@anesthesia Books 2018 Atlas of

https://t.
me/Anesthesia_Books
Atlas Of
Sonoanatomy for
Regional Anesthesia
and Pain Medicine
FM.indd 1 01-09-2017 11:16:48

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FM.indd 2 01-09-2017 11:16:49

Atlas Of
Sonoanatomy for
Regional Anesthesia
and Pain Medicine
Manoj K. Karmakar, MD, FRCA, DA(UK), FHKCA,
FHKAM
Professor, Consultant Anesthesiologist and Director Of Pediatric
Anesthesia
Department of Anesthesia and Intensive Care
The Chinese University of Hong Kong
Prince of Wales Hospital
Hong Kong, China
Edmund Soh, BSc, MRCP, FRCR

Senior Consultant
Department of Radiology
Ng Teng Fong General Hospital
Singapore
Victor Chee, MD, M.Med (Anesthesiology)

Consultant Anesthesiologist
Mount Elizabeth Medical Center
Singapore
Kenneth Sheah, MBBS, FRCR, MMed (Diagnostic Radiology)

Consultant Radiologist
Lifescan Imaging
Singapore
New York Chicago San Francisco Athens London Madrid

Mexico City Milan New Delhi Singapore Sydney Toronto
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Copyright © 2018 by McGraw-Hill Education, Inc. All rights reserved. Except as permitted under the United States Copyright Act of
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Contents
Preface................................................................................................................................................................................................... vii
Acknowledgments............................................................................................................................................................................... ix
1. Basics of Musculoskeletal and Doppler Ultrasound Imaging for Regional Anesthesia and Pain Medicine.......................... 1
2. Sonoanatomy Relevant for Ultrasound-Guided Upper Extremity Nerve Blocks.......................................................................... 18
3. Sonoanatomy Relevant for Ultrasound-Guided Lower Extremity Nerve Blocks.......................................................................... 64
4. Sonoanatomy Relevant for Ultrasound-Guided Abdominal Wall Nerve Blocks........................................................................ 106
5. Ultrasound Imaging of the Spine: Basic Considerations..................................................................................................................... 126
6. Sonoanatomy Relevant for Ultrasound-Guided Injections of the Cervical Spine..................................................................... 139
7. Ultrasound of the Thoracic Spine for Thoracic Epidural Injections................................................................................................. 161
8. Ultrasound Imaging of the Lumbar Spine for Central Neuraxial Blocks....................................................................................... 179
9. Ultrasound Imaging of Sacrum and Lumbosacral Junction for Central Neuraxial Blocks...................................................... 203
10. Sonoanatomy Relevant for Thoracic Interfascial Nerve Blocks: Pectoral Nerve Block and Serratus Plane Block........... 219
11. Sonoanatomy Relevant for Ultrasound-Guided Thoracic Paravertebral Block.......................................................................... 240
12. Sonoanatomy Relevant for Ultrasound-Guided Lumbar Plexus Block.......................................................................................... 265
Index................................................................................................................................................................................................... 281
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preface
This Atlas is intended to illustrate the aspects of sonoanatomy This book is divided into chapters that present the sono-
that are important in the performance of ultrasound guided anatomy specific for interventions in the area of interest. With
nerve blocks for acute and chronic pain medicine. The use of a total of 768 illustrations this book is designed to be the com-
ultrasound has increased exponentially in the area of regional plete resource for gross anatomy, CT, MR and sonoanatomy of
anesthesia and pain medicine in the last decade. During this the specific area of interest for easy cross-reference between
time of evolution, learning sonoanatomy was hampered with gross anatomy and the various modalities allowing users to
the need to refer to various resources for the technical aspects better understand the sonoanatomy. These cross-referenced
of machine optimization, correlating sonoanatomy with gross images are presented with the relevant anatomy in the same
anatomy and other imaging modalities and discovering the cross sectional plane of the ultrasound image. Within each
ergonomic aspects of imaging and intervention. area of interest, users are guided to acquire the ideal ultra-
For regional anesthesia, transitioning from landmark based sound image for targeted intervention with attention to the
techniques for nerve blocks to real time ultrasound image required ergonomics for operator safety and comfort.
guided nerve blocks required the development of the ability Each approach to the relevant sonoanatomy is accompanied
to visualize and understand the cross sectional anatomy of by clinical pearls to aid readers acquire ultrasound images of
the area of interest outside the traditional transverse, sagittal the area of interest with ease, provide guidance for successful
and coronal axis views presented by current modalities such intervention and avoid pitfalls.
as computed tomography and magnetic resonance imaging. This Atlas has been written both as an introduction for new
For pain medicine, transitioning from fluoroscopy guided users to ultrasonography and as a review and instruction aid
interventions to real time ultrasound image guided or assisted for users familiar with the subject. It is our sincere hope that
interventions required the development of new points of ref- the users of this book will develop an appreciation of the ease
erence for interventions and a move away from traditional and usefulness of ultrasonography and the beauty of sono-
fluoroscopic guided endpoints for intervention. anatomy.
vii
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Acknowledgments
We would like to express our deepest gratitude to Philips illustrations in this book are reproduced with the kind permis-
Medical for their assistance, with special appreciation to – sion from www.aic.cuhk.edu.hk/usgraweb of the Department
Inainee binte Abu Bakar, Lynette Barss, Cheong Yew Keong, of Anesthesia and Intensive care of The Chinese University
Doxie Davis, Nicolaas Delfos, Cellinjit Kaur, William Kok, of Hong Kong.
Nah Lee Tang and Wayne Spittle. And, of course, our families
Manoj K. Karmakar, MD, FRCA, DA(UK), FHKCA,
for their support and encouragement.
FHKAM
The anatomic images are courtesy of the Visible Human
Edmund Soh, MD
Server at Ecole Polytechnique Fédérale de Lausanne, Visible
Victor Chee, MD
Human Visualization Software (http://visiblehuman.epfl.ch),
Kenneth Sheah, MD
and Gold Standard Multimedia www.gsm.org. All figures and
ix
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Basics of Musculoskeletal and Doppler Ultrasound
Imaging for Regional Anesthesia and Pain Medicine CHAPTER 1
A sound knowledge of the basic concepts of musculoskeletal Examples: A high-frequency (6–13 MHz) ultrasound
ultrasound is essential to obtain optimal images during ultra- transducer is used to image superficial structures such as
sound-guided regional anesthesia (USGRA). This chapter the brachial plexus in the interscalene groove or supracla-
briefly summarizes the ultrasound principles that the operator vicular fossa. A lower-frequency transducer (5–10 MHz) is
should be aware of when performing USGRA. suitable for slightly deeper structures such as the brachial
plexus in the infraclavicular fossa, and a low-frequency
transducer (2–5 MHz) is used to image deep structures
Ultrasound Transducer Frequency such as the lumbar paravertebral region or the sciatic nerve.
Spatial resolution is the ability to distinguish two closely High-frequency (6–13 MHz) linear transducers with a small
situated objects as separate. Spatial resolution includes axial footprint (25–26 mm) are particularly suited for regional
resolution (the ability to distinguish two objects at different blocks in young children.
depths along the path of the ultrasound beam) and lateral
resolution (the ability to distinguish two objects that are side
by side perpendicular to the ultrasound beam). Higher trans-
Scanning Plane
ducer frequencies increase spatial resolution but penetrate Scans can be performed in the transverse (axial) or longitudi-
poorly into the tissues. Lower transducer frequencies pen- nal plane. During a transverse scan, the transducer is o riented
etrate deeper into the tissues at the expense of lower spatial at right angles to the long axis of the target, producing a
resolution. Spatial resolution and beam penetration have to be cross-sectional display of the structures (Fig. 1-1A). During a
balanced when choosing the transducer frequency. longitudinal (sagittal) scan, the transducer is oriented parallel
Transverse scan
A Transverse, or Axial, or Cross-sectional, Axis of Scan
Longitudinal scan
B Longitudinal, or Sagittal, Axis of Scan
FIGURE 1-1 ■ Axis of scan.
ch01.indd 1 23-08-2017 16:01:55

2 n Chapter 1 / Basics of Musculoskeletal and Doppler Ultrasound Imaging for Regional Anesthesia and Pain Medicine
to the long axis of the target (eg, a blood vessel or nerve) the monitor represents superficial structures, and the bottom
(Fig. 1-1B). During USGRA, ultrasound scans are most com- of the monitor deep structures.
monly performed in the transverse plane in order to easily
visualize the nerves, the adjacent structures, and the circum-
ferential spread of the local anesthetic. Image Optimization
The image should be optimized by adjusting the depth, focal
zone, and gain. Imaging depth affects temporal resolution
Transducer and Image Orientation (the ability to accurately depict moving structures) and should
The ultrasound image must be correctly oriented in order
to accurately identify the anatomical relationships of the
various structures on the display monitor. Ultrasound trans-
ducers have an orientation marker (eg, a groove or a ridge)
on one side of the transducer, which corresponds to a marker L
on the monitor (eg, a dot or logo) (Fig. 1-2). There are no orientation
marker T
accepted standards on how to orient a transducer, but it is
C
common to have the orientation marker on the transducer
directed cephalad when performing a longitudinal scan, and
The orientation marker should be pointed:
directed towards the right side of the patient when performing 1. To the patients right side of the patient for a transverse scan
a transverse scan (Fig. 1-3). In this way, the monitor “marker” 2. To the patients head for a longitudinal scan
should be at the upper-left corner of the screen representing FIGURE 1-2 ■ Transducer orientation. Note the orientation marker
the cephalad end during a longitudinal scan, or the right side varies between different providers of ultrasound systems. L, longitu-
of the patient during a transverse scan (Fig. 1-3). The top of dinal, T, transverse and C, coronal.
Right Left
Transverse Scan of Right Axilla

Left of Screen = Patients Right
FIGURE 1-3 ■ Image orientation – transverse scan.
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Chapter 1 / Basics of Musculoskeletal and Doppler Ultrasound Imaging for Regional Anesthesia and Pain Medicine n 3
be reduced to the smallest field of view (FOV) that is prac- on the monitor (Fig. 1-5). It is important to note that this echo-
tical. The focal zone should be positioned at the region of genic dot may not represent the tip of the needle because it is a
interest to increase lateral resolution at that site. Reducing the short-axis view. In the in-plane approach the needle is inserted
total number of focal zones also improves temporal resolu- along the plane of imaging and therefore both the shaft and tip
tion. Finally, the time gain compensation (TGC) and overall of the needle are visible on the monitor (Fig. 1-6).
gain should be adjusted to produce an image with appropriate Both approaches are commonly used, and there are no
brightness. The TGC is usually adjusted with the near field data showing that one is better than the other. Pros and cons
gain turned down and the far field gain turned up in steady for both methods have been debated. Proponents of the out-
progression to adjust for beam attenuation with depth. of-plane approach have had great success with this method
and claim that it causes less needle-related trauma and pain
Echogenicity because the needle is advanced through a shorter distance
to the target. However, critics of the out-of-plane approach
Certain terms are frequently used to describe the sonographic
express concerns that the inability to reliably visualize the
appearance of musculoskeletal structures (Fig. 1-4):
needle and using tissue movement as a surrogate marker to
locate the needle tip during a procedure can lead to complica-
Isoechoic: The structure is of the same brightness or echo-
tions. The needle is better visualized in the in-plane approach,
genicity as the surrounding tissues.
but this requires good hand–eye coordination, and reverbera-
Hyperechoic: The structure is bright.
tion artifacts from the shaft of the needle can be problem-
Hypoechoic: The structure is dark but not completely black.
atic. Moreover, there are claims that the in-plane approach
Anechoic: The structure has no echoes and appears com-
also causes more discomfort in awake patients because longer
pletely black.
needle insertion paths are required.
Contrast resolution is the ability to distinguish subtle dif-

ferences in echogenicity between two adjacent structures. Field of View and Needle Visibility
Having an adequate FOV during USGRA is important because
Axis of Intervention it not only allows one to visualize the “target,” but also the
During USGRA, the block needle can be visualized in its neighboring structures (eg, blood vessel, pleura, etc.) that one
short axis (out-of-plane approach) (Fig. 1-5) or long axis wishes to avoid injury to. Linear array transducers have a nar-
(in-plane approach) (Fig. 1-6). In the out-of-plane approach, row FOV, whereas curved array transducers have a divergent
the needle is initially outside the plane of imaging and there- ultrasound beam resulting in a wider FOV (Fig. 1-7).
fore not visible. The needle only becomes visible when it Needles are best visualized when imaged perpendicular to
crosses the plane of imaging and is seen as an echogenic dot the ultrasound beam. Needles at steep angles required for deep
Isoechoic Hypoechoic Hyperechoic Anechoic
FIGURE 1-4 ■ Echogenicity of tissues.
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Axis of Intervention - Short Axis
Short Axis
SAX
Out of Plane
FIGURE 1-5 ■ Axis of intervention – out-of-plane needle insertion.
Axis of Intervention - Long Axis
In-plane
LAX
Longitudinal Axis
FIGURE 1-6 ■ Axis of intervention – in-plane needle insertion.
ch01.indd 4 23-08-2017 16:02:15

Field of Vision
Infraclavicular Fossa Scan
Linear array transducer: Narrow Field of View Curved array transducer - Wide Field of View
Linear array transducer 10-5 MHz Curved array transducer 5-2 MHz
FIGURE 1-7 ■ Comparative field of view of the infraclavicular fossa with linear and curved array transducers.
blocks may not be easily visualized with linear array trans- deviations of even a few millimeters from this plane can result
ducers. Linear array transducers are best suited for superfi- in an inability to visualize the needle. Even with experience,
cial blocks (eg, axillary or interscalene brachial plexus block, needle tip visibility is a problem when performing blocks at
femoral nerve block). Curved array transducers are more suit- depth, in areas that are rich in fatty tissue, and in the elderly.
able for deep blocks (eg, sciatic nerve block, lumbar plexus Under such circumstances gently jiggling (rapid in-and-out
block, and central neuraxial blocks). However, curved array movement) the needle and observing tissue movement or per-
transducers have reduced lateral resolution at depth due to the forming a test injection of saline or 5% dextrose (1–2 mL)
diverging ultrasound beam. and observing tissue distention can help locate the position of
Other factors can also influence needle visibility. The needle the needle tip. The preference is for 5% dextrose for the latter
is better visualized in its long axis than in its short axis, and its when nerve stimulation is used because it does not increase
visibility decreases linearly with smaller needle diameters. The the electric current required to elicit a motor response.
needle tip is better visualized when in its long axis for shallow
angles of insertion (less than 30 degrees), and in its short axis
when the angle of insertion is steep (greater than 60 degrees).
Anisotropy
This is also true when the needle is inserted with its bevel facing Anisotropy, or angular dependence, is a term used to describe
the ultrasound transducer. To overcome the effect of angle on the change in echogenicity of a structure with a change in the
needle visibility, some high-end ultrasound machines allow the angle of insonation of the incident ultrasound beam (Fig. 1-8).
operator to steer the ultrasound beam (beam steering) towards It is frequently observed during scanning of nerves, muscles,
the needle during steep insertions. However, this requires expe- and tendons. This occurs because the amplitude of the echoes
rience, and decreases in needle visibility can still occur. Needle returning to the transducer varies with the angle of insonation.
visibility is also enhanced in the presence of a medium-sized Nerves are best visualized when the incident beam is at right
guide wire. Priming a needle with saline or air, insulating it, or angles; small changes in the angle away from the perpen-
inserting a stylet prior to insertion does not improve visibility. dicular can significantly reduce their echogenicity. Therefore,
We believe that the anesthesiologist’s skill in aligning the during USGRA the transducer should be tilted from side to
needle along the plane of imaging is by far the most impor- side to minimize anisotropy and optimize visualization of
tant variable influencing needle visibility because minor the nerve. Although poorly understood, different nerves also
ch01.indd 5 23-08-2017 16:02:18

Median Nerve
A B
Optimal Scan Anisotropy
FIGURE 1-8 ■ Anisotropy – effect of angulation of the transducer on the echogenicity of the median nerve (white arrow) in the forearm.
The median nerve appears hypoechoic in the image on the right.
exhibit differences in anisotropy; this may be related to the and axilla. The exact reason for this is not clear, but may be
internal architecture of the nerve. related to the relative proportion of neural and connective tis-
sue within the nerve. The ratio of neural to non-neural tissue
content within the epineurium of the nerve increases from 1:1
Identification of Normal Structures in the interscalene/supraclavicular fossa to 1:2 in the mid-
Nerve infraclavicular/paracoracoid regions. Nerve motion can also
Peripheral nerves consist of hypoechoic nerve fascicles sur- be demonstrated on dynamic ultrasound imaging.
rounded by hyperechoic connective tissue and have a “hon-
Tendon
eycomb” appearance in the transverse axis (Fig. 1-9). They
have a fibrillar appearance in the longitudinal axis with fine Tendons are hyperechoic with a fibrillar pattern on longitu-
parallel hyperechoic lines separated by fine hypoechoic lines. dinal scans. Tendons are more hyperechoic than nerves and
Generally, nerves appear hyperechoic, but the appearance can move more than adjacent nerves when the corresponding
vary depending on the surrounding structures. For example, muscle is contracted or passively stretched.
nerves appear hyperechoic when surrounded by hypoechoic
muscle, but can appear hypoechoic when surrounded by Muscle
hyperechoic fat. The echogenicity of a nerve may also vary Muscle fiber bundles are hypoechoic. The separating and
depending on the location where it is scanned; for example, surrounding connective tissue perimysium and epimysium
the brachial plexus nerves appear hypoechoic at the intersca- are hyperechoic (Fig. 1-9). Muscle fibers converge to become
lene groove, but are hyperechoic at the infraclavicular fossa tendons or aponeuroses.
ch01.indd 6 23-08-2017 16:02:21

Nerve and Muscle
Brachial plexus
Brachial plexus
Median nerve
SA
1. Brachial plexus - Interscalene groove 2. Brachial plexus - Supraclavicular fossa 3. Median nerve - Forearm
Sciatic nerve
Sciatic nerve CPN TN
Femur
4. Sciatic nerve - Subgluteal space 5. Sciatic nerve - Infratrochanteric 6. Sciatic nerve - Popliteal fossa
FIGURE 1-9 ■ Echogenicity of muscles and nerves at different locations in the upper and lower extremity. SA, subclavian artery,
CPN, common peroneal nerve, TN, tibial nerve.
Subcutaneous Fat Color Doppler or Power Doppler modes can also be used
to demonstrate the presence of blood flow and differentiate
Subcutaneous fat lobules appear as round to oval hypoechoic
arteries from veins.
nodules that are separated by fine hyperechoic septa. They
are slightly compressible and appear similar on transverse Pleura
and longitudinal scans.
The pleura appear as a hyperechoic line slightly deep to
Bone the hyperechoic ribs (Fig. 1-10). “Comet-tail” artifacts
may be present as vertically oriented echogenicities arising
Bone reflects most of the ultrasound beam. Therefore, the
from the pleura. On real-time imaging, sliding movement
bone surface appears hyperechoic on ultrasound with poste-
between the parietal and visceral pleura can be discerned
rior acoustic shadowing, and possibly posterior reverberation,
with respiration (lung sliding sign).
distal to it (Fig. 1-10).
Fascia
Special Ultrasound Features
Fascia, peritoneum, and aponeuroses appear as thin hyper-
echoic layers. Tissue Harmonic Imaging
Harmonics refer to frequencies that are integral multiples
Blood Vessel of the frequency of the transmitted pulse (the fundamental
Blood vessels have anechoic lumens. Arteries are intrin- frequency or first harmonic). The second harmonic has a
sically pulsatile and are not compressible with moderate frequency of twice the fundamental frequency. Harmonics
pressure. Veins are not pulsatile and are compressible. are generated due to tissues distorting the transmitted pulse,
ch01.indd 7 23-08-2017 16:02:31

Bone, Pleura and Lung
Rib
Intercostal Articular
space process
Ligament
Pleura
Pleura Lung
Lung
Acoustic shadow
of rib
Intercostal space - Bone, Thoracic paravertebral space - Bone,

pleura, lung ligament, pleura, lung
FIGURE 1-10 ■ Echogenicity of bone, pleura and lung at the intercostal space. Note the acoustic shadow deep to the rib.
Tissue Harmonic Imaging
Sagittal Scan - Infraclavicular Fossa
A B
Conventional Scan Scan with THI - note the reduction

in noise and clutter
FIGURE 1-11 ■ Effect of Tissue Harmonic Imaging (THI) during ultrasound imaging of the infraclavicular fossa. Note the improved spatial
and contrast resolution on the right.
usually at the center of the image (midfield) rather than at spatial and contrast resolution (Fig. 1-11). THI is most suitable
superficial or deep locations. Structures that cause imaging for assessment of midfield structures.
artifacts also tend to produce less or no harmonics. Tissue
Harmonic Imaging (THI) is a technique in which structures Compound Imaging
that produce harmonics are selectively displayed, reducing Ultrasound images depend on reflection of the ultrasound
imaging artifacts. This results in reduced noise and improved beam from tissue interfaces back to the transducer. Not all
ch01.indd 8 23-08-2017 16:02:41

Compound Imaging
Transverse Scan of the Axilla
A B
Conventional Scan Compound Imaging - note the speckle

reduction and improvement in resolution
FIGURE 1-12 ■ Effect of Compound Imaging during ultrasound imaging of the axilla. Note the reduction in noise and the improved definition
of the image on the right.
Panoramic Imaging of the Forearm
tissues are good reflectors, and certain structures cause scat- Lateral Anterior Medial
tering of the ultrasound beam resulting in scattered signals
radiating in all directions. As a result only a small amount
Radial artery
FDS
of energy is reflected back to the transducer. The scattering
Ulnar nerve
of the ultrasound beam results in noise, which makes the
ultrasound image appear grainy. In compound imaging, the Median FDP FCU
FPL
same structure is imaged from several different angles using nerve Ulnar artery
computed beam steering. The returning echoes are then pro-
cessed producing a composite image that has reduced noise Radius Posterior
and improved definition (Fig. 1-12). The disadvantage of
compound imaging is increased blurring of the image with FIGURE 1-13 ■ Panoramic transverse sonogram of the midforearm.
movement. FDS, flexor digitorum superficialis; FDP, flexor digitorum profundus;
FPL, flexor pollicis longus; FCU, flexor carpi ulnaris.
Panoramic Imaging
Conventional 2-D ultrasound has a limited FOV and allows Three-Dimensional Ultrasound
visualization of only a small portion of any large structure. Three-dimensional ultrasound acquires data as a volume and
Panoramic imaging, as the name implies, is a technique used allows reconstruction at any imaging plane without needing to
to extend the FOV so that larger structures can be visual- move the transducer (Figs. 1-14 and 1-15). This can improve
ized in their entirety. During a panoramic scan, the operator spatial awareness at the region of interest, visualization of
slowly slides the transducer across a region of interest. Image the block needle, and distribution of the local anesthetic.
information obtained during this motion is accumulated and Potential advantages include reduced needle-associated
then combined to form the composite panoramic image complications and increased block success with smaller vol-
(Fig. 1-13). Although useful for annotation, documentation, umes of local anesthetic. In addition, the volume data can be
teaching, and research, it is rarely used during USGRA at stored and retrospectively analyzed for teaching or research.
present. The main challenges with 3-D ultrasound at present include
ch01.indd 9 23-08-2017 16:02:51

Sciatic nerve
Sciatic nerve
Femur
A Transverse B Sagittal
Sciatic nerve
Perineural
space
C Coronal
FIGURE 1-14 ■ A multiplanar 3-D ultrasound image of the sciatic nerve at the midthigh with the reference marker (green crosshair) placed
over the sciatic nerve.
Artifacts
Posterior
An ultrasound artifact is information that is visible in the
ultrasound image that does not correlate with any anatomical
Biceps femoris structure. The ultrasound machine makes several assumptions
when generating an image:
Perineural space
1. The ultrasound beam travels in a straight line with a con-

Sciatic Nerve stant rate of attenuation.
Adductor magnus 2. The speed of sound through body tissue is 1540 meters/
Femur
second.
3. The ultrasound beam is infinitely thin with all echoes
originating from its central axis.
Anterior
4. The depth of a reflector is directly related to the round-
trip time of the ultrasound signal.
FIGURE 1-15 ■ A rendered 3-D ultrasound image of the sciatic
nerve at the midthigh. The front and right surfaces of the 3-D volume
are displayed. Note the hypoechoic perineural space posterior to the Artifacts arise when there is deviation from these
sciatic nerve in this image. assumptions. Some artifacts are undesirable and interfere
with interpretation, whereas others help identify certain
lack of availability of ergonomic probes that can operate at structures. It is essential to recognize them in order to
high frequencies to assess superficial structures, slow screen avoid misinterpretation. Therefore, whenever a structure
refresh rates, and reduced temporal resolution when perform- appears abnormal on ultrasound, it must be examined at
ing real-time interventions. different angles and orientations to avoid making a wrong
ch01.indd 10 23-08-2017 16:03:03

interpretation. Real anatomical structures are visible in all (Fig. 1-17). They are reduced if the needle is less perpen-
planes of imaging, whereas artifacts are generally only vis- dicular to the transducer, but this may also reduce needle
ible in one plane. visibility.
Artifacts that are frequently encountered during USGRA 3. Mirror image artifact
include: Mirror image artifact is a type of reverberation artifact
that occurs at highly reflective interfaces. The first image
1. Contact artifact is displayed in the correct position, and a false image
This is the most common artifact that occurs whenever is produced on the other side of the reflector due to its
there is a loss of acoustic coupling between the skin mirrorlike effect (Fig. 1-18).
and the transducer. This could simply occur because the 4 . Propagation speed artifact
transducer is not touching the skin, but more frequently These artifacts occur when the media through which the
it is due to air bubbles that are trapped between the skin ultrasound beam passes does not propagate at 1540 meters/
and the transducer. Therefore, it is prudent to apply lib- second, resulting in echoes that appear at incorrect depths
eral amounts of ultrasound gel to exclude air from the on the monitor. An example of propagation speed artifact
skin–transducer interface.
2. Reverberation artifact
Reverberation artifacts, also known as “repetitive echoes,” Block needle
occur whenever there is repeated reflection of the ultra-

sound beam between two highly reflective surfaces.
Some of the ultrasound signals returning to the trans-
ducer are reflected back, which then strike the original AA
interface and are reflected back towards the transducer a
second time. As a result the first reverberation artifact is MCN
twice as far from the skin surface as the original inter- Reverberation
Humerus
artifact
face. One may also see a second or third reverberation
artifact (Fig. 1-16). Due to attenuation, the intensity of
the artifacts decreases with increasing distance from the
transducer. Reverberation artifacts are frequently seen
during ultrasound-guided axillary brachial plexus blocks,
FIGURE 1-17 ■ Reverberation artifact induced by the block
particularly when the needle is viewed in its long axis needle during an ultrasound-guided axillary brachial plexus block.
AA, axillary artery; MCN, musculocutaneous nerve.
Transducer Subclavian artery
Block needle
Rib
Screen
Display Anterior
Artifact
Lateral
FIGURE 1-16 ■ Schematic diagram illustrating how a reverberation FIGURE 1-18 ■ Mirror image artifact of the subclavian artery.
artifact is produced.
ch01.indd 11 23-08-2017 16:03:15

Pectoralis major
Lateral cord
Pectoralis minor Medial cord
Sciatic nerve
LA Axillary
LA artery
Axillary
LA vein
Posterior Anterior
Artifact (Acoustic
Lateral enhancement)
Caudal
FIGURE 1-19 ■ Bayonet artifact induced by the local anesthetic FIGURE 1-20 ■ Acoustic enhancement seen posterior to the
injection during an ultrasound guided popliteal sciatic nerve block. axillary artery and vein during an ultrasound guided infraclavicular
Note the shaft of the needle appears bent close to the area occupied brachial plexus block. The bright echoes posterior the axillary artery
by the local anesthetic. may be confused as the posterior cord.
is the “bayonet artifact,” which has been reported dur- Imaging the Challenging Patient
ing an ultrasound-guided axillary brachial plexus block.
The shaft of the needle appeared bent when it acciden- The Elderly Patient
tally traversed the axillary artery. We have observed the Muscle fibers become hyperechoic with age (Fig. 1-21) due
same phenomenon after local anesthetic injection during to muscle atrophy and infiltration by fat and connective tis-
a popliteal sciatic nerve block (Fig. 1-19). This happens sue. The hyperechoic muscle is more likely to reflect the
because of the difference in the velocity of sound between ultrasound beam and reduce penetration of deeper structures.
whole blood (1580 meters/second), or the injected local Reduced contrast resolution between the echogenic muscle
anesthetic, and soft tissue (1540 meters/second). and an adjacent echogenic nerve decreases accurate delinea-
5. Acoustic shadowing tion of the peripheral nerve. These factors make USGRA in
An acoustic shadow is a hypoechoic or anechoic region the elderly challenging. Strategies that can help depict the
deep to surfaces that are highly reflective or attenuating peripheral nerve in the elderly include THI to improve resolu-
such as bone (Fig. 1-10) or metallic implants. The impli- tion, compound imaging to reduce noise, and increasing the
cation for regional anesthesia is that tissues in the region dynamic range to improve contrast resolution.
of the shadow cannot be visualized. One benefit of this
artifact is that the acoustic shadow of the block needle The Obese Patient
helps in identifying its location. Excess adipose tissue hinders ultrasound imaging by attenu-
6 . Acoustic enhancement ating the transmitted ultrasound beam, increasing scatter,
Acoustic enhancement results when the ultrasound beam and increasing the overall depth to the region of interest.
passes through a low-attenuating structure resulting in The main strategies likely to improve image quality include
brighter echoes from the deeper tissues. It is commonly using a low-frequency transducer to increase penetration,
seen deep to fluid-filled structures such as blood ves- maximizing the power output to boost the signal-to-noise
sels. The increased brightness may saturate the display ratio, decreasing the dynamic range to produce high-contrast
and make it difficult to identify nerves posterior to large images, narrowing the sector width to improve resolution, and
blood vessels. A common example is when one visualizes using physical compression to reduce the depth to the region
the posterior cord of the brachial plexus at the paracora- of interest. Compound imaging, THI, and a speckle reduc-
coid (lateral infraclavicular fossa) location. The bright tion filter can also be useful. Brightness color (B-color or
echoes posterior to the axillary artery (second part) and color B-mode imaging) can also be used in imaging the obese
deep to the pectoralis major and minor muscles may be patient. B-color is based on the principle that the human eye
confused as the posterior cord (Fig. 1-20). can only appreciate a limited number of shades of gray, but
ch01.indd 12 23-08-2017 16:03:32

BM
BM
Humerus
Humerus
A Biceps muscle scan - 28 yr B Biceps muscle scan - 94 yr
RA
RA
Radius
Median nerve Median nerve
Radius
C Mid-forearm scan - 28 yr D Mid-forearm scan - 94 yr
FIGURE 1-21 ■ Effect of age on the echogenicity of musculoskeletal structures. Note the increase in echogenicity and the loss of contrast
between the nerve and the muscle in the elderly. BM, biceps muscle, RA, radial artery.
is able to distinguish a greater number of color hues. Subtle

differences in musculoskeletal imaging can be enhanced by Transducer
using a color-scale display.
FT FR
Doppler Ultrasound: The Basics V
Doppler ultrasound essentially measures a moving object.

When ultrasound waves hit a stationary object, the reflected
ultrasound has the same frequency as the transmitted ultra-
sound. If the object is moving towards the transducer (source
Blood vessel
of the ultrasound), the reflected frequency will be higher
than the transmitted frequency. If the object is moving away
from the transducer, the reflected frequency will be lower FIGURE 1-22 ■ Doppler equation. ∆F – change in frequency
than the transmitted frequency. This change in frequency (Doppler shift), FR – received frequency, FT – transmitted frequency,
of the reflected ultrasound is a result of the Doppler effect v – velocity of object towards the transducer, θ – angle between the
(Fig. 1-22): incident ultrasound beam and the direction of the moving object
(Doppler angle) and C – velocity of sound in the medium (1540 m/s
ΔF = FR − FT = (2FT vcosθ)/C in human tissue).
ch01.indd 13 23-08-2017 16:03:49

From this equation, the following points can be made:
1. Doppler shift is dependent on the velocity of the mov-

ing object. In addition, information can be obtained
on the direction of the moving object. If the object is
moving towards the transducer, the change in frequency
is greater than zero. If the object is moving away from
the transducer, the change in frequency is less than
zero.
2. Doppler shift is also dependent on the ultrasound-

transmitted frequency. Higher transmitted ultrasound A Color Doppler; Poor signal
frequencies produce larger Doppler shifts and better sen-
sitivity to moving objects, but also result in higher tissue
attenuation. Lower transmitted ultrasound frequencies
have better penetration of tissue. Sensitivity and penetra-
tion have to be balanced when choosing the ultrasound-
transmitted frequency.
3. Maximum Doppler shift is obtained when the Doppler
angle is 0 degrees, and no Doppler shift is obtained when
the Doppler angle is 90 degrees (remember that cos 0 = 1
and cos 90 = 0; Fig. 1-23). Optimal imaging is obtained
B Color Doppler; Good signal
when the transducer is as parallel as possible to the direc-
tion of the moving object. When the Doppler angle is FIGURE 1-23 ■ Doppler ultrasound image of an artery. A. Poor
above 60 degrees, small changes in the Doppler angle signal is shown in the center (white arrows) because flow in that
result in large changes in cos θ, and therefore, propor- part of the vessel is near 90 degrees to the ultrasound beam and little
tionately larger errors. Doppler shift is observed. B. Flow is clearly seen when the vessel is
significantly less than 90 degrees to the ultrasound beam.
In contrast, with a conventional gray-scale display, the best

images are obtained when the structures are imaged perpen-
dicular to the ultrasound beam.
Doppler Display
VEIN
The Doppler shift can be presented as a Color Doppler or a
Spectral Doppler image.
Color Doppler
Color Doppler displays different colors (usually red and
blue), depending on flow direction, and uses the degree
of color saturation to indicate the amount of Doppler shift ARTERY
(Figs. 1-24 and 1-25). Its limitation compared to Spectral

Doppler is that it is a qualitative assessment.
Power Doppler
FIGURE 1-24 ■ Color Doppler image. In this example, red indi-
Power Doppler is an alternative means of displaying a color cates flow towards the transducer (or probe) and blue indicates flow
map by assessing the number of moving blood cells (power) away from the transducer. Each color pixel represents the mean
rather than mean Doppler shift. It does not measure velocity Doppler shift at that point.
ch01.indd 14 23-08-2017 16:03:57

or direction and therefore is less dependent on the Doppler extremely sensitive to movement, which can cause flash
angle than Color Doppler. It also does not suffer from alias- artifacts.
ing and has less visible noise. This results in increased
sensitivity for detecting flow at the expense of velocity Spectral Doppler
and direction information (Fig. 1-26). Power Doppler is
Spectral Doppler presents the Doppler shift data in graphic
form as a plot of the frequency spectrum over time (Fig. 1-27).
It displays the peak and range of velocities at a single location
+24.1
along the ultrasound beam. Specific measurements are made
on the Spectral Doppler display to obtain information related
to flow resistance.
Other Technical Considerations

Aliasing
–24.1 Doppler data (Pulsed-Wave Doppler) is reconstructed from
cm/s
regularly timed transmitted and received ultrasound pulses
FIGURE 1-25 ■ Color Doppler bar and image. In this example, equivalent to the pulse repetition frequency (PRF) of the
blue indicates flow towards the transducer and red indicates flow Doppler machine. A low PRF is required when assessing
away from the transducer. Deep shades represent low velocities and deep vessels in order to allow enough time for the transmit-
light shades represent high velocities. Velocity scale indicators are ted ultrasound pulse to arrive back before transmitting a new
present at each end of the color bar. pulse. If the PRF is less than twice the maximum Doppler
shift of the moving object (Nyquist limit), aliasing results
(Figs. 1-28 and 1-29).
FIGURE 1-26 ■ Power Doppler image of an artery. No direction FIGURE 1-27 ■ Spectral Doppler image of the external iliac vein.
information is available. The venous waveform changes with respiration.
–100
50
–50
cm/s cm/s
+50
FIGURE 1-28 ■ A. Spectral Doppler display of an artery demonstrating aliasing – “wraparound” of the higher velocities to display below
the baseline. B. Aliasing can be reduced in this example by moving the baseline downwards (increasing the velocity scale above baseline).
ch01.indd 15 23-08-2017 16:04:09

