@anesthesia - Books 2014 Regional Anaesthesia - A Pocket Guide

REGIONAL
ANAESTHESIA
A POCKET GUIDE
REGIONAL
ANAESTHESIA
A POCKET GUIDE
D R A LW I N C H U A N
&
D R D AV I D M S C OT T
1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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First Edition published in 2014
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ISBN 978–0–19–968423–6
Printed in Great Britain by
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CONTENTS
Abbreviations vii
Preface ix
About the authors xi
CHAPTER 1 Introduction to regional anaesthesia 1

Pre-anaesthesia 2
General technical guidelines for performing regional anaesthesia 3
Catheter technique for continuous infusions 4
Ultrasound-guided regional anaesthesia 5
Troubleshooting for neurostimulation-guided regional anaesthesia 19
General side effects and complications of regional anaesthesia 20
Systemic effects of local anaesthetic intoxication 21
Post-operative analgesia 23
References 25
CHAPTER 2 The head 27

Anatomy of the nerve supply to the head and scalp 28
Sensory supply 29
Peribulbar block 30
Sub-Tenon’s eye block 32
Supraorbital and supratrochlear nerve block 34
Infraorbital nerve block 36
Mental nerve block 38
Maxillary nerve block 40
Anterior ethmoidal nerve block 42
References 44
CHAPTER 3 Upper extremities 45

Anatomy of the brachial plexus 46
Sensory supply 47
Motor response 48
Scanning tips for the upper extremities 49
Interscalene plexus block 52
Supraclavicular plexus block 56
Infraclavicular plexus block: vertical approach 60
Infraclavicular plexus block: lateral approach 64
Suprascapular nerve block 66
Axillary plexus block 68
Supplementary blocks for the upper limb 72
Wrist blocks 76
References 80
vi CONTENTS
CHAPTER 4 Lower extremities 81

Anatomy of the lumbosacral plexus 82
Sensory supply of the lower extremities 84
Sensory supply of the bony structure 85
Motor response 86
Scanning tips for the lower extremities 87
Psoas compartment (lumbar plexus) block 90
Femoral nerve block 94
Lateral femoral cutaneous nerve block 98
Fascia iliaca block 100
Obturator nerve block 102
Sacral plexus block 106
Sciatic nerve block: subgluteal to popliteal fossa 108
Sciatic nerve block: proximal anterior/ventral 112
Saphenous nerve block 114
Ankle blocks 116
References 122
CHAPTER 5 Spine and para-axial region 123

Anatomy of the spine and para-axial region 124
Sensory supply 125
Thoracic paravertebral block 126
Epidural block for labour anaesthesia 130
Intercostal block 132
Posterior transversus abdominis plane (TAP) block 136
Subcostal TAP block 138
Rectus sheath block 140
Ilioinguinal iliohypogastric block 142
Genitofemoral block 144
Dorsal penile block 146
References 148
Index 149
Management of severe local anaesthetic
toxicity—quick reference safety guideline 152
ABBREVIATIONS
a. artery
ASIS anterior superior iliac spine
CFD colour flow Doppler
cm centimetre
CNS central nervous system
CPR cardiopulmonary resuscitation
2D two-dimensional
ECG electrocardiogram
h hour
IP in-plane
IT ischial tuberosity
kg kilogram
L litre
LA local anaesthetic
LAX long axis
m. muscle
mA milliampere
MHz megahertz
min minute
mL millilitre
mm millimetre
mm. muscles
mmHg millimetre of mercury
ms millisecond
n. nerve
NSAID non-steroidal anti-inflammatory drug
OOP out-of-plane
PSIS posterior superior iliac spine
SAX short axis
scm sternocleidomastoid
TAP transversus abdominis plane
U unit
v. vein
PREFACE
Regional anaesthesia is an essential component of the anaesthetists’ skill

set. Correct application of regional anaesthesia provides opportunity
for enhanced patient recovery and rehabilitation through improved
perioperative analgesia and reduced doses of systemic anaesthetic and
analgesic agents.
Successful regional anaesthesia relies on two critical tasks: the
identification of target nerves within their anatomical surroundings and
the application of local anaesthetic solution as close as possible to the
target nerve.
First published in Australia, the Regional Anaesthesia Pocket Guide was
written as a quick-reference pocketbook, full of clinical photographs and
anatomical drawings, to help anaesthetists apply anatomical knowledge in
practical anaesthetic procedures. Following on from its success amongst
consultants and trainees, the authors have revised the text to reflect the
evolving practice of ultrasound guidance in anaesthesia practice and
given the book a more international focus. High-frequency ultrasound
allows better visualization of target nerves and identification of individual
anatomical variation. Real-time observation of needle placement permits
more accurate deposition of local anaesthetic solution, reducing the total
volume and dose required and reducing the risk of inadvertent puncture
of blood vessels and other vulnerable structures.
This new international edition of Regional Anaesthesia places added
emphasis on ultrasound-guided blocks; suitable landmark-based blocks
have been retained for practitioners who do not have access to ultrasound
guidance. Blocks where ultrasound guidance is not relevant, such as blocks
of the head, are also included.
We are confident that this unique compilation of regional anaesthesia
techniques for peripheral and para-axial nerve blocks will continue to
support the application of regional anaesthesia within your anaesthetic
practice.
Alwin Chuan and David Scott
ABOUT THE AUTHORS
Dr Alwin Chuan MB BS (Hons), PGCertCU, FANZCA,

Consultant Anaesthetist, Sydney, New South Wales
Dr Chuan has a strong interest in perioperative ultrasonography, including
ultrasound-guided regional anaesthesia. He has been a guest speaker
and workshop tutor in Australia and internationally and has written on
ultrasound-guided regional techniques. Dr Chuan is actively involved in
curriculum development of the postgraduate ultrasound degrees at the
University of Melbourne and in the Regional Anaesthesia Special Interest
Group of the ASA/ANZCA/NZSA. Dr Chuan is a VMO at Liverpool Hospital,
Sydney, where he helped to establish an Anaesthesia Fellowship in perioperative
ultrasonography.
Dr David M Scott BMed, PGCertCU, FANZCA,

Consultant Anaesthetist, Lismore Base Hospital,
Lismore, New South Wales
Dr Scott has interests in regional anaesthesia and military anaesthesia. Dr Scott
is the founding chairman of the Regional Anaesthesia Special Interest Group
of the ASA/ANZCA/NZSA. He has lectured on regional anaesthesia extensively,
nationally and internationally, and has facilitated many regional anaesthesia
workshops. Dr Scott is also a Group Captain in the Royal Australian Air Force
Specialist Reserve and has been deployed overseas on many missions.
CH AP T E R O N E
INTRODUCTION
TO REGIONAL
ANAESTHESIA
Pre-anaesthesia 2
General technical guidelines for performing regional
anaesthesia 3
Catheter technique for continuous infusions 4
Ultrasound-guided regional anaesthesia 5
Troubleshooting for neurostimulation-guided regional
anaesthesia 19
General side effects and complications of regional
anaesthesia 20
Systemic effects of local anaesthetic intoxication 21
Post-operative analgesia 23
References 25
2 REGIONAL ANAESTHESIA
Pre-anaesthesia
Patient consultation prior to anaesthesia1
• Anaesthetists should consult with patients prior to scheduled anaesthesia to assess
the patient’s medical status and plan appropriate anaesthesia management:
• Introduce themselves to the patient
• Complete an appropriate medical assessment of the patient
• Discuss details of the anaesthetic management that may be of significance
to the patient, including complications of regional anaesthesia techniques
• Obtain informed consent for the anaesthesia and related procedures
• Order medications considered necessary
• Consult with professional colleagues, if required
• Document a summary of the consultation.
Equipment and operation room
• Resuscitation equipment and drugs should be readily available and easily
accessible in the room that the regional anaesthesia procedure is performed
• In Australia and New Zealand, refer to Australian and New Zealand
College of Anaesthetists Professional Document T1 ‘Recommendations on
minimum facilities for safe administration of anaesthesia in operating suites
and other anaesthetising locations’ (http://www.anzca.edu.au/resources/
professional-documents/technical/t1.html).
Examples of regional anaesthesia needles and catheters
Examples of regional anaesthesia needles and catheters can be seen in Box 1.1.
Nerve stimulators
• Detailed descriptions of the requirements for, and use of, nerve stimulators can
be found at the New York School of Regional Anaesthesia website (http://www.
nysora.com/regional_ anesthesia/equipment/3114-nerve_stimulators.html).
BOX 1.1 REGIONAL ANAESTHESIA NEEDLES AND

CATHETERS
Single shot
• Stimuplex (B. Braun)
®
• A series: 30° bevel
• D series: 15° or 30° bevel.
• UniPlex (PAJUNK ) ®
• SPROTTE or Tuohy cannulae.

®
Continuous
• StimuCath™ (Arrow)
• Contiplex (B. Braun)
®
• Plexolong (PAJUNK ) ®
• SPROTTE , Tuohy, or Facet cannulae.

®
• Stimulong Plus (PAJUNK ) ®
• Direct stimulation of the nerve by the catheter.

Spinal needle
• Spinocan (B. Braun)
®
• Quincke bevel
• Spinocath (B. Braun)
®
• Continuous injection
• SPROTTE Pencil Point Spinal Needle (B. Braun).
®
• Whitacre Pencil Point Spinal Needle (BD)

• Gertie Marx Spinal Needle (IMD).
®
INTRODUCTION TO REGIONAL ANAESTHESIA 3
General technical guidelines for

performing regional anaesthesia
• Ensure technique is aseptic for epidural and spinal blocks, and for major
peripheral nerve blocks
• Prior to performing the nerve block, infiltrate the needle insertion site with
local anaesthetic:
• If available and time permits, pre-treat the injection site with a topical local
anaesthetic cream to lessen the pain of injection. Most studies investigating
the supplementation of topical analgesia with infiltration anaesthesia
demonstrated reduced pain experienced during infiltration2
• If using a short bevel needle (e.g. 45° bevel), it may be useful to incise the skin
with a lancet before needle insertion
• When using nerve stimulation:
• Stimulate nerves at 1.0 mA until muscle contractions are visible in the
corresponding innervation area. Reduce current to between 0.3 mA/0.1 ms
and 0.5 mA/0.1 ms before injecting the local anaesthetic
• An immediate loss of muscle response with injection of 0.5 mL saline
or local anaesthetic (Raj test) is reassuring. Alternatively, inject 1 mL 5%
dextrose, which maintains or augments the motor response, followed by
local anaesthetic3
• When injecting large doses of local anaesthetic, inject in fractions and
maintain verbal communication with the patient for early detection of
accidental intravascular injection. Avoid forceful injection
• In patients who are uncooperative or under sedation, or when performing
a block distal to an established central block (e.g. femoral nerve block in
the presence of spinal anaesthesia), use a nerve stimulator and an insulated
needle (but not for infiltration anaesthesia of purely sensory nerves) or
ultrasound
• Monitor patients:
• Clinical monitoring of fundamental physiological variables is essential.
Monitor the patient’s cardiorespiratory status at frequent and clinically
appropriate intervals, and interpret the patient’s oximetric values in
conjunction with clinical observation. Standard monitoring equipment
includes a pulse oximeter, ECG, temperature monitor, and frequent blood
pressure measurement.4
Catheter technique for continuous

infusions
Preparation
• Perform continuous infusions using a sterile technique, with gown and gloves,
as for placement of an epidural
• Prepare skin appropriately. If using alcohol-containing solutions, take care to
avoid contamination of the catheter with the solution, as it is neurotoxic and
may move along the catheter by capillary action
• Drape the field appropriately.
Continuous catheter technique

• Unless otherwise specified, direct and place the needle as described for the
single injection technique. With ultrasound, it may be helpful to use a slightly
oblique approach for in-plane needle visualization
• Confirm needle placement by stimulation of appropriate muscles if using a
nerve stimulator
• If using a stimulating catheter, e.g. StimuCath™:
• Advance the catheter through the needle, and attach the stimulator to the
catheter
• Advance the catheter while stimulating (a higher stimulating current may be
required)
• If muscle twitch is lost, withdraw the catheter; rotate the needle slightly;
reattain muscle twitch, then readvance the catheter
• Confirm catheter position, and withdraw the needle, leaving the catheter
in place
• Tunnel the catheter, if desired
• Inject initial bolus of local anaesthetic through the catheter while
stimulating—muscle twitch should be immediately abolished
• If using a non-stimulating catheter, e.g. Plexolong or Contiplex® (19.5 G,
insulated Tuohy needle and 20 G catheter):
• Inject a small bolus of local anaesthetic or saline—this creates a space for
the catheter to be placed
• Pass the catheter firmly, but not forcefully, through the needle until it is
2–5 cm beyond the needle tip, visualizing with ultrasound, if available
• Remove the needle, taking care not to dislodge the catheter
• If the catheter has an internal wire, it should be removed at this point
• Inject local anaesthetic for surgical anaesthesia through catheter while
visualizing with ultrasound, if available
• Secure the catheter with an adhesive dressing, and consider subcutaneous
tunnelling
• Infuse local anaesthetic at a rate of 2–10 mL/h
• Alternatively, a patient-controlled regional anaesthesia pump can be
programmed for a 2 mL/h infusion and 5 mL bolus with 30-minute lockout.
Ultrasound-guided regional
anaesthesia
Ultrasound-guided regional anaesthesia allows identification and
visualization of:5–8
• Neural structures and their relationship to anatomical planes
• Surrounding critical structures, such as pleura and blood vessels
• Anatomical variations in individual patients
• The needle tip
• The spread of local anaesthetic around the target structures.
Visualization of the nerve’s anatomical relationships and the needle tip position
may allow:5–8
• Optimal positioning of the needle
• Minimization of potential complications, such as intravascular and intraneural
injection, and tissue damage
• Re-insertion or redirection of the needle to accommodate for anatomical
variation
• Real-time repositioning of the needle during blockade if the local anaesthetic
spreads in the wrong direction and does not surround the nerve.
Potential advantages of ultrasound-guided regional anaesthesia include:5–8
• Reduced reliance on surface anatomy landmarks for needle insertion,
particularly in the trauma, post-surgical, congenital deformity, or morbidly
obese patient populations
• Decrease in local anaesthetic dose required for an effective block
• Faster sensory onset times
• Longer duration of blocks
• Improved quality of block.
Equipment
Ultrasound machine
See Figure 1.1.
Linear-array ultrasound probes (>10 MHz)
High frequency provides excellent resolution of peripheral nerves. However,
deeper nerves are less well visualized, as penetration is reduced. The large
transducer face allows for a wider field of view but can make it difficult to
maintain skin contact in paediatric patients and patients with a smaller body
habitus. See Figure 1.2.
FIGURE 1.1 Ultrasound machine.

FIGURE 1. 2 Linear-array ultrasound probes.
Curvilinear ultrasound probes (2–5 MHz)

These provide better penetration than linear array probes and are useful when
visualizing deeper nerves, such as the lumbar plexus. The transducer face is larger
than that of linear probes and allows for a wide field of view. See Figure 1.3.
Ultrasound spatial terms
Figures 1.4 and 1.5 demonstrate ultrasound spatial terms.
First-principles approach to ultrasound-guided blocks

Scanning technique
• In the SAX view (see Figure 1.6), with the probe perpendicular to the long
axis of the nerve, the nerve appears in a round to oval shape, with internal
hypoechoic nerve fascicles surrounded by the hyperechoic epineurium9
• In the LAX view (see Figure 1.7), the nerve appears as a linear hypoechoic
fascicular component mixed with hyperechoic bands which correspond to the
interfascicular epineurium.9
Appearance of nerves and blood vessels with ultrasound
• Several factors may influence the appearance of nerves when imaged using
ultrasound:
• Ultrasound resolution
• Imaging depth
• Nerve structure
• Probe angle
FIGURE 1. 3 Curvilinear ultrasound probe.

(a)
Nerve
Ultrasound plane
(b)
Nerve
Ultrasound plane
FIGURE 1.4 Nerve views. (a) Short axis (SAX) view. The ultrasound imaging
plane is perpendicular to the nerve. (b) Long axis (LAX) view. The ultrasound
imaging plane is parallel to the nerve.
(a)
IP
Ultrasound plane
(b)
OOP
Ultrasound plane
FIGURE 1. 5 Needle approach. (a) In-plane (IP) approach. The needle is

imaged along the entirety of its shaft within the ultrasound plane. (b) Out-of-
plane (OOP) approach. The needle is inserted at right angles to the imaging
plane. Move the imaging plane to keep the needle tip in constant view as the
needle is advanced.
• The characteristic appearance of nerves at various locations may assist in

their identification. Lower frequencies increase the penetration of ultrasound
energy—useful for the identification of deeper nerves—at the expense of
resolution
• The neck is the only location where it is possible to image nerve roots and
the proximal few centimetres of peripheral nerves, visible as a dark centre
surrounded by a hyperechoic rim
• The appearance of peripheral nerves in cross section may vary from rounded
to flattened
(a)
(b)
FIGURE 1.6 (a) SAX view of the median nerve forearm. (b) LAX view of the
median nerve forearm.
• Anisotropy is a helpful property for the identification of peripheral nerves. It is

recognized as the enhanced ultrasound reflection when the nerve is imaged
perpendicular to the fibre direction. See Figures 1.8 and 1.9
• Tendons share a similar characteristic and must be differentiated from
nerves prior to nerve blockade. Tendons disappear into muscles when
scanned proximally. See Figure 1.10
• The echogenicity of nerves varies, according to their location. Peripheral
branches of the sciatic nerve and brachial plexus, for example, are
predominantly hyperechoic, while nerve roots and trunks of the brachial
plexus in the interscalene and supraclavicular region appear hypoechoic.9 See
Figures 1.11 and 1.12
• Blood vessels are frequently used as landmarks for the localization of nerves:
• Well-demarcated vessel walls surround the sonolucent black blood flow
• Arteries are rounder, with thick walls, and may be pulsatile
• Veins have thinner, readily collapsible walls when gentle pressure is applied
• Colour flow Doppler and colour power Doppler may assist with the
identification of vessels. See Figures 1.13 and 1.14
• Vessels usually have a post-cystic enhancement.
(a)
Median n.
(b)
Nerve
FIGURE 1.7 (a) SAX view of the median nerve. (b) LAX view of the

median nerve.
FIGURE 1. 8 Anisotropy (median nerve not visible).
Preoperative assessment
• Routine preoperative assessment is still required prior to performing
ultrasound-guided blocks
• Remember to consider contraindications
• Informed consent is required prior to performing ultrasound-guided blocks;
specific information should be provided to patients:
• Example forms are available at: (http://www.acecc.org.au/default.aspx)
• Refer to resources under the Regional Anaesthesia Special Interest Group
(SIG) (http://www.acecc.org.au/RegAnaes.aspx).
Median n.
FIGURE 1.9 Anisotropy (median nerve visible).
Tendons
Median n.
FIGURE 1.10 Median nerve and tendons.
SCM
Scalenus anterior Scalenus medius
Interscalene plexus
FIGURE 1.11 SAX view of the interscalene.

Axillary v.
Axillary a.
FIGURE 1.12 SAX view of the axillary uncompressed CFD.
Axillary a.
FIGURE 1.13 SAX view of the axillary compressed CFD.
Axillary a.
Post-cystic enhancement
FIGURE 1.14 SAX view of the axillary compressed CFD.
Set-up and equipment

• Optimal ergonomics are essential for the success of ultrasound-guided
10
regional anaesthesia:
• The patient is positioned appropriately for the specific block to be
administered
• The operator should ensure that the ultrasound screen is easily seen without the
need to twist or turn their body—this may be on the opposite side of the patient
• Figures 1.15 and 1.16 demonstrate good and bad ergonomics for
ultrasound-guided regional anaesthesia
FIGURE 1.15 Bad ergonomics for ultrasound-guided regional anaesthesia.
FIGURE 1.16 Good ergonomics for ultrasound-guided regional

anaesthesia.
• Ensure all equipment is prepared prior to application of the probe so that the 10
block procedure may continue immediately without the need to reorientate:
• The ultrasound probe should be covered with a sterile plastic sheath,
ensuring no seam overlies the tip
• Depending on the type of probe, water, saline, or gel may be used inside
the sheath, and sterile gel, water, saline, or antiseptic solution used outside
the sheath as a coupling medium between the probe and the patient.
Sterile water is recommended when performing central neuraxial block to
avoid contact between the needle and ultrasound gel
• Needle choice will vary with the procedure and the experience of the
anaesthetist; larger Tuohy needles are easier for beginners to visualize, while
the more experienced may prefer to use finer needles. Echogenic tipped
needles are a useful alternative when attempting to block deeper nerves
• Additional personnel should be available to assist the anaesthetist, as required:
• Non-sterile assistants are required to open sterile items and equipment
• Sterile/gloved assistants should be available to assist with holding the probe
or injection of agents.
Infection control in ultrasound-guided regional anaesthesia
• Published guidelines recommend the use of surgical mask and gloves,
11
following proper handwashing for single shot blocks
• A sterile gown should be added for continuous catheters
• Appropriate infection control practices for the ultrasound machine and probe
should be undertaken:
• Avoid cross-contamination from the probe by sheathing prior to, and
decontaminating after, each patient. See Figure 1.17
• Heavily soiled probes should be cleaned thoroughly with mild detergent.
Preprocedure scanning
• Ultrasonic examination should be performed before deciding on the block:
• Identify anatomical variations that may preclude specific blocks
• Optimize ultrasound images
• Choose procedure, and plan needle path
• The best images are obtained before the probe is in a sterile sheath
• Opportunity to determine the most appropriate block and approach for
needle (IP/OOP).
Performing the procedure

Several factors should be considered to maximize the advantages of
ultrasound-guided regional anaesthesia.
• Asepsis should be strictly maintained
• Ultrasound-guided regional anaesthesia is not constrained by surface or
palpable landmarks. Perform the block at a location such that the projected
needle trajectory maximizes needle tip visualization but avoids critical
structures to reduce the risk of complications
• Gentle tissue handling skills are required to minimize the risk of iatrogenic
damage to anatomical structures:
•
Align the needle trajectory towards the corners of nerves to avoid direct
needle trauma if the tip is placed deeper than expected. See Figures 1.18
to 1.21
• Many nerves relevant to regional anaesthesia lie in a fascial plane:
• Align the needle trajectory towards fascial planes, and hydrodissect the
plane with local anaesthesia, saline, or 5% dextrose
• Correct needle tip placement is confirmed with optimal injectate spread
around the nerve. See Figure 1.22
(a) (b)
FIGURE 1.17 (a) and (b) Sheathing of probe to prevent

cross-contamination.
Probe
Needle inserted at
45° to ultrasound
beam
Ultrasound beam
Minimal ultrasound
scatter back to
transducer, resulting in
poor needle visibility
FIGURE 1.18 Needle tip visibilities 45°. The needle is inserted at 45° to the
ultrasound probe.
Needle
FIGURE 1.19 Needle tip is visible in the ultrasound at 45°.
Probe
Ultrasound beam
More ultrasound
reflections back to
transducer, resulting
in bright needle
visibility
Needle
Reverberation artefacts
FIGURE 1. 20 Needle tip visibilities 90°. Needle is inserted at 90° to

ultrasound probe.
Needle
FIGURE 1. 21 Needle tip is visible in the ultrasound at 90°.
c
d
b
a
FIGURE 1. 22 Subcostal TAP—correct plane.

a Tuohy needle c External oblique m.
b Local anaesthetic hydrodissection d Internal oblique m.
in TAP e Transversus abdominis m.
• Needle advancement and injectate spread are best visualized in real time

• Ultrasound-guided regional anaesthesia may be a multi-injection technique,
where the needle is repositioned several times to optimize spread of local
anaesthetic. Figures 1.23 to 1.26 demonstrate this process of repositioning:
• Bolus–observe–reposition
• Attention should be paid to the incorporation of ultrasound-guided nerve
blocks into the overall flow of the procedure for each patient to allow
sufficient time for effective block prior to the procedure and to avoid the
block wearing off prematurely.
Troubleshooting for ultrasound-guided regional

anaesthesia
• Several steps may be taken if the ultrasound images obtained are of poor
10
quality:
• Inspect the ultrasound machine settings, including power, frequency, depth,
gain, time gain compensation, focus, and software
(a)
Ulnar nerve
Fascial planes
Needle
(b)
Ulnar n.
Needle shaft
Needle tip below nerve
FIGURE 1. 23 Ulnar block, step one: aiming for nerve corners. (a) Aim the
needle at the corners of the nerves to avoid direct nerve trauma. (b) Correct
position of the needle shaft shown in ultrasound.
(a)
Needle
Local anaesthetic injected below
fascial plane
(b)
Ulnar n. Fascial planes
Local anaesthetic (in wrong plane and not surrounding nerve)
FIGURE 1. 24 Ulnar block, step two: bolus and observe. (a) Aim to position

needle tip into fascial plane; local anaesthetic will then hydrodissect naturally
around nerve target. (b) Here, local anaesthetic is shown in the wrong plane
and not surrounding nerve.
(a)
Needle
Local anaesthetic
boluses
(b)
Needle repositioned above nerve
Local anaesthetic (in wrong plane)
FIGURE 1. 25 Ulnar block, step three: reposition, then bolus–observe.

