Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
27.3.2 Current Application and Appropriate Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
27.3.3 Modifications to Inappropriate Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
27.4 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
27.4.1 Scanning Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
27.4.2 Sonographic Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
27.4.3 Needle Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
27.5 Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
27.6 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
27.7 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

DOI 10.1007/978-0-387-79964-3_27
426 B.C.H. Tsui
27.1 Indications • Extensor hallucis tendon: This tendon can be located in

an awake child by asking them to extend their big toe.
• Club foot repair. • Achilles tendon.
• Reconstructive surgeries (e.g., polydactyly). • Anterior tibial artery: Pulsation of the artery is sought at
• Removal of a foreign body. the level of the skin crease on the anterior midline surface
• Ankle blocks can also be used as a diagnostic tool to of the ankle.
determine surgical procedures to correct foot deformities
in children with cerebral palsy [1]. To block all five nerves at the ankle, more than one point
of needle insertion is necessary. For the superficial nerves
(superficial peroneal and saphenous), a line is drawn on the
27.2 Surface Anatomy anterior surface of the ankle, uniting the medial and lateral
malleoli. The point of needle entry for the posterior tibial
The patient is positioned supine with the foot placed on the nerve is midway between the medial malleolus and the
table or extended (for deep peroneal nerve block). If using medial border of the Achilles tendon; the nerve is located
nerve stimulation, it will be necessary to either support the just posterior to the tibial artery (Fig. 27.1). The deep pero-
foot above the table or extend the leg beyond the table. neal nerve is located between the extensor hallucis longus
Surface landmarks include: tendon and the extensor digitorum longus tendon (Fig. 27.2).
To block the deep peroneal nerve, insert the needle either
• Medial malleolus. lateral to the extensor hallucis tendon or to the anterior tibial
• Lateral malleolus. artery.
Fig. 27.1 Surface anatomy and landmarks for posterior tibial nerve Fig. 27.2 Surface anatomy and landmarks for deep peroneal nerve
block block
27 Ankle Blocks 427
27.3 Nerve Stimulation Technique artery (whichever is used) and inject into the deep planes
below the fascia.
The posterior tibial nerve and the peroneal nerve are the only • Sural nerve: Insert the needle perpendicular to the skin
motor nerves at the ankle. Table 14.5 summarizes motor between the lateral malleolus and the calcaneus.
responses associated with nerve stimulation.
27.3.1 Needle Insertion 27.3.2 Current Application and Appropriate

Responses
• The nerves are all superficially located, and a short (20–
30 mm) 25G–27G needle with a short bevel (or a hypo- • Applying an initial current of 0.8 mA (2 Hz, 0.1–0.3 ms)
dermic needle) should be used for the blocks. is sufficient for nerve stimulation. After obtaining the
• Superficial nerves: Insert the needle to deposit local anes- appropriate motor response, the current is reduced to aim
thetic subcutaneously in a ringlike fashion along the line for a threshold current of 0.4 mA (0.1–0.2 ms) before
drawn between the malleoli. injection.
• Isolated saphenous nerve block: Infiltrate the area overly- • Twitches of the first (medial plantar branch) and fifth (lat-
ing and anterior to the medial malleolus. eral plantar branch) toes are typical responses to nerve
• Posterior tibial nerve: Insert the needle perpendicular to stimulation.
the skin between the medial malleolus and the medial • For the deep peroneal nerve, toe extension is seen.
border of the Achilles tendon, directed toward the pulsa-
tion of the posterior tibial artery. The nerve is located
behind the posterior tibial artery. 27.3.3 Modifications to Inappropriate
– Aspiration will be important to rule out intravascular Responses
placement.
• Deep peroneal nerve: Insert the needle perpendicular to • In general, alternate motor responses from direct muscle
the skin and with a slight anterior tilt either lateral to the stimulation will not be elicited since this region is mainly
extensor hallucis longus tendon or the anterior tibial composed of tendons rather than muscle fibers.
428 B.C.H. Tsui
27.4 Ultrasound-Guided Technique • Posterior tibial nerve: The probe is positioned in trans-
verse (short) axis to the nerve just posterior and inferior to
Ultrasound imaging may be suitable for visualizing the the medial malleolus. Alternatively, the nerve can be
deep nerves (posterior tibial and deep peroneal). Imaging identified in the distal quarter of the lower leg above the
at the medial aspect of the ankle will enable the block to medial malleolus (Fig. 27.3).
be localized to the posterior tibial nerve prior to its divi- – Color Doppler is helpful to localize the nerve at the
sion into the medial and lateral plantar nerves. Imaging above locations since in each one the nerve lies poste-
for the deep peroneal block may be helpful in children rior and deep to the posterior tibial artery (Fig. 27.4).
since the voluntary extension of the toe, to localize the The nerve should be localized before it branches into
extensor hallucis tendon, will not be possible in anesthe- the medial and lateral plantar nerves.
tized patients. • Deep peroneal nerve: The probe is placed in transverse
(short) axis to the nerve at the anterior surface of the ankle
joint. Alternatively, the nerve can also be found in the dis-
27.4.1 Scanning Technique tal quarter of the lower leg above the ankle joint (Fig. 27.5).
However, the nerve itself can be difficult to see, and only
• High-frequency, short footprint probes (e.g., SLA the artery can be consistently located.
6–13 MHz, 25 mm footprint hockey stick probe, – Color Doppler can be used at both locations to illumi-
MicroMaxx, SonoSite, Bothell, WA) are used for these nate the anterior tibial artery lying medial to the nerve
blocks. (Fig. 27.4).
Fig. 27.3 (a) VHVS and MRI images of major anatomical structures surrounding the tibial nerve. (b) Ultrasound image of major anatomical
structures surrounding the tibial nerve
27 Ankle Blocks 429
Extensor hallucis
longus tendon Anterior tibial artery
Deep peroneal n.
Tibialis anterior
tendon Extensor digitorum
longus tendon
Flexor Talus Medial and

digitorum longus lateral malleoli
tendon
Tibialis posterior Flexor hallucis

tendon longus tendon
Posterior
Calcaneal (Achilles)
tibial vein
tendon
Posterior
tibial
artery Posterior
tibial n.
Fig. 27.4 Transverse section at the ankle showing spatial relationship

of subcutaneous structures
430 B.C.H. Tsui
Fig. 27.5 (a) VHVS and MRI images of major anatomical structures surrounding the deep peroneal nerve. (b) Ultrasound image of major ana-
tomical structures surrounding the deep peroneal nerve
27 Ankle Blocks 431
27.4.2 Sonographic Appearance 27.4.3 Needle Insertion
• Posterior tibial nerve: The hypoechoic circular posterior • Posterior tibial nerve: A 3.5–5 cm needle is inserted using
tibial vein lies immediately posterior to the artery; the vein either an OOP approach (Fig. 27.6) with the needle cau-
may be compressed and not apparent on the screen. Posterior dal or an IP approach (Fig. 27.7) with the needle posterior
to the artery, the nerve appears slightly more hyperechoic to the transversely positioned probe.
than the surrounding tissues and looks like a condensed • Deep peroneal nerve: An OOP approach (Fig. 27.8) will
“honeycomb-appearing” structure [2] (Fig. 27.3b). be most suitable here since the tendons lie on either side
• Deep peroneal nerve: If seen, the nerve appears as a small of the nerve, although an IP approach can also be
cluster of hyperechoic fascicular-appearing fibers immedi- employed (Fig. 27.9). A 3.5–5 cm needle is inserted OOP
ately lateral to the artery, with both the nerve and artery adja- and caudal to the transversely positioned small footprint
cent to the well-demarcated distal end of the tibia (Fig. 27.5b). probe.
Fig. 27.6 Out-of-plane needling technique for ultrasound-guided pos- Fig. 27.7 In-plane needling technique for ultrasound-guided posterior
terior tibial nerve block. Blue rectangle indicates probe footprint tibial nerve block. Blue rectangle indicates probe footprint
432 B.C.H. Tsui
Fig. 27.8 Out-of-plane needling technique for ultrasound-guided deep Fig. 27.9 In-plane needling technique for ultrasound-guided deep
peroneal nerve block. Blue rectangle indicates probe footprint peroneal nerve block. Blue rectangle indicates probe footprint
27 Ankle Blocks 433
27.5 Local Anesthetic Application ankle, ultrasound improved the onset of the block without
improving the overall block quality [5].
• The total amount of local anesthetic should be monitored
and will depend on the size of the child. 0.1 mL/kg of
0.25 % bupivacaine or 0.2 % ropivacaine may be given, 27.7 Case Study
but generally, a small volume, such as 1–3 mL, is suffi-
cient without overexerting pressure in the perineural Ankle blocks can be useful if popliteal sciatic nerve block is
space. contraindicated. Since popliteal sciatic blocks can be per-
• A volume of 1–3 mL is adequate for an isolated block of formed easily and reliably under ultrasound with a single
the saphenous nerve. injection, ankle blocks – which usually require multiple
• For the posterior tibial nerve, a fan-shaped injection of injections – are now often administered by the surgeon for
1–3 mL can be performed in the triangle formed by the supplementary analgesia following surgery.
artery, the Achilles tendon, and the tibia.
• Epinephrine should not be added to the anesthetic
solution. References
1. Carpenter EB. Role of nerve blocks in the foot and ankle in cerebral
palsy: therapeutic and diagnostic. Foot Ankle. 1983;4:164–6.
Clinical Pearls 2. Silvestri E, Martinoli C, Derchi LE, Bertolotto M, Chiaramondia M,
• For both nerves, injection of 1–3 mL (depending on Rosenberg I. Echotexture of peripheral nerves: correlation between
the age and size of the child) of local anesthetic US and histologic findings and criteria to differentiate tendons.
Radiology. 1995;197:291–6.
solution near the nerve will anesthetize the nerve.
3. Redborg KE, Antonakakis, Beach M, Chinn C, Sites B. Ultrasound
Care should be taken to avoid the nearby vessels; it improves the success rate of a tibial nerve block at the ankle. Reg
is important to perform aspiration prior to Anesth Pain Med. 2009;34:256–60.
injection. 4. Redborg KE, Sites BD, Chinn CD, Gallagher JD, Ball PA,
Antonakakis JG, Beach ML. Ultrasound improves the success rate
• Due to the limited and compact space at the ankle,
of a sural nerve block at the ankle. Reg Anesth Pain Med. 2009;34:
OOP needling approaches are easier to perform 24–8.
than IP approaches, although IP or OOP needling 5. Antonakakis JG, Scalzo DC, Jorgenson AS, Figg KK, Ting P, Zuo
may be possible if the probe is moved proximally Z, Sites BD. Ultrasound does not improve the success rate of a deep
peroneal nerve block at the ankle. Reg Anesth Pain Med. 2010;35:
3–4 cm cephalad to the ankle.
217–21.
• Ankle blocks can be very stimulating; therefore,
adequate depth of anesthesia is required.
• Placing a bolster under the foot improves access for
ankle block. Suggested Reading
Dalens B. Complementary and distal blocks of the extremities. In:
Dalens B, editor. Regional anesthesia in infants, children, and ado-
lescents. Philadelphia: Lippincott Williams & Wilkins; 1995.
27.6 Current Literature in Ultrasound- p. 384–8.
Guided Approaches Dalens BJ. Distal conduction blocks. In: Dalens BJ, editor. Pediatric
regional anesthesia. Boca Raton: CRC Press, Inc; 1990. p. 340–4.
Peutrell JM, Mather SJ. Regional anaesthesia for babies and children.
There is limited evidence documenting the use of ultrasound
Oxford: Oxford University Press; 1997. p. 174–84.
in ankle blocks in children. Nonetheless, ultrasound has been Tsui BC. Ankle blocks. In: Tsui BC, editor. Atlas of ultrasound and
shown to improve success in posterior tibial and sural nerve nerve stimulation-guided regional anesthesia. New York: Springer;
blocks in adults [3, 4]. For deep peroneal nerve block at the 2007. p. 205–13.
Part X
Nerve Blocks at the Trunk
Paravertebral Blocks
28
Heather Yizhen Z. Ting, Karen R. Boretsky,
and Ban C.H. Tsui
Contents
28.1 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
28.2 Clinical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
28.3 Block Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
28.3.1 Landmark-Based Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
28.3.2 Nerve Stimulation Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
28.3.3 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
28.4 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
28.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
H.Y.Z. Ting, MD, FRCPC

University of Alberta Hospital, 8440-112 St NW, 2-150
Clinical Sciences Building, Edmonton, AB T6G 2G3, Canada
K.R. Boretsky, MD
Department of Anesthesia, Perioperative and Pain Medicine,
Harvard Medical School, Boston Children’s Hospital,
300 Longwood Avenue, Boston, MA 02115, USA

DOI 10.1007/978-0-387-79964-3_28
438 H.Y.Z. Ting et al.
28.1 Indications space at the lumbar level is divided segmentally by the

origins of the psoas muscle.
Paravertebral blocks are indicated for unilateral surgical pro- Since there is large interindividual variation in respect
cedures, such as renal surgery and thoracotomy (thoracic to patient size, knowledge of the depth of the paravertebral
paravertebral blocks) and lower limb (hip and thigh) surger- space is important to accurately position the needle at the
ies (lumbar paravertebral blocks). Paravertebral blocks can correct location. The depth of the paravertebral space has
provide postoperative analgesia lasting 12–48 h, often longer been found to correlate well with patient parameters (i.e.,
than what is expected of the local anesthetic used. There is weight, height, and body surface area), and a formula
generally less motor blockade of the extremities than with using patient weight has been reported for calculating the
epidurals, unless lumbar spinal levels are incorporated (L2 depth of needle penetration when using a medially orien-
and below). Visceral pain may not be blocked, and there may tated puncture site [2] (see below). Alternatively, ultra-
be a need to increase the depth of anesthesia compared to sound imaging can be used to view anatomical structures
caudal or epidural blockade. Although placement of a cath- relevant to the paravertebral block (e.g., transverse pro-
eter under direct vision during thoracic surgery can be per- cesses) and to help determine the accurate depth for needle
formed in children and provides effective postoperative placement. With some patients, ultrasound imaging may
analgesia for cholecystectomy and renal surgery [1], only also allow the operator to view the local anesthetic spread
percutaneous techniques (mainly single-shot blocks) will be and to dynamically control the needle trajectory in order to
described in this chapter. avoid penetration of the epidural space and the pleura. The
ability to use dynamic, “real-time” ultrasound guidance
will usually depend on the patient’s age and visibility of
28.2 Clinical Anatomy the anatomical structures (including nerves). Young
patients will have little ossification of many bony elements
On either side of the vertebral column, there is a wedge- in the vertebral column, and the ultrasound beam will
shaped paravertebral space through which the spinal nerves therefore more effectively penetrate to the paravertebral
depart after exiting from the intervertebral foramina. In the space.
thoracic region, the boundaries of the paravertebral space are
as follows: medially lies the vertebral body, intervertebral
disc and foramen, and spinous processes; anterolaterally is 28.3 Block Techniques
the parietal pleura; and posteriorly lies the anterior surface of
the transverse process and superior costotransverse ligament Prepare the needle insertion site and skin surface with an
positioned between the adjacent ribs (Fig. 13.1). The space antiseptic solution. If using ultrasound, prepare the probe
often has a slightly caudal orientation. The paravertebral surface by applying a sterile adhesive dressing prior to nee-
space communicates medially with the intervertebral fora- dling (see Chap. 4).
men and laterally with the intercostal space. In the thoracic
region, adjacent levels of the paravertebral space communi-
cate with each other, and some spread of the local anesthetic 28.3.1 Landmark-Based Technique
solution will occur.
The lumbar paravertebral space is surrounded by the 28.3.1.1 Patient Positioning
psoas major muscle anteriorly, which makes up most of the
lumbar paravertebral space; the vertebral bodies, the inter- • The patient is often placed in the prone position, although
vertebral disks, and the intervertebral foramen medially; and the lateral decubitus position may be used. Conscious
the lumbar transverse process along with its ligaments patients may adopt a seated position, but this is rare.
between adjacent transverse processes posteriorly. The psoas • In the prone position, the arms should be abducted when
major muscle consists of a fleshy anterior part and a thin performing thoracic blocks. A pillow can be placed under
posterior (accessory) part. The anterior part originates from the abdomen to minimize the lumbar lordosis.
the anterolateral surface of the vertebral bodies, while the • Rounding out the back (increasing the thoracic kyphotic
posterior part originates from the anterior surface of trans- curve) in the lateral or sitting position will increase the
verse process. The ventral rami of the spinal nerve roots distance between the transverse processes and may ease
extend laterally within the psoas muscle, and the paravertebral injection.
28 Paravertebral Blocks 439
28.3.1.2 Landmarks and Surface Anatomy proportionally smaller pelvis, and the sacrum is located
more cephalad relative to the iliac crests; in neonates and
Thoracic Paravertebral Block infants, the intercristal line crosses the midline of the ver-
tebral column at the L4–L5 or L5–S1 interspace [3, 4]).
• Spinous processes: Locate T7 at the tips of the scapulae A vertical line intersecting the posterior superior iliac
(Fig. 28.1a). Look for scoliosis, which may require further spine (S2 level) is drawn (Fig. 28.1b).
study of the anatomy of the spinal column with ultrasound. • Transverse processes: The transverse processes of the
• Transverse processes: At T1, the transverse process is lumbar spine are long and slender and are located directly
located directly lateral to its corresponding spinous pro- lateral to their corresponding spinous process. The infe-
cess. Subsequent transverse processes are extended to rior borders of the relevant transverse processes are
increasingly cephalad locations (i.e., the T7 transverse pro- marked on the skin, and a line is drawn through these
cess is lateral to T6 spinous process) due to the increasingly marks.
inferior angulation of the spinous processes. The inferior
borders of the relevant transverse processes are marked on The distance between the spinous process and the corre-
the skin, and a line is drawn through these marks. sponding transverse process is variable, depending on the
patient’s age. At the thoracic level, the needle puncture site is
Lumbar Paravertebral Block lateral to the spinous process but may be 1 cm or larger
(2.5 cm) (Fig. 28.1a). For the lumbar levels, the puncture site
• Spinous processes: Typically, the spinous process of L4 is is also 1–2.5 cm lateral to the corresponding spinous process
at the level of the iliac crests (neonates and infants have a (Fig. 28.2).
a b
Fig. 28.1 (a) Surface anatomy for thoracic paravertebral block. (b) Skeletal model showing the L4 transverse process and posterior superior iliac
spine (PSIS) landmarks
Fig. 28.2 Surface anatomy for lumbar paravertebral block

28.3.1.3 Needle Insertion process (SP-PVS distance) since they correlate with the
patient’s body weight:
Thoracic Paravertebral Block 1. S − PVS depth ( mm ) = 0.48 × body weight ( kg ) + 18.7
2. SP − PVS distance ( mm ) = 0.12 × body weight ( kg ) + 10.2
• After aseptic skin preparation and patient sedation, local
anesthetic skin wheals are raised at the marked transverse Lumbar Paravertebral Block
processes.
• If using nerve stimulation, an insulated needle (5–8 cm, • After aseptic skin preparation and patient sedation, local
22G needles are used, depending on the size of the child) is anesthetic skin wheals are raised at the marked transverse
introduced through the skin wheal in the sagittal plane and processes.
directed slightly cephalad to contact the transverse process • If using nerve stimulation, an insulated needle (5–8 cm,
or, sometimes, likely the costotransverse ligament. 22G needles are used, depending on the size of the child)
• Gentle cephalad or caudad exploration may be required to is introduced through the skin wheal in the sagittal plane,
identify the bone. penetrating the fascia surrounding the quadratus lumbo-
• The depth of the transverse process should be carefully rum muscle to contact the transverse process.
noted on the needle shaft. • Gentle cephalad or caudad exploration may be required to
• The needle is now withdrawn from the transverse process to identify the bone.
the skin level and reinserted 10° superiorly (to target the • The depth of the transverse process should be noted on
spinal nerve corresponding to the spinous process) or inferi- the needle shaft.
orly (corresponding to the vertebral level below the spinous • The needle is now withdrawn from the transverse process
process) and slightly deeper (usually up to a maximum of to the skin level and reinserted 10° superiorly (to target
1 cm) than the previously marked point of bone contact. the spinal nerve corresponding to the spinous process) or
• The needle should be angled slightly medially to avoid inferiorly (corresponding to the vertebral level below the
causing pneumothorax. There will be a subtle “give” at the spinous process) and slightly deeper (up to a maximum of
midpoint between these landmarks (spinous and transverse 1 cm) than the previously marked point of bone contact,
processes), indicating entrance into the paravertebral space. sliding off the superior or inferior edge of the transverse
• For the loss-of-resistance technique, an epidural set con- process.
taining an 18G–22G (the latter for children under 6 months • There will be a subtle “give” at the midpoint between
of age) Tuohy needle with a syringe is used. After walking these landmarks (spinous and transverse processes), indi-
off the transverse processes, a “pop” or loss of resistance cating entrance into the paravertebral space.
to air or D5W may be felt when entering the paravertebral • For the loss-of-resistance technique, an epidural set con-
space through the costotransverse ligament. taining an 18G–22G (the latter for children under
• Lonnqvist et al. [1] reported calculations using computed 6 months of age) Tuohy needle with a syringe is used.
tomography for determining both the depth of the para- After walking off the transverse processes, a “pop” or loss
vertebral space from the skin (S-PVS depth) and the lat- of resistance to air or D5W may be felt when entering the
eral distance of the paravertebral space from the spinous paravertebral space through the ligament.
exceed 2 mg/kg. Dilution with normal saline can help

Clinical Pearl increase the volume (to more effectively produce the
For intermittent or continuous blocks, an epidural block) while maintaining safe doses of local anesthetic.
catheter set is used, and the catheter is advanced
2–3 cm into the paravertebral space. After aspiration of
the catheter, a test dose using lidocaine 1 % (0.1 mL/
kg) with 1:200,000 epinephrine (0.5 μg/kg), followed 28.3.2 Nerve Stimulation Technique
by a bolus dose (0.5 mL/kg) of local anesthetic (0.125–
0.25 % bupivacaine, depending on age and weight of 28.3.2.1 Current Application
the child), can be injected over 5–10 min. Note that the and Appropriate Responses
heart rate increase can be unreliable, especially under
anesthesia [5]. The continuous block may be main- • An initial current of 1.5–3 mA is used, and the needle is
tained with hourly injections of 0.1–0.25 mL/kg/h of advanced until contractions of the appropriate muscles
the same solution. (e.g., abdominal muscles with thoracic paravertebral
block and quadriceps muscle twitch with lumbar paraver-
tebral block) are observed. The current intensity is then
reduced to localize the nerves at 0.4–0.6 mA.
28.3.1.4 Local Anesthetic Application • Until the paravertebral space is entered, the motor
response will be from the paraspinal muscles.
• Since the paravertebral space is well-vascularized, inad- • A test dose of local anesthetic (0.1 mL/kg of 1 % lido-
vertent vascular puncture will often occur, highlighting caine) will confirm nerve localization, and current dissi-
the need for frequent aspiration and injection in small pation at the needle tip by the conducting solution will
aliquots. eliminate the nerve response.
• If depending on multi-segmental block at the thoracic
level, inject 0.5 mL/kg of local anesthetic solution (e.g.,
0.25 % bupivacaine) with or without epinephrine. This 28.3.2.2 Modifications to Inappropriate
volume should cover at least four to five segments of spi- Responses
nal nerves. If using individual blocks for each segment,
the volume of local anesthetic will be reduced to 0.1 mL/ • Bilateral muscle twitches of the lower extremity may
kg. Vertical spread of local anesthetic is limited at the indicate epidural needle placement. Bilateral twitches at
lumbar level, so reduced volumes injected at each level low current (<1 mA) may indicate subdural needle
will be required. The dose of bupivacaine should not placement.
28.3.3 Ultrasound-Guided Technique paravertebral blocks is now used widely for both single-shot
blocks and catheter insertion [6, 7]. Ultrasound guidance can
Traditionally, ultrasound imaging has been used prior to (i.e., be used to help identify the paravertebral space and needle
“pre-procedural,” “supported,” or “off-line” imaging) rather placement and to monitor the spread of the local anesthetic.
than during (i.e., “real-time” or “on-line” imaging) block per- The MRI images in Figs. 28.3, 28.4, 28.5, 28.6, 28.7, and
formance to identify the deep bony landmarks, including the 28.8 correlate to the ultrasound images in these figures, allow-
articular and transverse processes. Real-time imaging for ing the reader to better understand the anatomy of the region.
Fig. 28.3 (a) VHVS and MRI images of transverse section at T9–10. (b) Ultrasound images of transverse section at T9–10
Fig. 28.4 (a) VHVS and MRI images of longitudinal section at the midline showing the spinous process of T9 and T10. (b) Ultrasound images
of longitudinal section at the midline showing the spinous process of T9 and T10
Fig. 28.5 (a) VHVS and MRI images of longitudinal section at the midline showing the laminae of T9 and T10. (b) Ultrasound images of longi-
tudinal section at the midline showing the laminae of T9 and T10
Fig. 28.6 (a) VHVS and MRI images of longitudinal section at the images of longitudinal section at the midline showing the articular pro-
midline showing the articular processes of T9 and T10. (b) Ultrasound cesses of T9 and T10
Fig. 28.7 (a) VHVS and MRI images of longitudinal section at the midline showing the transverse processes of T9 and T10. (b) Ultrasound
images of longitudinal section at the midline showing the transverse processes of T9 and T10
Fig. 28.8 (a) VHVS and MRI images of longitudinal section lateral to the midline showing the ninth and tenth ribs and the underlying pleural
space. (b) Ultrasound images of longitudinal section lateral to the midline showing the ninth and tenth ribs and the underlying pleural space
28.3.3.1 Scanning Technique • Moving laterally, the transverse processes appear (Fig. 28.7)
and look similar to the articular processes. The transverse
• Position a linear high-frequency (10–12 MHz) probe in processes will disappear from view when the probe is moved
the transverse plane in the midline to capture an overview beyond their tips, which can help distinguish them from the
of the vertebrae (Fig. 28.3). The vertebral laminae and articular processes and mark the lateral block location.
processes will be viewed, allowing the lateral distance to • Beyond the transverse processes in the thoracic region,
the transverse processes to be marked. the rib heads appear as long shadows within hyperechoic
• To obtain a more accurate localization (lateral distance borders deep to the linear hyperechoic muscle fibers of
and depth) of the transverse processes, rotate the probe to the paravertebral muscles (Fig. 28.8).
the longitudinal plane, and scan in a medial-to-lateral • The paravertebral space lies deep to the transverse pro-
direction. Starting at the spinous processes (Fig. 28.4), the cesses between the intercostal muscle and parietal pleura
scan will capture (in sequence) the lamina (Fig. 28.5), (Fig. 28.7), and the pleura can often be identified as a
articular (Fig. 28.6) and transverse processes (Fig. 28.7), bright hyperechoic line under the ribs (Fig. 28.8).
and, in the thoracic spine, the ribs (Fig. 28.8). • At the lumbar spine, the relatively bulky erector spinae
• To locate the desired segment at the lumbar spine, place muscles appear highly linear and overlay the vertebrae
the probe in the longitudinal plane at the lateral distance and spinal nerves during the scan.
of the transverse processes and shift the probe caudally • Deep to the medial aspect of the transverse processes, the
to capture the cephalad aspect of the sacrum. The trans- lumbar nerve roots may be seen between the hypoechoic
verse processes can then be counted during a cephalad shadows of the bones, as hypoechoic parallel bands inter-
scan. spersed with the hyperechoic striations of the related con-
nective tissue.
• In the lumbar paravertebral space, the lumbar plexus lies
28.3.3.2 Sonographic Appearance in the “psoas compartment” bordered by the psoas major
anteriorly and quadratus lumborum posteriorly (Figs.
• The initial transverse scan will show a hyperechoic out- 11.4 and 24.6a).
line of the vertebral spinous and transverse processes, the
lamina, and, in the thoracic spine, associated rib
(Fig. 28.3).
• The midline image in the longitudinal plane will capture Clinical Pearl
the spinous processes (Fig. 28.4). Lumbar plexus vs. lumbar paravertebral block:
• During the lateral scan with the probe placed longitudi- Lumbar plexus block, also known as the psoas
nally to the spine, the laminae will appear first as largely sheath block, is performed by injecting local anesthetic
overlapping linear structures (Fig. 28.5). within the psoas sheath and into the psoas muscle. The
• The articular processes in long-axis appear as multiple lumbar paravertebral block, which is also known as
“lumps” just lateral to the spinous processes and laminae psoas compartment block, involves injection of local
and are short, rectangular structures with hyperechoic anesthetic posterior to the psoas sheath, between the
lines with underlying hypoechoic bony shadowing psoas muscle and quadratus lumborum.
(Fig. 28.6).
28.3.3.3 Needle Insertion • Under real-time ultrasound guidance, please note:

1. With the probe placed in the sagittal/longitudinal
• When using ultrasound guidance for paravertebral block, plane, OOP needling (Fig. 28.10) may be more risky,
it is important to carefully observe the angulation of the as it often requires medial or lateral angulations
needle. Using an IP needle alignment to a longitudinal (described above).
probe may be most prudent (Fig. 28.9). 2. An IP needling approach can be more risky when the
• The needle should not be inserted in a significantly medial probe is placed in the coronal/transverse plane if the
direction due to a risk of spinal cord injury from intrafo- needle is advanced blindly.
raminal insertion and injection. Likewise, a lateral direc-
tion bears the risk of pneumothorax.
Fig. 28.9 In-plane needling technique for ultrasound-guided paraver- Fig. 28.10 Out-of-plane needling technique for ultrasound-guided
tebral block at T9–10. Blue rectangle indicates probe footprint paravertebral block at T9–10. Blue rectangle indicates probe footprint
28.3.3.4 Alternate Scanning Technique: • If the rib is seen articulating with the transverse pro-
Transverse Approach cess and the pleura is not visualized, slide the probe
The miniscule distance between transverse processes and the caudal or cephalad a few millimeters until the pleura
resultant steep angle of the needle required to access the and transverse process are visualized with no over-
paravertebral space makes a parasagittal approach difficult in shadowing rib.
very small patients. A transverse (lateral-to-medial) approach • When visible, the internal intercostal membrane (IICM)
allows continuous visualization of the advancing needle and, (the lateral continuation of the costotransverse ligament)
providing that the needle is never advanced blindly, is a safe is identified as a linear hyperechoic structure connecting
alternate technique. the edge of the internal intercostal muscle to the lower
edge of the transverse process.
• The appropriate thoracic level is identified using surface • The paravertebral space is located in the triangle formed
landmarks or ultrasound pre-scanning and marked (see by the anatomic anterior surface of the transverse pro-
parasagittal approach). cess and IICM, the anatomic posterior surface of the
• Place a high-frequency linear transducer in a transverse parietal pleura, and the lateral surface of the vertebral
orientation over the spinous process corresponding to the body.
dermatomal level to be blocked. The spinous process is • The needle is introduced with the bevel toward and in-
identified as a hyperechoic inverted V-shape with an plane with the probe, several centimeters from the lateral
acoustic shadow beneath. edge of the probe. The needle is advanced at an angle
• Slide the probe lateral and rotate to a slightly oblique ori- from lateral to medial until the needle tip penetrates the
entation following the direction of the rib (lateral probe IICM and passes into the paravertebral space immediately
edge slightly caudal) until the tip of the transverse process underneath the transverse process.
is visualized as a characteristic thumb shape (Fig. 28.11). • Correct positioning within the paravertebral space can be
Locate the transverse process in the center of the screen. confirmed by real-time ultrasound visualization of ante-
The pleura is seen just lateral and deep to the transverse rior displacement of the pleura following injection of a
process. small amount of sterile saline or D5W.
Fig. 28.11 Transverse view of transverse process and surrounding anatomy for medial-to-lateral approach for paravertebral block, IC intercostal
muscles; TP transverse process
28.3.3.5 Local Anesthetic Application • In young patients, the hypoechoic spread of local anes-
thetic can be seen as it displaces the parietal pleura ante-
• Local anesthetic spread will be difficult to view in most riorly during thoracic paravertebral block. During lumbar
patients if using real-time ultrasound guidance during this paravertebral block, local anesthetic spread can be seen
block. The overlying bones largely reflect the US beam posterior to the psoas major muscle.
and obstruct visibility of the paravertebral space. The • Chest X-ray following injection of omnipaque contrast
spread may be captured in young patients (generally dye (0.25 mL/kg) in a 6-month-old infant shows the
<2–3 years), since their neural arches have yet to fuse anterior-posterior spread of injectate across eight derma-
with the vertebral bodies (centrums), allowing the ultra- tomes following ultrasound-guided injection into the
sound beam to better penetrate to the paravertebral space. paravertebral space (Fig. 28.12).
Fig. 28.12 Chest X-ray showing anterior-posterior dermatomal spread

of contrast agent (arrowheads) following injection into paravertebral
space

Guided Approaches
Recently, Ponde et al. [8] attempted to create formulae that

would allow determination of the distances from the spine to
the needle insertion point and from the insertion point to the
paravertebral space at the thoracic (T1–T12), lumbar (L1),
and cervical (C6) levels in children up to 5 years old. The
formulae use ultrasound measurements and account for age
and weight, allowing easy calculation of the two distances.
A case report by Visoiu and Yang described the use of
continuous bilateral paravertebral blocks in a 16-year-old
patient with Denys-Drash syndrome and history of end-stage
renal failure who underwent exploratory laparotomy and
small bowel resection [9]. Despite the presence of mild coag-
ulopathy at the time of admission, bilateral paravertebral
catheters were installed at the T8 level; under ultrasound
guidance, a 90 mm, 18G Tuohy needle was inserted in-plane,
lateral to medial, followed by injection of 10 mL ropivacaine
0.5 % into the paravertebral space. A catheter was threaded
3 cm into the paravertebral space, and placement was con-
firmed with 2 mL of local anesthetic. Pain management fol-
lowing surgery was satisfactory, and the catheters were
removed without any problems on postoperative day 5.
Fig. 28.13 Ultrasound image of thoracic paravertebral block.