FIGURE 1-29 ■ Color Doppler display of an artery demonstrating aliasing (white arrow) – wraparound of the color map from one flow
d irection to the opposite direction. Aliasing is only seen in one portion due to higher velocities in that region.
A B
FIGURE 1-30 ■ A. Spectral broadening of an arterial waveform due to placing the sample volume too near the vessel wall. B. Normal
waveform for comparison.
Aliasing can be reduced by increasing the PRF (increasing large sample volume, by placing the sample volume too near
the velocity scale) or by reducing the Doppler shift (increas- the vessel wall, or by excessive system gain (Fig. 1-30).
ing the Doppler angle or using a lower-frequency transducer).
Doppler Gain
Spectral Broadening Optimal gain settings should be obtained for accurate Doppler
Spectral broadening indicates a large range of flow veloci- assessment (Fig. 1-31). Too low of a gain can result in under-
ties at a particular location and is one of the criteria used for estimation of the peak velocity. Too high of a gain results in
diagnosing high-grade vessel stenosis. Artifactual spectral artifactual spectral broadening and can result in overestima-
broadening can also be produced by using an excessively tion of the peak velocity.
ch01.indd 16 23-08-2017 16:04:23

–100
–50
cm/s
A B C
+50
FIGURE 1-31 ■ Spectral Doppler gain. A. Undergain. B. Optimal gain. C. Overgain.
Basic Steps for Doppler Imaging 5. Sites BD, Brull R, Chan VW, et al. Artifacts and pitfall errors
associated with ultrasound-guided regional anesthesia. Part II: a
1. Optimize the gray-scale image with the focal zone at the pictorial approach to understanding and avoidance. Reg Anesth
intended blood vessel. Pain Med. 2007;32:419–433.
2. Activate the Color Doppler. 6. Schafhalter-Zoppoth I, McCulloch CE, Gray AT. Ultrasound
visibility of needles used for regional nerve block: an in vitro
3. Position the color box over the vessel (keep the box size
study. Reg Anesth Pain Med. 2004;29(5):480–488.
as small as reasonably possible). 7. Tsui BC, Kropelin B, Ganapathy S, Finucane B. Dextrose 5%
4. Steer the color box to align with blood flow. in water: fluid medium for maintaining electrical stimulation of
5. Choose the appropriate velocity scale. peripheral nerves during stimulating catheter placement. Acta
6. Optimize the Color Doppler gain. Anaesthesiol Scand. 2005 November;49(10):1562–1565.
7. Place the Pulsed-Wave Doppler cursor within the vessel 8. Moayeri N, Bigeleisen PE, Groen GJ. Quantitative architec-
ture of the brachial plexus and surrounding compartments, and
lumen, and adjust the sample volume as required (try to
their possible significance for plexus blocks. Anesthesiology.
avoid the vessel walls). 2008;108(2):299–304.
8. Align the angle-correction cursor with the blood flow. If 9. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling
the Doppler angle is more than 60 degrees, reposition the out pneumothorax in the critically ill. Lung sliding. Chest.
transducer to obtain a smaller Doppler angle. 1995;108(5):1345–1348.
9. Activate the Pulsed-Wave Doppler for the Spectral 10. Karmakar M, Li X, Li J, Sala-Blanch X, Hadzic A, Gin T. Three-
dimensional/four-dimensional volumetric ultrasound imaging of
Doppler display.
the sciatic nerve. Reg Anesth Pain Med. 2012 January-February;
10. Optimize the Spectral Doppler velocity scale, baseline, 37(1):60–66.
and gain. 11. Karmakar MK, Li X, Li J, Hadzic A. Volumetric 3D ultrasound
imaging of the anatomy relevant for thoracic paravertebral
block. Anesth Analg. 2012;115(5):1246–1250.
Suggested Reading 12. Foxall GL, Hardman JG, Bedforth NM. Three-dimensional,
1. Hedrik WR, Hykes DL, Starchman DE, eds. Ultrasound Physics multiplanar, ultrasound-guided, radial nerve block. Reg Anesth
and Intrumentation. 4th ed. Philadelphia, PA: Elsevier Mosby; Pain Med. 2007;32(6):516–521.
2005. 13. Li X, Karmakar MK, Lee A, Kwok WH, Critchley LAH,
2. Rumack CM, Wilson SR, Charboneau JW, Levine D, eds. Diag- Gin T. Quantitative evaluation of the echo-intensity of the
nostic Ultrasound. 4th ed. Philadelphia, PA: Elsevier Mosby; 2011. median nerve and flexor muscles of the forearm in the young
3. Allan P, Dubbins PA, McDicken WN, Pozniak MA, eds. Clini- and the elderly. Br J Radiol. 2012;85:e140–e145.
cal Doppler Ultrasound. 2nd ed. Philadelphia, PA: Elsevier 14. Sofka CM, Lin D, Adler RS. Advantages of color B-mode imag-
Churchill Livingstone; 2006. ing with contrast optimization in sonography of low-contrast
4. Sites BD, Brull R, Chan VW, et al. Artifacts and pitfall errors musculoskeletal lesions and structures in the foot and ankle.
associated with ultrasound-guided regional anesthesia. Part I: J Ultrasound Med. 2005;24:215–218.
understanding the basic principles of ultrasound physics and
machine operations. Reg Anesth Pain Med. 2007;32:412–418.
ch01.indd 17 23-08-2017 16:04:24

Sonoanatomy Relevant for Ultrasound-Guided Upper
CHAPTER 2 Extremity Nerve Blocks
Introduction the vertebrae (Chassaignac’s tubercle), and the C7 transverse

process lacks the anterior tubercle. This feature can be used to
The neural innervations of the upper extremity provide unique
sonographically identify the C7 nerve root. At the root level,
opportunities for a wide selection of neural blockade options
the plexus gives off the dorsal scapular nerve and the long
that can be tailored to the desired outcome needed for anes-
thoracic nerve (Fig. 2-4).
thesia or analgesia of the extremity.
Gross Anatomy
The brachial plexus traverses the posterior triangle of the neck
and the axilla. It provides complete innervation to the upper
extremity. Proximally, the brachial plexus originates from the
ventral primary rami of the cervical spinal nerves (C5–T1)
(Figs. 2-1 and 2-2) and extends from the cervical spinal roots
in the neck to its terminal nerves in the axilla (Fig. 2-3). The
C5 and C6 rami unite to form the superior trunk, the C7 rami
forms the middle trunk, and the C8 and T1 rami unite to form
the inferior trunk (Fig. 2-4). The trunks of the brachial plexus
are located in the interscalene groove between the scalenus
anterior and the scalenus medius muscles, at the level of the FIGURE 2-2 ■ A magnetic resonance neurography (MRN) image
of the brachial plexus showing the formation of the brachial plexus
cricoid cartilage (approximate C6 vertebral body level) and
in a healthy young volunteer.
deep to the sternocleidomastoid muscle (Fig. 2-5). The ante-
rior tubercle of the C6 vertebra is the most prominent of all
C4
Brachial plexus C5
(Roots) C5
C6
C6
Brachial plexus
C7 C7
(Trunks)
C8 C8
Brachial plexus T1 T1
(Divisions)
Brachial plexus
(Cords)
Lateral cord
Axillary nerve Posterior cord
Medial cord
Musculocutaneous Axillary artery
nerve Ulnar nerve
Radial nerve Median nerve
FIGURE 2-1 ■ Anatomical illustration showing the formation of

the brachial plexus. The roots, trunks, and divisions of the brachial FIGURE 2-3 ■ Brachial plexus. Note the formation of the plexus
plexus have been represented using different colors to illustrate the and the relation of the nerve roots to the transverse process of the
formation of the cords and the terminal branches of the plexus. cervical vertebra.
18
ch02.indd 18 23-08-2017 19:03:16

Chapter 2 / Sonoanatomy Relevant for Upper Extremity Nerve Blocks n 19
C4 C4
C5
C5
Superior trunk C6
Middle trunk
Inferior trunk C6
C7
Suprascapular nerve
Lateral cord C8 C7
T1
T1
Axillary nerve
Medial cord
Posterior cord
Musculocutaneous
nerve
Median nerve
Radial nerve Long thoracic

nerve
Ulnar nerve
FIGURE 2-4 ■ The brachial plexus and relation of its components to the subclavian and axillary artery.
At the supraclavicular fossa, the trunks of the brachial

plexus are superficial and divide into their anterior and pos-
terior divisions and reunite as the cords distal to the clavicle.
The trunks and divisions lie above the first rib between the
scalenus anterior and scalenus medius muscles (Fig. 2-6). The
Scalenus anterior subclavian artery crosses over the top of the first rib at this
point as it exits the thoracic inlet and travels in the fascial
Scalenus medius plane between the scalenus anterior and the scalenus medius
and is anteromedial to the trunks and divisions of the brachial
Cervical sympathetic
1st Rib chain plexus at this level (Fig. 2-6). The subclavian vein crosses
Brachial Plexus the first rib lying anteriorly to the insertion of the scalenus
SA
anterior (Fig. 2-7). The pleura lies immediately deep to the
SV
AA
first rib. At the trunk level, the plexus gives off the nerve to
the subclavius and suprascapular nerve.
Lateral to the first rib the six divisions of the brachial
plexus regroup to form the three cords of the brachial plexus.
The posterior cord is formed from the three posterior divisions
(C5–C8 and T1), the lateral cord from the anterior division of
the upper and middle trunk (C5–C7), and the medial cord is a
continuation of the anterior division of the lower trunk (C8 and
FIGURE 2-5 ■ Brachial plexus and its relation to the scalene T1). The cords then enters the “costoclavicular space” (CCS,
muscles. Note how the brachial plexus is sandwiched between the Fig. 2-8), which is located deep and posterior to the middle-
anterior and middle scalene muscles. third of the clavicle.1,2 Within the CCS the cords are clustered
ch02.indd 19 23-08-2017 19:03:23

20 n Chapter 2 / Sonoanatomy Relevant for Upper Extremity Nerve Blocks
Interscalene groove Anterior ramus of C5
Levator scapulae Phrenic nerve

Scalenus medius
Trapezius
Sternocleidomastoid (cut)
Superior trunk of
brachial plexus Anterior ramus C6
Transverse cervical Scalenus anterior
artery IJV Aorta
Suprascapular nerve
Suprascapular artery
and vein
Anterior ramus C7
Clavicle Clavicle (cut)

SA SV Middle trunk of
Deltoid brachial plexus
Inferior trunk of
Brachial plexus 1st Rib brachial plexus
(Cords)
FIGURE 2-6 ■ Anatomy of the brachial plexus at the interscalene groove and supraclavicular fossa. Note the relation of the suprascapular
and transverse cervical artery to the brachial plexus. SA, subclavian artery; SV, subclavian vein; IJV, internal jugular vein.
C5
Anterior Pectoralis major r
no
is mi
Cranial Caudal Thoracoacromial artery ral
Scalenus (possibly pectoral branch) cto
Scalenus medius Pe
anterior Posterior
Aorta
Clavicle
Subclavius AV Rib
First Rib
Lateral cord
AA
Brachial plexus Posterior cord
Superior trunk Pleura
SA SV Medial cord
Middle trunk Costoclavicular
Inferior trunk space
r Lung
rio
nte Rib
u sa
FIGURE 2-7 ■ Brachial plexus at the supraclavicular fossa. Note rat
Ser
the relation of the trunks of the brachial plexus to the first rib, sub-
clavian artery, and the scalene muscles. The trunks and divisions of
the brachial plexus are located posterolateral to the subclavian artery. FIGURE 2-8 ■ Sagittal anatomic section through the midpoint of
SA, subclavian artery; SV, subclavian vein. the clavicle showing the costoclavicular space between the pectoral
head of the pectoralis major and subclavius muscle anteriorly and
the upper slips of the serratus anterior muscle overlying the second
rib posteriorly. Note how the cords of the brachial plexus are clus-
together lateral to the axillary artery and between the cla- tered together and lie cranial to the first part of the axillary artery.
vicular head of the pectoralis major muscle and the subcla- AA, axillary artery; AV, axillary vein.
vius muscle anteriorly, and the serratus muscle overlying the
second rib posteriorly (Figs. 2-8 and 2-9).1,2 The topography
of the cords relative to the axillary artery and to one another
is consistent at the CCS (Figs. 2-9 to 2-11). The lateral cord the CCS, and it is immediately lateral to the medial cord
is the most superficial of the three cords and always lies but posterolateral to the lateral cord (Figs. 2-9 to 2-11).3
anterior to both the medial and posterior cords (Figs. 2-9 The cords then descend to the lateral infraclavicular fossa,
to 2-11).3 The medial cord is directly posterior to the lat- deep to the pectoralis minor muscle, where they occupy their
eral cord but medial to the posterior cord (Fig. 2-9 to 2-11).3 respective position relative to the second part of the axillary
The posterior cord is the most lateral of the three cords at artery (Fig. 2-12). The posterior cord is located posterior to the
ch02.indd 20 23-08-2017 19:03:36

Clavicle Clavicular head of

Subclavius muscle Pectoralis major
Lateral cord Subclavius muscle

Posterior cord
Axillary vein Axillary Axillary vein

artery
Axillary artery
(first part)
Medial cord Serratus anterior Medial cord
Lateral cord muscle
Posterior cord
Serratus anterior 2nd Rib Anterior 2nd Rib
muscle
Lateral
FIGURE 2-9 ■ Transverse anatomic section through the right FIGURE 2-11 ■ Illustration showing the anatomy of the costocla-
costoclavicular space showing the anatomic arrangement and rela- vicular space and the anatomic relations of the cords to one another
tions of the cords of the brachial plexus. The anatomy is presented and to the axillary artery.
as though one were looking at it from caudal to cranial (caudocra-
nial view). Note how the cords of the brachial plexus are clustered
together lateral to the axillary artery.
Pectoralis major Lateral cord of

Pectoralis minor brachial plexus
Posterior cord Coracobrachialis Axillary vein
Lateral cord Lung
Tendon of short head
Axillary vein of biceps brachi Axillary artery
Tendon of long head Medial cord of
of biceps brachi brachial plexus
Posterior cord of
brachial plexus
Head of humerus Intercostal muscles
Rib
Axillary artery Deltoid Serratus anterior
(first part) Subscapularis
Scapula Infraspinatus
Anterior FIGURE 2-12 ■ Anatomy of the brachial plexus at the infraclavic-

Medial cord ular fossa (paracoracoid location, ie, lateral infraclavicular fossa).
Medial
Note the relation of the cords of the brachial plexus to the second
FIGURE 2-10 ■ Histological section from the right costoclavicular part of the axillary artery.
space, stained with hematoxylin and eosin, showing the anatomic
arrangement and relations of the cords of the brachial plexus (caudo-
cranial view) to one another and to the axillary artery.
The main terminal branches of the brachial plexus—

artery, the lateral cord lies in the superolateral aspect of the median, radial, ulnar, and musculocutaneous nerve—leave
artery, and the medial cord lies in the inferomedial aspect of the axilla with the axillary artery (Fig. 2-13) and continue
the artery.4 Position of the cords at the lateral infraclavicular their course into the arm (Fig. 2-14). At the anterior axillary
fossa is variable4 and affected by the position (abduction) of fold, the musculocutaneous nerve leaves the brachial plexus
the arm.5 The lateral cord gives off the lateral pectoral nerve, and travels between the biceps brachii and the coracobrachia-
musculocutaneous nerve and lateral root of median nerve; lis in the proximal arm and subsequently between the biceps
the posterior cord gives off the upper and lower subscapu- brachii and the brachialis in the midarm. Just before the cubi-
lar nerves, the thoracodorsal nerve, radial nerve, and axillary tal fossa, it emerges on the lateral border of the biceps tendon
nerve; the medial cord gives off the medial pectoral nerve, the and pierces the deep fascia to become superficial and con-
medial cutaneous nerve of the arm, medial cutaneous nerve of tinue its course down the lateral aspect of the forearm as the
the forearm, ulnar nerve, and medial root of the median nerve. lateral cutaneous nerve of the forearm.
ch02.indd 21 23-08-2017 19:03:48

Cranial SCM Scalenus post

Lateral Medial
Pectoralis major Caudal
Epimysium Median nerve Scalenus med VA
MCN
Ulnar nerve
Longus colli
Coracobrachialis Scalenus ant
Biceps
AA Clavicle
Radial nerve
Brachial plexus
AV Subclavius
Epimysium Coracoid process
SA
1st rib
Triceps
Humerus
FIGURE 2-15 ■ Coronal anatomical section showing the roots,
FIGURE 2-13 ■ Anatomy of the axilla at the level of the anterior trunks, divisions, and cords of the brachial plexus. SCM, sternoclei-
axillary fold (ie, where the pectoralis major muscle joins the biceps domastoid muscle; VA, vertebral artery; SA, subclavian artery.
muscle). Note the relation of the median, ulnar, and radial nerve to
the axillary artery and how the musculocutaneous nerve (MCN) is
embedded within the substance of the coracobrachialis muscle. AA,
axillary artery; AV, axillary vein.
Anterior
Sternohyoid
Lateral Medial
Sternothyroid
Posterior
SCM
Trachea
Brachial plexus Thyroid
Lateral cord IJV
Axillary nerve Posterior cord
Medial cord
Musculocutaneous nerve Axillary artery CA Esophagus
Scalenus ant
Lateral thoracic artery Brachial plexus
Brachial artery Longus colli
Clavicle
Subcapular artery
Radial nerve Scalenus med
Lateral antebrachial Median nerve

cutaneous nerve Ulnar nerve
Medial epicondyle Supraspinatus Scalenus post
of humerus
Radial artery Ulnar artery

FIGURE 2-16 ■ Transverse anatomical section of the neck showing
the brachial plexus sandwiched between the scalenus anterior and
FIGURE 2-14 ■ Anatomical illustration showing the terminal scalenus medius muscles in the interscalene groove. SCM, sterno-
branches of the brachial plexus as they course through the arm and cleidomastoid muscle; IJV, internal jugular vein; CA, carotid artery.
upper forearm.
Brachial Plexus: Interscalene Groove

transversarium (Fig. 2-17) of the C6 to C1 vertebrae and
Gross Anatomy ascends cranially.
In the posterior triangle, the roots and trunks of the brachial
plexus lie between scalenus anterior and medius muscles Computed Tomography Anatomy of the Neck
(Figs. 2-15 and 2-16). As the cervical nerve root (C3–C6) and Interscalene Region
exits from the intervertebral foramen, it travels between the Figs. 2-19 and 2-20
anterior and posterior tubercle of the corresponding cervi-
cal vertebra (Figs. 2-17 and 2-18). This unique feature can Magnetic Resonance Imaging Anatomy of the Neck
be easily demonstrated using ultrasound. Deep to the cer- and Interscalene Region
vical nerve root, the vertebral artery travels in the foramen Figs. 2-21 and 2-22
ch02.indd 22 23-08-2017 19:04:00

Carotid
id
to
artery
as
IJV
m
do
Foramen
Anterior
lei
transversarium SCM
tubercle
oc Vertebral
rn
artery
Ste
Scalenus ant Longus colli VA Anterior

tubercle
C6 nerve root
C5NR
Scalenus med C6 VB C6NR
Posterior
Posterior Posterior
tubercle
tubercle C7
tubercle
Scalenus post
Anterior
Levator scapulae Medial Lateral
Posterior
FIGURE 2-17 ■ Transverse anatomical section of the neck through FIGURE 2-19 ■ CT image of the cervical region at the level of C6.
the C6 vertebral body showing the anterior and posterior tubercle Note the C6 nerve root as it exits the intervertebral foramen and
of the C6 transverse process. Note how the C6 nerve root exits the lies between the anterior and posterior tubercle of the C6 transverse
intervertebral foramen and the location of the vertebral artery in the process before it enters the interscalene groove. Also note the ver-
foramen transversarium. tebral artery in the foramen transversarium of C6 vertebra. SCM,
sternocleidomastoid muscle; IJV, internal jugular vein; NR, nerve
root; VB, vertebral body; VA, vertebral artery.
Anterior
Lateral Medial id
to
Posterior as
om Carotid artery
id
c le
no SCM
er
St
Scalenus ant Longus colli IJV
VA
Scalenus med Brachial plexus
ScA
C7 nerve root in ISG
C7
Scalenus post ScM
Posterior
tubercle C7TP (posterior
C7NR tubercle)
Levator scapulae
FIGURE 2-18 ■ Transverse anatomical section of the neck through

the C7 vertebral body showing the C7 transverse process with only
FIGURE 2-20 ■ CT image of the cervical region at the level of
one (posterior) tubercle. The anterior tubercle is missing.
C7. Note the vertebral artery in close proximity to the C7 nerve
root before it enters the foramen transversarium of C6. VA, verte-
bral artery; NR, nerve root; ScA, scalenus anterior; ScM, scalenus
Technique of Ultrasound Imaging of the Brachial medius; ISG, interscalene groove; TP, transverse process; SCM,
sternocleidomastoid; IJV, internal jugular vein.
Plexus at the Interscalene Groove
1. Position:
a. Patient: Supine or semisitting position with head and ultrasound machine can be easily reversed for
turned to the contralateral side (Fig. 2-23). The head convenience or, for example, to allow a right-handed
rests on a low pillow with the arm adducted by the side. operator to perform an ultrasound-guided intersca-
b. Operator and ultrasound machine: Operator is lene brachial plexus block on the left side using his
positioned at the head end of the patient. The ultra- or her right hand.
sound machine is placed ipsilateral to the side exam- 2 . Transducer selection: High-frequency (15-8 or 17-5 MHz)
ined and directly in front. The position of the operator linear array transducer.
ch02.indd 23 23-08-2017 19:04:13

Trachea
Thyroid
SCM
TP (anterior
Longus tubercle) CA IJV
ScA
colli
C5NR
C6VB
VA
ScM
C6NR
TP (posterior
tubercle)
FIGURE 2-23 ■ Figure showing the position of the patient and the
FIGURE 2-21 ■ MRI image of the neck at the level of C6 verte- ultrasound transducer during a transverse scan of the neck at the
bra. Note the C6 nerve root (NR) between the anterior and posterior level of the interscalene groove. Note how the ultrasound transducer
tubercle of the C6 transverse process and the C5 nerve root in the is tilted (oblique) slightly caudally towards the supraclavicular fossa.
interscalene groove between the scalenus anterior (ScA) and scale-
nus medius (ScM) muscle. The vertebral artery (VA) is seen in the
foramen transversarium of the C6 transverse process. VB, vertebral
body; CA, carotid artery; SCM, sternocleidomastoid; IJV, internal
jugular vein.
Thyroid Trachea
IJV SCM
CA
CE ISG
Longus
colli VA ScA
C7VB
ScM
C6NR
C7NR
C7TP (posterior
tubercle) FIGURE 2-24 ■ Figure showing the position of the patient and the
ultrasound transducer during a transverse scan of the neck in the
midline at the level of the cricoid cartilage.
FIGURE 2-22 ■ MRI image of the neck at the level of C7 verte-

trachea (Fig. 2-26) in cross-section. Slide the transducer
bra. Note the vertebral artery in close proximity of the C7 nerve
root before it enters the foramen transversarium of C6 vertebra. The laterally to the side of interest, and identify the sternoclei-
nerve roots (C6 and C7) of the brachial plexus are seen in the inter- domastoid muscle, trachea, thyroid, carotid artery, and
scalene groove (ISG) between the scalenus anterior (ScA) and the internal jugular vein. Continue to manipulate the trans-
scalenus medius (ScM) muscle. VA, vertebral artery; NR, nerve root; ducer laterally in the transverse plane to the lateral edge
SCM, sternocleidomastoid; IJV, internal jugular vein; CE, cervical of the sternocleidomastoid muscle. The scalenus ante-
esophagus; CA, carotid artery; TP, transverse process.
rior and scalenus medius with the interscalene groove
are located deep to the lateral edge of the sternocleido-
3. Scan technique: As part of a scan routine, it is advisable mastoid muscle (Figs. 2-27 and 2-28). Alternatively one
to start the ultrasound scan of the neck by placing the can perform a transverse scan of the subclavian artery
transducer in the midline (Fig. 2-24) at the level of the at the supraclavicular fossa (see later). The trunks and
cricoid cartilage (C6). Place the transducer in a transverse divisions of the brachial plexus are seen as a cluster of
orientation to image the cricoid cartilage (Fig. 2-25) or hypoechoic and rounded nodules on the posterolateral
ch02.indd 24 23-08-2017 19:04:23

Ant
Lat
SM Sternocleidomastoid
SM Med Sternohyoid
AMI Post
Sternothyroid
Brachial plexus Thyroid

Right lobe CC CC
of Thyroid Trachea
IJV
Omohyoid Scalenus ant
CA
CA CA Scalenus med
CTJ
Esophagus
Anterior
Scalenus post Longus colli
Right Left
Posterior
FIGURE 2-25 ■ Transverse sonogram of the neck at the level of the FIGURE 2-27 ■ Anatomical section of the neck showing the bra-
cricoid cartilage (CC). The CC is seen as an “inverted-U” or arched chial plexus sandwiched between the scalenus anterior and scalenus
shaped structure. The inner surface of the anterior wall of the CC is medius muscles in the interscalene groove. IJV, internal jugular vein;
lined by the bright air-mucosal interface (AMI), and the two lobes of CA, carotid artery.
the thyroid gland are seen as uniformly hyperechoic structures lateral
to the CC. The posterior wall of the CC is obscured by an air column
and reverberation artifacts, but one can identify the cricothyroid junc-
tion (CTJ) as a hypoechoic gap in the posterolateral wall of the CC.
SM, strap muscles; CA, carotid artery. Ant
Lat
Med Sternocleidomastoid
Post
IJV Thyroid
Trachea Brachial plexus
SCM es
uscl
pm CA Trachea
Stra
IJV Omohyoid Scalenus ant
CA Thyroid Scalenus med
Esophagus
Longus colli
Scalenus post Longus colli
Transverse process
Cervical esophagus Ant FIGURE 2-28 ■ Figure highlighting the anatomical structures that
Lat Med are insonated during a transverse ultrasound scan at the level of the
Post interscalene groove.
FIGURE 2-26 ■ Transverse sonogram of the neck at the level of the

upper trachea. The trachea appears hypoechoic, is “U-shaped,” and is
outlined by the bright A-M interface anteriorly. However, unlike at the brachial plexus are clearly delineated in the interscalene
level of the cricoid cartilage the thyroid isthmus is seen anterior to the groove.
trachea, and the cervical esophagus may also be identified posterolat- 4 . Sonoanatomy: At the interscalene groove, the trunks
eral and to the left of the trachea. SCM, sternocleidomastoid muscle; of the brachial plexus are located between the scalenus
IJV, internal jugular vein; CA, carotid artery.
anterior and the scalenus medius muscles (Fig. 2-29).
They appear round to oval in shape, are hypoechoic in
appearance, and may have a hyperechoic rim (Fig. 2-30).6
aspect of the subclavian artery, like a “bunch of grapes,” The carotid artery and internal jugular vein are visualized
and between the scalenus anterior and scalenus medius medially, and the vertebral artery can also be seen adja-
muscles. Now slowly slide the transducer cephalad with cent to the C7 transverse process deep to the interscalene
a sweeping action when the roots and/or trunks of the groove (Fig. 2-29).
ch02.indd 25 23-08-2017 19:04:37

Anterior
Interscalene groove
Sternocleidomastoid Sternocleidomastoid
C5NR
Phrenic nerve
Scalenus
medius Scalenus C6NR IJV
anterior IJV
Brachial plexus Medial
Lateral
CA
VA
VA
Anterior
Lateral Medial JPEG

Posterior 3.0 *** bpm
Posterior
FIGURE 2-29 ■ Transverse sonogram of the neck showing the FIGURE 2-31 ■ Transverse sonogram of the neck at the level of the
interscalene groove with the brachial plexus (roots and trunks) C6 transverse process. Note the anterior and posterior tubercles of
between the scalenus anterior and scalenus medius muscle. VA, ver- the C6 transverse process and the roots of the hypoechoic C5 and C6
tebral artery; IJV, internal jugular vein. Note that the phrenic nerve is nerve root. The outlines of the anterior and posterior tubercles of the
visible on the anterior surface of scalenus anterior muscle. C6 transverse have been highlighted in the sonogram. Also note the
location of the vertebral artery (VA) relative to the transverse process.
IJV, internal jugular vein; CA, carotid artery; VA, vertebral artery;
NR, nerve root.
Sternocleidomastoid muscle
Anterior
Scalenus medius Phrenic nerve
Scalenus anterior
Scalenus anterior
Brachial Posterior tubercle of Sternocleidomastoid
Interscalene groove plexus C7 TP
C6NR
Anterior IJV
Lateral Medial Lateral Medial
C7 NR
Posterior
VA
VA CA
Acoustic shodow of the

FIGURE 2-30 ■ Zoomed (coned) view of the interscalene groove posterior tubercle of C7 TP
showing the hypoechoic roots and trunks of the brachial plexus sand- JPEG
3.0
Posterior *** bpm
wiched between the scalenus anterior and scalenus medius muscles.
Also note the hypoechoic phrenic nerve on the anterior surface of FIGURE 2-32 ■ Transverse sonogram of the neck at the level of
the scalenus anterior. the C7 transverse process. Note the transverse process of C7 has
only one tubercle (ie, the posterior tubercle).The anterior tubercle is
missing or very rudimentary. Also note the C6 and C7 nerve roots
5. Clinical Pearls: The trunks of the brachial plexus are
and the location of the vertebral artery (VA) relative to the transverse
best visualized within the interscalene groove just below
process. The outlines of the posterior tubercle of the C7 transverse
the level of the cricoid cartilage. They appear as three have been highlighted in the sonogram. IJV, internal jugular vein;
hypoechoic round-to-oval shaped structures, which produce CA, carotid artery; NR, nerve root.
a sonographic pattern resembling “traffic signal lights.”
If one traces these neural elements medially and proxi-
mally to their intervertebral foramen, each of the cervical C7 (Fig. 2-32) vertebral level. The C6 transverse process
nerve roots can be identified as they lie anterior to the is distinctive, as it is the first cervical vertebra count-
corresponding transverse processes. The roots of the bra- ing from below, which has two tubercles (anterior and
chial plexus are best visualized at the C6 (Fig. 2-31) or posterior, Fig. 2-31) on the transverse process. C3 to C6
ch02.indd 26 23-08-2017 19:04:58

Transverse cervical
SCM artery
IJV ScA Brachial plexus

ScM
Interscalene groove
Transverse cervical
SCM artery
FIGURE 2-33 ■ Sagittal sonogram of the neck demonstrating the IJV ScM
ScA
vertebral artery through the space (intertransverse space) between
Brachial plexus
the C4 and C5 transverse process (TP). Anterior
Medial Lateral
Posterior
cervical vertebrae have both the anterior and posterior B
tubercle on the transverse process. The C7 transverse

process has only one tubercle (the anterior tubercle is FIGURE 2-34 ■ Transverse sonogram of the neck at the level of the
rudimentary or absent), and this is typically posterior to interscalene groove (A, without and B, with Color Doppler) showing
the nerve root (Fig. 2-32). As a result of the two tubercles, the transverse cervical artery, which is a branch of the thyrocervical
trunk. It crosses the neck from a medial to lateral direction lying
the transverse processes of the lower cervical vertebrae
anterior to the scalene muscles and in front or in between the divi-
(C3–C6) produce a “U” shaped or “fish mouth” pattern
sions of the brachial plexus.
on the sonogram (Fig. 2-31). The resultant sonographic
pattern has also been referred to as the “two-humped
camel” sign.7 The corresponding nerve roots can be visu-
alized, coursing within the groove formed by the anterior artery, suprascapular artery (see later), or the transverse
and posterior tubercle just before they enter the neural cervical artery (Fig. 2-34). Verifying their course and ori-
foramen, by sliding the transducer proximally and dis- gin allows one to confirm the identity of the artery. The
tally. During the sliding maneuver, the vertebral artery superficial cervical plexus may also be visualized as a
can be visualized in the space between two adjacent small collection of hypoechoic nerves deep to or lateral
transverse processes (intertransverse space). This can be to the sternocleidomastoid muscle.
confirmed using Color or Power Doppler. The vertebral
artery is best visualized at the C7 vertebral level because Assessment of Diaphragm Excursions
of the absence of the anterior tubercle on the transverse Ultrasound imaging is a safe, simple, and accurate method
process (Fig. 2-32). Alternatively the vertebral artery of evaluating diaphragmatic function (excursion) in patients
can be visualized by performing a sagittal scan at the with diaphragmatic paresis or paralysis.10 In regional anesthe-
level of transverse process through the intertransverse sia ultrasound imaging can be used to evaluate phrenic nerve
space (Fig. 2-33). The phrenic nerve may be seen on the involvement by assessing diaphragmatic excursion after an
anterior surface of the scalenus anterior (Figs. 2-29 and interscalene brachial plexus block.11 A 5-2 MHz curved array
2-30) as a small hypoechoic structure, and its identity transducer is used, and a B-mode ultrasound scan is initially
can be confirmed by tracing the nerve proximally and performed with the patient in the supine position. A transverse
distally along its course,8 also referred to as the “trace scan of the subcostal region is performed with the ultrasound
back technique.”9 It is also common to visualize vascu- transducer placed between the midclavicular and midaxillary
lar structures at the base of the posterior triangle of the line. The liver or spleen (on the left side) provides the acous-
neck. These may be the inferior thyroid artery, vertebral tic window for the ultrasound scan. For optimal imaging the
ch02.indd 27 23-08-2017 19:05:06

FR 23Hz
M-mode line M2
RS
2D / MM
44% 44% Right lobe
C 55 of Liver
P Med
Gen Diaphragm
Diaphragmatic
excursion
14
0
10
JPEG
DIAPHR R 6.6sec *** bpm
FIGURE 2-35 ■ Figure showing the use of M-mode ultrasound to evaluate diaphragmatic excursion. Note the M-mode line passes through
the right lobe of the liver, diaphragm, and part of the lung posteriorly in the B-mode image. The M-mode trace (below) shows the excursion
of the liver, diaphragm (hyperechoic line), and lung toward the transducer along this line with time.
ultrasound transducer is also directed cranially, posteriorly,

Post Cran
SCM
and medially to image the posterior third of the diaphragm. Trapezius
Once an optimal B-mode image is obtained, the M-mode Caud Ant
function is activated, with the M-mode line passing through Scalenus ant
Supraspinatus Brachial plexus IJV
the diaphragm (Fig. 2-35). Resting or forced diaphragmatic
Scapula Scalenus med
excursion after the “sniff test” (rapid nasal inspiration with
SA
the mouth closed) can then be assessed. Serratus ant
1st rib
Subscapularis
Pleura
Brachial Plexus: Supraclavicular Fossa Pleura
Gross Anatomy
At the supraclavicular fossa, the brachial plexus is relatively
superficial and lies beneath the subcutaneous tissue and the
inferior belly of the omohyoid. The trunks and division of the FIGURE 2-36 ■ Coronal anatomical section through the supracla-
brachial plexus are seen as a cluster of nerves on the postero- vicular fossa. Note the relation of the components of the brachial
plexus to the scalene muscles, subclavian artery, and the first rib at
lateral aspect (Figs. 2-6, 2-7, 2-15, and 2-36) of the subclavian
the supraclavicular fossa. SCM, sternocleidomastoid muscle; IJV,
artery (Figs. 2-4 to 2-7). The subclavian artery lies on top of internal jugular vein; SA, subclavian artery.
the first rib (Fig. 2-36), and the subclavian vein is anterior to
the scalenus anterior muscle (Figs. 2-6 and 2-7).
Technique of Ultrasound Imaging of the Brachial
Computed Tomography Anatomy Plexus at the Supraclavicular Fossa
of the Supraclavicular Fossa 1. Position:
Fig. 2-37 a. Patient: Supine position with head turned to the
contralateral side. Position the head on a low pillow
Magnetic Resonance Imaging Anatomy with the arm adducted by the side. A small roll or
of the Supraclavicular Fossa jelly pad placed under the shoulder may be helpful,
Fig. 2-38 as it increases the distance between the bed and the
ch02.indd 28 23-08-2017 19:05:17

Anterior
Brachial Caudal
Scalenus plexus
anterior
Subclavian
vein
Scalenus
Clavicle medius
1st Rib
Subclavian
artery
Lung
FIGURE 2-39 ■ Figure showing the position and orientation of

FIGURE 2-37 ■ Sagittal CT image showing the subclavian artery the ultrasound transducer during a transverse scan for the brachial
on top of the first rib and the close relation of the components of the plexus at the supraclavicular fossa.
brachial plexus to the first rib, lung, and scalene muscles.
Post Cran
SCM
Trapezius
Anterior Caud Ant
Scalenus ant
Caudal Brachial plexus IJV
Supraspinatus
Scapula Scalenus med
SA
Brachial plexus Scalenus Serratus ant
1st rib
posterior Subscapularis
Scalenus
anterior Pleura
Pleura
Subclavian
artery
1st Rib FIGURE 2-40 ■ Figure highlighting the anatomical structures that
are insonated during an ultrasound scan for the brachial plexus at the
Lung supraclavicular fossa. SCM, sternocleidomastoid muscle; IJV, inter-
nal jugular vein; SA, subclavian artery.
3. Scan technique: The transducer is placed parallel to