(a) The needle is repositioned above the nerve, aiming at the nerve corner
and into the fascial plane. Bolus demonstrates the position is still incorrect.
(b) The needle has been repositioned but is still in the wrong plane.
(a)
Local
anaesthetic
from previous
boluses
Needle Fascial planes hydrodissected

away from nerve by LA
Correct placement of local
anaesthetic bolus around nerve
(b)
Needle tip (not fully visible)
Fascial planes
hydrodissected
Local anaesthetic ideally away from nerve
surrounding nerve by LA
FIGURE 1. 26 Ulnar block, step four: ideal placement. (a) The needle is

repositioned again, and another bolus is injected and observed; an ideal
U-shaped spread of local anaesthetic is then observed. (b) The needle is now
shown correctly positioned.
• Ensure sufficient coupling medium exists between the probe and the
patient, both within and outside the sheath. Remove any sheath seams or
bubbles from over the probe
• Try holding the probe in place, with gentle pressure for a few seconds, to
improve the picture quality
• Nerve stimulators may be used in combination with ultrasound to accurately
identify individual nerves:10
• Recommended when the operator is unsure of the anatomy
• Limitations include failure to successfully stimulate the nerve, despite direct
contact with the needle, and patient discomfort.
Follow-up
• Follow-up is required to detect any new onset of paraesthesiae, tingling,
abnormal sensation, weakness, or pain post-block
• The authors recommend patient follow-up over 7–10 days post-block.
A suggested algorithm can be found at the International Registry of Regional
Anaesthesia (AURORA), at http://www.anaesthesiaregistry.org.12
Troubleshooting for
neurostimulation-guided regional
anaesthesia
There are many reasons why anaesthetists experience difficulty when performing
regional anaesthesia blocks, and it can be difficult to discern why a nerve cannot
be located.
If experiencing difficulty, the following tips may be of use:
• Confirm that the nerve stimulator is connected and that the battery is charged
• Ensure the connections are good (wires not broken)
• Ensure good contact with the ECG electrode
• Confirm that an appropriate current is set (start at approximately 1 mA)
• Verify the anatomical landmarks—this is especially important with obese
patients. Ensure the correct projection of bony landmarks to the skin, as errors
are easily generated when bony landmarks are poorly localized and loose skin
causes midline shift
• If the patient is conscious, moving, and uncooperative, consider general
anaesthesia prior to regional anaesthesia if the techniques are to be
performed together. Evidence suggests that the risk of nerve damage while
performing regional anaesthesia blocks is no greater in unconscious patients
than in conscious patients
• When learning to perform regional anaesthesia techniques, allow ample time
to administer the block and for the block to take effect
• Do not accept an inferior muscle twitch—ensure that the correct muscle is
stimulated and that the muscle is not being directly stimulated
• Ensure the stimulating current is low enough to be close to the nerve
• When stimulation achieves the desired muscle twitch, gently inject 0.5 mL
of local anaesthetic, which should abolish the twitch. If further stimulation is
required, then 5% dextrose should be used as the test bolus. If not, or there
is radicular pain or high injection pressures, reposition the needle slightly to
avoid intraneural injection
• Always inject local anaesthetic gently, and aspirate gently for every 5 mL of
local anaesthetic injected
• Keep the needle immobile while injecting. For blocks where the needle is
well held by the tissues (e.g. sciatic nerve block), release of the needle may be
advantageous so that, if the patient moves, the needle will remain in position.
General side effects and complications

of regional anaesthesia
Systemic toxicity of the local anaesthetic
• Most commonly caused by unintended intravascular injection
• To minimize risk:
• Adhere to the recommended dosages
• Aspirate repeatedly, and inject fractionally (negative aspiration does not
entirely exclude intravascular injection)
• Observe spread of local anaesthetic on ultrasound
• Inject slowly
• Observe and maintain verbal contact with the patient.
Nerve damage (extremely rare)
• Ensure needle tip is in view before advancing when using ultrasound
• Avoid paraesthesiae when inserting the needle
• Use a suitable nerve stimulator
• Use atraumatic needles.
Haematoma
• Consider not performing blocks in patients with a clinically manifest
coagulation disorder or receiving anticoagulation treatment
• Refer to guidelines for regional anaesthesia in patients receiving
antithrombotic therapy.13
Infection (especially with continuous catheter

technique)
• Insert the needle using an aseptic technique
• Avoid injection through infected areas
• Regularly check the catheter insertion site (at least once a day)
• Immediately remove the catheter if the patient reports tenderness at the
point of catheter entry (most sensitive indicator of infection).
General contraindications
See Box 1.2.
BOX 1.2 GENERAL CONTRAINDICATIONS TO REGIONAL

ANAESTHESIA
• Allergy to local anaesthetic

• Rejection of technique by patient
• Clinically manifest severe coagulation disorders
• Infection or haematoma at injection site
• Lack of experience with performing nerve block
• Relative contraindication: neurological defects (previous documentation
necessary).
Systemic effects of local anaesthetic

intoxication
See Figure 1.27.
Management of local anaesthetic toxicity

The Association of Anaesthetists of Great Britain and Ireland (AAGBI) Safety
Guideline for Management of Severe Local Anaesthetic Toxicity is a guideline
that outlines the steps for recognition, immediate management, and treatment
of cases of local anaesthetic toxicity.14
Local anaesthetic toxicity may occur some time after the initial injection and
may be recognized by several signs:14
• Alteration of mental status, severe agitation, or loss of consciousness:
• May be associated with tonic-clonic convulsions
• Cardiovascular collapse:
• Sinus bradycardia, conduction blocks, asystole, and ventricular
tachyarrhythmias possible.
Treatment of local anaesthetic toxicity14

• Immediately, stop injection of local anaesthetic, and call for help
• Maintain the airway, securing with a tracheal tube, if necessary
• Give 100% oxygen, ensuring adequate lung ventilation
• Confirm/establish intravenous access
• Control seizures with a benzodiazepine, thiopental, or propofol, administered
in small incremental doses
• Monitor cardiovascular status throughout
• If circulatory arrest occurs:
• Start cardiopulmonary resuscitation (CPR), using standard protocols
• Manage arrhythmias:
• Arrhythmias may be very refractory to treatment
• Do not use lignocaine
• Administer intravenous lipid emulsion, according to protocol outlined under
Treatment of local anaesthetic toxicity with intravenous lipid emulsion:
Time Apnoea
Central Circulatory collapse/
cardiac arrest
nervous Coma
system Seizures Ventricular
fibrillation
Muscle twitching
Restlessness Ventricular
Confusion arrhythmia
Visual disturbances Tachycardia
Verbal or vocalization Multifocal ectopic
problems beats
Metallic taste QRS widening Cardiovascular
Peri-oral and tongue
paraesthesiae Long PR interval system
Dizziness Bradycardia Dose
FIGURE 1. 27 Symptoms and signs of local anaesthetic toxicity.

Adapted from Meier G & Büttner J. Regional anaesthesia. Pocket compendium of peripheral
nerve blocks. 3rd edn. Munich: Acris Publishing Company, 2005.
• Continue CPR throughout administration

• Propofol is not a suitable substitute for lipid emulsion
• Recovery from cardiac arrest may take over 1 hour.
• If circulatory arrest does not occur:
• Use conventional therapies to treat hypotension, bradycardia, and
tachyarrhythmia
• Do not use lignocaine.
Treatment of local anaesthetic toxicity with intravenous

lipid emulsion14
Immediately:
• Inject an initial intravenous bolus of 20% lipid emulsion (1.5 mL/kg body
weight) over 1 minute, and
• Start an intravenous infusion of 20% lipid emulsion (0.25 mL/kg body weight
per minute, equivalent to 15 mL/kg body weight per hour).
After 5 minutes:
• A maximum of two repeat boluses of 20% lipid emulsion (1.5 mL/kg body
weight) should be given if:
• Cardiovascular stability has not been restored, or
• Adequate circulation deteriorates
• Continue the infusion at the same rate, but double the rate to 0.50 mL/kg
body weight per minute (30 mL/kg body weight per hour) at any time after 5
minutes, if:
• Cardiovascular stability has not been restored, or
• Adequate circulation deteriorates.
Other points to note:
• A maximum of three boluses may be given, including the initial bolus
• Leave 5 minutes between boluses
• Do not exceed a maximum cumulative dose of 12 mL/kg
• Following initial recovery, the patient should be transferred for appropriate
further monitoring until sustained recovery is achieved
• Cases of local anaesthetic toxicity should be reported appropriately
• A quick reference guide to treatment of local anaesthetic toxicity is located
on p.152.
Allergic reactions
Allergy for amide local anaesthetics is extremely rare and should be treated like
any allergic reaction.
Post-operative analgesia
Injectable local anaesthetics
Concentrations, dosages, and durations of various injectable local anaesthetics
are given in Tables 1.1 and 1.2, and Figure 1.28. Box 1.3 details the special
features of some of these drugs.
Care of catheters for continuous infusions

• At least once a day:
• Check the catheter position and insertion site for infection
• Assess effectiveness of analgesia
• Analyse indications critically
• Document carefully.
• If analgesia is insufficient:
• Check that the catheter is positioned correctly and has not dislodged
• Inject bolus (e.g. 10 mL 0.2% ropivacaine) if analgesia is only partially
effective
• Provide supplementary analgesics (NSAID, paracetamol, opioids orally),
as needed
• Provide additional pain medication when removing the catheter.
• Duration of treatment:
•Usually up to 3–5 days, depending on the indication (for chronic pain
therapy, a duration of more than 100 days has been described)
•An analgesic catheter can be used in outpatients, but the corresponding
prerequisites must be considered.
TABLE 1.1 Concentration and recommended dosage17–19
Bupivacaine Lignocaine Ropivacaine

Single injection
Concentration 0.25–0.5% 1–2% 0.5–1%
Dosage* Up to 2 mg/kg Up to 4 mg/kg Up to 2.5 mg/kg
Time until effective 10–25 min 5–15 min 10–25 min
Analgesic duration Up to 12 h 2–5 h Up to 12 h
Continuous infusion
Concentration 0.125–0.25% NA 0.2%
Dosage* Up to 18.75 NA Up to 28 mg/h
mg/h
NA, not administered for continuous infusions.
* The anaesthetist’s experience and knowledge of the patient’s physical status are important
determinants when calculating the anaesthetic dose to be administered.
TABLE 1. 2 Pharmacokinetic profile following experimental intravenous

administration in adults17–19
Bupivacaine Lignocaine Ropivacaine

Total plasma clearance 0.58 0.95 0.44
(L/min)
Steady-state distribution 73 91 47
volume (L)
Elimination half-life in 2.7 1.6 1.8
plasma (h)
Intermediate hepatic 0.40 0.65 0.40
extraction ratio
Single injection
Lignocaine 2% Continuous infusion
Bupivacaine 0.5%
Ropivacaine 0.75%
Bupivacaine 0.125–0.25%*
Ropivacaine 0.2%*
2 4 6 8 10 12 14
Hours
FIGURE 1. 28 Analgesic duration of bupivacaine, lignocaine, and

ropivacaine.
* Start infusion before the onset of post-operative pain; otherwise, start with an initial bolus.
BOX 1.3 SPECIAL FEATURES
Bupivacaine
• Long duration of action and slow onset.15
Lignocaine
• Produces a rapid onset of intense motor and sensory nerve blockade.16
Ropivacaine
• Long duration of action and slow onset15
• Reduced cardiovascular and CNS toxicity, compared with racemic
bupivacaine.16
References
1 Australian and New Zealand College of Anaesthetists. Recommendations
on the pre-anaesthesia consultation. Viewed 24 January 2010, <http://www.
anzca.edu.au/resources/professional-documents/professional-standards/
pdfs/PS7-2008.pdf>.
2 Oranje A and de Waard-van der Spek F (1995). Use of EMLA cream in
dermatosurgical interventions of skin and genital mucosa. In: Koren G, ed.
Eutectic Mixture of Local Anesthetics (EMLA), pp. 123–36. New York : Marcel
Dekker, Inc .
3 Tsui B and Kropelin B (2005). The electrophysiological effect of dextrose
5% in water on single-shot peripheral nerve stimulation. Anesth Analg 100,
1837–9.
4 Australian and New Zealand College of Anaesthetists. Recommendations
on monitoring during anaesthesia. Viewed 24 January 2010, <http://www.
anzca.edu.au/resources/professional-documents/professional-standards/
pdfs/PS18-2008.pdf>.
5 Marhofer P, Greher M, Kapral S (2005). Ultrasound guidance in regional
anaesthesia. Br J Anaesth 94, 7–17.
6 Gray A (2006). Ultrasound-guided regional anaesthesia. Current state of the
art. Anesthesiology 104, 368–73.
7 Chuan A (2007). Ultrasound guided regional anaesthesia. In: Ashley C ,
Chuan A , George L , Harrison J, eds. Ultrasound in anaesthetic practice.
Training manual. 2nd edn, pp. 23–54. Sydney : Westmead Hospital
Anaesthetic Department .
8 Neal J, Brull R , Chan V, et al. (2010). The ASRA evidence-based medicine
assessment of ultrasound-guided regional anesthesia and pain medicine.
Executive summary. Reg Anesth Pain Med 35, S1–S9.
9 Perlas A and Chan V. Ultrasound-assisted nerve blocks.
New York: New York School of Regional Anaesthesia. Viewed 19
October 2009, <http://www.nysora.com/peripheral_nerve_blocks/
ultrasound-guided_techniques/3063-ultrasound_assisted_nerve_blocks.
html>.
10 Hebbard P, Barrington M, Royse C. Ultrasound guided procedures in
anaesthesia 2nd edn. Parkville: HeartWeb. Viewed 19 October 2009, <http://
www.heartweb.com.au/>.
11 Australian and New Zealand College of Anaesthetists. Review Professional
Standards 3—Guidelines for the management of major regional analgesia.
Viewed 21 December 2009, <http://www.anzca.edu.au/resources/
professional-documents/professional-standards/pdfs/PS3.pdf>.
12 Australasian Regional Anaesthesia Collaboration. 7-day follow up pathway.
Viewed 20 October 2009, <http://www.regional.anaesthesia.org.au/>.
13 Horlocker T, Wedel D, Rowlingson J, et al. (2010). Regional anesthesia in the
patient receiving antithrombotic or thrombolytic therapy: American Society
of Regional Anesthesia and Pain Medicine evidence-based guidelines (3rd
edn). Reg Anesth Pain Med 35, 64–101.
14 Association of Anaesthetists of Great Britain & Ireland. AAGBI Safety
guideline: Management of severe local anaesthetic toxicity. London: AAGBI.
Viewed 1 February 2010, <http://www.aagbi.org/publications/guidelines/
docs/la_toxicity_2010.pdf>.
15 Tetzlaff J (2000). The pharmacology of local anaesthetics. Anesth Clin North
America 18, 217–33.
16 McLure H and Rubin A (2005). Review of local anaesthetics. Minerva
Anestesiol 71, 59–74.
17 Naropin®. Australian Approved Product Information. 10 September 2010.
18 Xylocaine® Plain and Xylocaine® with Adrenaline. Australian Approved
Product Information. 20 September 2010.
19 Marcain® and Marcain® with adrenaline. Australian Approved Product
Information. 20 September 2010.
CHAPTER TWO
THE HEAD
Anatomy of the nerve supply to the head

and scalp 28
Sensory supply 29
Peribulbar block 30
Sub-Tenon’s eye block 32
Supraorbital and supratrochlear nerve block 34
Infraorbital nerve block 36
Mental nerve block 38
Maxillary nerve block 40
Anterior ethmoidal nerve block 42
References 44
Anatomy of the nerve supply to the

head and scalp
The trigeminal ganglion (the fifth cranial nerve) is divided into sensory and
motor branches. The ophthalmic and maxillary nerves are purely sensory. The
mandibular nerve has both sensory and motor functions. These branches
provide innervation to the face, scalp to the top of the head, conjunctiva, eye,
paranasal sinuses, oral cavity, teeth, and dura. See Figure 2.1.
d
b
c
e
2
1 3
4
g
f
FIGURE 2 .1 Anatomy of the nerve supply to the head and scalp.