28.5 Case Study TP transverse process, PV paravertebral space; arrowheads indi-
cate shadow of needle. See Case Study for details
Thoracic Paravertebral Block (Provided by A. Sawardekar)

A 16-year-old male, 76 kg, with a history of pectus
excavatum presented with ongoing pain in the right
chest wall. The patient had received a Nuss procedure References
to repair the defect 18 months prior, and upon chest
X-ray, it was determined that the Nuss bar should be 1. Lonnqvist PA. Continuous paravertebral block in children. Initial
experience. Anaesthesia. 1992;47:607–9.
removed. An ultrasound-guided paravertebral block 2. Lonnqvist PA, Hildingsson U. The caudal boundary of the thoracic
was administered with a 22G needle (see Fig. 28.13). paravertebral space. A study in human cadavers. Anaesthesia.
The right T6 paravertebral space was identified using a 1992;47:1051–2.
13–6 MHz linear high-frequency probe. A longitudinal, 3. Busoni P, Messeri A. Spinal anesthesia in children: surface anat-
omy. Anesth Analg. 1989;68:418–9.
out-of-plane approach was used to advance the needle 4. Busoni P, Messeri A. Spinal anesthesia in infants: could a L5–S1
with saline hydrodissection below the costotransverse approach be safer? Anesthesiology. 1991;75:168–9.
ligament. Ten mL of 0.25 % bupivacaine was injected 5. Tanaka M, Nishikawa T. Simulation of an epidural test dose with
at this site. Duration of surgery was 60 min, and block intravenous epinephrine in sevoflurane-anesthetized children.
Anesth Analg. 1998;86:952–7.
duration was 12 h. No additional analgesics were 6. Bhalla T, Sawardekar A, Dewhirst E, Jagannathan N, Tobias
needed in the recovery room or on the ward. JD. Ultrasound-guided trunk and core blocks in infants and chil-
dren. J Anesth. 2013;27:109–23.
7. Boretsky K, Visoiu M, Bigeleisen P. Ultrasound-guided approach to Suggested Reading

the paravertebral space for catheter insertion in infants and children.
Dalens BJ. Blocks of nerves of the trunk. In: Dalens BJ, editor. Pediatric
8. Ponde VC, Desai AP. Echo-guided estimation of formula for para-
regional anesthesia. Boca Raton: CRC Press, Inc.; 1990. p. 459–3.
vertebral block in neonates, infants and children till 5 years. Indian
J Anaesth. 2012;56:382–6.
9. Visoiu M, Yang C. Ultrasound-guided bilateral paravertebral con-
2013. p. 835–879.
tinuous nerve blocks for a mildly coagulopathic patient undergoing
Tsui BC. Paravertebral and intercostal blockade. In: Tsui BC, editor.
exploratory laparotomy for bowel resection. Pediatr Anesth.
2011;21:459–62.
Intercostal Nerve Blocks
29
Ban C.H. Tsui
Contents
29.1 Clinical Anatomy ............................................................................................................................ 456
29.1.1 Intercostal Nerves ............................................................................................................... 456
29.1.2 Costovertebral Articulations ............................................................................................... 456
29.2 Landmark-Based Technique .......................................................................................................... 456
29.2.1 Patient Positioning .............................................................................................................. 456
29.2.2 Landmarks and Surface Anatomy ....................................................................................... 457
29.4 Ultrasound-Guided Technique .......................................................................................................... 458
29.6 Case Study ....................................................................................................................................... 461
References ................................................................................................................................................... 461
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_29
456 B.C.H. Tsui
29.1 Clinical Anatomy umbilical area, travels laterally between the transversus
abdominis and the internal oblique muscles and then courses
29.1.1 Intercostal Nerves between the rectus sheath and the posterior wall of the rec-
tus abdominis muscle (see Chap. 30). Within each intercos-
Figure 13.10 illustrates a transverse section of the hemitho- tal groove, the nerve runs inferior to the intercostal artery,
rax. Thoracic spinal nerves emerge from the intervertebral with the vein located uppermost.
(spinal) foramina, between the superior and inferior articula-
tions of the vertebral bodies and ribs. The spinal nerves
divide to supply paraspinal muscles and skin of the back 29.1.2 Costovertebral Articulations
(dorsal ramus) and the intercostal spaces (ventral ramus).
The ventral rami of the thoracic spinal nerves form 11 pairs The ribs articulate with the vertebral column through two
of intercostal nerves (T1–T11) for the 11 intercostal spaces synovial joints (Fig. 13.6). The costovertebral joint is formed
(the ventral rami of T1 split into two and the larger branch by the head of the rib articulating with the demifacets on the
serves as the brachial plexus) and the subcostal nerve (T12), adjacent thoracic vertebral bodies and the corresponding
which courses below the 12th rib. The nerves relay and intervertebral disk of the upper vertebral joint. The costo-
receive information with the ganglia of the paravertebral transverse joint is formed by the articular facets on the tuber-
sympathetic chain through gray and white rami communi- cles of the ribs articulating with the transverse processes of
cantes. The intercostal nerves give off cutaneous branches at the thoracic vertebrae. Ultrasound imaging may help deter-
the anterior and lateral aspects of the thoracic wall. mine the needle puncture point for intercostal nerve block by
Initially, the intercostal nerves run along the dorsal aspect marking the location of the costotransverse joint.
of the intercostal space, between the intercostal membrane
and the parietal pleura. From here, they course laterally past
the angle of the rib, pierce the internal intercostal mem- 29.2 Landmark-Based Technique
brane, and run between the internal and middle intercostal
muscles (also referred to as the innermost and internal inter- 29.2.1 Patient Positioning
costal muscles, respectively). Laterally, the nerves give off
both collateral (running adjacent to the nerve within the • For unilateral intercostal nerve block, the patient is usu-
intercostal space) and lateral cutaneous branches, the latter ally placed in the lateral decubitus position with the upper
dividing into ventral and dorsal branches. Rather than arm resting on a support.
branching, the second intercostal nerve supplies the inter- • For bilateral blockade, the patient may be placed in the
costobrachial nerve, which innervates the axillary region. prone position or (if conscious) asked to sit. Their arms
As they travel anteriorly, the nerves again contact the pari- are draped over the edge of the stretcher or operating table
etal pleura before dividing into the anterior cutaneous nerves so that the scapula falls away laterally from the midline.
of the thorax. The tenth intercostal nerve, supplying the • For anterior blocks, the patient may be supine or sitting.
29 Intercostal Nerve Blocks 457
29.2.2 Landmarks and Surface 29.2.3 Needle Insertion

Anatomy (Fig. 29.1)
• The same procedure will be repeated at all levels to be
• Midaxillary line: This line is drawn longitudinally from blocked. Posterior blocks are described here.
the midpoint of the axilla and is used in younger children • Most anesthesiologists prefer to stand on the side that
(younger than 10 years). At this more lateral location, the allows their dominant hand to hold the syringe at the cau-
nerves are separated from the parietal pleura by the inter- dal end of the patient.
nal intercostal muscle. • A short-beveled needle with a length of no longer than
• Scapular line: This line is drawn downward at the inferior 3 cm should be used to allow maximum appreciation, or
angle of the scapula. The insertion site is immediately “feel,” of the tissue resistances and to avoid trauma.
medial to the scapula or along the scapular line. This line • Generally, 22G–24G needles will be used. A Tuohy nee-
is more suitable for older children (older than 10 years) dle will allow a catheter to be placed for continuous
and adolescents. blocks.
• Ribs: The lower border of each rib marks the needle punc- • Plastic tubing should be placed between the needle and
ture site for the nerve of the same level. syringe containing the local anesthetic solution in order to
• Nipples and sternum (anterior block). avoid needle disturbances from chest movements during
respiration.
Needle insertion typically occurs at the intersection of the • Starting with the lowest rib, the index finger of the cepha-
midaxillary line (for children <10 years old) or scapular line lad hand retracts the skin overlying the rib in a cephalad
(for children >10 years old) or immediately medial to the direction.
scapula (Fig. 29.1). For the 11th intercostal nerve and the • With the bevel of the needle directed cephalad, insert the
subcostal nerve (T12), the puncture point will be medial to needle, maintaining a constant 20° cephalad angulation.
the scapular line, with the length of the corresponding rib • After contact is made with the inferior border of the rib,
determining the point. Although an anterior approach has withdraw the needle slightly, and release the cephalad
been described [1], it is rarely indicated and will not be distraction slowly.
cussed here. • The cephalad hand takes over the needle and syringe, and
the needle is allowed to “walk down” to below the rib
at the same angle.
• Advance the needle slightly (2–3 mm) while maintaining
the cephalad angle.
• Maintaining pressure on the syringe will allow a loss of
resistance to be felt upon penetration of the intercostal
space.
Fig. 29.1 Surface anatomy and needle insertion points for intercostal
nerve block
458 B.C.H. Tsui
29.2.4 Local Anesthetic Application

Clinical Pearl
• The needle is placed within the intercostal space, inferior • Despite frequent concern about the incidence of
to the overlying rib, and after obtaining a negative pneumothorax with intercostal blocks, this compli-
aspiration test, 0.5–1 mL (depending on the patient) of cation is rare in experienced hands. This depends
local anesthetic solution is injected. The lower volume is primarily on maintaining strict safety features of the
typically used in patients under the age of three. Since described technique. Emphasis should be placed on
larger volumes may produce a more effective block, the absolute control of the syringe and needle at all
solution should be diluted with normal saline to avoid times, particularly during injection.
overdose.
• Since absorption of local anesthetic by the blood is high
at the intercostal space, peak plasma levels of local anes-
thetic are reached after injection, and high toxicity poten- 29.3 Nerve Stimulation Technique
tial exists. To reduce the solution’s absorption, the use of
epinephrine is advised, although a maximum dose of Generally, nerve stimulation is not used to confirm nerve
4 μg/kg, with typical concentrations of 1:400,000, is used. localization.
Incremental injection with frequent aspiration is an addi-
tional measure to avoid toxicity.
• A shorter duration block will be achieved when using lido- 29.4 Ultrasound-Guided Technique
caine (0.25–1 %), while longer duration (up to 16–18 h)
will be attainable with bupivacaine (0.125–0.25 %). The intercostal space is depicted in the MRI and correspond-
ing ultrasound images in Fig. 29.2.
Fig. 29.2 (a) VHVS and MRI images of sagittal section showing the intercostal space. (b) Ultrasound images of sagittal section showing the
intercostal space
29.4.1 Scanning Technique • When using the M-mode to visualize the intercostal
space, the typical “seashore sign” illustrating the position
• At each level, place a high-frequency probe perpendicular of the pleura and lung tissue can be better appreciated
to the ribs at the appropriate position (mid-axillary line or (Fig. 29.3).
scapular line or immediately medial to the scapular line) • The muscles appear hypoechoic with a pennate pattern.
to capture an image of the cephalad and caudal rib and the • The neurovascular space can be difficult to visualize, but
underlying pleura. the vascular bundle can be made more obvious with color
Doppler.
29.4.2 Sonographic Appearance
• The ribs will appear hyperechoic with dorsal shadowing,

and the hypoechoic pleural cavity will appear interspersed
between and deep to the ribs (Fig. 29.2b).
Fig. 29.3 Ultrasound image showing the intercostal space in M-mode. “seashore sign” indicates normal lung sliding. Blue rectangle indicates
The linear pattern is tissue superficial to the pleura (arrowhead). The ultrasound probe footprint
granular or “sandy” appearance below the pleura is lung tissue; this
460 B.C.H. Tsui
29.4.3 Needle Insertion 29.4.4 Local Anesthetic Application
• Insert a short-beveled, 22G–24G needle using an OOP • Inject 0.5–1 mL of local anesthetic solution into each
alignment to the probe (Fig. 29.4). level, and view the spread between the middle and inter-
• Apply color Doppler to help confirm the location of the nal intercostal muscles in the vicinity of the neurovascular
intercostal blood vessels. space.
• Position the needle immediately inferior to the cephalad • The spread will appear as a small expansion of
rib and inferior to the artery. hypoechogenicity.
• For the IP technique, the needle is inserted caudad to the
ultrasound probe which is placed in a parasagittal plane.
The needle is aimed at the inferior part of the rib, where 29.5 Current Literature in Ultrasound-
the neurovascular bundle is situated: between the inner- Guided Approaches
most intercostal membrane and internal intercostal mus-
cle (Fig. 29.5). Local anesthetic absorption for intercostal block is the high-
est of all peripheral blocks due to the area’s abundant vascu-
larity. Peak plasma concentration of bupivacaine 0.5 %
occurs between 5 and 15 min in children; [2] thus, addition
of epinephrine can help slow the systemic absorption.
A retrospective review was performed by Shelly and Park
on liver transplant patients who received intercostal blocks
[3]. This study showed that children who received intercostal
block had much lower opioid requirements than those not
receiving intercostal blocks. A prospective study of 20 chil-
dren (5–12 years) who received intercostal block for thora-
cotomy also showed improved pain control compared to
those maintained on opioids alone [4].
Fig. 29.4 Out-of-plane needling technique for ultrasound-guided

intercostal nerve block. Blue rectangle indicates probe footprint
Fig. 29.5 In-plane needling technique for ultrasound-guided intercos-

tal nerve block. Blue rectangle indicates probe footprint
29.6 Case Study References

1. Dalens B. Regional anesthesia in infants, children, and adolescents.
Baltimore: Williams & Wilkins; 1995. p. 464–5.
Intercostal Nerve Block (Contributed by S. Suresh) 2. Rothstein P, Arthur GR, Feldman HS, Kopf GS, Covino
A 6-year-old female, 25.7 kg, presented with arhinia BG. Bupivacaine for intercostal nerve blocks in children: blood con-
due to congenital anomalies of the skull and face centrations and pharmacokinetics. Anesth Analg. 1986;65:625–32.
3. Shelly MP, Park GR. Intercostal nerve blockade for children.
bones. A nasal reconstruction was scheduled using a Anaesthesia. 1987;42:541–4.
cartilage graft from the left sixth rib to the nose. 4. Matsota P, Livanios S, Marinopoulou E. Intercostal nerve block
A one-view chest X-ray was taken prior to surgery. with bupivacaine for post-thoracotomy pain relief in children. Eur J
An in-plane, ultrasound-guided intercostal block Pediatr Surg. 2001;11:219–22.
was performed using a 22G needle and 3 mL 0.25 %
bupivacaine with epinephrine 1:200,000 (see
Fig. 29.6). Duration of the surgery was 5 h, 25 min; Suggested Reading
block duration was 6–8 h.
Dalens BJ. Blocks of nerves of the trunk. In: Dalens BJ, editor. Pediatric
regional anesthesia. Boca Raton: CRC Press; 1990. p. 441–50.
Peutrell JM, Mather SJ. Regional anaesthesia for babies and children.
Oxford: Oxford University Press; 1997. p. 117–24.
2013. p. 835–79.
Tsui BC. Paravertebral and intercostal blockade. In: Tsui BC, editor.
Fig. 29.6 Ultrasound-guided intercostal nerve block. N inter-

costal nerve, A intercostal artery, V intercostal vein (See “Case
Study” for details)
Rectus Sheath and Transversus
Abdominis Plane (TAP) Blocks 30
Bryan J. Dicken and Ban C.H. Tsui
Contents
30.1 Rectus Sheath Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
30.1.1 Clinical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464
30.1.4 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . 468
30.1.5 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
30.2 Transversus Abdominis Plane (TAP) Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
30.2.1 Clinical Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
30.2.4 Catheter Placement Under Direct Visualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
30.2.5 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
30.2.6 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
B.J. Dicken, MSc, MD, FRCSC

Division of Pediatric Surgery, Department of Surgery,
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_30
464 B.J. Dicken and B.C.H. Tsui
30.1 Rectus Sheath Block • The posterior wall of the sheath is not attached to muscle,
and the area between the rectus abdominis muscle and
30.1.1 Clinical Anatomy sheath can be separated for the block.
• The nerve’s anterior cutaneous branch, formed as it
• The anterior abdominal wall is innervated by the inferior crosses the rectus muscle, supplies the skin of the umbili-
seven thoracic nerves (T6–T12) and one lumbar nerve cal area.
(L1). These nerves travel laterally between the transver- • The rectus sheath block aims to place local anesthetic
sus abdominis and the internal oblique muscles and then, between the posterior aspect of the rectus sheath and the
at the level of the linea semilunaris (or lateral edge of the rectus abdominis muscle. The posterior wall of the sheath
rectus abdominis muscle), penetrates the rectus sheath to is not attached to the muscle and thus can be separated dur-
travel between the posterior wall of the rectus sheath and ing the block injection (i.e., represents a potential space).
the rectus abdominis muscle. From there, the nerves pen-
etrate anteriorly through the rectus muscle to innervate
the skin. 30.1.2 Landmark-Based Technique
• The rectus sheath is formed by the aponeuroses of the lat-
eral three abdominal muscles and encloses the rectus 30.1.2.1 Patient Positioning
abdominis muscle (Fig. 13.9). Bilateral sheaths are joined
at the linea alba above the arcuate line. The arcuate line is • A supine position is most appropriate for this block.
the horizontal line separating the lower limit of the poste-
rior layer of the rectus sheath, which is derived from the
posterior layer of the internal oblique aponeurosis and the 30.1.2.2 Landmarks and Surface Anatomy (Fig. 30.1)
transversus abdominal aponeurosis.
• The arcuate line also marks the point where the inferior • Umbilicus
epigastric vessels are separated by the posterior fascia of • Linea semilunaris: the lateral edge of the rectus abdomi-
the rectus abdominis. nal muscle
Fig. 30.1 Surface anatomy for rectus sheath block

30 Rectus Sheath and Transversus Abdominis Plane (TAP) Blocks 465
30.1.2.3 Needle Insertion 30.1.2.4 Local Anesthetic Application
• After marking the external layer of the rectus sheath on • For children up to 7 years of age, 0.2 mL/kg 0.2 % ropiva-
both sides of the abdomen, insert a short-bevel needle at caine is adequate.
the point where the outer border of the rectus sheath • For older children, 0.2–0.3 mL/kg 0.5 % levobupivacaine
intersects a horizontal line at the level of the should be used.
umbilicus.
• Advance the needle 60° to the skin toward the umbilicus
until a loss of resistance and a “pop” is felt, indicating 30.1.3 Ultrasound-Guided Technique
puncture of the anterior rectus sheath.
• After injection of local anesthetic on one side, repeat the Subcutaneous structures of the rectus sheath at the level of
above steps for the other side. L3–L4 are depicted in the MRI and corresponding ultra-
sound images in Fig. 30.2.
Fig. 30.2 (a) VHVS and MRI images of the abdominal wall, showing the rectus abdominal muscle and the rectus sheath. (b) Ultrasound image
of the abdominal wall, showing the rectus abdominal muscle and the rectus sheath
30.1.3.1 Scanning Technique • The peritoneum is seen behind the posterior rectus sheath.
• The muscles of the lateral abdominal wall (external
• Multiple injections are required for a successful rectus sheath oblique, internal oblique, and transversus abdominis,
block. A typical approach is injection of local anesthetic on from superficial to deep) are seen lateral to the rectus
either side of the midline at the upper and lower ends of the muscle.
excision for a total of four needle insertion points. • The internal oblique muscle is on the same plane as the
• A linear (6–15 MHz) transducer is placed in a transverse rectus muscle, and they are separated by the aponeurosis
location on the anterior abdominal wall lateral to the pro- of the internal oblique.
posed incision site. • The target nerves are not visible. They course between
• The required depth for penetration is usually 2–4 cm but internal oblique and transversus abdominis before piercing
varies with the depth of the subcutaneous layer. the posterior rectus sheath to traverse the belly of the rectus
muscle.
• The target for injection is the lateral gutter between the
30.1.3.2 Ultrasonographic Appearance (Fig. 30.2b) posterior rectus sheath and the rectus muscle.
• The inferior epigastric vessels run through the rectus
• At the midline, the hyperechoic linea alba is seen between muscle. They may be seen if the Doppler function is uti-
the belly of the rectus muscle on either side. The most lized (Fig. 30.3). It is important to avoid puncturing or
superficial layer is subcutaneous fat. injecting local anesthetic into these vessels.
Fig. 30.3 Doppler ultrasound image showing location of inferior epi-

gastric vessels in the rectus muscle (RM)
30.1.3.3 Needle Insertion rectus muscle and thereby avoids the inferior epigas-
tric vessels.
• Depending on subcutaneous fat depth, use a 4–10 cm, • Needle tip position may be confirmed by injection of
22G needle. 1–2 mL D5W.
• An in-plane (IP) approach is used (Fig. 30.4).
• Intermittent injection with D5W is recommended to con- 30.1.3.4 Local Anesthetic Application
firm needle tip position.
• The needle is inserted from lateral to medial. To avoid • Performing a test dose with D5W is recommended prior
puncturing the inferior epigastric vessels, a lateral to local anesthetic application to visualize the spread and
needle insertion point is chosen. The needle is directed confirm needle tip localization.
through the external and internal oblique muscles • Inject 0.2 mL/kg 0.2 % ropivacaine, 0.25 % bupivacaine,
into the lateral gutter of the rectus muscle directly or 0.5 % bupivacaine on each side.
superficial to the posterior rectus sheath. Using this • The local anesthetic should be seen to spread between the
approach, the needle does not enter the belly of the posterior rectus sheath and the rectus muscle.
Fig. 30.4 In-plane needling technique for ultrasound-guided rectus

sheath block. Blue rectangle indicates probe footprint
30.1.4 Current Literature in Ultrasound- guide needle placement, suggesting that improved accuracy
Guided Approaches leads to more successful blocks.
For rectus sheath block, the probe is placed over the linea 30.1.4.1 Umbilical Nerve Block
semilunaris (at the lateral aspect of the rectus abdominis For umbilical hernia repair, an umbilical nerve block can be
muscle) at a level beneath the umbilicus, and the lateral edge performed. The scanning field of view should be increased to
of the rectus muscle is positioned at the edge of the screen. include the medial aspect of the lateral abdominal muscles
The posterior wall of the sheath may be poorly defined at and the region where their aponeuroses join to form the
locations caudad to the umbilicus (i.e., below the arcuate rectus sheath. Laterally, the lateral abdominal muscles may
line) [1]. The peritoneum appears thick with a hyperechoic be delineated with oblique hyperechoic lines separating
border beneath the muscles. them. The external oblique abdominal muscle lies outermost,
Willschke et al. described their approach for ultrasound- overlying the internal oblique abdominal and transversus
guided rectus sheath block in the clinical portion of their abdominis muscles. The thick rectus abdominis muscle can
two-part study evaluating the sonoanatomy and clinical fea- be identified medially, as can the rectus sheath, formed by
sibility of this block [2]. They stated that their injection site the aponeurosis of the transversus abdominis muscle and
was situated at the location where an optimal view of the internal and external oblique abdominal muscles. The inter-
posterior sheath was obtained. A short-beveled needle (e.g., costal nerve(s) will likely not be visualized by ultrasound
22G, 40 mm with facet tip) was inserted using an out-of- imaging. The nerves are small and run longitudinally, thus
plane approach at the inferior edge of a linear hockey stick tangential, to the probe [1]. The hyperechoic and linear
probe, using an angle most suitable for the depth of the appearance of the nerves will closely resemble the aponeuro-
sheath. The needle tip was placed just between the posterior sis of the musculature in this region.
rectus sheath and the posterior aspect of the rectus abdomi- De Jose Maria et al. [1] have described their approach to
nis muscle. After negative aspiration (for epigastric vessel an ultrasound-guided umbilical nerve block. The probe
puncture), local anesthetic solution was injected; expansion (10 MHz frequency) was placed where a line between the
of the space between the sheath and posterior aspect of the tenth intercostal space and the umbilicus intersects the rectus
rectus muscle denoted proper placement of the needle. abdominis muscle. They rotated the probe between trans-
The median depth of the posterior sheath in 30 children was verse and longitudinal planes in order to obtain a good view
8.0 mm (range 5–13.8); moreover, there was poor correlation clearly delineating the musculature and rectus sheath. The
between the depth of the posterior rectus sheath and weight, longitudinal plane was used during the block, and the ideal
height, or body surface area [3]. With the sheath’s proximity to position of the probe was that which best captured the forma-
the peritoneum and without the possibility of reliable estimation of the rectus sheath, by the aponeuroses of the transver-
tions or calculations of optimal needle depth, ultrasound imag- sus abdominis and internal oblique abdominal muscles. The
ing during the block is especially useful. It is also important to needle was inserted using an in-plane approach to place the
note that the posterior wall of the sheath is poorly defined tip close to the lateral edge of the rectus muscle and between
below the arcuate line [1]. Placing the needle more lateral, and the aponeurosis of the abdominal muscles. The local anes-
thus potentially avoiding puncture into the peritoneum, the thetic spread was observed behind the rectus abdominis mus-
umbilical nerve block targets the region lateral to the sheath cle and under the internal oblique abdominal muscle.
where the nerves exit from their course between the transversus
abdominis and internal oblique abdominal muscles. 30.1.4.2 Outcome Evaluation for Blocks at
Two recent studies compared ultrasound-guided rectus the Anterior Trunk
sheath block to the traditional method of local anesthetic Earlier reports of the rectus sheath block, using “blind” tech-
infiltration for pain control during umbilical hernia repair. niques, describe successful blocks as performed in small
Both demonstrated a reduction in consumption of postopera- numbers of patients [8, 9]. Using ultrasound guidance for
tive opioid and non-opioid analgesia in the rectus sheath rectus sheath blocks in 20 children, Willschke et al. reported
block group [4, 5]. Gurnaney et al. [5] showed no difference a 100 % success rate for intra- and postoperative analgesia
in time to rescue analgesia between the groups, and (until time to discharge at 4 h), using (predetermined vol-
Dingeman et al. [4] showed that postoperative pain scores umes in their study) lower doses of local anesthetics (i.e.,
were lower with the ultrasound-guided block. These studies’ levobupivacaine 0.25 % 0.1 mL/kg versus bupivacaine 0.5 %
findings are supported by a case series of ultrasound-guided 0.2 mL/kg) than previously described when using “blind”
rectus sheath block for umbilical hernia repair which showed technique with the same injection protocol [3, 9]. Similar
that patients receiving the block consumed less opioid anal- doses of local anesthetic have been used for the umbilical
gesia in the post-op recovery unit [6]. These results also con- nerve block as those for the ultrasound-guided rectus sheath
trast those of a prior study [7] that did not use ultrasound to block (i.e., bupivacaine 0.25 % 0.1 mL/kg) [1].
30.1.5 Case Study
Rectus Sheath Block (Provided By A. Spencer) 0.5 mL was injected into the aponeurosis adjoining the
A 4-year-old girl, 16 kg, presented for same-day repair of rectus abdominis muscle to the external and internal
epigastric hernia. The patient underwent a general anes- oblique and transversus abdominis muscles. Block dura-
thetic combined with an ultrasound-guided periumbilical tion was 6–12 h; time of surgery was 1 h 10 min.
nerve block in line with the umbilicus (correlating with Acetaminophen 15 mg/kg po liquid was administered
thoracic tenth dermatome level). A 22G 40 mm, B-beveled preoperatively, and ketorolac 0.3 mg/kg was given peri-
needle was inserted in-plane, and 3.5 mL ropivacaine operatively; no morphine was given during the case. The
0.25 % with epinephrine was deposited bilaterally below patient was comfortable in recovery 30 and 60 min post-
the rectus abdominis muscle and posterior fascia (equiva- op. No additional analgesia was required in the recovery
lent to 0.2 mL/kg per side) (Fig. 30.5). An additional room or on the day surgery ward prior to going home.
Fig. 30.5 Ultrasound-guided rectus sheath block. EOM

external oblique muscle, IOM internal oblique muscle, TAM
transversus abdominis muscle, RAM rectus abdominis muscle.
See Case Study for details
30.2 Transversus Abdominis Plane (TAP) Block 30.2.2 Landmark-Based Technique
30.2.1 Clinical Anatomy 30.2.2.1 Patient Positioning
• The sensory innervation of the abdominal wall is derived • The patient may be supine or lateral.
from anterior divisions of the thoracolumbar nerves • When performing the block on an awake patient, it may
(T6–L1). be convenient to use a lateral position, which will increase
• T6–T11 begin as intercostal nerves; T12 is the subcostal exposure to the posterior axillary line and permit a more
nerve; L1 is the ilioinguinal and iliohypogastric nerve. posterior approach.
• The thoracolumbar nerve roots exit the space that is bor-
dered between the latissimus dorsi posteriorly and the 30.2.2.2 Landmarks and Surface Anatomy
transversus abdominis anteriorly, within the “lumbar tri-
angle of Petit.” • Iliac crest
• There are often extensive anastomoses involving the seg- • Costal margin
mental nerves that emerge from the costal margin, such • Triangle of Petit:
that they rapidly lose their segmental origin [10]. – A weakness in the lateral abdominal wall that can be
• The intercostal nerves, subcostal nerves, and the first lum- palpated when performing a landmark technique. Its
bar nerves run in a neurovascular plane known as the base is the iliac crest, and it is bordered anteriorly by
transversus abdominis plane (TAP) (Fig. 13.9). the external oblique muscle and posteriorly by latissi-
• The TAP is situated between the internal oblique and mus dorsi (Fig. 30.6).
transversus abdominis muscles; the plane allows adequate
spread of local anesthetic.
Fig. 30.6 Surface anatomy of transversus abdominis plane block