FIGURE 2-38 ■ Coronal MRI image showing the close relation of the clavicle in the supraclavicular fossa (Fig. 2-39). The
the components (trunks and divisions) of the brachial plexus to the ultrasound beam is directed towards the first rib and tho-
first rib, lung, subclavian artery, and the scalene muscles. racic inlet (Fig. 2-40). The first reference structure to
locate is the subclavian artery as it crosses the first rib.
transducer. This facilitates needle placement and 4. Sonoanatomy: At the supraclavicular fossa the trunks
manipulation during an in-plane approach for supra- and divisions of the brachial plexus appear as a cluster
clavicular brachial plexus block. of hypoechoic nodules,12 each with a hyperechoic rim
b. Operator and ultrasound machine: The operator (Fig. 2-41). Collectively, they appear as a “bunch of
sits or stands at the head end of the patient. The ultra- grapes” on the posterolateral aspect of the subclavian
sound machine is placed ipsilateral to the side to be artery. Variations in this relationship have been described
examined and directly in front of the operator. with the brachial plexus located farther laterally in relation
2. Transducer selection: High-frequency (15-8 or 17-5 MHz) to the subclavian artery.13 The subclavian artery is pulsa-
linear array transducer. tile, can be demonstrated using Color Doppler, and is seen
ch02.indd 29 23-08-2017 19:05:28

on top of the first rib. The first rib appears hyperechoic Brachial Plexus: Infraclavicular Fossa
and is associated with an acoustic shadow (Fig. 2-41). The
pleura is hyperechoic, deep to or on either side of the first Gross Anatomy
rib, and exhibits the typical “lung sliding” sign.14 The infraclavicular fossa can be divided into two main areas:
5 . Clinical Pearls: With the transducer placed as described (1) the medial infraclavicular fossa (MICF), which extends
earlier and the subclavian artery visualized, optimiza- from the lateral border of the first rib cranially to the superior
tion of the image to best visualize the brachial plexus is (medial) border of the pectoralis minor muscle inferiorly, and
achieved with the tilting maneuver. The subclavian vein (2) the lateral infraclavicular fossa (LICF), which lies deep to
can often be seen lying on top of the pleura medially. It the pectoral muscles and in relation to the second part of the
is also common to visualize one or more small arteries in axillary artery. At the MICF, the cords of the brachial plexus
this area. These are the suprascapular artery (Fig. 2-42) emerge from under the clavicle and enter the CCS lying deep
and the transverse cervical artery (Figs. 2-6 and 2-34).15 to the pectoralis major (clavicular head) and subclavius muscle
anteriorly and the upper slips of the serratus anterior muscles
posteriorly (Figs. 2-8 and 2-9). The cords of the plexus are
Anterior
clustered together lateral to the first part of the axillary artery
0
(Figs. 2-9 to 2-11).1–3 This anatomical arrangement of the cords
Brachial plexus Sternocleidomastoid at the CCS makes it a suitable site for brachial plexus block
Scalenus
anterior (costoclavicular BPB).2 Very few BPB techniques have been
1
Lateral Scalenus Medial described at the medial infraclavicular fossa.16,17 This may be
medius SA IJV
Pleura Pleura due to the close proximity of the pleura to the plexus and the
fear of inadvertent pleural or pulmonary puncture. As the plexus
2
1st Rib descends laterally towards the axilla, the cords of the brachial
Acoustic shadow
of 1st Rib plexus are closely related to the second part of the axillary
artery. They lie deep to the pectoralis major and minor mus-
3
cles and anterior to the subscapularis muscle (Fig. 2-43). At the
Posterior
FIGURE 2-41 ■ Transverse sonogram of the supraclavicular fossa. Anterior

The trunks and divisions of the brachial plexus are visualized like
Cranial Caudal
a “bunch of grapes” on the posterolateral aspect of the subclavian
Posterior
artery. SA, subclavian artery; IJV, internal jugular vein.
Anterior
Pect major
IJV Pect minor

Brachial plexus
AA
Acoustic shadow of SA
1st Rib Lat cord
1st Rib Med cord
Post cord
Parietal pleura
Subscapularis
Lateral Posterior Medial
FIGURE 2-42 ■ Doppler sonogram of the supraclavicular fossa

demonstrating the suprascapular artery as it courses through the FIGURE 2-43 ■ Sagittal anatomical section of the infraclavicular
trunks and divisions of the brachial plexus. SA, subclavian artery; fossa from just medial and inferior to the coracoid process (paracora-
IJV, internal jugular vein. coid). AA, axillary artery.
ch02.indd 30 23-08-2017 19:05:42

Anterior Clavicle Subclavius Pectoralis major

Cephalic vein
Cranial Caudal Pect major
Axillary vein
Posterior
Pectoralis minor
Coracoid
Pect minor process
Lung
Subclavius Med cord
Clavicle
Lat cord AA Lung
Post cord
Serratus ant Brachial plexus

Axillary
artery
FIGURE 2-44 ■ Sagittal anatomical section of the infraclavicular FIGURE 2-45 ■ Transverse CT image of the medial infraclavicular
fossa from between the midpoint of the clavicle and the coracoid fossa showing the relation of the cords of the brachial plexus to the
process (ie, between the medial infraclavicular fossa and the para- axillary vessels and the cephalic vein.

coracoid location). Note that the pleura and lung are visualized pos-
teriorly at this location.
paracoracoid location or LICF, the cords of the brachial plexus

have taken up their respective position around the axillary artery Clavicle
(Figs. 2-43 and 2-44). Generally, the lateral cord is superior, the
Cephalic Subclavius
posterior cord is posterior, and the medial cord is caudal to the vein
axillary artery, respectively (Figs. 2-12 and 2-43). The position
of the individual cords of the plexus can vary with the position Pectoralis
major
of the arm (abduction or adduction).5 Also the pleura and lung
are not part of the posterior relation of the brachial plexus at the
LICF (Fig. 2-44). Therefore it is a popular site for infraclavicular
BPB,18 as pleural puncture is thought to be unlikely. However, Axillary Axillary Brachial
Pectoralis plexus
inadvertent pleural puncture has been reported,19 which may minor vein artery
be due to the block needle being inserted more medially than

intended19 when the pleura and lung are posterior to the axillary FIGURE 2-46 ■ Sagittal CT image of the medial infraclavicular
artery and brachial plexus (Fig. 2-44). Pleural complications fossa at the level of the midpoint of the clavicle. Note the relation-
ship of the pectoralis major and subclavius muscles to the neurovas-
should be avoidable with ultrasound guidance.
cular bundle and how the cords of the brachial plexus are clustered
Computed Tomography Anatomy of the on the superior aspect of the axillary artery.
Infraclavicular Fossa
Figs. 2-45 to 2-48 b. Operator and ultrasound machine: The operator is
positioned at the head end of the patient. The ultra-
Magnetic Resonance Imaging Anatomy sound machine is placed on the ipsilateral side to be
of the Infraclavicular Fossa examined and directly in front.
Figs. 2-49 to 2-52 2. Transducer selection: High-frequency linear array
transducer (12-5 or 15-8 MHz).
Technique of Ultrasound Imaging of the Brachial 3. Scan technique:
Plexus at the Medial Infraclavicular Fossa a. Transverse scan of the MICF: Transverse scan of
1. Position: the MICF is performed in five sequential steps, over
a. Patient: Supine with the ipsilateral arm abducted five contiguous sites (Fig. 2-53). This is done to better
(90 degrees) and the head turned slightly to the con- define the anatomy of the CCS and the neighboring
tralateral side. structures that are relevant for infraclavicular BPB.
ch02.indd 31 23-08-2017 19:05:53

Clavicle
Clavicle
Pectoralis
major
Brachial plexus Subclavius
(cords)
Pectoralis
minor AV
AA
AV Brachial plexus
AV (cords)
AA
Pectoralis AV
major
FIGURE 2-47 ■ Sagittal CT image of the infraclavicular fossa

from midway between the midpoint of the clavicle and the coracoid Pectoralis
minor
process. AA, axillary artery; AV, axillary vein.
FIGURE 2-50 ■ Sagittal MRI image of the brachial plexus at the

Clavicle medial infraclavicular fossa. AA, axillary artery; AV, axillary vein.
Pectoralis
major
Pectoralis Brachial plexus

minor (lateral cord)
Brachial plexus Brachial plexus

AA
(posterior cord) lateral cord
AV
Brachial plexus AV
(medial cord) AV
Brachial plexus
Posterior cord
AA
FIGURE 2-48 ■ Sagittal CT image of the infraclavicular fossa from
Brachial plexus
immediately medial to the coracoid process (paracoracoid location).
Pectoralis AV medial cord
Note the relationship of the cords of the brachial plexus to the second major AV
part of the axillary artery. AA, axillary artery; AV, axillary vein. AV
Pectoralis major
Clavicle Subclavius Cephalic vein
Pectoralis minor
Axillary
Deltoid
vein
Axillary
artery
Pectoralis minor
Lung
Brachial plexus
FIGURE 2-51 ■ Sagittal MRI image of the brachial plexus at the
infraclavicular fossa between the midpoint of the clavicle and the
coracoid process. AA, axillary artery; AV, axillary vein.
FIGURE 2-49 ■ Transverse (axial) MRI image of the medial

infraclavicular fossa.
ch02.indd 32 23-08-2017 19:06:12

Clavicle
Brachial plexus
(lateral cord)
Brachial plexus
(posterior cord)
AA
Subscapularis
Pectoralis minor
Pectoralis
major AV
Brachial plexus
(medial cord)
FIGURE 2-54 ■ Figure showing the position and orientation of the
ultrasound transducer during a transverse ultrasound scan for the
brachial plexus at the medial infraclavicular fossa and the costocla-
FIGURE 2-52 ■ Sagittal MRI image of the brachial plexus at the vicular space.
lateral infraclavicular fossa immediately medial and lateral to the
coracoid process. AA, axillary artery; AV, axillary vein. clavicle and the second rib (Figs. 2-56 to 2-59).2,3 The
ultrasound image is optimized until all three cords of
the brachial plexus are clearly visualized lateral to
Subclavius Clavicular head of
muscle pectoralis major the axillary artery (Figs. 2-56 and 2-58). If the ultra-
sound image is less than optimal, the medial end of
Cephalic vein
Axillary artery Clavicle the ultrasound transducer should be gently pivoted
(1st part) 1
Thoracoacromial 2 caudally to try and insonate the ultrasound beam at
artery 3
Deltoid
4 right angles to the cords and thus minimize anisot-
Pectoralis 5
minor Long thoracic ropy (Fig. 2-56).
nerve
Lateral pectoral Step 3: The transducer is then gently manipulated lat-
nerve
erally, maintaining the same transverse orientation and
Sternal head of applying minimal pressure over the area scanned, until
pectoralis major
the cephalic vein is visualized (Figs. 2-60 and 2-61).
Medial pectoral nerve
Step 4: From this position the transducer is manipu-
lated further laterally until the thoracoacromial artery
(TAA) is seen to emerge from the axillary artery
FIGURE 2-53 ■ Illustration showing the positions of the ultrasound (second part) (Figs. 2-62 and 2-63).
transducer during the ultrasound scan sequence at the medial infracla-
Step 5: The ultrasound transducer is manipulated
vicular fossa (MICF). Note that positions 1 to 5 are over contiguous
sites over the MICF and in the order in which the scan is performed. further laterally to the LICF (Fig. 2-64).
b. Sagittal scan of the MICF: A sagittal scan of
the MICF can be performed with the ultrasound
Step 1: The transducer is positioned directly over the transducer (a) at right angles to the midpoint of the
midpoint of the clavicle in the transverse orientation clavicle (Figs. 2-65 to 2-67) or (b) with the ultra-
(Fig. 2-54) with its orientation marker directed later- sound transducer parallel to (or in line with) the neu-
ally (outwards). The clavicle is visualized as a curved rovascular structures (Figs. 2-68 to 2-70). From each
hyperechoic structure with an underlying acoustic of these positions the ultrasound transducer is gently
shadow (Fig. 2-55). manipulated laterally (ie, towards the shoulder) to
Step 2: The transducer is gently moved caudally until view the related anatomy.
it slips off the inferior border of the clavicle and the 4. Sonoanatomy of the MICF:
axillary artery (first part) and vein are visualized. It a. Transverse sonoanatomy of the MICF: On a
may be necessary to gently tilt the transducer cepha- transverse sonogram of the upper part of the MICF
lad to direct the ultrasound beam towards the CCS, immediately below the midpoint of the clavicle
that is, the space between the posterior surface of the (Step 2 of the transverse scan sequence), one can
ch02.indd 33 23-08-2017 19:06:27

MICF - Transverse scan sequence: Step 1
Clavicle
Acoustic shadow
of clavicle
Anterior
Lateral
FIGURE 2-55 ■ Figure demonstrating the transverse sonographic view of the clavicle as obtained during Step 1 of the transverse ultrasound
scan sequence at the medial infraclavicular fossa (MICF).
MICF - Transverse scan sequence: Step 2
Lateral cord
PM
Subclavius
Posterior AA AV
cord
SA
Medial cord
Rib
Posterior
Lateral
FIGURE 2-56 ■ Transverse sonogram of the medial infraclavicular fossa immediately below the midpoint of the clavicle (Step 2 of the
transverse ultrasound scan sequence) demonstrating the cords of the brachial plexus in the costoclavicular space. Note the arm of the subject
is abducted and the three cords are clustered together lateral to the axillary artery (AA). Accompanying photographs illustrate the position
and orientation of the ultrasound transducer during the scan.
visualize the CCS between the clavicular head of the artery, and they exhibit a consistent triangular topo-
pectoralis major and subclavius muscle anteriorly graphical arrangement (Figs. 2-58 and 2-59).1,2
and the serratus anterior muscle overlying the second The lateral cord is the most superficial of the three
rib posteriorly (Figs. 2-58 and 2-59).1,2 The first part cords and lies anterior to both the medial and pos-
of the axillary artery and the axillary vein appear as terior cords (Figs. 2-58 and 2-59).3 The medial cord
two hypoechoic round-to-oval structures within the is directly posterior to the lateral cord but medial to
CCS (Fig. 2-58). The axillary artery is pulsatile and the posterior cord (Fig. 2-58).3 The posterior cord is
located lateral to the axillary vein (Fig. 2-58). Deep the most lateral of the three cords at the CCS, and
to the axillary artery the upper slips of the serratus it is immediately lateral to the medial cord but pos-
anterior muscle, second rib, intercostal muscles, and terolateral to the lateral cord (Figs. 2-58 and 2-59).3
parietal pleura are clearly delineated (Fig. 2-59). The In the transverse sonogram immediately lateral to
cords are clustered together lateral to the axillary the CCS (Step 3 of the transverse scan sequence), the
ch02.indd 34 23-08-2017 19:06:34

Cranial
Clavicle
Posterior Anterior
Pectoralis major
Ultrasound Caudal
scan plane
Brachial plexus
Cephalic vein Subclavius Lateral cord
Axillary
artery Axillary vein
Serratus
anterior Posterior cord Axillary
Axillary vein
2nd Rib Pectoralis artery
major Medial cord
Pectoralis Anterior
minor Serratus anterior
Lateral Medial
Lung
Posterior
Pleura
Lung
FIGURE 2-59 ■ Coned (zoomed) view of the right costoclavicular

FIGURE 2-57 ■ Figure highlighting the anatomical structures that space demonstrating the cords of the brachial plexus within the cos-
are insonated during a transverse ultrasound scan for the brachial toclavicular space and lying lateral to the axillary artery. Note the
plexus at the medial infraclavicular fossa below the midpoint of the relationship of the cords to one another and to the axillary artery.
clavicle. AA, axillary artery.
Because the cephalic vein lies anterior to the cords, this

ultrasound window is not ideal for performing BPB
Pectoralis major because of the risk of puncturing the cephalic vein.
Lateral cord –1
Also if one does see the cephalic vein in the ultrasound
window during a costoclavicular BPB, then it implies
Posterior cord Subclavius
that the transducer is positioned lower than the desired
location. If one now slides or tilts the transducer slightly
Medial cord
Axillary –2
Axillary artery vein laterally from the scan position described earlier (Step 4
(1st part)
of the transverse scan sequence), the cephalic vein is no
Serratus anterior longer visible and the TAA, which is a branch of the
2nd Rib –3 axillary artery, is visualized (Figs. 2-62 and 2-63). It is
JPEG seen emerging from the anterior surface of the axillary
artery and may be seen either as two arteries (Fig. 2-62)
FIGURE 2-58 ■ Transverse sonogram of the medial infraclavicular or as a single vessel lying deep and close to the upper
fossa immediately below the midpoint of the clavicle (Step 2 of the border of the pectoralis minor muscle (Fig. 2-63).
transverse ultrasound scan sequence) demonstrating the cords of the From this position gentle lateral manipulation of the
brachial plexus in the costoclavicular space. Note the relationship of transducer will reveal the LICF where the cords of the
the cords to one another and to the axillary artery. brachial plexus are closely related to the second part of
the axillary artery (Fig. 2-64).
b. Sagittal sonoanatomy of the MICF: On a sagittal
cephalic vein is seen arching over the axillary artery to sonogram of the MICF, with the ultrasound trans-
join the axillary vein from a lateral to medial direction ducer positioned at a right angle to the midpoint of
(Figs. 2-60 and 2-61). The cephalic vein is easily com- the clavicle (Fig. 2-65), the cords of the brachial
pressible with pressure from the transducer, but the plexus are seen as multiple hypoechoic round to oval,
axillary artery is more resistant to compression. The structures each with a hyperechoic rim lying superior
cords of the brachial plexus are seen as a hyperechoic to the pulsatile axillary artery (Figs. 2-66 to 2-68).
cluster of nerves that lie deep to the cephalic vein and The cords lie within the CCS formed by the pecto-
lateral to the axillary artery (Figs. 2-60 and 2-61). ralis major and subclavius muscle anteriorly and the
ch02.indd 35 23-08-2017 19:06:46

MICF: Transverse scan sequence - Step 3
Lateral cord PM
CV
Subclavius
Posterior AA AV
cord
Serratus anterior
Medial cord
Rib Anterior
Lateral
FIGURE 2-60 ■ Transverse oblique sonogram of the right medial infraclavicular fossa (MICF) from just distal to the costoclavicular space
(Step 3 of the transverse scan sequence). Note how the cephalic vein arches over the cords of the brachial plexus and the axillary artery to
join the axillary vein from a lateral to medial direction. PM, pectoralis major muscle; CV, cephalic vein; AA, axillary artery; AV, axillary vein.
Anterior lying anterior to the medial cord, and the posterior

cords lying superior to the medial and lateral cord
(Figs. 2-66 to 2-68).20
Pectoralis major
On a sagittal sonogram of the MICF, with the
ultrasound transducer positioned parallel to the long
axis of the neurovascular structures (Figs. 2-69 to
Lateral Cephalic Medial
vein Axillary
2-71) and from a medial to lateral direction, the axil-
Brachial plexus
(cords) vein lary vein is the first structure visualized (Fig. 2-69).
Axillary
artery
Rib The axillary vein is hypoechoic, nonpulsatile, easily
compressible, and lies on the anterior chest wall. The
Pleura cephalic vein is also delineated and, after it traverses
the gap between the clavicular head of the pectoralis
Posterior
major and the subclavius muscle, joins the axillary
FIGURE 2-61 ■ Transverse oblique sonogram (zoomed view) of vein from above (Fig. 2-69). In the adjoining sagit-
the medial infraclavicular fossa (MICF) showing the cephalic vein tal sonogram, the pulsatile axillary artery is visual-
joining the axillary vein. Note the cords of the brachial plexus are ized (Fig. 2-70). The axillary artery, after it emerges
located posterior to the cephalic vein and lateral to the axillary artery. from the CCS, lies in the MICF, deep to the clavicu-
lar head of the pectoralis major muscle and above
the superior border of the pectoralis minor muscle
upper slips of the serratus anterior muscle and chest (Fig. 2-69). The cephalic vein lies anterior to the
wall posteriorly (Figs. 2-66 to 2-68). The axillary vein axillary artery at the MICF (Fig. 2-69). The axillary
is located caudal to the axillary artery (Figs. 2-66 to artery continues distally to enter the LICF, where it
2-68), and the cephalic vein joins the axillary vein is located posterior to the pectoralis major and minor
from above (Fig. 2-68). Deep to the serratus ante- muscles (Fig. 2-70). The axillary artery also gives off
rior muscle outlines of the anterior intercostal the TAA from its anterior wall, and the latter ascends
space and the hyperechoic pleura are clearly visu- cranially, lying close to the posterior surface of the
alized. The arrangement of the cords in the sagittal pectoralis minor muscle (Fig. 2-70). In the sagittal
sonogram is also consistent,20 with the lateral cord sonogram acquired immediately lateral and parallel
ch02.indd 36 23-08-2017 19:06:52

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

MICF: Transverse scan sequence - Step 4 to the cords (Fig. 2-71). Due to the anatomic arrange-
ment of the cords at the MICF (Figs. 2-10 and 2-11),
all three cords of the brachial plexus are rarely
PM visualized in a single sagittal sonogram. It is more
TAA
common to visualize two cords, that is, the lateral
Brachial plexus Pm
(cords) cord lying anterior to the medial cord (Fig. 2-71).
5. Clinical Pearls: The CCS may offer advantages for
AA AV
Anterior BPB, and ultrasound-guided costoclavicular BPB has
all recently been described.2 At the CCS, and in contrast to
st w
Lateral Che
that at the LICF, the cords of the brachial plexus are rela-
tively superficial (2–3 cm) in location, they are clustered
together lateral to the axillary artery,1–3 and they share a
FIGURE 2-63 ■ Transverse oblique sonogram of the upper part consistent anatomical relationship with one another and
of the lateral infraclavicular fossa (LICF) close to the upper bor- to the axillary artery.1–3 All three cords of the brachial
der of the pectoralis minor muscle (Step 5 of the transverse scan plexus are also visualized in a single transverse sono-
sequence). Note the thoracoacromial artery (TAA) is seen as a single gram of the MICF.2 Therefore, it is possible to produce
vessel (close to its origin) in this sonogram. The cords of the brachial BPB at the CCS using a single injection of a relatively
plexus are also seen as a cluster of nerves lying lateral and superolat-
low volume (20 mL) of local anesthetic,2 unlike that at
eral to the axillary artery (second part). The TAA may be confused
for the medial cord in the upper part of the LICF. the LICF where multiple injections21 and relatively large
volumes of local anesthetics (up to 35 mL) are often
required to produce an effective BPB.21,22 The CCS is
to the axillary artery, the cords of the brachial plexus also a useful site for catheter placement when a con-
are visualized as longitudinal hyperechoic structures tinuous BPB is planned for postoperative pain manage-
(Fig. 2-71) and lying within the CCS (close to the ment,2 because the cords are close to one another. In
clavicle), MICF and LICF from a cranial to caudal our experience continuous BPB can be achieved via the
direction (Fig. 2-71). At the MICF the cephalic vein CCS using very small volumes of local anesthetic for
ch02.indd 37 23-08-2017 19:07:00

LICF: Sagittal scan
Lateral cord
TAA PM
Pm
AA
Posterior AV
cord
Anterior
Cranial
FIGURE 2-64 ■ Sagittal sonogram of the lateral infraclavicular fossa (LICF). Note the lateral and posterior cords are visualized above the
axillary artery (second part). Also the thoracoacromial artery (TAA) is identified as a round, hypoechoic structure between the axillary artery
and vein, and may be confused for the medial cord unless one used Doppler ultrasound.
–0
Clavicle
Pectoralis major
Subclavius
Acoustic shadow of clavicle
Brachial plexus –1
–2
AA
Serratus anterior AV
–3
Anterior
Cranial Caudal
FIGURE 2-65 ■ Figure showing the position and orientation of Pleura
Posterior
the ultrasound transducer during a sagittal ultrasound scan of the
medial infraclavicular fossa immediately below the midpoint of the
FIGURE 2-66 ■ Sagittal sonogram of the medial infraclavicular
clavicle.
fossa immediately below the midpoint of the clavicle showing the
cords of the brachial plexus clustered together above the axillary
artery and in a triangular space (costoclavicular) bound by the cla-
the infusion (eg, 4–5 mL/h of levobupivacaine 0.125%). vicular head of pectoralis major and subclavius muscle anteriorly,
and the serratus anterior muscle posteriorly, the axillary artery infe-
However, currently there are limited published data on
riorly, and the inferior surface of the clavicle superiorly. AA, axillary
the safety and efficacy of BPB at the MICF.16,17 Overall, artery; AV, axillary vein.
a medial approach may be desirable for BPB, but needle
interventions at the MICF carry a definite risk of pleural
puncture. Therefore, until more data on safety and effi- Ultrasound Imaging of the Brachial Plexus
cacy are available, infraclavicular BPB techniques at the at the Lateral Infraclavicular Fossa
MICF should be considered an advanced technique and 1. Position:
used with caution because the lateral sagittal infracla- a. Patient: Supine with the ipsilateral arm abducted
vicular BPB technique, despite some of its limitations, (90 degrees) and the head turned slightly to the con-
is effective and has a long track record of safety.18,23 tralateral side.
ch02.indd 38 23-08-2017 19:07:08

Anterior
Clavicle
Subcutaneous fat
Pectoralis
major
Clavicle
Pectoralis major
BP - lateral cord
CV Ce
Subclavius pha
Subclavius lic
Acoustic shadow ve
in
of clavicle
Pectoralis minor
AA
AV Cranial Caudal
BP - posterior cord
Serratus anterior Axillary
BP - medial cord Cords of the vein
Brachial Plexus Axillary
artery
Anterior
Serratus
Pleura anterior Pleura
Cranial Caudal
Posterior Posterior
FIGURE 2-67 ■ Sagittal sonogram of the medial infraclavicu- FIGURE 2-68 ■ Sagittal sonogram of the medial infraclavicular
lar fossa lateral to the position described earlier (Fig. 2-66). Note fossa showing the cephalic vein joining the axillary vein. Note how
how the cords of the brachial plexus (BP) are clustered together and the cords of the brachial plexus are clustered together posterior to
located above the axillary artery in a space (costoclavicular) bound the cephalic vein and superior to the axillary artery. The position
by the inferior surface of the clavicle superiorly, the axillary artery of the cephalic vein relative to the cords of the brachial plexus in
inferiorly, the subclavius muscle anteriorly, and the serratus anterior the sagittal sonogram often precludes safe needle insertion at this
muscle posteriorly. The cephalic vein (CV) is located anterior to the level.
axillary artery. AA, axillary artery; AV, axillary vein.
MICF: Sagittal scan Sequence - Step 1
Clavicle Cephalic
Subclavius
vein
PM
AV
SA
Rib
Anterior
Cranial
FIGURE 2-69 ■ Sagittal sonogram of the medial infraclavicular fossa with the ultrasound transducer placed parallel (in-line) to the
axillary vein (Step 1 of the sagittal scan sequence). Note the axillary vein lies between the subclavius muscle anteriorly and the serratus
anterior (SA) muscle posteriorly at the costoclavicular space. Also the cephalic vein is seen joining the anterior wall of the axillary vein
(AV) from above. PM, pectoralis major muscle. Accompanying photograph illustrates the position and orientation of the transducer during
the ultrasound scan.
b. Operator and ultrasound machine: The operator is 2. Transducer selection: High-frequency linear array
positioned at the head end of the patient. The ultra- transducer (12-5 or 15-8 MHz). For ultrasound imaging of
sound machine is placed on the ipsilateral side to be the LICF (paracoracoid location), we prefer to use a high-
examined and directly in front. frequency linear array transducer (12-5 or 15-8 MHz,
ch02.indd 39 23-08-2017 19:07:22

MICF: Sagittal scan sequence - Step 2

Cephalic
Clavicle
vein Thoracoacromial
Subclavius artery
PM
Pm
AA
SA
Rib 3rd Rib
FIGURE 2-70 ■ Sagittal sonogram of the medial infraclavicular fossa (MICF) with the ultrasound transducer positioned parallel to the
axillary artery (Step 2 of the sagittal scan sequence). Note the axillary artery (AA) enters the MICF by traversing the costoclavicular space
between the clavicular head of the pectoralis major (PM) and subclavius muscle anterior and the upper slips of the serratus anterior (SA)
muscle overlying the second rib posteriorly. The cephalic vein is also seen in the MICF anterior to the axillary artery. The thoracoacromial
artery also originates from the axillary artery close to the upper border of the pectoralis minor muscle and ascends cranially before it divides
into its four (clavicular, acromial, deltoid, and pectoral) branches. Accompanying photograph illustrates the position and orientation of the
transducer during the ultrasound scan.
MICF: Sagittal scan sequence - Step 3

Clavicle
Lateral Subclavius
cord TAA M3
0
PM
1
CV
Pm
Medial SA
cord 3
Rib Anterior
Cranial
Figure 2-71 ■ Sagittal sonogram of the medial infraclavicular fossa (MICF) with the ultrasound transducer positioned parallel to the axil-
lary artery (Step 3 of the sagittal scan sequence). The cords of the brachial plexus are seen as hyperechoic longitudinal structures exiting the
costoclavicular space to enter the MICF and then the lateral infraclavicular fossa deep to the pectoralis minor. Note the relationship of the
cephalic vein (CV) and thoracoacromial artery (TAA) to the cords of the brachial plexus at the MICF. Accompanying photograph illustrates
the position and orientation of the transducer during the ultrasound scan. PM, pectoralis major muscle; Pm, pectoralis minor muscle; SA,
serratus anterior muscle.
Fig. 2-72). However, in muscular or obese individuals, inferior to the coracoid process (Figs. 2-64 and 2-72). The
a high-frequency curved array transducer (eg, 8-5 MHz) first objective is to locate the axillary artery and vein. It
with a small footprint may be preferable. may be necessary to gently tilt, slide, or rotate the trans-
3 . Scan technique: The transducer is positioned just below ducer to obtain an optimal view of the axillary artery.
the clavicle and over the deltopectoral groove, medial and Also during the scan it is possible to obtain a sagittal view
ch02.indd 40 23-08-2017 19:07:34

Pectoralis major
Pectoralis minor
AA
AV
Lateral cord
Medial cord Pleura

Anterior Post cord
Cranial Caudal
Posterior
FIGURE 2-74 ■ Sagittal sonogram of the lateral infraclavicular

fossa midway between the midpoint of the clavicle and the coracoid
ultrasound transducer during a sagittal ultrasound scan of the lateral
process. Note the pleura is visible posteriorly and deep to the axil-
infraclavicular fossa immediately medial and inferior to the coracoid
lary artery and vein. AA, axillary artery; AV, axillary vein.
process (paracoracoid location).
Ant
Ant
Cran Caud
Cran Caud Pect major Pect major
Post
Post
Pect minor
Pect minor Deltoid
Clavicle Med cord

Lat cord AA
Subclavius Med cord Post cord Rib
Clavicle Trapezius
Lat cord AA Lung
Post cord
Supraspinatus Subscapularis
Serratus ant
FIGURE 2-75 ■ Figure highlighting the anatomical structures

FIGURE 2-73 ■ Figure highlighting the anatomical structures that that are insonated during a sagittal ultrasound scan for the brachial
are insonated during a sagittal ultrasound scan for the brachial plexus plexus in the lateral infraclavicular fossa midway between the mid-
immediately medial and inferior to the coracoid process (paracora- point of the clavicle and the coracoid process (paracoracoid location).
coid location). AA, axillary artery. AA, axillary artery.
of the LICF with (medial position, Figs. 2-73 and 2-74) may change during the respiratory cycle. The cords of the
or without (lateral position, Figs. 2-75 to 2-77) insonating brachial plexus are closely related to the axillary artery. If
the chest wall and pleura. one likens the cross-sectional image of the axillary artery
4 . Sonoanatomy at the LICF: On a sagittal sonogram to a clock face with its 12 o’clock position located ante-
of the LICF (paracoracoid location), the axillary artery riorly and the 6 o’clock position located posterior to the
(second part) appears as a hypoechoic round-to-oval artery, then with the arm adducted at the shoulder, the
pulsatile structure under the pectoralis major and minor lateral, medial, and posterior cords of the brachial plexus
muscles (Figs. 2-76 and 2-77). The axillary vein is also are most frequently observed in the 10 o’clock, 3 o’clock,
hypoechoic, oval to elliptical in shape, and located cau- and 6 o’clock positions, respectively (Figs. 2-76 and
dal to the artery. The shape and size of the axillary vein 2-77). Despite this relation in most cases it is not easy to
ch02.indd 41 23-08-2017 19:07:53

Anterior scan during a lateral sagittal infraclavicular BPB and the

needle inserted lateral to this site, that is, through an ultra-
sound window where no pleura is visualized (Figs. 2-76
Pectoralis major
and 2-77).
5 . Clinical Pearls: Ultrasound visualization of the brachial
Lateral cord Caudal plexus at the LICF is best achieved with the arm in the
Cranial
Medial cord
abducted position. Abduction of the arm brings the cords
Pectoralis minor
closer to the skin and elevates the lateral part of the clavi-
AA
cle, which makes more space available below the clavicle
Subs AV
capu
laris
mus for placement of the ultrasound transducer. In the paracor-
cle
Posterior cord acoid area, the axillary artery is 3 to 7 cm under the skin
JPEG surface.16 This makes confirmation of the artery by com-
4.0– ***bpm
Posterior
pressibility insensitive. Also, although one may expect
FIGURE 2-76 ■ Sagittal sonogram of the lateral infraclavicular to be able to compress the axillary vein with pressure at
fossa with the ultrasound transducer placed immediately medial the LICF, it may not always be possible. Therefore, it is
and inferior to the coracoid process. AA, axillary artery; AV, axil- advisable to use Doppler ultrasound whenever possible
lary vein. to differentiate the artery from the vein. Rarely one may
visualize a bifid axillary artery25 in the infraclavicular
fossa as a normal variant of the a xillary artery anatomy. It
is also common to see a hyperechoic shadow posterior to
the axillary artery at the 6 o’clock position. This is usu-
ally an artifact caused by acoustic enhancement resulting
Pectoralis major from the sudden reduction in acoustic impedance as the
ultrasound signal travels through the blood in the axil-
Medial
Lateral cord lary artery. This hyperechoic shadow may be mistaken as
cord
the posterior cord. Tilting the transducer or performing a
Pectoralis “trace back technique”9 may help to differentiate an arti-
minor
AA fact from the posterior cord. The LICF is a popular site
AV
for brachial plexus catheter placement. The target loca-
Anterior
Posterior AV tion for the catheter placement should be posterior (ie,
Cranial Caudal
cord
at the 6 or 7 o’clock position) to the axillary artery. The
Posterior
muscles of the chest wall, through which the catheter is
passed, help stabilize the catheter and may prevent cath-
FIGURE 2-77 ■ Sagittal sonogram of the lateral infraclavicular
fossa in chroma mode with the ultrasound transducer placed imme- eter dislodgement.
diately medial and inferior to the coracoid process. Chroma mode
using different shades of color (color maps) is often used to improve
Brachial Plexus: Axilla
contrast resolution and therefore recognition of structures in an
ultrasound image. AA, axillary artery; AV, axillary vein. Gross Anatomy
As the brachial plexus enters the arm, its four main terminal
nerves (median, ulnar, radial, and musculocutaneous) travel in
identify all three cords of the brachial plexus in a single close proximity to the third part of the axillary artery (Fig. 2-13
ultrasound scan plane.24 Also the position of the cords of and 2-78). The nerves lie superficial to the conjoint tendon
the brachial plexus varies with abduction or adduction of of the teres major and latissimus dorsi muscles and under
the arm.5 If the transducer is moved medially, the pleura the subcutaneous tissue lateral to the anterior axillary fold
comes into view (Fig. 2-74). One can understand how (Fig. 2-78). When the arm is abducted and externally rotated,
inadvertent pleural puncture can occur during an infra- the median nerve is located on the anterior or anterolateral
clavicular (lateral sagittal) BPB (Fig. 2-74).19 We recom- aspect of the axillary artery (97.9%), the ulnar nerve is located
mend that the pleura be routinely identified as part of the on the anteromedial side of the artery (91.3%), and the radial
ch02.indd 42 23-08-2017 19:08:00

Pectoralis major muscle

Cephalic vein and tendon
Musculocutaneous
nerve Biceps brachii
Long head
Coracobrachialis Short head
Medial antebrachial
cutaneous nerve
Deltoid
Median nerve
Brachial artery and vein
Humerus Ulnar nerve
Medial brachial
cutaneous nerve
Radial nerve
Triceps brachii
Lateral head Tendon of latissimus
Long head dorsi muscle
Teres major
FIGURE 2-78 ■ Cross-sectional anatomy of the axilla at the level of the anterior axillary fold (ie, where the pectoralis major muscle joins the
biceps muscle). Note the relation of the median, ulnar, and radial nerve to the axillary artery and how the musculocutaneous nerve is embedded
within the substance of the coracobrachialis muscle.
nerve is located posterior to the axillary artery (89.9%).26 The

musculocutaneous nerve lies between the coracobrachia-
Biceps
lis and biceps muscles, but can also be within the substance
of the coracobrachialis muscle (Figs. 2-78 to 2-81). MC
Occasionally the musculocutaneous nerve may also be located