1 Trigeminal n. ganglion a Supraorbital n.
2 Ophthalmic n. b Supratrochlear n.
3 Maxillary n. c Nasociliary n.
4 Mandibular n. d Anterior ethmoidal n.
e Anterior ethmoidal n. (external
nasal branch)
f Infraorbital n.
g Buccal n.
h Lingual n.
i Mental n.
j Inferior alveolar n.
THE HEAD 29
Sensory supply
See Figure 2.2.
FIGURE 2 . 2 Sensory
supply of the head
and scalp.
Divisions of the
trigeminal nerve: V1
V1 Ophthalmic area
V2 Maxillary area
V3 Mandibular area
Cervical plexus: V2
1 Greater occipital area
(posterior division
of C2)
V3
2 Lesser occipital area
(posterior division
of C2)
V1
1
V2
V3
Peribulbar block
COMPLEXITY:
Indications
• Anaesthesia and analgesia for eye surgery (e.g. cataract extraction,
trabeculectomy, vitrectomy, and strabismus repair).
Specific contraindications
• Penetrating eye injury
• Scleromalacia
• Severe coagulopathy
• Axial length is >26 mm.
See Figures 2.3 to 2.5.
Technique
Patient position: supine. Ask the patient to look directly ahead and focus on a
fixed point of the ceiling. This will ensure neutral positioning of the eyes.
Landmark: inferior orbital rim.
Technique: anaesthetize the conjunctiva by instilling three drops of 1%
amethocaine or oxybuprocaine into the eye. Repeat three times at 1-minute
intervals, if required. Clean the lower eyelid with half-strength iodine solution.
At the lateral one-third and medial two-thirds junction of the inferior orbital
rim, insert the needle percutaneously through the lower eyelid. Direct and
advance the needle sagittally, parallel to the orbital floor and under the globe,
until the needle hub is at the same depth as the iris (no more than 31 mm
beyond the orbital rim). A distinctive ‘pop’ may be felt as the needle passes
through the lower orbital septum. Following negative aspiration, inject 10–15
mL of anaesthetic solution slowly. Close the eye with adhesive tape, and apply
gentle pressure for 5–10 minutes (manually or with an oculopressor) to lower
intraocular pressure and allow spread of local anaesthetic.
Needle: 25 G, 2.5 cm.
Local anaesthetic: 0.75% or 1% ropivacaine with 75–150 U/mL hyaluronidase.
Comments: infiltration of the skin at the injection site with 0.5 mL 1%
lignocaine improves patient comfort. Advantages of peribulbar anaesthesia over
retrobulbar anaesthesia include reduced incidence of retrobulbar haemorrhage,
optic nerve and globe damage, and intradural injection. A single injection is
usually sufficient for anaesthesia and is easy to perform. If insufficient, a second
superior injection is required.1 Hyaluronidase is commonly added to facilitate
anaesthetic spread. Less than 10 mL of ropivacaine is required for anaesthesia
if 300 U/mL of hyaluronidase is added. A total of 8 mL of a 1:1 mixture of 2.0%
lignocaine and 0.5% bupivacaine (with 75–150 U/mL hyaluronidase) can also
be injected.2 Potential disadvantages of combining anaesthetic agents include
bacterial contamination, substitution errors, and limited shelf life.
THE HEAD 31
FIGURE 2 . 3 Muscles 3
in the region of the eye. 2
1 Medial rectus m.
1
2 Superior rectus m.
3 Superior oblique m.
4 Needle insertion site
5 Inferior oblique m.
6 Lateral rectus m.
7 Inferior rectus m.
7 6
5
FIGURE 2 .4 Insert
the needle at the lateral
one-third and medial
two-thirds junction of
the inferior orbital rim.
a Needle insertion site
FIGURE 2 . 5 Direct
and advance the needle
sagitally, parallel to the
orbital floor and under
the globe.
Sub-Tenon’s eye block
COMPLEXITY:
Tenon’s capsule is a layer of elastic white connective tissue that surrounds
the globe deep to the conjunctiva. Anteriorly, it merges with the conjunctiva,
approximately 1 mm from the limbus, and extends posteriorly to attach to a
fibrous ring around the optic nerve. A potential space between the Tenon’s
capsule and the sclera is the sub-Tenon space.
Indications
• Anaesthesia and analgesia for eye surgery (e.g. cataract extraction,
trabeculectomy, vitrectomy, and strabismus repair).
• Penetrating eye injury
• Scleromalacia.
Technique
Patient position: supine. To expose the inferonasal quadrant of the anterior
eye, ask the patient to look up and out over their ipsilateral shoulder.
Landmarks: inferonasal quadrant and limbus.
Technique: anaesthetize the conjunctiva by instilling three drops of 1%
amethocaine or oxybuprocaine into the eye. Prepare the eye with half-strength
povidone-iodine solution. Place a wire lid speculum to hold the eyelids open.
Using Moorefields forceps, lift the conjunctiva (and underlying Tenon’s capsule) in
the inferonasal quadrant, and make a small incision with Wescott spring scissors
through the conjunctiva approximately 5 mm from the limbus. White bare sclera
should be visible through the cut. While lifting the conjunctiva, gently advance the
closed scissors through the incision to blunt dissect anterior adhesions between
the Tenon’s capsule and the sclera. Remove scissors, and insert the sub-Tenon
cannula (with syringe attached) through the incision, and gently advance, following
the curvature of the globe. Beyond the equator of the globe, clear adhesions that
may hinder the passage of the cannula by gentle hydrodissection. Infuse 5 mL of
anaesthetic slowly when the cannula is fully inserted. Close the eyelid on removing
the cannula, and apply gentle direct digital pressure to the insertion point (or
oculopressure device 35 mmHg for 5 minutes). The anaesthetic will initially fill the
sub-Tenon’s space, then pass posteriorly into the retrobulbar space and eventually
into the extraconal space. Complete akinesia and anaesthesia should occur within
5 minutes. Ptosis commonly occurs with injection of 5 mL of anaesthetic.
Needle: 19 G, 25 mm sub-Tenon cannula (blunt, flattened, and curved).
Local anaesthetic: 2% lignocaine, 0.5% bupivacaine, or 0.75–1% ropivacaine
with 60–300 U/mL hyaluronidase.
Comments: as this block requires a low volume of anaesthetic and minimal
pressure, surgery can proceed rapidly as changes in intraocular pressure
are minimal.3 The addition of hyaluronidase facilitates the speed of onset of
anaesthesia.4 This block is more comfortable than peribulbar block and as
effective as retrobulbar block, without the risks of retrobulbar haemorrhage,
nerve or globe injury, or subdural injection.5
THE HEAD 33
FIGURE 2 .6 Anatomy
for sub-Tenon’s eye block
1 Levator palpebral
superioris m.
2 Superior rectus m.
1
3 Connective tissue
bands 2
7
4 Optic n. 3
8
5 Bulbar fascia 4 9
6 Inferior rectus m. 5
7 Cornea 10
8 Superior tarsus 6
9 Lens
10 Inferior tarsus
FIGURE 2 .7 Insert
the sub-Tenon cannula
through the inferonasal
incision.
FIGURE 2 . 8 The
sub-Tenon cannula is
fully inserted.
Supraorbital and supratrochlear

nerve block
COMPLEXITY:
Indications
• Anaesthesia and analgesia for lower forehead and upper eyelid surgery (e.g.
excision of skin lesions, suturing of lacerations).
Side effects and complications
• Periorbital ecchymosis (black eye; uncommon). 6
See Figures 2.9 and 2.10.
Technique
Patient position: supine.
Landmark: supraorbital ridge.
Technique: insert the needle in the midline just above the supraorbital
ridge, and raise a bleb of local anaesthetic. Inject 3–4 mL of anaesthetic
subcutaneously and slowly along the supraorbital ridge in a lateral direction to
block both the supraorbital and supratrochlear nerves. Repeat on the opposing
side to block the nerve bilaterally.
Needle: 25 G, 38 mm.
Local anaesthetic: 2% lignocaine with adrenaline 1:200 000, 0.5% bupivacaine
or 0.75–1% ropivacaine.
Comments: lignocaine with adrenaline provides surgical anaesthesia for up to 3
hours and analgesia for 6–9 hours. Prior to injecting lignocaine with adrenaline,
cover the patient’s eye with an eye pad to prevent adrenaline from seeping onto
the eye.6 As injections in the face can cause anxiety in patients, it is important
to be gentle, inject anaesthetic slowly and carefully, and wait for a result. An
anxiolytic, such as midazolam, may be given to patients to reduce their anxiety.
THE HEAD 35
FIGURE 2 .9 The
supraorbital,
infraorbital, and b a
mental foramen
align parasagittally
on the face.
a Needle
insertion site
b Inject the local
anaesthetic to
midpoint of
supraorbital ridge
FIGURE 2 .10
1 Supraorbital n.
2 Supratrochlear n. 1
3 Supraorbital foramen
2
4 Orbital cavity
4
Infraorbital nerve block
COMPLEXITY:
Indications
• Anaesthesia and analgesia for upper lip, lower eyelid and cheek surgery (e.g.
excision of skin lesions and suturing of lacerations).
• Minor bruising 6
• Retrograde passage of the anaesthetic if injected into (rather than adjacent to)
the infraorbital foramen, resulting in more generalized anaesthetic effects than
expected.6
Technique
Landmarks: extra-oral: infraorbital foramen; intra-oral: junction of alveolar and
buccal mucosa.
Technique: for extra-oral injection, palpate the infraorbital foramen (1 cm below
the midpoint of the inferior orbital margin). Insert the needle adjacent to the
infraorbital foramen, and inject the anaesthetic slowly. For intra-oral injection,
retract the upper lip with the thumb and forefinger. Insert the needle parallel to the
face at the junction of the alveolar and buccal mucosa. Advance the needle gently
through the mucosa for approximately 1 cm. Inject 1–2 mL of anaesthetic slowly.
Needle: 25 or 27 G, 10 mm.
Local anaesthetic: 2% lignocaine with adrenaline 1:200 000.
Comments: lignocaine with adrenaline provides surgical anaesthesia for up to
3 hours and analgesia for 6–9 hours. Injection of bupivacaine or ropivacaine
is not recommended, as this will result in a lip that is heavily blocked for many
hours. Direct infiltration of the operative site with lignocaine with adrenaline
is a better alternative. As injections in the face can cause anxiety in patients, it
is important to be gentle, inject slowly and carefully, and wait for a result. An
anxiolytic, such as midazolam, may be given to patients to reduce their anxiety.
Warn patients to avoid hot drinks until the block has worn off.
FIGURE 2 .11
1 Infraorbital foramen
2 Infraorbital n.
2
THE HEAD 37
a
b
FIGURE 2 .12 Extra-oral route: insert the needle adjacent to, but not into,
the infraorbital foramen.
a Infraorbital foramen b Needle insertion site
FIGURE 2 .13 Intra-oral route: insert the needle into the gum at the
junction of the alveolar and buccal mucosa.
Mental nerve block
COMPLEXITY:
Indications
• Anaesthesia and analgesia for the bottom lip and chin surgery (e.g. complete
vermilionectomy, wedge resection).
• Minor bruising 6
• Salivary drooling while the block is effective.

6
Technique
Landmark: mental foramen (located below the second premolar or between
the first and second premolar teeth).
Technique: for intra-oral injection, insert the needle at the junction of the
alveolar and buccal mucosa (topical lignocaine may be applied prior to injecting
the anaesthetic). Advance the needle about 1 cm through the mucosa until it is
over the mental foramen. Inject 1–2 mL of anaesthetic slowly. To perform full
surgery of the lower lip, both inside and out, block the nerve bilaterally.
Needle: 25 G, 38 mm.
Local anaesthetic: 2% lignocaine with adrenaline 1:200 000.
Comments: lignocaine with adrenaline provides surgical anaesthesia for up to
3 hours and analgesia for 6–9 hours. As for infraorbital block, avoid injecting
bupivacaine or ropivacaine, and infiltrate the operative site with lignocaine
with adrenaline. Blocking the mental nerve does not anaesthetize the gums or
teeth. As injections in the face can cause anxiety in patients, it is important to
be gentle, inject slowly and carefully, and wait for a result. An anxiolytic, such as
midazolam, may be given to patients to reduce their anxiety. Warn patients to
avoid hot drinks until the block has worn off.
THE HEAD 39
FIGURE 2 .14
1 Mental foramen
2 Mental n.
1
2
FIGURE 2 .15
Insert the needle
into the gum at
the junction of the
alveolar and buccal
a
mucosa.
a Needle
insertion site
Maxillary nerve block
COMPLEXITY:
Indications
• Anaesthesia and analgesia for maxillary teeth, buccal and palatal soft tissue as
far as the midline, upper lip, lateral aspect of the nose, and the lower eyelid
sugery (for nasal surgery, see Anterior ethmoidal nerve block)
• Supplemental anaesthesia for transphenoidal hypophysectomy.

• Haematoma formation.
Technique (lateral extra-oral approach)

Patient position: supine with head in neutral position.
Landmark: zygomatic arch (posterior and anterior limits) and lateral
pterygoid plate.
Technique: palpate the zygomatic arch, and locate its posterior and anterior
limits. To identify the posterior limit, ask the patient to open their mouth to
feel the movement of the mandible head just in front of the tragus. The point
at which the arch joins the posterior convexity of the zygomatic process of the
maxilla is the anterior limit. Locate the midpoint on the inferior border of the
arch by bisecting the length of the arch. Infiltrate the area with 2% lignocaine
(2 mL). Insert and advance the needle (approximately 4–5 cm) until it contacts
the lateral pterygoid plate. Note needle depth; place a 0.25 cm marker on the
needle, and withdraw. Redirect the needle anteriorly and superiorly to pass
anterior to the lateral pterygoid plate into the pterygopalatine fossa. Advance
the needle no further than 0.25 cm deeper than the lateral pterygoid plate.
Following negative aspiration, inject 5 mL of anaesthetic slowly.
Needle: 25 G, 10 cm, short bevel, or 22 G spinal needle.
Local anaesthetic: 2% lignocaine with adrenaline 1:200 000, or 0.75%
ropivacaine.
THE HEAD 41
FIGURE 2 .16
1 Trigeminal ganglion
2 Maxillary n.
3 Pterygopalatine
fossa
4 Zygomatic arch 1 2 4
5 Mandible
3 5
FIGURE 2 .17 Insert

until it contacts the lateral
pterygoid plate.
a Midpoint of the
inferior border of the
zygomatic arch and
needle insertion site
a
FIGURE 2 .18 Redirect

the needle anteriorly
and superiorly to pass
anterior to the lateral
pterygoid plate into the
pterygopalatine fossa.
Anterior ethmoidal nerve block
COMPLEXITY:
The anterior ethmoidal nerve is the terminal branch of the nasociliary nerve. It
exits the skull into the orbit, re-enters through the anterior ethmoidal foramen,
and runs along the cribriform plate and anteriorly down the nose.
Indications
• Anaesthesia and analgesia of the anterior third of the nose and nasal septum
(use in conjunction with maxillary nerve block for nasal surgery).
• Periorbital haematoma.
Single injection technique

Patient position: supine with head in neutral position.
Landmark: orbital margin and inner canthus.
Technique: insert needle 1.5–2 cm lateral to the orbital margin and 1 cm above
the inner canthus. Advance the needle 2 cm until it touches the medial orbital
wall near the anterior ethmoidal foramen. Inject 3 mL of anaesthetic. Perform
the block bilaterally.
Local anaesthetic: 2% lignocaine with adrenaline 1:200 000, or 0.75%
ropivacaine.
THE HEAD 43
FIGURE 2 .19
1 Nasociliary n.
2 Anterior ethmoidal n.
3 Anterior ethmoidal foramen
4 Infratrochear n. (from
1 2 3
nasociliary n.)
5 Anterior ethmoidal
n. (external nasal branch) 4
FIGURE 2 . 20
a Anterior ethmoidal
foramen
FIGURE 2 . 21
Insert the needle lateral
to the orbital margin
and above the inner
canthus.
a
References
1 Hendrick S, Rosenberg M, Lebenbom-Mansour M (1997). Efficacy and
safety of single injection peribulbar block performed by anesthesiologists
prior to cataract surgery. J Clin Anesth 9, 285–8.
2 Corke P, Baker J, Cammack R (1999). Comparison of 1% ropivacaine and a
mixture of 2% lignocaine and 0.5% bupivacaine for peribulbar anaesthesia in
cataract surgery. Anaesth Intensive Care 27, 249–52.
3 Verma S and Makker R (2001). Sub-Tenon eye block: approaching the ideal?
[letter]. Anesthesiology 94, 376–7.
4 Guise P and Laurent S (1999). Sub-Tenon’s block: the effect of hyaluronidase
on speed of onset and block quality. Anaesth Intensive Care 27, 179–81.
5 Davison M, Padroni S, Bunce C , Rüschen H (2007). Sub-Tenon’s anaesthesia
versus topical anaesthesia for cataract surgery (review). Cochrane Database
Syst Rev 3, CD006291.
6 Simpson S (2001). Regional nerve blocks. Part 2—the face and scalp. Aust
Fam Physician 30, 565–8.
CH AP T E R THR E E
UPPER
EXTREMITIES
Anatomy of the brachial plexus 46

Sensory supply 47
Motor response 48
Scanning tips for the upper extremities 49
Interscalene plexus block 52
Supraclavicular plexus block 56
Infraclavicular plexus block: vertical approach 60
Infraclavicular plexus block: lateral approach 64
Suprascapular nerve block 66
Axillary plexus block 68
Supplementary blocks for the upper limb 72
Wrist blocks 76
References 80
Anatomy of the brachial plexus

The brachial plexus is formed by the anterior primary rami of the C5 to T1
(variably C4 and T2) spinal nerves and runs from the vertebral column between
the clavicle and the first rib. The brachial plexus enters the upper limb in the
axilla before dividing into four main terminal branches: the median, radial, ulnar,
and musculocutaneous nerves. See Figure 3.1.
C4 C4
B
C5 C5
C6 C6
a C7
A b C8 C7
1
d c T1
e
f T1
B
3 9
10
2
11
5
6 8
12
4 7
FIGURE 3.1 Anatomy of the brachial plexus. Inset A and B: sectional plane

in the infraclavicular and axillary region. Note the position of the cords.
a Superior trunk (rami ventrales C5 3 Axillary n.
and C6) 4 Radial n.
b Middle trunk (ramus ventralis C7) 5 Median n.
c Inferior trunk (rami ventrales C8 6 Ulnar n.
and T1)
7 Medial antebrachial cutaneous n.
d Lateral cord
8 Medial brachial cutaneous n.
e Posterior cord
9 Intercostobrachial n.
f Medial cord
10 Intercostal n. I
1 Suprascapular n. 11 Intercostal n. II
2 Musculocutaneous n. 12 Long thoracic n.
UPPER EXTREMITIES 47
Sensory supply
See Figure 3.2.
C3
1 1
C4 C4
C5 2 2
T2 T2 C5
3
4
5 4
5 T1
C6
6 6
T1 7
7 C6
8
C6 8 C8
10 9 9 C7
C7 C8
10
FIGURE 3. 2 Sensory supply of the arm and hand.

1 Supraclavicular n. 6 Medial antebrachial cutaneous n.
2 Axillary n. (lateral cutaneous 7 Lateral antebrachial cutaneous
brachial n.) n. (musculocutaneous n.)
3 Intercostobrachial n. 8 Radial n.
4 Medial brachial cutaneous n. 9 Ulnar n.
5 Posterior antebrachial cutaneous 10 Median n.
n. (radial n.)
Motor response
See Figure 3.3.
a c
FIGURE 3. 3 Motor response of the arm and hand.

a Radial n.: stretching elbow and fingers
b Median n.: flexion of the fingers
c Musculocutaneous n.: flexion (and supination) of the forearm
d Ulnar n.: flexion of the fourth and fifth fingers, with opposition of the first
finger
Scanning tips for the upper extremities

Brachial plexus
Imaging of the brachial plexus is best achieved with high-frequency linear
probes with a range of 10–15 MHz, although probes with a range of 4–7 MHz
may be required for the infraclavicular region where the plexus cords may be
more deeply located.1
Interscalene
The cervical nerve roots that form the brachial plexus are located between the
anterior and middle scalene muscles. Scanning the lateral aspect of the neck
in an axial oblique plane is the best approach for visualizing these nerve roots.
Identify the sternocleidomastoid muscle superficially, and the anterior and
middle scalene muscles deeper. In the interscalene groove, visualize one or
more nerve roots as mostly hypoechoic structures with some internal punctuate
echoes. The vertebral artery and vein are seen alongside the transverse spinous
processes deeper again, while the carotid artery and internal jugular veins are
located medially and anteriorly.1 See Figure 3.4.
Supraclavicular/infraclavicular
Use a linear probe in a coronal oblique plane to scan the brachial plexus in the
supraclavicular region. Identify the subclavian artery immediately superior to the
first rib; the anterior and middle scalene muscles as they insert on the first rib;
and the pleura immediately deep to the first rib. Posterior and cephalad to the
subclavian artery, the divisions of the brachial plexus are visualized tightly arranged
and may have the appearance of a bunch of dark grapes. The plexus may be
somewhat spread out, with the C7 trunk between the first rib and the artery.1
If the anatomy is unclear, the plexus may be confirmed by scanning in a
caudad-cephalad motion, following the hypoechoic roots and trunks along
their paths.
FIGURE 3.4 Scanning the brachial plexus—interscalene.

For the infraclavicular approach, use a linear probe with a range of 4–7 MHz in a
parasagittal plane immediately medial to the coracoid process. The cords of the
plexus lie deep to the pectoralis major and pectoralis minor muscles and appear
hyperechoic in a transverse view adjacent to the axillary vessels. For orientation
in larger patients, it may be helpful to commence scanning at the midpoint of
the clavicle. The plexus here is generally located cephaloposterior to the artery;
the lateral cord is cephalad to the artery, while the posterior cord is posterior
to the artery. The medial cord is often—but not always—identified between the
artery and vein.1
Axillary
The terminal branches of the brachial plexus, including the musculocutaneous,
median, ulnar, and radial nerves, are located superficially in the axilla and the
upper arm within the bicipital sulcus.1
Abduct the arm 90°, and flex the forearm. Use a linear 10–15 MHz probe,
positioned as close to the axilla as possible, perpendicular to the long axis
of the arm. Identify the round pulsatile axillary artery in the bicipital sulcus,
distinguishable from the axillary veins that are readily compressed. Visualize the
round to oval-shaped hypoechoic nerves in the axilla, with the hyperechoic
epineurium within. In this region, the median nerve is usually medial to the
artery, while the ulnar nerve is lateral. The location of the radial nerve is highly
variable but is often posterior or posterolateral to the artery. More proximally,
the musculocutaneous nerve branches off and may be visualized as a
hyperechoic structure between the biceps and coracobrachialis muscles before
it enters the body of the coracobrachialis muscle.1
Local anaesthetic should be injected individually around each nerve for most
consistent results when performing an axillary block. It is presumed that the
spread of local anaesthetic within the sheath compartment is restricted by the
septae.1
See Figure 3.7.
FIGURE 3. 5 Scanning the brachial plexus—supraclavicular.

FIGURE 3.6 Scanning the brachial plexus—infraclavicular.
FIGURE 3.7 Scanning the brachial plexus—axillary.

Interscalene plexus block
COMPLEXITY:
Indications
• Anaesthesia and analgesia for open and arthroscopic shoulder surgery (e.g.
acromioplasties, total shoulder replacements, debridement of labral and
rotator cuff tears)
• Mobilization (e.g. frozen shoulder)
• Physiotherapy in the shoulder region
• Therapy for pain syndromes
• Sympathicolysis.
• Contralateral phrenic and recurrent paresis
• Chronic obstructive pulmonary disease (relative contraindication).
• Spread of anaesthetic to other tissues that may manifest as ipsilateral
numbness of the face, recurrent laryngeal nerve block resulting in variable
paralysis of the vocal cord,2 Horner’s syndrome (unequal pupils; 100%),2 or
variable ipsilateral phrenic nerve block3
• Vertebral artery injection
• Subarachnoid injection
• Epidural injection
• Pneumothorax.
See Figures 3.8, 3.9 and 3.10.
Single injection technique4

Patient position: supine, with head rotated away from the side to be blocked.
Place the ipsilateral arm on the patient’s lap. It may be helpful to sit patients
with a short neck upright. In thin patients, the plexus may be palpated as a ropy
structure running medial to lateral towards the shoulder.
Landmarks: sternocleidomastoid muscle (lateral border), scalenus anterior
muscle, interscalene groove, and cricoid cartilage.
Technique: with the patient’s head elevated slightly, palpate the lateral border of
the sternocleidomastoid muscle, and place the index and middle fingers of the
non-injecting hand immediately behind this muscle. Ask the patient to relax so
that the palpating fingers move medially behind this muscle and come to rest on
the belly of the scalenus anterior muscle. Roll fingers laterally across this muscle
until the interscalene groove is palpated. In many patients, the plexus may be
palpated as a firm band running from medial to lateral in the neck. Insert the
needle in the interscalene groove, 2 cm cephalad to the cricoid cartilage. Direct
the needle caudad and laterally (towards the middle third of the contralateral
clavicle) along the interscalene groove at a 30° angle to the skin. Twitching of the
deltoid and/or biceps brachii muscles at a stimulating current of 0.3 mA/0.1 ms
indicates correct needle placement. Inject 20–30 mL of anaesthetic slowly (initial
injection may be uncomfortable).
Needle: 22 G, 2–4 cm, short bevel, insulated.
Local anaesthetic: 1% lignocaine (30 mL), 0.5% bupivacaine, or 0.75%
ropivacaine.
Comments: Meier’s approach differs to the classical interscalene plexus block
described by Winnie (1970) in that the needle is inserted 1–2 cm cephalad from
that described by Winnie, and is directed.
FIGURE 3. 8
a Sternocleidomastoid m.
b Interscalene groove a
c Subclavian a.
b
b
FIGURE 3.9
11 10 9
1 Sternocleidomastoid
m.
2 Phrenic n.
3 Scalenus medius m.
4 Brachial plexus
(supraclavicular) 8
5 Scalenus anterior m. 7
6 Omohyoid m.
7 Brachial plexus 1
(infraclavicular) 2
8 Subclavian a. 3 4 5 6
9 External jugular v.
10 Internal jugular v.
11 Cricoid cartilage
FIGURE 3.10 Insert
the needle in the
interscalene groove.
a
Interscalene plexus block
COMPLEXITY:
Laterally, rather than medially, dorsally and caudad, and approaches the brachial
plexus at a more tangential angle, rather than at a right angle. As the plexus is
superficial (usually no deeper than 2 cm), most complications are caused by
advancing the needle tip too deeply. Contraction of the levator scapulae muscle
with stimulation indicates the needle has been directed too posteriorly, whereas
contraction of the diaphragm (phrenic nerve) indicates the needle has been
directed too anteriorly.
See Figures 3.11, 3.12, and 3.13.