showing the triangle of Petit landmark
30.2.2.3 Needle Insertion • The above steps can be repeated for the other side of the
abdomen.
• A blunt needle is recommended to facilitate easier detec-
tion of loss of resistance as the needle penetrates the 30.2.2.4 Local Anesthetic Application
external and internal oblique muscles.
• Insert the needle through the triangle of Petit, just anterior • For each side, 0.2–0.3 mL/kg of 0.25 % bupivacaine or
to the point at which the latissimus dorsi attaches to the 0.2 % ropivacaine can be used.
external lip of the iliac crest, until the needle contacts the • Total dose of either drug should not exceed 3 mg/kg.
iliac crest. A “pop” may be felt as the needle passes
through the external oblique muscle.
• The needle can then be “walked off” the iliac crest until 30.2.3 Ultrasound-Guided Technique
an obvious “pop” is felt as the needle punctures the inter-
nal oblique muscle. The needle is now in the plane The abdominal wall with the associated musculature and rec-
between the internal oblique and transversus abdominis tus sheath is depicted in the MRI and corresponding ultra-
muscles where the local anesthetic is to be injected. sound images in Fig. 30.7.
Fig. 30.7 (a) VHVS and MRI images showing the three layers of the lateral abdominal muscles. (b) Ultrasound image showing the three layers
of the lateral abdominal muscles
30.2.3.1 Scanning Technique • The transversalis fascia lies deep to the transversus
abdominis muscle. The peritoneum is adherent to the
• A linear (6–15 MHz) transducer is placed in a transverse transversalis fascia. The peritoneal cavity and intestines
location on the midaxillary line between the iliac crest lie beneath this fascia.
and the costal margin.
• A curved probe may be used in obese patients, but the 30.2.3.3 Needle Insertion
resultant image may be more challenging to interpret.
• The required depth for penetration is usually 2–4 cm but • Depending on skin-to-TAP distance, use a 5- to 10 cm,
varies with the depth of the subcutaneous layer. 22G needle.
• The individual muscle layers may be difficult to identify; • Most commonly, an in-plane (IP) approach (Fig. 30.8) is
however, the internal oblique muscle is always the widest, used. The out-of-plane (OOP) approach (Fig. 30.9) is
and it is important to identify the superficial subcutaneous rarely used since it is difficult to visualize the needle tip
layer. due to the target depth. Intermittent injection with D5W is
recommended to confirm needle tip position in this
30.2.3.2 Ultrasonographic Appearance instance.
• For an IP approach, the needle is inserted 3–4 cm from the
• The nerves might not be visible; the target for injection is medial aspect of the probe and typically directed in a
the fascial plane (TAP) which the nerves traverse. medial-to-lateral fashion at anterior axillary line, although
• Three muscle layers can be seen, above which lies the some experts have also used a lateral-to-medial approach.
subcutaneous fat (not to be mistaken for a muscle layer) This insertion point permits greater visibility as the nee-
and below which lies the peritoneum, peritoneal cavity, dle is more parallel to the transducer. Because of the tar-
and loops of intestine (Fig. 30.7b). get depth, an insertion point close to the transducer
• The most superficial layer is subcutaneous fat. This has a surface would necessitate a steeper angle of approach and
mostly hypoechoic appearance with occasional hyper- poor needle visibility.
echoic striations running through it. – A distinct “pop” may be felt as the needle penetrates
• The muscle layers from superficial to deep are external the fascial planes. The needle tip position may be con-
oblique, internal oblique, and transversus abdominis mus- firmed by injection of 1–2 mL of D5W.
cles. They have a much greater hyperechogenic appear- • For the OOP approach, the ultrasound probe is placed in
ance than the superficial subcutaneous layer. the same location as for the IP technique. The needle is
• The internal oblique muscle is the widest layer, and the then inserted in a cephalad-to-caudad direction. Due to
transversus abdominis muscle is the thinnest. the depth of the transverse abdominis plane, using a
• Each muscle layer is separated by a distinct hyperechoic “walk-down” approach (see Chap. 4) is essential to avoid
fascial plane. The TAP separates the internal oblique from intraperitoneal needle insertion.
the transversus abdominis muscle.
Fig. 30.8 In-plane needling technique for ultrasound-guided transver- Fig. 30.9 Out-of-plane needling technique for ultrasound-guided trans-
sus abdominis plane block. Blue rectangle indicates probe footprint versus abdominis plane block. Blue rectangle indicates probe footprint
30.2.3.4 Local Anesthetic Application cutaneously through the abdominal wall cephalad to the
incision at the lateral border of the transversus abdominis
• Performing a test dose with D5W is recommended prior muscle.
to local anesthetic application to visualize the spread and • The catheter is inserted in a medial-to-lateral direction,
confirm needle tip localization. and the catheter tip is positioned at the most lateral point
• 0.2–0.3 mL/kg of local anesthetic, (e.g., 0.2 % ropivacaine of the incision.
or 0.25 % bupivacaine) is injected per side. • After full closure of the incision in three separate layers
• The correct response to injection is longitudinal spread of (transversus abdominis, internal oblique, external
the hypoechoic-appearing local anesthetic within the oblique), the catheter is affixed to the skin.
TAP. Injection with the internal oblique or transversus • Both unilateral and bilateral TAP catheters may be placed
abdominis muscles requires repositioning of the needle. using this technique.
• The advantages of this approach include:
– Familiarity of the surgeon with the anatomy of the
30.2.4 Catheter Placement Under Direct abdominal wall musculature enables accuracy in cath-
Visualization (Fig. 30.10) eter placement and positioning.
– Removes the ambiguity of whether the fascial plane
An alternative to landmark- and ultrasound-guided place- between the internal oblique and transversus abdominis
ment of a TAP catheter(s) is placement under direct vision by muscles has been penetrated, [10] as is sometimes the
the surgeon at the end of the procedure: case with landmark- and ultrasound-guided approaches.
– Reduces significantly the risk of iatrogenic damage
• Following closure of the transversus abdominis and rec- caused by advancement of the needle using blind or
tus abdominis muscle layers, the catheter is inserted per- ultrasound-guided approaches.
Fig. 30.10 Placement of a transversus abdominis plane catheter

under direct visualization. The top panel shows placement of
the catheter tip at the lateral point of the incision (arrow); bottom
panel shows securement of the catheter following closure of the
surgical site
30.2.5 Current Literature in Ultrasound- Simpson et al. [21] described a case in which ultrasound-
Guided Approaches guided TAP block was administered for chronic pain associ-
ated with anterior cutaneous nerve entrapment syndrome
Mai et al. [11] recently published a comprehensive review of (ANCES) in a 13-year-old patient. Bilateral TAP blocks
the use of TAP block in the pediatric population, including were performed with a 22G needle inserted in-plane; 20 mL
history, complications, and outcomes of published reports. bupivacaine 0.25 % with 1:400,000 epinephrine was injected.
Laghari et al. were first to describe an approach to perform- Patient pain scores improved, and after 6 weeks, another set
ing an ultrasound-guided TAP block in children [12]. In a of TAP blocks was administered, extending pain relief for
9-year-old girl, these authors used an out-of-plane needle another month.
alignment to a linear probe placed in the flank above the iliac More recently, Sandeman et al. [22] showed that patients
crest. The needle (21G, 50 mm insulated) was placed approx- receiving ultrasound-guided TAP block for laparoscopic
imately 2 cm above the highest point of the iliac crest and appendectomy reported reduced postoperative pain scores
directed cranially using a shallow angle. The needle was compared to patients not receiving a block. However, this
advanced until its tip was viewed in the TAP, thus between study did not find a significant difference in time to first anal-
the transverse and internal oblique abdominal muscles. Local gesia after surgery or opioid consumption. These results con-
anesthetic was injected incrementally, and the spread was trast those obtained by Elshaikh et al. and Sahin et al. [23,
observed within the plane. No intraoperative analgesia was 24] which demonstrated significant reductions in pain scores
required, and excellent pain scores (0/10) were recorded and perioperative opioid consumption, as well as an increase
soon after the open appendectomy. A simple technique for in time to first analgesia, in patients receiving ultrasound-
placement of the TAP block in infants and children has since guided TAP blocks versus a control group which received
been described with a step-by-step approach to performing systemic opioids for pain control. As an added benefit, the
this block in infants and children [13]. TAP group experienced less incidence of vomiting compared
Fredrickson et al. [14] have described their early experi- to the opioid group.
ence with TAP block under ultrasound guidance. They An observational study by Palmer et al. [25] studied the
placed a linear probe in the axial plane above the iliac crest, multilevel block properties of ultrasound-guided TAP block.
or at a location where the three lateral abdominal muscle Although pediatric guidelines have recommended TAP block
layers were most evident on the ultrasound screen. An infor upper and lower abdominal surgeries [13], Palmer et al.
plane needle alignment was used, with the needle (a short found that only a quarter of patients experienced upper
22G spinal needle) directed from anterior to posterior to abdominal block extension. No significant correlation was
allow the needle to be viewed along its axis. Upon viewing found between dermatomal spread and local anesthetic dose,
the needle tip in the TAP, the local anesthetic was injected volume, or concentration.
while observing the spread within the plane. The blocks Recently, the Pediatric Regional Anesthesia Network
were successful, with the exception of those patients who queried their database to provide information on complica-
required intraoperative opioid supplementation due to sper- tions, including puncture of vasculature/peritoneum/organs,
matic cord manipulation (genitofemoral nerve). Following pulmonary and/or neurological symptoms, hematoma, and
this report, the successful use of ultrasound-guided TAP infection, following TAP block [26]. A total of 1994 cases
blocks in neonates was demonstrated [15–17]. A recent were assessed, of which, only two had complications. More
audit of the use of ultrasound-guided TAP blocks, both uni- concerning was the finding that a relatively wide range of
lateral and bilateral and for various surgeries, confirms the doses (0.47–2.29 mg bupivacaine equivalents per kg) were
block’s efficacy in controlling postoperative pain in neo- used, with around 7 % of patients receiving potentially toxic
nates and infants [18]. doses. This survey reveals that, while TAP blocks have a
Taylor et al. [19] published a report of two cases in which relatively low incidence of complications in pediatric
TAP catheters were installed under ultrasound guidance in patients, care should be taken in determining dosing, with
children with a history of significant spina bifida. Both chil- attention paid to avoiding delivery of a potentially toxic
dren underwent appendicovesicostomy and received bilat- dose.
eral TAP catheters through which a continuous infusion of The TAP block provides analgesia to the abdominal wall,
bupivacaine was delivered. Pain control was excellent for through blockade of the lower thoracic and first lumbar
both patients, and neither required supplementary analgesics spinal nerves at the lateral aspect of the abdomen prior to
during the postoperative period. A later case series described their course between the transversus abdominis and internal
the use of TAP catheters installed under ultrasound guidance oblique abdominal muscles. In adults, there may be reliance
in low-weight (<15 kg) children in whom epidural anesthesia on palpating the “lumbar triangle of Petit” at the base of
was contraindicated [20]. In these cases, all blocks were suc- which lies the internal oblique muscle [27]. Because there is
cessful, with no adverse events reported. no distinctly palpable triangle of Petit in children (or one
only enabling sensation of a tiny hole), ultrasound may be coagulation abnormalities. Since this block includes block-
especially valuable for determining the point of needle punc- ade of the first lumbar nerve root, it may substitute the ilioin-
ture during this block. Indications for the TAP block include guinal/iliohypogastric block in cases when the region
postoperative pain control following abdominal surgery anterior and medial to the ASIS offers suboptimal imaging;
including colostomy and laparotomy especially when a cen- the muscles in this region are apparently prone to anisotropy
tral neuraxial block is contraindicated as in children with (i.e., artifactual images produced due to the beam penetra-
spinal dysraphism (neural tube defect) or in children with tion angle in relation to the muscles) [14].
30.2.6 Case Study
Transversus Abdominis Plane Block (Provided By S. Suresh) was performed using a 27G needle with an in-plane
A male toddler, 35 months old and weighing 13.5 kg, pre- approach (see Fig. 30.11). Eight milliliters 0.25 % bupi-
sented for laparoscopic gastrostomy tube insertion. The vacaine with 1:200,000 epinephrine was injected.
patient had a history of cystic fibrosis without mention of Duration of surgery was 1 h, and block duration was 6 h.
meconium ileus and failure to thrive and had previously At 45 min post-op, the patient reported 5/10 for pain on
undergone an X-ray of the upper gastrointestinal tract. An the FLACC scale. A 7 mg injection of ketorolac (Toradol)
ultrasound-guided transversus abdominis plane block was given 1 h post-op.
Fig. 30.11 Ultrasound-guided transversus abdominis plane

block. EOM external oblique muscle, IOM internal oblique
muscle, TAM transversus abdominis muscle (See Case Study
for details)
References 16. Jacobs A, Thies KC. Ultrasound-guided transversus abdominis

plane block for reversal of ileostomy in a 2-kg premature neonate.
1. de Jose MB, Gotzens V, Mabrok M. Ultrasound-guided umbilical
17. Tekin M, Gurkan Y, Solak M, Toker K. Ultrasound-guided bilateral
nerve block in children: a brief description of a new approach.
transversus abdominis plane block in a 2-month-old infant. J
Anesth. 2009;23:643–4.
2. Willschke H, Bosenberg A, Marhofer P, Johnston S, Kettner SC,
18. Jacobs A, Bergmans E, Arul GS, Thies KC. The transversus
Wanzel O, Kapral S. Ultrasonography-guided rectus sheath block
abdominis plane (TAP) block in neonates and infants – results of an
in paediatric anaesthesia–a new approach to an old technique. Br J
audit. Pediatr Anesth. 2011;21:1078–80.
Anaesth. 2006;97:244–9.
19. Taylor LJ, Birmingham P, Yerkes E, Suresh S. Children with spinal
3. Willschke H, Bosenberg A, Marhofer P, Johnston S, Kettner S,
dysraphism: transversus abdominis plane (TAP) catheters to the
Eichenberger U, Wanzel O, Kapral S. Ultrasonographic-guided
rescue! Pediatr Anesth. 2010;20:951–4.
ilioinguinal/iliohypogastric nerve block in pediatric anesthesia:
20. Visoiu M, Boretsky KR, Goyal G, Cladis FP, Cassara
what is the optimal volume? Anesth Analg. 2006;102:1680–4.
A. Postoperative analgesia via transversus abdominis plane (TAP)
4. Dingeman RS, Barus LM, Chung HK, Clendenin DJ, Lee CS,
catheter for small weight children-our initial experience. Pediatr
Tracy S, Johnson VM, Dennett KV, Zurakowski D, Chen
Anesth. 2012;22:281–4.
C. Ultrasonography-guided bilateral rectus sheath block vs local
21. Simpson DM, Tyrrell J, De RJ, Campbell FA. Use of ultrasound-
anesthetic infiltration after pediatric umbilical hernia repair: a pro-
guided subcostal transversus abdominis plane blocks in a pediatric
spective randomized clinical trial. JAMA Surg. 2013;148:707–13.
patient with chronic abdominal wall pain. Pediatr Anesth.
5. Gurnaney HG, Maxwell LG, Kraemer FW, Goebel T, Nance ML,
2011;21:88–90.
Ganesh A. Prospective randomized observer-blinded study compar-
22. Sandeman DJ, Bennett M, Dilley AV, Perczuk A, Lim S, Kelly
ing the analgesic efficacy of ultrasound-guided rectus sheath block
KJ. Ultrasound-guided transversus abdominis plane blocks for lap-
and local anaesthetic infiltration for umbilical hernia repair. Br J
aroscopic appendicectomy in children: a prospective randomized
Anaesth. 2011;107:790–5.
trial. Br J Anaesth. 2011;106:882–6.
6. Alsaeed AH, Thallaj A, Khalil N, Almutaq N, Aljazaeri
23. Elshaikh SM, Abdel Halim JMK, El-Awady GA, Saad A. Effects of
A. Ultrasound-guided rectus sheath block in children with umbili-
preoperative ultrasonography-guided TAP block in pediatric
cal hernia: case series. Saudi J Anaesth. 2013;7:432–5.
patients undergoing major abdominal surgeries for intraabdominal
7. Isaac LA, McEwen J, Hayes JA, Crawford MW. A pilot study of the
malignancies on surgical outcome and postoperative analgesia.
rectus sheath block for pain control after umbilical hernia repair.
Egypt J Anaesth. 2009;25:335–43.
24. Sahin L, Sahin M, Gul R, Saricicek V, Isikay N. Ultrasound-guided
8. Courreges P, Poddevin F, Lecoutre D. Para-umbilical block: a new
transversus abdominis plane block in children: a randomised com-
concept for regional anaesthesia in children. Pediatr Anesth.
parison with wound infiltration. Eur J Anaesthesiol. 2013;30:
1997;7:211–4.
409–14.
9. Ferguson S, Thomas V, Lewis I. The rectus sheath block in paediat-
25. Palmer GM, Luk VH, Smith KR, Prentice EK. Audit of initial use
ric anaesthesia: new indications for an old technique? Pediatr
of the ultrasound-guided transversus abdominis plane block in chil-
Anesth. 1996;6:463–6.
dren. Anaesth Intensive Care. 2011;39:279–86.
10. Rozen WM, Tran TM, Ashton MW, Barrington MJ, Ivanusic JJ,
26. Long JB, Birmingham PK, De Oliveira GS Jr, Schaldenbrand KM,
Taylor GI. Refining the course of the thoracolumbar nerves: a new
Suresh S. Transversus abdominis plane block in children: a multicenter
understanding of the innervation of the anterior abdominal wall.
safety analysis of 1994 cases from the PRAN (Pediatric Regional
Clin Anat. 2008;21:325–33.
Anesthesia Network) database. Anesth Analg 2014;119:395–9.
11. Mai CL, Young MJ, Quraishi SA. Clinical implications of the trans-
27. Rafi AN. Abdominal field block: a new approach via the lumbar
versus abdominis plane block in pediatric anesthesia. Pediatr
triangle. Anaesthesia. 2001;56:1024–6.
Anesth. 2012;22:831–40.
12. Laghari ZA, Harmon D. Ultrasound-guided transabdominus plane
block. J Clin Anesth. 2008;20:156–8.
13. Suresh S, Chan VW. Ultrasound guided transversus abdominis plane
block in infants, children and adolescents: a simple procedural guid- Suggested Reading
ance for their performance. Pediatr Anesth. 2009;19:296–9.
14. Fredrickson M, Seal P, Houghton J. Early experience with the trans- Bhalla T, Sawardekar A, Dewhirst E, Jagannathan N, Tobias
versus abdominis plane block in children. Pediatr Anesth. JD. Ultrasound-guided trunk and core blocks in infants and chil-
2008;18:891–2. dren. J Anesth. 2013;27:109–23.
15. Fredrickson MJ, Seal P. Ultrasound-guided transversus abdominis Karmakar MK, Kwok WH. Ultrasound-Guided Regional Anesthesia. In:
plane block for neonatal abdominal surgery. Anaesth Intensive Cote CJ, Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB
Care. 2009;37:469–72. Saunders; 2013. p. 880–908.
Ilioinguinal and Iliohypogastric Nerve
Blocks 31
Ban C.H. Tsui
Contents
31.1 Clinical Anatomy ............................................................................................................................ 478
31.2 Landmark-Based Technique (Fascial “Click” Method) .............................................................. 478
31.2.1 Patient Positioning .............................................................................................................. 478
31.2.2 Landmarks and Surface Anatomy ....................................................................................... 478
31.4.2 Ultrasonographic Appearance ............................................................................................. 480
31.6 Case Study ....................................................................................................................................... 482
References ................................................................................................................................................... 483
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_31
478 B.C.H. Tsui
31.1 Clinical Anatomy 31.2.3 Needle Insertion
• The ilioinguinal and iliohypogastric nerves are both There are several recommendations for determining the
extensions of the anterior rami of the L1 segmental nerve puncture point for needle insertion. Different sites may also
(Figs. 11.2 and 11.4). necessitate variation in needle puncture angle. Low success
• The nerves represent the most inferior spinal level of the rates may be attributed to anatomic variability or the needle
segmental innervation of the body wall. Below L1, the puncture being too medial [1].
anterior rami contribute to the lumbar and sacral plexuses
to supply the lower limb, buttocks, and perianal region. • The traditional puncture site places the needle above the
• Both nerves pass laterally on the quadratus lumborum ASIS at a point one-fourth, or sometimes one-third, of the
muscle where they pierce the transversus abdominis to way from the lateral aspect of a line between the ASIS and
enter the transversus abdominis plane (TAP) between the the umbilicus (Fig. 31.1); however, as Van Shoor et al. [1]
transversus abdominis and internal oblique muscles. suggested, this point may be too medial for most patients and
• The iliohypogastric nerve continues within the TAP plane instead recommend that the puncture point be just 2.5 mm
to segmentally supply the suprapubic skin, subcutaneous from the ASIS on the above mentioned line (Fig. 31.1).
tissue, and muscles of the lower abdominal wall (Fig. • Alternatively, the puncture site is considered at a point one
13.8). It also gives a lateral cutaneous branch which fingerbreadth (of the patient) medial and inferior to the ASIS
leaves the TAP at the iliac crest to supply the skin over the (the lower range for infants and young children) [2, 3].
upper buttock behind where the T12 subcostal nerve pro- • In a study of ultrasonographic imaging during ilioingui-
vides cutaneous supply. nal block, the ilioinguinal nerve was situated between 5
• The ilioinguinal nerve passes anteriorly in the TAP until it and 11.3 mm from the ASIS, depending on the weight of
pierces the internal oblique at the superficial inguinal ring the child, although there was no significant correlation
to lie on the spermatic cord or round ligament. It supplies between weight and this distance [4].
the ipsilateral penile base, hemiscrotum, and a small area • Any one of these points may be suitable, although in general,
of medial thigh below the inguinal ligament. there is much variation in the nerves’ locations, and ultra-
sound guidance is recommended for optimizing localization.
• A 3–4 cm, short-beveled or facet tipped, 22G–27G needle
31.2 Landmark-Based Technique is inserted at a 45° angle to the midline at the puncture
(Fascial “Click” Method) point (2.5 mm along the line between the ASIS and the
umbilicus) until the characteristic “click” is detected after
31.2.1 Patient Positioning internal oblique muscle penetration.
• However, the author prefers to insert the needle perpen-
• The block is most easily performed with the patient dicularly at only one patient’s fingerbreadth medial to the
supine. ASIS; this technique should reduce the risk of inadvertent
bowel perforation.
• Although two “clicks” may be experienced upon crossing
31.2.2 Landmarks and Surface Anatomy the external and internal oblique muscles, one “click” is
often detected. In many patients, the external oblique mus-
• Anterior superior iliac spine (ASIS): follow the iliac crest cle has already turned into an aponeurosis at this level.
anteriorly to lateral abdomen and palpate the prominent
spine.
• Umbilicus
Fig. 31.1 Surface anatomy for ilioinguinal nerve block

31 Ilioinguinal and Iliohypogastric Nerve Blocks 479
31.2.4 Local Anesthetic Application 31.3 Nerve Stimulation Technique
• Ensure negative aspiration prior to injecting local Nerve stimulation is not commonly performed for ilioingui-
anesthetic. nal nerve blocks.
• Inject local anesthetic (typically 0.3–0.5 mL/kg of 0.25 %
levobupivacaine or 0.5 % bupivacaine when using “blind”
technique) after detecting the fascial “click” upon pene- 31.4 Ultrasound-Guided Technique
tration of the internal oblique muscle. A fanlike injection
pattern, with both cephalad (toward the umbilicus) and The ilioinguinal nerve and surrounding musculature are
caudad (toward the groin) directions, has been described. depicted in the MRI and corresponding ultrasound images in
• Alternatively, this author prefers to maintain the needle Fig. 31.2. Prepare the needle insertion site and skin surface
perpendicular to the skin while injecting one-third of the with antiseptic solution. Prepare the ultrasound probe surface
local anesthetic injection upon feeling the second “click” by applying a sterile adhesive dressing to it prior to needling
(internal oblique fascia), withdrawing the needle slightly as discussed in Chap. 4.
and injecting another one-third above this layer, and then
withdrawing slightly again and injecting the remaining
one-third above the first “click” (external oblique fascia).
• An initial injection of some of the local anesthetic may be
performed subcutaneously prior to advancing the needle
to the intermuscular plane.
• Upon withdrawal of the needle, an additional 0.5–1 mL is
deposited subcutaneously to ensure blockade of the ilio-
hypogastric nerve.
Fig. 31.2 (a) VHVS and MRI images showing the ilioinguinal nerve and surrounding musculature. (b) Ultrasound images showing the ilioingui-
nal nerve and surrounding musculature
480 B.C.H. Tsui
31.4.1 Scanning Technique 31.4.3 Needle Insertion
• A linear (6–15 MHz) transducer is placed in an oblique • Needle length will depend upon the adiposity of the
location parallel to a line connecting the ASIS to the patient. A 5–10 cm, short-beveled 22G needle or an 18G
umbilicus. Tuohy needle should be utilized.
• A curved probe may be used in obese patients, but the • Either an in-plane (IP) (Fig. 31.3) or out-of-plane (OOP)
muscle and fascial layers will likely be more difficult to (Fig. 31.4) approach may be utilized. However, if the tar-
appreciate. get is deep, the needle tip will be difficult visualize in an
• The required depth for penetration is usually 1–4 cm but OOP approach. Intermittent injection with D5W is rec-
varies with the depth of the subcutaneous layer. ommended to confirm needle tip position in this instance.
• The layers of the abdominal wall and underlying muscles, • For an IP approach, the needle is inserted at a shallow
as well as bone and target nerves, should be able to be angle at the lateral end of the probe. The planes are often
identified in children. very shallow so that the needle is more parallel to the
transducer.
• This angle of insertion has the advantage that if the needle
31.4.2 Ultrasonographic Appearance inadvertently passes too deep, then either the iliacus mus-
cle or ilium will likely be contacted and not the bowel.
• The layers of the abdominal wall should be visible, • A distinct “pop” will usually be felt on passage through
namely: skin, adipose tissue, external and internal oblique the fascial planes, as well as distinct “tenting” of the tis-
and transversus abdominis, peritoneum, and underlying sues on imaging. Needle tip position may be confirmed by
bowel. The iliacus muscle and the ilium will be visible injection of 1–2 mL of D5W.
deeper to the working depth. • For the OOP approach, the ultrasound probe is placed in
• The external oblique may in 50 % of patients be aponeu- an oblique position along a line joining the ASIS and
rotic in this location [4]. umbilicus. The needle should be inserted equidistant to
• If the spermatic cord or round ligament is visible, then the the depth of the target nerve caudad or cephalad to the
probe is too medial and distal. probe at a 45° angle, such that the needle tip can be visu-
• The ilioinguinal and iliohypogastric nerves are usually in alized as it approaches the nerve.
proximity to each other.
• The ilioinguinal and iliohypogastric nerves will be visible
in children either between the external oblique and inter-
nal oblique or between the internal oblique and transversus
abdominis muscle. The nerves are likely to much more
difficult to appreciate in adults but may become more vis-
ible by using some fluid as contrast.
• Color flow Doppler may assist in identifying the neuro-
vascular bundle; however, it is often too small to
visualize.
• The endpoint for the block is to surround the identified
ilioinguinal and iliohypogastric nerves with local anes-
thetic. Alternatively, if the nerves are not visible, for
example, in adults or obese children, place local anes-
thetic in the TAP plane as well as the plane between the
internal and external oblique muscles.
Fig. 31.3 In-plane needling technique for ultrasound-guided ilioingui-
nal/iliohypogastric nerve block. Blue rectangle indicates probe
footprint

Guided Approaches
Willschke et al. [4] performed a prospective, randomized

double-blinded study with 100 children scheduled for inguinal
surgery to compare block efficacy between ultrasound-guided
and conventional ilioinguinal/iliohypogastric nerve block. The
endpoint in the ultrasound group was capturing a view of the
local anesthetic solution surrounding the nerves. Detection of a
fascial “click” was used to indicate injection in the traditional
block group. Fewer children received intra- or postoperative
(up to 4 h) analgesia in the ultrasound group (4 % and 6 %,
respectively) than in the fascial click group (26 and 40 %).
Furthermore, the volume of local anesthetic injected was lower
in the ultrasound group (0.19 mL/kg versus 0.30 mL/kg).
Fig. 31.4 Out-of-plane needling technique for ultrasound-guided ilio- Further evaluation of the optimal volume of local anes-
inguinal/iliohypogastric nerve block. Blue rectangle indicates probe thetic required for ultrasound-guided ilioinguinal/iliohypo-
footprint gastric blocks was performed by this group in a subsequent
study [5]. Using a modified step-up-step-down approach,
with ten patients in each group starting at 0.2 mL/kg, a vol-
31.4.4 Local Anesthetic Application ume of 0.75 mL/kg was found to achieve 100 % block suc-
cess for the first 4 h of postoperative care (longer analgesia
• Performing a test dose with D5W is recommended prior may require higher volumes). These authors state that using
to local anesthetic application to visualize the spread and lower volumes of local anesthetic could reduce the risk of
confirm needle tip localization. local anesthetic toxicity and the incidence of adverse side
• 10 mL of 0.25 % bupivacaine or 0.2 % ropivacaine sur- effects, such as femoral nerve palsy.
rounding the nerves (0.3–0.5 mL/kg in children) or Recent findings tend to support the use of lower volumes
0.2 mL/kg in the TAP and 0.2 mL/kg between the external of local anesthetic when placing ilioinguinal blocks under
and internal oblique muscles if the nerves are not visible. ultrasound guidance, compared to the landmark-based tech-
• The correct appearance is to have the hyperechoic nerves nique [6]. In a pharmacokinetic study, plasma levels of ropi-
surrounded with hypoechoic local anesthetic. If intramus- vacaine were found to be higher using ultrasound guidance
cular injection is evident, then the needle should be in comparison to a single “pop” technique (Cmax: 1.78 [0.62]
repositioned. versus 1.23 [0.70] μg/mL). Although this finding is interest-
ing and will likely encourage the planning of similar studies,
the plasma levels reached in this study have never been asso-
ciated with any clinical signs of toxicity.
Clinical Pearls
Hong et al. [7] studied anatomical location of the ilioin-
• The probe may be positioned slightly obliquely guinal and iliohypogastric nerves in children of various age
toward the umbilicus for better visualization of the groups and attempted to examine whether a correlation exists
ilioinguinal and iliohypogastric nerves as they tra- between age and distance between the nerves and the
verse down distally. ASIS. They found that ASIS-ilioinguinal distance correlated
• When using an IP approach, a medial-to-lateral positively with age and ASIS-umbilicus distance, while
technique is preferred since the needle tip will be ASIS-iliohypogastric distance correlated positively with age
aiming toward the bony ASIS. Conversely, a lateral- and ASIS-pubis distance. No correlations were made
to-medial technique will direct the needle toward between distances and height or weight nor were any corre-
the peritoneum. lations detected between age and depth of nerves from the
• The authors have found it equally effective to use a skin or distance from nerves to peritoneum.
landmark technique in which the needle is inserted
perpendicularly at only one patient’s fingerbreadth
medial to the ASIS. While maintaining the needle
perpendicular to skin, local anesthetic is injected as
described in 31.2.4. Using this approach, the risk of
inadvertent bowel perforation should be minimal.
482 B.C.H. Tsui
Fredrickson et al. [8] recently tested the theory that 31.6 Case Study
ultrasound-guided TAP block could be used in place of the
more common ultrasound-guided ilioinguinal block for pain
control following pediatric inguinal surgery. The authors Ilioinguinal Nerve Block (Provided by S. Suresh)
found that reporting of pain and oral analgesic intake was A 7-year-old female, 20 kg, with no past medical his-
higher in the TAP group, suggesting that ilioinguinal blocks tory or relevant family history was presented for right
provide superior pain control for this procedure. However, inguinal hernia repair. An ilioinguinal block was per-
ultrasound image quality was deemed better for the TAP formed under ultrasound guidance. Ten mL 0.125 %
blocks, and needle time under the skin was significantly bupivacaine (epinephrine 1:200,000) was injected with
greater for the ilioinguinal block group. Ultrasound-guided a 22G needle (Fig. 31.5). Duration of the block was
ilioinguinal blocks can also be given to enhance postopera- 6–12 h; surgery lasted 54 min. Pain control in recovery
tive pain relief in children who receive caudal block for groin was reported at 0/10 (verbal) 1 h following the opera-
surgeries, particularly inguinal hernia repair. tion. Postoperative analgesia included acetaminophen
(Tylenol), 240 mg orally (every 6 h as needed), and
hydrocodone-acetaminophen 3–200 mg orally (every
6 h as needed).
Fig. 31.5 Ultrasound-guided ilioinguinal/iliohypogastric nerve

block. EO external oblique, IO internal oblique, Il/Ih ilioingui-
nal/iliohypogastric nerves, TA transversus abdominis muscle
(See Case Study for details)
References 7. Hong JY, Kim WO, Koo BN, et al. The relative position of ilioingui-
nal and iliohypogastric nerves in different age groups of pediatric
patients. Acta Anaesthesiol Scand. 2010;54:566–70.
1. van Schoor AN, Boon JM, Bosenberg AT, et al. Anatomical consid-
8. Fredrickson MJ, Paine C, Hamill J. Improved analgesia with the
erations of the pediatric ilioinguinal/iliohypogastric nerve block.
ilioinguinal block compared to the transversus abdominis plane
block after pediatric inguinal surgery: a prospective randomized
2. Schulte-Steinberg O. Ilioinguinal and iliohypogastric nerve block.
trial. Pediatr Anesth. 2010;20:1022–7.
In: Saint-Maurice C, Schulte-Steinberg O, Armitage EN, editors.
Regional anesthesia in children. Norwalk: Appleton & Lange; 1990.
p. 156.
3. Sethna NF, Berde CB. Pediatric regional anesthesia. In: Gregory
GA, editor. Pediatric anesthesia. New York: Churchill Livingston; Suggested Reading
1989. p. 647–78.
4. Willschke H, Marhofer P, Bosenberg A, et al. Ultrasonography for Dalens BJ. Blocks of nerves of the trunk. In: Dalens BJ, editor. Pediatric
ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth. regional anesthesia. Boca Raton: CRC Press; 1990. p. 476–9.
2005;95:226–30. Karmakar MK, Kwok WH. Ultrasound-Guided Regional Anesthesia.
5. Willschke H, Bosenberg A, Marhofer P, et al. Ultrasonographic- In: Cote CJ, Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB
guided ilioinguinal/iliohypogastric nerve block in pediatric anesthe- Saunders; 2013. p. 880–908.
sia: what is the optimal volume? Anesth Analg. 2006;102:1680–4. Suresh S, Polaner DM, Cote CJ. Regional Anesthesia. In: Cote CJ,
6. Weintraud M, Lundblad M, Kettner SC, et al. Ultrasound versus Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
landmark-based technique for ilioinguinal-iliohypogastric nerve 2013. p. 835–79.
blockade in children: the implications on plasma levels of ropiva-
caine. Anesth Analg. 2009;108:1488–92.
Penile Blocks
32
Heather Yizhen Z. Ting, Peter D. Metcalfe,
and Ban C.H. Tsui
Contents
32.1 Clinical Anatomy 486
32.2 Landmark-Based Technique (Subpubic Approach) 488
32.3.2 Ultrasonographic Appearance 489
32.5 Case Study 491
References 492
H.Y.Z. Ting, MD, FRCPC (*)