AA
adjacent to the median nerve. M
CB U
Magnetic Resonance Imaging Anatomy

of the Axilla R
Figs. 2-80 and 2-81

Ant Med
Humerus Triceps
Technique of Ultrasound Imaging of the Brachial
Lat Post
Plexus at the Axilla
1. Position: FIGURE 2-79 ■ Transverse anatomical section of the axilla. AA,
a. Patient: Supine with the ipsilateral arm abducted axillary artery; M, median nerve; U, ulnar nerve; R, radial nerve;
90 degrees at the shoulder. CB, coracobrachialis muscle; MC, musculocutaneous nerve.
b. Operator and ultrasound machine: The operator
sits at the head end of the patient, and the ultrasound
machine is placed directly in front on the ipsilateral (Figs. 2-84 and 2-85). The initial goal is to identify the
side. Alternatively, the position of the operator and axillary artery. Minor adjustments (tilting or rotation) in
the ultrasound machine can be reversed. the position of the ultrasound transducer may be required
2. Transducer selection: High-frequency linear array to obtain a true or optimal cross-sectional image of the
transducer (15-8 or 12-5 MHz). axillary artery. The axillary vein is compressible and lies
3. Scan technique: The ultrasound transducer is placed medial to the axillary artery. Doppler ultrasound can also
transversely across the upper arm (Figs. 2-82 and 2-83) at be used to differentiate the axillary artery from the vein.
the axillary fold just lateral to the pectoralis major muscle It is common to see more than one vein in the sonogram.
ch02.indd 43 23-08-2017 19:08:08

Coracobrachialis
Biceps brachii Axillary artery
Axillary vein
Median nerve
Deltoid
Humerus Ulnar nerve
Radial nerve
Conjoint tendon
Musculocutaneous nerve
Anterior
Lateral Medial
Posterior
Triceps
(long head)
FIGURE 2-80 ■ Transverse (axial) MRI of the axilla above the

anterior axillary fold. Note the position of the musculocutaneous
nerve.
Musculocutaneous
nerve
Biceps brachi
Brachial vein
FIGURE 2-82 ■ Figure showing the position of the ultrasound
Coracobrachialis
Brachial vein transducer relative to the humerus during an ultrasound scan of the
axilla at the axillary fold.
Humerus Ulnar nerve
Median nerve
Brachial artery
Triceps Biceps
Anterior
Lateral Medial MC
Posterior
AA
M
CB U
FIGURE 2-81 ■ Transverse (axial) MRI of the axilla at the level
of the anterior axillary fold. Note the musculocutaneous nerve is
located between the biceps and coracobrachialis muscle. R
Humerus Ant Med

These vascular structures should be confirmed by com- Triceps
pression and occlusion before any needle intervention. Lat Post
Doppler ultrasound can also be used to confirm hypoechoic
structures that are suspected to be vascular in nature. The FIGURE 2-83 ■ Figure highlighting the anatomical structures
conjoint tendon of the latissimus dorsi and teres major that are insonated during a transverse ultrasound scan of the axilla.
muscles and its humeral insertion should subsequently AA, axillary artery; M, median nerve; U, ulnar nerve; R, radial
nerve; CB, coracobrachialis muscle; MC, musculocutaneous nerve.
be identified. It may be necessary to slide the transducer
medially to visualize this tendon. The conjoint tendon is a
useful sonographic landmark to locate the radial nerve as vein is also hypoechoic, situated caudal to the artery,
it often lies on top of this tendon. oval or elliptical in shape, and may collapse from pres-
4 . Sonoanatomy: The axillary artery, when imaged in true sure of the transducer. The shape and size of the axillary
cross-section, is typically round, pulsatile, and relatively vein may also vary during the respiratory cycle. Lateral to
superficial in location (Figs. 2-86 to 2-88). The axillary the axillary artery is the biceps and the coracobrachialis
ch02.indd 44 23-08-2017 19:08:24

Medial
AV
Anterior Posterior U
Biceps AA
Lateral
AV R
MC
CB
Conjoint tendon
Triceps, long head
Humerus

the ultrasound transducer during a transverse ultrasound scan of the FIGURE 2-86 ■ Transverse sonogram of the axilla. AV, axillary
axilla at the axillary fold. vein; AA, axillary artery; U, ulnar nerve; R, radial nerve; CB, cora-
cobrachialis muscle; MC, musculocutaneous nerve.
Med
Ant
M
Lat Post
Biceps AA U
R
AV
AV
MC
CB
Conjoint tendon
Triceps
Humerus
the ultrasound transducer during a transverse ultrasound scan of the
axilla at the axillary fold (different view compared to Figure 2-84). FIGURE 2-87 ■ Transverse sonogram of the axilla showing all four
Note how the ultrasound transducer is positioned just distal to the terminal branches of the brachial plexus. M, median nerve; R, radial
anterior axillary fold. nerve; U, ulnar nerve; MC, musculocutaneous nerve; CB, coracobra-
chialis muscle; AA, axillary artery; AV, axillary vein.
muscles. The musculocutaneous nerve lies in a fascial

plane between these two muscles and is frequently visu- of the brachial plexus, relative to the axillary artery, in the
alized as an elliptical hyperechoic structure (Fig. 2-89). axilla is also variable. The nerves are highly mobile and
However, the shape and size of the musculocutaneous can be seen to change their position relative to the artery
nerve are variable27 and can also be oval, round, flat-oval, when pressure is applied on the ultrasound transducer. If
or triangular (Figs. 2-86 to 2-90) in shape.27 On the pos- one imagines the transverse image of the axillary artery
terior aspect of the axillary artery, a diagonal hyperechoic as a clock face where the 9 o’clock position represents
structure travelling from the anteromedial to the postero- the lateral aspect and the 3 o’clock position represents
lateral direction can be visualized. This is the conjoint the medial aspect of the artery, then the median nerve
tendon, and the triceps muscle is seen posterior to this is typically located in the anterolateral (9 to 12 o’clock)
tendon (Figs. 2-86 to 2-89). The nerves in the axilla have sector. The radial nerve is typically located on the sur-
mixed echogenicity, but are more frequently hyperechoic face of the conjoint tendon,28 in the posteromedial (4 to
in appearance. The position of the various terminal nerves 6 o’clock) sector deep to the axillary artery. The ulnar
ch02.indd 45 23-08-2017 19:08:38

Ulnar nerve
Musculocutaneous
Median nerve Biceps nerve
Coracobrachialis
Biceps AV
Musculocutaneous
nerve AA
Coracobrachialis
AV
Radial nerve
AA
Conjoint tendon
Median Ulnar
Humerus Conjoint nerve nerve
Humerus tendon
FIGURE 2-88 ■ High-resolution transverse sonogram of the axilla FIGURE 2-90 ■ Transverse sonogram of the musculocutaneous
acquired using a 13-MHz linear ultrasound transducer. All four ter- nerve at the upper arm in sepia chroma mode. The musculocutaneous
minal branches of the brachial plexus are clearly delineated. Note nerve is located between the biceps and coracobrachialis muscles and
the tissues plane/compartment separating the radial nerve from the appears triangular in shape. AA, axillary artery; AV, axillary vein.
ulnar nerve in this sonogram. AA, axillary artery; AV, axillary vein.
during the scout scan. It is common for the veins in the

axilla to be occluded by light pressure. This may increase
the potential risk for inadvertent intravascular injection if
Musculocutaneous intravascular placement of the block needle or spread of
nerve
the injectate is not recognized on the ultrasound image
Biceps during the injection. Rarely a bifid axillary artery may be
AV seen as a normal variant in the axilla. The “trace back”
AA
technique is useful to confirm the identity of a particu-
AV
Coracobrachialis AV lar nerve in the axilla. The median nerve can be traced
and observed to travel with the brachial artery. The ulnar
nerve can be traced and is seen on the medial aspect of the
Humerus
brachial artery. The radial nerve typically lies on the ante-
JPEG rior surface of the conjoint tendon28 and descends deep
towards the spiral groove of the humerus with the deep
FIGURE 2-89 ■ Transverse sonogram of the musculocutaneous artery of the arm. The musculocutaneous nerve lies in a
nerve at the upper arm. The musculocutaneous nerve is located
plane between the biceps and coracobrachialis muscles
between the biceps and coracobrachialis muscles and appears oval
in shape. AA, axillary artery; AV, axillary vein. and moves away from the axillary artery as it descends
down the arm.27
nerve is typically located in the caudal (2 to 4 o’clock) Midhumeral Region – Median and
sector, and there may be several veins between it and the Ulnar Nerve
axillary artery.
5 . Clinical Pearls: The axillary region is highly vascu- Gross Anatomy
lar, and examination of the brachial plexus in this area In the upper arm the terminal branches of the brachial plexus
should be preceded by a careful examination to locate (ie, the median, ulnar, and radial nerves) separate from one
the arteries and veins around the potential target nerves. another and take up their respective positions. The median
Alternating firm and light pressure on the ultrasound nerve is closely related to the brachial artery throughout its
transducer can be used to delineate the veins in the axilla course in the arm. In the midhumeral region, the median nerve
ch02.indd 46 23-08-2017 19:08:54

lies lateral to the artery (Figs. 2-91 and 2-92); in the middle Magnetic Resonance Imaging Anatomy
of the arm it crosses the artery anteriorly from the lateral to of the Midhumeral Region
medial side and continues to descend on the medial side of
Fig. 2-97
the artery (Figs. 2-14, 2-93, and 2-94) up to the elbow. At
the antecubital fossa the median nerve is relatively superficial Technique of Ultrasound Imaging for the Median
and lies medial to the brachial artery, posterior to the bicipital and Ulnar Nerve at the Midhumeral Region
aponeurosis, and anterior to the brachialis muscle (Figs. 2-95 1. Position:
and 2-96). a. Patient: Supine with the ipsilateral arm abducted
In the arm, the ulnar nerve lies medial to the brachial artery and externally rotated such that the palm of the hand
up to about the insertion of the coracobrachialis muscle, is facing the ceiling.
where it pierces the medial intermuscular septum to enter the b. Operator and ultrasound machine: For a right-
posterior compartment of the arm. It then continues its distal sided scan, a right-handed operator sits or stands
course and passes behind the medial epicondyle to enter the at the head end of the patient and the ultrasound
ulnar nerve sulcus (Fig. 2-96). machine is placed directly in front on the ipsilateral
Biceps brachii Median nerve

Cephalic vein
Brachial artery and veins LACN Biceps brachii Brachial artery
Cephalic vein
and veins
Musculocutaneous MACN
nerve Brachialis MACN
MBCN
Brachialis
Basilic vein Brachioradialis Median nerve
Posterior antebrachial
cutaneous nerve Ulnar nerve Radial nerve Basilic vein
Humerus
Radial collateral Superior ulnar collateral
artery and vein artery and veins Extensor carpi
radialis longus Ulnar nerve
Radial nerve
PACN
Middle collateral
artery
Humerus
Triceps
Lateral head
Medial head Triceps brachii muscle
Long head and tendon
FIGURE 2-91 ■ Cross-sectional anatomy of the arm at the mid- FIGURE 2-93 ■ Cross-sectional anatomy of the lower arm above
humeral level. Note the relation of the median and ulnar nerve to the elbow joint. MACN, medial antebrachial cutaneous nerve;
the brachial artery. MACN, medial antebrachial cutaneous nerve; LACN, lateral antebrachial cutaneous nerve; PACN, posterior ante-
MBCN, medial brachial cutaneous nerve. brachial cutaneous nerve.
Anterior
Median nerve Lateral Medial
Biceps Basilic vein
BA Biceps Posterior
Ulnar nerve
CB BA
M
Deltoid Brachialis
BV
Humerus BV
U
Brachialis Basilic V
Triceps
Triceps
Anterior
Lateral Medial
Posterior
FIGURE 2-92 ■ Transverse anatomical section of the arm at the FIGURE 2-94 ■ Transverse anatomical section of the lower arm
midhumeral level. BA, brachial artery; BV, brachial vein; CB, cora- above the elbow joint. M, median nerve, U, ulnar nerve; BA, brachial
cobrachialis muscle. artery; BV, brachial vein.
ch02.indd 47 23-08-2017 19:09:08

side. Alternatively, the position of the operator and

Basilic vein
ultrasound machine can be reversed.
Biceps brachi Brachial artery 2. Transducer selection: High-frequency (15-8 or 17-5 MHz)
Brachialis Inferior ulnar collateral
artery
linear array transducer.
Brachioradialis
(retracted laterally) Ulnar nerve 3. Scan technique: The transducer is placed transversely
Radial nerve in
radial tunnel Medial epicondyle across the groove between the biceps and triceps mus-
Deep branch of Median nerve cle at the middle of the humerus on the medial aspect
radial nerve
Superficial branch of
(Figs. 2-98 to 2-100). The initial goal is to identify the
Ulnar artery
radial nerve
brachial artery. The image should be optimized by rota-
Radial artery tion or tilting the transducer to obtain a true cross-sec-
Pronator teres tional image of the brachial artery. Vascular structures
should be identified by compression and occlusion before
intervention. Doppler can be used to confirm hypoechoic
FIGURE 2-95 ■ Anatomy of the median, radial, and ulnar nerve at structures that are suspected to be vascular in nature.
the cubital fossa.
4. Sonoanatomy: The median and ulnar nerves are visual-
ized as hyperechoic structures with a honeycomb appear-
ance. Both nerves lie adjacent to the brachial artery at this
level (Fig. 2-101).
5. Clinical Pearls: The median and ulnar nerves are con-
Basilic V
Brachial firmed in this region using the “trace back” technique.
Extensors artery Median nerve
Pronator teres
Both nerves can easily be followed proximally and dis-
tally along the arm. The median nerve typically lies on the
Brachialis
Radius FCR
Humerus PL FDS
Anterior
Anconeus
Ulna Ulnar
Lateral Medial nerve
Posterior
FIGURE 2-96 ■ Cross-sectional anatomy of the arm at the level

of the elbow joint. FCR, flexor carpi radialis; PL, palmaris longus;
FDS, flexor digitorum superficialis.
Median nerve Basilic vein

Brachial vein
Cephalic vein
Biceps
Ulnar nerve
Brachial artery
Brachialis
Brachial vein Triceps
l
dia
Triceps
Me
Radial nerve
r
rio
te
An

FIGURE 2-97 ■ Transverse (axial) MRI of the arm at the mid- transducer relative to the humerus during an ultrasound scan of the
humeral level. arm at the level of the midhumerus.
ch02.indd 48 23-08-2017 19:09:21

Anterior
Median nerve
BV
X
BA
Medial
Lateral Ulnar nerve
BV –1
s
cep
Tri
CB
–2
Posterior

ultrasound transducer during a transverse ultrasound scan of the arm FIGURE 2-101 ■ Transverse sonogram of the median nerve and
at the midhumeral level. ulnar nerve at the midhumeral level. BA, brachial artery; BV, brachial
vein; CB, coracobrachialis muscle.
(Figs. 2-78 and 2-88). It then enters the posterior compartment

of the arm to lie in the spiral groove on the posterior aspect of
M the humerus and in between the medial and lateral heads of
Biceps BA Basilic V
the triceps muscles (Figs. 2-88, 2-102, and 2-103). The radial
U
CB nerve then emerges on the lateral aspect of the humerus and
comes to lie between the brachialis, brachioradialis, and exten-
Deltoid
BV sor carpi radialis longus muscles. It gives off the posterior
antebrachial cutaneous nerve and continuous to the radial tun-
Brachialis
Triceps
nel in the forearm (upper), where it divides into its superficial
and deep branches.
Anterior
Lateral Medial Magnetic Resonance Imaging of the Midhumeral
Posterior Region (Radial Nerve)
FIGURE 2-100 ■ Figure highlighting the anatomical structures that Figs. 2-104 and 2-105
are insonated during a transverse scan of the arm at the midhumeral
level. M, median nerve; U, ulnar nerve; BA, brachial artery; BV Ultrasound Scan Technique for Radial Nerve at the
brachial vein; CB, coracobrachialis muscle. Radial Groove
1. Position:
a. Patient: Supine with the patient asked to touch the
lateral aspect of the brachial artery proximally, crosses opposite shoulder tip with the ipsilateral hand. An
the brachial artery anteriorly, and continues on its medial assistant may help to steady the arm in position.
side distally. The ulnar nerve lies in the medial side of the b. Operator and ultrasound machine: The operator
brachial artery. The position of both nerves in relation to sits or stands caudal to the abducted arm facing the
the artery are variable, and they can be observed “rolling” head of the patient. The ultrasound machine is placed
from one to the other side of the artery. cephalad to the abducted arm on the ipsilateral side
and directly in front of the operator.
Midhumeral Region – Radial Nerve 2. Transducer selection: High-frequency (15-8 or 17-5 MHz)
Gross Anatomy 3. Scan technique: The transducer is placed transversely over
At the level of the anterior axillary fold, the radial nerve lies the posterolateral aspect of the midhumerus (Figs. 2-106
deep to the axillary artery and superficial to the conjoint tendon to 2-108). The initial goal is to image the triceps muscle
ch02.indd 49 23-08-2017 19:09:36

Infraspinatus
Suprascapular nerve Teres minor

Posterior circumflex
humeral artery
Circumflex scapular artery Axillary nerve
Deltoid
Teres major Radial nerve in

radial groove
Deep artery of arm
Latissimus dorsi (cut)
Lateral head of
triceps brachi (cut)
Long head of triceps brachi
Medial head of triceps brachi Olecranon
Superior ulnar collateral artery

Ulnar nerve
Medial epicondyle
FIGURE 2-102 ■ Anatomy of the radial nerve at the level of the spiral groove of the humerus.
Anterior
Lateral Medial
Deltoid Skin marker
Biceps Posterior
Brachialis
Coracobrachialis
Median nerve Triceps Triceps
Basilic vein and Profundus brachii
artery artery
Ulnar nerve Radial nerve
Brachialis
Radial nerve Triceps
Radial collateral and (medial head) Ulnar nerve
middle collateral artery Humerus
Triceps (lateral head) Brachial artery P
ost
Triceps (long head) and vein eri
or
Median nerve
Biceps Me
dia
l
FIGURE 2-103 ■ Transverse anatomical section of the arm at the FIGURE 2-104 ■ Transverse (axial) MRI of the arm at the level of
level of the radial groove. the radial groove.
and the humerus. The image should be optimized by 4. Sonoanatomy: The posterior surface of the humerus
gently rotating and tilting the transducer to minimize appears as a hyperechoic curvilinear structure with a
anisotropy and obtain a true cross-sectional image of the corresponding acoustic shadow anteriorly. The radial
radial nerve in the radial groove (spiral or musculospiral nerve is visualized as an oval hypoechoic structure
groove), together with the deep artery of the arm, which with a hyperechoic outline in the spiral groove between
is also referred to as the profunda brachii artery (Figs. the two heads of the triceps muscle. It is also com-
2-109 and 2-110). mon to visualize the pulsatile deep artery of the arm,
ch02.indd 50 23-08-2017 19:09:44

Biceps
Radial nerve
Brachialis
Profunda brachii
artery
Brachioradialis
Posterior antebrachial
cutaneous nerve
Lateral head
Anterior of triceps
Medial Lateral
Long head Humerus
of triceps Medial head
Posterior of triceps

FIGURE 2-105 ■ Transverse (axial) MRI of the arm distal to the the ultrasound transducer during an ultrasound scan for the radial
radial groove showing the radial nerve at the lateral aspect of the nerve at the radial groove.
humerus.
Deltoid
Biceps
Brachialis
Coracobrachialis
Median nerve
Basilic vein and artery

Ulnar nerve
Radial nerve Triceps (medial head)

Radial collateral and middle
collateral artery
Triceps (lateral head)

Triceps (long head)
Anterior
Lateral Medial
Posterior
FIGURE 2-108 ■ Figure highlighting the anatomical structures that

are insonated during a transverse scan of the arm at the level of the
radial groove.
Profunda brachii
artery
Triceps
Radial nerve
Brachialis
Posterior
Humerus
Lateral Medial
Anterior

transducer relative to the humerus during an ultrasound scan of the FIGURE 2-109 ■ Transverse sonogram of the radial nerve at the
arm at the level of the radial groove. radial groove of the humerus.
ch02.indd 51 23-08-2017 19:09:57

Triceps
Radial nerve
Profunda brachii
artery
Brachialis
Posterior
Humerus
Lateral
FIGURE 2-110 ■ Transverse sonogram of the arm at the level of the radial groove showing the radial nerve accompanied by the profunda
brachii artery. Accompanying photograph illustrates the position and orientation of the transducer during the ultrasound scan.
b. Operator and ultrasound machine: The opera-

tor sits or stands at the patient’s side on the side to
be examined, and the ultrasound machine is placed
directly in front of the operator on the ipsilateral side.
2. Transducer selection: High-frequency (15-8 or 17-5 MHz)
3. Scan technique: The ultrasound transducer is positioned
transversely over the lateral aspect of the lower arm
(Fig. 2-111).
4. Sonoanatomy: The lateral aspect of the humerus is visual-
ized as a hyperechoic structure with a corresponding acoustic
shadow anteriorly (Figs. 2-112 and 2-113). The radial nerve
and its posterior antebrachial cutaneous branch are often
the ultrasound transducer during an ultrasound scan for the radial seen as round-to-oval hypoechoic structures between the bra-
nerve at the lateral aspect of the arm. chialis (medially) and the brachioradialis and extensor carpi
radialis longus muscles (laterally).
5. Clinical Pearls: The lateral aspect of the lower arm can
which accompanies the radial nerve at the spiral groove be a useful site for rescue block of the radial nerve during
(Figs. 2-109 and 2-110). forearm and hand surgery because a single injection of
5 . Clinical Pearls: The radial nerve is confirmed at the local anesthetic at this site will block both the superficial
spiral groove using the “trace back” technique. Although and deep branches of the nerve.
the radial nerve can be imaged at the spiral groove of the
humerus, its blockade at this site does not confer any
advantage to blockade nearer the elbow.29 Elbow Region – Median, Ulnar, and
Ultrasound Scan Technique for Radial Nerve
Radial Nerves
at the Lateral Aspect of the Arm Gross Anatomy
1. Position: At the elbow, the median nerve lies medial to the brachial artery,
a. Patient: Supine with the arm abducted and internally deep to the bicipital aponeurosis and on the anterior surface of
rotated such that the hand and forearm are resting on the brachialis muscle (Figs. 2-14, 2-95, and 2-96). The ulnar
the abdomen (Fig. 2-111). nerve winds around the medial aspect of the medial epicondyle
ch02.indd 52 23-08-2017 19:10:03

Radial nerve
Brachialis
Triceps
Humerus
Lateral
Anterior
FIGURE 2-112 ■ Transverse sonogram of the radial nerve at the lateral aspect of the arm. Accompanying photograph illustrates the position
and orientation of the transducer during the ultrasound scan.
Ant
Lat Med
Post
Radial tunnel FCR Median nerve PL

PACN
FDS
Lateral head of
FCU
triceps
Pronator teres Ulnar nerve
BCR
Radial nerve FDP
Supinator
Radial artery with
Brachialis superficial branch of Radius
Humerus radial nerve Ulna
Lateral Common extensor muscles
Anterior Posterior
Medial
FIGURE 2-113 ■ Transverse sonogram of the radial nerve at the lat- FIGURE 2-114 ■ Transverse anatomical section of the upper forearm
eral aspect of the arm. PACN, posterior antebrachial cutaneous nerve. at the radial tunnel. FCR, flexor carpi radialis muscle; PL, palmaris
longus muscle; FDS, flexor digitorum superficialis muscle; FCU,
flexor carpi ulnaris muscle; BCR, brachioradialis muscle; FDP, flexor
digitorum profundus muscle.
in the ulnar groove (Figs. 2-95, 2-96, and 2-102) and enters the deep layers of the supinator muscle (Fig. 2-115) in the “radial
anterior compartment of the forearm between the two heads of tunnel” (Fig. 2-114)30 and enters the posterior compartment of
the flexor carpi ulnaris and comes to lie between the flexor carpi the arm as the posterior interosseous nerve. The deep branch of
ulnaris (medially), flexor digitorum superficialis, and the flexor the radial nerve is often accompanied by the recurrent branch
digitorum profundus in the forearm (Figs. 2-114 and 2-115). of the radial artery and its vena comitans.31 The superficial
The radial nerve lies beneath the brachioradialis in the anterior branch of the radial nerve runs under the brachioradialis and on
compartment of the lower arm (Figs. 2-93 and 2-95). Within the supinator and pronator teres muscles (Fig. 2-116). It then
3 cm of the elbow joint the radial nerve divides into its superfi- descends close to the lateral aspect of the radial artery in the
cial (cutaneous branch) and deep (posterior interosseous nerve) midforearm (Figs. 2-116 and 2-117) after which it leaves the
branches (Fig. 2-9). The deep branch winds around the neck artery and courses backward under the tendon of the brachiora-
of the radius and travels distally between the superficial and dialis to reach the posterior surface of the wrist.
ch02.indd 53 23-08-2017 19:10:17

Median antebrachial
vein Common interroseous
Radial artery Pronator teres artery
Ulnar artery and Flexor carpi radialis
Superficial branch of median nerve
radial nerve Palmaris longus
Cephalic vein
and LACN Flexor digitorum
superficialis
Brachioradialis
Ulnar nerve
Extensor carpi
radialis longus Radius
Basilic vein
Extensor carpi
radialis brevis Supinator
Ulna Flexor carpi
ulnaris
Deep branch of
radial nerve
Flexor digitorum
Extensor digitorum profundus
Extensor digiti minimi Anconeus

PACN Extensor carpi ulnaris
FIGURE 2-115 ■ Cross-sectional anatomy of the proximal forearm just below the elbow joint. LACN, lateral antebrachial cutaneous nerve;
PACN, posterior antebrachial cutaneous nerve.
Flexor carpi radialis Palmaris longus

Flexor digitorum
Brachioradialis superficialis
Radial artery Median nerve
Superficial branch of Ulnar nerve and
radial nerve artery
Flexor pollicis
longus Flexor carpi ulnaris
Radius
Extensor carpi
radialis longus Ulna Flexor digitorum
profundus
Extensor carpi
radialis brevis
Anterior interosseous
nerve and artery
Abductor pollicis
longus Extensor carpi ulnaris
Extensor digitorum
Extensor pollicis longus
Posterior interssoseous
nerve and artery Extensor digiti minimi
FIGURE 2-116 ■ Cross-sectional anatomy of the mid forearm showing the median, ulnar, and radial nerves.
Magnetic Resonance Imaging of the Elbow Region b. Operator and ultrasound machine: The opera-
Figs. 2-118 to 2-120 tor is positioned at the caudal side of the abducted
arm facing the head of the patient. The ultrasound
Elbow Region Ultrasound Scan Technique machine is placed on the ipsilateral side cepha-
1. Position: lad to the abducted arm directly in front of the
a. Patient: Supine with the arm abducted 90 degrees at operator.
the shoulder and externally rotated such that the palm 2. Transducer selection: High-frequency (15-8 or 17-5 MHz)
of the hand is facing the ceiling. linear array transducer.
ch02.indd 54 23-08-2017 19:10:21

Radial nerve
Lateral antebrachial Ulnar nerve (superficial branch)
cutaneous nerve Pronator teres
Brachioradialis
Flexor carpi radialis
Palmaris longus
Superficial branch of ECRL
radial nerve
Median nerve FDS
ECRB
Anterior interrroseous
nerve and artery Radial tunnel
Ulnar nerve Radial nerve Ulnar artery
(deep branch) and nerve
Radial artery EDC
Ulnar artery FCU
Supinator
Radius FDP
Ulna
FIGURE 2-117 ■ Median, radial, and ulnar nerve at the forearm. FIGURE 2-119 ■ Transverse (axial) MRI of the upper forearm
demonstrating the radial nerve in the radial tunnel. ECRL, extensor
carpi radialis longus muscle; ECRB, extensor carpi radialis brevis
muscle; EDC, extensor digitorum communis muscle; FDP, flexor
digitorum profundus muscle; FCU, flexor carpi ulnaris muscle;
FDS, flexor digitorum superficialis.
Olecranon
(ulna)
Cephalic vein Brachial artery Ulnar nerve
and vein Median nerve
Biceps tendon Common flexor
Brachioradialis Basilic vein muscles
Extensor carpi Pronator teres

Trochlea
radialis longus (Humerus)
Brachialis
Radial nerve
(superficial branch) Pronator
teres
Medial epicondyle
Lateral epicondyle of humerus
of humerus
Olecranon of
ulna
FIGURE 2-118 ■ Transverse (axial) MRI demonstrating the median FIGURE 2-120 ■ Transverse (axial) MRI demonstrating the ulnar
nerve at the level of the elbow joint (cubital fossa). nerve in the ulnar groove.
3. Scan technique: The median nerve is imaged by plac-

ing the transducer transversely across the elbow joint
(Figs. 2-121 and 2-122). The initial goal is to image the
brachial artery in a true cross-sectional view. The brachial
artery and median nerve are relatively superficial at this
level with only the bicep aponeurosis, subcutaneous tis-
sue, and skin covering it. The median nerve is located
medial to the brachial artery (Fig. 2-123). To locate the FIGURE 2-121 ■ Figure showing the position and orientation of
radial nerve at the elbow, identify the brachial artery as the ultrasound transducer during an ultrasound scan for the median
described earlier and slide the transducer laterally towards nerve at the cubital fossa.
ch02.indd 55 23-08-2017 19:10:29

Ant
Lat Med
Post
Basilic V
Brachial
artery Median nerve
Extensors
Pronator teres
Brachialis
Radius FCR
Humerus PL FDS
Anconeus Ulna Ulnar

nerve
FIGURE 2-124 ■ Figure showing the position and orientation

FIGURE 2-122 ■ Figure highlighting the anatomical structures that of the ultrasound transducer during an ultrasound scan for the
are insonated during an ultrasound scan for the median nerve at the radial nerve at the lateral aspect of the upper forearm (radial
level of the elbow joint. Basilic V, basilic vein; FCR, flexor carpi radia- tunnel).
lis muscle; PL, palmaris longus muscle; FDS, flexor digitorum super-
ficialis muscle.
Ant
Lat Med
Post
Radial tunnel FCR Median nerve PL

FDS
FCU
BA Pro Pronator teres
nat BCR Ulnar nerve
or FDP
ter
Brachioradialis es
Supinator
Median nerve Radial artery with

Brachialis superficial branch of Radius
radial nerve Ulna
Extensor carpi Common extensor muscles

radialis longus
Anterior
Elbow joint line Lateral Medial
Posterior are insonated during a transverse ultrasound scan for the radial nerve
at the lateral aspect of the upper forearm (radial tunnel). FCR, flexor
FIGURE 2-123 ■ Transverse sonogram of the median nerve at the carpi radialis muscle; PL, palmaris longus muscle; FDS, flexor digi-
elbow. Note the median nerve lies immediately medial to the bra- torum superficialis muscle; FCU, flexor carpi ulnaris muscle; BCR,
chial artery. BA, brachial artery. brachioradialis muscle.
the lateral humeral epicondyle and 2 to 3 cm below the nerve. Contact artifacts are a problem when scanning for
elbow joint (Figs. 2-124 and 2-125). The radial nerve the ulnar nerve at the ulnar groove. Therefore, it is easier
or its branches are located between the brachioradialis to locate the ulnar nerve just proximal to the ulnar groove
and supinator muscle. The ulnar nerve can be imaged by (Fig. 2-128).
abducting the arm at the shoulder with external rotation 4 . Sonoanatomy: The median nerve appears as an oval or
to expose the posteromedial aspect of the medial humeral elliptical-shaped, hyperechoic, and honeycombed struc-
epicondyle (Figs. 2-126 and 2-127). Manual palpation of ture medial to the brachial artery at the elbow (Fig. 2-123).
the ulnar groove may aid initial transducer placement. The ulnar nerve at the ulnar groove is frequently triangu-
The ultrasound transducer is placed transversely across lar in shape and hypoechoic in appearance (Fig. 2-129).
the ulnar groove to obtain a transverse image of the ulnar Proximal to the ulnar groove the ulnar nerve is relatively
ch02.indd 56 23-08-2017 19:10:48

Ulnar nerve Sup. ulnar collateral vessels
Common flexor muscles
Olecrnon
Pronator teres

the ultrasound transducer during an ultrasound scan for the ulnar
nerve at the posteromedial aspect of the elbow.
FIGURE 2-129 ■ Transverse sonogram of the ulnar nerve at the
elbow just proximal to the ulnar groove.
Ulnar nerve Post Med
PL FDS Lat Ant

Ulna FCR superficial and appears hypoechoic (Fig. 2-128). When
examining the radial nerve at the elbow, the radius appears
Ulnar groove
as a curved hyperechoic structure with an accompanying
Pronator teres
Anconeus
acoustic shadow anteriorly. The two branches of the radial
Humerus nerve are seen as discrete hypoechoic structures between
the brachioradialis and the supinator muscle (Fig. 2-130).
Brachialis The recurrent branch of the radial artery accompanies
the deep branch and can be identified using Doppler
ultrasound.
5 . Clinical Pearls: The identity of the nerves at the elbow
is confirmed using the “trace back” technique and
FIGURE 2-127 ■ Figure highlighting the anatomical structures that visualized along their expected course based on ana-
are insonated during an ultrasound scan for the ulnar nerve at the
tomical knowledge. Median nerve block at the elbow can
ulnar groove. PL, palmaris longus muscle; FDS, flexor digitorum
superficialis muscle; FCR, flexor carpi radialis muscle.
Medial epicondyle
Ulnar nerve
of humerus
Posterior
Medial
FIGURE 2-128 ■ Transverse sonogram of the ulnar nerve just above the ulnar groove and on the posteromedial aspect of the lower arm.
Accompanying photograph illustrates the position and orientation of the transducer during the ultrasound scan.
ch02.indd 57 23-08-2017 19:10:59

Anterior
Radial nerve Radial artery

Deep branch
Superficial branch FCR PL
Brachioradialis
Median nerve
FDS
BCR
FCU
Superficial branch FDP

Supinator Lateral ECU
Medial of radial N Ulna
FPL
Common extensor
Radius Radius muscles
APL Ant
Lat Med
Posterior Post
FIGURE 2-130 ■ Transverse sonogram showing the superficial FIGURE 2-131 ■ Transverse anatomical section through the mid-
and deep branches of the radial nerve lying in between the bra- forearm showing the median nerve. FCR, flexor carpi radialis muscle;
chioradialis and supinator muscle at the lateral aspect of the upper PL, palmaris longus muscle; FDS, flexor digitorum superficialis
forearm. muscle; FCU, flexor carpi ulnaris muscle; BCR, brachioradialis
muscle; FPL, flexor pollicis longus muscle; FDS, flexor digitorum
superficialis muscle; FDP, flexor digitorum profundus muscle; ECU,
extensor carpi ulnaris muscle; APL, abductor pollicis longus muscle.
be performed as a rescue block or when there is surgi- nerve is accompanied by the ulnar artery (Fig. 2-132) and
cal dressing or plaster casts covering the forearm. When enters the hand superficial to the flexor retinaculum.
examining the ulnar nerve at the ulnar groove or cubital
tunnel, apply liberal amounts of ultrasound gel and apply Magnetic Resonance Imaging Anatomy
minimal pressure during the ultrasound scan to reduce of the Midforearm
contact artifacts. It may also be safer to perform an ulnar
Figs. 2-133 and 2-134
nerve block at a more proximal site rather than at the
ulnar groove because of the perceived increased risk of Midforearm Ultrasound Scan Technique
nerve injury at the ulnar groove.
1. Position:
a. Patient: Supine with the arm abducted and exter-
Midforearm Region – Median, Ulnar, nally rotated such that the palm of the hand is facing
and Radial Nerves the ceiling.
b. Operator and ultrasound machine: The operator is
Gross Anatomy positioned at the caudad side of the abducted arm fac-
In the midforearm the median nerve lies in a fascial plane ing the head of the patient. The ultrasound machine is
between the flexor digitorum superficialis and the flexor placed on the ipsilateral side to be examined on the
digitorum profundus muscle (Figs. 2-116 and 2-131). At the cephalad side of the abducted arm directly in front of
wrist, the median nerve lies lateral to the flexor digitorum the operator.
superficialis muscle and beneath the palmaris longus tendon 2. Transducer selection: High-frequency (15-8 or 17-5 MHz)
(Fig. 2-132) and continues under the flexor retinaculum to linear array transducer.
enter the hand. At the midforearm the ulnar nerve runs between 3. Scan technique: To image the median nerve, the ultra-
the flexor digitorum profundus (posteriorly), the flexor digi- sound transducer is placed in the transverse orientation
torum superficialis (anteriorly), and the flexor carpi ulnaris across the volar surface of the midforearm (Figs. 2-135
(medially) muscle (Fig. 2-116). In the distal forearm the ulnar to 2-137). The median nerve is seen as a hyperechoic
ch02.indd 58 23-08-2017 19:11:12

Flexor carpi radialis tendon Median nerve Palmaris longus Flexor digitorum
tendoon superficialis
Flexor pollicis Flexor digitorum
longus profundus
Radial artery Ulnar nerve and artery