Technique: locate the interscalene groove, as described for the single injection
technique. Insert the needle in a more cephalad position and direct caudad.
Perform the continuous catheter technique, as described under Catheter
technique for continuous infusions.
Equipment: StimuCath™, or Plexolong or Contiplex® (19.5 G, 3–6 cm, insulated
Tuohy needle and wire-stiffened 20 G catheter).
Local anaesthetic: 0.2% ropivacaine.
Ultrasound-guided technique
Patient position: lateral, with side to be blocked uppermost.
Landmarks: surface: larynx and sternocleidomastoid muscle;
sonoanatomical: thyroid gland, carotid artery, and internal jugular vein.
Technique: place the ultrasound probe lateral to the larynx, and visualize
the thyroid gland, the carotid artery, and the internal jugular vein. Move the
probe sideways to the lateral border of the sternocleidomastoid muscle while
moving the tip of the probe slightly caudad. In the SAX view, the brachial plexus
will become visible as multiple round or oval hypoechoic areas between the
scalenus anterior and scalenus medius muscles. Using an IP approach, insert the
needle from posterior, advancing through the scalenus medius muscle into the
interscalene groove. Confirm needle placement with a test dose of anaesthetic,
then inject 10–15 mL (maximum 20 mL) of anaesthetic, observing spread
around nerve roots. If placing a catheter, pass it 1–2 cm beyond the needle
tip under vision, and withdraw needle. Dose through catheter, observing local
anaesthetic spread; small volumes may be required.
Needle: 22 G, 4 cm with a facette tip.
Local anaesthetic: 1% lignocaine, 0.5% bupivacaine, 0.75% ropivacaine, or 1:1
mixture of 2% lignocaine and 1% ropivacaine.
Comments: in some patients, a scalenus intermedius muscle or fascial layer may
divide the plexus into a more superficial (upper trunk) and deeper (middle and
lower trunks) structure. Phrenic nerve block is minimized, as the spread of local
anaesthetic out of the interscalene groove can be avoided. To block the entire
brachial plexus, slightly reposition the needle to include the T1 root.5 The T1 root
forms part of the ulnar nerve and is not blocked by nerve stimulation guidance.
FIGURE 3.11 Insert the

needle from posterior,
using an IP approach.
FIGURE 3.12 SAX view

of the interscalene.
a Sternocleidomastoid
b Interscalene plexus
a
Scalenus anterior Scalenus medius

of the interscalene.
a Sternocleidomastoid
b Interscalene plexus a
Scalenus medius
c Carotid a.
b
c
Scalenus anterior
Supraclavicular plexus block
COMPLEXITY:
Indications
• Anaesthesia and analgesia for upper and lower arm, and hand surgery.
• Severe chronic airways disease (relative).
• Pneumothorax
• Phrenic nerve block
• Horner’s syndrome
• Subclavian artery puncture
• Haemothorax.
See Figures 3.14, 3.15, and 3.16.

Patient position: semi-sitting, with the head elevated and rotated 30° away
from the arm to be blocked.
Landmarks: interscalene groove and subclavian artery.
Technique: palpate the lateral border of the sternocleidomastoid muscle, and
place the index and middle fingers of the non-injecting hand immediately
behind this muscle. Ask the patient to relax so that the palpating fingers move
medially behind this muscle and come to rest on the belly of the scalenus
anterior muscle. Roll fingers laterally across this muscle until the interscalene
groove is palpated. Palpate the interscalene groove caudad until the subclavian
artery is felt above the clavicle (50% of patients). Place a finger on the artery,
and insert a needle into the posterior part of the groove and posterior
to the subclavian artery. With the needle hub against the neck, direct the
needle caudad and parallel to the midline. Advance the needle to the plexus.
Stimulation will elicit flexion or extension of the fingers with correct needle
placement. Inject 30–40 mL of anaesthetic slowly.
Needle: 22 G, 5 cm, short bevel, insulated.
Local anaesthetic: 1.5–2% lignocaine, 0.5% bupivacaine, or 0.75–1% ropivacaine.
Comments: unless contraindicated, a nerve stimulator-guided infraclavicular
plexus block is the preferred approach. The supraclavicular plexus block has
been included as a nerve stimulator-guided approach for completeness.
The authors do not recommend this block without ultrasound guidance for
inexperienced anaesthetists, as the risk of serious complications is relatively high.
The patient’s weight will influence the amount of pressure the palpating finger
needs to exert. Palpation helps to reduce the distance between the brachial
plexus and skin and decreases the needle trajectory. This technique should
be avoided if the subclavian artery cannot be palpated. Continuous catheter
technique is not recommended, as there is a risk of catheter dislodgement.
FIGURE 3.14
a Sternocleidomastoid m.
b Interscalene groove
c Subclavian a. a
b
c
FIGURE 3.15
11 10 9
1 Sternocleidomastoid m.
2 Phrenic n.
3 Scalenus medius m.
4 Brachial plexus
(supraclavicular)
5 Scalenus anterior m. 8
6 Omohyoid m. 7
7 Brachial plexus
(infraclavicular) 1
8 Subclavian a. 2
9 External jugular v. 3 4 5 6
10 Internal jugular v.
11 Cricoid cartilage
FIGURE 3.16 Direct
the needle caudad and
parallel to the midline,
and advance to the
plexus.
a
Supraclavicular plexus block
COMPLEXITY:
See Figures 3.17, 3.18, and 3.19.
Patient position: semi-sitting, with head rotated away from the arm to be
blocked. The patient lowers their shoulder and flexes their elbow so that their
forearm rests on their lap.
Landmarks: surface: supraclavicular fossa; sonoanatomical: subclavian artery
and scalenus medius and scalenus anterior muscles.
Technique: place the ultrasound probe in the supraclavicular fossa (the posterior
triangle of the neck bordered by the collarbone, the posterior margin of the
sternocleidomastoid muscle, and the trapezius muscle) in an almost parasagittal
plane. In most patients, the brachial plexus is cephaloposterior to the subclavian
artery and may be seen between the scalenus medius and scalenus anterior
muscles. Insert the needle, using either an IP or OOP approach. Initially, place the
needle close to the first rib, and place initial dose to block the lower trunk, then
reposition to block more superior trunks. Confirm needle placement with a test
dose of anaesthetic, then inject up to 20 mL of anaesthetic slowly.
Needle: 22 or 24 G, 2.5–5 cm, short bevel.
Local anaesthetic: 1.5–2% lignocaine, 0.75–1% ropivacaine, or a 1:1 mixture of
2% lignocaine and 1% ropivacaine.
Comments: variation in the location of the brachial plexus at the supraclavicular
level can be accommodated for by ultrasound, ensuring that all nerves that
form the plexus are anaesthetized. In particular, carefully examine the region
between the subclavian artery and the first rib for nerves, which may account for
patchy blocks. Division of the plexus by vascular structures is also common, and,
in the supraclavicular region, the dorsal scapular artery may divide the plexus.
Ultrasound enables positioning of the planned needle trajectory away from
vascular structures.
FIGURE 3.17 Insert
(a)
the needle, using an
(a) OOP approach or
(b) IP approach.
(b)

of the supraclavicular.
a Subclavian a. Anterior Posterior
b Pleura
Scalenus anterior
c Plexus
Scalenus medius
d First rib a
b d
c
FIGURE 3.19 SAX
view of the 20
supraclavicular CFD.
–20
Infraclavicular plexus block:

vertical approach
COMPLEXITY:
Indications
• Anaesthesia and analgesia for upper arm, lower arm, and hand surgery
• Analgesia for physiotherapeutic treatment
• Treatment of pain syndrome
• Thorax deformity
• Foreign bodies in the needle insertion area (e.g. pacemaker)
• Clavicular malunion.
• Intravascular injection
• Pneumothorax
• Horner’s syndrome.
See Figures 3.20, 3.21, and 3.22.

Landmarks: acromion (ventral process) and clavicle.
Technique: palpate the ventral process of the acromion. Make a mark 2 cm
caudad and 2 cm medial to this point. Direct the needle sagittally, and advance
approximately 3 cm (or to the same depth as the middle of the head of the
humerus, depending on patient habitus). Correct placement of the needle will
elicit flexion of the fingers (median nerve) at a stimulating current of 0.3 mA/0.1
ms. Inject 30 mL of anaesthetic slowly.
Needle: 22 G, 4–6 cm, short bevel.
Local anaesthetic: 1.5% lignocaine (30–40 mL), 0.5% bupivacaine, or 0.75%
ropivacaine.
Comments: risk of pneumothorax. To avoid, do not insert the needle too far
medially or deviate from the sagittal direction of insertion. Always perform this
block using a nerve stimulator. If stimulation induces twitching of the biceps
brachii muscle only, withdraw needle to a subcutaneous position; shift it slightly
lateral, and re-advance it in a strictly sagittal direction. As the musculocutaneous
nerve exits the brachial sheath before the coracoid process, twitching only of
the biceps brachii muscle indicates incorrect needle placement and yields poor
results. Stimulation of the median nerve yields the best results.

Technique: locate the nerve as described above. Perform continuous catheter
technique as described under Catheter technique for continuous infusions.
Tuohy needle, and wire-stiffened 20 G catheter).
FIGURE 3. 20
a Acromion (ventral
process)
b Clavicle
c Needle insertion site
b
c
a
FIGURE 3. 21 4
1 Pectoralis major m. 32 1
2 Subclavian a.
3 Pectoral n.
4 Brachial plexus
(infraclavicular)
5 Deltoid m.
6 Suprascapular n.
6 5
FIGURE 3. 22 Direct
and advance the
needle approximately
3 cm sagitally.

vertical approach
COMPLEXITY:
See Figures 3.23, 3.24, 3.25, and 3.26.
Patient position: supine, with arm by side. To position the brachial plexus more
superficially, abduct the patient’s arm over their head.
Landmarks: surface: deltopectoral triangle; sonoanatomical: subclavian artery,
vein, and nerve cords.
Technique: place a linear array ultrasound probe in a lateral position at the
deltopectoral triangle to obtain a SAX view of the plexus. The subclavian artery
and vein, and the medial and lateral cords of the plexus, should be visible.
To visualize the posterior cord (and the pleura), it may be necessary to tilt
the probe obliquely. To anaesthetize each cord individually, insert the needle
either superior or inferior to the probe, using an IP approach. Confirm needle
placement with a test dose of anaesthetic. Deposit 5–6 mL of anaesthetic
around each cord. A ring of anaesthetic should be visible around each
cord. Alternatively, the plexus may be anaesthetized without identifying and
anaesthetizing each individual cord. Visualize the subclavian artery, and aim
to deposit a U-shaped bolus superior, posterior, and inferior to the artery. The
maximum total volume injected is 20 mL.
Needle: 21–22 G, 9 cm, Stimuplex®.
Comments: the skin and pectoralis major muscle can be infiltrated with
anaesthetic prior to injection to increase patient comfort. It is not uncommon
to see the posterior cord fused with another cord, most commonly the medial
cord. Abducting the arm 110° and externally rotating the shoulder bring the
brachial plexus more superficial and pleura anterior, thus care is required with
needle insertion. Deposition of a U-shaped bolus under the subclavian artery is
quicker and easier to perform than identifying and anaesthetizing each cord of
the plexus individually. The target point for single injection technique or catheter
placement is cephaloposterior to the artery. Local anaesthetic will displace the
subclavian artery anteriorly if the correct U-shaped deposit is achieved. For
continuous catheter techniques, place the catheter in the cephaloposterior
quadrant behind the subclavian artery, adjacent to the posterior cord. In this
quandrant, all three cords are in close proximity.
FIGURE 3. 23 Insert the needle superior to the probe, using an IP

approach.
FIGURE 3. 24 SAX
view of the
infraclavicular.
a Pectoralis major
a
b Pectoralis minor
c Subclavian a. b
d Subclavian v.
c
e Brachial plexus
d
FIGURE 3. 25 SAX
view of the 20
infraclavicular CFD.
a Subclavian –20
v. (oblique view)
FIGURE 3. 26 1
1 Needle path
2 Pectoralis major m. 2
3 Pectoralis minor m.
4 Subclavian a.
5 U-shaped deposit of 3
local anaesthetic
4
5

lateral approach
COMPLEXITY:
Indications
• Anaesthesia and analgesia for the upper and lower arm, and hand surgery
• Analgesia for physiotherapeutic treatment
• Treatment of pain syndrome
• Thorax deformity
• Foreign bodies in the needle insertion area (e.g. pacemaker)
• Clavicular malunion.
• Intravascular injection
• Pneumothorax.

Patient position: supine, with the patient’s head turned away from the side to
be blocked and arm abducted 90° and elevated 30°.
Landmarks: jugular notch, acromion (ventral process), and axillary artery.
Technique: palpate the jugular notch and the ventral process of the acromion.
Insert the needle approximately 1 cm caudad to the clavicle at the midpoint
between these landmarks. Direct the needle laterally at a 45–60° angle towards
the most proximal point where the axillary artery can still be palpated in the
axilla. Advance the needle 3–8 cm. Stimulation at this depth with a current of
0.2–0.3 mA/0.1 ms should elicit flexion of the hand or fingers (median nerve).
Inject 30 mL of anaesthetic slowly.
Needle: 22 G, 6–10 cm, insulated.
Local anaesthetic: 1% lignocaine (30–40 mL), 0.5% bupivacaine, or 0.75%
ropivacaine.
Comments: the risk of pneumothorax is low, as the needle is inserted and
directed laterally.
FIGURE 3. 27
1 Suprascapular n.
2 Deltoid m.
3 Brachial plexus 54
(infraclavicular)
4 Pectoral n.
5 Subclavian a.
6 Pectoralis major m.
1 2 3 6
FIGURE 3. 28 Direct
the needle towards the
most proximal point of
the axillary artery at a
45–60° angle.
a Axillary a.
b Needle insertion site
a
Suprascapular nerve block
COMPLEXITY:
Indications
• Anaesthesia supplementary to incomplete interscalene plexus block
• Analgesia of shoulder conditions (adhesive capsulitis, arthritis, rupture of the
rotator cuff)
• Diagnostic for shoulder pain of unclear origin.

Patient position: sitting, with the hand of the shoulder to be blocked placed on
the opposing shoulder.
Landmarks: acromion (lateral posterior portion) and scapula (medial border).
Technique: palpate the lateral posterior portion of the acromion and the medial
border of the scapula. Draw a line to connect these two landmarks, and mark its
midpoint. Insert the needle 2 cm cephalad and 2 cm lateral from the midpoint.
Direct the needle laterocaudadly and slightly ventral towards the head of the
humerus at an angle of approximately 30°. Advance the needle to a depth of
3–5 cm where stimulation elicits motor responses in the supraspinatus and
infraspinatus muscles. Inject 10–15 mL of anaesthetic slowly.
Needle: 22 G, 6–8 cm, insulated.
Local anaesthetic: 1% lignocaine, 0.5% bupivacaine, or 0.75% ropivacaine.
Comments: the risk of pneumothorax is limited if recommended guidelines are
followed. Although extremely rare, aspirate to avoid intravascular injection in the
suprascapular artery. If nerve stimulation is unsuccessful in locating the nerve,
anaesthetic may be injected into the supraspinous groove, as detected by bony
contact.
FIGURE 3. 29 4 5 6
1 Supraspinatus m.
3 7
2 Infraspinatus m.
3 Trapezius m.
4 Suprascapular a.
5 Transverse scapular
ligament
6 Suprascapular n.
7 Suprascapular
n. (articular
branches)
8 Deltoid m.
1 2 8
d
c
FIGURE 3. 30 Direct the needle laterocaudadly at an angle of

approximately 30°.
a Acromion (lateral posterior portion)
b Scapula (medial border)
c Midpoint between the acromion (lateral posterior portion) and the scapula
(medial border)
d Needle insertion site
Axillary plexus block
COMPLEXITY:
Indications
• Anaesthesia and analgesia for the distal upper arm, forearm, and hand surgery
• Physiotherapy
• Pain syndrome

Patient position: supine, with head facing away from the side of the block.
Abduct the arm to be blocked 90° and rotate externally, and flex elbow 90°.
Landmarks: axillary artery and coracobrachialis muscle.
Technique: palpate the axillary artery and coracobrachialis muscle. Insert the
needle between these two landmarks. Direct the needle proximally and parallel
to the artery at a 30–45° angle to the skin. When the needle penetrates the
neurovascular sheath (although unreliable, a click or pop may be felt), lower the
distal end and advance 1–2 cm. Effortless needle advancement indicates correct
needle placement and can be confirmed by nerve stimulation (which improves
the success of this block when performed by inexperienced anaesthetists). Inject
40 mL of anaesthetic slowly.
Needle: 18 G, 4 cm, short bevel (45°), insulated.
Local anaesthetic: 1.5% lignocaine, 0.25–0.5% bupivacaine, or 0.75%
ropivacaine.
Comments: a supplementary radial and musculocutaneous nerve block may be
required if anaesthesia of the radial nerve distribution is insufficient.

Technique: locate the nerve, as described above. Perform continuous catheter
technique, as described under Catheter technique for continuous infusions.
Tuohy needle and wire-stiffened 20 G catheter).
FIGURE 3. 31
1 Coracobrachialis m.
2 Radial n.
3 Medial antebrachial 8
cutaneous
n. (posterior to the 7
basilic v.)
4 Ulnar n.
5 Brachial a. 1
6 Median n. 2
7 Musculocutaneous n.
8 Pectoralis major m. 5
6 3
4
b
a c
FIGURE 3. 32 Direct the needle medially, above and parallel to the axillary
artery at a 30–45°angle to the skin.
a Axillary a.
b Coracobrachialis m.
Axillary plexus block
COMPLEXITY:
See Figures 3.33, 3.34, and 3.35.
Patient position: supine, with head facing away from the side of the block.
Abduct the arm to be blocked 90° and rotate externally, and flex elbow 90°.
Landmarks: surface: pectoralis major muscle; sonoanatomical: axillary artery.
Technique: to obtain a SAX view of the axillary plexus, place the ultrasound
probe perpendicular to the skin, in line with the pectoralis major muscle. Move
the probe distally. Minimal pressure on the probe will ensure visualization of
the multiple veins surrounding the axillary artery. Typically, the median nerve
is located superoanteriorly, the ulnar nerve inferoposteriorly, and the radial
nerve posteriorly to the axillary artery. The musculocutaneous nerve is seen
either within the coracobrachialis muscle or, more commonly, in a fascial plane
between the biceps brachii and coracobrachialis muscles. Insert the needle,
using an IP approach. Confirm needle placement with a test dose of anaesthetic.
Inject 5 mL of anaesthetic around each nerve.
Needle: 21 G, 4 cm, Stimuplex®.
Comments: the location of the median, radial, and ulnar nerves around the
axillary artery varies significantly from patient to patient. Visualizing their
location by ultrasound allows direct deposition of anaesthetic on each nerve
and ensures a higher success rate, compared with the single-shot, high-volume
approach.
FIGURE 3. 33 Insert the needle, using an IP approach.

a b c
FIGURE 3. 34 SAX view of the axilla.

a Median n. d Radial n.
b Axillary a. e Musculocutaneous n.
c Ulnar n. f Biceps m.
20
–20
FIGURE 3. 35 SAX view of the axillary vein compressed CFD.

a Axillary a.
Supplementary blocks for the

upper limb
COMPLEXITY:
An incomplete brachial plexus block may be supplemented by additional
nerve blocks in the upper arm or in the mid-forearm. Ultrasound guidance
is recommended, as it avoids dependence on palpable surface landmarks,
ensures needle trajectories are directed away from vascular structures, improves
accuracy, and allows local anaesthetic deposition distant from the cubital tunnel.
Indications
• Incomplete brachial plexus block.
See Figures 3.36, 3.37, and 3.38.
Ultrasound-guided technique: radial nerve block

Patient position: supine, with arm placed over the abdomen.
Landmarks: surface: brachial artery; sonoanatomical: brachial artery.
Technique: place a linear 38 mm, high-frequency 10–15 MHz transducer on
the lateral aspect of the distal third of the upper arm. Locate the radial nerve
within the spiral groove, adjacent to the humerus bone, and deep to the triceps
muscle. Scanning in a cephalad direction, the nerve moves away from the
humerus and travels laterally towards the lateral condyle. The profunda brachii
artery is often seen accompanying the nerve, assisting in its identification. Inject
2–5 mL of local anaesthetic around the radial nerve.
Needle: 22 G, 5 cm.
FIGURE 3. 36
1 Musculocutaneous n.
2 Median n.
3 Ulnar n.
1
4 Radial n.
2
3
FIGURE 3. 37
Radial nerve
a
block at the spiral
groove; insert the
needle, using an IP
approach.
a Shoulder
b Elbow
FIGURE 3. 38 SAX
view of the radial
spiral groove.
a Radial n.
b Humerus
a b
Supplementary blocks for the

upper limb
COMPLEXITY:
See Figures 3.39, 3.40, 3.41, and 3.42.
Ultrasound-guided technique: ulnar nerve block

Patient position: supine, arm rotated and flexed to expose the medial aspect of
the forearm.
Landmarks: surface: ulnar artery; sonoanatomical: ulnar artery.
Technique: the ulnar nerve can be identified distally at the wrist by its
association with the ulnar artery. Once identified, scan proximally until the
nerve moves away from the artery—in the mid-forearm—and block at this
level to minimize the risk of accidental arterial injection. Alternatively, trace the
ulnar nerve from the cubital tunnel distally into the mid-forearm. Inject 2–5
mL of local anaesthetic, aiming to achieve circumferential spread around the
ulnar nerve.
Needle: 25 G, hypodermic.
Ultrasound-guided technique: median nerve block

Patient position: supine, with arm supinated at the antecubital fossa.
Landmarks: surface: brachial artery; sonoanatomical: brachial artery.
Technique: the median nerve lies immediately deep to the bicipital
aponeurosis, medial to the pulsatile brachial artery. The median nerve block is
performed in the proximal third of the forearm, choosing a needle trajectory
away from the brachial artery, either OOP or IP. Block the medial nerve in the
mid-forearm where it is easily visualized and separated from other structures.
A median nerve block, in combination with an ulnar nerve block, is useful for
hand surgery involving the palm of the hand. Inject 2–5 mL of local anaesthetic,
aiming to achieve circumferential spread around the median nerve.
Needle: 25 G, hypodermic.
FIGURE 3. 39 Ulnar nerve block. Insert the needle, using an IP approach.