University of Alberta Hospital, 8440-112 St NW, 2-150 Clinical
Sciences Building, Edmonton, AB, Canada
P.D. Metcalfe, MD, MSc, FRCSC
Division of Pediatric Surgery, Division of Urology,
Department of Surgery, Stollery Children’s Hospital,
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_32
32.1 Clinical Anatomy • From the base of the penis, the dorsal nerves divide sev-
eral times and encircle the shaft of the penis before reach-
• The penis is supplied mainly by the two dorsal nerves of ing the glans penis.
the penis, although there is some contribution to the base • The two dorsal nerves are usually blocked separately due
of the penis from the perineal, genitofemoral, and ilioin- to an often present anteroposterior septum (fundiform
guinal nerves. ligament) at the level of the suspensory ligament of the
• The pudendal nerves (S2-S4) originate from the sacral penis, which divides the subpubic space into two
plexus (Figure 12.1). At the distal pudendal canal where they compartments.
run into ischial fossa, the pudendal nerves give off the infe- • Two fascia envelop the penis; the superficial fascia of the
rior hemorrhoidal nerve and then divide into two terminal penis, a continuation from the superficial fascia of the
branches: (1) the perineal nerve which supplies the perineal abdomen, and the deep layer (Buck’s fascia), surrounding
muscles and scrotum, and (2) the dorsal nerve of the penis. all three cavernous bodies, and which is continuous with
• The dorsal nerves (terminal branches of pudendal nerve; Scarpa’s fascia.
S2-S4) enter the subpubic space, pass under the pubic • The subpubic space is bordered anteriorly by the skin,
bone, and then lie deep in the suspensory ligament of the subcutaneous tissue, the superficial fascia, and deep
penis. The dorsal nerves then accompany the dorsal arter- (Scarpa’s) fascia of the abdomen. It is also bounded crani-
ies of the penis bilaterally, in contact with the corpus cav- ally by the pubis and caudally by the crura of corpora
ernosum, encased by Buck’s fascia (Figs. 32.1 and 32.2). cavernosa.
Superficial dorsal
Skin penile vein
Deep dorsal
penile vein
Superficial fascia
Dorsal penile Dorsal n.

artery of penis
Deep penile
artery
Corpus
cavernosum
Deep (Buck’s)
fascia continuous
with penile
suspensory
Urethra ligament
Fig. 32.1 Transverse section Corpus
of penis spongiosum
32 Penile Blocks 487
Fig. 32.2 VHVS and MRI images of anatomical structures surrounding the dorsal nerve of the penis; (a) anterior view, (b) sagittal view, (c)
transverse view
32.2 Landmark-Based Technique • The dorsal penile block provides good analgesia, but
(Subpubic Approach) may not block the ventral penis sufficiently, especially
the frenulum. A ring block around the base of the penis
32.2.1 Patient Positioning [1] can ensure more effective coverage, especially when
used in combination with the dorsal penile block. Ring
• The patient lies in the supine position. block has been shown to be more effective than dorsal
penile block or topical anesthetic for circumcision in
neonates [2].
32.2.2 Landmarks and Surface Anatomy • The ring block can be performed with the same cutaneous
puncture site as the dorsal block. The needle can be
• Pubic symphysis fanned out subcutaneously to the 3 and 9 o’clock position
• Inferior border of the pubic rami and then repositioned to these positions to administer sub-
cutaneous local anesthetic through the 6 o’clock/scrotal
area (see Fig. 32.4).
32.2.3 Needle Insertion – The ring block may interfere with hypospadias surgery
or circumcision if done preoperatively; therefore, com-
• Two marks are made on the lateral side of the pubic sym- munication with the urologist is important to ensure
physis, just below each pubic ramus (0.5 cm for babies that the tissue planes are not disrupted.
and 1 cm for older boys).
• With the penis held downward, the needle is inserted at
the puncture site in a slight medial and caudal direction 32.2.4 Local Anesthetic Application
(10–15° to the vertical axis in both directions).
• A “pop” is felt as the needle penetrates Scarpa’s fascia, • Bupivacaine 0.25–0.5 % is the local anesthetic of choice
approximately 8–30 mm below the skin (depth does not cor- for penile block, although lidocaine is also effective. For
relate with patient age or weight). A “pop” may also be felt each side, 0.1 mL/kg is injected up to a maximum of 5 mL
as the needle passes through the superficial fascia (Fig. 32.3). per side. Blocks will last, on average, 5–12 h.
• Short-beveled 23G needles, 30 mm in length, are gener- • Epinephrine is absolutely contraindicated since the dorsal
ally used for penile block. arteries of the penis are terminal arteries.
Symphysis pubis
Scarpa’s fascia
Suspensory ligament
continuous with
Scarpa’s fascia
Corpus cavernosum
Corpus spongiosum
Urethra
Fig. 32.3 Needle insertion

through Scarpa’s fascia into the
subpubic space

1. Needle positioned
dorsally
32.3.1 Scanning Technique
• A linear probe may be placed sagittally along the shaft of

the penis, which will allow visualization of the subpubic
space.
2. Needle positioned
at 3 o’clock and
9 o’clock 32.3.2 Ultrasonographic Appearance (Fig. 32.5)
• The subpubic space is identified as a triangle bordered by:

Fig. 32.4 Ring block of the penis. The needle is initially positioned Buck’s fascia covering the corpora cavernosa and neuro-
dorsally and fanned out to the 3 o’clock and 9 o’clock positions while vascular bundle inferiorly; pubic symphysis superiorly;
injecting local anesthetic. The needle is then repositioned to the 3
and by Scarpa’s fascia anteriorly.
o’clock and 9 o’clock positions to ensure local anesthetic spread to the
6 o’clock/scrotal area • The fundiform ligament, which forms a midline septum
within the deep fascia of the penis, appears fan-shaped
under ultrasound.
• Injection deep to Scarpa’s fascia can be visualized with
ultrasound; this will help to confirm the spread of local
anesthetic.
Fig. 32.5 Ultrasound image of the subpubic space for dorsal penile block
32.3.3 Needle Insertion 32.3.4 Local Anesthetic Application
• As described above, the needle is inserted once on either • As described above, 0.1 mL/kg bupivacaine 0.25–0.5 %
side of the fundiform ligament (i.e., once on each side of on each side is sufficient to provide adequate surgical
the probe) to the depth of the subpubic space, deep to anesthesia and postoperative analgesia.
Scarpa’s fascia. Ultrasound imaging will reveal the spread
of local anesthetic in the subpubic space as a hypoechoic
triangular area.

Guided Approaches
Sandeman and Dilley were the first to describe ultrasound-

guided dorsal penile nerve block [3]. It was later shown that Since the injection site for penile block is required to
ultrasound-guided penile nerve block improved block effi- be close to the surgical field, many surgeons prefer to
cacy compared to the traditional landmark-based technique perform the block themselves during the procedure.
with respect to postoperative pain during the first postopera- An example is shown in Fig. 32.6. The patient received
tive hour and the time to the first requirement for postopera- a landmark-guided dorsal penile nerve block for cir-
tive analgesia [4]. However, a later study by Sandeman et al. cumcision. After palpating the anterior edge of the
[5] demonstrated the advantages of ultrasound-guided dorsal symphysis pubis, a 23G pediatric needle was inserted
penile nerve block compared to the landmark method and slightly medially and cephalad until Buck’s fascia was
caudal epidural analgesia for circumcisions on boys aged penetrated. Local anesthetic was injected at this loca-
5 months to 15 years. The ultrasound and caudal epidural tion. Following caudal redirection of the needle, the
groups required significantly less morphine postoperatively remainder of the local anesthetic was injected in a sub-
and had shorter stays on the post-op ward compared to cutaneous wheal across the ventral surface of the mid-
patients in the landmark-guided group. Furthermore, the line of the penis. Pain control was excellent with no
ultrasound and landmark groups had significantly lower complications.
times to first analgesia administration compared to the cau-
dal epidural group. Patients receiving ultrasound-guided
blocks also required less intraoperative opiates than patients
receiving landmark-guided blocks.
Fig. 32.6 Landmark-guided penile block performed by the surgeon,

showing initial needle position (top) and needle position after redirec-
tion (bottom) (See Case Study for details)
References 5. Sandeman DJ, Reiner D, Dilley AV, Bennett MH, Kelly KJ. A retro-
spective audit of three different regional anaesthetic techniques for
circumcision in children. Anaesth Intensive Care. 2010;38:519–24.
1. Broadman LM, Hannallah RS, Belman AB, Elder PT, Ruttimann U,
Epstein BS. Post-circumcision analgesia—a prospective evaluation
of subcutaneous ring block of the penis. Anesthesiology. 1987;67:
399–402.
2. Lander J, Brady-Fryer B, Metcalfe JB, Nazarali S, Muttitt Suggested Reading
S. Comparison of ring block, dorsal penile nerve block, and topical
anesthesia for neonatal circumcision: a randomized controlled trial. Dalens BJ. Blocks of nerves of the trunk. In: Dalens BJ, editor. Pediatric
JAMA. 1997;278:2157–62. regional anesthesia. Boca Raton: CRC Press; 1990. p. 457–64.
3. Sandeman DJ, Dilley AV. Ultrasound guided dorsal penile nerve Peutrell JM. Penile block. In: Peutrell JM, Mather SJ, editors. Regional
block in children. Anaesth Intensive Care. 2007;35:266–9. anaesthesia for babies and children. Oxford: Oxford University
4. Faraoni D, Gilbeau A, Lingier P, Barvais L, Engelman E, Press; 1997. p. 130–40.
Hennart D. Does ultrasound guidance improve the efficacy of Suresh S, Polaner DM, Cote CJ. Regional Anesthesia. In: Cote CJ,
dorsal penile nerve block in children? Pediatr Anesth. 2010; Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
20:931–6. 2013. p. 835–79.
Part XI
Neuraxial Blockade
Epidural and Caudal Anesthesia
33
Ban C.H. Tsui
Contents
33.1 Epidural Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
33.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
33.1.2 Patient Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
33.1.3 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
33.1.4 Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
33.1.6 Electrocardiograph (ECG) Monitoring Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
33.1.8 Needle Insertion Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
33.1.9 Catheter Insertion and Confirmation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
33.1.10 Case Study: Lumbar Epidural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
33.2 Caudal Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
33.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
33.2.2 Patient Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
33.2.3 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
33.2.5 Ultrasound-Guided Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
33.2.6 Case Study: Caudal Epidural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
33.3 Advancing a Catheter to the Lumbar or Thoracic Area from a Caudal Insertion Site . . . . . . 520
33.3.1 Epidural Stimulation Guidance Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
33.3.2 Local Anesthetic Application (“Test”) to Confirm Avoidance
of Intravascular Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
33.3.4 Scanning Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
33.3.5 Sonographic Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
33.3.6 Catheter Insertion and Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
33.3.7 Case Study: Thoracic Epidural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
33.4 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_33
496 B.C.H. Tsui
33.1 Epidural Anesthesia The distance of catheter threading will determine which
technique to use for continuous blocks. The epidural stimu-
33.1.1 Introduction lation test is useful when catheters are threaded at a distance
into the epidural space but has only moderate application
Epidural needle placement may fail for several reasons, during direct placement of the catheter. In these cases, loss of
including anatomical variability (e.g., limited interlaminar resistance to saline will accurately determine epidural place-
space, ossified or calcified ligamentum flavum, enlarged facet ment, and ultrasound guidance can be helpful. Nevertheless,
joints, or rotated vertebrae), faulty identification of the mid- the epidural stimulation test is useful in warning against
line (e.g., obesity, scoliosis), and poor patient compliance or unintentional intrathecal or intravascular local anesthetic
cooperation. In children, these issues may not be significant, injection.
but because the patients are usually under general anesthesia,
the absence of any possible sensory warning of intrathecal or Indications
spinal cord placement adds inherent risks to the procedure. Usually provides postoperative analgesia but occasionally
Both epidural stimulation and ultrasound may be useful as provides surgical anesthesia for:
adjuncts to other tests, such as loss of resistance to saline, for • Lower limb surgery
identifying needle entry into the epidural space. The epidural • Pelvic and urological surgery
stimulation test may be especially beneficial to warn of a nee- • Abdominal surgery
dle misplaced in the subdural or intrathecal spaces or if the • Thoracic surgery
needle is abutting a nerve root. The main benefit of ultrasound
imaging is the ability to gauge the depth and direction to the
epidural space prior to the procedure, which can help refine the 33.1.2 Patient Positioning
point of needle puncture and angle of needle insertion. One
may visualize the disruption caused by the injection of fluid Position an anesthetized patient in the lateral position;
into the epidural space when using the loss-of-resistance tech- awake patients can be sitting up.
nique in the lumbar region in pediatric patients, but this obser-
vation is limited in the more compact thoracic spine (Fig. 33.1).
Fig. 33.1 Pediatric spine

model showing spinal column in
the thoracic and lumbar regions
33 Epidural and Caudal Anesthesia 497
33.1.3 Surface Anatomy 33.1.4 Approaches
Lumbar (Fig. 33.2) and thoracic (Fig. 33.3) spine: 33.1.4.1 Direct Lumbar Approach
• Spinous Processes* • Perform the lumbar epidural puncture with the patient in
– In the midline, palpate the spinous processes; a line the lateral position.
drawn between the tips of the scapulae will run through • Locate iliac crests of pelvic and use this landmark to iden-
the T7 vertebrae. tify the spine of L4.
– In the lumbar region, L4 is at level of the iliac crests, • Resistance to air or saline can be used to identify the lum-
and S1 is on horizontal line drawn between the two bar epidural space, although both have their own advan-
posterior superior iliac spines. tages and disadvantages.
• Transverse processes – Air embolism (if needle accidently punctures a vein)
– These lie lateral to the midline in varying distances, and pneumoencephalocele are rare but potential risks
depending on the age of the child. when using loss of resistance (LOR) to air.
* The neural arches, forming the spinous processes, are not – Occasionally, the loss of resistance to saline may be
completely fused until the end of the first year (except at equivocal.
L5, where they fuse significantly later), so it is common – When using LOR to saline, use a small amount of
to palpate two separate bony landmarks in infants. saline to avoid diluting the local anesthetic.
– The hanging drop technique can be used to identify the
epidural space although this method is more suited to
patients in the sitting position (i.e., not well suited for
sedated pediatric patients).
• The skin to epidural space can be estimated as 1 mm/kg or
[10 + (age in years ×2)] mm.
• Midline approach is typically used (Fig. 33.4), and para-
median approach is generally not needed or recommended
unless abnormal anatomical landmarks are encountered
or suspected in the lumbar region.
• When abnormal anatomical landmarks are encountered, a
careful survey of the patient’s spinal anatomy using ultra-
sound is strongly recommended to allow:
– Identification of the midline
– Measurement of epidural (ligamentum flavum) and
dural space depth
Fig. 33.2 Surface anatomy of the lumbar spine – Prediction of the best path (projection and angulation)
that the needle should take to reach the epidural space
Fig. 33.3 Surface anatomy of the thoracic spine

498 B.C.H. Tsui
Fig. 33.4 Loss-of-resistance

(LOR) technique. (Left) Midline
approach. In the lumbar region,
the needle is typically inserted
with minimal angulation.
(Right) Paramedian approach. In
the thoracic region, cephalad
angulation is often needed to
reach the epidural space
33.1.4.2 Direct Thoracic Approach ensure that the needle tip is in the midline when it enters
In the pediatric population, continuous thoracic epidural anes- the epidural space.
thesia is used only for major surgery. Placement of a thoracic • Compared to the lumbar region, the spinal canal at the
epidural requires a high skill level and can be a challenging level of T10–T12 is slightly superficial due to short spi-
procedure to perform. In children over the age of 6–12 months, nous processes.
the effectiveness of ultrasound guidance for thoracic epidural • Choose a needle that is appropriate for the size of the
placement is limited since the bony anatomy of the region child; for children ≤12 kg, a 5 cm, 19G Tuohy needle is
restricts and obstructs ultrasound visualization of the epidural suitable, while an 18G version can be used for larger chil-
space. Therefore, anesthesiologists continue to rely on a tactile dren. Also available is a thin-walled, 18G needle that
approach with either a loss of resistance method or a hanging allows a 20G catheter to be inserted through; an advantage
drop technique, both of which result in challenging needle of this needle is that when the needle is inserted with ceph-
insertion due to the angle required to access the thoracic epi- alad angulation, the bevel is parallel to the epidural space,
dural space. A median or paramedian approach can be used; reducing the risk of dural puncture by the needle tip.
however, each approach can be difficult and even dangerous if • Similar to lumbar epidural, resistance to air or saline can
the patient is uncooperative. This procedure is therefore typi- be used to identify the thoracic epidural space. In children
cally performed with the patient asleep. On rare occasions and 1 year or older, the ligamentum flavum provides adequate
for selective cases (i.e., mature teenager), it is occasionally resistance, and the negative pressure of the thoracic epi-
possible to insert a thoracic epidural in an awake patient. dural space can be identified easily.
• For infants and young children, small 3 or 5 mL syringes
33.1.4.3 General Approaches can be used; for older patients, use a 5–10 mL syringe.
• Perform the thoracic epidural puncture with the patient in

the lateral position; locate the prominent spine of the sev- 33.1.4.4 Median Approaches
enth cervical vertebra and use this landmark to calculate A successful thoracic block will rely on an acute angle of
other vertebral levels. The lower extremity of the shoulder insertion relative to the skin due to the angle of the spines.
blade, which is at the level of the seventh thoracic verte- This is particularly noticeable when using the median
bra, can also be used as a landmark. approach in the midthoracic region compared to lumbar
• The paramedian approach allows one to choose the angle region, since the needle typically needs to be angulated more
of insertion into the epidural space regardless of the space cephalad to reach the epidural space (Fig. 33.4). This tech-
available between adjacent vertebral spines. However, the nique may facilitate easier catheter movement in a cephalad
paramedian approach requires skill and experience to direction within the epidural space.
33.1.4.5 Paramedian Approach Note: As shown in Fig. 33.6, steps 2 and 3 must be per-
Most anesthesiologists find the paramedian approach to be formed separately, as the epidural space may be missed if the
the most effective technique for thoracic epidural placement. needle is “walked off” diagonally (i.e., medial and cephalad
This technique involves the following steps (Fig. 33.5): angulation at the same time).
This procedure can be difficult to master. Accurate place-
1. Insert the epidural needle 0.5–2 cm (e.g., one to two fin- ment of the needle requires fine motor skills, which are best
gerbreadths distance) lateral to the spinous process of the learned through hands-on practice. Training may be aided by a
vertebra. Note: Use the patient’s finger as measurement of phantom model that reproduces the anatomy necessary to learn
the distance lateral to the spinous process. and practice the paramedian approach to thoracic epidurals.
2. Advance the needle perpendicular to the skin until it con-
tacts the lamina.
3. Redirect the needle approximately 15° medially to “walk 33.1.5 Nerve Stimulation Technique
off” the lamina.
4. Angle the needle cephalad, and continue the “walk off” Electrical stimulation has been used in epidural anesthesia
technique to locate the epidural space. and for peripheral nerve blocks for many years. The epidural
Fig. 33.5 Paramedian approach for thoracic epidural placement in a Fig. 33.6 Common mistakes: with simultaneous medial and cephalad
spine model. (Top) Insert needle lateral to spinous process and perpen- angulation, the epidural space may be missed as the needle is “walked
dicular to the skin to contact the lamina. (Middle) Redirect the needle off” diagonally onto the spinous process or lamina of the spinal level
approximately 15° medially to “walk off” the lamina. (Bottom) Angulate above
the needle cephalad while maintaining needle 15° medially, and con-
tinue to “walk off” to reach the epidural space
500 B.C.H. Tsui
Table 33.1 Catheter location determined by motor response and current threshold during the epidural stimulation test
Catheter location Motor response Currenta
Subcutaneous None N/A
Subdural Bilateral (many segments) <1 mA
Subarachnoid Unilateral or bilateral <1 mA
Epidural space
Against nerve root Unilateral <1 mA
Non-intravascular Unilateral or bilateral 1–15 mA (threshold current increases after local anesthetic injection)
Intravascular Unilateral or bilateral 1–15 mA (no change in threshold current after local anesthetic injected)
a
Needle placement at the caudal and lumbar spine adheres well to these criteria, although placement at thoracic spinal levels may necessitate higher
upper limits (up to 17 mA has been shown). The lower threshold applies to both catheter and needle placement
stimulation test (Tsui test) was developed to confirm epidural metal-containing epidural catheter using an electrode
catheter placement, applying similar principles to those of adaptor such as the Johans ECG adaptor (Fig. 2.9a).
peripheral nerve blockade (i.e., using electrical pulses and the • Prime the catheter and adaptor with sterile normal saline
current versus nerve-distance relationship). This test has (0.2–1 mL).
demonstrated 80–100 % positive prediction for epidural cath- • Attach the cathode lead of the nerve stimulator directly to
eter placement. It has also been shown to be effective to guide the cable of the stimulating catheter or metal hub of the
catheters to within two segmental levels (with radiologic con- adaptor and the grounding anode lead to an electrode on
firmation), which can assist smooth placement to appropriate the patient’s body surface.
levels and allow adjustments in the event of catheter migra- • Set the nerve stimulator to a low frequency and pulse
tion, kinking, or coiling. In addition to confirming and guid- width (2 Hz; 0.2 ms).
ing epidural catheter placement, this test has been shown to • Carefully and slowly increase the current intensity until
be useful for detecting intrathecal, subdural, or intravascular motor activity begins.
catheter placement. • The characteristics of the various responses are compared in
Table 33.1. Catheter location is identified, and the required
33.1.5.1 Needle Confirmation adjustments are made depending to location indicated.
The procedure is performed along with standard mechanical
tests (e.g., loss of resistance to saline or air) for determining 33.1.5.3 Mechanism of the Test
epidural needle placement:
• Needle or catheter placement is confirmed by stimulating
• After sterile preparation, the nerve stimulator is attached the spinal nerve roots (not spinal cord) with an electrically
to an 18G insulated Tuohy needle (see Fig. 1.3). conducting catheter that conducts a low-amplitude elec-
• The current is applied after skin puncture and during trical current through normal saline.
advancement; the epidural stimulation test is used together • An appropriate motor response (1–10 mA; Table 33.1)
with detection of a “pop” or loss of resistance to saline. confirms accurate placement of the epidural catheter tip,
• The threshold current range for determining correct needle defined as 1–2 cm from the nerve roots (see Fig. 2.8).
placement is similar for the lumbar or caudal routes, but • Responses observed with a significantly lower threshold
the higher limit of 10 mA may be extended for thoracic current (<1 mA), especially if substantially diffuse or
placement (mean of 11.1 mA and up to 17 mA) [1, 2]. bilateral, may warn of catheter placement in the intrathe-
• The test may provide further confirmation during direct cal or subdural space (i.e., contacting highly conductive
epidurals, with the added benefit of warning that a needle CSF) or in close proximity to a nerve root.
is entering lumbar epidural space if the current is set • The segmental level of the catheter tip may be predicted
above 6 mA [3]. However, this technique has not been based on the progressive nature of the motor twitches as
applied widely in clinical practice except in the study the catheter is advanced (i.e., lower limbs followed by
environment. intercostals and then upper limbs).
• A local anesthetic test dose helps confirm epidural versus
intravascular location. If the catheter is localized in the epi-
33.1.5.2 Catheter Confirmation dural space, the motor threshold current should increase after
injection of local anesthetic. Unintentional injection into the
• The same procedure as described above for an insulated systemic circulation (i.e., removing local anesthetic from the
needle applies, with the exception that the nerve stimula- vicinity of the nerve) will allow subsequent motor stimula-
tor is connected to an epidural stimulating catheter or a tion at the same current.
When Used for Needle Placement in the intrathecal or intravascular space. In pediatric patients,
• Insulated needles seem to provide lower electrical thresh- aspiration alone may fail to detect up to 86 % of intravascular
old current required for this test. entry of epidural needles or catheters [5]. The threshold cur-
• The upper limit of the threshold current designating a rent for a motor response during catheter and needle place-
positive test using needles is different depending on the ment with the electrical stimulation test may help predict
level of needle placement (caudal = mean 3.7 mA; [4] intrathecal placement. Intravascular placement may be
lumbar = mean 3.84 mA; thoracic = mean 11.1 mA; intra- detected with the electrical stimulation test in conjunction
thecal = mean 0.77 mA). with a local anesthetic test dose.
• The higher threshold currents that may be seen with direct
thoracic level needle insertion may be related to the mini- Intrathecal
mal depth of needle penetration that is inherently used for • When a needle/catheter is situated properly within the
caution at this level. epidural space, a current greater than 1 mA should be
required to elicit muscle twitches.
• Using insulated needles, currents to elicit a motor response
33.1.5.4 Considerations for Test Performance in the epidural space (3.84 ± 0.99 mA and 5.2 ± 2.4 mA)
and Interpretation are much higher than that for the intrathecal space
(0.77 ± 0.32 mA and 0.6 ± 0.3 mA).
• Since local muscle contraction in the trunk region can be • If any motor response is detected with a current less than
confused with epidural stimulation, it is recommended to 1 mA, intrathecal catheter or needle placement should be
place the anode lead on the upper extremity for lumbar suspected.
epidurals and the lower extremity for thoracic epidurals.
• The 1–10 mA test criteria should be used as a guideline
only. Epidural stimulation may occur outside this range. Intravascular
The reason we recommend this range is that it is easy to • Repeated injections of local anesthetic into a properly
remember. In addition: placed epidural catheter result in impairment of nerve
– It is important to begin using the lowest current to allow conduction and require a gradual increase in the ampli-
detection of intrathecal placement or nerve root prox- tude of electrical current to produce a positive motor
imity; the lower limit of 1 mA applies to all situations. response.
– Some cases will require stimulation upwards of • If the local anesthetic is inadvertently injected into the
17 mA, particularly when using insulated needles in intravascular space (i.e., systemic circulation, thereby
the thoracic region. reducing the concentration in the vicinity of the nerves),
– The best predictor of epidural placement is a combina- the threshold will remain the same instead of incremen-
tion of the threshold current level and the distribution tally increasing with repeated application.
of elicited motor responses (i.e., correlation with • Caution is required when extrapolating the intravascular
approximate segmental location) since subcutaneous information because this application has only been tested
placement would not elicit such predictive and seg- in a few adult obstetric patients and never in the pediatric
mental responses. population.
• An epinephrine test dose (0.5 μg/kg) should still be
administered to identify inadvertent intravascular place-
33.1.5.5 Detecting Intrathecal and Intravascular ment by observing specific ECG changes (i.e., >25 %
Catheter and Needle Placement increase in T-wave or ST segment changes irrespective of
(Table 33.1) chosen lead).
Aspiration should always be performed prior to local anes- • When using a the test dose in combination with the epi-
thetic injection. However, the inability to aspirate blood or dural stimulation test, one can confidently rule out the risk
CSF does not indicate that an epidural needle/catheter is not of accidental intravascular or intrathecal injection.
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33.1.6 Electrocardiograph (ECG) Monitoring Procedure