Brachioradialis tendon
Pronator quadratus
Abductor pollicis Flexor carpi ulnaris
tendon Interrroseous
Superficial branch of membrane
radial nerve
Extensor pollicis
brevis tendon
Extensor carpi radialis Dorsal branch of
longus tendon ulnar nerve
Radius Ulna
Extensor carpi radialis Extensor carpi

brevis tendon ulnaris tendon
Extensor pollicis Posterior interroseous

longus tendon nerve and artery
Extensor digitorum Extensor indicis Extensor digiti
tendons muscle and tendon minimi tendon
FIGURE 2-132 ■ Cross-sectional anatomy of the distal forearm showing the median, ulnar, and superficial and deep (posterior interosseous
nerve) branches of the radial nerve.
Flexor digitorum
Flexor carpi
superficialis Flexor carpi Unar artery
radialis
radialis
Radial artery
Median nerve
Brachioradialis
Median nerve FDS Flexor carpi
Superficial branch ulnaris
of radial nerve Ulnar artery FDP
Caphalic vein and nerve
Pronator
Radius quadratus
FDP Flexor carpi
ulnaris Radius
Ulna Ulnar nerve
Basilic vein
Interossous Ulna
membrane Anterior
Anterior interosseous
artery and vein
Lateral
FIGURE 2-133 ■ Transverse (axial) MRI of the midforearm dem- FIGURE 2-134 ■ Transverse (axial) MRI of the distal forearm
onstrating the median, radial, and ulnar nerves. FDP, flexor digitorum demonstrating the median and radial nerve. FDS, flexor digitorum
profundus. superficialis muscle; FDP, flexor digitorum profundus muscle.
ch02.indd 59 23-08-2017 19:11:16

Radial artery
FCR
Median nerve PL
FDS
BCR
FCU
Superficial branch FDP

of radial N Ulna ECU
FPL
Common extensor
Radius muscles
APL Ant
Lat Med
Post

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

transducer relative to the forearm during an ultrasound scan for the
median nerve at the midforearm.
Flexor carpi
radialis
Flexor digitorum
superficialis
Median nerve
Flexor digitorum Anterior

Flexor pollicis
profundus
longus Lateral Medial
Posterior
FIGURE 2-138 ■ Transverse sonogram of the median nerve at the

FIGURE 2-136 ■ Figure showing the position and orientation of midforearm.
the ultrasound transducer during an ultrasound scan for the median
nerve at the midforearm.
n odule between the flexor digitorum superficialis, which ultrasound scan at the wrist by locating the ulnar artery
is superficial to the nerve, and the flexor digitorum pro- (Figs. 2-142 and 2-143). The ulnar nerve lies medial to
fundus, which is deep to the nerve (Figs. 2-138 to 2-141). the ulnar artery at the wrist. One can then trace the ulnar
To image the ulnar nerve, slide the ultrasound medially nerve back to the midforearm (Figs. 2-144 and 2-145).
from the earlier position. It may be easier to start the To image the superficial (cutaneous) branch of the radial
ch02.indd 60 23-08-2017 19:11:30

Anterior
Flexor carpi
radialis
Flexor digitorum
Median nerve superficialis
Lateral Medial
Flexor digitorum
Flexor pollicis
profundus
longus
Radius
Posterior
FIGURE 2-139 ■ Transverse sonogram of the median nerve at the the ultrasound transducer during a ultrasound scan for the median
midforearm in sepia mode. nerve at the distal forearm.
Anterior
Anterior
Lateral Medial
Median nerve Posterior
Flexor muscles FCR FCU

FDS
of forearm Superficial branch of radial N
Ulnar nerve
Cranial Caudal FDP
FPL
Median nerve
Prenator quadratus Ulna
Extensor muscles
of forearm Radius
Common extensor muscles
Posterior
FIGURE 2-140 ■ Sagittal sonogram of the median nerve at the

midforearm.
that are insonated during an ultrasound scan for the ulnar nerve
at the midforearm. FCR, flexor carpi radialis muscle; FDS, flexor
digitorum superficialis muscle; FPL, flexor pollicis longus muscle;
FDP, flexor digitorum profundus muscle; FCU, flexor carpi ulnaris.
1 2
Median nerve FDS FCU

UA
Ulnar nerve
FDP
Anterior
C Coronal Lateral Medial
Ulna
Posterior
FIGURE 2-141 ■ Three-dimensional multiplanar image of the
median nerve at the midforearm. Reference marker has been placed
over the median nerve: (a) transverse view, (b) sagittal view, and FIGURE 2-144 ■ Transverse sonogram of the median and ulnar
(c) coronal view. nerves at the midforearm.
ch02.indd 61 23-08-2017 19:12:05

Lateral Anterior Medial
FCU
BCR
Median nerve FDS UA
RA
Ulnar nerve FCRL
FDP
FPL Superficial branch of FDS
FDP FCRB radial nerve
Ulna Radius
Anterior
Median nerve
Lateral Medial
FDP
Posterior Posterior
FIGURE 2-145 ■ Transverse sonogram of the median and ulnar FIGURE 2-147 ■ Transverse sonogram demonstrating the superfi-
nerves at the midforearm in sepia mode. cial branch of the radial nerve at the distal forearm. Note the superficial
branch of the radial nerve is hyperechoic and located lateral to the radial
artery.
also allows for easy manipulation of the transducer to image

the nerves in their long (sagittal) axis for confirmation. In
the distal forearm and wrist, it may be more challenging
to image the median nerve, as there are many tendons at
this location. In the forearm the median nerve is accompa-
nied by the median artery, which is a branch of the ante-
rior interosseous artery. The radial nerve below the elbow
is small and hard to visualize using ultrasound. Therefore,
the “trace back” technique should be used to confirm the
identity of the radial nerve below the elbow. The superficial
branch of the radial nerve is also a small nerve and may not
the ultrasound transducer during an ultrasound scan at the distal be readily visualized in the distal forearm.
forearm to insonate the superficial branch of the radial nerve and the
median nerve.
References
1. Demondion X, Herbinet P, Boutry N, Fontaine C, Francke JP,
nerve, the ultrasound transducer is placed laterally on Cotten A. Sonographic mapping of the normal brachial plexus.
the volar surface of the midforearm and traced distally AJNR Am J Neuroradiol. 2003;24:1303–1309.
(Fig. 2-146). The superficial branch of the radial nerve 2. Karmakar MK, Sala-Blanch X, Songthamwat B, Tsui BC.
is seen lateral to the radial artery (Fig. 2-147). Benefits of the costoclavicular space for ultrasound-guided

infraclavicular brachial plexus block: description of a costocla-
4. Sonoanatomy: The median, radial, and ulnar nerves all
vicular approach. Reg Anesth Pain Med. 2015;40:287–288
appear as an elliptical/oval, hyperechoic, and honeycombed 3. Sala-Blanch X, Reina MA, Pangthipampai P, Karmakar MK.
structure on a transverse sonogram of the midforearm. Anatomic basis for brachial plexus block at the costoclavicu-
5 . Clinical Pearls: The nerves in the forearm are markedly lar space: a cadaver anatomic study. Reg Anesth Pain Med.
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Use of magnetic resonance imaging to define the anatomical
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infraclavicular brachial plexus: an ultrasound study. Anesth 18. Sandhu NS, Capan LM. Ultrasound-guided infraclavicular
Analg. 2009;108:364–366. brachial plexus block. Br J Anaesth. 2002;89:254–259.
6. Chan VW. Applying ultrasound imaging to interscalene brachial 19. Crews JC, Gerancher JC, Weller RS. Pneumothorax after
plexus block. Reg Anesth Pain Med. 2003;28:340–343. coracoid infraclavicular brachial plexus block. Anesth Analg.
7. Narouze S, Peng PW. Ultrasound-guided interventional 2007;105:275–277.
procedures in pain medicine: a review of anatomy, sonoanatomy, 20. Moayeri N, Renes S, van Geffen GJ, Groen GJ. Vertical infra-
and procedures. Part II: axial structures. Reg Anesth Pain Med. clavicular brachial plexus block: needle redirection after elicitation
2010;35:386–396. of elbow flexion. Reg Anesth Pain Med. 2009;34:236–241.
8. Canella C, Demondion X, Delebarre A, Moraux A, Cotten H, 21. Rodriguez J, Barcena M, Taboada-Muniz M, Lagunilla J,
Cotten A. Anatomical study of phrenic nerve using ultrasound. Alvarez J. A comparison of single versus multiple injections on
Eur Radiol. 2010;20:659–665. the extent of anesthesia with coracoid infraclavicular brachial
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for identification of the sciatic nerve. Reg Anesth Pain Med. Minimum effective volume of lidocaine for ultrasound-guided
2006;31:481–482. infraclavicular block. Reg Anesth Pain Med. 2011;36:190–194.
10. Gerscovich EO, Cronan M, McGahan JP, Jain K, Jones CD, 23. Sandhu NS, Manne JS, Medabalmi PK, Capan LM. Sono-
McDonald C. Ultrasonographic evaluation of diaphragmatic graphically guided infraclavicular brachial plexus block in
motion. J Ultrasound Med. 2001;20:597–604. adults: a retrospective analysis of 1146 cases. J Ultrasound
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ch02.indd 63 23-08-2017 19:12:12

Sonoanatomy Relevant for Ultrasound-Guided Lower
CHAPTER 3 Extremity Nerve Blocks
Introduction The sigmoid colon, ureter, internal iliac artery, and vein lie
anterior to it. The superior gluteal artery and vein lies between
Four main nerves of the lumbosacral plexus provide sensory
the lumbosacral trunk and the first sacral nerve, and the infe-
and motor innervation to the lower extremity: the femoral,
rior gluteal artery and vein lie between the second and third
lateral femoral cutaneous, obturator, and the sciatic nerve.
Gross Anatomy
Lumbosacral
The anatomy of the lumbar plexus is described in detail in trunk
L4
Chapter 8 (Fig. 3-1). The terminal nerves of the lumbosacral Sympathetic trunk
plexus relevant for innervating the lower extremity include L5
the lateral cutaneous nerve of the thigh, the femoral nerve, S1

S2
the obturator nerve, and the sciatic nerve. The lateral cutane- S3
S4
ous nerve of the thigh and the femoral nerve leave the lum-
bar plexus along the posterolateral border of the psoas major
muscle; the obturator nerve emerges from the medial border Posterior femoral
cutaneous nerve
of the psoas muscle at the pelvic brim and crosses in front of
the sacroiliac joint.1 The sacral plexus provides sensorimotor Sciatic nerve
Common peroneal Sciatic nerve
Pudendal nerve
innervation to the posterior thigh, most of the lower extrem- division Tibial division
ity, the entire foot, and parts of the pelvis. It is formed by the
union of the anterior primary rami of the spinal nerves of L4, FIGURE 3-2 ■ Anatomical illustration (frontal view) showing the
L5, S1, S2, S3, and S4 (lumbosacral plexus, Fig. 3-2). The formation of the sacral plexus and the sciatic nerve.
sacral plexus lies deep within the pelvis between the piriformis
muscle posteriorly and the pelvis fascia anteriorly (Fig. 3-3).
L4 L5
Lumbosacral
T12 trunk
12th rib
L1
Subcostal nerve
Superior gluteal
L2 nerve
Iliohypogastric nerve Sacrum
S1
Ilioinguinal nerve L3 Lumbar plexus
Greater sciatic
L4 foramen S2
S3
Lateral femoral L5 Piriformis
cutaneous nerve Lumbosacral trunk
Inferior gluteal S4
Femoral nerve nerve
Sacral plexus Sciatic nerve
Sacrospinous
Genitofemoral nerve ligament
Pudendal nerve
Obturator nerve
Sciatic nerve
FIGURE 3-3 ■ Anatomical illustration (frontal view) showing the

relation of the sacral plexus to the piriformis muscle and the greater
FIGURE 3-1 ■ Anatomical illustration showing the formation of the sciatic foramen. Note how the superior gluteal, inferior gluteal, and
lumbosacral plexus. pudendal nerve exit the greater sciatic foramen.
64
ch03.indd 64 23-08-2017 16:38:06

Chapter 3 / Sonoanatomy Relevant for Lower Extremity Nerve Blocks n 65
sacral nerves. The nerves forming the sacral plexus converge (Fig. 3-5), to enter the “subgluteal space” between the greater
as they descend towards the lower part of the greater sciatic trochanter and ischial tuberosity (Figs. 3-6 and 3-7).2,3 Sciatic
foramen and unite within the pelvis to form the sciatic nerve nerve and piriformis muscle anomaly are seen in 16.2% (95%
(Fig. 3-4). The sciatic nerve is the largest (thickest) nerve of CI: 10.7–23.5%) of individuals.4 The entire sciatic nerve or
the body and exits the pelvis through the greater sciatic fora- one of its components (tibial or common peroneal) may rarely
men, between the piriformis and the superior gemellus muscles exit the pelvis by passing through or above the superior border
Superior gluteal Gluteus medius

nerve
L4
Gluteus minimus
L5 Superior gluteal
nerve Gluteus maximus
S1 Piriformis
S2 Gemellus superior
S3 Inferior gluteal Sciatic nerve Tendon of obturator
nerve internus
Posterior femoral
S4 cutaneous nerve
Nerve to obturator Greater trochanter
internus Ischial tuberosity Gemellus inferior
Nerve to quadratus
Pudendal nerve femoris Quadratus femoris
Sciatic nerve Adductor magnus

Semitendinosus
Common peroneal division
Tibial division Semimembranosus
Posterior femoral Biceps femoris
cutaneous nerve
FIGURE 3-4 ■ Anatomical illustration (dorsal view) showing the FIGURE 3-5 ■ Anatomical illustration showing the relation of the
sciatic nerve as it exits the pelvis through the greater sciatic foramen. sciatic nerve to the muscles of the buttock and upper thigh.
Note the relation of the superior and inferior gluteal nerves, posterior
cutaneous nerve of the thigh, nerve to obturator internus, and puden-
dal nerve to the sciatic nerve as they exit the greater sciatic foramen.
A.Transverse B. Sagittal Anatomy

Anatomy
B. Coronal Anatomy
FIGURE 3-6 ■ Multiplanar 3-D anatomy (rendered from the Visible Human Server) of the sciatic nerve at the subgluteal space. Note the
reference marker (green crosshair) has been placed over the sciatic nerve in the transverse view and its corresponding position in the sagit-
tal and coronal images can be seen. AM, adductor magnus; VL, vastus lateralis; IT, ischial tuberosity; QF, quadratus femoris; GM, gluteus
maximus; GS, gemellus superior; GI, gemellus inferior; BF, biceps femoris; OI, obturator internus; PF, piriformis.
ch03.indd 65 23-08-2017 16:38:14

66 n Chapter 3 / Sonoanatomy Relevant for Lower Extremity Nerve Blocks
of the piriformis muscle.4 The sciatic nerve, after it emerges and common peroneal nerves may also arise separately from
from the pelvis, descends along the back of the thigh, lying the sacral plexus.
deep to the semitendinosus and biceps femoris muscles, to
about its lower third (Figs. 3-8 and 3-9), where it bifurcates
into its two branches: the tibial and common peroneal (fibular)
Femoral Nerve at the Inguinal Region
nerves. This bifurcation may take place at any point between Gross Anatomy
its origin at the sacral plexus and the lower third of the thigh The femoral nerve is the largest branch of the lumbar plexus and
or at a variable distance from the popliteal crease.5 The tibial originates from the posterior divisions of the anterior primary
rami of the L2, L3, and L4 spinal nerves. It descends through
the fibers of the psoas muscle and exits the lateral border of the
inferior part of the psoas muscle in the retroperitoneal space.
Greater trochanter
It then descends between the psoas and the iliacus muscle
deep to the fascia iliaca. It enters the femoral triangle of the
Iliotibial tract
Nerve to long head thigh behind the inguinal ligament, lying lateral to the femo-
of biceps femoris Quadratus femoris
ral artery and in a groove between the iliacus and psoas mus-
Ischial cles (Fig. 3-10 and 3-11). In between the inguinal ligament
tuberosity Ascending circumflex
femoral artery and the inguinal crease, the femoral vein, femoral artery, and
Gluteus Nerve to short head the femoral nerve have a “VAN” (vein, artery, nerve) relation
maximus of biceps femoris
Subgluteal space from the medial to lateral side (Fig. 3-11). The femoral artery
Sciatic nerve with its and vein are enclosed by the femoral sheath and lie deep to
comitants artery and vein
Subgluteal Posterior cutaneous nerve

the fascia lata (deep fascia of the thigh), and the femoral nerve
Inferior gluteal artery
of thigh
and nerve space lies outside the femoral sheath and deep to both the fascia lata
FIGURE 3-7 ■ Anatomical illustration showing the transverse and fascia iliaca on the anteromedial aspect of the iliopsoas
anatomy of the gluteal region at the level of the greater trochan- muscle (Fig. 3-12). The femoral nerve divides into its anterior
ter and ischial tuberosity. Note the subgluteal space and its contents and posterior branch after a short course of about 2 cm below
between the gluteus maximus and quadratus femoris muscles. the inguinal ligament or at the level of the inguinal crease.6
A. Transverse Anatomy B. Sagittal Anatomy
B. Coronal Anatomy
FIGURE 3-8 ■ Multiplanar 3-D anatomy of the sciatic nerve at the midthigh. AL, adductor longus; AM, adductor magnus; BF, biceps
femoris; GM, gluteus maximus; RF, rectus femoris; SM, semimembranosus; SR, sartorius; ST, semitendinosus; VI, vastus intermedialis;
VL, vastus lateralis; VM, vastus medialis.
ch03.indd 66 23-08-2017 16:38:20

A. Transverse Anatomy B. Sagittal Anatomy
B. Coronal Anatomy
FIGURE 3-9 ■ Multiplanar 3-D anatomy of the sciatic nerve at or close to the apex of the popliteal fossa. AM, adductor magnus; AL, adductor
longus; BF, biceps femoris; GR, gracilis; SM, semimembranosus; SR, sartorius; ST, semitendinosus; VI, vastus intermedialis; VL, vastus
lateralis; VM, vastus medialis; RF; rectus femoris.
Iliacus muscle
Iliac Crest Psoas tendon
Psoas minor tendon
Femoral artery Sartorius Inguinal ligament

Inguinal ligament
Femoral vein
Femoral canal
Femoral Nerve FA
Pectineal ligament Tensor
Femoral ring Femoral nerve FV
Fascia
Rectus femoris
Lacunar ligement lata Iliopsoas
Sartorius
Pectineus
Femur
FIGURE 3-11 ■ Transverse anatomical section of the inguinal

FIGURE 3-10 ■ Anatomy of the femoral nerve at the inguinal region at the level of the inguinal ligament. Note the relation of the
region. Note the relation of the femoral nerve to the femoral artery femoral nerve to the iliopsoas muscle.
and vein and the iliopsoas muscle.
Computed Tomography Anatomy of the Inguinal Region Femoral Nerve Ultrasound Scan Technique
Fig. 3-13 1. Position:
Magnetic Resonance Imaging Anatomy of the a. Patient: Supine with the ipsilateral leg slightly
Inguinal Region abducted and externally rotated and the knee slightly
flexed.
Fig. 3-14
ch03.indd 67 23-08-2017 16:38:35

Femoral artery Femoral vein

Femoral sheath Fascia
Femoral Nerve Fascia
iliaca
lata
Femoral canal
Fasica lata Sartorius
Sartorius
Pectineus Femoral Rectus Tensor fascia
Fascia iliaca FA nerve femoris lata
FV Iliopsoas
Inguinal
canal
Pectineus
Gluteus Gluteus
Iliopsoas minimus medius
Acetabulum
Femoral
head
FIGURE 3-12 ■ Fascial anatomy in relation to the femoral nerve at
the level of the inguinal crease. Note both the femoral artery and vein
lie deep to the fascia lata and are enclosed by the femoral sheath, and FIGURE 3-14 ■ Transverse (axial) MRI image of the inguinal
the femoral nerve lies outside the femoral sheath and deep to both region showing the femoral nerve at the level of the inguinal crease.
the fascia lata and iliaca. Note the relation of the femoral nerve to the femoral vessels and the
neighboring fascia (lata and iliaca).
Inguinal Fascia lata the ultrasound machine on the contralateral side and
canal Fascia iliaca directly in front. This is vice versa for left-handed
Femoral nerve
operators.
Sartorius
Rectus femoris
FA Tensor fascia linear array transducer.
FV lata
3. Scan technique: For a transverse scan of the femoral
Iliopsoas
Pectineus nerve, place the ultrasound transducer parallel to the
inguinal ligament and approximately 1 cm proximal to
Acetabulum
the inguinal crease (Figs. 3-15 to 3-17). Gently slide
Gluteus the transducer in a medial to lateral direction until a
Gluteus medius
Femoral head minimus cross-sectional view of the femoral artery is obtained.
The femoral vein lies medial to the femoral artery, and
the femoral nerve is lateral to the artery (Fig. 3-18). The
FIGURE 3-13 ■ Transverse (axial) CT of the inguinal region at the
femoral vein is compressible, but the femoral artery may
level of the inguinal crease showing the relation of the femoral nerve
to the femoral vessel, fascia lata, fascia iliaca, and iliopsoas muscle. not be easily compressible. Color or Power Doppler
FA, femoral artery; FV, femoral vein. should be used to differentiate the femoral artery from
the vein as part of one’s scan routine (Fig. 3-19). The
femoral nerve is most commonly seen on the anterome-
dial surface of the iliopsoas muscle (Fig. 3-18).
b. Operator and ultrasound machine: The operator 4. Sonoanatomy: The femoral nerve is typically identified
stands on the side of the intervention and faces the on the anteromedial surface of the psoas muscle as a flat,
patient’s head. The ultrasound machine is placed on hyperechoic, and elliptical-shaped structure (Fig. 3-18).
the same side between the operator and the patient’s Outlines of the fascia iliaca, with the femoral nerve lying
head. Alternatively, the operator may choose to posi- deep to this fascia, may be visualized in some individuals
tion the ultrasound machine based on his or her (Fig. 3-18).
“handedness.” Right-handed operators who hold the 5. Clinical Pearls: The femoral nerve is markedly aniso-
ultrasound transducer with their left hand and carry tropic in the inguinal region.7 Therefore, it may be nec-
out needle interventions with their right hand should essary to gently tilt or rotate the transducer during the
stand on the right side of the patient and position ultrasound scan before it can be clearly delineated. It is
ch03.indd 68 23-08-2017 16:38:49

Sartorius
FA
Tensor Femoral nerve FV
Fascia
Rectus femoris
lata Iliopsoas
Pectineus
Femur

are insonated during a transverse ultrasound scan for the femoral
nerve at the inguinal region. FA, femoral artery; FV, femoral vein.
Fascia lata
FA Fascia iliaca
FIGURE 3-15 ■ Figure showing the position of the ultrasound FV
Iliopsoas
muscle
transducer during a transverse ultrasound scan for the femoral nerve
at the inguinal region. Femoral nerve
Femur
Anterior
Medial Lateral
Posterior
FIGURE 3-18 ■ Transverse sonogram of the femoral nerve at the

Anterior superior
iliac spine
inguinal region. Note the relation of the femoral nerve to the femoral
vessel, iliopsoas muscle, and the neighboring fascia (lata and iliaca).
FV, femoral vein; FA, femoral artery.
FIGURE 3-16 ■ Figure showing the position and orientation of Femoral

the ultrasound transducer during a transverse ultrasound scan for FA nerve
Iliopsoas
the femoral nerve at the inguinal region. muscle
FV
our experience that the position of the femoral nerve, Femur

relative to the femoral artery, in the femoral triangle is Anterior
quite variable. Therefore, we prefer to look for the fem- Medial Lateral
oral nerve on the anteromedial surface of the iliopsoas Posterior
muscle rather than immediately lateral to the femoral

FIGURE 3-19 ■ Color Doppler sonogram of the femoral vessels at
the inguinal region. FA, femoral artery; FV, femoral vein.
ch03.indd 69 23-08-2017 16:39:13

artery during the scan. Also in order to locate the femo- Obturator Nerve at the Inguinal Region
ral nerve before it divides into its anterior and posterior
branches, it is preferable to start the ultrasound scan Gross Anatomy
immediately below the inguinal ligament rather than at The obturator nerve is a branch of the lumbar plexus and
the inguinal crease. The profunda femoris artery, which formed by the anterior division of the anterior primary rami of
is the largest branch of the femoral artery, can be a use- the L2, L3, and L4 spinal nerves. It exits the pelvis and enters
ful clue as to the level at which the ultrasound scan is the thigh through the obturator canal. It then divides into its
being performed. If the profunda femoris artery is seen anterior and posterior divisions, usually lateral and distal to
adjacent (lateral) to the femoral artery in the ultrasound the pubic tubercle (Fig. 3-1).8 The anterior division courses
image (Fig. 3-20), it indicates that the ultrasound scan distally, lying between the adductor brevis and the adduc-
is being performed too low and below the division of tor longus muscles, and the posterior division passes distally
the femoral nerve because the profunda femoris artery is between the adductor brevis and adductor magnus muscles
generally given off from the femoral artery, about 4 cm (Figs. 3-21 and 3-22).
below the inguinal ligament.
Femoral nerve
Rectus femoris
Sartorius
FA
Iliopsoas
PFA
FV muscle
Adductor longus
Vastus lateralis
ius
m ed
ter
us
Anterior s in
ne
u
ast
cti
V Adductor brevis
Pe
Medial
as
pso
Femur
Ilio
Adductor magnus
FIGURE 3-20 ■ Transverse sonogram of the inguinal region show- FIGURE 3-21 ■ Anatomical section of the anterior and medial
ing the origin of the profunda femoris artery from the femoral artery. compartments of the thigh 5 to 8 cm distal to the inguinal crease.
Profunda femoris
Sartorius
Iliopsoas artery and vein Femoral nerve
Vastus medialis Pectineus (branches)
Lateral femoral Femoral artery and vein
cutaneous nerve Great saphenous vein
Rectus femoris
Adductor longus
Tensor fascia lata Obturator nerve
(anterior branch)
Vastus intermedius
Gracilis
Iliotibial tract
Adductor brevis
Femur Obturator nerve
(posterior branch)
Adductor magnus
Vastus lateralis
Semimembranosus
Gluteus maximus Semitendinosus

Sciatic nerve Biceps femoris
Posterior femoral
cutaneous nerve (long head)
FIGURE 3-22 ■ Cross-sectional anatomy of the thigh distal to the inguinal crease. Note the relation of the anterior and posterior divisions
of the obturator nerve to the adductor muscles (longus, brevis, and magnus).
ch03.indd 70 23-08-2017 16:39:28

Computed Tomography Anatomy of the allows optimal visualization of the obturator nerve
Upper Thigh and its branches.8
Fig. 3-23 b. Operator and ultrasound machine: The operator
stands on the ipsilateral side of the scan or interven-
Magnetic Resonance Imaging Anatomy of the tion and faces the patient’s head. The ultrasound
Upper Thigh machine is placed on the ipsilateral side directly in
Fig. 3-24 front of the operator. Alternatively, the operator may
choose to position the ultrasound machine depending
Obturator Nerve Ultrasound Scan Technique on his or her “handedness.” Right-handed operators
1. Position: who hold the ultrasound transducer with their left
a. Patient: Supine with the ipsilateral leg straight and hand and carry out needle interventions with their
slightly externally rotated at the hip. This position right hand should stand on the right side of the patient
and position the ultrasound machine on the opposite
side of the patient. This is vice versa for left-handed
operators.
Sartorius
Femoral nerve
Femoral artery
Profunda femoris
artery
Adductor longus
Rectus femoris
3. Scan technique: The transducer is placed in the transverse
Obturator nerve
Tensor fascia
(anterior branch) orientation 2 cm distal to the pubic tubercle on the medial
lata FV
Adductor aspect of the thigh (Figs. 3-25 and 3-26). Alternatively
Vastus brevis
lateralis Obturator nerve
Pectineus (posterior branch)
Vastus
intermedius Adductor
Femur magnus
Inferior pubic
iliopsoas ramus
Quadratus femoris
Hamstring tendons
Sciatic nerve Anterior
Gluteus maximus Lateral Medial
Posterior
FIGURE 3-23 ■ Transverse (axial) CT of the proximal thigh show-

ing the obturator nerves and their relations. FV, femoral vein.
Femoral artery
Lymph node
(inguinal)
Sartorius Adductor
longus
Femoral nerve
Obturator nerve
(anterior branch)
Femoral vein Adductor
Profunda femoris brevis
artery Obturator nerve
Pectineus (posterior branch)
Adductor
magnus
Inferior pubic
Quadratus rami
femoris
Anterior
Hamstring
tendons Lateral Medial
Posterior
FIGURE 3-24 ■ Transverse (axial) MRI image of the proximal transducer relative to the thigh during a transverse scan for the
thigh showing the obturator nerves and their relations. anterior and posterior divisions of the obturator nerve.
ch03.indd 71 23-08-2017 16:39:39

Adductor Obturator nerve

longus (anterior branch)
Adductor
brevis
Pectineus
Adductor
Obturator nerve magnus
(posterior branch)
Anterior
Lateral
FIGURE 3-26 ■ Transverse sonogram of the medial compartment of the upper thigh showing the branches of the obturator nerve in the
intermuscular plane between the adductor muscles. Accompanying photographs show the position and orientation of the transducer during
the ultrasound scan.
the obturator nerve are flat and small nerves,8 it is easier

to identify them in their respective intermuscular fascial
Rectus femoris planes by sliding the transducer proximally and distally
Sartorius analogous to the trace back technique. Slightly tilting or
rotating the transducer may also help improve visualiza-
tion. If one traces the two divisions of the obturator nerve
Adductor longus proximally, they are seen to come together to form the
Vastus lateralis
s
ed
iu common obturator nerve.8 Color or Power Doppler ultra-
m
ter sound can also be used to identify the obturator artery that
us
s in
ne
u
ast
cti
V Adductor brevis accompanies the common obturator nerve.8

Pe
sa
4. Sonoanatomy: The common obturator nerve or its divi-

pso
Ilio
Adductor magnus sions (anterior and posterior) are not readily identified
as discrete nerves on ultrasound imaging, as they are
FIGURE 3-27 ■ Figure highlighting the anatomical structures that small and flat nerves.8 Unlike other peripheral nerves,
are insonated during a transverse ultrasound scan for the anterior the anterior and posterior divisions of the obturator nerve
and posterior division of the obturator nerve at the medial aspect of appear as two flat and hyperechoic structures in the inter-
the upper thigh. muscular fascial planes between the adductor muscles
(Fig. 3-28).
5 . Clinical Pearls: The anterior division travels in the inter-
start the ultrasound scan by placing the transducer paral- muscular plane between the adductor longus and adduc-
lel to the inguinal ligament and over the inguinal crease.9 tor brevis muscles. The posterior division travels in the
Then slide the transducer medially until the pectineus is plane between the adductor brevis and adductor magnus
visualized on the lateral aspect of the ultrasound screen.9 muscles. The typical appearance on a transverse sonogram
At this point, the adductor muscles (longus, brevis, and would include the pectineus muscle on the lateral aspect of
magnus) are visualized adjacent to the pectineus (Fig. the screen and the three adductors muscles on the medial
3-27). Because the anterior and posterior divisions of aspect, with the adductor longus being most superficial,
ch03.indd 72 23-08-2017 16:39:57

Inguinal ligament
Anterior superior
iliac spine
Obturator nerve Adductor longus
(anterior branch) Lateral femoral Femoral artery
cutaneous nerve
Femoral vein Deep inguinal
Sartorius lymph node
Femoral nerve Femoral canal
Obturator nerve Adductor brevis Pectineus
Iliopsoas
(posterior division) Pubic
tubercle
Anterior Adductor magnus

Lateral Medial
Posterior
FIGURE 3-29 ■ Anatomical illustration showing the lateral femo-
ral cutaneous nerve entering the thigh under the lateral edge of the
FIGURE 3-28 ■ Transverse sonogram of the medial compart- inguinal ligament and medial to the anterior superior iliac spine
ment of the proximal thigh showing the adductor muscles (longus, (ASIS).
brevis, and magnus) and the anterior and posterior divisions of the
obturator nerve in the intermuscular plane between the adductor
muscles.
Ant
the adductor brevis in the middle, and the adductor magnus Lat Med
deepest, respectively (Figs. 3-27 and 3-28). Small branches Post Sartorius
Tensor Fascia IO
of the obturator vessels accompany the divisions of the Lata TA
obturator nerve in the intermuscular plane and can be iden-

ASIS
tified using Color or Power Doppler ultrasound.8 However, Iliopsoas
to what extent this is reliable in locating the nerves is yet to

be determined, as the position of the obturator vessels rela-
Gluteus
tive to the nerves is variable. muscles
Lateral Cutaneous Nerve of the Thigh

Gross Anatomy
FIGURE 3-30 ■ Transverse anatomical section of the upper thigh
The lateral cutaneous nerve of the thigh, also called the l ateral and lower abdomen a few centimeters distal to the anterior superior
femoral cutaneous nerve of the thigh, innervates the skin on iliac spine showing the anatomy related to the lateral femoral cutane-
the lateral aspect of the thigh. It is a branch of the lumbar ous nerve (the nerve is not seen in this image), which usually lies on
plexus and formed within the psoas muscle by the fusion of the anterior surface of the sartorius muscle or in the groove between
the posterior divisions of the L2 and L3 spinal nerves. It exits the sartorius and the iliacus muscles at this level. IO, internal oblique
muscle; TA, transversus abdominis muscle.
the psoas muscle from its lateral border, in the retroperito-
neum, at about its middle and travels across the iliacus muscle
obliquely lying deep to the fascia iliaca (Fig. 3-1). It enters the
thigh medial to the anterior superior iliac spine (ASIS) lying ligament is also highly variable. Five different variations have
under the lateral edge of the inguinal ligament (Figs. 3-29 and been identified: type A, posterior to the ASIS, across the iliac
3-30). It then crosses over the sartorius muscle in a medial to crest; type B, anterior to the ASIS and superficial to the ori-
lateral direction. The course of the lateral cutaneous nerve gin of the sartorius muscle but within the substance of the
of the thigh is highly variable. It is found most commonly inguinal ligament; type C, medial to the ASIS, ensheathed in
10 to 15 millimeters medial to the ASIS but can be located the tendinous origin of the sartorius muscle; type D, medial
as far medially as 46 millimeters.10 Its depth in relation to to the origin of the sartorius muscle located in an interval
the soft tissues in the region, the sartorius, and the inguinal between the tendon of the sartorius muscle and thick fascia
ch03.indd 73 23-08-2017 16:40:05

of the iliopsoas muscle deep to the inguinal ligament; and

type E, most medial and embedded in loose connective tissue,
deep to the inguinal ligament, overlying the thin fascia of the
iliopsoas muscle, and contributing the femoral branch of the
genitofemoral nerve.11
Magnetic Resonance Imaging Anatomy of the Lateral

Cutaneous Nerve of the Thigh
Fig. 3-31
Lateral Cutaneous Nerve of the Thigh Ultrasound

Scan Technique
1. Position:
a. Patient: Supine position
may stand on the ipsilateral side of the intervention
and face the patient’s head. The ultrasound machine
is placed on the same side between the operator and
the patient’s head. Alternatively, the operator may
choose to position the ultrasound machine depending
on his or her “handedness.” Right-handed operators
who hold ultrasound transducer with their left hand
and carry out needle interventions with their right
transducer during a transverse scan for the lateral femoral cutaneous
hand should stand on the right side of the patient nerve at the inguinal region.
and position the ultrasound machine on the opposite
operators.
Lateral cutaneous nerve Sartorius

of thigh
Iliac bone
Iliopsoas
muscle
Gluteus
muscle
FIGURE 3-31 ■ Transverse (axial) MRI image of the upper thigh FIGURE 3-33 ■ Figure showing the position and orientation of the
showing the lateral cutaneous nerve of the thigh. ultrasound transducer during a transverse ultrasound scan for the
lateral femoral cutaneous nerve at the inguinal region. Note the ultra-
sound transducer is positioned a few centimeters distal and medial to
the anterior superior iliac spine.
ch03.indd 74 23-08-2017 16:40:12