FIGURE 3.4 0 SAX
view of the
ulnar nerve.
a Ulnar n.
b Tendon
c Ulnar a.
a b
FIGURE 3.41
Median nerve
block. Insert the
needle, using an IP
approach.
FIGURE 3.42 SAX
view of the
median nerve.
a Median n.
a
Wrist blocks
COMPLEXITY:
This is a basic, non-ultrasound block. If ultrasound is used, the medial,
radial, and ulnar nerves should be approached, using the ultrasound-guided
techniques described under Supplementary blocks for the upper limb.
Indications
• Analgesia and anaesthesia for hand surgery
• Management of fractured metacarpals and lacerated hands
• Supplementation of incomplete brachial block.
• History of nerve entrapment syndromes.
See Figures 3.43, 3.44, and 3.45.
Technique
Median nerve
Patient position: arm is stretched laterally and externally rotated, and hand supine.
Landmarks: palmaris longus muscle tendon and palmar crease.
Technique: insert the needle at the palmar crease on the ulnar side of the
tendon of the palmaris longus muscle, and direct towards the ulna (away from
the nerve). Ask the patient to move their fingers, and adjust the needle to ensure
that it is not inserted into a tendon. Inject 4–5 mL of anaesthetic slowly. A diffuse
swelling indicates deposition of anaesthetic deep to the flexor retinaculum
and correct needle placement. A discrete bleb indicates superficial needle
placement, resulting in an ineffective block. Anaesthesia can be achieved,
albeit slowly, by manually pushing the bleb in a radial direction to spread the
anaesthetic across to the nerve.
Needle: 25 G, 1 cm.
Comments: in the classic approach, the needle is placed between the tendons
of the palmaris longus muscle and the flexor carpi ulnaris muscle.
Ulnar nerve
Patient position: arm is stretched laterally and externally rotated, and hand supine.
Landmark: flexor carpi ulnaris muscle tendon.
Technique: palpate the tendon of the flexor carpi ulnaris muscle. Insert the
needle posterolaterally, and direct horizontally. Withdraw the needle and
redirect if paraesthesiae is elicited. Inject 3–5 mL of anaesthetic slowly.
Needle: 27 G, 1 cm.
Comments: this approach avoids the artery and allows the anaesthetic to
‘float’ up from behind the tendon. In the classic approach, the anaesthetic is
injected medial to the artery at the dorsum of the wrist. The classic approach is
associated with greater neuropraxia.
FIGURE 3.43 1 2 3 4
1 Pisiform bone
2 Ulnar n.
3 Ulnar a.
4 Flexor carpi ulnaris
m. tendon
5 Palmaris m. longus
tendon
6 Flexor carpi radialis
5 6 7 8
m. tendon
7 Median n.
8 Radial a.
FIGURE 3.4 4 To block
the median nerve, insert
the needle at the palmar
crease on the ulnar side
of the palmaris longus
m. tendon.
FIGURE 3.45 To
block the ulnar nerve,
insert the needle
posterolaterally to the
flexor carpi ulnaris
m. tendon.
a
Wrist blocks
COMPLEXITY:
Technique
Radial nerve
Patient position: arm is stretched laterally, and hand supine.
Technique: insert the needle on the radial side of the wrist, 3–5 cm proximal to
the joint, and infiltrate 10 mL of anaesthetic subcutaneously.
Needle: 22–24 G, 1 cm.
FIGURE 3.46
1 2
1 Radial
n. (superficial
branches)
2 Radial a.
FIGURE 3.47 To
block the radial
nerve, insert the
needle on the radial
side of wrist.
a Needle
insertion site
a
References
html>.
2 Seltzer J (1977). Hoarseness and Horner’s syndrome after interscalene
brachial plexus block. Anesth Analg 56, 585–6.
3 Urmey W and McDonald M (1992). Hemidiaphragmatic paresis during
interscalene brachial plexus block: effects on pulmonary function and chest
mechanics. Anesth Analg 74, 352–7.
4 Meier G and Büttner J (2005). Regional anaesthesia. Pocket compendium of
peripheral nerve blocks. 3rd edn. Munich: Acris Publishing Company.
5 Marhofer P, Greher M, Kapral S (2005). Ultrasound guidance in regional
anaesthesia. Br J Anaesth 94, 7–17.
6 Borgeat A , Ekatodramis G, Dumont C (2001). An evaluation of the
infraclavicular block via a modified approach of the Raj technique. Anesth
Analg 95, 436–41.
CH AP T E R FO UR
LOWER
EXTREMITIES
Anatomy of the lumbosacral plexus 82

Sensory supply of the lower extremities 84
Sensory supply of the bony structure 85
Motor response 86
Scanning tips for the lower extremities 87
Psoas compartment (lumbar plexus) block 90
Femoral nerve block 94
Lateral femoral cutaneous nerve block 98
Fascia iliaca block 100
Obturator nerve block 102
Sacral plexus block 106
Sciatic nerve block: subgluteal to popliteal fossa 108
Sciatic nerve block: proximal anterior/ventral 112
Saphenous nerve block 114
Ankle blocks 116
References 122
Anatomy of the lumbosacral plexus

Lumbar plexus
The lumbar plexus is formed by the ventral rami of the L1–L4 spinal nerves.
Nerves of the lower extremities relevant for anaesthesia include the femoral
nerve and its terminal branch, the saphenous nerve, the lateral femoral
cutaneous nerve, and the obturator nerve.
The femoral nerve is the largest branch of the lumbar plexus and arises from
the second, third, and fourth lumbar nerves. It supplies the anterior and medial
thigh, femur, patella, and majority of the knee joint, as well as the cutaneous
strip along the medial calf to the medial malleous and medial instep. See
Figure 4.1.
Sacral plexus
The sacral plexus is formed by the ventral rami of the L4 and L5 spinal nerves
(lumbosacral trunk) and S1–S3. Nerves of the lower extremities relevant to
anaesthesia include the sciatic nerve and its terminal branches, the common
peroneal nerve and tibial nerve, and the posterior femoral cutaneous nerve. See
Figure 4.2.
T12
L1
XI
L1
XII L2
L2
L3
L3
1
L4 L4
2
L5
L5
3
6
7
FIGURE 4.1 The lumbar plexus.

1 Iliohypogastric n. 5 Femoral n.
2 Ilioinguinal n. 6 Obturator n.
3 Genitofemoral n. 7 Sciatic n.
4 Lateral femoral cutaneous n. 8 Pudendal n.
LOWER EXTREMITIES 83
5
6
7
FIGURE 4. 2 The sacral plexus.

1 Posterior femoral cutaneous n. 5 Lateral femoral cutaneous n.
2 Sciatic n. 6 Genitofemoral n.
3 Iliohypogastric n. 7 Obturator n.
4 Ilioinguinal n. 8 Femoral n.
Sensory supply of the lower extremities

See Figure 4.3.
6
2
5
7 7
3 4 3
4
4
9
10
10
12
11 13 9
FIGURE 4. 3 Sensory supply of the lower extremities. Areas of sensory

distribution: ! Femoral n. and its branches ! Sciatic n. and its branches
! Lateral femoral cutaneous n. ! Obturator n.
1 Lateral femoral cutaneous n. 8 Posterior tibial n.

2 Femoral n. 9 Sural n.
3 Peroneal n. 10 Superficial peroneal n.
4 Saphenous n. 11 Deep peroneal n.
5 Sciatic n. 12 Medial plantar n.
6 Posterior femoral cuta neous n. 13 Lateral plantar n. (tibial n.)
7 Obturator n.
Sensory supply of the bony structure

See Figure 4.4.
1
4
1
3 4
10
5
8
8
12
11 9
12
13
13
12
FIGURE 4.4 Sensory supply of the bony structure. Areas of sensory

distribution: ! Femoral n. and its branches ! Sciatic n. and its branches
! Obturator n. (variable innervation).
1 Collateral branch of femoral n. 8 Tibial and posterior tibial nerves

2 Femoral n. 9 Sural n.
3 Superior gluteal n. 10 Common peroneal n.
4 Inferior gluteal n. 11 Deep peroneal n.
5 Sciatic n. 12 Medial plantar n.
6 Sacral nerves 13 Lateral plantar n.
7 Obturator n.
Motor response
See Figure 4.5.
FIGURE 4. 5 Motor response.

1 Tibial n.: plantarflexion (foot inversion)
2 Peroneal n.: dorsiflexion (foot eversion)
Scanning tips for the lower extremities

Lumbosacral plexus
Innervation to the lower extremity is provided by the lumbosacral plexus.
Imaging of the lumbosacral plexus and its proximal branches may be difficult
due to the depth of these structures.1
Lumbar plexus
The patient should be positioned either prone, with a pillow under the
abdomen to reduce lumbar lordosis, lateral, or sitting. Use a curved 4–5
MHz probe to image the paravertebral region. Identify the lumbar transverse
processes approximately 3 cm from the midline by positioning the probe
longitudinally in a parasagittal plane. Turn the transducer 90° into the transverse
axial plane, positioning it between two transverse processes to minimize the
interference to the ultrasound beam. Deep to the subcutaneous plane, identify
the erector spinae muscle immediately lateral to the spinous process and, more
laterally, the smaller quadratus lumborum. Anterior to these two muscles, the
psoas muscle lies adjacent to the vertebral bodies and intervertebral discs.
The lumbar plexus is usually found between the anterior two-thirds and the
posterior third of the psoas muscle. The plexus may be difficult to identify
with ultrasound alone; adjuvant use of nerve stimulation is recommended.
Administer local anaesthetic in the plexus with this technique. Avoid inadvertent
needle trauma to the kidney by identification of the inferior pole of the kidney,
as low as L3–L4.1
See Figures 4.6, 4.7, and 4.8 for a demonstration of this technique.
Femoral nerve—lumbar/inguinal
The lumbar plexus has three main terminal branches, the femoral, obturator,
and lateral femoral cutaneous nerves. The largest branch is the femoral nerve,
derived from L2–L4. Use a linear 10–15 MHz transducer, placed over the
inguinal crease in the transverse axial plane, to identify the hyperechoic oval or
triangular-shaped femoral nerve lateral to the femoral vessels. The femoral nerve
overlies the iliopectineal arch, overlying the groove between the iliac and psoas
muscles, and, for a short distance, may be imaged distally until it divides into
small terminal branches, indistinguishable sonographically from the surrounding
tissue. The saphenous nerve may be imaged next to the femoral vessels in the
mid- to distal thigh.1
See Figure 4.9.
Sciatic nerve—proximal/anterior mid-thigh/distal
The lumbosacral plexus is the origin of the sciatic nerve, which enters the gluteal
region between two muscle planes through the greater sciatic foramen. The
obturator internus and inferior gemellus form the anterior muscle plane, while
the more superficial gluteus maximus muscle forms the posterior plane. The
depth of the sciatic nerve in the gluteal region makes it difficult to identify; it lies
more superficial in the subgluteal region.1
Position the patient semi-prone, with the limb to be blocked uppermost. Use a
curved 2–7 MHz transducer to obtain a transverse view of the sciatic nerve. The
greater trochanter of the femur is identified laterally and the ischial tuberosity
medially; the sciatic nerve lies approximately in the midpoint of a line between
both landmarks. Frequently, the appearance of the sciatic nerve is hyperechoic
and elliptical, deep to the distal gluteus maximus muscle and lateral to the
biceps femoris muscle. The aponeurosis of the surrounding muscles surrounds
the sciatic nerve as a well-defined border.1
A 7–15 MHz linear probe may be used to image the sciatic nerve more
caudally to the popliteal fossa. Here, the sciatic nerve often appears round and
hyperechoic, lying posterior to the femur, lateral and superficial to the popliteal
artery, and anterior to the semitendinous and semimembranous muscles
medially and the biceps femoris muscle laterally, before dividing into the
peroneal and tibial nerves. Moving distally, the peroneal nerve may be followed
to the level of the head of the fibula.1
See Figures 4.10, 4.11, and 4.12.
FIGURE 4.6 Scanning
the lumbar plexus in
the left lateral decubitus
(semi-prone) position;
position the curvilinear
probe longitudinally in
a parasagittal plane.
a Right side of patient
FIGURE 4.7 Next,
position the curvilinear
probe in the transverse
axial plane between
two transverse
processes.
FIGURE 4. 8 Relative
positions of the probe
and needle for an IP
approach to the right
lumbar plexus block.
a Lumbar spine
a
a
a
Caudad
FIGURE 4.9 Scanning
the femoral nerve; use
a linear transducer
placed over the inguinal
crease in the transverse
axial plane.
a Right thigh
FIGURE 4.10 Scanning
the proximal sciatic
nerve, using a
curvilinear probe.
FIGURE 4.11 Scanning
the distal sciatic nerve,
using a linear probe.
FIGURE 4.12 SAX
view of the sciatic
n. subgluteal.
a b
a Sciatic nerve
b Gluteus maximus
c Greater trochanter
d Quadriceps femoris e c
d
e Ischial tuberosity
Psoas compartment (lumbar

plexus) block
COMPLEXITY:
Indications
• Leg surgery when in combination with proximal sciatic nerve block
• Wound treatment in the ventral and lateral thigh regions
• Skin grafts in the upper thigh region
• Physiotherapy
• Analgesia (after hip or knee surgery).
• As per contraindications for neuroaxial block.
• Spinal anaesthesia
• Spread of anaesthetic to the epidural space, causing an epidural-like block
• Haematoma.
Technique
Patient position: lateral with legs flexed, the operative leg uppermost, and the
back kyphotic.
Landmarks: intercristal line, ischial tuberosity (IT), and posterior superior iliac
spine (PSIS).
Technique: palpate the iliac crests, and mark the intercristal line. Locate the
projection of the IT posteriorly and the PSIS. Draw a line connecting these two
landmarks, and extend it to intersect the intercristal line. Insert the needle at
right angles to all surfaces. The needle may contact the transverse process of
L5. If so, withdraw the needle 1–3 cm, and redirect more cephalad. The plexus
will be 10–15 mm deeper. Contraction of the quadratus femoris muscle at a
stimulating current of 0.3 mA/0.1 ms indicates correct needle placement. Inject
a test dose to preclude an intraspinal needle position prior to injecting 30 mL of
anaesthetic slowly.
Needle: 22 G, 15 cm, insulated, Stimuplex®.
Local anaesthetic: 1% lignocaine or 0.75% ropivacaine (20–30 mL).
Comments: infiltration is recommended prior to needle insertion. Anaesthetic
injected at the level of the L3 spinous process does not improve the quality
of anaesthesia and carries a risk of causing a subcapsular haematoma of the
kidney. Injection into the peritoneal cavity may occur when the needle depth
is very deep. A complete block of the sacral plexus at this level is not possible,
even with higher volumes of anaesthetic.

Technique: locate the nerve, as described in the previous section. Perform
the continuous catheter technique, as described under Catheter technique for
continuous infusions.
Equipment: StimuCath™, or Plexolong or Contiplex® (19.5 G, 15 cm, insulated
Tuohy needle and 20 G catheter).
FIGURE 4.13 1 3 4 5
2
1 Lumbar plexus
2 Psoas major m.
3 Fascia iliaca
4 Transverse process
(costal process)
5 Erector spinae m.
6
6 Needle direction
Body of L5
Ventral Dorsal
FIGURE 4.14
a Intercristal line
b Ischial tuberosity
c Posterior superior b
iliac spine a
d
d Needle insertion site
c
Psoas compartment (lumbar

plexus) block
COMPLEXITY:
Patient position: lateral with legs flexed, the operative leg uppermost, and the
back kyphotic.
Landmarks: surface: L2–L5 spinous processes; sonoanatomical: psoas major,
quadratus lumborum, and erector spinae muscles.
Technique: place a 2–5 MHz curved-array ultrasound probe along the L2–L5
spinous processes, and locate the L3 and L4 vertebrae in a longitudinal view.
Rotate the probe into a transverse view, and visualize the transverse process of
L4, the psoas major, the quadratus lumborum, and the erector spinae muscles.
Using the frequency and gain controls, optimize the sonoanatomy image and
ensure the psoas major, the quadratus lumborum, and the erector spinae muscles
are clearly delineated. Identify the junction of the posterior third and anterior
two-thirds of the psoas major muscle. This is the reference point for needle
advancement. Insert the needle 4–5 cm lateral to the spinous process and medial
to the probe, and perpendicular to the skin, using an IP approach. Advance the
needle to the reference point, and inject 30 mL of anaesthetic slowly.
Needle: 22 G, 12 cm, insulated, Tuohy.
Comments: a curved-array probe at lower frequencies provides appropriate
tissue penetration and image size but less spatial resolution. This may create
difficulty and cause poor differentiation between peripheral nerves and tendon
fibres within the psoas major muscle. As it is often not possible to visualize
the lumbar plexus within the psoas major muscle, neurostimulation is a useful
adjunct to ultrasound for this block. The patient may also be positioned sitting,
with the lumbar region kyphotic (as shown in Figures 4.15 and 4.18).
FIGURE 4.15
Ultrasound probe
position for a
longitudinal SAX
view of the psoas
compartment.
a L4 spinous
process
a
FIGURE 4.16
Longitudinal SAX view of Cephalad L4 Caudad
L3
the psoas muscle.
a Lumbosacral plexus
b Psoas m. a b
FIGURE 4.17
Longitudinal SAX view
of the psoas muscle and Cephalad Caudad
kidney.
a
a Erector spinae m.
Kidney
b Psoas m. b
FIGURE 4.18
Transverse SAX
view of the psoas a
compartment.
a Psoas major m. b
c
b Erector spinae m.
c Quadratus
lumborum m.
L4 transverse process
FIGURE 4.19
Transverse SAX view of
the psoas.
a Psoas m.
L4
a
Femoral nerve block
COMPLEXITY:
In this technique, the needle is inserted a few centimetres below, rather than at,
the level of the inguinal ligament. The ‘3-in-1 block’,2 which blocks the femoral,
lateral femoral cutaneous, and obturator nerves, is only truly a ‘3-in-1 block’
one-third of the time. Successful blockade of the obturator nerve with this
technique is low. In addition, the lateral femoral cutaneous nerve is blocked in
only 50% of these blocks performed if a large volume of anaesthetic is injected,
presumably a result of the lateral spread of anaesthetic.3
Indications
• Surgery of the anterior thigh and knee, and quadriceps tendon repair
• Post-operative analgesia after femur or knee surgery, knee arthroplasty,
anterior cruciate ligament or femoral fracture repair.
See Figures 4.20, 4.21, and 4.22.
Technique
Patient position: supine, with both legs extended. Place a pillow underneath
the hips of obese patients to facilitate palpation of the femoral artery.
Landmarks: inguinal ligament and femoral artery pulse.
Technique: infiltrate the needle insertion area subcutaneously. Palpate the
inguinal ligament and the pulse of the femoral artery. Standing to the side of
the patient, with one hand palpating the femoral artery, insert the needle at
the lateral border of the artery, and advance in a sagittal and slightly cephalad
plane. A visible or palpable twitch of the quadratus femoris muscle at 0.2–0.5
mA/0.1 ms, reduced from 1.0 mA/0.1 ms, indicates correct needle placement.
If twitching occurs in the sartorius muscle only, redirect the needle laterally, and
advance several millimetres deeper. Inject 20 mL of anaesthetic slowly.
Needle: skin infiltration: 25 G, 3 cm; injection: 25 G, 5 cm, short bevel, insulated.
Local anaesthetic: 1.5% lignocaine with adrenaline 1:200 000, 0.5%
bupivacaine, or 0.75% ropivacaine.
Comments: always confirm correct needle placement with quadratus femoris
muscle twitching, as stimulation of the sartorius muscle can be obtained in or
outside of the sheath of the femoral nerve. The nerve to the sartorius muscle appears
medial to, and travels over, the femoral nerve, entering the sartorius muscle laterally.
If the sartorius muscle is stimulated, redirect the needle medially, laterally, or deeper.