Technique (Fig. 33.7) 1. Place left-leg (red in figure) and left-arm (black in figure)
electrodes at their standard positions.
One limitation of the epidural stimulation technique is that it 2. Record a standard reference ECG (lead II) by connecting
cannot be performed reliably if any significant clinical neu- the right-arm electrode (white in figure) to a skin elec-
romuscular blockade is present or if local anesthetics have trode on the patient’s back at the target spinal level.
been administered in the epidural space. To overcome this 3. Connect the right-arm electrode (white in figure) to the
limitation, an alternative monitoring technique using electro- metal hub of an electrode adaptor to record a tracing from
cardiograph (ECG) monitoring was developed [6]. Using the epidural catheter.
epidural ECG, the anatomical position of the epidural cath-
eter is determined by comparing the ECG signal from the tip
of the catheter to a signal from a surface electrode positioned Interpreting the ECG Method
at the “target” segmental level. Thus, advancement of an epi- • When the epidural catheter tip is positioned in the lumbar
dural catheter from the lumbar or sacral region into the and sacral regions, the amplitude of the QRS complex is
thoracic region can easily be monitored and placed within relatively small since the recording electrode (epidural tip) is
two vertebral spaces of the targeted level under ECG a considerable distance from the heart, and the vector of the
guidance. cardiac electrical impulse is at approximately a 90° angle.
Fig. 33.7 ECG monitoring technique for thoracic epidural catheter placement via advancement from lumbar or caudal levels
• As the epidural tip advances toward the thoracic region, with the ultrasound device. Second, real-time or “online”
the amplitude of the QRS complex increases as the imaging can be used during epidural procedures to observe
recording electrode comes closer to the heart and becomes needle puncture, catheter placement, and local anesthetic
more parallel to the cardiac electrical impulse. application (each of these actions is improved through direct
• As the catheter tip passes the target level, the amplitude of visualization of movement or by indirect means). There are
QRS should match the amplitude of the reference surface some challenges with using ultrasound in neuraxial proce-
electrode. dures, but it has demonstrable benefits for infants and neo-
nates and may have some efficacy (e.g., reduced needle
attempts and visibility of the sacral hiatus for caudal blocks)
Limitations with older pediatric patients.
The ECG technique cannot warn of a catheter placed in the Generally, the lower lumbar region has the highest visibil-
intrathecal or intravascular space. In addition, this tech- ity (i.e., ultrasound “window”), as it is less compact than the
nique may not be suitable when threading catheters a short more cephalad high-lumbar and thoracic levels. In pediatric
distance, as ECG changes may be too subtle to observe. patients, the ratio of visible to nonvisible segments to be 2:1
at the sacral, 1:1 at the lumbar, and 1:2 at the thoracic levels.
Visibility of neuraxial structures in the lumbar and thoracic
regions is best in patients 3 months of age and under, with
33.1.7 Ultrasound-Guided Technique age-dependent decreases in quality thereafter. As shown in
Fig. 33.8, there will be variation in the structures that are vis-
Generally, two approaches can be used for applying ultra- ible in different planes of ultrasound scanning as illustrated
sound imaging for epidural procedures. First, an “ultrasound- in the skeleton model (i.e., paramedian longitudinal scanning
supported” approach employs a pre-procedural scan to will visualize the dura mater better than median longitudi-
identify the puncture site, depth of epidural space, and ideal nal), and different techniques may require separate planes,
needle trajectory. These procedures require multiple “still although many approaches will require two or more planes
images” in different planes to capture accurate measurement for comprehensive assessment.
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Fig. 33.8 Possible ultrasound views using a pediatric skeleton model. views. (Bottom) For the thoracic region, an epidural window cannot be
(Top) For the lumbar region, an ultrasound epidural window (i.e., no seen easily and only with a paramedian view
bone obstruction) can be obtained with both transverse and paramedian
33.1.7.1 Preparing the Needle Insertion Site 33.1.7.2 Scanning Technique

Sterile technique is critical during performance of neuraxial
blocks due to the disastrous consequences of infection in the • Use a low-frequency (5–2 MHz) probe to scan the lumbar
epidural space. and thoracic spine in transverse and longitudinal planes.
• Figures 33.9 and 33.10 show the MRI anatomical struc-
• Full aseptic technique should be undertaken, with the pro- ture and ultrasound appearance in the transverse plane at
ceduralist gowned, gloved, and wearing a face mask and the lumbar and thoracic spine, respectively. Positioning
hat. the patient with a flexed spine will be advantageous for
• The area should be prepped with a chlorhexidine and viewing in this plane since it will improve location of an
alcohol solution, which should be allowed to dry. ultrasound window between the vertebrae. If the spinous
• Sterile draping of the area should be undertaken. processes obstruct the view of dura, then the “expected
• The needle, catheter, and other equipment required should position” of the dura can be estimated in most cases (see
be assembled on a sterile tray and be easily accessible. below for explanation).
Fig. 33.9 (a) VHVS and MRI images of transverse plane at the lumbar spine. (b) Sonographic appearance of transverse plane at the lumbar spine
506 B.C.H. Tsui
Fig. 33.10 (a) VHVS and MRI images of transverse plane at the thoracic spine. (b) Sonographic appearance of transverse plane at the thoracic spine
• Figures 33.11 and 33.12 show the MRI anatomical struc- will provide the best ultrasound window with reasonably
ture and ultrasound appearance in the midline and para- good visibility of the dura mater for surrogate marking of
median longitudinal plane at the lumbar and thoracic the puncture site and loss of resistance depth (see below
spine, respectively. The longitudinal paramedian plane for explanation).
Fig. 33.11 (a) VHVS and MRI images of midline longitudinal plane longitudinal plane at the lumbar spine. (d) Sonographic appearance of
at the lumbar spine. (b) Sonographic appearance of midline longitudi- paramedian longitudinal plane at the lumbar spine
nal plane at the lumbar spine. (c) VHVS and MRI images of paramedian
d
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Fig. 33.12 (a) VHVS and MRI images of midline longitudinal plane longitudinal plane at the thoracic spine. (d) Sonographic appearance of
at the thoracic spine. (b) Sonographic appearance of midline longitudi- paramedian longitudinal plane at the thoracic spine
nal plane at the thoracic spine. (c) VHVS and MRI images of paramedian
33.1.7.3 Sonographic Appearance Iso-/Hypoechoic Structures (Identical Density;

As illustrated in Fig. 33.13, ultrasound imaging in neonates Appear Grey)
and infants (<12 months of age) results in a superior image.
• Epidural space: located beyond the relatively hyperechoic
Hyperechogenic Tissues (Bright) dura mater.
• Spinal cord: low echogenicity with a double line at the
• Dura mater: appears thin, linear, and bright, usually with thoracic level.
a double-layered appearance in longitudinal view; it is
best viewed in a longitudinal paramedian plane.
• Bony structures: highly reflective and bright on the sur- Anechoic Structures/Substances (Black)
face, although they cast a dark shadow underneath.
• Conus medullaris and cauda equina: appear almost fibril- • Local anesthetic: upon injection, a hypoechogenic expan-
lar with a nearly hyperechoic appearance. sion is visible at the site of injection and often separates
• Catheter: appears as a double-linear structure in longitu- the neural and vascular structures.
dinal view and as a single hyperechoic dot on short-axis • Intrathecal Space: filled with CSF
view (see below).
Fig. 33.13 Transverse and longitudinal ultrasound images at the high-lumbar (a) and sacral (b) levels in a 12-month-old infant. Note that there is
more visibility in the infant spine due to the lack of calcification and fusion of the posterior elements of the canal
510 B.C.H. Tsui
Lumbar spine of a 10-year-old: vertebral bodies being the deepest structure, with the
potential for viewing intrathecal structures. Imaging
Transverse axis (Fig. 33.9b): of needle trajectory is limited except for indication of
• The center of the screen contains the circular subdural lateralization.
space within the vertebral (spinal) canal, with the • Median longitudinal/sagittal imaging depicts the spi-
internal anechoic CSF and hypoechoic intrathecal nous processes and interspinous space quite clearly.
nerve roots (not viewed in Fig. 33.9) surrounded by a Needle trajectory can be controlled through this
thin circular layer of hyperechoic dura. approach
• Superficially, it is possible to view the linear layer of • In young patients, there is a good “soft tissue window,”
hyperechoic subcutaneous tissue and inverted V-shape and the usually bilayered dura mater is clearly visual-
of the pedicles and spinous processes. ized, while the ligamentum flavum, intrathecal space,
Paramedian longitudinal axis (Fig. 33.11d) spinal cord, nerve roots, and fibers (including the
• The image contains an alternating dark (dorsal shad- cauda equina) all have intermediate but identifiable
owing from bone) and bright (ultrasound “window”) echogenicity.
pattern (mainly intervertebral spaces). • Paramedian longitudinal imaging can be used, allowing
• If seen, the conus medullaris and cauda equina have a greatest visibility of the dura mater. There is less
hyperechoic and almost fibrillar appearance. interference from ossification with this approach, allow-
• Hypoechoic CSF lies adjacent to the spinal nerve roots ing enhanced image quality and more visibility of the
and within the linear hyperechoic dura mater. interspace.
• The ligamentum flavum may be seen on the dorsal aspect • In the paramedian longitudinal view (Fig. 33.11d), the
of the dura and would also mark the epidural space. lamina and facet joints are visible, rather than the spinous
processes (as seen more clearly with median longitudinal
Thoracic spine of a 10-year-old: viewing).
• A remaining challenge with the paramedian longitudinal
Transverse viewing (Fig. 33.10b): technique is the tangential (OOP; short-axis) relation of
• The “starry night” appearance of the paravertebral mus- the needle (midline) and probe (paramedian), which only
cles is evident on either side of the hypoechoic matter enables clear needle tip visibility and limits accurate
(shadowing) from the long and thin spinous process. angular positioning control of the shaft.
• A wide scanning transverse view is often large enough
to visualize the articular and transverse processes.
• In patients older than a few months, the central “win- Indirect Imaging
dow” of the spinal canal viewed in the lumbar and sacral
spine is not nearly as well depicted in the thoracic region • Continuous visualization of needle tip penetration and
due to the compact nature of the bony elements. catheter advancement is sometimes difficult due to the
• Generally, the hyperechoic meninges are not delin- ultrasound beam reflecting off bony structures.
eated, and the position of the dura is estimated at best. • Needle punctures are often made visible by movements of
Paramedian longitudinal viewing (Fig. 33.12d) the needle tip and displacement of the surrounding
• Appears similar to that seen at the lumbar spine, except tissue.
the spinal cord appears hypoechoic with the surround- • Occasionally, widening of the epidural space and ventral
ing dura appearing as a thin hyperechoic line between movement of the dura mater can be seen upon saline
shadows from the overlaying spinous processes. injection.
• The ligamentum flavum may be seen and the epidural • Catheter advancement is generally visualized indirectly
space determined to some extent. by the spread of injectate and movement of the dura in the
vicinity of the catheter tip.
• This method limits the ability to reassess the catheter
Direct Imaging position post-procedure.
• It has been reported that the use of metal-coiled catheters,
• Transverse imaging shows the spinous processes with which appear bright with striated features, may help, but
shadowing in the midline, the facet joints laterally, and the our experience shows that this effect is limited.
33.1.8 Needle Insertion Technique • Depth of the epidural space = slightly more shadow
than skin-to-dural distance
Pre-procedural (ultrasound-supported) measurements: – If the lamina but not the dura is seen:
• Depth of the epidural space = slightly deeper than
• Use short- and long-axis scanning with a paramedian skin-to-lamina distance
probe alignment. • Determination of the ideal puncture location and trajec-
• Ultrasound can be used to assess neuraxial anatomy and, tory can be performed.
depending on visibility, measure various distances in the • Pre-procedural assessments can be performed prior to
vertebral (spinal) canal, including those from skin and real-time ultrasound guidance or in isolation before pro-
bone to dural, epidural, and intrathecal spaces. ceeding with a standard loss-of-resistance technique.
• Ultrasound-guided determination of epidural space depth
and depth to loss of resistance may be beneficial with Real-time guidance
good correlation between ultrasound-measured and clini-
cal loss of resistance depth. • The value of dynamic ultrasound guidance in the thoracic region
– This can be useful to assess the vertebral column (transverse may be limited in patients older than a few months of age.
and longitudinal views) and to estimate the epidural space • The puncture is typically made with a midline approach at
(i.e., anticipated loss of resistance depths) (Fig. 33.14). the required segment, and the probe is best aligned longi-
– If the dura is seen: tudinally along the paramedian plane.
Fig. 33.14 (a) Estimation of epidural depth based on transverse plane images at the thoracic spine. (b) Estimation of epidural depth based on
longitudinal plane images at the thoracic spine
512 B.C.H. Tsui
• The needle shaft and probe beam are OOP, and only the detect LOR (e.g., Episure AutoDetect Syringe, Indigo
needle tip may be seen. Orb, CA, USA) to free a hand to manipulate the ultra-
• The loss-of-resistance technique is still required and may sound probe.
be aided by directly visualizing the needle penetrating the • When performing ultrasound-guided epidural placements
ligamentum flavum, particularly in the lumbar spine. in infants (<10 kg), a 20G needle should be used.
However, confirmation of epidural space localization will • After epidural space confirmation, injection of the local
generally occur by visualizing a test dose of local anes- anesthetic solution will be visualized with a caudal and
thetic and the subsequent dural movement it causes. cephalad spread.
– For ultrasound guidance during epidural anesthesia, an
assistant will often be needed to perform the imaging,
which allows the anesthesiologist to use both hands to
perform the LOR (Fig. 33.15). Otherwise, the anesthe- 33.1.9 Catheter Insertion and Confirmation
siologist will need to utilize an automotive device to
• To confirm correct catheter insertion, we recommended

using loss of resistance to saline technique despite the
availability of ultrasound guidance or epidural stimula-
tion testing.
• The catheter is introduced once the needle positioning in
the epidural space has been confirmed by direct visualiza-
tion of penetration and dural movement upon injection of
a test dose of local anesthetic.
• The catheter tip may be visible upon entry and during
advancement with local anesthetic injection.
• The epidural stimulation test may be used to confirm cor-
rect epidural needle entrance (i.e., to prevent intrathecal
or intravascular placement), although its use in short-
distance (2–5 cm) catheter advancement may be limited.
• Once correct catheter tip placement is confirmed, rule out
intrathecal placement, and inject the local anesthetic.
Epidural placement may be confirmed if the movement of
Fig. 33.15 Real-time (online) needling during a low-thoracic epidural
dura is obvious and the catheter tip is visible. Catheter tip
showing out-of-plane alignment of the needle (median) and probe
(paramedian). An assistant is needed to perform the ultrasound identification is possible in children under 3–6 years of
imaging age (see Fig. 33.16).
Fig. 33.16 Transverse and longitudinal views of an epidural catheter at the lumbar spine in a 14-month-old child
33.1.10 Case Study: Lumbar Epidural
Lumbar Epidural (Provided by A. Spencer) A 5 cm, 20G Tuohy needle was inserted, and a
A 2-month-old female, 3.3 kg, was scheduled to 24G multilumen epidural catheter was threaded into
undergo a reversal of stoma and mucous fistula. The the epidural space (Fig. 33.17). An initial test dose of
child had previously undergone a laparotomy due to 0.3 mL lidocaine 1 % with epinephrine 1:200,000 was
meconium ileus; following this surgery, the patient injected, followed by an initial bolus of 2.5 mL ropiva-
remained intubated for 3 weeks due to difficulty caine 0.25 %. Two 1 mL boluses of ropivacaine 0.25 %
with ventilation and sedation. The patient was also were given intraoperatively. Postoperatively, a contin-
diagnosed with cystic fibrosis and pulmonary hyper- uous infusion of 1 mL/h ropivacaine 0.08 % (0.23 mg/
tension during this period. A lumbar epidural with kg/h) was ordered. Pain control was supplemented
insertion at the L2–L3 level was administered under with acetaminophen 40 mg q6h per rectum for 2 days.
ultrasound guidance. A pre-procedural ultrasound The patient was comfortable in recovery. Upon
scan was performed to obtain a paramedian, longi- being moved to the surgical ward, a low-dose morphine
tudinal view of neuraxial structures, including the infusion at 10 μg/kg/h was started since the patient
sacral, lumbar, and lower thoracic levels; the depth seemed irritable and hungry but was NPO. Acute pain
from skin to dura; and the location of the tip of the service followed the patient for 48 h, at which time the
conus medullaris. epidural was discontinued and removed.
Fig. 33.17 Lumbar

epidural block. SP
spinous process, Dm
dura mater (See Case
Study for details)
514 B.C.H. Tsui
33.2 Caudal Anesthesia The development of the epidural electrical stimulation

test has enhanced the current repertoire of methods that
33.2.1 Introduction assess correct needle placement in the caudal canal and is a
more objective method than those currently available.
Single-shot caudal epidural anesthesia is suitable for block- Ultrasound may be useful to determine the best puncture site
ade of the lumbar and sacral dermatomes. Although needle for caudal needle placement. As with other spinal levels,
puncture may be considerably safer at the sacral hiatus than ultrasound imaging at the sacral spine may be most benefi-
at other regions in the spinal canal because it is below the cial in young infants (<1 year old) since there is less ossifica-
spinal cord, there is still a high failure rate (up to 25 %) asso- tion and therefore a good ultrasound “window” in this region.
ciated with needle placement into the caudal canal, and inad- The main disadvantage with both ultrasound and nerve stim-
vertent vascular puncture occurs with some frequency ulation is that they do not provide immediate warning in
(5–9 % of patients). Usually, a “pop” is detected as the nee- cases of intravascular puncture.
dle enters the sacral canal through the sacral hiatus and pos-
terior sacrococcygeal membrane, and this sign, together with Indications
ease of advancement of the angiocatheter and local anes- Analgesia or surgical anesthesia for:
thetic injection, is traditionally used to determine correct • Urogenital surgery
needle placement (Fig. 33.18). • Lower limb surgery
Fig. 33.18 Caudal blockade involves needle/catheter entry at the usually felt (upper right). The ease of intravenous cannula advancement
sacral hiatus and through the posterior sacrococcygeal ligament (upper and local anesthetic injection is also used to confirm caudal epidural
left). As the needle enters the sacral canal and epidural space, a “pop” is space localization
33.2.2 Patient Positioning 33.2.4 Nerve Stimulation Technique
Position the patient in the lateral position.

• An insulated, sheathed 22G needle is required for the epi-
dural stimulation test.
33.2.3 Surface Anatomy (Fig. 33.19) • After sterile preparation, connect a nerve stimulator to the
needle.
Iliac crests: • Attach the cathode (negative; black) lead of the nerve
• Approximately at the level of the L4 spinous process stimulator to the insulated needle, and attach the ground-
Posterior superior iliac spines (PSIS): ing anode (positive; red) lead to an electrode on the
• Approximately 4–5 cm lateral to S1/S2. patient’s body surface.
• Set the nerve stimulator to a low frequency and pulse
Median sacral crest:* width (1 or 2 Hz; 0.1 or 0.2 ms).
• Fused spinous processes of the sacrum (on dorsal • Insert the needle perpendicular to the skin at the level of
surface) the sacral cornua (located by palpation).
• May be difficult to palpate in patients with excessive • Advance the needle until the characteristic “give” or “pop”
subcutaneous tissue is felt, indicating entrance into the caudal epidural space.
• Carefully and slowly increase the current intensity until
Sacral hiatus:* motor activity begins.
• Sacral cornua (horns) can be palpated approximately • The correct motor response is contraction of the anal
5 cm above the tip of the coccyx. sphincter (S2–S4) at a current threshold generally between
• The sacral hiatus lies at the midpoint between these cornua. 1 and 15 mA.
• Localized muscular twitches of the gluteal or back mus-
*These landmarks are suitable as reference points in older cles are an incorrect response and indicate that the needle
children only. Refer to Fig. 13.4 for more information. is likely in the subcutaneous space outside the sacrococ-
cygeal ligament. Additionally, the current may be higher
(>8 mA) in this case.
Clinical Pearl • Refer to Table 33.1 for information on the threshold cur-
Using a landmark approach with an angiocatheter rent of motor response, particularly with respect to intra-
(Fig 33.18): thecal placement.
• The ease of intravenous cannula advancement is • After negative aspiration for CSF, an epinephrine test
the most important sign to confirm caudal epidural dose (0.5 μg/kg) should be administered to identify inad-
location. vertent intravascular placement, as indicated by specific
• Inadvertent intravascular placement can be detected ECG changes (i.e., >25 % increase in T-wave or ST seg-
easily by gentle aspiration once the needle is removed. ment changes, irrespective of chosen lead).
• The presence of any physical signs of subcutaneous bulg-
ing or tissue resistance upon the injection of local anes-
thetic indicates improper needle placement and an
unsuccessful caudal block.
33.2.5 Ultrasound-Guided Block
33.2.5.1 Preparing the Needle Insertion Site

The area should be prepared by cleaning with an alcohol-
based chlorhexidine surgical wash and draping the area for
sterility. Any catheter techniques should have the same
meticulous attention to sterile technique as for epidural
insertion.
Fig. 33.19 Patient positioning and surface landmarks for caudal block
516 B.C.H. Tsui
33.2.5.2 Scanning Technique • Linear probes are advantageous in most patients, although
curvilinear array transducers with lower frequencies may be
• Begin with a short-axis transverse probe (5–12 MHz lin- beneficial with older and/or obese patients. Smaller footprint
ear) orientation at the level of the fifth sacral vertebra to (hockey stick) probes are more appropriate in smaller patients.
identify landmarks. The sacral cornua (bilateral horns of • After entry into the caudal epidural space, the probe can
sacrum), dorsal surface of the sacrum and posterior sacro- be rotated from a longitudinal to a transverse orientation
coccygeal ligament, and sacral hiatus may be visualized to locate the needle in short axis (as a dot) between the
(Fig. 33.20). sacrococcygeal ligament and the pelvic (ventral) surface
• Upon skin puncture, rotate the probe 90° for long-axis of the sacrum (i.e., caudal epidural space).
(longitudinal) viewing between the two cornua • For young infants (best results in patients over 1 year old),
(Fig. 33.21), which may allow IP imaging of the needle the probe (7–12 MHz linear) can be placed over the mid-
trajectory toward the entrance to the sacrococcygeal liga- sacral level (S2–S3) due to the limited ossification of the
ment; beyond this barrier, the characteristic “pop” can be sacral vertebrae (see Fig. 33.13). A long-axis view will
used to confirm needle placement within the caudal epi- allow clear visibility of the needle trajectory through the
dural space. caudal entrance into the epidural space.
Fig. 33.20 (a) VHVS and MRI images of transverse plane of the caudal space. (b) Transverse/short-axis image captured by a linear probe at the
level of the sacral hiatus in a 10-year-old patient
Fig. 33.21 (a) VHVS and MRI images of longitudinal plane of the caudal space. (b) Longitudinal/long-axis image captured by a linear probe
placed between the sacral cornua of a 10-year-old patient
518 B.C.H. Tsui
33.2.5.3 Sonographic Appearance between the sacrococcygeal ligament and sacral bone
(with the caudal epidural space cephalad and beneath
• Short-axis view at sacral hiatus (Fig. 33.20b): the dorsal surface of the sacrum).
– Superficially, the two sacral cornua are seen as hyper- – The needle may appear as a hyperechoic and linear
echoic inverted U-shaped structures beneath the vari- structure outside the epidural space. The needle is not
ably echogenic linear subcutaneous tissue. visible within the epidural space due to the beam
– Deep and between the cornua are two hyperechoic reflection from the dorsum of the sacrum (not shown).
bands indicating the posterior sacrococcygeal mem-
brane (first) and the dorsal side of the pelvic surface
(“base”) of the sacrum; the hypoechoic space between 33.2.5.4 Caudal vs. Intrathecal Injection
these is the sacral hiatus.
– Deep to the cornua and bands, the image may show • When performing caudal blocks, there is a risk of dural
lateral darkening and a medial hypoechogenic epidural puncture leading to accidental intrathecal injection.
space; this will be variable. Effects of intrathecal injection range from headache to
– The needle can be seen as a hyperechoic dot within the total spinal blockade.
sacral hiatus following sacrococcygeal membrane • Several methods, including the “whoosh” and “swoosh”
puncture (not shown). tests, electrical stimulation, and imaging, have been used
• Long-axis view at sacral hiatus (Fig. 33.21b): to guide needle placement and help ensure a caudal
– The sacrococcygeal ligament appears broad, hyper- location.
echoic, and linear and is slanted at a caudal angle. • It was recently shown that color flow Doppler ultrasound
– The dorsal surface of the sacrum appears hyperechoic can predict with high sensitivity and specificity whether
deep and cephalad to the membrane. injection is occurring in the caudal or intrathecal space; a
– The dorsal side of the ventral (pelvic) surface of the clear signal is obtained with caudal injection, whereas
sacrum appears dark at the bottom of the image, with a intrathecal injection produces no detectable signal
moderately hypoechogenic space – the sacral hiatus – (Fig. 33.22).
Fig. 33.22 Color Doppler

ultrasound for confirming local
anesthetic spread into the
lumbar (L4) epidural space.
Preinjection (left), no
illumination and a central
circular intrathecal space are
seen; postinjection (right), local
anesthetic appears as a medley
of colors and expands the
epidural space slightly
33.2.5.5 Needle Insertion and Local Anesthetic • Advance the needle until a “pop” is felt, signifying caudal
Application epidural space entrance.
In pediatric patients, caudal anesthesia follows general anes- • The reduced fusion and calcification of the dorsal sacrum
thesia in most cases. in infants may allow visibility of the needle tip beyond the
For patients older than 1 year, position the probe at the ligament and within the epidural space.
sacral hiatus. For infants, place it at S2–S3. • Rotate the probe to the short axis to confirm needle loca-
tion (a bright dot in the epidural space) and inject the local
• Insert a 22G needle perpendicular to the skin and in the anesthetic.
midline at the sacral hiatus. • Local anesthetic may be seen directly as an expansion of
• With the probe placed longitudinally, the needle can be hypoechogenicity and indirectly through dural movement.
seen in long axis as it advances to and penetrates the
sacrococcygeal ligament.
33.2.6 Case Study: Caudal Epidural
Caudal Epidural (Provided by S. Suresh) (Fig. 33.23). Duration of surgery was 2 h; block dura-
A 9-month-old boy, 11 kg, was scheduled for a caudal tion was 4–6 h. No pain was reported in recovery (0 on
block for hypospadias repair. The block was performed FLACC scale). Postoperative analgesia consisted of a
under ultrasound guidance with a 22G needle and 6 mg injection of ketorolac (Toradol).
10 mL 0.25 % bupivacaine with epinephrine 1:200,000
Fig. 33.23 Ultrasound-

guided caudal epidural
block (See Case Study
for details)
520 B.C.H. Tsui
33.3 Advancing a Catheter to the Lumbar 33.3.1 Epidural Stimulation Guidance

or Thoracic Area from a Caudal Technique (Fig. 33.24)
Insertion Site
Advancing catheters from the sacral (or low lumbar) epidural Procedure
space to lumbar or thoracic levels has the advantage of reduc- • Estimate the length necessary to thread a 20G styletted
ing the risk of direct spinal cord trauma (especially as there epidural stimulating catheter or metal-containing epidural
will be no sensory warning in anesthetized pediatric patients) catheter the required distance (Fig. 2.10).
and may be technically easier in patients with prior spinal • Adjust the stylet to a point within the distal end of the
surgery at higher levels. Confirmation of both proper catheter epidural catheter to obtain the desired stiffness.
placement in the epidural space and monitoring the catheter’s • After sterile preparation, insert an 18G IV catheter, using
cephalad advancement is important, and both ultrasound and similar technique to that of the single-shot approach into
electrical epidural stimulations may be beneficial because of the caudal epidural space; correct placement will be char-
the dynamic nature of these techniques. The epidural stimula- acterized by the typical “give” or “pop” upon penetration
tion test can provide a warning of intrathecal, and possibly of the sacrococcygeal ligament (Fig. 33.18).
intravascular, needle or catheter placement. • Use the electrode adaptor to connect a nerve stimulator to
This is most successful in patients under 1 year of age since the epidural catheter.
after this age, the lumbar curve becomes more pronounced, • Prime the stimulating catheter and adaptor with sterile
preventing easy advancement of epidural catheters from the normal saline (1–2 mL).
caudal space. However, with specialized styletted catheters and • Attach the cathode lead of the nerve stimulator to the
using the epidural stimulation test to guide positioning, caudal metal hub of the adaptor and the grounding anode lead to
catheter advancement is now possible in older children. an electrode on the patient’s body.
1. Measure the length of

catheter required
Nerve stimulator
Fig. 33.24 Epidural catheter

insertion using electrical
epidural stimulation. First,
estimate the length of a styletted
metal-containing catheter. 2. Adjust epidural
Secondly, insert the catheter into catheter according to
the caudal epidural space using epidural stimulation
traditional methods (i.e., loss of responses
resistance), and advance the
catheter. Observe responses to
nerve stimulation to confirm
epidural placement and the
segmental level of catheter tip
location
• Set the nerve stimulator to a low frequency and pulse 33.3.2 Local Anesthetic Application (“Test”)
width (2 Hz; 0.2 ms). to Confirm Avoidance of Intravascular
• For continuous caudal anesthesia, advance the catheter a Placement
few millimeters and gradually apply current to the cathe-
ter until motor activity or a twitch response of the anal
sphincter (S2–S4) is visible. • After aspirating to rule out intrathecal placement, inject a
• For threading to lumbar or thoracic levels, advance the test dose of local anesthetic (0.1 mL/kg lidocaine 1 %
catheter while gradually applying current. with 1:200,000 epinephrine) to confirm catheter place-
• Follow progressive motor responses (from lower limbs ment and to ensure it is not intravascular.
and lumbar (back) to intercostals to thoracic and upper • If catheter placement is correct, the current threshold
limbs) through cranial advancement until desired level is should increase, and the motor response should cease
reached. upon local anesthetic injection.
• Minor resistance encountered during catheter threading • If the catheter tip is within the intravascular space, the
can be overcome by injecting normal saline through the local anesthetic will disperse systemically, and the motor
catheter and/or simple flexion or extension of the patient’s response will remain the same with repeated injections of
vertebral column. local anesthetic.
• Inject a test dose of local anesthetic to rule out intravascu- • Once intravascular placement is ruled out, the catheter
lar placement. can be affixed to the skin as described above.
• Compare the total characteristics of the response to
Table 33.1 to determine catheter placement and make any
required adjustments. 33.3.3 Ultrasound-Guided Technique
• If the catheter does not reach the desired level, it can be
pulled back and reinserted. This technique is most suitable for young infants
• Once optimally positioned, withdraw the 18G intrave- (0–6 months) since, due to incomplete ossification of the ver-
nous catheter and the stylet. tebrae, the catheter tip and a greater number of anatomical
• Affix the catheter immediately cephalad to the site of structures are more easily visualized. The thoracic spine pro-
insertion with several layers of occlusive dressing vides less of an “ultrasound window” due to its smaller size
(Fig. 33.25). and overlapping spinous processes.
33.3.4 Scanning Technique
• An assistant must perform the ultrasound imaging during

catheter placement.
• During caudal cannula placement and epidural catheter
advancement, follow the scanning technique described
earlier for caudal needle placement in young infants.
• For viewing the lumbar and thoracic regions of the spine,
position the probe in a longitudinal median or paramedian
plane (probe lateral to the spinous processes).
• Either alignment may be suitable for the lumbar spine,
although paramedian may be superior, as it allows clear visi-
bility of the dura, and dural movement upon catheter entrance
has been shown to be a better indicator of ligamentum flavum
penetration (as seen best through median alignment).
• The paramedian position (whether transverse or longitu-
dinal axis) is the best choice for the thoracic spine as there
Fig. 33.25 Epidural catheter secured on an infant’s back with sterile is more ossification here, and the long, obliquely oriented
occlusive dressing to maintain sterility spinous processes overlap each other significantly.
522 B.C.H. Tsui
33.3.5 Sonographic Appearance 33.3.6 Catheter Insertion and Local Anesthetic