Ant
Lat Med
Post
Iliacus
Lateral femoral cutaneous
Anterior superior
nerve
iliac spine Sartorius
Anterior
Lateral Medial
Posterior
FIGURE 3-34 ■ Figure highlighting the anatomical structures that FIGURE 3-35 ■ Transverse sonogram of the inguinal region at the
are insonated during a transverse ultrasound scan for the lateral fem- level of the anterior superior iliac spine showing the lateral cutane-
oral cutaneous nerve at the inguinal region. ous nerve of the thigh lying on the anterior surface (superficial to)
the iliacus muscle.
3. Scan technique: The transducer is placed with one edge edge of the ASIS, the groove between the satorius and
on the ASIS. The medial edge of the transducer is rotated iliacus, and the anterior surface of the sartorius. The
slightly caudally such that the transducer is parallel to the nerve can usually be located at one of these areas and
inguinal ligament. Slide the transducer medially along “traced back” to confirm its identity along the course.
the inguinal ligament (Figs. 3-32 to 3-34). The ASIS Injection of a small volume of normal saline around
appears as a hyperechoic line with an acoustic shadow. the nerve can be used to delineate its course (hydrolo-
Immediately medial to the ASIS is the iliacus muscle. cation). It is common to see the injectate spread along
At the level of the inguinal ligament, the lateral cutane- its course proximally under the inguinal ligament and
ous nerve can be visualized deep to the fascia lata just under the fascia iliaca within the pelvis.
medial to the ASIS.12 The transducer can be slid distally
approximately 5 cm caudad to the ASIS and rotated to a
transverse orientation relative to the femur. At this loca- Saphenous Nerve at the Adductor Canal
tion, the lateral cutaneous nerve of the thigh is located on
the sartorius muscle or in the groove between the sarto- Gross Anatomy
rius and the iliacus muscles (Fig. 3-35). Distal to the inguinal crease, the femoral nerve divides into
4. Sonoanatomy: The lateral cutaneous nerve of the thigh its terminal branches.6 The saphenous nerve is a branch of
is a small nerve that may appear as a hypoechoic to the anterior division of the femoral nerve and supplies the
hyperechoic structure. At the level of the inguinal liga- skin on the medial aspect of the leg and foot up to the ball
ment, it lies medial to the ASIS and deep to the fascia of the big toe. It travels with the femoral artery within the
iliacus. It then courses distally in the groove between the anterior fascial compartment of the thigh under the sarto-
sartorius and iliacus, crossing over the anterior surface of rius muscle (subsartorial), and local anesthetic injected into
the sartorius (Fig. 3-35) to the lateral aspect of the sarto- this intermuscular space produces saphenous nerve block.13
rius muscle. The “subsartorial canal” is also referred to as the adductor
5. Clinical Pearls: The lateral cutaneous nerve of the thigh canal or Hunter’s canal and is located on the medial aspect
is a small nerve and can be best visualized using a high- of the middle one-third of the thigh (Fig. 3-36). The adductor
frequency linear transducer. The “trace back” technique canal is triangular in cross-section (Figs. 3-37 and 3-38) and
is important and useful to confirm the identity of the extends from the apex of the femoral triangle, above, to the
nerve. The important landmarks here are the medial tendinous opening in the adductor magnus muscle (adductor
ch03.indd 75 23-08-2017 16:40:20

hiatus), below. The anterior wall of the adductor canal is medialis (Fig. 3-38). The femoral vein lies posterior to the
formed by the vastus medialis muscle; the posterior wall or femoral artery in the upper part of the adductor canal and
floor is formed by the adductor longus, above, and the adduc- lateral to the artery in the lower part of the canal (Fig. 3-39).
tor magnus, below; and the roof or medial wall is formed by The saphenous nerve crosses the femoral artery anteriorly
a strong fibrous membrane underlying the sartorius muscle from a lateral to medial direction. The “subsartorial plexus”
(Figs. 3-37 and 3-38). of nerves lie on the fibrous roof of the adductor canal deep to
The adductor canal contains the following structures: the sartorius muscle (Fig. 3-38) and are formed by branches
femoral artery and vein, saphenous nerve, anterior and pos- from the medial cutaneous nerve of the thigh, saphenous
terior division of the obturator nerve, and nerve to vastus nerve, and anterior division of the obturator nerve. It supplies
Rectus femoris Vastus medialis Vastus medialis

Sartorius
Saphenous nerve
Nerve to vastus
Vastus intermedius Adductor canal
medialis
Sartorius muscle
Adductor Femur
Vastus lateralis
longus Subsartorial
plexus
Femur Gracilis
Fibrous roof
Biceps femoris
Adductor Femoral artery
magnus
Sciatic nerve Adductor Femoral vein
Semitendinosus canal Adductor longus
Semimembranosus
FIGURE 3-36 ■ Transverse anatomical section of the midthigh FIGURE 3-38 ■ Anatomical illustration showing the boundaries
showing the anatomy of the anterior, medial, and posterior compart- and contents of the adductor canal.
ment of the thigh.
Rectus femoris Vastus medialis

Nerve to vastus medialis
Vastus intermedius Saphenous nerve

Sartorius
Vastus lateralis Femoral arery
and vein
Great saphenous vein
Femur Adductor longus
Gracilis
MK
Biceps femoris Adductor brevis
(short head)
Adductor magnus
Biceps femors
(long head) Semimembranosus
Semitendinosus Sciatic nerve
FIGURE 3-37 ■ Transverse anatomical illustration of the midthigh showing the anatomy of the adductor canal.
ch03.indd 76 23-08-2017 16:40:28

the neighboring skin and overlying fascia lata. The femoral carry out needle interventions with their right hand
artery exits the adductor canal through the adductor hiatus should stand on the right side of the patient and
and continues as the popliteal artery. At the adductor hiatus, position the ultrasound machine on the opposite
the saphenous nerve leaves the femoral artery and travels side of the patient. This is vice versa for left-handed
along the lower edge of the aponeurosis of the canal and is operators.
closely related to the saphenous branch of the descending 2. Transducer selection: High-frequency (15-8 MHz) lin-
genicular artery.14 The saphenous nerve then courses distally ear array transducer. A curved array low-frequency (5-2
along the medial side of the knee deep to the sartorius and MHz) transducer can also be used if one wishes to visual-
pierces the fascia lata, between the tendons of the sartorius ize the sciatic nerve, which is located at a depth, at the
and gracilis muscles. same time.
3 . Scan technique: The ultrasound transducer is placed on
a medial aspect of the thigh of the middle third of the
Computed Tomography Anatomy of the
Midfemoral/Adductor Canal Region
Fig. 3-40
Magnetic Resonance Imaging Anatomy of the Rectus femoris
Midfemoral/Adductor Canal Region Vastus

intermedius Vastus medialis
Fig. 3-41 Vastus Superficial femoral

artery and vein
lateralis
Sartorius
Saphenous
Midfemoral/Adductor Canal Region Ultrasound Scan Femur nerve
Technique Adductor
longus
Common peroneal
1. Position: nerve Gracilis
a. Patient: Supine position with the ipsilateral hip
Adductor
slightly externally rotated and knee slightly flexed. Biceps femoris magnus
(long head) Tibial nerve
b. Operator and ultrasound machine: The operator Semitendinosus Semimembranosus
may choose to position the ultrasound machine based
on his or her “handedness.” Right-handed operators FIGURE 3-40 ■ Transverse (axial) CT of the midthigh showing the
who hold ultrasound probes with their left hand and relation and contents of the adductor canal.
Vastus medialis Superficial femoral

Rectus femoris
Femoral vein artery and vein
Sartorius
Nerve to vastus
Femoral artery Vastus intermedius Saphenous nerve
medialis
Great
Anterior and posterior Vastus saphenous vein
division of obturator lateralis Adductor
nerve longus
Muscular branch of
femoral artery Saphenous nerve
Gracilis
Femur
Descending genicular
artery
Femoral vein Adductor
Superior Sciatic nerve magnus
Posterior division of Lateral Medial Biceps femoris Semimembranosus

obturator nerve Posterior femoral Semitendinosus
Inferior cutaneous nerve
FIGURE 3-39 ■ Anatomical illustration showing the course of the FIGURE 3-41 ■ Transverse (axial) MRI image of the midthigh
saphenous nerve relative to the femoral vessels within the adductor showing the relation and contents of the adductor canal.
canal.
ch03.indd 77 23-08-2017 16:40:40

thigh (midfemoral region) in the transverse orientation visualize the artery at its most superficial location and
(Figs. 3-42 to 3-46). The reference structure to identify is just proximal to the point where the femoral artery passes
the femoral artery in the transverse view. Thereafter slide the adductor hiatus to become the popliteal artery.15 The
the transducer along the medial border of the sartorius to sartorius is typically triangular/elliptical in shape when
imaged transversely. Beneath the sartorius, the femoral
artery and veins can be imaged and followed until they
pass through the adductor hiatus.
Rectus femoris Vastus medialis

Sartorius
Vastus intermedius Adductor
canal
Adductor
Vastus lateralis
longus
Femur Gracilis
Biceps femoris
Adductor
magnus
Sciatic nerve
Semimembranosus Semitendinosus

are insonated during a transverse ultrasound scan of the adductor
canal at the midthigh.

transducer relative to the thigh during a transverse ultrasound scan
for the saphenous nerve at the adductor canal (midthigh).
Nerve to vastus
medialis
Vastus medialis
Profunda femoris
artery and vein
Femur Saphenous
nerve
Sartorius
Adductor canal
Femoral artery
and vein
Adductor longus
Gracilis
Plane of the
ultrasound
beam (blue)
FIGURE 3-43 ■ Figure showing the position and orientation of FIGURE 3-45 ■ Figure highlighting the anatomical structures that
the ultrasound transducer during a transverse ultrasound scan of the are imaged during a transverse ultrasound scan at the level of the
adductor canal at the midthigh. midthigh using a low-frequency transducer. Note that the sciatic
nerve is also included in the highlighted area and can be visualized
during the midthigh (midfemoral) scan.
ch03.indd 78 23-08-2017 16:40:48

4. Sonoanatomy: The saphenous nerve is a small nerve and using a periarterial injection deep to the sartorius, medial
may not be visualized as a discrete structure in all indi- to the artery is adequate for a successful saphenous nerve
viduals at the adductor canal. When visualized, it is seen block.15
as a hyperechoic structure that is closely related to the
femoral artery (Fig. 3-47).
5. Clinical Pearls: Because the saphenous nerve is a small Sciatic Nerve at the Parasacral Region
nerve, the trace back technique16 is useful for locating it.
Gross Anatomy
It can also be followed distally where it lies between the
sartorius and the gracilis muscles and with the saphenous A parasacral sciatic nerve block is the technique of injecting
branch of the descending genicular artery. When there is local anesthetic in a fascial plane around the nerves of the
difficulty visualizing the saphenous nerve, imaging the sacral plexus before the sciatic nerve is formed.17,18 Therefore,
most superficial portion of the distal adductor canal and it may be considered a sacral plexus block.17,18 Currently, the
majority of published data describe using peripheral nerve
stimulation19–21 but recently ultrasound-guided parasacral
sciatic nerve block has been described.22 Because the sacral
plexus is located deep within the pelvis in a fascial plane
between the piriformis muscle and the pelvic fascia (Figs. 3-2
Saphenous nerve
and 3-3), the block needle has to enter the pelvis through the
Femoral artery and vein
greater sciatic foramen during a parasacral sciatic nerve block
Vastus medialis
(Fig. 3-48). The internal iliac artery and vein or their branches
Sartorius and the pelvic veins are also closely related to the sacral plexus
Acousic shadow Adductor canal in the pelvis (Figs. 3-49 to 3-51). The following structures
of femur
Adductor longus also pass through the greater sciatic foramen: (a) piriformis
Adductor brevis
muscle; (b) structures passing above the piriformis muscle:
BIceps femoris Adductor magnus
superior gluteal vessels and nerve; and (c) structures passing
Semimembranosus
Semittendinosus
Sciatic nerve
FIGURE 3-46 ■ Anatomical structures that are visualized during a

midfemoral (midthigh) ultrasound scan.
Gluteus maximus Sciatic nerve
Obturator internus
Piriformis tendon Gemellus inferior
–0
Gluteus
medius Quadratus
femoris
Sartorius Saphenous nerve
Ilium
–1 Ischium
Gemellus
Sacral plexus
Sacrum superior
s
gu
on
Obturator Obturator
l
FA
or
internus exturnus
ct
–2
du
Ad
x
Vastus
FV
medialis
Anterior
FIGURE 3-48 ■ Anatomical illustration showing the sacral plexus
(within the pelvis) formation of the sciatic nerve and how it exits the
Lateral Medial –3
pelvis through the greater sciatic foramen to enter the gluteal region.
Posterior JPEG Note in this anatomical section one of the components of the sciatic
nerve is seen to exit the pelvis by traversing the piriformis muscle
FIGURE 3-47 ■ Transverse sonogram showing the boundaries and to join the other component in the infrapiriformis fossa (a normal
contents of the adductor canal. FA, femoral artery; FV, femoral vein. anatomical variation).
ch03.indd 79 23-08-2017 16:40:57

below the piriformis: inferior gluteal vessels and nerve, sci- Sciatic Nerve – Parasacral Region Ultrasound Scan
atic nerve, posterior cutaneous nerve of thigh, nerve to qua- Technique
dratus femoris muscle, pudendal nerve and vessels, and nerve
1. Position:
to obturator internus.
a. Patient: Semiprone (Sims’) position with the side to
Computed Tomography Anatomy of the Sciatic be examined uppermost and the upper hip flexed to
Nerve – Parasacral Region about 90 degrees.
Figs. 3-49 and 3-50
sits or stands behind the patient with the ultrasound
Magnetic Resonance Imaging Anatomy of the Sciatic machine placed directly in front.
Nerve – Parasacral Region 2. Transducer selection: Low-frequency (5-2 MHz) curved
array transducer.
Fig. 3-51
3. Scan technique: Various techniques for identifying the
sonoanatomy relevant for parasacral sciatic nerve block
have been described in the literature.22 We prefer to start
Gluteus Piriformis Inferior gluteal artery the ultrasound scan by placing the transducer in the trans-
Gluteus Ilium maximus and vein
medius
Ischium verse orientation between the greater trochanter and ischial
tuberosity. Here the sciatic nerve is consistently identified
Obturator
internus as a hyperechoic oval structure in the subgluteal space
between the gluteus maximus muscle posteriorly and the
quadratus femoris muscle anteriorly.2,3 The ultrasound
image is optimized after which the transducer is rotated
Sciatic nerve
through 90 degrees to obtain a sagittal view of the sciatic
Iliopsoas
Pubic symphysis nerve. Then gently slide the transducer cephalad, keeping
Posterior Pelvic veins the sciatic nerve in view until it is seen to lie in the infrapir-
Bowel External iliac artery Bladder
Cranial Caudal
and vein iformis fossa between the gluteus maximus posteriorly and
Anterior the gemelli muscles and tendon of obturator internus ante-
riorly (Figs. 3-52 to 3-54). Dynamic scanning by asking an
FIGURE 3-49 ■ Sagittal oblique CT image demonstrating the sci-
assistant to rotate the hip (externally and internally), with
atic nerve between the ilium and ischium (greater sciatic foramen).
the knee flexed, will demonstrate a side-to-side gliding
Sacrum Ilium Gluteus

Posterior medius Gluteus
Cranial Caudal maximus
Gluteus medius Anterior
Sacral plexus Piriformis
Piriformis Inferior gluteal
Bowel artery and vein
Gluteus maximus
Internal iliac
vein
Bladder Sciatic nerve Ilium
Uterus
Iliopsoas
Obturator Gemelli and
internus obturator internus Ischium
Cranial
External iliac Pelvic Sciatic nerve Obturator
Anterior Posterior
artery External iliac
veins Sacral internus
Caudal vein plexus
Ischium
FIGURE 3-50 ■ Sagittal oblique CT image depicting the parasacral FIGURE 3-51 ■ Sagittal oblique MRI image at the level of the
relations and course of the sciatic nerve in the gluteal region. Note greater sciatic foramen demonstrating the sacral plexus and the para-
the close proximity of the iliac veins and large bowel to the sacral sacral relation of the sciatic nerve.
plexus and sciatic nerve at the level of the greater sciatic foramen.
ch03.indd 80 23-08-2017 16:41:12

motion of the piriformis muscle on the ultrasound image. to the transverse orientation to obtain a transverse view of
Color or Power Doppler ultrasound can be used to identify the sciatic nerve as it exits the pelvis through the greater
the inferior gluteal artery, which emerges from under the sciatic foramen (Figs. 3-55 and 3-56).
inferior border of the piriformis muscle. The inferior bor- 4 . Sonoanatomy: The sciatic nerve appears as a thick,
der of the ilium and ischium, with their acoustic shadows, hyperechoic linear structure in a sagittal sonogram of
and the greater sciatic foramen can then be delineated in this region (Figs. 3-57 and 3-58). In some individu-
the sagittal sonogram. One can then rotate the transducer als a distinct perineural space, similar to that seen at
Tendon of obturator
Gluteus maximus internus
Gemellus Gemellus Biceps femoris

superior inferior
Gluteus
medius
Piriformis Adductor magnus
Ilium Quadratus femoris
Ischium
Posterior
Cranial Caudal
Obturator
externus Anterior
FIGURE 3-52 ■ Figure showing the position of the ultrasound FIGURE 3-53 ■ Figure highlighting the anatomical structures that
transducer during a sagittal scan for the sacral plexus and sciatic are insonated during a sagittal ultrasound scan for the sacral plexus
nerve at the level of the greater sciatic foramen (parasacral scan). and sciatic nerve at the level of the greater sciatic foramen (parasa-
cral scan).
M5
Gluteus
maximus
0
Sciatic 1
nerve
Ilium 2
3
Sacral plexus
Piriformis x
4
Posterior RPS Ischium 6

Gemelli
Cranial muscles 7
FIGURE 3-54 ■ Sagittal sonogram of the sciatic nerve as it exits the pelvis through the greater sciatic foramen. Accompanying photograph
shows the position and orientation of the ultrasound transducer during a sagittal ultrasound scan for the sacral plexus and sciatic nerve at the
level of the greater sciatic foramen (parasacral scan). RPS, retroperitoneal space.
ch03.indd 81 23-08-2017 16:41:34

the subgluteal space3 or thigh,2 can be delineated at the as hyperechoic linear elements posterior (external) to the
parasacral region (Figs. 3-57 and 3-58). Proximally the peritoneum (Fig. 3-57). The inferior gluteal artery can
greater sciatic foramen is seen as an acoustic window also be identified using Doppler ultrasound (Fig. 3-59).
between the acoustic shadows of the inferior border of the On a transverse sonogram at the level or just distal to
ilium and the ischium (Fig. 3-57). The pelvic peritoneum the greater sciatic foramen, the sciatic nerve is seen as a
can be identified as a hyperechoic linear shadow through flat-to-oval hyperechoic structure in between the gluteus
this acoustic window, and the sacral plexus nerves appear maximus and gemelli muscles (Fig. 3-60).
Cranial Posterior Caudal
1
Piriformis Sciatic nerve
Gluteus maxmus Perineural
space 2
Quadratus
femoris
3
Tendon of x
Ilium obturator
internus 4
Gemellus
superior
Sacral plexus 5
Peritoneum Ischium
Pelvic cavity
6
Anterior
FIGURE 3-57 ■ Sagittal sonogram at the level of the greater sciatic

foramen (parasacral scan) showing the sacral plexus and the sciatic
nerve as it exits the pelvis to enter the infra-piriformis fossa.

transducer during a transverse scan for the sciatic nerve at the level
of the greater sciatic foramen (parasacral scan).
M5
Gluteus 0
maximus Sciatic nerve 1
Gluteus 2
medius
3
x4
Ilium 5
RPS 6
7
Ischium
Posterior 8
Lateral 9
FIGURE 3-56 ■ Transverse sonogram of the sciatic nerve as it exits the pelvis through the greater sciatic foramen. Accompanying photo-
graph shows the position and orientation of the ultrasound transducer during a transverse ultrasound scan for the sciatic nerve at the level of
the greater sciatic foramen (parasacral scan). RPS, retroperitoneal space.
ch03.indd 82 23-08-2017 16:41:48

Posterior Posterior
Cranial Caudal
Anterior
Gluteus
maximus
Perineural Gluteus maximus Sciatic nerve
space Sciatic nerve
Piriformis Lateral Medial
Quadratus Ilium Ischium

Gemelli and tendon
femoris
of obturator internus
Gemellus inferior /
Quadratus femoris
Ischium
Anterior
FIGURE 3-58 ■ Sagittal sonogram showing the sciatic nerve, FIGURE 3-60 ■ Transverse sonogram showing the sciatic nerve,
between the piriformis muscle posteriorly and the gemelli muscles between the gluteus maximus and the gemelli muscles, immediately
anteriorly, immediately distal to the greater sciatic foramen. Note distal to the greater sciatic foramen (parasacral position).
the hypoechoic perineural space between the sciatic nerve and the
piriformis muscle posteriorly. The sciatic nerve is also seen to con-
tinue distally to enter the subgluteal space between the gluteus maxi-
mus posteriorly and the quadratus femoris anteriorly.
the sciatic nerve exits the pelvis and descends caudally
deserves further investigation as a site for local anes-
thetic injection because it can be identified using ultra-
+27.7 sound imaging (Figs. 3-57 and 3-58). We believe that
local anesthetic injected into this perineural space close
0
to the greater sciatic foramen will not only anesthetize the
1
sacral plexus nerves, but also the sciatic nerve because of
Gluteus
2
maximus cranial and caudal spread of the local anesthetic through
Inferior gluteal x 3 –27.7 the intermuscular “conduit.” This may also be safer than
artery cm/s
4 inserting the block needle into the pelvis to anesthetize
5 the sacral plexus nerves during a parasacral sciatic nerve
um
block. Future research to validate this hypothesis in clini-

hi
6
Isc
Posterior
7 cal practice is warranted.
Cranial Caudal
8
Anterior
9
Sciatic Nerve – At the Subgluteal Region
FIGURE 3-59 ■ Color Doppler sonogram showing the inferior glu- Gross Anatomy
teal artery as it exits the greater sciatic foramen.
Once the sciatic nerve exits the greater sciatic foramen, it
enters the subgluteal space below the piriformis muscle. It then
descends on the dorsal surface of the ischium, together with the
5. Clinical Pearls: Because the parasacral sciatic nerve posterior cutaneous nerve of the thigh, lying on the posterior
block is a deep block with potential for complications surface of the gemellus superior muscle, tendon of obturator
such as pelvic hematoma formation, visceral injury internus, gemellus inferior muscle, and the quadratus femoris
(colon or ureter), inadvertent intravascular injection, tran- muscle (in a cranial to caudal direction) before it enters the
sient sciatic neuralgia,19 we believe it should be consid- hollow between the greater trochanter and the ischial tuberos-
ered an advanced regional anesthetic technique and only ity (Figs. 3-5 to 3-7).23 The “subgluteal space” is a well-defined
used when other sciatic nerve block techniques are con- anatomical space between the anterior surface of the gluteus
sidered inadequate or inappropriate. Also the presence maximus and the posterior surface of the quadratus femoris
of an “intermuscular perineural space”2 through which muscle (Fig. 3-61)23 and contains the sciatic nerve, posterior
ch03.indd 83 23-08-2017 16:42:06

cutaneous nerve of the thigh, inferior gluteal vessels and nerve, Sciatic Nerve at the Subgluteal Region – Ultrasound
nerve to the short and long heads of the biceps femoris, the Scan Technique
comitans artery and vein of the sciatic nerve, and the ascend-
1. Position:
ing branch of the medial circumflex femoral artery (Fig. 3-7).23
a. Patient: Lateral position with the side to be exam-
Computed Tomography Anatomy of the Sciatic ined uppermost (nondependent side) and the hip and
Nerve – Subgluteal Region knees slightly flexed. It is also possible to position
the patient in the semiprone (Sims’) position.
Fig. 3-62
Magnetic Resonance Imaging Anatomy of the Sciatic sits or stands behind the patient with the ultrasound
Nerve – Subgluteal Region machine placed directly in front.
2. Transducer selection: Low-frequency (5-2 MHz) curved
Fig. 3-63
array transducer.
3. Scan technique: The ultrasound transducer is placed par-
Sartorius
Iliopsoas allel to a line joining the greater trochanter and the ischial
Rectus femoris
Pectineus
Tensor fascia lata tuberosity (Figs. 3-64 to 3-66) to obtain a transverse
Adductor longus image of the sciatic nerve in the subgluteal space. It may
Gluteus medius
Adductor brevis be necessary to slide the transducer in a cranial to caudal
Adductor magnus
Greater
direction to obtain an optimal image of the sciatic nerve.
Gracilis Femur trochanter
The greater trochanter and the ischial tuberosity are visu-
Obturator externus
alized at the edges of the ultrasound image. They appear
Quadratus
femoris hyperechoic with a corresponding acoustic shadow and
Ischial tuberosity
are key landmarks for imaging this region. Rotating the
Hamstring
transducer through 90 degrees produces a sagittal image
Gluteus maximus
tendons
of the sciatic nerve and the subgluteal space.
Sciatic nerve Subgluteal space
4. Sonoanatomy: The sciatic nerve in the subgluteal region
appears as a triangular to oval hyperechoic structure
FIGURE 3-61 ■ Anatomical illustration showing the sciatic nerve
approximately 1.5 to 2 cm in diameter and lying deep
at the subgluteal space between the gluteus maximum muscle poste-
riorly and the quadratus femoris muscle anteriorly.
Quadratus Obturator Anterior

femoris externus Obturator
Medial Lateral
externus
Posterior
Greater
trochanter
Obturator
Greater internus Quadratus
trochanter femoris
Subgluteal
Ischial Subgluteal space
tuberosity space
Ischial
Gluteus tuberosity Gluteus
maximus maximus
Semitendinosus
tendon Sciatic nerve Sciatic nerve
Posterior femoral
Posterior cutaneous
cutaneous nerve
nerve of thigh Semimembranosus Inferior gluteal
Biceps femoris Semimembranosus Inferior gluteal
Biceps femoris
tendon tendon artery and vein tendon artery and vein
tendon
FIGURE 3-62 ■ Transverse (axial) CT image demonstrating the FIGURE 3-63 ■ Transverse (axial) MRI image demonstrating the
subgluteal space at the level of the greater trochanter and ischial subgluteal space, between the gluteus maximus muscle posteriorly
tuberosity. Note the subgluteal space between the gluteus maximus and the quadratus femoris muscle anteriorly, at the level of the greater
muscle posteriorly and the quadratus femoris muscle anteriorly. trochanter and ischial tuberosity. Note the tendons of semitendinosus
and biceps femoris at the medial end of the subgluteal space.
ch03.indd 84 23-08-2017 16:42:36

obturator externus
Greater
trochanter
Quadratus
Ischial femoris
tuberosity
Subgluteal
space
Gluteus
maximus
Hamstring
tendons Sciatic nerve

are insonated during a transverse ultrasound scan for the sciatic
nerve at the subgluteal space between the greater trochanter and
ischial tuberosity.
Posterior
Greater
trochanter Origin of biceps
Epimysium of
FIGURE 3-64 ■ Figure showing the position of the ultrasound gluteus maximus
femoris
transducer during a transverse scan for the sciatic nerve at the level Lateral
Gluteus maximus
Medial
of the subgluteal space between the greater trochanter and ischial
tuberosity.
Subgluteal space
Quadratus
Epimysium of femoris
quadratus femoris
Ischial
tuberosity
Anterior
FIGURE 3-67 ■ Transverse sonogram demonstrating the

hypoechoic subgluteal space between the hyperechoic epimysium of
the gluteus maximus muscle and the quadratus femoris muscle. The
Greater trochanter
sciatic nerve is seen as a hyperechoic nodule in the medial aspect
of the subgluteal space. Also note the origin of the tendon of biceps
femoris from the ischial tuberosity.
Ischial tuberosity
to the gluteus maximus muscle.23 The sciatic nerve
is visualized in a hypoechoic space, the “subgluteal
space,”23 between the epimysium of the gluteus maximus
muscle and the quadratus femoris muscle (Fig. 3-67).23
Although well defined, the subgluteal space can vary in
width, is more prominent close to the greater trochanter,
ultrasound transducer during a transverse scan for the sciatic nerve and is generally obscured close to the ischial tuberosity
at the subgluteal space between the greater trochanter and ischial (Fig. 3-67).23 This may be due to the attachment of the ten-
tuberosity. don of biceps femoris and semitendinosus to the ischial
ch03.indd 85 23-08-2017 16:42:56

tuberosity (Fig. 3-63). The subgluteal space also extends

Posterior
in a cranial and caudal direction as an intermuscular peri-
neural tunnel or as a conduit for the sciatic nerve.2 This
Subgluteal is clearly visualized on a sagittal sonogram (Fig. 3-68),
space Gluteus Epimysium of
maximus gluteus maximus multiplanar 3-D ultrasound images (Fig. 3-69), or i-slice
Sciatic nerve display (Fig. 3-70) of the subgluteal region.
5 . Clinical Pearls: The sciatic nerve exhibits anisotropy at
Cranial
the subgluteal region and requires slight tilting or rotation
Quadratus Caudal
femoris of the transducer during the ultrasound scan to clearly
delineate the nerve. Color or Power Doppler ultrasound
Ischium is useful in delineating the inferior gluteal artery, which
is close to the sciatic nerve in the subgluteal space.
Sciatic Nerve at the Infragluteal Region

Anterior
Gross Anatomy
FIGURE 3-68 ■ Sagittal sonogram in color mode demonstrating the After the sciatic nerve descends from the subgluteal space, it
hypoechoic subgluteal space and sciatic nerve between the hyper-
enters the back of the thigh lying relatively superficial at the
echoic epimysium of the gluteus maximus muscle posteriorly and
the quadratus femoris muscle anteriorly.
infragluteal region (ie, below the gluteal crease). Here the sci-
atic nerve is relatively flat in shape and lies in an intermuscular
Sciatic nerve Sciatic nerve
IT
GT
A. Transverse B. Sagittal
1 2
Sciatic nerve
C. Coronal
3
FIGURE 3-69 ■ A multiplanar 3-D view of the sciatic nerve at the subgluteal space, between the greater trochanter and ischial tuberosity.
The “reference maker” (green crosshair) has been placed over the sciatic nerve and corresponding views of the sciatic nerve in the transverse,
sagittal, and coronal planes are visualized. GT, greater trochanter; IT, ischial tuberosity.
ch03.indd 86 23-08-2017 16:43:04

1 2 3 4
44.6 mm 45.5 mm 46.3 mm 47.2 mm

5 6 7 8
Sciatic nerve
48.1 mm 48.9 mm 49.8 mm 50.6 mm

9 10 11 12
51.5 mm 52.4 mm 53.2 mm 54.1 mm

13 14 15 16
54.9 mm 55.8 mm 56.7 mm 57.5 mm
FIGURE 3-70 ■ A transverse i-slice display of the sciatic nerve at the subgluteal space in color (sepia tone) mode. In this figure 16 contiguous
sagittal cuts of the sciatic nerve volume, which are 0.9 mm apart, are displayed.
fascial plane between the lower slips of the gluteus maximus Sciatic Nerve at the Infragluteal Region – Ultrasound
and biceps femoris muscle posteriorly and the adductor magnus Scan Technique
muscle anteriorly (Figs. 3-71 and 3-72).
1. Position:
Computed Tomography Anatomy of the Sciatic a. Patient: Lateral position with the side to be exam-
Nerve – Infragluteal Region ined uppermost (nondependent side) and the hip and
knees slightly flexed. It is also possible to position the
Fig. 3-73
patient in the semiprone (Sims’) or prone position.
Magnetic Resonance Anatomy of the Sciatic b. Operator and ultrasound machine: The operator
Nerve – Infragluteal Region sits or stands behind the patient with the ultrasound
Fig. 3-74 machine placed directly in front.
ch03.indd 87 23-08-2017 16:43:12

Sciatic nerve
Adductor longus Sartorius Femoral Lateral circumflex
nerve artery and vein
Gluteus maximus Rectus femoris
Obturator nerve
(anterior branch) Vastus
intermedius
FA
Gracilis FV
Biceps femoris Vastus
Semitendinosus PFV lateralis
Obturator nerve PFA
(posterior branch)
Adductor brevis Femur
Vastus
lateralis Adductor Vastus medialis
magnus
Adductor magnus
Semimembranosus
Vastus
intermedius Femur
Semitendinosus Gluteus maximus
Posterior
Biceps Sciatic nerve
Lateral Medial
femoris Posterior femoral
Anterior cutaneous nerve
FIGURE 3-71 ■ Transverse anatomical section of the thigh show- FIGURE 3-73 ■ Transverse (axial) CT image of the thigh showing
ing the sciatic nerve at the infragluteal location (ie, distal to the the relations of the sciatic nerve at the infragluteal location. FA, fem-
inferior border of the gluteus maximus). Note the sciatic nerve is oral artery; FV, femoral vein; PFA, profunda femoris artery; PFV,
relatively superficial and located between the biceps femoris muscle profunda femoris vein.
posteriorly and the adductor magnus muscle anteriorly. Some of the
lower slips of the gluteus maximus muscle are also seen posterior to
the biceps femoris muscle.
Sartorius Saphenous
Superficial femoral nerve Vastus
artery and vein medialis Rectus femoris
Sciatic nerve
Adductor
Gluteus longus
maximus Femur Vastus
Obturator nerve intermedius
(anterior branch)
Gracilis Vastus
Quadratus lateralis
femoris Adductor
Femur
brevis
Sciatic nerve Obturator nerve
(posterior branch)
Biceps
femoris Adductor
Adductor Gluteus maximus
magnus
magnus
Anterior Sciatic nerve
Medial Lateral Semitendinosus Biceps femoris

Posterior femoral
Posterior cutaneous nerve
FIGURE 3-72 ■ Sagittal anatomical section of the thigh showing FIGURE 3-74 ■ Transverse (axial) MRI image of the thigh show-
the sciatic nerve at the infragluteal location. ing the relations of the sciatic nerve at the infragluteal location. Note
the posterior femoral cutaneous nerve of the thigh on the posterior
aspect of the semitendinosus muscle.
2. Transducer selection: Because the sciatic nerve is nerve at the subgluteal space (Figs. 3-75 to 3-77). Once
relatively superficial at this level, it is possible to use a the sciatic nerve is identified in the transverse sonogram,
high-frequency (12-5 MHz) linear array transducer for slide the transducer caudally until it is below the glu-
the ultrasound scan. We prefer to use a low-frequency teal crease. The sciatic nerve is seen lying superficially
(5-2 MHz) curved array transducer because it provides a between the biceps femoris muscle posteriorly and the
wider field of view. adductor magnus muscle anteriorly. It is not uncommon
3. Scan technique: Start by placing the ultrasound trans- to visualize the lower slips of the gluteus maximus mus-
ducer parallel to a line joining the greater trochanter and cle posterior to the biceps femoris muscle in the trans-
the ischial tuberosity as described earlier for the sciatic verse sonogram.
ch03.indd 88 23-08-2017 16:43:44

Sciatic nerve Semitendinosus

Posterior
Biceps femoris Lateral Medial
Gluteus maximus Anterior
Adductor
Vastus lateralis magnus
Gracilis
Vastus
brevis
Adductor
Vastus medialis longus
Sartorius
Rectus femoris

are insonated during a transverse ultrasound scan for the sciatic
nerve at the infragluteal position.
Lateral Posterior Medial
1
Gluteus maximus Sciatic nerve
transducer during a transverse scan for the sciatic nerve at the infra- 2
gluteal position.
Biceps femoris
3
Femur Adductor magnus
4
JPEG 6
Anterior *** bpm
FIGURE 3-78 ■ Transverse sonogram showing the sciatic nerve as

an oval-to-elliptical hyperechoic structure between the gluteus maxi-
mus muscle posteriorly and the adductor magnus anteriorly at the
infragluteal position.
4. Sonoanatomy: The sciatic nerve is visualized as a trian-

gular hyperechoic structure between the biceps femoris
muscle posteriorly and the adductor magnus muscle ante-
Ischial riorly (Fig. 3-78). Some of the lower slips of the gluteus
tuberosity
maximus muscle may also be visualized posterior to the
biceps femoris muscle in the transverse sonogram.
FIGURE 3-76 ■ Figure showing the position and orientation of the 5. Clinical Pearls: Because the sciatic nerve is relatively
ultrasound transducer during a transverse scan for the sciatic nerve superficial at the infragluteal region, it is a recommended
at the infragluteal position. site for sciatic nerve block in the obese.
ch03.indd 89 23-08-2017 16:44:17

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

magnus
Biceps
Tibial nerve Biceps femoris short head
Sartorius
Semimembranosus Common
peroneal nerve Vastus lateralis
Popliteal artery Vastus medialis
Vastus intermedius
Popliteal vein
Posterior
Medial Lateral Rectus femoris
Gastrocnemius Gastrocnemius Anterior
(medial head) (lateral head)
FIGURE 3-81 ■ Transverse anatomical section of the lower thigh
Small saphenous Sural nerve
vein showing the anatomy of the sciatic nerve before its division into the
tibial and common peroneal nerve at the popliteal fossa.
FIGURE 3-79 ■ Anatomical illustration showing the sciatic nerve

at the popliteal fossa.
Semitendinosus Tibial nerve

Common
Semimembranosus
Rectus femoris peroneal nerve
tendon Vastus medialis
Vastus intermedius
Popliteal artery Biceps femoris
Gracilis
and vein
Vastus lateralis Adductor magnus
tendon Sartorius
Descending genicular
Articularis genus
artery
Sartorius Adductor
Vastus
Femur magnus Femur
Saphenous nerve intermedius
Great saphenous
Biceps femoris vein Vastus lateralis
Vastus medialis
Gracilis
Common peroneal Semimembranosus
(fibular) nerve Tibial nerve
Semitendinosus
FIGURE 3-80 ■ Transverse anatomical illustration showing the FIGURE 3-82 ■ Transverse anatomical section of the lower thigh
relations of the tibial and common peroneal nerve at the popliteal showing the sciatic nerve after its division into the tibial and com-
fossa. mon peroneal nerves at the popliteal fossa.
ch03.indd 90 23-08-2017 16:44:38