Technique: locate the nerve, as described previously. Perform the continuous
catheter technique, as described under Catheter technique for continuous infusions.
Tuohy needle and 20 G catheter).
Local anaesthetic: 0.25% bupivacaine or 0.2% ropivacaine.
Comments: care should be taken to avoid medial insertion of the needle and
the consequent puncture of the femoral artery.
FIGURE 4. 20
a Inguinal ligament
b Femoral a.
FIGURE 4. 21 Lateral Medial

1 Fascia lata 1 2 3 4
2 Femoral n.
3 Femoral a.
4 Femoral v.
5 Femoral sheath
6 Fascia iliaca
7 Ilioacus m.
8 Pectineus m.
5 8
7
6
FIGURE 4. 22 Insert
and direct the needle
in a sagittal and slightly
cephalad plane.
a
Femoral nerve block
COMPLEXITY:
Landmarks: surface: inguinal ligament; sonoanatomical: femoral vein and
femoral artery. In most patients, the femoral artery is a useful orientation marker,
as it is located medial to the femoral nerve.
Technique: palpate the inguinal ligament. Place a high-frequency (>7 MHz)
linear-array ultrasound probe on, and in line with, the inguinal ligament. From
medial to lateral, the femoral vein, femoral artery, and femoral nerve should
be visible below the iliopectineal fascia. The needle can be inserted, using an
IP or OOP approach. For the OOP approach, position the probe so that the
femoral nerve is centre of the screen, as it correlates well with the midpoint of
the lateral surface of the probe. This optimizes needle insertion and femoral
nerve visualization. For the IP approach, insert the needle on the lateral edge of
the probe. In both approaches, advance the needle towards the femoral nerve.
Visualize the needle tip penetrating the iliopectineal fascia to ensure positioning
of the needle within the femoral canal. Confirm needle placement with a test
dose of anaesthetic. Inject 20 mL of anaesthetic, repositioning the needle while
injecting to optimize the spread of anaesthetic. Hypoechoic expansion of
fluid will occur and is easily visualized and will be contained wholly under the
iliopectineal fascia.
Needle: 20 or 21 G, Stimuplex®.
Comments: as the sonoanatomy and course of the femoral nerve vary among
patients, scan above and below the inguinal ligament to identify variations
in vascular structures and identify the course of the femoral nerve. This will
assist in selecting the most appropriate needle insertion site and direction for
approaching the femoral nerve. A Tuohy needle will assist cephalad catheter
placement for continuous injection. In some patients, the nerve may be
difficult to identify, and the use of a nerve stimulator can be helpful. The lateral
circumflex femoral artery is usually a branch of the profunda femoris and may
run under, or through, the femoral nerve. Use ultrasound to locate and identify
this artery to minimize the risk of vascular puncture and injection. Preferential
spread of local anaesthesia may also be adversely affected due to the division of
the femoral nerve by the artery.
FIGURE 4. 23 Insert
the needle, using an IP
approach.
FIGURE 4. 24 SAX
a
view of the
femoral nerve.
a Femoral n.
b Iliacus m.
c Femoral a.
d Femoral v. c
b
d
FIGURE 4. 25 Oblique
a
SAX view of the
femoral nerve.
a Femoral n.
b Femoral a.
d
c Iliacus m.
d Quadriceps m.
c
b
FIGURE 4. 26 SAX
view of femoral nerve
a
with lateral circumflex Lateral Medial
femoral artery.
a Lateral circumflex
femoral a. e
b Femoral v. d
c Femoral a.
c b
d Iliacus m.
e Femoral n. (divided)
FIGURE 4. 27 SAX 20 a b
view of the lateral
femoral cutaneous
artery CFD. –20
a Lateral circumflex
femoral a.
b Femoral a.
Lateral femoral cutaneous nerve block

COMPLEXITY:
Indications
• Small skin grafts of the lateral aspect of the thigh
• Diagnostic tool for myalgia paraesthetica (neuralgia of the lateral cutaneous
nerve of the thigh).
See Figures 4.28, 4.29, and 4.30.
Technique
Patient position: supine, with the anaesthetist at the patient’s side.
Landmark: anterior superior iliac spine (ASIS).
Technique: insert the needle 2 cm medial and 2 cm caudad to the ASIS, and
advance until a loss of resistance is felt as the needle passes through the fascia
lata. Inject 10 mL of anaesthetic in a fanwise fashion, from medial and lateral,
both above and below the fascia lata.
Needle: 22 G, 4 cm, short bevel.
Local anaesthetic: 2% lignocaine, 0.5% bupivacaine, or 0.75–1% ropivacaine.
Comment: fanwise injection is suggested, as the loss of resistance through the
fascia lata is not consistent and perception of loss may vary among anaesthetists.
FIGURE 4. 28
a Anterior superior
iliac spine
b
FIGURE 4. 29
1 Anterior superior
iliac spine
2 Lateral femoral
cutaneous n.
3 Sartorius m.
4 Tensor fasciae latae m. 1
5 Femoral n.
2
6 Inguinal ligament
3
5 6
FIGURE 4. 30 Direct the

needle sagittally until a
loss of resistance is felt.
Fascia iliaca block
COMPLEXITY:
The fascia iliaca block only reliably blocks the femoral and lateral femoral
cutaneous nerves. This block has been previously described, using landmark
techniques (Dalen’s technique),4 and relies on fascial clicks for correct needle
depth. Ultrasound increases the ease, reliability, and safety of this block by
allowing visualization of the needle, local anaesthetic spread, and fascial planes.
Indications
• Surgery in the region of the thigh and knee
• Anaesthesia in conjunction wvith sciatic nerve block
• It produces more reliable block of the lateral femoral cutaneous nerve of the
thigh, compared to the 3-in-1 block.
Landmarks: surface: ASIS, iliac bone; sonoanatomical: femoral vessels, iliacus
muscle, fascia iliaca plane.
Technique: use a linear-array probe. For the inguinal technique, follow the
fascia iliaca from the femoral vessels to the ASIS along the inguinal ligament.
Perform the block, using either an IP or OOP approach. After confirmation of
accurate needle positioning using 0.5–1.0 mL test bolus, hydrodissect the fascia
iliaca using 20–30 mL of local anaesthetic.
For the suprainguinal technique, place the probe over, and perpendicular to,
the inguinal ligament, scanning towards the xiphoid process. Locate the femoral
artery medially and the anterior inferior iliac spine laterally, under the muscle
belly of the iliacus. An IP approach is used, inserting the needle from the thigh
and penetrating the fascia iliaca deep to the inguinal ligament. Confirm needle
position with a test bolus, observing the spread of fluid between the iliacus
muscle and the fascia iliaca, before hydrodissecting the plane using more local
anaesthetic. A catheter may be inserted into the hydrodissected plane, if desired.
Needle: 21 G, 10 cm, short bevel, stimulating or Tuohy.
Local anaesthetic: 0.5–0.75% ropivacaine.
FIGURE 4. 31
Insert the needle,
using an OOP
approach for the
infrainguinal fascia
iliaca block.
a Right inguinal
crease
a
FIGURE 4. 32
Fascia iliaca
a
infrainguinal
approach. Lateral Medial
a Fascia iliaca
b Iliacus m.
c ASIS
c b
FIGURE 4. 33
Insert the needle,
using an IP
approach for the
suprainguinal
fascia iliaca block.
a Right inguinal
crease
a
FIGURE 4. 34
Fascia iliaca Inferior
Superior
suprainguinal
approach.
a Fascia iliaca
b Iliacus m.
a
b
Obturator nerve block
COMPLEXITY:
The anterior branch of the obturator nerve innervates the anterior adductor
muscles, the hip joint, and, to a varying degree, a section of the skin on
the inner surface of the thigh. The posterior branch of the obturator nerve
innervates the deep adductor muscles and, to a varying degree, medial portions
of the knee joint.
Indications
• Transurethral resection of tumours of the ipsilateral wall of the bladder
• Supplementary anaesthesia for incomplete lumbar plexus block
• Diagnosis/therapy for pain syndrome in the hip joint
• Adductor spasm.
See Figures 4.35, 4.36, and 4.37.
Technique
Patient position: supine, with leg abducted.
Landmark: adductor longus muscle (tendon).
Technique: palpate the proximal attachment point of the tendon of the
adductor longus muscle. Insert the needle immediately ventral to the proximal
attachment point of the tendon, and advance cephalad at a 45° angle to the
longitudinal axis of the body and in a slightly dorsal direction. At a needle depth
of 4–8 cm, contraction of the adductor muscles at a stimulating current of
0.3 mA/0.1 ms indicates proximity to the obturator nerve. Inject 10–15 mL of
anaesthetic slowly.
Needle: 20 G, 10 cm, short bevel, insulated.
FIGURE 4. 35
a Femoral a.
b Adductor longus
m. tendon
FIGURE 4. 36
1 Obturator n. (anterior
branch)
2 Obturator n. (posterior
branch)
1
3 Adductor longus m.
2
4 Adductor brevis m.
7
5 Adductor magnus m.
6 Gracilis m. 3 4
7 Needle direction
5
6
FIGURE 4. 37 Direct
the needle cephalad and
dorsally.
a
Obturator nerve block
COMPLEXITY:
Patient position: supine, with the leg to be blocked slightly externally rotated.
Landmarks: surface: adductor longus muscle; sonoanatomical: femur, adductor
magnus, brevis and longus.
Technique: expose the groin and the medial aspect of the proximal thigh. Place
a high-frequency linear transducer in the inguinal crease, and select a depth
of field approximately 2–4 cm, although a greater depth may be required in
obese patients. Obtain images in the SAX view, and scan slightly distally in the
upper medial thigh. The obturator nerve in the upper thigh has divided into its
posterior and anterior branches, lying above and below the adductor brevis. The
branches of the obturator nerve are hyperechoic and may be accompanied by
vessels.
Insert the needle perpendicular to the transducer and the ultrasound beam
(OOP approach), and identify the anterior and posterior branches of the
obturator nerve. Inject 5–10 mL of local anaesthetic in each of the two
intermuscular fascial planes. Observe distension of the intermuscular planes and
surrounding of the hyperechoic nerve structures by the local anaesthetic.
Needle: 22 G, 50 mm, insulated.
Comments: first, inject deep to the adductor brevis (posterior branch), then pull
back and inject superficial to brevis (anterior branch).
FIGURE 4. 38 Insert the needle, using an OOP approach.

a Right thigh
b Right inguinal crease
a b
FIGURE 4. 39 SAX view of the obturator nerve.

a Anterior branch
b Posterior branch
c Adductor brevis
Sacral plexus block
COMPLEXITY:
Indications
• Hip surgery
• Surgery of the sciatic distribution.
Technique
Patient position: lateral, with the leg to be anaesthetized superior and the hip
flexed 60°.
Landmarks: PSIS and IT.
Technique: locate the PSIS, and draw a line connecting it to the IT. Insert the
needle along this line, 40% from the PSIS, and advance along the sagittal plane.
If bone is contacted, remove and redirect the needle 1–2 cm caudad and lateral
to the previous insertion point. Brisk motor response of the ankle and foot at a
stimulating current of 0.3 mA indicates correct needle placement. Inject 20 mL
of anaesthetic slowly.
Needle: 22 G, 15 cm.
Local anaesthetic: 1.5% lignocaine with adrenaline 1:200 000 (30 mL), 0.5%
bupivacaine, or 0.75% ropivacaine.
Comment: this technique uses similar landmarks to the psoas compartment
(lumbar plexus) block and is useful for hip surgery when performed with the
psoas compartment block. Isolated twitches of the hamstring muscles on
stimulation also indicates correct needle placement. Twitching of the gluteus
muscles indicates superficial needle placement. This is the easiest and most
reliable landmark-based approach to the sciatic nerve.
1 3 2
FIGURE 4.4 0
1 Posterior superior iliac spine
2 Sciatic n.
3 Ischial tuberosity
a b
FIGURE 4.41 Insert and direct the needle in a sagittal plane.

a Posterior superior iliac spine
Sciatic nerve block: subgluteal

to popliteal fossa
COMPLEXITY:
The sciatic nerve is a large structure and may be blocked at different levels to
provide regional anaesthesia and analgesia for a wide range of indications.
Consideration must be given to both the indication for the nerve block and the
location where the sciatic nerve is best visualized with ultrasound to determine
the best location to perform a block. Refer to Scanning tips for the lower
extremities for a more detailed description of scanning the sciatic nerve.
Indications
• Hip surgery (proximal)
• Surgery of the sciatic distribution
• Leg surgery, when combined with a lumbar plexus block
• Analgesia (proximal for above the knee; distal for below the knee)
• Sympathicolysis (achillodynia, diabetic gangrene, circulatory or
wound-healing disorders, complex regional pain syndrome)
• Foot or ankle surgery.
Patient position: the patient may be positioned semi-prone, with the limb to
be blocked uppermost (all approaches); supine, with the hip and knee flexed
(distal sciatic block); or supine (anterior approach).
Landmarks: surface: superior iliac spine and ischial tuberosity, greater
trochanter, and ischial tuberosity at gluteal fold and popliteal crease at knee;
sonoanatomical: ischial tuberosity, greater trochanter, femur, and popliteal artery.
Technique: place a curved transducer (3–7 MHz) on the posterior thigh. The
hyperechoic sciatic nerve may be identified between the gluteus maximus and
adductor magnus muscles and posterior to the femur. In the mid-thigh, it may
appear round or rectangular, while, distally, it appears circular and divides into
two branches at its bifurcation. (Note: the nerve may be divided as proximal
as the gluteal fold.) Distally, the sciatic nerve lies posterior (superficial) to the
popliteal artery. Confirm nerve identity, and follow the course of the nerve by
scanning proximally and distally to confirm anatomy before determining the
appropriate level to block:
• Proximal sciatic (sacral plexus or subgluteal block) to block the hip
• Mid-thigh or more proximal sciatic to block the knee
• Distal sciatic, usually at or above the bifurcation, to block the knee and below.
An IP or OOP needle approach may be used; if using peripheral nerve
stimulation, observe for an appropriately distal twitch. Inject 20–30 mL of local
anaesthetic slowly to surround the nerve, observing spread.
Needle: 10–15 cm, stimulating for single shot; 10–15 cm, Tuohy for continuous
blockade.
Comments: proximal (subgluteal) sciatic nerve may be difficult to identify with
ultrasound, so landmarks may be required. Nerve stimulation is recommended
if the nerve is deep.
FIGURE 4.42 Scan with a

curvilinear probe to obtain
a
a SAX view of the proximal
sciatic nerve (patient in left
lateral position).
a Greater
trochanter
b Knee
FIGURE 4.43 Scan
with a linear probe to
obtain a SAX view of a
the mid-femoral sciatic
nerve; the needle is
shown in an IP approach.
The needle insertion
point is on the groove
between the biceps
femoris and vastus
lateralis muscles.
a Knee
FIGURE 4.4 4 Scan
with a linear probe to
obtain a SAX view of a
the distal sciatic nerve.
a Knee
FIGURE 4.45 SAX
Anterior view of the proximal
sciatic nerve.
a Sciatic n.
Posterior
FIGURE 4.46 SAX
6 view of the proximal
sciatic nerve CFD.
a Sciatic n.
–6
b Accompanying
vessels
Anterior FIGURE 4.47 SAX

view of the mid-femoral
sciatic nerve.
a Sciatic n.
a
Posterior
FIGURE 4.48 SAX
Anterior view of the distal
sciatic nerve.
a a Sciatic n.
Posterior
FIGURE 4.49 SAX
view of the sciatic nerve
bifurcation.
a Common peroneal n.
b Tibial n.
FIGURE 4. 50 SAX
view of the sciatic nerve
bifurcation.
a Common peroneal n.
b Tibial n. a
FIGURE 4. 51 Probe
position for proximal
sciatic (subgluteal)
block; insert the needle,
using an IP approach. a
a Greater trochanter
FIGURE 4. 52 Probe
position for distal sciatic
(popliteal) block; insert
approach. a
a Femoral condyle
b Biceps femoris b
m. tendon
Sciatic nerve block: proximal

anterior/ventral
COMPLEXITY:
Indications
• Leg surgery, when combined with lumbar plexus block
• Analgesia
Landmarks: surface: inguinal crease; sonoanatomical: femur, lesser trochanter,
femoral artery.
Technique: place a curved, low-frequency (2–5 MHz) transducer on the thigh,
approximately 8 cm from the inguinal crease. Ensure the needle trajectory
is proximal to the femoral vessels entering the adductor canal. Observe the
transverse view of the femur (short axis) as a curved hyperechoic line with an
underlying bone shadow. Identify the lesser trochanter as the wide segment
immediately above the femoral shaft by moving the transducer proximally
and distally. The sciatic nerve may be identified in the proximal thigh, deep to
the adductor muscles and posterior-medial to the femur, as predominantly
hyperechoic and oval or elliptical in shape.
Visualization of the sciatic nerve may be improved by more medial orientation
of the probe—anisotropy is an important determinant in optimizing sciatic
sonoanatomy.
Both IP and OOP approaches may be used to perform this block. For the OOP
approach, align the nerve target with the midpoint of the transducer and then
insert the needle in the same location. Clear identification of the needle tip
can be technically challenging when the needle angle is steep and the needle
is deep inside the muscle layers. Walking the needle off the medial aspect of
the femoral shaft may assist with needle placement. Confirm needle-to-nerve
contact by electrical stimulation, and observe local anaesthetic spread, or by
jiggling the needle. Alternatively, hydrodissection may be performed, using 5%
dextrose to maintain electrical stimulation.
The IP approach is more difficult to perform, as the contralateral leg often
obstructs the needle trajectory. Insert the needle on the medial side of the
ultrasound transducer, following infiltration of the skin with local anaesthetic.
Advance the needle in a medial to lateral direction, in addition to an anterior
to posterior direction, medial to the femoral neurovascular bundle (displaced
laterally once the thigh is externally rotated). The steep angle of needle
advancement may make it difficult to clearly visualize the block needle. Nerve
movement may indicate contact with the needle. It is recommended that
electrical stimulation be used for additional confirmation. Inject 20–30 mL of
local anaesthetic around the sciatic nerve for post-operative analgesia.
Needle: 20 G, 15 cm, insulated block.
Comments: a single injection site may be sufficient, with adequate local
anaesthesia spread around the nerve. Failing this, the needle may be withdrawn
slightly and repositioned so that local anaesthetic is deposited on the medial
and lateral aspects of the nerve. This block is very well tolerated by patients if
performed following femoral nerve block for knee surgery.
FIGURE 4. 53 Use a
curvilinear probe, and
insert the needle, using
an OOP approach.
b
a Right thigh
b Abdomen
FIGURE 4. 54
Close-up SAX view of
the anterior sciatic. a
a Femoral vessels
and n.
b Femur
c Sciatic n. b
FIGURE 4. 55 SAX
deep view of the anterior
a
sciatic.
a Femoral n. and vessels
b Femur
b
c Sciatic n.
c
FIGURE 4. 56 SAX 22
view of the anterior
Lateral Medial
sciatic CFD.
–22
a Femoral a. and femoral
v. (and femoral n.) a
b Femur
c Sciatic n. b
c
Saphenous nerve block
COMPLEXITY:
Ultrasound guidance may facilitate the success of saphenous nerve blocks, as
the success rate for traditional landmark techniques is only 33%.
Indications
• Anaesthesia supplementary to incomplete lumbar plexus block (medial
lower leg)
• Complete anaesthesia of the lower leg, in combination with a sciatic
nerve block.
Patient position: supine, with the leg externally rotated and hip and knee
flexed.
Landmarks: sonoanatomical: femoral nerve, artery and vein, sartorius muscle.
Technique: place a high-frequency, linear-array ultrasound probe on the
mid-thigh over the sartorius muscle, which runs lateral to medial from the ASIS
to the tibia across the anterior thigh. In the SAX view, observe the sartorius
muscle overlying the femoral vessels proximal to the adductor canal. The
terminal branches of the femoral nerve, of which the saphenous nerve is the
major branch, lie adjacent to the femoral artery. Alternatively, if this view is
difficult to obtain, commence scanning in the inguinal region for the femoral
vessels in a SAX orientation. Trace down the femoral artery distally until the
sartorius muscle forms a roof over the artery and saphenous nerve, proximal to
the adductor canal.
Perform the block, using an OOP or IP approach, ensuring local anaesthetic
deposition is below the saphenous muscle, and hydrodissect around the nerves
surrounding the femoral artery.
Needle: 25 G, 6 cm.
Local anaesthetic: 1% ropivacaine.
FIGURE 4. 57 Probe position for SAX view of the saphenous nerve.

a Right knee
FIGURE 4. 58 Needle insertion, using an IP approach.

a Right knee
FIGURE 4. 59 Needle insertion, using an OOP approach.

a Right knee
FIGURE 4.60 SAX view of the saphenous n.