Application
The appearance of the caudal epidural space will match that
seen when performing single-shot anesthesia (see Figs. 33.20
and 33.21). • On the exterior of the patient’s body, measure the length
of catheter required.
Catheter Visibility (14-Month-Old) • Perform the block using an 18G IV cannula and a 20G
• At the lumbar spine, the tip of the catheter may be seen epidural catheter (stimulating if using electrical epidural
upon entry and during advancement (Fig. 33.16), although stimulation).
more than one imaging plane may be required. In children • If using epidural stimulation, follow the procedure in the
older than 3–6 years of age, the catheter tip may not be previous section while viewing the catheter using
clearly identified following insertion. ultrasound.
• Generally, the catheter is viewed indirectly by observing • If using ultrasound alone with the classic “pop” at the
movement of the dura upon fluid injection; the hypoechoic caudal epidural space, visualize catheter advancement
local anesthetic will appear to expand the epidural space either directly (in young infants) or with the aid of local
and cause ventral movement of the dura. anesthetic injection to cause movement of the dura.
• Once catheter tip placement is deemed correct, rule out
inadvertent intrathecal placement (Table 33.1), and inject
Local Anesthetic Injection local anesthetic to check for inadvertent intravascular
• In general, local anesthetic cannot be seen directly, but injection. Ultrasound may also be of use in this regard if
occasionally, caudad and cephalad spread can be appreci- the movement of dura is clear and if the catheter tip is vis-
ated indirectly from displacement of the dura. ible in the epidural space.
33.3.7 Case Study: Thoracic Epidural
Thoracic Epidural (Provided by B. Tsui) reached the desired location (with confirmation by nerve
An 8-month-old child underwent open Nissen fundopli- stimulation), it was secured as shown in Fig. 33.25. Real-
cation surgery. After induction of general anesthesia time ultrasound imaging was performed during catheter
without muscle relaxation, the child was placed in a lat- advancement. A transverse view at L3/L4 (Fig. 33.26a)
eral position. Under strict sterile conditions, an epidural and paramedian longitudinal view (Fig. 33.26b) were
catheter was introduced via the caudal space using simi- obtained at the midthoracic level; the dura mater and epi-
lar technique to that shown in Figs. 33.18 and 33.24. dural catheter can be easily appreciated in these images.
Using nerve stimulation guidance, the catheter was The infant was wakened up without any signs of discom-
advanced into the thoracic space. Once the catheter fort and was discharged to the ward postoperatively.
Fig. 33.26 Ultrasound-guided thoracic epidural catheter placement via caudal insertion. Transverse (a) and paramedian longitudinal (b)
views are shown. Blue rectangle indicates probe footprint (See Case Study for details)
524 B.C.H. Tsui
33.4 Current Literature in Ultrasound- blockade. Lundblad et al. [10] used ultrasound imaging to
Guided Approaches show a significant inverse relationship with regard to age,
weight, and height and maximum cranial spread after caudal
There is a relative abundance of recent literature covering blockade. Triffterer et al. [11] assessed local anesthetic injec-
topics in ultrasound-guided techniques in pediatric practice. tion speed (0.5 mL/s vs. 0.25 mL/s) during ultrasound-guided
Most studies have compared ultrasound guidance to tradi- caudal block and found no significant difference in level of
tional non-ultrasound methods; an important outcome that cranial spread or distance of spread relative to the conus
this comparison addressed is needling time. For thoracic epi- medullaris in the epidural space. Ueda et al. [12] were able to
durals, Tachibana et al. [7] found a significantly shorter nee- demonstrate that transesophageal echocardiography could
dling time in the ultrasound group compared to the control be used to visualize both catheter position and local anes-
group (median 100 (77–116) vs. 165 (130–206) s) when thetic spread in three dimensions for thoracic epidural
ultrasound prescanning was used. Nevertheless, one consid- blocks. Finally, in a prospective observational study of chil-
eration when ultrasound is used is the time taken to do the dren undergoing a surgical procedure or ongoing chemother-
scan in the first place; in the Tachibana study, the scan to visu- apy regime, Tsui et al. [13] found that color flow Doppler
alize neuraxial structure took, in most cases, over 2 min to ultrasound could be used to successfully distinguish epidural
perform. In certain circumstances, this may unnecessarily injection from intrathecal injection.
extend the overall needling time. In another study of block Ultrasound has also been used to provide more informa-
performance time, Wang et al. [8] compared ultrasound- tion on subcutaneous neuraxial structures. Koo et al. [14]
guided caudal block by sacral hiatus injection to traditional used ultrasound to examine movement of the dural sac
sacral canal injection and reported a significantly shorter time depending on patient positioning; they observed significant
for the ultrasound group (145 ± 23 vs. 164 ± 31 s), but did not cephalad shifts in dural sac position in the lateral flexed posi-
comment on the time taken to perform the scan itself. Thus, tion versus a neutral position. The same group used ultra-
ultrasound prescanning shortens actual needling time but will sound to determine the prevalence of spinal dysraphism in
in all likelihood extend the overall block procedure time. children with urogenital anomalies [15]. Children suspected
Success of neuraxial blocks under ultrasound guidance is of spinal cord tethering showed a lower level of conus medul-
another outcome that has been studied. Wang et al. [8] found laris and thicker filum terminale when compared to the nor-
that, although the overall success rate of caudal block was mal group. Kim et al. [16] used information obtained from
similar between groups whose blocks were performed under ultrasound scanning of the sacral hiatus to show that the tra-
ultrasound guidance or using LOR (92.8 % vs. 95.7 %), suc- ditional equiangular triangle method of identifying the sacral
cess rates for the first puncture were significantly higher with hiatus may not be reliable. Using ultrasound to estimate
ultrasound (92.8 % vs. 50 %). Similarly, Tachibana et al. [7] depth of structures, Tachibana et al. [7] showed a significant
showed that the number of epidural puncture attempts was correlation between needle depth and ultrasound estimation
reduced when ultrasound prescanning was done, and those of the skin-dura distance, while Shin et al. [9] revealed sig-
performing the blocks reported significantly more difficulty nificant differences in depth of the sacral space at S2–3 when
without a prescan. Shin et al. [9] compared two ultrasound- compared to the sacral hiatus.
guided caudal block approaches – one involving the com- With regard to block quality, Willschke et al. [17] retro-
monly used sacral hiatus and the other involving the S2–3 spectively described the performance of ultrasound-guided
interspace. The first epidural puncture attempt success rate thoracic epidural blocks for 20 infants with hypertrophic
was significantly higher with the latter approach despite a pylorus stenosis. Ultrasound-guided single-shot epidural
similar overall success rate between the two approaches. blocks provided sufficient analgesia in all infants following
Several recent studies have assessed direct visualization surgery and were associated with stable heart rate and oxy-
of local anesthesia spread using ultrasound during neuraxial gen saturation intraoperatively.
References 13. Tsui B, Leipoldt C, Desai S. Color flow Doppler ultrasonography

can distinguish caudal epidural injection from intrathecal injection.
Anesth Analg. 2013;116:1376–9.
1. Tsui BC, Wagner A, Cave D, Seal R. Threshold current for an insu-
14. Koo BN, Hong JY, Kim JE, Kil HK. The effect of flexion on the
lated epidural needle in pediatric patients. Anesth Analg. 2004;99:
level of termination of the dural sac in paediatric patients.
694–6.
Anaesthesia. 2009;64:1072–6.
2. Tsui BC, Wagner AM, Cunningham K, Perry S, Desai S, Seal
15. Koo BN, Hong JY, Song HT, Kim JM, Kil HK. Ultrasonography
R. Threshold current of an insulated needle in the intrathecal space
reveals a high prevalence of lower spinal dysraphism in children
in pediatric patients. Anesth Analg. 2005;100:662–5.
with urogenital anomalies. Acta Anaesthesiol Scand. 2012;56:
3. Tsui BC, Wagner AM, Cunningham K, Perry S, Desai S, Seal
624–8.
R. Can continuous low current electrical stimulation distinguish
16. Kim MS, Han KH, Kim EM, Jeong SH, Lee JR. The myth of the
insulated needle position in the epidural and intrathecal spaces in
equiangular triangle for identification of sacral hiatus in children
pediatric patients? Pediatr Anesth. 2005;15:959–63.
disproved by ultrasonography. Reg Anesth Pain Med. 2013;38:
4. Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation of caudal
243–7.
needle placement using nerve stimulation. Anesthesiology. 1999;
17. Willschke H, Machata AM, Rebhandl W, Benkoe T, Kettner SC,
91:374–8.
Brenner L, Marhofer P. Management of hypertrophic pylorus steno-
5. Fisher QA, Shaffner DH, Yaster M. Detection of intravascular
sis with ultrasound guided single shot epidural anaesthesia – a ret-
injection of regional anaesthetics in children. Can J Anesth. 1997;
rospective analysis of 20 cases. Pediatr Anesth. 2011;21:110–5.
44:592–8.
6. Tsui BC. Thoracic epidural catheter placement in infants via the
caudal approach under electrocardiographic guidance: simplifica-
tion of the original technique. Anesth Analg. 2004;98:273.
7. Tachibana N, Yamauchi M, Sugino S, Watanabe A, Yamakage Suggested Reading
M. Utility of longitudinal paramedian view of ultrasound imaging
for middle thoracic epidural anesthesia in children. J Anesth. 2012; Dalens B. Caudal anesthesia. In: Dalens B, editor. Regional anesthesia
26:242–5. in infants, children, and adolescents. Philadelphia: Lippincott
8. Wang LZ, Hu XX, Zhang YF, Chang XY. A randomized compari- Williams & Wilkins; 1995. p. 171–94.
son of caudal block by sacral hiatus injection under ultrasound Dalens B. Lumbar epidural anesthesia. In: Dalens B, editor. Regional
guidance with traditional sacral canal injection in children. Pediatr anesthesia in infants, children, and adolescents. Philadelphia:
Anesth. 2013;23:395–400. Lippincott Williams & Wilkins; 1995. p. 207–48.
9. Shin SK, Hong JY, Kim WO, Koo BN, Kim JE, Kil HK. Ultrasound Dalens B, Khandwala R. Thoracic and cervical epidural anesthesia. In:
evaluation of the sacral area and comparison of sacral interspinous Dalens B, editor. Regional anesthesia in infants, children, and
and hiatal approach for caudal block in children. Anesthesiology. adolescents. Philadelphia: Lippincott Williams & Wilkins; 1995.
2009;111:1135–40. p. 249–60.
10. Lundblad M, Lonnqvist PA, Eksborg S, Marhofer P. Segmental distri- Suresh S, Polaner DM, Cote CJ. Regional Anesthesia. In: Cote CJ,
bution of high-volume caudal anesthesia in neonates, infants, and tod- Lerman J, Anderson BJ, Eds. 5th ed. Philadelphia: WB Saunders;
dlers as assessed by ultrasonography. Pediatr Anesth. 2011;21:121–7. 2013. p. 835–79.
11. Triffterer L, Machata AM, Latzke D, Willschke H, Rebhandl W, Tsui BC. Epidural anesthesia using electrical epidural stimulation and
Kimberger O, Marhofer P. Ultrasound assessment of cranial spread ultrasound guidance. In: Tsui BC, editor. Atlas of ultrasound and
during caudal blockade in children: effect of the speed of injection nerve stimulation-guided regional anesthesia. New York: Springer;
of local anaesthetics. Br J Anaesth. 2012;108:670–4. 2007. p. 235–55.
12. Ueda K, Shields BE, Brennan TJ. Transesophageal echocardiogra- Tsui BC. Caudal and epidural blockade. In: Tsui BC, editor. Atlas of
phy: a novel technique for guidance and placement of an epidural ultrasound and nerve stimulation-guided regional anesthesia.
catheter in infants. Anesthesiology. 2013;118:219–22. New York: Springer; 2007. p. 271–93.
Spinal Anesthesia
34
Adam O. Spencer, Santhanam Suresh, and Ban C.H. Tsui
Contents
34.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
34.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
34.2.1 Clinical Use and Special Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
34.2.2 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
34.3 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
34.3.1 Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
34.3.2 Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
34.3.3 Surface Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
34.3.4 Sonographic Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
34.3.5 Nerve Stimulation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
34.4 Equipment and Spinal Needle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
34.4.1 Needles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
34.5 Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
34.5.1 Adjuvants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
34.6 Assessment of the Block Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
34.7 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
34.8 Current Literature in Ultrasound-Guided Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
34.9 Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
A.O. Spencer, MSc, MD, FRCPC

Vi Riddell Complex Pain and Rehabilitation Centre,
Alberta Children’s Hospital, Calgary, AB, Canada
S. Suresh, MD
Department of Pediatric Anesthesiology,
Ann & Robert Lurie Children’s Hospital of Chicago,
Chicago, IL, USA
AB T6G 2G3, Canada

DOI 10.1007/978-0-387-79964-3_34
528 A.O. Spencer et al.
34.1 Introduction 34.2 Indications
In 1885, James Leonard Corning administered the first spi- • Despite the use of spinal anesthesia for multiple pro-
nal anesthetic published in a peer-reviewed medical journal cedures in pediatric anesthesia, it is usually restricted
[1]. It was not until 1901 that the use of spinal anesthesia in to infants, particularly premature infants with a his-
children was reported [2], and in 1909, Gray published the tory of apneas and bradycardias and chronic lung dis-
first pediatric case series [3]. Despite early pediatric suc- ease who would otherwise have received a general
cesses and effective use of the technique in adults, it was not anesthetic or awake caudal block with high-dose local
until the 1980s that the technique was resurrected for pedi- anesthetic [10].
atric use by Abajian [4], who showed that spinal anesthesia • Some key advantages of a spinal anesthetic include:
could be used to mitigate the perioperative risks commonly – Decreased use of sedatives and opioids and avoidance
associated with general anesthesia in the high-risk ex- of airway manipulation
premature neonate presenting for inguinal hernia repair. – Quick onset
Today, spinal anesthesia continues to be most commonly – Favorable surgical conditions with complete sensory
used in neonates and infants when risk is increased with a and motor block
general anesthetic. – Rapid postoperative recovery
It is important to be aware of some key age-dependent • The technique is not limited to the premature population
neuraxial anatomical differences between adult and pediatric and has been used extensively in healthy and at-risk pedi-
patients with regard to spinal anesthesia, including: atric patients of all ages for a variety of surgical proce-
dures including general, orthopedic, urological, spine,
• Conus medullaris: In early neonatal and infancy period, and cardiac surgery [11].
the spinal cord has been reported to extend to the L2–L3
level, whereas the conus ends at the L1–L2 level at 1 year
of age and T12–L2 in adults [5] (Fig. 13.12). 34.2.1 Clinical Use and Special Concerns
• Dural sac: The dural sac of neonates and infants termi-
nates more caudad at a level of S3 compared to adults at a Spinal anesthesia is commonly used for lower abdominal,
level of S1. urological, and lower limb surgery. There are important con-
• Subarachnoid space: The subarachnoid space is found at siderations prior to proceeding with a spinal anesthetic:
a much reduced depth in the pediatric patient. Compared
to adults, there is a relationship between weight or body • Coagulation status: Clinical history is insufficient to
surface area and the depth to the subarachnoid space, detect coagulation abnormalities in neonates and
especially in neonates and infants. Estimates of this depth infants aged less than 1 year. Coagulation status in the
increase from 10 to 15 mm at birth to 20 mm (3 years), ex-premature neonate is recommended prior to pro-
25 mm (5 years), and over 30 mm (10 years). In addition, ceeding with a spinal anesthetic. Coagulation tests,
the spinal canal space is also narrower, especially in the including prothrombin time (PT/INR), activated partial
younger pediatric patient [6–8]. thromboplastic time (APTT), and platelet counts,
• Volume and distribution of cerebrospinal fluid (CSF): The should be compared against age-specific reference
total volume of CSF in infants has been estimated at ranges. See “Suggested Reading” for additional infor-
4 mL/kg vs. 2 mL/kg in adults, and there is a greater pro- mation [12, 13].
portion of this volume in the spinal canal compared to • Length of surgery: Although dependent on the local anes-
adults. These are significant differences which may help thetic and use of adjuvants, as a sole single-injection
explain the shorter duration of action of spinal anesthetics technique, a spinal will last up to a maximum of approxi-
in infants despite a larger local anesthetic dose [9]. mately 90 min. If surgery time is expected to take more
34 Spinal Anesthesia 529
than 60–75 min, there is risk of needing additional seda- 34.3 Technique
tion or general anesthetic. An alternate anesthetic plan
should always be readily available. 34.3.1 Preparation
• Patient position during surgery: Immediately following
postspinal injection, it is necessary to avoid raising the • Due to the limited duration of the spinal anesthetic, it is
legs or trunk above the level of the head as this can cause necessary to have good communication with the surgical
a high anesthetic block. staff and for the team to be readied to begin surgery once
the spinal is complete.
• Skin topicalization using 4 % tetracaine (amethocaine;
34.2.2 Contraindications Ametop®, AnGel®) 30 min prior to the procedure or eutec-
tic mixture of local anesthetic cream of lidocaine and pri-
• Contraindications include patient or parent refusal, locaine (EMLA) 1 h prior to the procedure can offer some
presence or suspicion of coagulopathy, infection (local local anesthesia for both intravenous access and spinal
or systemic), hypovolemia, and raised intracranial access. The topical gel or cream may be covered using a
pressure. 3M Tegaderm® dressing. Depending on the anesthetic
• Relative contraindications specific to spinal anesthesia goal and age of the child, a premedication may be used in
include anatomical abnormality of the spine, the presence addition to skin topicalization.
of degeneration of or diseases affecting the central ner- • We recommend intravenous access prior to completing
vous system, and the presence of ventriculoperitoneal the spinal anesthetic. Several reasons include:
shunts or intrathecal catheters. 1. The possibility of delaying the surgical start after spi-
nal anesthesia due to unforeseen difficulties obtaining
vascular access.
2. Venous access allows premedication with atropine
(10 μg/kg) prior to completing the spinal.
3. Acute complications following the spinal without
immediate vascular access (e.g., high spinal, profound
apnea) may be more challenging to manage.
34.3.2 Patient Positioning 34.3.3 Surface Anatomy
• Following intravenous access and premedication with Important surface anatomy landmarks that should be identi-
atropine (10 μg/kg), the patient is placed in a lateral decu- fied prior to sonographic assessment of the spine include:
bitus or sitting position based on the anesthesiologist’s
preference. The lateral position may help to create a more • Spinous processes to ascertain midline and to assess for
optimal flexed position in an awake infant or in an older abnormal spine curvature: Due to delayed fusion in neo-
child who has received sedation. nates and infants, these may be palpable as two adjacent
• In the lateral position (Fig. 34.1), a trained assistant flexes bony landmarks.
the patient’s legs at the knees and hips while the neck and • Iliac crests: An imaginary line between the anterior iliac
shoulders are gently flexed forward with careful attention crests, commonly known as the intercristal (or Truffier’s)
to maintain a patent airway, especially in neonates and line, will cross the L5–S1 interspace in neonates and infants
infants. The flexed fetal position facilitates palpation of less than 1 year old and L4–L5 in older children (Fig. 34.2).
bony landmarks and increases the accessible area between • Shoulders: Ensure that the left shoulder is not rotated for-
spinous processes. ward and that both shoulders remain square to the bed.
• An alternative position for infants is to have an assistant This will help ensure effective upper trunk flexion and
hold the patient in a sitting position with the hips flexed alignment of the thoracic and lumbar spine, which may
and the head flexed forward. Cooperative adolescent help with eventual dural puncture success.
patients can assume this sitting position themselves with
a trained assistant facing them for support. The advantage Optimal positioning cannot be overemphasized and, once
of the sitting position is to increase the CSF pressure in established, the Tegaderm® dressing should be removed and
the lumbar region and improve CSF flow through the spi- the residual gel wiped off. Prior to the spinal attempt, a sono-
nal needle. graphic assessment of the lumbar spine should be completed.
Fig. 34.1 Lateral positioning of patient for spinal anesthesia Fig. 34.2 Surface anatomy for pediatric spinal anesthesia. White and
black lines indicate positions of iliac crests and intercristal line for neo-
nates and children over 1 year old, respectively
34.3.4 Sonographic Assessment which in neonates and infants can be narrow (6–8 mm)
[6]. If significant pressure is used with the probe dur-
• Sonographic assessment for spinal anesthesia is similar to ing the sonographic assessment, the estimated depth
that for lumbar epidural anesthesia (see Fig. 33.11). High- may be erroneous.
frequency (10–13 Hz) probes produce excellent resolu- • Recently, it was demonstrated that real-time color flow
tion in small children and infants; however, in adolescents, Doppler ultrasound can be used to distinguish epidural
the depth of neuraxial structures may necessitate a lower- injection from intrathecal injection (i.e., epidural injec-
frequency probe such as a curvilinear 2–6 MHz probe to tion produces a positive signal; intrathecal produces no
gain adequate signal penetration. signal) (see Fig. 33.22) [14].
• A wider footprint linear-array transducer (10–13 MHz)
allows for an excellent median or paramedian longi-
tudinal view. Occasionally, a paramedian longitudinal Clinical Pearls
view provides better detail, but this usually adds little to • Ultrasound may be useful for pre-scanning.
a median view in neonates and infants that are less than • Spinal anesthesia may be completed under real-
6 months of age. time ultrasound guidance, but the merit of this
• Expect the sonoanatomy to be excellent (>80 %) in chil- approach is uncertain and may increase the risk of
dren under 3 months of age, but it will gradually decline contamination due to the required extra equipment
in quality to approximately 30–40 % by 9 months of age. and personnel.
• There are significant benefits to completing a transverse
and median or paramedian view of the lumbar spine prior
to performing the spinal anesthetic. This allows one to:
– Identify the lumbar and sacral levels prior to dural 34.3.5 Nerve Stimulation Technique
puncture.
– Delineate the spinous processes and ideal needle The use of nerve stimulation to assist for spinal anesthesia in
trajectory. pediatric patients is not a common practice and therefore will
– Identify the conus medullaris to be confident that dural not be described. However, the electrical epidural stimula-
puncture is below the termination of the cord. tion test can assist in distinguishing the epidural space
– Estimate the depth to the subarachnoid space; the dis- (>1 mA) from the intrathecal space (<1 mA) when using an
tance between skin and the dura can be estimated, insulated needle (see Chap. 2) [15].
34.4 Equipment and Spinal Needle nal needle. The type of needle has not been shown to have
an effect on success or postspinal complications in the
• Similar to all regional anesthetic blocks, there should be pediatric population [16, 17]. However, a smaller needle
strict adherence to aseptic technique. size could reduce the risk of post-dural puncture headache
• An absorbent pad should be placed between the warming which is difficult to assess in this population.
blanket and the patient prior to the spinal anesthetic. • Various types of spinal needles are available in pediatric
Following the successful injection of the spinal anes- sizes. Our approach is to use a 2.5 cm, 25G pencil-point
thetic, the patient will occasionally have a bowel move- needle (Pencan® Paed, B.Braun, Melsungen, Germany) and,
ment; an absorbent pad may be used to soak up these if not successful, a 3.8 cm, 22G Quincke spinal needle. An
liquids that may otherwise inadvertently cool the patient introducer is not necessary in neonates and young infants.
over the course of the procedure. • In children, the ligamentum flavum is soft, and a distinc-
• Once in position for the spinal, the skin should be prepped tive “pop” may not be appreciated when the dura is
with a 2 % chlorhexidine gluconate and 70 % isopropyl punctured.
alcohol solution and allowed to dry. • It is important to remove the stylet intermittently and
• A sterile clear plastic drape should be used, and a spinal examine for CSF flow. Initial CSF may be slightly blood
needle and syringe containing the spinal anesthetic should tinged; ensure continued flow of clear fluid prior to injec-
be readily available. tion of the anesthetic.
• Ensure comfortable ergonomics for both the anesthesiol- • In neonates and young infants, use a 1 mL syringe (tuber-
ogist and the assistant holding the patient. We suggest that culin syringe with clear gradations) to inject the drug
the anesthesiologist sit for stability and improved dexter- slowly. A good rule of thumb is to inject over a 15–20 s
ity when attempting a spinal on an awake younger pediat- period while avoiding the barbotage method as it may
ric patient in lateral decubitus position. result in unacceptably high levels of motor blockade.
• If no topical gel or cream is used, infiltrate the skin with • Once the subarachnoid block is performed, avoid elevat-
lidocaine 1 % using a 27G–30G needle prior to using the ing the legs or lower trunk. This will help to prevent ceph-
spinal needle. alad spread of local anesthetic and is especially important
during the application of the return pad which is typically
fixed to the backs of neonates and young infants.
34.4.1 Needles
• The lumbar puncture is performed using a midline

approach, preferably with a short 25G–27G styletted spi-
34.5 Local Anesthetics 34.5.1 Adjuvants
• Many drugs have been used for pediatric spinal anesthesia • Clonidine (1 μg/kg) added to bupivacaine (1 mg/kg) has
in variable doses for various surgical procedures. These been used in spinal anesthesia in neonates and infants
drugs have been used as sole agents and also in combina- weighing 5 kg or less and provides almost twice the dura-
tion with sedation and general anesthesia. Intrathecal tion of spinal anesthesia when compared to local anes-
agents used in the pediatric population include bupiva- thetic alone [18]. Raising the intrathecal clonidine dose to
caine, tetracaine, lidocaine, ropivacaine, and levobupiva- 2 μg/kg provided no added benefit with propensity for
caine; adjuvants include morphine, fentanyl, clonidine, transient drops in blood pressures intraoperatively and
epinephrine, neostigmine, and dextrose. increased sedation in the postoperative period in this age
• The commonly used local anesthetics for pediatric spinal group.
anesthesia include bupivacaine and tetracaine. Generally, • The use of intravenous caffeine (5–10 mg/kg) has been
a dose of 0.4–1 mg/kg of tetracaine or bupivacaine for shown to prevent potential apnea in the postoperative
spinal anesthesia will offer favorable surgical anesthesia. period, especially if clonidine is used in the spinal anes-
Higher doses per kg are preferred in the pediatric popula- thetic solution [18, 19].
tion, but the risk of a total spinal is rare as long as the • An epinephrine washout of a tuberculin syringe may be
procedure is carried out diligently. At our institution, the preferred to a standard dose of intrathecal epinephrine
drug of choice is preservative-free plain bupivacaine (e.g., 0.01 mL/kg of 1:100,000 diluted epinephrine) for
0.5 %. In neonates and infants weighing 5 kg or less, extending spinal block duration.
preservative-free plain bupivacaine 0.5 %, 1 mg/kg • When compared to a eubaric solution, hyperbaric solution
(0.2 mL/kg) is an effective dose that will provide 60 min with dextrose does not seem to alter the duration of the
of surgical anesthesia for inguinal hernia repair. spinal block in children.
Unfortunately, data for children outside the neonatal and
infant stages are limited. As a general guide, the follow- See Table 34.1 for a summary of suggested local anesthet-
ing suggested doses may be used: ics and adjuvants.
– 0.3–0.5 mg/kg bupivacaine 0.5 % for children 2 months
to 12 years of age Table 34.1 Dosages of local anesthetics and additives for spinal
– 0.3–0.4 mg/kg hyperbaric tetracaine in children aged anesthesia
12 weeks to 2 years Local anesthetic solution
– 0.2–0.3 mg/kg hyperbaric tetracaine in older children Bupivacaine 0.3–1 mg/kg
of >2 years Tetracaine 0.4–1 mg/kg
Additives
Epinephrine washout
Clonidine 1 μg/kg
Morphine 5 μg/kg for postoperative analgesia in
general pediatric procedures (e.g.,
scoliosis repair)
10 μg/kg for cardiac surgical patients
who will be ventilated postoperatively
34.6 Assessment of the Block Level 34.7 Complications
• Assessment of the sensory and motor block can be chal- • The most common complications include multiple
lenging, especially in neonates, small children, and attempts, sensory and motor block failure requiring sup-
sedated patients. plemental anesthetic, and surgical procedure outlasting
• In infants, response to cold stimuli (e.g., ice wrapped in a the block.
glove or an alcohol swab) can be used. • Other less common complications include bleeding and
• A Bromage score (see Table 34.2) [20], which is the gold hematoma, infection, allergic reaction, local anesthetic
standard, can usually be obtained for children greater than toxicity, cardiovascular complications, and nerve injury.
2 years of age. The risk of methemoglobinemia is present with the use of
• If a rapidly rising level of blockade is noted, the patient tetracaine.
may be placed in reverse Trendelenburg position to pre- • Although possible complications include post-dural
vent further cephalad spread of local anesthetic. puncture headache and transient radicular symptoms,
these are less commonly reported in children.
Table 34.2 Bromage scale for spinal block assessment

Grade Criteria Degree of block
I Free movement of legs and feet Nil 0 %
II Just able to flex knees with free movement of feet Partial 33 %
III Unable to flex knees but with free movement of feet Almost complete 66 %
IV Unable to move legs or feet Complete 100 %
34.8 Current Literature in Ultrasound- value in identifying neuraxial structures and verifying the
Guided Approaches presence of anatomic abnormalities if they are present. Koo
et al. [21] demonstrated that ultrasound could be used on
There is limited literature regarding the use of ultrasound for children with urogenital abnormalities to identify occult spi-
spinal anesthesia in the pediatric population, as the landmark nal dysraphism. Further discussion of the use of pre-
technique has traditionally been used with success in chil- procedural ultrasound scanning for neuraxial blocks is found
dren. However, as discussed above, ultrasound has potential in a review by Chin and Perlas [22].
34.9 Case Study
Case Study: Spinal Anesthetic (Contributed by A. Spencer)

solution was found, 0.2 mL/kg (for a total volume of
A 56-day-old baby presented for repair of bilateral 0.5 mL) of preservative-free bupivacaine 0.5 % was
inguinal hernias. This triplet was born at 30 weeks ges- slowly injected over 20 s. Block duration was 70 min;
tational age and, at time of surgery, weighed 2.48 kg. duration of surgery was 50 min.
After birth, the patient remained in the neonatal inten- Acetaminophen 15 mg/kg p.o. liquid was given preop-
sive care unit for 5 weeks due to apneic episodes associ- eratively and q6h postoperatively for 48 h. The patient was
ated with bradycardia and due to dietary issues and was comfortable 30 min post-op. The patient spent the next
ultimately discharged home at 36 weeks corrected age. 24 h under observation in the pediatric intensive care unit
She had no known drug allergies and was on no regular due to her age and prematurity and history of apneas and
medications except for daily iron and multivitamins. bradycardia. This observation period was uneventful, and
Thirty minutes prior to the spinal anesthetic, Ametop the patient was discharged home the next day.
gel (tetracaine 4 %) was applied to the L3–L5 lumbar
spinal level and covered with a Tegaderm® dressing.
After induction with sevoflurane (up to 4 %), the patient
was placed in left lateral decubitus position and held in
fetal position by an operative nurse. The dressing was
removed and the residual gel wiped off, and the skin
was prepped with a 2 % chlorhexidine gluconate and
70 % isopropyl alcohol swab. A linear-array transducer
(10–13 MHz) was used to image the patient’s spine in a
paramedian longitudinal view (Fig. 34.3). An assess-
ment of the spinous processes, identification of lumbar
levels, and assessment of the depth to the posterior dura
and spinal cord and tip of the conus medullaris were
completed. The sonogram of the lumbosacral region
was then used to mark an entry level that would be
below the conus. A 2.5 cm, 25G styletted spinal needle
was used for dural puncture. Once cerebrospinal Fig. 34.3 Paramedian longitudinal ultrasound scan of neuraxial
structures in an infant (see “Case Study” for details)
References 17. Kokki H, Salonvaara M, Herrgard E, Onen P. Postdural puncture

headache is not an age-related symptom in children: a prospective,
open-randomized, parallel group study comparing a 22-gauge
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18. Rochette A, Raux O, Troncin R, Dadure C, Verdier R, Capdevilla
children using spinal analgesia. Arch Pediatr. 1901;18:570–4.
X. Clonidine prolongs spinal anesthesia in newborns: a prospective
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Lancet. 1909;2:913–7.
19. Henderson-Smart DJ, Steer PA. Prophylactic caffeine to prevent
4. Abajian JC, Mellish RW, Browne AF, Perkins FM, Lambert DH,
postoperative apnoea following general anaesthesia in preterm
Mazuzan Jr JE. Spinal anesthesia for surgery in the high-risk infant.
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20. Bromage PR. A comparison of the hydrochloride and carbon diox-
5. Kesler H, Dias M, Kalapos P. Termination of the normal conus
ide salts of lidocaine and prilocaine in epidural analgesia. Acta
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1995;82:809–22. Ganesh A, Kim A, Casale P, Cucchiaro G. Low-dose intrathecal
11. Tobias JD. Spinal anaesthesia in infants and children. Pediatr morphine for postoperative analgesia in children. Anesth Analg.
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14. Tsui B, Leipoldt C, Desai S. Color flow Doppler ultrasonography atric patients: a single centre experience with 1132 cases. Pediatr
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15. Tsui BC, Wagner AM, Cunningham K, Perry S, Desai S, Seal Anaesthesia. 1998;53:980–1001.
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Index
A landmarks and surface anatomy, 426