Computed Tomography Anatomy of the Popliteal

Fossa
Figs. 3-83 to 3-85
Adductor
magnus Gluteus
Magnetic Resonance Imaging Anatomy of the maximus
Popliteal Fossa
Superficial femoral
Figs. 3-86 to 3-88 artery and vein Sciatic nerve
Adductor
magnus Biceps femoris
Vastus
medialis Common
Posterior peroneal nerve
Vastus Adductor
Lateral Medial intermedius Rectus femoris Tibial nerve
Vastus medialis hiatus
Anterior
Superficial femoral
artery and vein
Vastus Popliteal artery
lateralis Saphenous nerve
Sartorius Popliteal vein
Femur
Adductor Gracilis Gastrocnemius
magnus
Tibia
Biceps femoris
(short head) Great saphenous
vein
Sciatic nerve
Semimembranosus
Biceps femoris
(long head)
FIGURE 3-85 ■ Coronal CT image of the thigh showing the relations
Posterior femoral Semitendinosus
cutaneous nerve of the sciatic nerve. Note the large fat-filled perineural space (inter-
muscular tunnel) surrounding the sciatic nerve. Please refer to Figs.
FIGURE 3-83 ■ Transverse (axial) CT image of the lower thigh 3-82 and Fig. 3-83 for the corresponding transverse CT images.
showing the anatomy of the sciatic nerve before its division into the
tibial and common peroneal nerve at the popliteal fossa. Note the
large fat-filled perineural space (intermuscular tunnel) surrounding
the sciatic nerve.
Anterior Vastus intermedius Superficial femoral Saphenous

Rectus femoris Vastus artery and vein nerve Sartorius
Lateral Medial medialis
Vastus medialis Rectus Great saphenous
Posterior femoris vein
Sartorius Adductor
magnus
Vastus lateralis Vastus
Superficial femoral intermedius
artery and vein
Gracilis
Great
Vastus
Biceps femoris Saphenous vein lateralis
(short head) Saphenous
nerve Semimembranosus
Common peroneal Gracilis
nerve
Biceps femoris
Tibial nerve (short head) Semitendinosus
Biceps femoris Semimembranosus Sciatic

Semitendinosus Biceps femoris Posterior femoral
(long head) nerve cutaneous nerve
(long head)
FIGURE 3-84 ■ Transverse (axial) CT image of the lower thigh FIGURE 3-86 ■ Transverse (axial) MRI image of the lower thigh
showing the anatomy of the sciatic nerve after its division into the showing the relations of the sciatic nerve before its division into the
tibial and common peroneal nerve at the popliteal fossa. The peri- tibial and common peroneal nerve. The perineural space is clearly
neural space is also delineated at this level. delineated and filled with hyperintense fat.
ch03.indd 91 23-08-2017 16:45:00

Vastus Superficial femoral

Rectus medialis artery and vein
femoris Sartorius
Great saphenous
vein
Saphenous
Vastus nerve
intermedius
Gracilis
Vastus
lateralis
Adductor
magnus
Biceps femoris
(short head) Semimembranosus
Common peroneal Semitendinosus

nerve Biceps femoris Tibial Posterior femoral
(long head) nerve ctaneous nerve
FIGURE 3-87 ■ Transverse (axial) MRI image of the lower thigh

showing the relations of the sciatic nerve after its division into the
tibial and common peroneal nerve.
Adductor Vastus
magnus intermedius
Vastus
lateralis
Biceps femoris transducer during a transverse scan for the sciatic nerve at the
Sartorius popliteal fossa.
Tibial nerve
Semimembranosus Common peroneal

nerve
Popliteal artery
and vein Cranial
ultrasound probes with their left hand and carry out
Medial Lateral
Caudal
needle interventions with their right hand should
stand on the right side of the patient and position
the ultrasound machine on the opposite side of the
FIGURE 3-88 ■ Coronal MRI image of the thigh showing the rela-
tions of the sciatic nerve.
patient. This is vice versa for left-handed operators.
2. Transducer selection: Because the sciatic nerve or its
branches are relatively superficial at the popliteal fossa,
a high-frequency (13-5 or 15-8 MHz) linear array trans-
Sciatic Nerve at the Popliteal Fossa – Ultrasound ducer is adequate for imaging.
Scan Technique 3 . Scan technique: The transducer is placed in the trans-
1. Position: verse orientation at the lower thigh (Figs. 3-89 to 3-91).
a. Patient: Prone position with the knee slightly bent Slowly slide the transducer distally towards the popliteal
and ankle supported. crease. The sciatic nerve is typically oval in shape in the
b. Operator and ultrasound machine: The opera- lower thigh and can be seen to bifurcate into its termi-
tor sits or stands on the side to be examined and nal branches at the popliteal fossa. Close to the popliteal
faces the patient’s head. The ultrasound machine is crease, the popliteal artery and vein can be visualized on
placed on the same side between the operator and the the posteromedial aspect of the sciatic nerve.
patient’s head. Alternatively the operator may choose 4. Sonoanatomy: The sciatic nerve appears as an oval hyper-
to position the ultrasound machine based on his or echoic structure in the mid to lower thigh (Fig. 3-92). It
her “handedness.” Right-handed operators who hold divides into its terminal branches at a variable distance
ch03.indd 92 23-08-2017 16:45:11

Semitendinosus
Epimysium of Biceps femoris
biceps femoris
Perineural space
Paraneural
sheath
Adductor
magnus Femur
Posterior Sciatic nerve

Medial Lateral
Anterior

ultrasound transducer during a transverse scan for the sciatic nerve FIGURE 3-92 ■ Transverse sonogram showing the sciatic nerve as
at the popliteal fossa. a hyperechoic structure between the hyperechoic epimysium of the
biceps femoris muscle posteriorly and the adductor magnus muscle
anteriorly at the lower thigh. Also note an additional hyperechoic
layer of connective tissue posterior to the sciatic nerve which repre-
sents the “paraneural sheath.”24 The hypoechoic perineural space is
also seen posteriorly between the epimysium of the biceps muscle
Semitendinosus
Biceps posteriorly and the sciatic nerve.
Semimembranosus long head
Gracilis
Sciatic nerve
Adductor
magnus
Biceps
short head Biceps femoris
Sartorius
Tibial
Vastus lateralis nerve Common
Vastus medialis peroneal
Vastus intermedius nerve
Posterior PV
Medial Lateral Rectus femoris PA

Anterior
FIGURE 3-91 ■ Figure highlighting the anatomical structures that Femur

are insonated during a transverse ultrasound scan for the sciatic Posterior
nerve at the popliteal fossa. Medial Lateral
Anterior
FIGURE 3-93 ■ Transverse sonogram showing the sciatic nerve

from the popliteal crease (Fig. 3-93). A hypoechoic after its division into the tibial and common peroneal nerve at the pop-
perineural space surrounds the sciatic nerve at the thigh liteal fossa. Note the relations of the tibial nerve to the popliteal vessels
and common peroneal nerve to the biceps femoris muscle (tendon).
(Figs. 3-94 and 3-95).2 This is continuous with the peri-
PA, popliteal artery; PV, popliteal vein.
neural space in the subgluteal (Figs. 3-67 and 3-68) and
parasacral (Figs. 3-57 and 3-58) regions2,3 and acts like an
intermuscular tunnel or conduit through which the sciatic
nerve travels from the parasacral region to the popliteal (epineurium) of the sciatic nerve (Figs. 3-95 and 3-96).
fossa.2 With high-definition ultrasound imaging it is now This represents the “paraneural sheath,”24 which is dis-
possible to delineate an additional hyperechoic layer of tinct from the epineurium24 and better delineated after
connective tissue that is interposed between the epimy- local anesthetic injection (Fig. 3-97)24 and envelopes not
sium of the surrounding muscle and the outer surface only the sciatic nerve but also the common peroneal and
ch03.indd 93 23-08-2017 16:45:35

Posterior Subepimyseal perineural

Thigh muscles compartment
Biceps femoris Epimysium

Subparaneural
Epimysium of compartment Paraneural sheath
biceps femoris Sciatic nerve
Epineurium (external)
Lateral CPN Medial

TN
Perineurium
Epineurium
(internal)
Posterior Nerve fascicles
Epimysium of
Perineural space adductor magnus Thigh muscles
Cranial Caudal
Sciatic vessels
Adductor magnus Anterior
Anterior
FIGURE 3-94 ■ Sagittal sonogram showing the sciatic nerve as a FIGURE 3-96 ■ Schematic diagram illustrating the fascial com-
hyperechoic structure within a narrow hypoechoic space (perineural partments surrounding the sciatic nerve at the popliteal fossa. CPN,
space) between the hyperechoic epimysium (short white arrows) of common peroneal nerve; TN, tibial nerve.
the surrounding muscles at the lower thigh.
The subepimyseal perineural compartment (Fig. 3-96),

Subepimyseal perineural
Epimysium compartment also referred to as the perineural space,25 is a well-defined
intermuscular space surrounding the sciatic nerve.2,3,25 It is
Paraneural sheath
Epineurium
filled with fat and blood vessels25 and clearly delineated in
Tibial nerve
ultrasound (2-D3 and 3-D2), CT25 (Figs. 3-83 to 3-85), and
MRI images (Figs. 3-86 and 3-87) of the thigh. In contrast
Subparaneural
compartment the subparaneural compartment is a potential space with
Nerve fascicles a thin layer of fat separating the paraneural sheath from
Common peroneal the epineurium of the nerve (Fig. 3-96)24 and serves like a
nerve
Posterior “plane of cleavage”26 that provides some degree of mobil-
Lateral Medial ity and protection to the neural elements housed within.
Anterior 5 . Clinical Pearls: The site where the sciatic nerve bifur-
cates into its terminal branches at the popliteal fossa is
FIGURE 3-95 ■ High-definition transverse sonogram of the sci- best identified using the “trace back” technique. One can
atic nerve at the level of its bifurcation into the tibial and common also locate the popliteal artery to identify the tibial nerve
peroneal nerve at the popliteal fossa. The paraneural sheath (white as it lies posterior and lateral to the artery.
arrow heads) is interposed between the epimysium (short white
arrows) of the surrounding muscles and the outer surface of the sci-
atic nerve (epineurium), which also appears hyperechoic. The sub- Sciatic Nerve at the Thigh – Anterior
epimyseal (perineural) and subparaneural compartments are seen as
hypoechoic areas between the epimysium and the paraneural sheath
Approach
and between the paraneural sheath and the epineurium, respectively. Gross Anatomy
The anterior approach for sciatic nerve block is technically
demanding and generally performed when the patient can-
tibial nerves separately.24 Local anesthetic injected during not be positioned in the lateral decubitus position. It produces
a popliteal sciatic nerve block is seen to compartmentalize complete anesthesia of the leg below the knee joint except for
into two areas around the sciatic nerve (Fig. 3-97)—that is, the skin on the medial aspect of the leg and foot supplied by
subepimyseal (but external to the paraneural sheath) and the saphenous nerve. The point for needle insertion is approxi-
subparaneural (beneath or deep to the paraneural sheath). mately 6 to 7 cm distal to the inguinal crease with the patient
ch03.indd 94 23-08-2017 16:45:55

Epimysium
Epimysium
CPN TN CPN
Subepimyseal
spread
LA
LA
LA TN
Paraneural Epimysium
sheath LA
Subparaneural Paraneural Subparaneural
spread sheath spread
A. Transverse plane B. Sagittal plane
CPN
TN
Paraneural
sheath Subepimyseal CPN TN
spread
Epimysium
Subparaneural Paraneural
spread LA
sheath Subparaneural
Subepimyseal Epimysium spread
spread LA LA
C. Coronal plane D. Volume view (front, left and top surface)
FIGURE 3-97 ■ Multiplanar 3-D view of the common peroneal (CPN) and tibial (TN) nerve at the popliteal fossa after an ultrasound-guided
sciatic nerve block. A rendered 3D volume demonstrating the front, right, and top surfaces of the volume is also presented in Fig. 3-97D. The
reference marker has been placed over the tibial nerve (Fig. 3-97A). Spread of the local anesthetic (LA) relative to the sciatic nerve and its
divisions or the paraneural sheath is clearly delineated in the multiplanar views.
in the supine position.27 This usually corresponds to the level Rectus femoris
Adductor longus
of the lesser trochanter of the femur in the thigh (Figs. 3-98 Sartorius
Tensor fascia lata
to 3-100). In a transverse anatomical section of the thigh at
this level, the sciatic nerve lies deep in between the adductor Vastus lateralis
Adductor
Pectineus brevis
magnus or quadratus femoris muscle anteriorly and the glu- Gluteus medius
Iliopsoas
teus maximus muscle posteriorly (Figs. 3-22 and 3-98). Lesser trochanter
Vastus
intermedialis
Computed Tomography Anatomy of the Sciatic Nerve Adductor
Sciatic nerve Quadratus magnus
at the Thigh Femoris
Fig. 3-99
Anterior Gluteus maximus
Lateral Medial
Magnetic Resonance Imaging Anatomy of the Sciatic Posterior
Nerve at the Thigh

FIGURE 3-98 ■ Transverse anatomical section of the upper thigh
Fig. 3-100 at the level of the lesser trochanter.
Sciatic Nerve at the Thigh – Anterior Approach b. Operator and ultrasound machine: The operator
Ultrasound Scan Technique may choose to position the ultrasound machine based
1. Position: on his or her “handedness.” Right-handed operators
a. Patient: Supine with the leg fully extended and who hold ultrasound probes with their left hand and
slightly internally rotated.28 carry out needle interventions with their right hand
ch03.indd 95 23-08-2017 16:46:10

Femoral artery
and vein Adductor
Sartorius longus
Femoral nerve
Rectus femoris Gracilis
LCF artery Adductor brevis
and vein
Tensor fascia
lata Pectineus
PFA
Vastus Adductor
medialis magnus
Lesser trochanter
Vastus
lateralis
Semitendinosus
tendon
Anterior
Sciatic nerve
Lateral Medial Gluteus
Semimembranosus Biceps femoris maximus
Posterior tendon tendon
FIGURE 3-99 ■ Transverse (axial) CT image of the upper thigh at

the level of the lesser trochanter. PFA, profunda femoris artery.
Sartorius Femoral nerve

Rectus femoris Femoral artery
Vastus and vein
longus
Tensor fascia
lata
PFA
Adductor brevis
Vastus
lateralis
Pectineus
Lesser
Vastus
trochanter
medialis
transducer during a transverse scan for the sciatic nerve at the upper
thigh during an anterior approach for sciatic nerve block.
Gluteus Adductor
maximus magnus
Semitenidinosus
Sciatic nerve
Semimembranosus Biceps femoris
tendon tendon
FIGURE 3-100 ■ Transverse (axial) MRI image of the upper thigh

at the level of the lesser trochanter. PFA, profunda femoris artery.
Pulsation of femoral
artery
should stand on the right side of the patient and

position the ultrasound machine on the opposite
ASIS
operators.
2. Transducer selection: Low-frequency (5-2 MHz) curve
array transducer. Keep leg fully extended and slightly
internally rotated
3 . Scan technique: The transducer is placed on the medial GT
Inguinal crease
aspect of the thigh approximately 6 to 7 cm distal and
parallel to the inguinal crease in a transverse orientation
(Figs. 3-101 to 3-103). The reference structure to visu-
alize is the femur (lesser trochanter). Once visualized, the ultrasound transducer during a transverse scan for the sciatic
slide the transducer medially to bring the femur to the nerve at the upper thigh during an anterior approach for sciatic nerve
lateral edge of the ultrasound image. The sciatic nerve is block. GT, greater trochanter; ASIS, anterior superior iliac spine.
ch03.indd 96 23-08-2017 16:46:34

Rectus femoris
visualized as a hyperechoic structure between the adduc-
Sartorius tor magnus muscle anteriorly and gluteus maximus muscle
Tensor fascia lata
posteriorly (Fig. 3-104).
Vastus lateralis 4. Sonoanatomy: In a transverse sonogram the sciatic nerve
Pectineus
Gluteus medius is typically visualized as an elliptical and hyperechoic
Iliopsoas Lesser
trochanter structure between the adductor magnus and gluteus maxi-
Vastus
intermedialis mus muscle (Fig. 3-104). This can be confirmed by rotat-
Adductor
magnus
ing the transducer to the sagittal orientation in relation to
Sciatic nerve Quadratus
Femoris the femur to visualize the hyperechoic laminated appear-
ance of the sciatic nerve.
Anterior Gluteus maximus 5 . Clinical Pearls: The anterior approach for sciatic nerve
Lateral Medial
block is an advanced regional anesthetic technique and
Posterior
can be technically demanding. The sciatic nerve is deep
FIGURE 3-103 ■ Figure highlighting the anatomical structures that at this level, and there are no reference vascular struc-
are insonated during a transverse ultrasound scan for the sciatic nerve tures in close vicinity. The sagittal axis may be superior
at the upper thigh during an anterior approach for sciatic nerve block. to the transverse axis for visualizing the sciatic nerve at
this level.29
Lateral Anterior Medial
Rectus
femoris
Terminal Nerves in the Leg
Gross Anatomy
Vastus
medialis Adductor The four terminal nerves of the leg below the knee pro-
longus
vide sensation and motor function to the foot and ankle
Adductor (Figs. 3-105 to 3-107). The tibial nerve is a terminal branch of
magnus
Perineural the sciatic nerve. It lies deep to the gastrocnemius and soleus
space
Femur
Sciatic nerve muscles and on the posterior surface of the tibialis posterior
muscle (Fig. 3-106). The tibial nerve accompanies the pos-
Lesser
trochanter
Gluteus terior tibial artery (Fig. 3-106) and at the level of the medial
maximus
Posterior
malleolus lies medial to the artery and lateral to the flexor hal-
lucis longus tendon under the flexor retinaculum (Figs. 3-108
FIGURE 3-104 ■ Sonogram demonstrating the sciatic nerve at the
and 3-109). The saphenous nerve is a terminal branch of the
upper thigh at the level of the lesser trochanter during an anterior
approach for sciatic nerve block.
Tibial tuberosity
Tibialis anterior
Anterior tibial
artery and vein Tibia
Extensor digitorum Sartorius
longus (tendon)
Fibularis longus Great saphenous
Popliteus
vein
Fibula
Gracilis
(tendon)
Common peroneal
nerve Semitendinosis
(tendon)
Soleus
Gastrocnemius Popliteal
(lateral head) artery and vein
Tibial nerve Gastrocnemius
Plantaris tendon (medial head)
FIGURE 3-105 ■ Transverse anatomical illustration of the leg at the level of the tibial tuberosity.
ch03.indd 97 23-08-2017 16:46:48

Extensor digitorum Tibialis anterior

Anterior tibial longus
artery and vein Tibia
Deep peroneal nerve
Fibularis longus
Tibialis posterior
Fibula Flexor digitorum
longus
Flexor hallucis
Great saphenous
longus
vein
Fibular artery
Posterior tibial
and vein
artery and vein
Gastrocnemius Gastrocnemius
(lateral head) (medial head)
Sural nerve
Soleus
Small saphenous
Tibial nerve
vein
FIGURE 3-106 ■ Transverse anatomical illustration of the leg above the middle of the leg.
Deep peroneal
Extensor hallucis Anterior tibial
nerve
longus artery and vein
Cutaneous branches of Tibialis anterior
superficial peroneal nerve tendon
Extensor digitorum Tibia
Fibula Great saphenous
vein
Peroneus longus
tendon Saphenous nerve
Small saphenous Tibialis posterior

vein tendon
Peroneus
Flexor digitorum
brevis
longus tendon
Flexor hallucis Posterior tibial
longus artery and vein
Sural nerve Posterior tibial
Calcaneal
nerve
tendon
FIGURE 3-107 ■ Transverse anatomical illustration of the leg above the medial malleolus.
Posterior Tibial Artery femoral nerve (Fig. 3-110). It typically pierces the deep fascia
Tibial Nerve
on the medial aspect of the knee after emerging between the
TA
FDL tendons of the sartorius and gracilis. It then travels down the
Tendon Achilles
FHL leg superficially along the course of the great saphenous vein
Tibia
(Figs. 3-105 to 3-107, 3-110, and 3-111).
The deep peroneal nerve is a terminal branch of the com-
PB/PL
Fibula mon peroneal nerve and originates within the substance of the
peroneus longus muscle on the lateral aspect of the proximal
Medial fibula. The nerve enters the anterior compartment of the leg
Anterior Posterior
by piercing the interosseous membrane and descends deep
Lateral
to the extensor digitorum longus muscle (Fig. 3-106). As it
descends distally towards the ankle, the nerve lies lateral,
FIGURE 3-108 ■ Transverse anatomical section through the distal
leg at the ankle region demonstrating tibial nerve. TA, tibialis ante- then anterior, and finally lateral to the anterior tibial artery
rior; FDL, flexor digitorum longus; FHL, flexor hallucis longus; PB, (Figs. 3-106, 3-107 and 3-112) as it enters the extensor reti-
peroneus brevis; PL, peroneus longus. naculum at the ankle.
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Tibialis posterior
Tibialis anterior
Flexor digitorum
longus
Extensor hallucis Medial
longus malleolus Flexor hallucis
longus
Posterior tibial
artery
Tibial nerve
Flexor retinaculum
Calcaneal tendon
Abductor hallucis
FIGURE 3-109 ■ Anatomical illustration of the foot and ankle demonstrating the relations of the tibial nerve on the medial aspect of the
ankle.
Deep Peroneal Nerve

Tibialis Anterior
EHL
Sahenous nerve EDL
Anterior
Tibial Artery
Posterior tibial
Fibula
artery Peroneus
Tibia Longus/Brevis
Tibial nerve
Medial malleolus
Anterior
Medial Lateral
Posterior
FIGURE 3-110 ■ Anatomical illustration demonstrating the saphe-

nous and tibial nerves on the medial aspect of the foot.
leg at the level of the ankle demonstrating the deep peroneal nerve
and the anterior tibial artery. EHL, extensor hallucis longus; EDL,
extensor digitorum longus.
Great Saphenous Vein
Tibialis Posterior Tibialis Anterior

The superficial peroneal nerve is also a terminal branch
Flexor Digitorum Longus of the common peroneal nerve (Fig. 3-113) and like the deep
Tibia peroneal nerve originates within the substance of the pero-
neus longus muscle. It descends first between the peroneus
longus and brevis muscle and then between the intermuscular
septum of the peroneus brevis and extensor digitorum longus
Fibula
Medial muscle (Fig. 3-114). It then pierces the deep crural fascia and
Posterior Anterior becomes cutaneous in the lower part of the leg at a variable
Lateral distance from the ankle (Fig. 3-107).30
The sural nerve (Fig. 3-115) arises from cutaneous
branches of the tibial nerve and common peroneal nerve. It
leg at the level of the ankle. The saphenous nerve is located in the descends on the posterior aspect of the leg between the two
same fascial plane as the saphenous vein. heads of the gastrocnemius and descends along the lateral
ch03.indd 99 23-08-2017 16:47:16

Saphenous nerve
Superficial peroneal nerve
Tibialis anterior tendon Superficial peroneal
Extensor digitorum nerve
Extensor hallucis
longus tendon
longus tendon
Fibula Deep peroneal nerve
Superficial peroneal nerve Medial malleolus Sural nerve
Intermediate dorsal
cutaneous nerve Superficial peroneal nerve
Medial dorsal cutaneous
Medial dorsal cutaneous
branch
nerve
Dorsal digital Intermediate dorsal
branches of deep cutaneous branch
peroneal nerve
Lateral malleolus
Lateral dorsal cutaneous nerve

(continuation of sural nerve)
FIGURE 3-113 ■ Anatomical illustration of the foot demonstrat-
FIGURE 3-115 ■ Anatomical illustration of the foot demonstrating
ing the course and divisions of the saphenous, superficial, and deep
the course and divisions of the superficial peroneal and sural nerves.
peroneal nerves.
Small Saphenous Vein

Superficial Peroneal Nerve Peroneus Brevis/ Sural Nerve
longus
EDL Tendon Achilles
PL
PB
TA EHL
Fibula Fibula
Tibia TP
FHL Tibia
Soleus
FDL l
era ior
Lat ter
Pos
Anterior Gastrocnemius ior dia
l
ter Me
An
Medial Lateral
Posterior
FIGURE 3-114 ■ Transverse anatomical section through the dis- FIGURE 3-116 ■ Anatomical section through the distal leg at the
tal leg demonstrating the intermuscular plane between the peroneus ankle region demonstrating the sural nerve in the vicinity of the
brevis and the extensor digitorum longus in which the superficial small saphenous vein.
peroneal nerve is located.
TA
Anterior tibial EHL
artery and veins, and Great saphenous vein
deep peroneal nerve
EDL
edge of the Achilles tendon (Figs. 3-107 and 3-116), lying Tib post
close to the short saphenous vein (Fig. 3-116), to the space Peroneal
FDL Posterior tibial
artery and veins,
artery and branch
between the lateral malleolus and the calcaneus. FHL and tibial nerve
Computed Tomography Anatomy of the Terminal Peroneus

brevis and longus
Soleus
Gastrocnemius
Nerves of the Leg Short saphenous vein tendon
Fig. 3-117
FIGURE 3-117 ■ Transverse (axial) CT image of the distal leg
Magnetic Resonance Imaging Anatomy of the demonstrating the tibial nerve and vascular structures on the medial
aspect of the ankle. TA, tibialis anterior; EHL, extensor hallucis lon-
Terminal Nerves of the Leg
gus; EDL, extensor digitorum longus; Tib Post, tibialis posterior;
Figs. 3-118 and 3-119 FHL, flexor hallucis longus; FDL, flexor digitorum longus.
ch03.indd 100 23-08-2017 16:47:28

TA
Terminal Nerves of the Leg – Ultrasound Scan
EHL
Anterior tibial artery Technique
EDL and veins, and deep
Superficial peroneal
nerve Tibia peroneal nerve
1. Position:
Deep fascia
Peroneal artery a. Patient: Supine position. The leg that is examined
Fibula Great saphenous vein
and vein
TP
and saphenous nerve is positioned according to the nerve to be examined.
PB
Peroneus longus FHL
FDL For the saphenous (Fig. 3-120) and tibial (Fig. 3-121)
Posterior tibial artery and
veins, and tibial nerve nerves the ipsilateral knee and hip is slightly flexed
Soleus
and externally rotated. For the superficial peroneal
Sural nerve and short
saphenous vein Gastrocnemius tendon (Fig. 3-122), deep peroneal (Fig. 3-123), and sural
(Fig. 3-124) nerves the ipsilateral knee is flexed
FIGURE 3-118 ■ Transverse (axial) MRI image of the distal leg
demonstrating the terminal nerves of the leg. EDL, extensor digitorum
longus; EHL, extensor hallucis longus; TA, tibialis anterior; TP, tibi-
alis posterior; PB, peroneus brevis; FHL, flexor hallucis longus; FDL,
flexor digitorum longus.
Tibialis anterior tendon

Deep peroneal nerve EHL
EDL Anterior tibial

Superficial peroneal
artery and veins
nerve
Tibia
Fibula
Tibialis posterior
Peroneus longus tendon
tendon FDL
Peroneus brevis FHL
Posterior tibial
artery and veins
Short saphenous
vein/sural nerve and Tibial nerve
branches Achilles tendon
FIGURE 3-119 ■ Transverse (axial) MRI image of the ankle region FIGURE 3-121 ■ Figure showing the position and orientation of
demonstrating the terminal nerves of the leg. EDL, extensor digi- the ultrasound transducer during a transverse ultrasound scan for the
torum longus, EHL; extensor hallucis longus; FHL, flexor hallucis tibial nerve at the distal leg.
longus; FDL, flexor digitorum longus.
FIGURE 3-120 ■ Figure showing the position and orientation of FIGURE 3-122 ■ Figure showing the position and orientation of
the ultrasound transducer during a transverse ultrasound scan for the the ultrasound transducer during a transverse ultrasound scan for the
saphenous nerve at the distal leg. superficial peroneal nerve at the distal leg. Note an assistant is sup-
porting the leg during the ultrasound scan.
ch03.indd 101 23-08-2017 16:47:47

FIGURE 3-125 ■ Transverse sonogram demonstrating the tibial

nerve and its relations at the distal leg.
the ultrasound transducer during a transverse ultrasound scan for the
deep peroneal nerve at the distal leg.
FIGURE 3-126 ■ Transverse sonogram demonstrating the saphe-

nous nerve and its relations at the distal leg.
view of the posterior tibial artery, which is the key sono-

graphic landmark for this nerve block (Fig. 3-125). The
FIGURE 3-124 ■ Figure showing the position and orientation of structures visualized should be surveyed proximally to
the ultrasound transducer during a transverse ultrasound scan for the confirm the identity of the flexor hallucis longus and
sural nerve at the distal leg.
observe the characteristic course of the tibial nerve and
tibial artery. The flexor hallucis longus tendon, which lies
on the medial and posterior aspect of the tibial nerve, can
and the sole of the foot is placed flat on the bed. An be confirmed by moving the first toe and observing the
assistant may be asked to support the leg during the movement of the tendon and muscle.
examination. a. To image the saphenous nerve (Fig. 3-120), the trans-
b. Operator and ultrasound machine: The operator is ducer is placed just above the medial malleolus. Apply
positioned at the caudal end of the patient. The ultra- light pressure over the skin with the transducer during
sound machine is placed on the ipsilateral side to be the scan as the long saphenous vein is easily com-
examined on the cephalad side. pressible. The long saphenous vein is the key sono-
2. Transducer selection: High-frequency (15-8 or 17-5 MHz) graphic landmark for this nerve block (Fig. 3-126).
linear array transducer. In some individuals, the saphenous nerve may not be
3. Scan technique: To image the tibial nerve, the transducer consistently visualized at this level.
is placed between the medial malleolus and the Achilles b. To image the deep peroneal nerve, the transducer is
tendon (Fig. 3-121) to obtain a transverse sonographic placed along a line joining the medial malleoli and the
ch03.indd 102 23-08-2017 16:47:58

FIGURE 3-127 ■ Transverse sonogram demonstrating the deep FIGURE 3-129 ■ Transverse sonogram demonstrating the sural
peroneal nerve and its relations at the distal leg. EDL, extensor digi- nerve and its relations at the distal leg. Note the short saphenous
torum longus; EHL, extensor hallucis longus; TA, tibialis anterior. vein adjacent to the sural nerve.
peroneal nerve. The superficial peroneal nerve appears

as a honeycomb structure (Fig. 3-128) that lies in the
groove within the intermuscular septum approximately
5 to 10 cm above the lateral malleoli (Fig. 3-114). It
lies below the deep crural fascia of the leg in the midleg
and pierces this fascia to lie superficial to it as the nerve
travels down the leg towards the lateral malleolus.
d. To image the sural nerve, the transducer is placed
transversely along a line joining the lateral malleolus
FIGURE 3-128 ■ Transverse sonogram demonstrating the superfi- and the Achilles tendon (Fig. 3-124). Apply light pres-
cial peroneal nerve and its relations at the distal leg. sure over the skin with the transducer during the scan,
as the short saphenous vein is easily compressible. The
short saphenous vein is visualized and confirmed by
lateral malleoli (Fig. 3-123). The anterior tibial artery is compression and surveyed proximally along its course.
confirmed by observing its pulsations and using Color/ The short saphenous vein is the key sonographic land-
Power Doppler ultrasound. At this level, the deep pero- mark for this nerve block. The sural nerve appears as
neal nerve appears as a small hypoechoic structure lat- a honeycomb structure and usually lies posterior to
eral to the artery (Fig. 3-127). The anterior tibial artery the short saphenous vein between the short saphenous
is the key sonographic landmark for this nerve block. vein and the Achilles tendon (Fig. 3-129) and can be
c. To image the superficial peroneal nerve (Fig. 3-122), confirmed by tracing it back and forth along its course.
the transducer is placed transversely across the fibula 4. Sonoanatomy: The tibial nerve has a typical honey-
just above the lateral malleoli to image the fibula in a comb appearance and is located deep and medial to the
transverse section (Fig. 3-128). The transducer is then tibial artery at the level just above the medial malleolus
moved proximately along the fibula. During this survey, (Fig. 3-125). The saphenous nerve also has a honey-
the fibula is observed to move deeper as the muscle of combed appearance in the short axis (Fig. 3-126) but is
the lateral and anterior leg compartments become more not consistently visualized in all individuals. The deep
pronounced. An intermuscular septum arises from the peroneal nerve appears as a hyperechoic structure with
edge of the fibula which separates the extensor digi- hypoechoic dots in the short axis (Fig. 3-127). The super-
torum longus and the peroneus brevis/peroneus lon- ficial peroneal nerve appears as one or two fusiform
gus. This is the intermuscular septum that divides the hypoechoic structures in the short axis (Fig. 3-128). The
anterior and lateral compartment of the leg. This is the sural nerve appears as a honeycombed structure in the
key sonographic landmark to identify the superficial short axis (Fig. 3-129).
ch03.indd 103 23-08-2017 16:48:09