a Sartorius m.
b Saphenous n.
c Femoral a.
Ankle blocks
COMPLEXITY:
The foot is supplied by five nerves: four originate in the sciatic nerve (superficial
and deep peroneal nerves, tibial and sural nerves), and the other (saphenous
nerve) is the terminal branch of the femoral nerve. This block is often painful to
perform, and the patient may require sedation to tolerate its placement.
Indications
• Anaesthesia supplementary to incomplete lumbosacral plexus block
• Foot surgery
• Analgesia
• Diagnostic block.
See Figures 4.61, 4.62, and 4.63.
Technique
Superficial peroneal nerve
Supplies the skin on the back of the foot and toes, except an area between the
great and second toes.
Landmarks: tibia (anterior edge) and lateral malleolus (upper edge).
Technique: insert the needle between the anterior edge of the tibia and the
upper edge of the lateral malleolus, approximately a hand-width above the
lateral malleolus. Infiltrate the area subcutaneously with 5–10 mL of anaesthetic.
Sural nerve
Supplies the lateral edge of the foot and is variable up to the fifth toe.
Landmarks: Achilles tendon and lateral malleolus.
Technique: insert the needle between the Achilles tendon and the lateral
malleolus, approximately a hand-width above the lateral malleolus. Infiltrate the
area subcutaneously with 5 mL of anaesthetic.
Saphenous nerve
Supplies the skin medially from the inner ankle and is variable up to the great toe.
Landmarks: tibia (anterior edge) and medial malleolus.
Technique: insert the needle at the anterior edge of the tibia, approximately a
hand-width above the medial malleolus. Infiltrate the area subcutaneously with
5–10 mL of anaesthetic, from the anterior edge of the tibia to the Achilles tendon.
Needle: 22–24 G, 4–6 cm.
Comments: if these subcutaneous blocks are initially performed as a ring
infiltration, subsequent needle-sticks will be pain-free.
FIGURE 4.61
a Extensor digitorum
longus m. tendon
b Dorsalis pedis a.
c
c Medial malleolus a
d Lateral malleolus
FIGURE 4.62 3 2
1 Sural n.
2 Superficial peroneal n.
3 Deep peroneal n.
FIGURE 4.63
Subcutaneous ring
infiltration above the
ankle to block the
superficial peroneal and
sural nerves (lateral)
and saphenous nerve
(medial).
Ankle blocks
COMPLEXITY:
Technique
Deep peroneal nerve
Supplies the medial side of the great toe and the lateral side of the second toe.
Landmarks: extensor digitorum longus muscle (tendon) and dorsalis pedis
artery.
Technique: palpate the tendon of the extensor digitorum longus muscle. Insert
the needle between the tendon and the dorsalis pedis artery, perpendicular
to the skin. Advance the needle slightly under the artery. Inject 2–5 mL of
anaesthetic, following negative aspiration.
Needle: 24 G, 3–5 cm.
Local anaesthetic: 1% lignocaine, 0.5% bupivacaine, or 0.75% ropivacaine
(2–3 mL).
Posterior tibial nerve
Supplies the sole of the feet, with the exception of the extreme lateral and
proximal segments.
Patient position: supine, with the leg of the foot to be blocked rotated
externally.
Landmarks: posterior tibial artery, Achilles tendon, and medial malleolus.
Technique: insert the needle directly dorsal to the posterior tibial artery on the
medial side of the joint or, alternatively, directly anterior of the Achilles tendon
at the level of the medial malleolus. Insert the needle perpendicular to the skin.
Inject 3–8 mL of anaesthetic while aspirating intermittently.
Needle: 22 or 24 G, 5 cm, insulated.
Local anaesthetic: 1% lignocaine, 0.5% bupivacaine, or 0.75% ropivacaine
(3–4 mL).
Comments: nerve stimulation is recommended. Plantarflexion of the toes
indicates correct needle placement.
FIGURE 4.6 4
2 3 4
1 Superficial peroneal n.
2 Saphenous n.
3 Dorsalis pedis a.
4 Deep peroneal n.
1 4
FIGURE 4.65 Insert the

needle perpendicular to
the skin.
a Extensor digitorum
longus m. tendon a
b Dorsalis pedis a. b
c
FIGURE 4.66
1 Saphenous n.
2 Posterior tibial a.
3 Tibial n.
3 2 1
FIGURE 4.67 Insert
the needle dorsal of the
artery and perpendicular
to the skin. a
a Posterior tibial a.
b Medial malleolus b
c
Ankle blocks
COMPLEXITY:
As the superficial peroneal, saphenous, and sural nerves can be blocked by
subcutaneous infiltration, ultrasound guidance is only recommended for blocks
of the deep peroneal and posterior tibial nerves. Prior to blocking the deep
peroneal or posterior tibial nerve, block the superficial peroneal, sural, and
saphenous nerves by subcutaneous infiltration (as described in the previous
sections) with 5–8 mL of anaesthetic.
Deep peroneal nerve
Landmarks: surface: tibia (anterior edge); sonoanatomical: anterior tibial and
dorsalis pedis arteries.
Technique: place a linear ultrasound probe lateral to the anterior edge of the
tibia, about 5 cm proximal to the foot. Locate the anterior tibial artery, which
continues as the dorsalis pedis artery in the foot. Colour flow Doppler and the
pulsatile nature of the artery will confirm the location of the artery. Lateral to
the artery, the hyperechoic deep peroneal nerve is visualized. Using an OOP
approach, deposit 3–4 mL of anaesthetic around the nerve after confirming
needle placement with a test dose of anaesthetic.
Needle: 22 G, Stimuplex®.
Local anaesthetic: 0.75% ropivacaine or 1:1 mixture of 1% lignocaine and
0.75% ropivacaine.
Posterior tibial nerve
Patient position: supine, with the hip and knee flexed and the foot placed
across the contralateral leg to expose the medial malleolus.
Landmarks: surface: medial malleolus; sonoanatomical: posterior tibial artery.
Technique: place the linear-array probe 5 cm above the medial malleolus, and
locate the posterior tibial artery. Confirm this either by its pulsatile nature or
with colour flow Doppler. The tibial nerve is the hyperechoic structure posterior
to the artery. Using an OOP approach, inject 3–4 mL of anaesthetic slowly after
confirming needle placement with a test dose of anaesthetic.
Needle: 22 G, Stimuplex®.
0.75% ropivacaine.
FIGURE 4.68
Insert the needle
lateral to the
anterior tibial artery,
using an OOP
approach.
FIGURE 4.69 SAX
view of the deep
peroneal nerve.
a Anterior tibial a. a
b Deep peroneal n. b
c Tibia
FIGURE 4.70 Insert
OOP approach.
a Medial malleolus
FIGURE 4.71 SAX
view of the posterior
tibial nerve.
a Posterior tibial a.
b Posterior tibial n.
a
b
References
html>.
2 Winnie A , Ramamurthy S, Durrnai Z (1973). The inguinal paravascular
technic of lumbar plexus anesthesia: the ‘3-in-1 block’. Anesth Analg 52,
989–96.
3 Ganapathy S, Wassserman R , Watson J, et al. (1999). Modified continuous
femoral three-in-one block for postoperative pain after total knee
arthroplasty. Anesth Analg 89, 1197–202.
4 Dalens B, Vanneuville G, Tanguy A (1989). Comparison of the fascia iliaca
compartment block with the 3-in-1 block in children. Anesth Analg 69,
705–13.
CH AP T E R FI VE
SPINE AND
PARA-AXIAL
REGION
Anatomy of the spine and para-axial region 124

Sensory supply 125
Thoracic paravertebral block 126
Epidural block for labour anaesthesia 130
Intercostal block 132
Posterior transversus abdominis plane (TAP)
block 136
Subcostal TAP block 138
Rectus sheath block 140
Ilioinguinal iliohypogastric block 142
Genitofemoral block 144
Dorsal penile block 146
References 148
Anatomy of the spine and

para-axial region
See Figure 5.1.
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
1 2 3
4
FIGURE 5.1 Anatomy of the spine and para-axial region.

1 Ventral root 4 Dorsal ramus ganglion
2 Dorsal root 5 Dorsal ramus
3 Rootlets 6 Ventral ramus (intercostal)
SPINE AND PARA-AXIAL REGION 125
Sensory supply
See Figure 5.2.
T2
T3
T4
T5
T2 T6 T2
T7
T8
T9
T1 T10 T1
T11
T12
S2
S3
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L3
S1
Coccyx
S5
S4
S3
FIGURE 5. 2 Sensory supply. T1 and T2 send nerve fibres to the upper limbs
and the upper thorax; T3–T6 supply the thorax; T7–T11 supply the lower
thorax and abdomen, and T12 innervates the abdominal wall and the skin of
the front part of the gluteal region.
Thoracic paravertebral block
COMPLEXITY:
Indications
• Breast and axillary surgery
• Pain management after thoracic surgery or rib fractures.
• Total spinal anaesthesia
• Epidural anaesthesia
• Quadratus femoris muscle weakness can occur when the spinous process
levels are not determined accurately and the levels below L1 are blocked.
See Figures 5.3, 5.4, and 5.5.
Technique
Patient position: sitting or lateral decubitus and kyphotic. If sitting, rest the
patient’s feet on a stool to increase comfort and the degree of kyphosis.
Landmarks: midline of spinous processes (relevant to the anaesthesia).
Technique: locate the midline of, and outline, each spinous process. After
subcutaneous infiltration, insert the needle perpendicular to the skin, 2.5 cm
lateral from the midline at the level of the spinous process requiring anaesthesia.
Advance the needle towards to the transverse process. After contacting the
transverse process, note the needle depth; withdraw the needle to the skin;
redirect 10° cephalad, and re-advance. ‘Step off’ the transverse process, and
advance the needle 1–1.5 cm further, using a loss-of-resistance technique
with saline (a subtle loss of resistance is felt). If difficulty is experienced with
locating space, redirect the needle 10° caudad and re-advance. Inject 4–5 mL
of anaesthetic into the paravertebral space. Repeat for each spinous process
requiring anaesthesia. The cephalad-caudad space between the first two
transverse processes anaesthetized can be used to locate the remaining transverse
processes requiring anaesthesia. For breast surgery, a single injection of 20 mL only
at T3 or T4 is required. Placement of this dose via catheter is recommended.
Needle: 18 G, 8 cm, Tuohy.
Local anaesthetic: 2% lignocaine with adrenaline 1:200 000, 0.5% bupivacaine
with adrenaline 1:200 000, or 0.5% ropivacaine.
Comments: ultrasound is useful to locate the position and depth of the
transverse process. Kyphosis increases the distance between adjacent transverse
processes and assists needle progression beyond the transverse process. Patients
may experience moderate discomfort and may require sedation. Directing the
needle medially will increase the risk of epidural or spinal injection and laterally
will increase the risk of pneumothorax. The depth at which the needle contacts
the transverse process varies, according to the patient’s habitus and the level of
the spinous process. In the average patient, contact with the transverse process
at T1 and T2, and L4 and L5 occurs at 6–8 cm needle depth, whereas, at T5
and T10, contact occurs at 2–4 cm needle depth. Recent evidence suggests this
block reduces phantom pain post-mastectomy and may reduce breast cancer
recurrence.1
FIGURE 5. 3
a Midline of the
spinous processes
b Paramedial line
2.5 cm lateral to the
midline
a b
FIGURE 5.4
3
1 Spinal n.
2 Transverse process
3 Spinous process 2
FIGURE 5. 5 Insert
in a sagittal direction.
Thoracic paravertebral block
COMPLEXITY:

Technique: locate the paravertebral space, as described. Inject an initial bolus of
5 mL of anaesthetic into the paravertebral space. Advance the catheter 3–5 cm
beyond the needle tip; if the catheter does not feed easily, repeat the block.
Secure the catheter to the skin with clear dressing, and complete the block
via catheter. Infuse the anaesthetic at a rate of 10 mL/hour, or 6 mL/hour if a
patient-controlled analgesia is planned.
Equipment: 18 G, Tuohy needle and catheter.
Local anaesthetic: initial bolus: 0.5% bupivacaine or 0.5% ropivacaine;
continuous infusion: 0.25% bupivacaine or 0.2% ropivacaine.
Comments: to manage breakthrough pain, administer a bolus of anaesthetic
through the catheter; increasing the rate of infusion is rarely adequate. If pain is
unrelieved after 30 minutes, the catheter should be considered dislodged and
removed.
FIGURE 5.6 (a) Insert (a)

the needle, and contact
the transverse process of
the individual vertebrae
(note the depth of
contact, usually 2–4 cm). 1
(b) Withdraw the needle to
the skin, and re-advance
cephalad at a 10° angle.
‘Step off ’ the transverse
process, and advance 1 cm
deeper.
1 Spinous processes 2
(b) 3
2 Transverse processes
3 Spinal nerves
FIGURE 5.7 Scanning
with a curvilinear probe
is useful to locate the
position and depth of the
transverse processes.
a Thoracic spine
FIGURE 5. 8 Thoracic
paravertebral block. a
a Paravertebral space
b Transverse process.
b
Epidural block for labour anaesthesia
COMPLEXITY:
Indications
• Anaesthesia and analgesia during labour.
• Recent antepartum haemorrhage
• Cephalopelvic disproportion.
• Accidental puncture of the dura
• Haematoma, owing to puncture of an epidural vein
• Intravascular or intrathecal injection
• Total spinal block, owing to intrathecal injection
• Uterine hypotension (when higher concentrations of anaesthetic are injected,
e.g. 0.25% bupivacaine)
• Post-dural puncture headache
• Meningitis.
Continuous catheter technique (midline approach)

Patient position: left lateral or sitting.
Landmarks: iliac crest and midline of L2–L4 spinous processes.
Technique: palpate and draw a line between the iliac crests to estimate the
level of the L3–L4 spinous processes. Raise a subcutaneous bleb of anaesthetic
between two adjacent vertebrae (L2–L3 or L3–L4), and infiltrate deeper in
the midline and paraspinously to anaesthetize the needle insertion site and
posterior structures. Insert the epidural needle sagittally between two adjacent
vertebrae. Direct and advance the needle slightly cephalad and slowly through
the supraspinous ligament and the interspinous ligament (2–3 cm). When the
needle is advanced into the ligamentum flavum, increased resistance is usually
felt. Control the needle’s movement by gripping its wing and resting the dorsum
of the non-injecting hand against the patient’s back. Attach a loss-of-resistance
syringe with 5–8 mL of air or a syringe with saline. With continuous pressure on
the syringe plunger, advance the needle slowly until its tip exits the ligamentum
flavum and enters the epidural space. A loss of resistance or ‘click’ (rare) may be
felt. Advance the epidural catheter 4–6 cm past the needle tip (never withdraw
the catheter through the needle—this risks shearing the catheter), and inject
a 5–10 mL bolus of anaesthetic through the catheter. Inject the bolus in 5 mL
increments, aspirating carefully between increments and checking the level to
ensure the catheter is not subarachnoid. The addition of adrenaline
(1:200 000) may reveal intravascular catheter placement if tachycardia is
induced. Fix the catheter, and infuse anaesthetic at a rate of 5–10 mL/hour.
Equipment: 16 or 18 G, 8 cm Tuohy needle and 18 or 20 G catheter.
Local anaesthetic: initial bolus: 0.125–0.5% bupivacaine or 0.2–0.5%
ropivacaine; continuous infusion: 0.125% bupivacaine or 0.2% ropivacaine.
Comment: as the interspinous ligament is extremely dense, injection into it
is almost impossible. It is not necessary to anaesthetize above the level of the
L1–L2 spinous processes for labour analgesia, and it has the increased risk of
spinal cord injury. The addition of 2 micrograms/mL of fentanyl produces a
better-quality block and reduces anaesthetic requirements.
FIGURE 5.9
a L3–L5 spinous
processes
b
a
FIGURE 5.10 1
1 Spinous process
2
2 Spinal cord within dura
3 Nerve root
4 Vertebral body
3
4
FIGURE 5.11 Direct
the needle in a
sagittal plane.
Intercostal block
COMPLEXITY:
Indications
• Analgesia for chest trauma, such as rib fractures
• Analgesia following surgery of the chest and upper abdominal area, such as
thoracotomy, thoracostomy, mastectomy, gastrostomy, and cholecystectomy.
• Haemostatic deficiencies
• When pneumothorax would be fatal.
• Pneumothorax and lung injury
• Toxicity is a concern, owing to the rapid absorption of anaesthetic from the
intercostal space.
Technique
Patient position: prone, sitting, or lateral, with block side up. If the patient is
prone, place a pillow under their abdomen, with their arms hanging to the side.
Patients who are sitting should lean forward, holding a pillow, and be supported
with their arms forward. The scapulae pull laterally in both positions, facilitating
access to the posterior rib angles above T7.
Landmarks: rib (inferior edge) and erector spinae muscles.
Technique: of the ribs to be anesthetized, mark their inferior edges just lateral to
the erector spinae muscle group (usually 6–8 cm and 4–7 cm from the midline
of the lower and upper ribs, respectively). Infiltrate the area subcutaneously.
Palpate the needle insertion site, and draw the skin approximately 1 cm
cephalad. Insert the needle cephalad (bevel facing cephalad) at a 20° angle.
Advance the needle until it contacts the rib (less than 1 cm for most non-obese
patients). A small volume of anaesthetic may be injected to anaesthetize the
periosteum. Gently ‘step’ the needle caudad, and allow the skin to move back
over the rib. Advance the needle 3 mm further, maintaining the 20° cephalad
angle. Aspirate for blood, and then inject 5–10 mL per rib anaesthetic. Repeat
for all ribs that require anaesthesia.
Needle: 22 or 24 G, 4–5 cm.
Local anaesthetic: 1% lignocaine with adrenaline 1:200 000, 0.5% bupivacaine,
or 0.75% ropivacaine.
Comments: for a single intercostal nerve block, it is desirable to block one
intercostal nerve cephalad and one caudad. To ensure the needle tip remains
fixed and unaffected by hand and chest movement, connect the needle to the
syringe with extension tubing, and have an assistant perform the aspiration and
injection.
FIGURE 5.12
1 Interpleural space 1
2 Subserous fascia 2
3 Endothoracic fascia 3
4 Intercostal v.
5 Intercostal a. 4
5
6 intercostal n.
6
7 Internal intercostal m.
FIGURE 5.13 Direct
the needle cephalad at a
20° angle.
a Rib (inferior edge)
b Spinous processes
c Needle insertion site c
b
Intercostal block
COMPLEXITY:
Patient position: sitting, with patient leaning forward, holding a pillow, and
supported with their arms forward. The scapulae pull laterally, facilitating access
to the posterior rib angles above T7.
Landmarks: surface: midline of spinous processes; sonoanatomical: inner and
intermediate intercostalis muscles, and parietal pleura.
Technique: place the linear-array ultrasound probe longitudinally 5 cm from the
midline of the spinous processes. Locate the intercostal space of interest, seen
between the two ribs as bony landmarks. Rotate the probe into a transverse
view along the intercostal space, imaging the inner and intermediate intercostal
muscles, parietal pleura, and neurovascular bundle under the rib. Colour flow
Doppler, or the pulsatile nature on 2D echo, will identify the intercostal artery.
Using an IP approach, insert the needle on the medial aspect of the probe, and
advance the needle tip to above the parietal pleura and intercostal muscles
adjacent to the intercostal artery. Confirm needle placement with a test dose of
anaesthetic, and aspirate for blood. Inject 5–7 mL of anaesthetic per rib. Repeat
for all ribs that require anaesthesia.
Needle: 25 G, 5 cm.
0.75% ropivacaine.
Comments: ultrasound-guided intercostal nerve block provides a distinct
advantage over the traditional technique, as pain and swelling of overlying tissue
may prevent rib palpation in some patients. Ultrasound also allows for rapid
screening of post-procedure pneumothorax.
FIGURE 5.14 Place
the probe longitudinally
5 cm from the midline of
the spinous processes.
a Spinous processes
FIGURE 5.15
Longitudinal SAX view
of the intercostal space.
a Rib (with dorsal Cephalad c Caudad
shadowing)
b Intercostal mm. b
a a
c Neurovascular bundle
d Parietal pleura
d
FIGURE 5.16 Rotate
the probe into a
transverse view along the
intercostal space, and
insert the needle using
an IP approach (medial
aspect of probe).
FIGURE 5.17 Transverse
oblique SAX view of the
intercostal space.
a Rib (with dorsal
b
shadowing)
a
b Neurovascular bundle
c Parietal pleura
c
Medial Lateral
Posterior transversus abdominis plane