Abajian, J.C., 528 local anesthetic application, 433
Abdomen, 197, 199, 200 nerve stimulation technique, 427
Absorption ultrasound-guided technique
administration routes, 102 needle insertion technique, 431–432
from epidural space, 102 scanning technique, 428–429
local anesthetic, 102, 458, 460 sonographic appearance, 430, 431
sound wave properties in tissue, 30 studies, 433
systemic, 242, 460 Anode, 13
Abu-Saad, H., 93 Antecubital fossa, 322, 323
Accessory obturator nerve, 173 Anterior cutaneous nerve entrapment syndrome (ANCES), 474
Accidental intravascular injection, 105 Anterior interosseous nerve, 158, 214
Achilles tendon, 221, 426, 427, 433 Anterior sciatic nerve block approach
Acoustic enhancement, 33 local anesthetic application, 409
Acoustic impedances, 30 nerve stimulation technique, 403–405
Acoustic shadowing, 33 modifications to inappropriate responses, 404
Adductor magnus muscle, 173, 377, 403, 408 motor responses and needle adjustments, 404, 405
Adjuvant, spinal anesthesia, 533 needle insertion site, 403
Adolescents, 136, 137, 233, 234, 249, 344, 346 procedure, 403
pain assessment surface anatomy, 401
CHEOPS, 83 surface landmarks, 401, 402
faces pain scale-revised, 82 ultrasound-guided technique
numeric rating scales, 82, 83 anatomical structures, 406, 407
Oucher, 82 flowchart, 406
pieces of hurt/poker chip scale, 82 needle insertion technique, 409
psychological and social impact, 90 scanning technique, 408
visual analogue scale, 82, 83 sonographic appearance, 407, 408
sacrum development, 193 Anterior superior iliac spine (ASIS), 169, 170, 356, 365, 370, 401,
Adult spinal cord, 202 478, 481
Advanced Life Support Guidelines (ACLS), 107 Anterior tibial artery, 183, 221, 426, 428
Age factors, pain assessment, 90 Antiseptic solution, 275, 288, 301, 306, 315, 342, 359, 366, 389,
Ahuja, S., 239 397, 406, 415, 438, 479
Alternate scanning technique, 450 Anxiety, 91, 92
Ambuel, B., 88 Aponeurosis, 146, 169, 182, 466, 468, 478
American Society of Regional Anesthesia, 126 Arachnoid mater, 201
Anechoic structures, 37, 509–510 Aradine, C., 89
Anesthesia Arm, medial cutaneous nerve, 157
epidural (see Epidural anesthesia) Arnold nerve blocks
lumbar epidural, 106, 531 block technique
regional, 4, 102 landmarks and surface anatomy, 262
thoracic epidural, 498 local anesthetic application, 263
ultrasound-assisted regional, 46 needle insertion technique, 263
ultrasound-guided regional, 108 patient positioning, 262
Anisotropy, 33 case study, 264
Ankle indications, 262
innervation of, 221 studies in ultrasound-guided approaches, 263
joints, 178, 183, 428 Arrow® StimuCath, 60, 61
medial, 215 Arthrogryposis multiplex congenital, 364
Ankle blocks Articular processes, 448
case study, 433 Auricular branch of vagus nerve block. See Arnold nerve blocks
indications, 426 Auroy, Y., 119

DOI 10.1007/978-0-387-79964-3
540 Index
Axillary artery, 69, 154, 306, 307, 312, 317, 326, 330 cords, 150, 153, 154
Axillary block roots (ventral rami), 150, 153
case study, 320 supraclavicular, 153
indications, 312 terminal nerves, 150, 152, 154–162
local anesthetic application, 319 trunks, 153–154
nerve stimulation technique components, 150
modifications to inappropriate responses, 314 innervation, 150
needle insertion site, 312, 313 interscalene and periclavicular block approaches, 150
procedure, 312, 313 schematic diagram, 150, 152
responses and needle adjustments, 312, 314 terminal nerves
patient positioning/surface anatomy, 312 axillary nerve, 154–156
ultrasound-guided technique lateral cutaneous nerve, forearm, 157
anatomical structure, 315, 316 medial cutaneous nerve, arm, 157
flowchart, 315 medial cutaneous nerve, forearm, 157
literature, 319 median nerve, 158–159
needle insertion technique, 318 musculocutaneous nerve, 157
preparing needle insertion site, 315 radial nerve, 162
scanning technique, 317 ulnar nerve, 160–161
sonographic appearance, 317 Breau, L.M., 86, 88
Axillary nerve, 154–156 Broadband transducers, 28
Axillary vein, 69, 150, 157, 306, 312 Bromage scale, spinal block assessment, 534
Brownlow, R.C., 252
Buck’s fascia, 486
B Bupivacaine, 98, 99, 102–107, 279, 308, 319, 351, 363, 368,
Bacterial infection, 126 373, 378, 391, 433, 458, 460
Baker, C., 89 Bupivacaine-induced cardiac toxicity, 107
Baloukov, A., 75–93 Byrne, K.P.A., 11–23
Berniere, J., 417
Beyer, J., 89
Biceps brachii muscle, 317, 326 C
Bicipital aponeurosis, 158, 322 Calcaneal (Achilles) tendon, 221, 426, 427, 433
Bigeleisen, P.E., 14 Calcaneal tuberosity, 182
Bilateral axillary brachial plexus block, 319 Capacitive Micromachined Ultrasound Transducers (CMUT), 39
Bilateral paravertebral catheter, 452 Cardiovascular toxicity, 105, 106, 117–118
Bildner, J., 77 Catheter-over-needle assembly, 63–64, 67–68
Blind technique, 368, 370, 410, 421, 468, 479 Catheters
Block techniques, 226–238 advancement, 63
arnold nerve blocks case study, 523
landmarks and surface anatomy, 262 catheter insertion and local anesthetic application, 522
local anesthetic application, 263 epidural stimulation guidance technique, 520–521
needle insertion technique, 263 local anesthetic application, 521
patient positioning, 262 non-stimulating, 60
occipital nerve blocks perineural, 12, 39, 60, 293
greater occipital nerve location, 256, 257 scanning technique, 521
landmarks and surface anatomy, 258 securing, 68
local anesthetic application, 259 sonographic appearance, 522
needle insertion technique, 258 stimulating, 60–62
patient positioning, 256 ultrasound-guided technique, 521
paravertebral blocks Cathode, 13
landmark-based technique, 438–441 Caudal anesthesia
nerve stimulation technique, 441 case study, 519
ultrasound-guided technique, 442–451 nerve stimulation technique, 515
trigeminal nerve blocks patient positioning, 515
intraoral approach, 233–238 surface anatomy, 515
superficial transcutaneous approach, 226–233 ultrasound-guided block
Blunt needle, 6 caudal vs. intrathecal injection, 518
Bone, 37 needle insertion and local anesthetic application, 519
Boretsky, K.R., 337–352, 437–452 needle insertion site, 515
Boschin, M., 319 scanning technique, 516–517
Brachial artery, 157, 158, 160, 162, 317, 322–324, 330 sonographic appearance, 518
Brachialis muscle, 214, 322 Caudal epidural space, 193, 194, 515, 516, 519, 522
Brachial plexus Caudal needle placement, 514, 521
anatomy of, 151 Caudal vs. intrathecal injection, 518
branches Central nervous system toxicity, 105, 106
Index 541
Cephaloposterior, 284 Deep brachial artery, 326, 327

Cerebrospinal fluid (CSF), 18, 126, 201, 202, 528 Deep cervical plexus block
Cervical plexus block anatomy, 242
deep cervical plexus block, 242–246 indications, 242
great auricular nerve blocks, 252–254 landmarks and surface anatomy, 243
indications, 242 local anesthetic application, 244
superficial cervical plexus block, 247–252 needle insertion technique, 243
Chayen, D., 338, 339 nerve localization, 244
Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), 83 patient positioning, 243
Chin, K.J., 535 risks, 242
Chronaxie, 13 studies, 246
Circumflex humeral nerve, 154 ultrasound image, 244–245
Clinical anatomy VHVS and MRI images, 244
brachial plexus, 149–162 Deep peroneal (fibular) nerve, 183, 221, 426–428, 431, 432
central neuraxis, 188–204 Deep peroneal nerve block
dematomes, 205–221 needling insertion technique, 431, 432
head and neck nerve stimulation technique, 427
cervical plexus, 142–144 scanning technique, 428–430
nerve of arnold, 146 sonographic appearance, 430, 431
occipital nerves, 145–146 surface anatomy and landmarks, 426
trigeminal nerve, 136–142 Deep trigeminal nerve blocks, 237–238
ilioinguinal and iliohypogastric nerve blocks, 478 Denys-Drash syndrome, 452
intercostal nerve blocks, 456 Dermatomes
joints innervation, 205–221 clinical anatomy, 206
lumbar plexus, 165–174 definition, 206
myotomes, 206 upper extremity (see Upper extremity)
osteotomes, 207 DeVera, H.V., 279
paravertebral blocks, 438 Dextrose 5 % in water (D5W), 12, 15, 17, 279, 308, 319, 324, 334,
penile block, 486 368, 373, 378, 391, 399, 409, 440
rectus sheath block, 464 Dick, B.D., 75–93
transversus abdominis plane block, 470 Dicken, B.J., 463–475
trunk, 187–204 Dillane, D., 97–108
Clonidine, 391, 533 Dilley, A.V., 491
Color Doppler, 44, 227, 239, 275, 306, 317, 323, 327, 361, 378, 399, Dillow, J.M., 421
408, 428, 459, 460, 518 Dingeman, R.S., 468
Color flow Doppler, 480 Direct lumbar approach, 497, 498
COMFORT scale, 84–85 Direct thoracic approach, 498
Compartment syndrome, 125 Distance-current curve, 14
Complex manual camera, 38 Distance-current relationship, 14–15
Compound imaging, 39 Doppler effect, 42, 43
Compressed air injection technique (CAIT), 9–10, 120 Doppler ultrasound, 31
Constant current output, 21 Dorsal penile block, 488, 490. See also Penile block
ContiStim® Catheters, 62 Dorsal scapular nerve, 153
Conus medullaris, 528 Dorsiflexion, 70, 216
Convex (or curved) arrays, 28 Dryden, A.M., 111–128
Coracobrachialis muscles, 157, 158, 209, 312, 317, 318, 322 Dural sac, 203, 528
Coracoid process, 69, 212, 300, 301, 306, 308 Dura mater, 201, 202, 509
Corning, J.L., 528 D5W. See Dextrose 5 % in water (D5W)
Costotransverse joint, 194–195
Costovertebral articulations, 456
Costovertebral joint, 194–195 E
Coulomb’s law, 14 Echogenic appearance, tissue, 35
Cricoid cartilage approach, 275 Echogenic needles, 8, 49
CRIES neonatal pain assessment tool, 80 Eipe, N., 227
CSF. See Cerebrospinal fluid (CSF) Ekenstam, B.E.B., 98
Current duration, 13 Elbow, 213, 214
Current intensity, 13 Electrical impedance, 16
Cyanoacrylate glue, 68 Electrical impulses, 12
Cystic fibrosis, 475 Electrical nerve stimulation
blocks vs. ultrasound-guided blocks, 23
electrophysiology
D current intensity and duration, 13
Dalens, B., 391 distance-current relationship, 14–15
De Jose, M.B., 293, 308, 468 electrical impedance, 16
542 Index
Electrical nerve stimulation (cont.) Epigastric hernia, 469

electrical impulses, 12 Epinephrine, 107, 108, 279, 391, 433, 458
electrodes (see Electrodes) Epineurium, 36, 202, 287, 400
injectates, 15–16 Equipment (nerve stimulator) variables, 21–22
rate of current change, 13 Extensor digitorum longus muscle, 221
equipment features Extensor digitorum longus tendon, 426
constant current output and display, 21 External oblique muscle, 470, 471, 478, 480
foot pedal/handheld remote control, 22
frequency of stimulation, 22
probes, 22 F
variable pulse width, 22 Faces Pain Scale-Revised, 82
general procedure, 12 Facet tip needle, 6, 7
practical consideration Far field, 31
documentation, 23 Farid, I.S., 363
population consideration, 23 Fascia iliaca, 69, 172, 363, 365, 367, 368
Electrocardiograph (ECG) monitoring technique, Fascia lata, 170, 172, 362, 363, 365, 367, 368
20, 502–503 Fascial tissue, 37
Electrodes Fat, 37
conductive properties, 15, 16 Femoral arterial puncture, 357
current density, 15 Femoral nerve, 171, 172, 220
stimulating and returning, 13 Femoral nerve block
surface, 14, 15 case study, 364
types of, 15 indications, 356
Electrodiagnostic techniques, 120 landmarks and surface anatomy, 356
Elnour, H.A., 319 local anesthetic application, 363
Elshaikh, S.M., 474 nerve stimulation technique
Englbrecht, J.S., 319 modifications to inappropriate responses,
Epidural anesthesia 358–359
case study, 513 needle insertion site, 357
catheter insertion and confirmation, 512 procedure, 358
direct lumbar approach, 497, 498 ultrasound-guided technique
direct thoracic approach, 498 anatomical structures, 359, 360
electrocardiograph monitoring technique, 502–503 flowchart, 359
indications, 496 literature, 363–364
median approach, 498 needle insertion site, 359
needle insertion technique, 511–512 needle insertion technique, 362
nerve stimulation technique scanning technique, 361
catheter confirmation, 500 sonographic appearance, 361, 362
intrathecal and intravascular catheter and needle vs. sciatic nerve block, 363–364
placement, 501 Femur-fibula-ulna (FFU) syndrome, 279
needle confirmation, 500 Fentanyl, 5
test mechanism, 500–501 Filum terminale externum, 203
test performance and interpretation, 501 Filum terminale internum, 203
paramedian approach, 499 FLACC (Faces, Limb, Activity, Cry, and Consolability), 81
patient positioning, 496 Flexor digitorum superficialis (FDS) muscle, 158, 160, 209,
surface anatomy, 497 330, 333
ultrasound-guided technique Flexor hallucis longus muscle, 221
needle insertion site, 505 Focal zone, 31
scanning technique, 505–508 Forearm
sonographic appearance, 509–510 cross section of distal, 158, 159
Epidurals lateral cutaneous nerve, 157
catheters, 9, 12, 17–21, 116, 520, 521 medial cutaneous nerve, 157
electrical epidural stimulation, 17 median ulnar nerve, 160, 161
placement, 17, 20, 496, 501, 512 Fossa
space, 102 antecubital, 322, 323
Epidural stimulation guidance technique, 520–521 infraclavicular, 308
Epidural stimulation test (Tsui test), 17 supraclavicular, 52, 150
catheter Fredrickson, M.J., 279, 474, 482
advancement, 20 Frequency-dependent blockade, 100
electrical current, effective conduction of, 19 Frontal nerve, 138
placement, 18
requirement, 19
consideration for, 20 G
equipment/procedure, 17 Gain functions, 31, 32
interpretation, 20 Gastrocnemius muscle, 182
limitation, 20 Genitofemoral nerve, 170
Index 543
Gharaibeh, M., 93 local anesthetic application, 481

Giaufre, E., 117 needle insertion, 480
Gluteus maximus muscle, 391 scanning technique, 480
Gray, A.T., 421 ultrasonographic appearance, 480
Great auricular nerve blocks Ilioinguinal nerve, 170
indications, 252 Image acquisition
landmarks and surface anatomy, 253 basic concepts, 42
local anesthetic application, 254 image optimization, 44–48
needle insertion technique, 254 probe alignment, 44
nerve localization, 254 probe preparation, 42–43
patient positioning, 252 Infants
risks, 252 CSF volume, 204
studies, 254 dural sac in, 203
Greater occipital nerve, 146 pain assessment
Greater palatine nerve, 235–236 biological factors, 90
Gurnaney, H.G., 363, 468 postoperative pain, 78, 81
Guyon’s canal, 160 sacrum development, 193
vertebral canal, 191
Inferior gluteal nerve, 179
H Inferior gluteal vessels, 178
Hand, 213–215 Inferior rectal nerve, 184
Hand-eye coordination, 51 Infraclavicular brachial plexus block
Head and neck case study, 309
cervical plexus indications, 300
cutaneous innervation, 143, 144 local anesthetic application, 308
nerve roots, 143, 144 nerve stimulation technique
schematic diagram of, 142, 143 modifications to inappropriate responses, 303
nerve of arnold, 146 needle insertion, 301
occipital nerves procedure, 301
greater occipital nerve, 146 responses and needle adjustment, 301, 302
lesser occipital nerve, 145 patient positioning/surface anatomy, 300
trigeminal nerve ultrasound-guided technique, 304–307
branches, 136 anatomical structures, 305
mandibular nerve, 142 needle insertion technique, 307
maxillary nerve, 140–141 patient positioning, 308
ophthalmic nerve, 138–139 preparing needle insertion site, 306
Hematoma, 125 scanning technique, 304, 306
Hester, N., 89 sonographic appearance, 306
Hicks, C.I., 89 studies, 308
Hilton’s law, 211 Infragluteal/subgluteal sciatic nerve blocks
Hip, innervation, 220 anatomical landmarks, 393
Hip joint capsule, 180 case study, 400
Hong, J.Y., 481 local anesthetic application, 399
Hummel, P., 77 nerve stimulation technique
Huskisson, E.C., 89 modifications to inappropriate responses, 396
Hyperechogenic tissues, 509 motor responses and needle adjustments, 396
Hyperechoic nerve, 329, 366, 399, 481 needle insertion site, 394
Hypnotics, 5 procedure, 395
Hypoechoic appearance, 472 surface anatomy, 393
Hypoechoic local anesthetic fluid, 318, 399, 481, 522 ultrasound-guided technique
Hypoechoic structures, 509 anatomical structures, 397, 398
Hypotension, 127 flowchart, 397
needle insertion technique, 399
scanning technique, 397
I sonographic appearance, 399
Iliohypogastric nerve, 169, 170 Infraorbital nerve, 140, 141
Ilioinguinal and iliohypogastric nerve blocks, 102 Injectates, 15–16
case study, 482 conductive properties, 15, 16
clinical anatomy, 478 current density of, 15
fascial click method Injection pressure monitoring, 9
landmarks and surface anatomy, 478 In-line pressure monitors, 9
local anesthetic application, 479 In-plane (IP) needling technique, 52–53, 278, 292, 307, 318, 324, 329, 333,
needle insertion, 479 351, 362, 367, 372, 377, 391, 392, 399, 409, 432, 449, 460
patient positioning, 478 ilioinguinal/iliohypogastric nerve block, 480
step-up-step-down approach, 481 rectus sheath block, 467
ultrasound-guided technique transversus abdominis plane block, 472
544 Index
Intercostal nerve blocks Laminae, 191–193, 444, 448

case study, 461 Landmark-based technique
clinical anatomy, 456 intercostal nerve blocks
landmark-based technique, 456–458 landmarks and surface anatomy, 457
nerve stimulation technique, 458 local anesthetic application, 458
ultrasound-guided technique needle insertion technique, 457
local anesthetic application, 460 patient positioning, 456
needle insertion technique, 460 paravertebral blocks
scanning technique, 459 landmarks and surface anatomy, 439
sonographic appearance, 458, 459 local anesthetic application, 441
studies in, 460 needle insertion technique, 440
Intercostal nerves, 188, 196–200 patient positioning, 438
Interscalene brachial plexus block Lateral cord, 69, 153, 154, 156, 157, 307, 312
case study, 280 Lateral epicondyle, 37, 162, 322, 326
indications, 268 Lateral femoral cutaneous nerve block
local anesthetic application, 279 case study, 369
nerve stimulation technique indications, 365
modifications to inappropriate responses, 272 local anesthetic application, 368
needle insertion site and procedure, 270 nerve stimulation technique, 365
procedure, 271 patient positioning, 365
responses and needle adjustment, 269 surface anatomy, 365
patient positioning, 268 ultrasound-guided technique
surface anatomy, 268 anatomical structures, 366
ultrasound-guided technique literature in, 368
anatomical landmarks, 273, 274 needle insertion technique, 367
flowchart, 273 scanning technique, 366
literature, 279 sonographic appearance, 366
needle insertion technique, 278 Lateral pectoral nerve, 154
needle site preparation, 275 Lateral-to-medial approach, 450, 472
patient positioning, 273, 274 Lateral-to-medial direction, 231, 292, 362, 363, 367, 391, 408
scanning technique, 275–276 Lesser occipital nerve, 143, 145, 247, 252, 258, 259
sonographic appearance, 277 Levobupivacaine, 98, 103, 106, 107, 334, 363, 391
Intralipid, 6, 66, 107, 117, 118 Lidocaine, 98, 99, 102–104, 106, 259, 368, 391, 458
Intraoral approach Linear array, 28
landmarks and surface anatomy, 234 Lipid emulsion, 107
local anesthetic application, 236 Local anesthetic application
needle insertion technique, 235–236 ankle blocks, 433
patient positioning, 233 anterior sciatic nerve block approach, 409
Intraoral infraorbital nerve, 235 arnold nerve blocks, 263
Intrathecal and intravascular catheter and needle placement, 501 axillary block, 319
Ip, V.H.Y., 3–10, 25–39, 41–56, 59–71 deep cervical plexus block, 244
Ischial tuberosity, 70, 179, 180, 389, 393, 397 femoral nerve block, 363
Ivani, G., 391, 419 great auricular nerve blocks, 254
infraclavicular brachial plexus block, 308
infragluteal/subgluteal approach, 399
J intercostal nerve blocks, 458, 460
Joint interscalene brachial plexus block, 279
costotransverse, 194 lateral femoral cutaneous nerve block, 368
costovertebral, 194 median nerve block, 324
upper extremity, innervation of obturator nerve block, 373
elbow, 213, 214 occipital nerve blocks, 259
shoulder, 212, 213 penile block, 490
wrist and hand, 213–215 popliteal/mid-thigh sciatic nerve block, 419
Joint capsule ankle, 183 posterior gluteal (labat) sciatic nerve block, 391
posterior lumbar plexus block, 351
radial nerve block, 330
K rectus sheath block, 467
Kim, M.S., 524 saphenous nerve block, 378
Kirchmair, L., 351, 352 superficial cervical plexus block, 252
Knee, 220–221 supraclavicular brachial plexus block, 292
Koo, B.N., 524, 535 trigeminal nerve blocks, 233, 236
Krechel, S.W., 77 ulnar nerve block, 334
Local anesthetics
absorption, 102, 458, 460
L adverse events
Labat nerve block approach, 384–392 allergic reactions, 115
Lacrimal nerve, 138 systemic toxic reactions, 115–119
Index 545
amino-amide, 98 Lumbosacral trunk, 178, 180

blockade, 150 Lundblad, M., 524
bupivacaine, 98, 99, 102–107, 279, 308, 319, 351, 363,
368, 373, 378, 391, 433, 458, 460
distribution, 103 M
dosing, 108 Maccani, R.M., 368
hepatic metabolism, 104 Magnetic resonance imaging (MRI)
history, 98 auricular branch of vagus nerve, 262
levobupivacaine, 98, 103, 106, 107, 334, 363, 391 brachial plexus anatomy, 274, 289
lidocaine, 98, 99, 102–104, 106, 259, 368, 391, 458 brachial plexus at axilla, 316
in pediatric patient, 65 deep cervical plexus block, 244
physiochemical properties femoral nerve block, 359, 360
amino-amide, 98 femoris artery, 361
duration of action, 99 greater occipital nerve, 257
onset of action, 99 infraclavicular brachial plexus block, 304, 305
potency, 99 intercostal nerve blocks, 458–459
sodium channel, 10 lateral femoral cutaneous nerve block, 366
physiological considerations, 101 mandibular nerve, 238
plasma protein binding, 103 obturator nerve block, 371
ropivacaine, 98, 99, 102–104, 106, 107, 279, 319, 351, 363, paravertebral block, 442–447
373, 378, 391, 433 radial nerve within arm, 328
routes of administration, 102 saphenous nerve block, 375, 376
toxicity superficial cervical plexus block, 249, 250
cardiovascular toxicity, 105, 106 trigeminal nerve blocks, 227, 228
central nervous system toxicity, 105, 106 ulnar nerve in forearm, 332
prevention, 108 Mai, C.I., 474
treatment, 107 Malviya, S., 86
Loland, V.J., 308 Mandibular nerve, 142
Long-beveled needles, 6 Marhofer, P., 308, 309
Long thoracic nerve, 153–154 Mastisol, 68
Lonnqvist, P.A., 440 Maxillary nerve, 140–141
Loss-of-resistance (LOR) technique, 17, 357, 440, 496–498, Maxillary nerve block, 237
511, 512 McNair, C., 77
Lower extremity Medial ankle, 215
innervation Medial cord, 153, 154, 156–158, 160, 306, 330
cutaneous distribution of peripheral nerves, 215–216 Medial epicondyle, 37, 157, 160, 214, 220, 317, 330–332
dermatomes, 215–216 Medial pectoral nerve, 154
joints, 219–221 Median nerve, 158–159, 214
motor responses with nerve stimulation, 216, 217 Median nerve block, 322
myotomes, 216–217 case study, 325
osteotomes, 218 local anesthetic application, 324
nerves, 166, 184 nerve stimulation technique, 323
terminal nerve blocks surface anatomy and landmarks, 322
femoral nerve block, 356–364 ultrasound-guided technique, 323–324
lateral femoral cutaneous nerve block, 365–369 Mental nerve, 235
obturator nerve block, 369–373 Mepivacaine, 319
saphenous nerve block, 374–378 Merkel, S., 88
Lower subscapular nerves, 154 Merritt, G., 135–146, 225–239
Ludot, H., 118 Mesnil, M., 239
Lumbar approach, 497, 498 Metcalfe, P.D., 485–491
Lumbar epidural anesthesia, 106, 531 Midazolam, 5
Lumbar paravertebral block Miller, B.R., 363, 368, 421
needle insertion technique, 439 Monitoring, 3–10
surface anatomy, 439 MRI. See Magnetic resonance imaging
Lumbar plexus Muscles
branches of, 168 adductor magnus, 173, 377, 403, 408
femoral nerve, 171, 172 biceps brachii, 317, 326
genitofemoral nerve, 170 brachialis, 214, 322
iliohypogastric nerve, 169 coracobrachialis, 312, 317, 322
ilioinguinal nerve, 170 external oblique, 470, 471, 478, 480
lateral femoral cutaneous nerve, 170 flexor digitorum superficialis, 158, 160, 209,
lower extremity nerves, 166 330, 333
major branches, 166 flexor hallucis longus, 221
obturator nerve, 173–174 gastrocnemius, 182
schematic diagram of, 166 pectoralis major, 69, 154, 306, 312
Lumbar spine, 191, 192 pectoralis minor, 69, 154, 306
Lumbar vertebrae, 166, 190, 192, 202 ultrasonographic characteristics, 37
546 Index
Musculocutaneous nerve, 153, 157, 183, 214, 268, 312, 317, 319 Needling technique, 52–56
Musculocutaneous nerve blocks, 318 Negative electrode, 13, 14
Myelination, 101, 117 Neonatal Facial Coding System (NFCS), 77
Myotomes Neonatal Infant Pain Scale (NIPS), 77
clinical anatomy, 206 Neonatal pain agitation and sedation scale
lower extremity, 216–217 (N-PASS), 79
upper extremity, 209 Neonatal spinal cord, 202
Neonats, pain assessment
biological factors, 90
N multidimensional measures requirement, 77
Nasociliary nerve, 138 NFCS and NIPS tool, 77
Near field, 31 postoperative pain, 79, 80
Needle Nerve(s)
adjustments, 269, 285, 302, 340, 387, 396, 404, 405 femoral, 171, 172, 220
alignment, 308 gemellus inferior, 179
echogenic, 8 gemellus superior, 179
gauges, 7 obturator, 173–174, 220, 221
length, 7 to obturator internus, 179
placement perineal, 184–185
caudal, 514, 521 piriformis, 179
confirm, 17, 516 quadratus femoris, 179
intraneural, 14, 16 radial, 162, 214–215
selection for block location, 38 saphenous, 221
tip design, 6–7 sciatic, 180–181
trajectory, 237 spinal, 118, 201–202
hand-eye coordination, 51 and tendons, ultrasonographic appearance of, 36
visibility of needles, 49–50 terminal (see Terminal nerves)
trauma tibial nerve, 182–183, 220, 221
peripheral nerve, 119–120 ulnar, 160–161, 214, 317, 330
pleura, 123 Nerve of Arnold. See Arnold nerve blocks
spinal cord, 121–122 Nerve stimulation technique
Needle insertion technique anterior sciatic nerve block approach, 403–405
anterior sciatic nerve block approach, 409 axillary block, 312–314
arnold nerve blocks, 263 deep peroneal nerve block, 427
axillary block, 318 epidural anesthesia
deep cervical plexus block, 243 catheter confirmation, 500
deep peroneal nerve block, 431, 432 intrathecal and intravascular catheter and needle
epidural anesthesia, 511–512 placement, 501
femoral nerve block, 362 needle confirmation, 500
great auricular nerve blocks, 254 test mechanism, 500–501
greater occipital nerve block, 258 test performance and interpretation, 501
greater palatine nerve, 234–236 femoral nerve block, 357–359
infraclavicular brachial plexus block, 307 infraclavicular brachial plexus block, 301–303
infragluteal/subgluteal sciatic nerve blocks, 399 infragluteal/subgluteal sciatic blocks, 394–396
infraorbital nerve block, 230–231 intercostal nerve blocks, 458
interscalene brachial plexus block, 270, 278 interscalene brachial plexus block, 269–272
intraoral infraorbital nerve, 234, 235 lateral femoral cutaneous nerve block, 365
lateral femoral cutaneous nerve block, 367 median nerve block, 323
lesser occipital nerve block, 258 obturator nerve block, 370–371
lumbar paravertebral block, 440 paravertebral blocks, 441
median nerve block, 324 popliteal/mid-thigh sciatic nerve block, 411–414
mental nerve, 232, 234, 235 posterior gluteal (labat) sciatic nerve block,
obturator nerve block, 372 385–388
paravertebral block, 449 posterior lumbar plexus block, 339–341
penile block, 490 posterior tibial nerve block, 427
popliteal/mid-thigh sciatic nerve block, 419 radial nerve block, 327
posterior gluteal sciatic nerve blocks, 391, 392 saphenous nerve block, 375
posterior lumbar plexus block, 350–351 supraclavicular brachial plexus block, 285–288
posterior tibial nerve block, 431, 432 ulnar nerve block, 332
radial nerve block, 329 Nerve stimulators, 9, 21–22
rectus sheath block, 467 Nervi erigentes, 185, 188
saphenous nerve block, 377 Nervous system toxicity, 117
superficial cervical plexus block, 251 Neuraxial nerve blocks/catheters, 9
supraclavicular brachial plexus block, 292 Noga, M.L., 25–39, 41–56
thoracic paravertebral block, 440 Non-Communicating Children’s Pain Checklist-Postoperative
transcutaneous supraorbital nerve block, 232 Version (NCCPC-PV), 86–87
ulnar nerve block, 333 Numeric rating scales (NRS), 82, 83
Index 547
O Oucher, 82
Oberndorfer, U., 363, 421 pieces of hurt/poker chip scale, 82
Obturator nerve, 173–174, 220, 221 visual analogue scale, 82, 83
Obturator nerve block Wong-Baker FACES Pain Scale, 82
case study, 373 Pajunk® SonoLong Curl, 60, 61
indications, 369 Pajunk® StimuLong Sono, 62
landmarks, 370 Pajunk® StimuLong Sono-Tsui Set, 62
local anesthetic application, 373 Palmer, G.M., 474
nerve stimulation technique, 370–371 Pande, R., 123
patient positioning/surface anatomy, 370 Paramedian approach, thoracic epidural
ultrasound-guided technique, 371–372 placement, 499
anatomical structures, 371 Paramedian longitudinal technique, 510
needle insertion technique, 372 Parasacral approach, 421
scanning technique, 372 Parasagittal plane, 306
sonographic appearance, 371, 372 Parascalene approach, 268
studies, 373 Parasympathetic fibers, 136, 188
Occipital nerve anatomy, 256 Paravenous approach, 375, 378
Occipital nerve blocks Paravertebral blocks
block techniques case study, 452
greater occipital nerve location, clinical anatomy, 438
256, 257 indications, 438
landmarks and surface anatomy, 258 landmark-based technique
local anesthetic application, 259 landmarks and surface anatomy, 439
patient positioning, 256 needle insertion technique, 440
case study, 259 patient positioning, 438
indications, 256 nerve stimulation technique, 441
studies in ultrasound-guided approaches, 259 ultrasound-guided technique
Occulusive dressing, 68, 128, 521 local anesthetic application, 451
OOP. See Out-of-plane (OOP) needling technique needle insertion technique, 449
Ophthalmic nerve (V1 division), 138–139 scanning technique, 442–448
Osteotomes sonographic appearance, 442–448
clinical anatomy, 207 studies, 452
lower extremity, 218 transverse approach, 450
upper extremity, 210 VHVS and MRI imaging, 442–447
Oucher, 82 Paravertebral space, 196, 438, 441, 448, 450–452
Out-of-plane (OOP) needling technique, 54–56, 278, 292, 307, Parents’ postoperative pain measure (PPPM), 81
318, 324, 329, 333, 351, 362, 367, 391, 392, 399, 409, Paresis, 125
432, 449, 460, 472, 480, 481 Paresthesia, 4, 23, 60, 112, 119, 125, 170, 279,
365, 375
Park, G.R., 460
P Partial palatal injections, 236
Pain assessment Patient positioning
adolescents, 82–83 ankle blocks, 426
age-related developmental changes, 90 anterior sciatic nerve block approach, 401
appropriate pain assessment scales, 88 axillary block, 312
behavioral pain assessment tools, 88 caudal anesthesia, 515
developmental disabilities, 90–91 epidural anesthesia, 496
medical history, 76 femoral nerve block, 356
pain-related stress responses, 76 great auricular nerve blocks, 252
parental responses, 76 ilioinguinal and iliohypogastric nerve blocks, 478
poor, 76 infraclavicular brachial plexus block, 300
postoperative pain (see Postoperative pain) intraoral approach, 233
principles, 76 paravertebral blocks, 438
psychological factors popliteal/mid-thigh sciatic nerve block, 410
anxiety, 91 posterior lumbar plexus block, 338
biases in health-care providers, 92 radial nerve block, 326
cultural factors, 93 rectus sheath block, 464
expectations, 91 supraclavicular brachial plexus block, 284
fear of pain and catastrophizing, 91 transversus abdominis plane block, 470
gender-related differences, 92 ulnar nerve block, 331
social and family factors, 91–92 Pectoralis major muscles, 69, 154, 306, 312
self-reporting pain assessment tools, 89 Pectoralis minor muscles, 69, 154, 306
CHEOPS, 83 Pediatric Initiative on Methods, Measurement,
faces pain scale-revised, 82 and Pain Assessment in Clinical Trials
numeric rating scales, 82, 83 (Ped-IMMPACT), 82
548 Index
Pediatric regional anesthesia complications Popliteal/mid-thigh sciatic nerve block

by equipment case study, 420
needles, 119–123 indications, 410
nerve stimulators, 123 local anesthetic application, 419
ultrasound probes, 123 needle insertion site, 410
general principles, 112–114 nerve stimulation technique
local anesthesia, adverse events modifications to inappropriate responses, 413, 414
allergic reactions, 115 motor responses and needle adjustments, 412, 413
systemic toxic reactions, 115–119 needle insertion site, 411
management and assessment, 128 procedure, 412
neuraxial blocks patient positioning, 410
hematoma, 126 surface anatomy, 410
hypotension, 127 ultrasound-guided technique
infection, 126 anatomical structures, 415, 416
post-dural-puncture headache, 126–127 flowchart, 415
subdural injections, 126 needle insertion site, 415, 417
total spinal anesthesia, 126 needle insertion technique, 419
patient selection factors, 112, 114 scanning technique, 418
peripheral nerve blocks schematic drawing, 415, 417
bacterial infection, 125 sonographic appearance, 418
hematoma, 125 Post-dural-puncture headache (PDPH), 126–127
phrenic nerve paralysis and paresis, 125 Posterior gluteal region, 390
subsequent sequelae, 125 Posterior gluteal (labat) sciatic nerve block
standard of care, 112, 113 anatomical landmarks, 384
Pediatric skeleton model, 503, 504 landmarks, 384
Pediatric spine model, 496 local anesthetic application, 391
Pelvic splanchnic nerves, 185, 188 nerve stimulation technique
Penile block modifications to inappropriate responses, 387, 388
case study, 491 motor responses and needle adjustment, 386, 387
clinical anatomy, 486 needle insertion site, 385
landmark-based technique, 488–489 procedure, 386
ultrasound-guided dorsal penile nerve block, 491 surface anatomy, 384
ultrasound-guided technique ultrasound-guided technique
local anesthetic application, 490 anatomical structures, 389, 390
needle insertion, 490 flowchart, 389
scanning technique, 489 needle insertion site, 389
ultrasonographic appearance, 489, 490 needle insertion technique, 391, 392
Percutaneous electrode guidance, 14, 15 scanning technique, 391
Perineal nerve, 184–185 sonographic imaging, 391
Perineural catheters, 12, 39, 60, 293 Posterior lumbar plexus block
Peripheral nerve catheters, 9 case study, 352
Peripheral nerves indications, 338
block complications, 125–126 local anesthetic application, 351
catheter placement, 60 nerve stimulation technique
cutaneous distribution, 207–208 modifications to inappropriate responses,
needle trauma, 119–120 340–341
ultrasonographic characteristics, 36 needle insertion site, 339
Peripheral nerve stimulators, 21 procedure, 340
Perisanidis, J.D., 246 patient positioning/surface anatomy, 338
Perlas, A., 535 ultrasound-guided technique
Peroneal (fibular) nerve, 183–184, 221 anatomical structures, 343
Pfefferbaum, B., 93 flow chart, 342
Pharmacokinetics, 102–104 needle insertion technique, 350–351
Pharmacological considerations, 97–108 scanning technique, 343–345
Phrenic nerve, 153 sonographic appearance, 344, 347–349
Phrenic nerve paralysis, 125 studies in, 352
Pia mater, 201 Posterior superior iliac spine (PSIS), 338, 384, 439,
Pieces of Hurt/Poker Chip Scale, 82 497, 515
Pither, C.E., 21 Posterior tibial nerve block
Pleura, 37 needling insertion technique, 431, 432
Plexuses. See Brachial plexus; Lumbar plexus; Sacral plexus nerve stimulation technique, 427
Pneumothorax, 306 scanning technique, 428
Ponde, V.C., 363, 421, 452 sonographic appearance, 428, 431
Popliteal fossa, 14, 46, 47, 180, 182, 410, 411, 416 surface anatomy and landmarks, 426
Index 549
Post-fixed plexus, 166 needle insertion, 465

Postoperative analgesia, 438 patient positioning, 464
Postoperative pain assessment ultrasound-guided technique
with cognitive impairments, 86–87 local anesthetic application, 467
critically ill children, 84–85 needle insertion, 467
FLACC and PPPM, 81 scanning technique, 466
infants and young children, 81 ultrasonographic appearance, 466
neonates and infants, 77–80 umbilical nerve block, 468
PIPP tool, 78 Reflection, 30
Post-surgery analgesia duration, 364 Refraction, 30
Power Doppler, 39 Regional block area setup, 3–10
Preferential cathodal stimulation, 13 Regional block catheter insertion
Pre-fixed plexus, 166 contraindications, 60
Premature infant pain profile (PIPP), 78 equipment/injectates
Preschoolers, pain assessment, 90 catheters (see Catheters)
Prevention choice of, 65
allergic reactions, 115 sterile transducer preparation, 65
needle trauma, 121 indications, 60
post-dural-puncture headache, 127 safety, 60
systemic toxic reactions, 116 specific block examples in children
Primary curves, 191 femoral nerve, 69–70
Probes/transducers infraclavicular catheterization, 69
alignment, 44–45 sciatic nerve, 70
linear, 54, 69, 70, 293, 308, 391, 397, 489, 516, 517 technique, 66–68
preparation, 42–43 catheter-over-needle assembly insertion, 67–68
selection for block location, 38 confirmation of catheter tip location, 66–67
ultrasound, surface, 275, 288, 315, 342, 359, 366, 389, 397, 406, Regional block technique
415, 479 block area setup, 4
Propofol, 5, 107, 119 equipment
PSIS. See Posterior superior iliac spine (PSIS) emergency drugs and resuscitating, 5
Pudendal nerve, 178, 184–185 general, 5
Pulses needles (see Needle)
optimal pulse frequency variation, 22 nerve block and catheter, 6
width-current curve, 14, 15 resuscitation, 6
storage cart, 4, 5
monitoring, 4, 6
Q pediatric vs. adult populations, 4
Quadratus femoris, 179 resuscitation drugs, 6
Quadratus lumborum, 168, 169, 339, 344, 346 Reid, K., 75–93
Remifentanil, 5
Resuscitation equipment, 6
R Returning electrodes, 13
Radial nerve, 162, 214–215 Rheobase, 13
Radial nerve block, 326 Robot-assisted regional anesthesia, 39
case study, 330 Ropivacaine, 98, 99, 102–104, 106, 107, 279, 319, 351, 363, 373,
local anesthetic application, 330 378, 391, 433
nerve stimulation technique, 327
patient positioning/surface anatomy, 326
ultrasound-guided technique S
needle insertion technique, 329 Sacral hiatus, 193, 384, 515, 518, 524
scanning technique, 327 Sacral plexus
sonographic appearance, 327, 328 direct muscular branches, 179
Radiocarpal joint, 215 location, 178
Raj, P.P., 13 and lumbosacral trunk, schematic diagram, 178
Raj test, 12, 15 major terminal nerves
Rate of current change, 13 common peroneal (fibular) nerve, 183–184
Real-time needling, 350 inferior gluteal nerve, 179
Real-time ultrasound imaging, 350, 442 pelvic splanchnic nerves, 185
Rectus sheath block posterior femoral cutaneous nerve,
block evaluation at anterior trunk, 468 179–180
case study, 469 pudendal nerve, 178, 184–185
clinical anatomy, 464 sciatic nerve, 178, 180–181
landmark-based technique superior gluteal nerve, 179
landmarks and surface anatomy, 464 tibial nerve, 182–183
local anesthetic application, 465 Sacral vertebrae, 193
550 Index
Sacrum nerve stimulation technique, 394–396

developmental anatomy, 193 surface anatomy, 393
fused spinous processes, 515 ultrasound-guided technique, 397–399
spinal nerves above, 202 popliteal/mid-thigh sciatic nerve block
Sahin, I., 474 case study, 420
Sandeman, D.J., 474, 491 indications, 410
Saphenous nerve, 221 local anesthetic application, 419
Saphenous nerve block needle insertion site, 410
case study, 378 nerve stimulation technique, 411–414
indications, 374 patient positioning, 410
local anesthetic application, 378 surface anatomy, 410
nerve stimulation technique, 375 ultrasound-guided technique, 415–419
surface anatomy, 374–375 posterior gluteal (labat) sciatic nerve block
ultrasound-guided technique, 375–377 anatomical landmarks, 384
anatomical structures, 375, 376 landmarks, 384
paravenous approach, 375 nerve stimulation technique, 385–388
scanning technique, 376, 377 surface anatomy, 384
sonographic appearance, 377 ultrsound-guided technique, 389–391
studies, 378 studies in ultrasound-guided approaches, 421
transsartorius perifemoral approach, 375 SCM. See Sternocleidomastoid muscle (SCM )
Scanning technique Secondary/compensatory curves, 191
anterior sciatic nerve block approach, 408 Sedatives, 5, 528
axillary block, 317 Segmental cutaneous innervation, 207
deep peroneal nerve block, 428–430 Segmental motor response, 209, 216
femoral nerve block, 361 Segmental sensory innervation, 215
infraclavicular brachial plexus block, 304, 306 Selander, D., 120
infragluteal/subgluteal sciatic nerve Sethuraman, M., 363
blocks, 397 Shah, S., 118
intercostal nerve blocks, 459 Shelly, M.P., 460
interscalene brachial plexus block Shin, S.K., 524
color Doppler, 275 Shoulder, 212, 213
cricoid cartilage approach, 275 Simpson, D.M., 474
traceback approach, 275, 276 Single-crystal transducers, 39
lateral femoral cutaneous nerve block, 366 Single-injection technique, 318, 319
median nerve block, 323 Single-shot blocks, 42, 438, 442
obturator nerve block, 372 Single-shot caudal epidural anesthesia, 514
paravertebral block, 442–448 Single-shot epidural injection, 102
penile block, 489 Sonix GPS, 39
popliteal/mid-thigh sciatic nerve block, 418 Sonographic appearance
posterior gluteal sciatic nerve blocks, 391 ankle blocks, 430, 431
posterior lumbar plexus block, 343–345 anterior sciatic nerve block approach, 407, 408
posterior tibial nerve block, 428 axillary block, 317
radial nerve block, 327 caudal anesthesia, 518
rectus sheath block, 466 deep peroneal nerve block, 430, 431
saphenous nerve block, 376, 377 epidural anesthesia, 509–510
supraclavicular brachial plexus block, 290 femoral nerve block, 361, 362
ulnar nerve block, 332 infraclavicular brachial plexus block, 306
Scarpa’s fascia, 486, 487 infragluteal/subgluteal sciatic nerve blocks, 399
Scattering, ultrasound, 30 intercostal nerve blocks, 458, 459
Schecter, N.L., 92 interscalene brachial plexus block, 277
School-age children, pain assessment, 90 lateral femoral cutaneous nerve block, 366
Schwemmer, U., 421 median nerve block, 323
Sciatic nerve, 180–181 obturator nerve block, 371, 372
Sciatic nerve blocks paravertebral block, 442–448
anterior sciatic nerve block approach popliteal/mid-thigh sciatic nerve block, 418
local anesthetic application, 409 posterior gluteal sciatic nerve blocks, 391
nerve stimulation technique, 403–405 posterior lumbar plexus block, 344, 347–349
surface anatomy, 401 posterior tibial nerve block, 428, 431
surface landmarks, 401, 402 radial nerve block, 327, 328
ultrasound-guided technique, 406–409 saphenous nerve block, 377
indications, 384 superficial cervical plexus block, 249–250
infragluteal/subgluteal approach supraclavicular brachial plexus block, 291
anatomical landmarks, 393 ulnar nerve block, 333
case study, 400 Spatial resolution, ultrasound, 30
local anesthetic application, 399 Specialized styletted catheter setup, 20
Index 551
Special Sprotte® cannulas, 6, 7 Supported/off-line ultrasound imaging, 350

Spencer, A.O., 527–536 Supraclavicular brachial plexus block
Spermatic cord, 170, 474, 480 case study, 294
Spinal anesthesia indications, 284
advantages, 528 local anesthetic application, 292
block level assessment, 534 nerve stimulation technique
case study, 536 modifications to inappropriate responses, 288
clinical use and special concerns, 528–529 needle insertion, 286
complications, 534 procedure, 287
contraindications, 529 responses and needle adjustment, 285
equipment and spinal needle, 532 patient positioning, 284
local anesthetics, 533 surface anatomy, 284
technique ultrasound-guided technique
nerve stimulation, 531 flowchart, 288
patient positioning, 530 literature, 293
preparation, 529 MRI and VHVS images, 288, 289
sonographic assessment, 531 needle insertion site preparation, 288
surface anatomy, 530 needle insertion technique, 292
ultrasound-guided approach, 535 scanning technique, 290
Spinal epidural space, 202 sonographic appearance, 291
Spinal nerves Supraorbital nerve, 138
above sacrum, 202 Suprascapular nerve, 154
origin, 118 Supratrochlear nerve, 138
roots, 201–202 Sural nerve, 182, 221, 427
Spinal segments, 209, 216 Suresh, S., 417, 527–536
Spine Surface anatomy
anterior superior iliac spine, 169, 170, 356, 365, 370, ankle blocks, 426
401, 478 arnold nerve blocks, 262
lumbar, 191–193, 448, 497, 505, 510, 512, 522 axillary block, 312
posterior superior iliac spine, 338, 384, 439, 497, 515 deep cervical plexus block, 243
thoracic, 191, 192, 202, 448, 497, 505, 506, 508, 510, 511, 521 femoral nerve block, 356
Spinous processes, 497 great auricular nerve blocks, 253
Spiral groove, 162, 326 greater occipital nerve block, 258
Starry night appearance, 37, 346, 510 greater palatine nerve block, 234
Steinfeldt, J., 293 infraclavicular brachial plexus block, 300
Sterile adhesive dressing, 275, 288, 306, 315, 342, 359, 366, infraorbital nerve block, 227
389, 397, 406, 415, 438, 479 interscalene brachial plexus block, 268
Sterile transparent dressing, 42, 43 intraoral infraorbital nerve block, 234
Sternocleidomastoid muscle (SCM ), 243, 246, 248, 249, intraoral mental nerve block, 234
251–254, 268 lesser occipital nerve block, 258
Stevens, B., 77 lumbar paravertebral block, 439
Stimulating catheters, 60–71 mental nerve block, 227
Stinson, J., 82 obturator nerve block, 370
Strength-duration curve, 13 posterior lumbar plexus block, 338
Subarachnoid space, 528 radial nerve block, 326
Subclavian artery pulsation, 284 saphenous nerve block, 374–375
Subclavius nerve, 154 sciatic nerve block
Subsequent sequelae, 125 anterior block approach, 401
Superficial cervical plexus block infragluteal/subgluteal approach, 393
anatomy, 247 popliteal/mid-thigh sciatic nerve block, 410
case study, 254 posterior gluteal (labat) sciatic nerve block, 384
indications, 242 superficial cervical plexus block, 248
ultrasound-guided technique supraclavicular brachial plexus block, 284
landmarks and surface anatomy, 248 supraorbital nerve block, 227
local anesthetic application, 252 thoracic paravertebral block, 439
needle insertion technique, 251 ulnar nerve block, 331
patient positioning, 248 Sympathetic (visceral efferent) fibers, 188
scanning technique, 249 Syringe/infusion pumps, 10
sonographic appearance, 249–250 Systemic toxicity, 115–119
studies, 252
Superficial peroneal (fibular) nerve, 221
Superficial transcutaneous approach T
patient positioning, 226–227 Tachibana, N., 524
surface anatomy, 227 Target nerves, 4, 46, 54, 466, 480
surface landmarks, 226, 227 Taylor, I.J., 474
Superior gluteal nerve, 179, 220 Teflon, 15
552 Index
Tegaderm®, 530 Trigeminal nerve

Tendons, 35, 36 branches, 136
Achilles (Calcaneal), 221, 426, 427, 433 mandibular nerve (V3 division), 142
biceps brachii, 157, 322, 327 maxillary nerve (V3 division), 140–141
Terminal nerves ophthalmic nerve (V1 division), 138–139
brachial plexus, 154–162 Trigeminal nerve blocks
lower extremity, 216, 217, 355–378 block techniques
sacral plexus, 179–185 intraoral approach, 233–238
upper extremity, 321–334 superficial transcutaneous approach, 226–233
Thoracic epidural anesthesia, 498 case study, 239
Thoracic epidurals, 20, 499, 501, 524 deep trigeminal nerve blocks, 237–238
Thoracic paravertebral block indications, 229
case study, 452 ultrasound-guided approaches, 239
needle insertion technique, 440 Trunk anatomy, 187–204
surface anatomy, 439 Tsui, B.C.H., 3–23, 25–39, 41–56, 59–71, 111–128, 135–146,
ultrasound images of, 452 149–162, 165–174, 177–185, 187–221, 225–239, 241–259,
Thoracic spinal nerves, 196–200 261–264, 267–280, 283–294, 299–309, 311–334, 337–352,
Thoracic spine, 191, 192, 202, 448, 497, 505, 506, 508, 510, 355–378, 383–421, 425–433, 437–452, 455–461, 463–475,
511, 521 477–482, 485–491, 495–524, 527–536
Thoracic vertebral bodies, 192 Tsui test, 9, 17, 500
Thoracodorsal nerve, 154 Tuberosity
Tibial nerve (posterior tibial nerve), 182–183, calcaneal, 182
220, 221 ischial, 70, 179, 180, 389, 393, 397
Time gain compensation (TGC), 31 Tuohy needle, 6, 7, 49, 60, 62, 63, 66, 67, 69, 70, 440, 452,
Ting, H.Y.Z., 383–421, 437–452, 485–491 457, 498, 500
Tissue-blood partition coefficients, 103
Tissues
fascial, 37 U
hyperechoic connective, 36, 308, 317, 346 Ueda, K., 524
ultrasound wave characteristics, 29–30 Ulnar artery pulse, 331
Toxicity, local anesthetics Ulnar nerve, 160–161, 214, 317, 330
cardiovascular toxicity, 105, 106 Ulnar nerve block
central nervous system toxicity, 105, 106 case study, 334
prevention, 108 local anesthetic application, 334
treatment, 107 nerve stimulation technique, 332
Traceback approach, 275, 276 surface anatomy and landmark, 331
Traceback method, 46–48 ultrasound-guided technique
Transcutaneous supraorbital nerve block, 232 needle insertion technique, 333
Transducers. See also Probes/transducers scanning technique, 332
broadband, 28 sonographic appearance, 333
convex arrays, 28 VHVS and MRI images, forearm, 332
high-frequency, linear array, 28 Ultrasonography, 59–71
phased array, 28 Ultrasound
pulse repetition frequency, 27 anisotropy, 33
schematic of ultrasound, 28 artifacts, 33–34
single-crystal, 39 clinical and practical aspects
sterile transducer preparation, 65 image acquisition, 42
Transsartorius perifemoral approach, 375 image optimization, 44–48
Transverse approach, 450 needle trajectory, control of, 49–56
Transverse axis, 408, 510 probe preparation, 42–43
Transverse processes, 142, 144, 190, 191, 243, 344, 346, 439, depth, 31
440, 446, 448, 497 Doppler effect, 31
Transverse scan, 448 echogenic appearance/various tissues, 35–37
Transversus abdominis plane (TAP) block equipment selection, 38
case study, 475 focal zone, 31
catheter placement, 473 frequency, 31
clinical anatomy, 470 gain function, 31, 32
landmark-based technique image quality, knobology, 31–32
landmarks and surface anatomy, 470 principles, 27
local anesthetic application, 471 sound wave in tissues, 29–30
needle insertion, 471 technology development, 39
patient positioning, 470 time gain compensation, 31
in pediatric population, 474 transducers, 27–28
ultrasound-guided technique Ultrasound-assisted regional anesthesia, 46
local anesthetic application, 473 Ultrasound-guided ankle blocks, 428–432
needle insertion, 472 Ultrasound-guided anterior sciatic nerve block approach,
scanning technique, 472 406–409
ultrasonographic appearance, 472 Ultrasound-guided arnold nerve blocks, 263
Triffterer, I., 524 Ultrasound-guided axillary block, 315–318
Index 553
Ultrasound-guided epidurals, 194–195, 350, 512 Vertebral (spinal) canal, 201

Ultrasound-guided fascia iliaca compartment block, 363 CSF volume, 204
Ultrasound-guided femoral nerve block, 359–362 development, 203
Ultrasound-guided infraclavicular brachial plexus block, developmental anatomy, 201
304–307 intermediate layer of leptomeninges, 201
Ultrasound-guided infragluteal/subgluteal sciatic nerve meninges surrounding, 201
blocks, 397–399 spinal cord dural sac termination, 203
Ultrasound-guided intercostal nerve blocks, 458–460 spinal cord segments vs. vertebral levels, 201–202
Ultrasound-guided interscalene brachial plexus block, 273–278 spinal nerves above sacrum, 202
Ultrasound-guided lateral femoral cutaneous nerve block, Vertebral column (spine), 188
366–367 development
Ultrasound-guided median nerve block, 323–324 chondrification (cartilaginous) stage, 190
Ultrasound-guided obturator nerve block, 371–372 growth and curves, 191
Ultrasound-guided occipital nerve blocks, 259 lumbar spine, 191, 192
Ultrasound-guided paravertebral blocks, 442–450 mesenchymal (precartilaginous) stage, 190
Ultrasound-guided popliteal/mid-thigh sciatic nerve block, 415–419 ossification (bony) stage, 190
Ultrasound-guided posterior gluteal sciatic nerve blocks, 389–391 sacrum, 193–194
Ultrasound-guided posterior lumbar plexus block, 342–351 thoracic spine, 191, 192
Ultrasound-guided radial nerve block, 327–329 origin, 188
Ultrasound-guided saphenous nerve block, 375–377 paravertebral space, 196
Ultrasound-guided superficial cervical plexus block, 247–252 Visceral afferent fibers, 188
Ultrasound-guided supraclavicular brachial plexus block, 288–292 Visible Human Visualization Software (VHVS)
Ultrasound-guided transsartorial perifemoral approach, 378 auricular branch of vagus nerve, 262
Ultrasound-guided ulnar nerve block, 332–333 brachial plexus anatomy, 274, 289
Ultrasound imaging, 20, 29, 290, 339, 415, 421, 428, 438, 442, brachial plexus at axilla, 316
496, 509 deep cervical plexus block, 244
Ultrasound machine, 9 femoral nerve block, 359, 360
Ultrasound wave characteristics, 29 femoris artery, 361
Umbilical nerve block, 468 greater occipital nerve, 257
Unitlateral surgical procedure, 438 infraclavicular brachial plexus block, 304, 305
Upper extremity infraorbital nerve, 227, 228
innervation intercostal nerve blocks, 458–459
cutaneous distribution of peripheral nerves, 207–208 lateral femoral cutaneous nerve block, 366
dermatomes, 207–208 mandibular nerve, 238
joints, 211–215 mental foramina, 227, 228
motor responses with nerve stimulation, 211 obturator nerve block, 371
myotomes, 209 paravertebral block, 442–447
osteotomes, 210 radial nerve within arm, 328
medial and lateral cords, 156 saphenous nerve block, 375, 376
peripheral nerves and vessels of, 154, 155 superficial cervical plexus block, 249, 250
posterior cords, 156 supraorbital nerve block, 227, 228
terminal nerve block ulnar nerve in forearm, 332
median nerve, 322–325 Visoiu, M., 452
radian nerve, 326–330 Visual analogue scale (VAS), 82, 83
studies in ultrasound-guided approaches, 334 Vital signs, 79, 80
ulnar nerve, 330–334 Voltage-gated sodium channel, 100
Upper subscapular nerves, 154 von Baeyer, C., 82, 89
Use-dependent blockade, 100
W
V Walji, A.H., 135–146, 149–162, 165–174, 177–185,
van der Wal, M., 374 187–221
van Geffen, G.J., 421 Wang, I.Z., 524
Van Shoor, A.N., 478 Weight-dependent depth of needle insertion, 286
Variable pulse width, 22 Willschke, H., 468, 481, 524
Vascular puncture, 125, 242, 285, 292, 306 Winnie, A.P., 385
Vascular structure, 37 Wong-Baker FACES Pain Scale, 82
Vasopressin, 107 Wong, D., 89
Veins, 37 Wrist, 213–215
axillary, 69, 150, 157, 306, 312
basilic, 157
cephalic, 157, 306 Y
external jugular, 150, 153, 253, 268 Yang, C.W., 293, 452
femoral, 372, 377
internal jugular, 142, 146, 150, 249, 275, 277
posterior tibial, 431 Z
subclavian, 150, 154, 291, 306 Zeidan, A., 246
Vermeylen, K., 293 Zide, B.M., 231
Verrier, M.J., 75–93 Zygomatic facial nerve, 140

Pediatric Atlas Of: Ultrasound-And Nerve Stimulation-Guided Regional Anesthesia

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Ban C.H.

Pediatric Atlas of Ultrasound-

ISBN 978-0-387-79963-6 ISBN 978-0-387-79964-3 (eBook)

Library of Congress Control Number: 2015949112

Springer New York Heidelberg Dordrecht London

Printed on acid-free paper

To my wife, Eliza, and my children, Jenkin and Jeremy—the real loves of my

I would like to dedicate this book to my family; my wife, Nina, and my

Charles Berde, MD, PhD

stimulation, and ultrasound guidance techniques in regional anesthesia, thereby improving

Edmonton, Alberta, Canada Ban C.H. Tsui, MSc, MD, FRCPC

Edmonton, Alberta, Canada Ban C.H. Tsui, MSc, MD, FRCPC

1 Regional Block Area Setup, Equipment, and Monitoring . . . . . . . . . . . . . . . . 3

2.5 Useful Equipment Features in Nerve Stimulation . . . . . . . . . . . . . . . . . . . . 21

4.4 Control of Needle Trajectory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Part II Considerations in Pediatric Regional Anesthesia

Part III Clinical Anatomy

12.3.6 Common Peroneal (Fibular) Nerve . . . . . . . . . . . . . . . . . . . . . . . . 183

Part IV Nerve Blocks of the Head and Neck

15.2.2 Intraoral Approach to Trigeminal Nerve Blocks:

Part V Nerve Blocks Above the Clavicle

Part VI Nerve Blocks Below the Clavicle

23.3.3 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332

Part VII Nerve Blocks of the Lumbar Plexus

25.4 Saphenous Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374

Part VIII Nerve Blocks of the Sacral Plexus

Part IX Nerve Blocks at the Ankle

27.5 Local Anesthetic Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Part X Nerve Blocks at the Trunk

30.2.3 Ultrasound-Guided Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471

Part XI Neuraxial Blockade

33.1.5 Nerve Stimulation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499

V.H.Y. Ip, MB ChB, MRCP, FRCA

© Springer Science+Business Media New York 2016 3

• Sterile skin preparation solution.

1.2.2 Emergency Drugs and Resuscitating

• Although the use of ultrasound allows reduced volumes

1.2.3 Resuscitation Equipment 1.2.7 Needles

• For continuous peripheral nerve blocks, the commonly

• Routine monitoring should be applied before sedation or

Fig. 1.2 Blunt needles for single-shot nerve blocks

There is a variety of different needles for single-shot nerve

1.2.7.2 Needle Lengths

• 25 mm (ProBloc SC® by Life-Tech INC., Texas, USA;

1.2.7.3 Needle Gauges

1.2.7.4 Other Needle Designs

1.2.8 Peripheral Nerve Catheters To ensure a good-quality image, selecting an appropriate

1.2.10 Additional Equipment

When performing a regional block, patient feedback and

1.2.10.1 Nerve Stimulator

1.2.10.2 Ultrasound Machine

1.2.10.4 Syringe/Infusion Pumps

K.P.A. Byrne, MB ChB, FANZCA

© Springer Science+Business Media New York 2016 11

Fig. 2.1 Schematic of cross section Perineurium

2.2.2 Current Intensity and Duration 2.2.3 Rate of Current Change

Whether or not a nerve is stimulated depends on a combina-

4.1 Image Acquisition 4.2 Probe Preparation

4.4.2 Hand-Eye Coordination population illustrates this point by focusing on the

4.4.3 Needling Technique • Most commercial needle-guiding tools involve physical