(TAP) block
COMPLEXITY:
Nine segments from the anterior rami of the T6–L1 spinal nerves innervate the
abdominal wall. These nerves pass inferoanteriorly from the intercostal spaces
and run in a neurovascular plane between the internal oblique and transversus
abdominis muscles. This is known as the transversus abdominis plane (TAP). The
lateral branch arises from the mid-axillary line and innervates the abdominal
wall to the edge of the rectus abdominis muscle. The anterior branch passes
forward in the TAP to penetrate the muscle layers and supply afferents to the
anterior abdominal wall.
Thoracoabdominal nerves arising from T7–T9 innervate the skin superior to
the umbilicus, those arising from T10 innervate the skin around the umbilicus,
and those arising from T11, T12 (cutaneous branches of the subcostal nerve),
and L1 (iliohypogastric and ilioinguinal nerves) innervate the skin inferior to the
umbilicus.
Indications
• Anaesthesia and analgesia of the somatic abdominal wall from the pubis to
the level of the umbilicus without neuraxial blockade
• Abdominal wall operations (laparotomy, appendicectomy, hernia repairs,
Caesarean section, and hysterectomy).
See Figures 5.18, 5.19, and 5.20.
Landmarks: surface: lateral abdominal wall, umbilicus, iliac crest, lower
costal margin; sonoanatomical: external and internal oblique, and transversus
abdominis muscles.
Technique: place a high-frequency ultrasound probe on the anterior abdominal
wall, on an angle along the line connecting the ASIS to the subcostal margin,
midway between the iliac crest and the ribs. Insert the needle, using an IP
approach, directed medial to lateral, in position between the transversus
abdominis and internal oblique muscles. Local anaesthetic should be deposited
deep to the fascial layer that separates these muscles. Aim to concentrate
the local anaesthesia between the ASIS and the anterior axillary line to block
T10–L1. Confirm needle placement with a test dose of anaesthetic or saline.
Following negative aspiration, inject 20 mL of anaesthetic slowly in divided
boluses, advancing the needle within the hydrodissected space to open the
TAP. The anaesthetic solution should spread widely, forming a hypoechoic ‘lens’
within the TAP as it hydrodissects the plane between the internal oblique and
the transversus abdominis muscles. Repeat on the opposite side for a bilateral
block. If the plane is unclear, choose to inject between the transversus muscle
and its more superficial fascia.
Needle: 21 or 22 G, 8–12 cm.
Comments: unless the procedure is for surgery within the anterior abdominal
wall, TAP block must be administered in conjunction with multimodal analgesia
for visceral or pelvic components of surgery. The amount of anaesthetic and
opioids administered may be reduced. This description differs slightly from the
classical approach and minimizes sparing of the L1 dermatome.
FIGURE 5.18
1 Branch of the anterior
cutaneous n. 1
2 Rectus abdominis m. 2
3 External oblique m.
4 Internal oblique m.
5 Branch of the lateral 3
cutaneous n. 4
6 Transversus 5
abdominis m.
6
FIGURE 5.19
Insert the needle,
using an IP
approach, directed
medial to lateral. Cephalad
a Costal margin
FIGURE 5. 20
Posterior TAP block. a
a Adipose tissue
b External oblique m. b
c Internal oblique m. c
d TAP d
e Transversus e
abdominis m.
f Peritoneal contents
f
Subcostal TAP block
COMPLEXITY:
The posterior TAP block does not reliably produce analgesia above the
umbilicus. The subcostal TAP block is a modification of the original technique,
created to extend the analgesia provided by the posterior TAP block above the
umbilicus.2
Indications
• Laparotomy incisions extending above the umbilicus.
Landmarks: surface: costal margin, xiphoid process;
sonoanatomical: transversus abdominis plane.
Technique: place a high-frequency ultrasound probe perpendicular to the
abdominal wall, just beneath and parallel to the costal margin, but oblique to
the sagittal plane. Adjust the field depth to 2–6 cm. Introduce the needle, using
an IP approach, near the xiphoid process, starting from medial to lateral along
the subcostal trajectory. Initial deposition of local anaesthetic is between the
transversus abdominis and the rectus abdominis muscles, or between the rectus
and the posterior rectus sheath if the transversus is not behind the rectus at that
level. Injection of 1–2 mL of local anaesthetic opens the insertion plane between
the rectus and transversus, allowing advancement of the needle into the space
hydrodissected by the local anaesthetic. Hydrodissection is used to open the
transversus plane progressively; the needle is intermittently advanced, parallel to
the costal margin and towards the iliac crest, with subsequent small injections
of local anaesthetic. Ensure the needle stays within the transversus plane and
does not pass superficial to the internal oblique at the lateral rectus edge. This
technique lends itself well as a continuous catheter technique; a catheter may be
placed down the needle which then lies largely along the transversus plane, with
the tip near the iliac crest. Local anaesthetic infused down the catheter passes
back up the transversus plane that was previously opened by hydrodissection.
Needle: 10–15 cm, Tuohy, or 22 G, 10–15 cm.
Local anaesthetic: 0.2–0.375% ropivacaine, 30 mL volume each side.
FIGURE 5. 21 Insert
Caudad
IP approach, directed
medial to lateral.
a Costal margin
b ASIS
a b
Cephalad
FIGURE 5. 22
Subcostal TAP.
a Rectus
c
b Peritoneal contents
d
c External oblique m.
d Internal oblique m. e
a
e TAP f
f Transversus
b
abdominis m.
FIGURE 5. 23
Subcostal a
TAP—correct plane.
a Local anaesthetic in d
internal oblique plane e
(incorrect placement)
b Tuohy needle f
c Local anaesthetic
hydrodissection in TAP
c
d External oblique m. b
e Internal oblique m.
f Transversus
abdominis m.
FIGURE 5. 24 a
Subcostal TAP catheter.
a Local anaesthetic
b Bevel of Tuohy needle
c Catheter entering
hydrodissected TAP
c b
Rectus sheath block
COMPLEXITY:
The anterior divisions of spinal segmental nerves that innervate the abdominal
wall run laterally between the transverse abdominis and internal oblique muscle
layers. These nerves then enter the lateral edge of the rectus sheath and run
posterior to the rectus muscle on the sheath. The nerves then variably pierce the
muscle and travel anteriorly to innervate the medial anterior abdominal wall.
Injection of local anaesthetic into the plane between the posterior rectus sheath
and the posterior rectus muscle may be used to block these nerves.
Indications
• Epigastric hernia repair, in combination with light general anaesthesia
• Post-operative analgesia following midline laparotomy.
Landmarks: surface: umbilicus; sonoanatomical: rectus abdominis muscle.
Technique: place a high-frequency ultrasound probe in an axial (transverse)
plane at the level of the umbilicus; scan laterally, and identify the lateral edge of
the rectus muscle. Visualize the three layers of the rectus sheath corresponding
to linea semilunaris. Introduce the needle, using an IP approach. Identify the
lateral edge of the rectus muscle, and place the needle deep to the muscle and
superficial to the posterior rectus sheath at this point. Correct needle placement
may be confirmed by first injecting saline and using ultrasound to observe
the spread of injectate between the rectus muscle and posterior sheath. Inject
5–10 mL of local anaesthetic. Depending on the size and location of the surgical
incision, three or four injection sites, approximately 5 cm apart, may be used
bilaterally.
Needle: 21 or 22 G.
Local anaesthetic: 0.25–0.75% ropivacaine, 5–10 mL for each point up to a
total 40 mL volume.
FIGURE 5. 25 Insert
approach, lateral to the Cephalad
umbilicus.
FIGURE 5. 26 Linea alba.
a Linea alba a
b Rectus mm.
FIGURE 5. 27 Rectus
muscle. Medial
Lateral
a Rectus
b External oblique m.
c Internal oblique m. b
FIGURE 5. 28 Rectus
a
lateral border.
Lateral Medial
a Linea semilunaris
b Rectus m.
c End point of needle in d
IP approach
e
d External oblique m.
e Internal oblique m. f b
f Transversus
abdominis m.
c
Ilioinguinal iliohypogastric block
COMPLEXITY:
Indications
• Analgesia following inguinal hernia repair.
Landmarks: surface: iliac crest, umbilicus; sonoanatomical: anterior superior
iliac spine (ASIS).
Technique: place a linear 10–15 MHz transducer obliquely along a line joining
the ASIS and the umbilicus, immediately superior and medial to the ASIS. The
three muscular layers of the abdominal wall are identified: the external oblique,
the internal oblique, and the transverse abdominis muscles. It is expected the
ilioinguinal and iliohypogastric nerves—often hyperechoic in appearance—will
lie between the transverse abdominis and internal oblique muscles above the
ASIS. Small vessels will commonly be visualized adjacent to both nerves within
the same plane. Colour Doppler may be used to confirm vascular identity.
Insert the needle parallel to, and in line with, the transducer and ultrasound
beam (IP approach), visualizing the needle shaft and tip during advancement.
Accuracy of needle position may be confirmed by injecting test boluses of
local anaesthetic or normal saline. Inaccurate placement of the needle within
a muscle layer will result in the visualization of intramuscular fluid injection.
Correct placement of the needle is indicated by fluid expansion in the space
bounded by the hyperechoic fascial sheath of the internal oblique and
transverse abdominis muscle layers; inject 10–15 mL of local anaesthetic into
this plane.
Needle: 22 G, 5–8 cm.
Comments: the same volume of local anaesthetic may be deposited around
the vessels in the fascial plane if the ilioinguinal or iliohypogastric nerves are not
visualized.
FIGURE 5. 29 Insert
approach.
a Costal margin
b ASIS
Cephalad
a
b
FIGURE 5. 30
SAX view of
a
the ilioinguinal
iliohypogastric
nerve.
a Blood vessel b
b ASIS
c Ilioinguinal
iliohypogastric n.
c
Genitofemoral block
COMPLEXITY:
Indications
• Herniorrhaphy, orchidopexy, or hydrocelectomy, in conjunction with
ilioinguinal iliohypogastric block
• Long saphenous vein stripping, in addition to femoral nerve block
• Diagnosis of genitofemoral neuralgia.
Landmarks: surface: pubic tubercle, inguinal ligament, inguinal crease, femoral
artery.
Technique: identify the femoral artery. To block the femoral branch of the
genitofemoral nerve, insert the needle at the lateral border of the femoral
artery superior to the inguinal crease. Inject 2–5 mL of local anaesthetic under
ultrasound guidance, just superficial to the femoral artery.
Needle: 25 G, 5 cm.
Comments: large-volume block at this level risks spread to the femoral nerve.
FIGURE 5. 31 Insert the

needle superior to the
inguinal crease, using an
IP approach.
a Costal margin a
b ASIS
c Right thigh b
d Inguinal crease
d
c
FIGURE 5. 32
SAX view of the
genitofemoral nerve.
a Iliopectineal fascia
b Femoral a.
a
c Genitofemoral n.
b
c
Dorsal penile block
COMPLEXITY:
Indications
• Dorsal slit of the foreskin
• Phimosis reduction
• Paraphimosis reduction
• Repair of penile lacerations.
See Figure 5.33 to 5.36.
Landmarks: surface: base of the penis.
Technique: scan in transverse and sagittal planes to identify the base of the
penis and suspensory ligaments; these structures define a triangular space.
Insert the needle under ultrasound guidance 0.25 cm laterally to the suspensory
ligament on either side, and fill the triangular space with 2–4 mL local
anaesthetic.
FIGURE 5. 33 Dorsal penile 4

pre-block.
5
1 Penis
6
2 Urethra
1 7
3 Scrotum
4 Probe 8
5 Needle 2
9
6 Superficial fascia
10
7 Pubic symphysis
8 Triangular space where
3
local anaesthetic is injected
9 Deep fascia
10 Dorsal nerve of the penis
FIGURE 5. 34 Transverse
cross-section through the 1
base of the penis. 2
1 Probe 3
2 Needle 4
3 Skin
5
4 Superficial fascia
6
5 Suspensory ligament
6 Dorsal nerve of penis 7
7 Penis
8
8 Urethra
FIGURE 5. 35 Dorsal
penile pre-block.
a b
a Base of penis
b Superficial fascia
FIGURE 5. 36 Dorsal
penile post-block
needle in situ.
a Needle shaft
b Triangular-shaped
local anaesthetic c
expansion
c Penis
b a
References
1 Vila HJ and Kavasmaneck D (2007). Paravertebral block: new benefits from
an old procedure. Curr Opin Anesthesiol 20, 316–18.
2 Hebbard P. New ‘sub-costal oblique’ TAP block and audit data.
Parkville: HeartWeb. Viewed 7 September 2009, <http://
www.heartweb.com.au/www/559/1001127/search.
asp?frombox=true&searchstring=TAP+block&selecttype=3>.
INDEX
3-in-1 block 94 epidural block for labour anaesthesia 130–1

equipment 2, 5–6
allergic reactions 22 ergonomics 11, 12
anisotropy 8, 9–10 eye, external muscles 31
ankle blocks 116–21
anterior ethmoidal nerve 28, 43 fascia iliaca block 100–1
anterior ethmoidal nerve block 42–3 femoral artery
anterior tibial artery 120, 121 femoral nerve block 94, 95, 97
arm see upper extremity genitofemoral block 144, 145
arrhythmias, local anaesthetic toxicity 21 saphenous nerve block 114, 115
aseptic technique 3, 4 femoral nerve
axillary artery/vein anatomy 82, 83, 95
axillary plexus block 68, 69 sensory distribution 84, 85
ultrasound imaging 11, 50, 70, 71 ultrasound imaging 87, 89, 97, 113
axillary nerve 46, 47 femoral nerve block 94–7
axillary plexus, ultrasound imaging 50, 51, continuous catheter technique 94
70, 71 ultrasound-guided technique 96–7
axillary plexus block 68–71 fentanyl 130
continuous catheter technique 68 follow-up, patient 18
single injection technique 68, 69
ultrasound-guided technique 70–1 genitofemoral block 144–5
genitofemoral nerve 82, 83
blood vessels, ultrasound appearances 8, 11 greater occipital nerve 29
brachial artery 72, 74
brachial plexus haematomas 20
anatomy 46 head 27–44
ultrasound imaging 49–51 anatomy of nerve supply 28
brachial plexus blocks 52–71 sensory supply 29
axillary 68–71 hyaluronidase 30, 32
incomplete, supplementation 72–5
infraclavicular 60–5 iliohypogastric nerve 82, 83, 136
interscalene 52–5 ilioinguinal iliohypogastric
supraclavicular 56–9 block 142–3
suprascapular 66–7 ilioinguinal nerve 82, 83, 136
buccal nerve 28 infection control 12–13
bupivacaine infections 20
pharmacokinetics 24 inferior alveolar nerve 28
post-operative analgesia 23, 24 inferior gluteal nerve 85
infiltration anaesthesia 3
carotid artery 49 infraclavicular plexus, ultrasound imaging
catheter technique for continuous infusions 50, 51, 62, 63
see continuous catheter technique infraclavicular plexus block: lateral approach
cervical spinal nerves 64–5
brachial plexus 46 infraclavicular plexus block: vertical
sensory distribution 29, 47 approach 60–3
ultrasound imaging 49 continuous catheter technique 60
common peroneal nerve see peroneal nerve single injection technique 60, 61
complications, regional anaesthesia 20–2 ultrasound-guided technique 62–3
consent, informed 9 infraorbital nerve 28, 36
continuous catheter technique 4 infraorbital nerve block 36–7
care of catheters 23 injection techniques 3, 19
complications 20 in-plane (IP) approach 7
equipment 2 intercostal block 132–5
infection control 12 technique 132–3
post-operative analgesia 23–4 ultrasound-guided technique 134–5
contraindications 20 intercostal nerves 46
coracobrachialis muscle 68, 69 intercostobrachial nerve 46, 47
coupling medium, ultrasound 12 interscalene groove 52, 53, 56, 57
interscalene plexus, ultrasound imaging 10,
Dalen's technique 100 49, 54, 55
deep peroneal nerve 84, 85, 119 interscalene plexus block 52–5
deep peroneal nerve block 118, 119 continuous catheter technique 54
ultrasound-guided technique 120–1 single injection technique 52
dorsal penile block 146–7 ultrasound-guided technique 54–5
150 INDEX
labour anaesthesia, epidural block 130–1 nerve damage 20

lateral antebrachial cutaneous nerve 47 nerves, ultrasound appearances 6–8, 9–10
lateral circumflex femoral artery 96, 97 nerve stimulators 2
lateral cutaneous brachial nerve 47 neurostimulation-guided regional
lateral femoral cutaneous nerve anaesthesia
anatomy 82, 83, 99 continuous catheter technique 4
sensory distribution 84 guidelines 3
lateral femoral cutaneous nerve block 98–9 troubleshooting 19
lateral plantar nerve 84, 85 ultrasound guidance plus 18
lesser occipital nerve 29
lignocaine obturator nerve
pharmacokinetics 24 anatomy 82, 83, 103
post-operative analgesia 23, 24 sensory distribution 84, 85
linea alba 141 obturator nerve block 102–5
linea semilunaris 140, 141 technique 102–3
lingual nerve 28 ultrasound-guided technique 104–5
lipid emulsion, intravenous 22, 150–1 operation room 2
local anaesthetics ophthalmic nerve 28, 29
allergic reactions 22 out-of-plane (OOP) approach 7
post-operative analgesia 23–4
local anaesthetic toxicity 20, 21–2 para-axial region see spine and para-axial
management guideline 150–1 region
symptoms and signs 21 paravertebral space 126, 129
treatment 21–2 peribulbar block 30–1
long axis (LAX) view 6, 7 peroneal nerve
long thoracic nerve 46 motor response 86
lower extremity 81–122 sensory distribution 84, 85
motor response 86 ultrasound imaging 87, 111
scanning tips 87–9 posterior antebrachial cutaneous nerve 47
sensory supply 84–5 posterior femoral cutaneous nerve
lumbar plexus anatomy 82, 83
anatomy 82 sensory distribution 84
ultrasound scanning 87, 88 posterior tibial artery 120, 121
lumbar plexus block see psoas compartment posterior tibial nerve
block anatomy 119
lumbar spinal nerves 82 sensory distribution 84, 85
lumbosacral plexus posterior tibial nerve block 118–19
anatomy 82–3 ultrasound-guided technique 120–1
ultrasound scanning 87–9 posterior transversus abdominis plane (TAP)
block 136–7
mandibular nerve 28, 29 post-operative analgesia 23–4
maxillary nerve 28, 29, 41 pre-anaesthesia 2
maxillary nerve block 40–1 preoperative assessment 9
medial antebrachial cutaneous nerve 46, 47 psoas compartment (lumbar plexus) block
medial brachial cutaneous nerve 46, 47 90–3
medial plantar nerve 84, 85 continuous catheter technique 90
median nerve ultrasound-guided technique 92–3
anatomy 46, 47, 77 pudendal nerve 82
motor response 48
ultrasound imaging 9–10, 50, 75 radial nerve
median nerve block anatomy 46, 47, 73, 79
forearm 74–5 motor response 48
wrist 76, 77 ultrasound imaging 50, 72, 73
mental nerve 28, 39 radial nerve block
mental nerve block 38–9 upper arm 72–3
monitoring, patient 3 wrist 78–9
motor response rectus sheath block 140–1
arm and hand 48 ropivacaine
lower extremity 86 pharmacokinetics 24
musculocutaneous nerve post-operative analgesia 23, 24
anatomy 46, 47
motor response 48 sacral nerves 82, 85
ultrasound imaging 50 sacral plexus 82, 83
sacral plexus block 106–7
nasociliary nerve 28, 43 saphenous nerve
needles 2 sensory distribution 84
insertion guidelines 3 ultrasound imaging 87, 114–15
ultrasound-guided regional anaesthesia saphenous nerve block
12, 13–15, 16–17 ankle 116–17
ultrasound imaging planes 7 upper leg 114–15
INDEX 151
scalp, anatomy of nerve supply 28–9 thoracic paravertebral block 126–9

sciatic nerve 82, 83 continuous catheter technique 128–9
sensory distribution 84, 85 technique 126–7
ultrasound imaging 87, 89, 109–11, 113 thoracic spinal nerves 125
sciatic nerve block 108–13 thoracoabdominal nerves 136
proximal anterior/ventral 112–13 tibial nerve
subgluteal to popliteal fossa 108–11 motor response 86
seizures, local anaesthetic toxicity 21 sensory distribution 84, 85
sensory supply ultrasound imaging 111
arm and hand 47 topical analgesia 3
head and scalp 29 transversus abdominis plane (TAP) 136,
lower extremity 84–5 137, 139
spine and para-axial region 125 transversus abdominis plane (TAP) block
short axis (SAX) view 6, 7 posterior 136–7
side effects, regional anaesthesia 20 subcostal 138–9
single injection technique 3 trigeminal ganglion 28, 41
equipment 2 trigeminal nerve 28–9
infection control 12
post-operative analgesia 23, 24 ulnar nerve
spinal needles 2 anatomy 46, 47, 77
spine and para-axial region 123–48 motor response 48
anatomy 124 ultrasound imaging 74, 75
sensory supply 125 ulnar nerve block
sternocleidomastoid muscle 52, 53, 56, 57 forearm 74, 75
subclavian artery needle repositioning 16–17
intraclavicular plexus block 62, 63 wrist 76, 77
landmarks 53, 56, 57 ultrasound-guided regional anaesthesia
ultrasound imaging 49, 59, 62, 63 5–18
subclavian vein 63 equipment 5–6
subcostal nerve, cutaneous branches 136 follow-up 18
subcostal transversus abdominis plane (TAP) infection control 12–13
block 138–9 preoperative assessment 9
sub-Tenon's eye block 32–3 preprocedure scanning 13
superficial peroneal nerve 84 procedure 13–15
superficial peroneal nerve block 116, 117 scanning technique 6
superior gluteal nerve 85 set-up and preparation 11–12
supraclavicular nerve 47 spatial terms 7
supraclavicular plexus, ultrasound imaging troubleshooting 15–18
49, 50, 58, 59 ultrasound probes
supraclavicular plexus block 56–9 coupling medium 12
single injection technique 56–7 curvilinear 5
ultrasound-guided technique 58–9 infection control 13
supraorbital nerve 28, 35 linear-array 4, 5
supraorbital nerve block 34–5 ultrasound scanning tips
suprascapular nerve 46 lower extremity 87–9
suprascapular nerve block 66–7 nerves and blood vessels 6–8, 9–11
supratrochlear nerve 28, 35 upper extremity 49–51
supratrochlear nerve block 34–5 upper extremity 45–80
sural nerve 84, 85 motor response 48
sural nerve block 116, 117 scanning tips 49–51
sensory supply 47
TAP see transversus abdominis plane
technical guidelines, general 3 vertebral artery/vein 49
tendons, ultrasound appearance 8, 10
Tenon's capsule 32 wrist blocks 76–9
Management of severe local anaesthetic toxicity—quick reference safety guideline
AAGBI Safety Guideline
Management of Severe Local
Anaesthetic Toxicity

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REGIONAL

CHAPTER 1 Introduction to regional anaesthesia 1

CHAPTER 2 The head 27

CHAPTER 3 Upper extremities 45

CHAPTER 4 Lower extremities 81

CHAPTER 5 Spine and para-axial region 123

Regional anaesthesia is an essential component of the anaesthetists’ skill

Dr Alwin Chuan MB BS (Hons), PGCertCU, FANZCA,

Dr David M Scott BMed, PGCertCU, FANZCA,

BOX 1.1 REGIONAL ANAESTHESIA NEEDLES AND

• SPROTTE or Tuohy cannulae.

• SPROTTE , Tuohy, or Facet cannulae.

• Stimulong Plus (PAJUNK ) ®

• Direct stimulation of the nerve by the catheter.

• Whitacre Pencil Point Spinal Needle (BD)

General technical guidelines for

Catheter technique for continuous

Continuous catheter technique

FIGURE 1.1 Ultrasound machine.

FIGURE 1. 2 Linear-array ultrasound probes.

Curvilinear ultrasound probes (2–5 MHz)

First-principles approach to ultrasound-guided blocks

FIGURE 1. 3 Curvilinear ultrasound probe.

FIGURE 1. 5 Needle approach. (a) In-plane (IP) approach. The needle is

• The characteristic appearance of nerves at various locations may assist in

• Anisotropy is a helpful property for the identiﬁcation of peripheral nerves. It is

FIGURE 1.7 (a) SAX view of the median nerve. (b) LAX view of the

FIGURE 1. 8 Anisotropy (median nerve not visible).

FIGURE 1.9 Anisotropy (median nerve visible).

FIGURE 1.10 Median nerve and tendons.

Scalenus anterior Scalenus medius

FIGURE 1.11 SAX view of the interscalene.

FIGURE 1.12 SAX view of the axillary uncompressed CFD.

FIGURE 1.13 SAX view of the axillary compressed CFD.

FIGURE 1.14 SAX view of the axillary compressed CFD.

Set-up and equipment

FIGURE 1.15 Bad ergonomics for ultrasound-guided regional anaesthesia.

FIGURE 1.16 Good ergonomics for ultrasound-guided regional

Performing the procedure

FIGURE 1.17 (a) and (b) Sheathing of probe to prevent

FIGURE 1.19 Needle tip is visible in the ultrasound at 45°.

FIGURE 1. 20 Needle tip visibilities 90°. Needle is inserted at 90° to

FIGURE 1. 21 Needle tip is visible in the ultrasound at 90°.

FIGURE 1. 22 Subcostal TAP—correct plane.

• Needle advancement and injectate spread are best visualized in real time

Troubleshooting for ultrasound-guided regional

Needle tip below nerve

Ulnar n. Fascial planes

Local anaesthetic (in wrong plane and not surrounding nerve)

FIGURE 1. 24 Ulnar block, step two: bolus and observe. (a) Aim to position

Local anaesthetic (in wrong plane)

FIGURE 1. 25 Ulnar block, step three: reposition, then bolus–observe.

Needle Fascial planes hydrodissected

Needle tip (not fully visible)

FIGURE 1. 26 Ulnar block, step four: ideal placement. (a) The needle is

General side effects and complications

Infection (especially with continuous catheter

BOX 1.2 GENERAL CONTRAINDICATIONS TO REGIONAL

• Allergy to local anaesthetic