5. Clinical Pearls: The “trace back” technique is par- 7. Soong J, Schafhalter-Zoppoth I, Gray AT. The importance of
ticularly useful for confirming the nerves in the leg. transducer angle to ultrasound visibility of the femoral nerve.
Reg Anesth Pain Med. 2005;30:505.
Compared with the traditional ankle block using land-
8. Soong J, Schafhalter-Zoppoth I, Gray AT. Sonographic imaging
mark techniques, ultrasound-guided ankle blocks are
of the obturator nerve for regional block. Reg Anesth Pain Med.
generally administered more proximal to the malleoli. 2007;32:146–151.
Sonographic study of the peripheral nerves at the ankle 9. Sinha SK, Abrams JH, Houle TT, Weller RS. Ultrasound-guided
typically involves the identification of key anatomical obturator nerve block: an interfascial injection approach without
landmarks (artery, vein, or intermuscular septum) associ- nerve stimulation. Reg Anesth Pain Med. 2009; 34:261–264.
10. Hospodar PP, Ashman ES, Traub JA. Anatomic study of the
ated with the nerve and then tracing it proximally until
lateral femoral cutaneous nerve with respect to the ilioinguinal
it is best visualized and targeted for nerve blockade. At
surgical dissection. J Orthop Trauma. 1999;13:17–19.
the level of the malleoli, numerous tendons look similar 11. Aszmann OC, Dellon ES, Dellon AL. Anatomical course of the
to the nerves in a sonogram. Muscles can be differenti- lateral femoral cutaneous nerve and its susceptibility to com-
ated from nerves by observing movement on sonography pression and injury. Plast Reconstr Surg. 1997;100:600–604.
by asking the patient to move his or her toes or ankle. 12. Hurdle MF, Weingarten TN, Crisostomo RA, Psimos C, Smith J.
Ultrasound-guided blockade of the lateral femoral cutaneous nerve:
In addition, the tendons will change in appearance as
technical description and review of 10 cases. Arch Phys Med
a dynamic scan is performed proximally. The tendons
Rehabil. 2007;88:1362–1364.
transform into their corresponding muscle proximally. 13. Saranteas T, Anagnostis G, Paraskeuopoulos T, et al. Anatomy
The nerves are mobile and may “slip” on either side of and clinical implications of the ultrasound-guided subsartorial
the vessels with transducer pressure. With respect to the saphenous nerve block. Reg Anesth Pain Med. 2011;36:399–402.
superficial peroneal nerve there are several variations on 14. Horn JL, Pitsch T, Salinas F, Benninger B. Anatomic basis to
the ultrasound-guided approach for saphenous nerve blockade.
where the nerve is located, that is, whether it is deep to
Reg Anesth Pain Med. 2009;34:486–489.
the crural fascia, where it divides into the medial dorsal
15. Tsui BC, Ozelsel T. Ultrasound-guided transsartorial perifemoral
cutaneous nerve and the intermediate dorsal cutaneous artery approach for saphenous nerve block. Reg Anesth Pain Med.
nerve, and where it pierces the crural fascia to lie super- 2009;34:177–178.
ficial to it. These variations may be difficult to appreciate 16. Tsui BC, Finucane BT. The importance of ultrasound land-
using ultrasound. The use of ultrasound for ankle blocks marks: a “traceback” approach using the popliteal blood vessels
for identification of the sciatic nerve. Reg Anesth Pain Med.
may improve the success rates of sural and tibial nerve
2006;31:481–482.
blocks.31,32 Also blockade of the saphenous nerve at the
17. Gaertner E, Lascurain P, Venet C, et al. Continuous parasacral
ankle may not be necessary for forefoot surgery.33 sciatic block: a radiographic study. Anesth Analg. 2004;98:
831–834, table.
18. Morris GF, Lang SA, Dust WN, Van der Wal M. The parasacral
sciatic nerve block. Reg Anesth. 1997;22:223–228.
References 19. Ripart J, Cuvillon P, Nouvellon E, Gaertner E, Eledjam JJ.
1. Farny J, Drolet P, Girard M. Anatomy of the posterior Parasacral approach to block the sciatic nerve: a 400-case survey.
approach to the lumbar plexus block. Can J Anaesth. 1994;41: Reg Anesth Pain Med. 2005;30:193–197.
480–485. 20. Hagon BS, Itani O, Bidgoli JH, Van der Linden PJ. Parasacral
2. Karmakar M, Li X, Li J, Sala-Blanch X, Hadzic A, Gin T. Three- sciatic nerve block: does the elicited motor response predict the
dimensional/four-dimensional volumetric ultrasound imaging success rate? Anesth Analg. 2007;105:263–266.
of the sciatic nerve. Reg Anesth Pain Med. 2012;37:60–66. 21. Ho AM, Karmakar MK. Combined paravertebral lumbar plexus
3. Karmakar MK, Kwok WH, Ho AM, Tsang K, Chui PT, and parasacral sciatic nerve block for reduction of hip fracture
Gin T. Ultrasound-guided sciatic nerve block: description of in a patient with severe aortic stenosis. Can J Anaesth. 2002;
a new approach at the subgluteal space. Br J Anaesth. 2007; 49:946–950.
98:390–395. 22. Ben-Ari AY, Joshi R, Uskova A, Chelly JE. Ultrasound localiza-
4. Smoll NR. Variations of the piriformis and sciatic nerve with tion of the sacral plexus using a parasacral approach. Anesth
clinical consequence: a review. Clin Anat. 2010;23:8–17. Analg. 2009;108:1977–1980.
5. Vloka JD, Hadzic A, April E, Thys DM. The division of the 23. Guardini R, Waldron BA, Wallace WA. Sciatic nerve block: a new
sciatic nerve in the popliteal fossa: anatomical implications for lateral approach. Acta Anaesthesiol Scand. 1985;29:515–519.
popliteal nerve blockade. Anesth Analg. 2001;92:215–217. 24. Andersen HL, Andersen SL, Tranum-Jensen J. Injection inside
6. Gustafson KJ, Pinault GC, Neville JJ, et al. Fascicular anatomy the paraneural sheath of the sciatic nerve: direct comparison
of human femoral nerve: implications for neural prostheses using among ultrasound imaging, macroscopic anatomy, and histologic
nerve cuff electrodes. J Rehabil Res Dev. 2009;46:973–984. analysis. Reg Anesth Pain Med. 2012;37:410–414.
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25. Floch H, Naux E, Pham DC, Dupas B, Pinaud M. Computed 30. Canella C, Demondion X, Guillin R, Boutry N, Peltier J,
tomography scanning of the sciatic nerve posterior to the femur: Cotten A. Anatomic study of the superficial peroneal nerve
Practical implications for the lateral midfemoral block. Reg using sonography. AJR Am J Roentgenol. 2009;193:174–179.
Anesth Pain Med. 2003;28:445–449. 31. Redborg KE, Sites BD, Chinn CD, et al. Ultrasound improves
26. Franco CD. Connective tissues associated with peripheral the success rate of a sural nerve block at the ankle. Reg Anesth
nerves. Reg Anesth Pain Med. 2012;37:363–365. Pain Med. 2009;34:24–28.
27. Ota J, Sakura S, Hara K, Saito Y. Ultrasound-guided anterior 32. Redborg KE, Antonakakis JG, Beach ML, Chinn CD, Sites BD.
approach to sciatic nerve block: a comparison with the posterior Ultrasound improves the success rate of a tibial nerve block at
approach. Anesth Analg. 2009;108:660–665. the ankle. Reg Anesth Pain Med. 2009;34:256–260.
28. Vloka JD, Hadzic A, April E, Thys DM. Anterior approach to 33. Lopez AM, Sala-Blanch X, Magaldi M, Poggio D, Asuncion J,
the sciatic nerve block: the effects of leg rotation. Anesth Analg. Franco CD. Ultrasound-guided ankle block for forefoot surgery:
2001;92:460–462. the contribution of the saphenous nerve. Reg Anesth Pain Med.
29. Tsui BC, Ozelsel TJ. Ultrasound-guided anterior sciatic nerve 2012;37:554–557.
block using a longitudinal approach: “expanding the view.” Reg
Anesth Pain Med. 2008;33:275–276.
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Sonoanatomy Relevant for Ultrasound-Guided
CHAPTER 4 Abdominal Wall Nerve Blocks
Introduction The aponeuroses on either side fuse in the midline to form a

median band called the linea alba. The RAM is longitudinal
Ultrasound-guided abdominal wall blocks are a recent in shape, runs vertically on either side of the linea alba
innovation of the traditional landmark-based techniques of (Fig. 4-6), and is enclosed in a fibrous sheath called the
performing abdominal wall field blocks.1 These blocks include “rectus sheath” (see later, Fig. 4-4).
the transverse abdominis plane (TAP) block (lateral/midaxillary The EOM originates as eight fleshy slips from the lower
and subcostal),1–8 rectus sheath block, iliohypogastric and eight ribs (Fig. 4-2). The upper slips of the origin of the
ilioinguinal nerve block,8 and the quadratus lumborum block
(QLB).8–12 They are fairly simple to perform, largely devoid
of complications, and produce sensory and motor blockade of
the abdominal wall.
Gross Anatomy
Muscles of the Anterior Abdominal Wall
Anterior rectus
The anterior abdominal wall is made of four large, flat External oblique
sheath
muscle
muscles on either side of the midline. They are the external
oblique muscle (EOM, Figs. 4-1 to 4-3), internal oblique External oblique
aponeurosis
muscle (IOM, Figs. 4-3 to 4-5), transversus abdominis m uscle
(TAM, Figs. 4-3, 4-6, and 4-7), and the rectus abdominis
muscle (RAM, Figs. 4-3 and 4-6). Two other smaller mus-
cles, the cremaster and the pyrimidalis, are also present. The
EOM, IOM, and the TAM each end in a fibrous aponeuro- FIGURE 4-2 ■ Figure showing the origin, insertion, and arrange-
sis that extends up to the midline (Figs. 4-1, 4-4, and 4-6). ment of the muscle fibers of the external oblique muscle.
T1
T2 T2
T3
T3
T4
T4 Serratus anterior
Long thoracic nerve T5 T5
T6 T6 External oblique (cut)
Latissimus dorsi
T7 T7 Posterior rectus
Lateral cutaneous branch of sheath
T8 T8 Rectus abdominis (cut)
intercostal nerve (T2-T11) T9
T10 Anterior rectus
Anterior cutaneous branch of sheath (cut)
intercostal nerve (T2-T11) T9 Transversus abdominis
T11
Internal oblique and
Lateral cutaneous branch of T10 aponeurosis
subcostal nerve (T12) Anterior cutaneous branch
T11 of subcostal nerve (T12)
Lateral cutaneous branch of Anterior cutaneous branch
iliohypogastric nerve (L1) of iliohypogastric nerve (L1)
Lateral femoral cutaneous Ilioinguinal nerve
nerve (L2,3) External oblique
aponeurosis (cut)
FIGURE 4-1 ■ Figure showing the innervation of the trunk and the abdominal wall. Note the aponeurosis of the external oblique muscle and
the anterior and posterior wall of the rectus sheath (cutout view).
106
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Chapter 4 / Sonoanatomy Relevant for Abdominal Wall Nerve Blocks n 107
Latissimus dorsi
Serratus anterior
External oblique External oblique
Transversus abdominis
Tendinous insertion
Posterior rectus
sheath Rectus abdominis
Internal oblique
External oblique
aponeurosis
Inguinal ligament
FIGURE 4-3 ■ Figure showing the anatomical arrangement of the muscles of the anterior abdominal wall (external oblique, internal oblique,
transversus abdominis, and rectus abdominis) with their aponeurosis, including the rectus sheath. Note the three tendinous insertions on the
anterior surface of the rectus abdominis muscle.
Latissimus dorsi
5
Serratus anterior Rectus abdominis
6
7
External oblique 8
aponeurosis (cut) Anterior rectus
9 sheath (cut)
10
External oblique (cut) Tendinous insertion
Internal oblique
Anterior rectus
sheath
Inguinal ligament
FIGURE 4-4 ■ Figure showing the anatomical arrangement of the internal oblique muscle with its aponeurosis.
EOM interdigitate with that of the serratus anterior mus- small triangular opening called the superficial inguinal ring.
cle, and the lower slips of the EOM interdigitate with that Medial to the lateral edge of the rectus abdominis muscle
of the latissimus dorsi muscle. The fibers of the muscle run the external oblique aponeurosis contributes to forming the
downwards, forward, and medially (Fig. 4-2) to end in a rectus sheath (Fig. 4-6, see later).
broad aponeurosis (Fig. 4-1), which is inserted (from above The IOM originates from the lateral two-thirds of the
downwards) to the xiphoid process, pubic symphysis, pubic inguinal ligament, anterior two-thirds of the intermediate area
crest, and the pectineal line of the pubis. The caudal fibers of the iliac crest (Fig. 4-5), and the thoracolumbar fascia pos-
of the muscle are inserted to the anterior two-thirds of the teriorly. From its origin the fibers of the IOM run obliquely
outer lip of the iliac crest (Fig. 4-2). The caudal end of upwards, forwards, and medially, crossing the fibers of
the external oblique aponeurosis is folded on itself to form the the EOM at right angles (Fig. 4-5), to end in an aponeuro-
inguinal ligament, and above the pubic tubercle there is a sis through which it is attached to the xiphoid process, the
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108 n Chapter 4 / Sonoanatomy Relevant for Abdominal Wall Nerve Blocks
seventh to ninth costal cartilage, linea alba, pubic crest, and linea alba, pubic crest, and pectineal line of the pubis. At the
pectineal line. The IOM aponeurosis also contributes to the lower part of the TAM the lower fibers of the muscle fuse with
formation of the rectus sheath (Fig. 4-4, see later). the lower fibers of the IOM to form the conjoint tendon. The
The TAM has a fleshy origin from the lateral one-third of TAM aponeurosis also takes part in the formation of the rectus
the inguinal ligament, anterior two-thirds of the inner lip of the sheath (Fig. 4-6, see later). The neurovascular structures of the
iliac crest, thoracolumbar fascia posteriorly, and the inner sur- abdominal wall lie in between the IOM and TAM (Fig. 4-8).
face of the lower six costal cartilages. The fibers of the TAM This intermuscular plane is also referred to as the transversus
are directed horizontally forwards (Figs. 4-6 and 4-7) and abdominis plane (TAP, Figs. 4-9 to 4-11) and is a popular site
end in an aponeurosis that is attached to the xiphoid process, for ultrasound-guided abdominal wall nerve blocks.
External oblique External oblique

(cut) muscle (cut)
Internal oblique
Internal oblique
muscle
muscle (cut) Transversus
abdominis
muscle
FIGURE 4-5 ■ Figure showing the origin and insertion of the mus- FIGURE 4-7 ■ Figure showing the origin and insertion of the trans-
cle fibers of the internal oblique deep to the external oblique muscle. versus abdominis muscle and its relation to the external and internal
Also note the direction of the muscle fibers of the internal oblique oblique muscles.
muscle (upwards and medially) relative to the external oblique
muscle.
Serratus anterior
Linea alba
Latissimus dorsi
External oblique
External oblique
(cut) Anterior rectus
sheath
Internal oblique
(cut) Rectus abdominis
Transversus abdominis Tendinous insertion
Transversus abdominis Internal oblique
aponeurosis (cut)
FIGURE 4-6 ■ Figure showing the anatomical arrangement of the transversus abdominis muscle. Note the direction of the muscle fibers of
the transversus abdominis muscle (transversely).
Ch04.indd 108 23-08-2017 19:29:12

Rectus abdominis
Anterior cutaneous
nerve
External oblique
Internal oblique
Transversus
abdominis
Lateral cutaneous Internal oblique
nerve
External oblique
TAP
Transverse abdominis
plane
Sacrospinalis
Posterior cutaneous
nerve Posterior primary
ramus
FIGURE 4-8 ■ Figure showing the anatomical course and divisions FIGURE 4-10 ■ Coronal cadaver anatomic section (rendered from
of a typical thoracolumbar nerve. Note the posterior primary rami the Visible Human Server) showing anatomical relations of the TAP
and the lateral and anterior cutaneous divisions of the nerve. (transversus abdominis plane).
Rectus abdominis
Rectus sheath
Transversus
abdominis Transversus
abdominis
Internal oblique
Internal
External oblique oblique
TAP
(subcostal) External
oblique
TAP
FIGURE 4-9 ■ Cross-sectional cadaver anatomical section of the FIGURE 4-11 ■ Cross-sectional cadaver anatomical section of the
upper abdomen (rendered from the Visible Human Server) showing abdomen (rendered from the Visible Human Server) showing the
the relations of the rectus abdominis muscle to the TAP (transversus posterior relations of the TAP (transversus abdominis plane).
abdominis plane).
The rectus abdominis muscle (RAM) originates as two or eight bellies (sections), which is also colloquially called
heads from the lateral (lateral head) part of the pubic crest the “six-pack” (Fig. 4-4). The tendinous insertions pass trans-
and from the anterior pubic ligament (medial head). The versely or obliquely across the muscle, are adherent to the
fibers of the RAM run vertically upwards to be inserted into anterior wall of the rectus sheath, and traverse only the ante-
the anterior aspect of the chest wall, that is, to the xiphoid rior half of the muscle. The RAM is enclosed in a sheath, the
process and the fifth to seventh costal cartilages (Fig. 4-12). rectus sheath (see later, Fig. 4-6), formed by the aponeurosis
There are three fibrous bands, also called the tendinous inser- of the three flat muscles of the abdomen.
tions or inscriptions, on the anterior surface of the RAM
(Figs. 4-6 and 4-12). The most cephalad tendinous insertion Nerves of the Anterior Abdominal Wall
lies opposite the free end of the xiphoid process, the second The skin and musculature of the abdominal wall is innervated
opposite the umbilicus, and the third approximately midway by the anterior primary rami of the lower six thoracic nerves
between the two (Fig. 4-6). This divides the RAM into six (T7-T12, Fig. 4-8) and the first lumbar nerve (L1) through
Ch04.indd 109 23-08-2017 19:29:23

Rectus abdominis
External oblique
Internal oblique
Rectus
TAP
abdominis
Transversus
abdominis
Iliacus
Tendinous
insertion
FIGURE 4-13 ■ Cross-sectional cadaver anatomical section of the

lower abdomen (rendered from the Visible Human Server) from
the level of the anterior superior iliac spine showing the relations
of the TAP (transversus abdominis plane) to the lower abdomen.
FIGURE 4-12 ■ Sagittal cadaver anatomic section (rendered from

Rectus abdominis
the Visible Human Server) showing the rectus abdominis muscle.
Note the tendinous insertions on the rectus muscle. Internal oblique
Transversus
abdominis
Iliacus
its iliohypogastric and ilioinguinal branches (Fig. 4-1).

The anterior primary rami of the lower five intercostal nerves
(T7-T11) emerge from their respective intercostal spaces
and come to lie in a neurovascular plane between the inter-
nal oblique and transversus abdominis muscles (Fig. 4-8).
This intermuscular plane is also referred to as the transversus
abdominis plane (TAP). The segmental nerves travel anteri-
orly and medially towards the midline in the TAP, giving off
their lateral cutaneous branches at the level of the midaxillary FIGURE 4-14 ■ Cross-sectional cadaver anatomical section of the
lower abdomen (rendered from the Visible Human Server) from
line and pierce the posterior lamina of the internal oblique
below the level of the anterior superior iliac spine. Note the external
aponeurosis anteriorly to enter the rectus sheath (Fig. 4-8). oblique muscle is missing because it is an aponeurotic layer at this
While within the rectus sheath the nerves pass behind the level.
rectus abdominis muscle and lie in front of the epigastric
arteries. They then pierce the rectus muscle and the anterior
rectus sheath to emerge anteriorly as the anterior cutaneous muscle and pierces the transversus abdominis muscle to enter
branches, which supply the overlying skin (Fig. 4-8). The lateral the TAP. The remaining part of the course of the subcostal
and anterior cutaneous branches supply the skin of the abdo- nerve is similar to that of the other thoracolumbar nerves
men from the midline to the anterior axillary line. T7 provides except that it supplies the pyramidalis muscle, and its lateral
sensory supply to the epigastrium, T10 to the umbilicus, and cutaneous branch supplies the upper and lateral aspect of the
L1 to the groin. gluteal region (Fig. 4-1).
The subcostal nerve is the anterior primary rami of the The first lumbar nerve (L1) divides in front of the quadra-
12th thoracic nerve and enters the abdomen posteriorly under tus lumborum muscle into the iliohypogastric and ilioinguinal
the lateral arcuate ligament of the diaphragm. It then passes nerves after which they pierce the transversus abdominis mus-
laterally on the anterior surface of the quadratus lumborum cle to enter the TAP (Figs. 4-13 and 4-14). The iliohypogastric
Ch04.indd 110 23-08-2017 19:29:33

nerve then travels anteriorly in the TAP and pierces the internal Magnetic Resonance Imaging Abdomen Showing the
oblique muscle about 1 inch in front of the anterior superior Lateral (Midaxillary) Transverse Abdominis Plane
iliac spine (Fig. 4-1). It then becomes superficial by pierc- Fig. 4-16
ing the external oblique aponeurosis close to the superficial
inguinal ring and supplies the skin over the suprapubic region. Ultrasound Scan Technique
The lateral cutaneous branch of the iliohypogastric nerve 1. Position:
supplies the upper and lateral aspect of the gluteal region a. Patient: Supine with the abdomen exposed between
(Fig. 4-1). The ilioinguinal nerve has no lateral cutaneous the subcostal margin and the iliac crest.
branch but also pierces the internal oblique muscle. It then b. Operator and ultrasound machine: Right-handed
traverses the inguinal canal with the spermatic cord or the operators who hold the ultrasound transducer with
round ligament of the uterus to emerge through the superficial their left hand and carry out needle interventions
inguinal ring or through the adjacent external oblique aponeu- with their right hand should stand on the right side
rosis to supply the skin of the upper and medial aspect of the of the patient and position the ultrasound machine
thigh and the genitals. on the contralateral side and directly in front. This is
vice versa for left-handed operators.
2. Transducer selection: High-frequency (13-8 MHz)
Lateral (Midaxillary) Transverse linear array transducer.
Abdominis Plane 3. Scan technique: The ultrasound transducer is placed in
the transverse orientation to the lateral abdominal wall
Gross Anatomy in the midaxillary line between the costal margin and
The lateral (midaxillary) TAP refers to the neurovascular the iliac crest (Fig. 4-17). The aim is to identify the three
plane between the internal oblique and transversus abdomi- muscular layers of the lateral abdominal wall with the fas-
nis muscle along the lateral abdominal wall (Figs. 4-10 and cial layers that separate them in the sonogram. It may be
4-11). The thoracolumbar nerves (T10-L1) traverse through necessary to gently slide the transducer in a craniocau-
the lateral (midaxillary) TAP. dal direction or even gently tilt or rotate the transducer to
obtain an optimal ultrasound image.
Computed Tomography Abdomen Showing 4. Sonoanatomy: On a transverse sonogram, the EOM,
the Lateral (Midaxillary) Transverse Abdominis Plane IOM, and TAM are identified as three longitudinal and
Fig. 4-15 hypoechoic structures deep to the skin and subcutaneous
Rectus abdominis
Rectus abdominis Transversus
Subcutaneous abdominis
fat
TAP
External
oblique External
Internal oblique
oblique Internal
TAP oblique
Transversus Bowel
abdominis
FIGURE 4-15 ■ Transverse CT of the abdomen showing the ana- FIGURE 4-16 ■ Transverse MRI of the abdomen showing the ana-
tomical relations of the TAP (transversus abdominis plane) relevant tomical relations of the TAP (transversus abdominis plane) relevant
for a lateral (midaxillary) TAP block. for a lateral (midaxillary) TAP block.
Ch04.indd 111 23-08-2017 19:29:36

Anterior Lateral Posterior
Subcutaneous fat
External oblique
Internal oblique Thoracolumbar nerve
TAP
Large bowel Lateral

Peritoneum
Anterior Posterior
Medial
Medial
ultrasound transducer during a transverse scan of the lateral abdomi- FIGURE 4-19 ■ Transverse sonogram of the lateral abdominal wall
nal wall for the lateral (midaxillary) TAP block. showing the TAP (transversus abdominis plane) in sepia mode (col-
orize mode). Note the flat hypoechoic structures, which represent
branches of the thoracolumbar nerves, within the TAP (transversus
abdominis plane).
Subcutaneous fat
also appear hyperechoic (Fig. 4-18). It is difficult to dif-
External oblique
ferentiate the fascia transversalis from the peritoneum
on a sonogram, but the peritoneum can be identified as a
TAP hyperechoic layer by observing peristaltic movement of
Internal oblique
the bowel loops (Fig. 4-18). The segmental thoracolum-
Transversus abdominis bar nerves are small terminal branches and are difficult to
define within the TAP using ultrasound. Occasionally the
terminal nerves may be seen in the TAP as multiple flat,
Peritoneum
Lateral
hyperechoic structures (Fig. 4-19). This is best done by
Anterior Posterior
locating the nerves distally in the groin (iliohypogastric
Medial and ilioinguinal nerve) and then tracing them (trace back
technique) back to the TAP.
FIGURE 4-18 ■ Transverse sonogram of the lateral abdominal 5 . Clinical Pearls: During a lateral (midaxillary) TAP
wall showing the TAP (transversus abdominis plane) between the
block with an in-plane needle insertion, the point of nee-
hypoechoic internal oblique and transversus abdominis muscles.
Also note the hyperechoic fascial layers, which probably repre- dle insertion (ie, how far medial to the transducer) can
sent the epimysium of the muscles, separating the three abdominal be determined by noting the depth at which the TAP is
muscles. located on the ultrasound monitor (depth scale). Normal
saline can be used to hydrodissect the TAP to confirm
correct needle tip position before the local anesthetic is
tissue (Fig. 4-18). A hyperechoic fascial layer (possibly injected. It is common to see a prominent bulge along
the epimysium of the individual muscle) is seen between the lateral abdominal wall, indicating paralysis of the
the three muscles (Fig. 4-18). The EOM is the outermost abdominal muscles, during the postoperative period after
(superficial) layer, the IOM the intermediate, and the a posterior TAP block.
TAM is the innermost layer. The thickness of the muscles
also varies, but the TAM is in general the thinnest and it Subcostal Transverse Abdominis Plane
also appears darkest (hypoechoic) of the three muscles on
the sonogram (Fig. 4-18). The TAP is located between the Gross Anatomy
IOM and TAM (Fig. 4-18). Deep to the TAM are the fas- Subcostal TAP refers to the neurovascular plane between
cia transversalis and the underlying peritoneum, which the IOM and the TAM that lies just below the costal m
argin
Ch04.indd 112 23-08-2017 19:29:45

(Fig. 4-9). The terminal branches of the intercostal nerves 2. Transducer selection: High-frequency (13-8 MHz)
(T7-T9) emerge from under the costal margin and enter the linear array transducer.
subcostal TAP. T7 and T8 nerves pass deep to the costal mar- 3. Scan technique: The ultrasound transducer is placed
gin and between the digitations of the TAM to enter the TAP, immediately below and parallel to the costal margin,
and T9 and T10 nerves exit from their respective intercostal typically lateral to the linea semilunaris (Fig. 4-22). The
spaces directly into the TAP. aim is to identify the three muscular layers of the lateral
abdominal wall with the fascial layers that separate them
Computed Tomography Abdomen Showing the on the sonogram.
Subcostal Transverse Abdominis Plane 4. Sonoanatomy: At the medial end, the linea semilunaris
is seen lateral to the RAM (Figs. 4-23 and 4-24), and the
Fig. 4-20
TAM may be the only muscle between the skin and the
Magnetic Resonance Imaging Abdomen Showing

the Subcostal Transverse Abdominis Plane
Fig. 4-21
Rectus abdominis Transversus
abdominis
Ultrasound Scan Technique TAP
Internal
1. Position: Liver
oblique
a. Patient: Supine with the abdomen exposed between External
oblique
the costal margin and the iliac crest.
Bowel
b. Operator and ultrasound machine: For a bilateral
subcostal TAP block, right-handed operators who
hold the ultrasound transducer with their left hand
and carry out needle interventions with their right
hand should stand on the left side of the patient and
position the ultrasound machine on the contralat-
eral side and directly in front. This is vice versa for
left-handed operators. FIGURE 4-21 ■ Transverse MRI of the upper abdomen showing
the anatomical relations of the TAP (transversus abdominis plane)
relevant for a subcostal TAP block.
Rectus
Liver
abdominis Subcutaneous
fat
Peritoneum
Transversus
abdominis
Bowel TAP
Internal
oblique
External
oblique
FIGURE 4-20 ■ Transverse CT of the upper abdomen showing FIGURE 4-22 ■ Figure showing the position and orientation of
the anatomical relations of the TAP (transversus abdominis plane) the ultrasound transducer during a transverse scan of the anterior
relevant for a subcostal TAP block. Note how the transversus abdom- abdominal wall for a TAP (transversus abdominis plane) block at the
inis muscle extends deep to and posterior to the rectus abdominis subcostal region.
muscle anteriorly.
Ch04.indd 113 23-08-2017 19:29:53

Anterior
Linea semilunaris Rectus abdominis

Lateral edge of Rectus (right)
Subcutaneous fat Linea semilunaris abdominis External oblique
Inernal oblique
External oblique Transversus – 5

abdominis
Lateral Medial
Internal oblique Transversus abdominis
Posterior rectus sheath Peritioneal cavity

dominis TAP
rsus ab
Transve
– 10
FIGURE 4-23 ■ Transverse sonogram of the anterior abdominal FIGURE 4-25 ■ Transverse sonogram (panoramic view) of the
wall showing the formation of the linea semilunaris and the trans- right subcostal region showing the anatomic relations of the anterior
versus abdominis plane (TAP) lateral to the lateral edge of the rectus abdominal muscles and the formation of the transversus abdominis
abdominis muscle (in colorize mode). Also note how the transver- plane (TAP).
sus abdominis muscle extends deep to and posterior to the rectus
abdominis muscle medially.
Anterior
Rectus abdominis
(left)
Subcutaneous fat Linea semilunaris Linea semilunaris
External oblique
External oblique Internal oblique

Rectus
abdominis Transversus
abdominis
Internal oblique Transversus abdominis
Lateral Medial
is –5
abd omin
v ersus
Trans
TAP
– 10
FIGURE 4-24 ■ Transverse sonogram of the anterior abdominal FIGURE 4-26 ■ Transverse sonogram (panoramic view) of the
wall showing a close-up view of the aponeurotic layers of the three left subcostal region showing the anatomic relations of the anterior
abdominal muscles at the level of the linea semilunaris lateral to the abdominal muscles and the formation of the transversus abdominis
lateral edge of the rectus abdominis muscle. plane (TAP).
peritoneum. Laterally and along the midclavicular line injection is deposited progressively more laterally from the
the three muscular layers of the abdominal wall and the linea semilunaris.
TAP are clearly delineated and appear similar to the lateral
(midaxillary) TAP (Figs. 4-23 to 4-26). Rectus Sheath
5 . Clinical Pearls: During a subcostal TAP block, a multiple
injection technique produces greater spread of the injec- Gross Anatomy
tate compared to a single injection in the TAP lateral to The rectus sheath is an aponeurotic sheath that covers the rec-
the linea semilunaris.13 The aim during a multiple injection tus abdominis muscle (Fig. 4-1). It is made up of an anterior
technique is to hydrodissect the TAP plane such that the and a posterior wall that are formed by the aponeurosis of the
Ch04.indd 114 23-08-2017 19:30:06

Rectus sheath Above the costal margin the anterior wall is formed by the
Rectus abdominis external oblique aponeurosis, and the posterior wall is defi-
External oblique cient and the muscle lies directly on the costal cartilages with
an intervening layer of fatty tissue (Fig. 4-27). In between
the costal margin and the arcuate line the anterior wall is
formed by the external oblique aponeurosis and the ante-
rior lamina of the IOM, and the posterior wall is formed
Costal cartilage Xiphoid
6th and 7th by the posterior lamina of the IOM and the aponeurosis of
the TAM (Fig. 4-28). Below the arcuate line the anterior wall
FIGURE 4-27 ■ Figure showing the formation of the rectus sheath
is formed by the a poneurosis of all the three flat muscles of
in transverse section above the costal margin.
the anterior abdominal wall, but the posterior wall is defi-
cient and the RAM lies directly on the fascia transversalis,
being separated from it by a layer of loose extraperitoneal
External oblique
aponeurosis Rectus abdominis
fatty tissue (Fig. 4-29). The rectus sheath on either side is
Anterior rectus
Internal oblique
aponeurosis
sheath
External oblique
held together in the midline by a median raphe, the linea alba
Transversus abdominis Internal oblique (Fig. 4-1), which extends form the xiphoid process to the
aponeurosis
pubic symphysis.
Computed Tomography Abdomen Showing the

Posterior rectus
sheath
Rectus Abdominis Muscle
Fascia transversalis Transversus abdominis
Fig. 4-30
Peritoneum
FIGURE 4-28 ■ Figure showing the formation of the rectus sheath Magnetic Resonance Imaging Abdomen Showing
in transverse section between the costal cartilage and the arcuate line. the Rectus Abdominis Muscle
Figs. 4-30 and 4-31
External oblique Ultrasound Scan Technique

aponeurosis Anterior rectus
sheath
Inernal oblique
aponeurosis
Rectus abdominis 1. Position:
External oblique
aponeurosis Internal oblique a. Patient: Supine with the abdomen exposed between
the costal margin and the iliac crest.
b. Operator and ultrasound machine: For a scan of
the RAM and rectus sheath, the operator stands on
one side of the subject and the ultrasound machine is
Fascia transversalis placed directly opposite on the contralateral side. For
Peritoneum a bilateral rectus sheath block, right-handed opera-
tors who hold the ultrasound transducer with their
FIGURE 4-29 ■ Figure showing the formation of the rectus sheath
in transverse section below the arcuate line. left hand and carry out needle interventions with
their right hand should stand on the left side of the
patient and position the ultrasound machine directly
three flat muscles of the abdomen (Figs. 4-27 to 4-29). The in front on the contralateral side. This is vice-versa
anterior wall is complete throughout its length and adherent for left-handed operators.
to the tendinous insertions of the RAM. In contrast, the pos- 2. Transducer selection: High-frequency (13-8 MHz) linear
terior wall of the rectus sheath is free (not adherent) from the array transducer.
RAM and incomplete below the “arcuate line” (Fig. 4-29). 3. Scan technique: For a transverse scan of the RAM
The latter is also referred to as the “linea semicircularis” or and the rectus sheath, the ultrasound transducer is posi-
“fold of Douglas” and lies about one-third the distance from tioned above the umbilicus (ie, above the arcuate line)
the umbilicus to the pubic crest, but there are variations. and to one side of the midline (Fig. 4-32). The aim is to
Ch04.indd 115 23-08-2017 19:30:10

A B
Linea alba Linea alba Subcutaneous
Rectus Rectus
abdominis abdominis fat
Bowel
Bowel
C Rectus D Linea
Rectus alba IEV
abdominis
EIV abdominis
IEV
Bladder
Uterus
Uterus
FIGURE 4-30 ■ Correlative transverse CT (Fig. 4-30A and C), MRI (Fig. 4-30B and D) images of the rectus abdominis muscle from above
and below the level of the umbilicus (arcuate line). IEV, inferior epigastric vessels; EIV, external iliac vessels.
Subcutaneous fat
Rectus abdominis
Posterior rectus
Bowel sheath
Transition
zone
Ovary Fascia transversalis
Uterus and peritoneum
Bladder
FIGURE 4-31 ■ Sagittal MRI image of the lower abdomen show- FIGURE 4-32 ■ Figure showing the position and orientation of the
ing the rectus abdominis muscle and the transition zone at the level ultrasound transducer during a transverse scan of the anterior abdom-
of the arcuate line on the posterior aspect of the muscle. inal wall for the rectus abdominis muscle above the arcuate line.
obtain a transverse view of the RAM, which is seen as a is surrounded by a hyperechoic epimysium (Figs. 4-33
hypoechoic oval-to-elliptical structure that is surrounded and 4-34). Between the costal margin and the arcuate
by its hyperechoic epimysium (Figs. 4-33 and 4-34). line, the RAM is enveloped by a further layer of fibrous
For a sagittal scan, the ultrasound transducer is rotated connective tissue, the rectus sheath (details provided ear-
through 90 degrees and positioned midway between the lier), which also appears hyperechoic and can be traced
xiphisternum and the umbilicus to obtain a longitudinal medially to the midline where it is continuous with the
view of the RAM (Fig. 4-35). linea alba (Fig. 4-34). Below the arcuate line the poste-
4. Sonoanatomy: On a transverse sonogram, the RAM rior rectus sheath is deficient (Fig. 4-36) and the RAM
is seen as a hypoechoic oval-to-elliptical structure that lies directly on the fascia transversalis, being separated
Ch04.indd 116 23-08-2017 19:30:20

Anterior rectus sheath

Epimysium of the Linea alba
RAM
Linea alba
RAM
RAM
A Posterior rectus sheath Peritoneum B Posterior Rectus sheath
Subcutaneous fat Anterior rectus sheath

Subcutaneous fat
RAM
RAM
Posterior rectus sheath Epimysium of

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

sheath
Right Posterior Left
FIGURE 4-34 ■ Transverse sonogram of the anterior abdominal FIGURE 4-35 ■ Figure showing the position and orientation of
wall (close to the midline) above the arcuate line showing the medial the ultrasound transducer during a sagittal scan of the anterior
aspect of the rectus abdominis muscle (RAM) from both sides with abdominal wall for the rectus abdominis muscle above the arcu-
the rectus sheath and the linea alba. ate line.
Ch04.indd 117 23-08-2017 19:30:29

Cranial Anterior Caudal

Anterior
Anterior rectus
Subcutaneous fat sheath
Subcutaneous fat
RAM RAM
RAM
Bowel
Bowel
Peritoneal cavity Peritoneal cavity
Posterior rectus Transition zone
sheath
Right Posterior Left Posterior
FIGURE 4-36 ■ Transverse sonogram of the anterior abdominal FIGURE 4-38 ■ Sagittal sonogram of the anterior abdominal wall
wall from below the level of the arcuate line showing the right rectus at the level of the arcuate line showing the “transition zone” where
abdominis muscle (RAM). Note that the anterior rectus sheath is the posterior rectus sheath ends. RAM, rectus abdominis muscle.
clearly visible but the posterior rectus sheath is deficient at this site.

Intramuscular tendinous
Subcutaneous fat insertion Subcutaneous fat
RAM RAM
RAM
Posterior rectus sheath Posterior rectus

sheath Transition zone
Peritoneum
Posterior
Posterior
FIGURE 4-37 ■ Sagittal sonogram of the anterior abdominal wall FIGURE 4-39 ■ Sagittal sonogram of the anterior abdominal
showing the rectus abdominis muscle (RAM) with the anterior and wall showing the intermuscular tendons (hyperechoic) of the rec-
posterior layers of the rectus sheath. Also note the hyperechoic ten- tus abdominis muscle (RAM). Because the ultrasound scan is at the
dinous insertion of the rectus abdominis muscle and the hypoechoic level of the arcuate line, the “transition zone” is clearly visible. The
space between the epimysium of the RAM and the posterior rectus peritoneum is also seen as a hyperechoic structure and distinct from
sheath. the posterior rectus sheath.
from it by a layer of loose, extraperitoneal fatty tissue to 4-39) that probably represent intramuscular ten-
(Fig. 4-29). With currently available ultrasound technol- don fibers. The epimysium of the RAM also appears
ogy, we believe it is not possible to delineate the fascia hyperechoic and covers both the anterior and posterior
transversalis on a transverse sonogram. walls of the muscle (Figs. 4-37 to 4-39). The rectus
On a sagittal sonogram the RAM is seen as a cylin- sheath appears as an additional hyperechoic layer lying
drical, hypoechoic structure lying deep to the skin and external to the epimysium of the muscle (Fig. 4-38).
subcutaneous fat (Figs. 4-37 to 4-40). Interspersed within The posterior rectus sheath is generally better delineated
the RAM are multiple hyperechoic strands (Figs. 4-37 than the anterior rectus sheath. This may be because the
Ch04.indd 118 23-08-2017 19:30:41

Anterior
Subcutaneous fat
Cranial Caudal
Rectus abdominis
Posterior
Intramuscular tendinous External
Subcutaneous insertion Internal oblique
fat oblique
Iliohypogastric
nerve
Subcutaneous fat Ilioinguinal
nerve
Transversus Bowel
RAM RAM
abdominis
ASIS / Iliac crest
Psoas
Transition Peritoneum
Peritoneal cavity Posterior rectus
zone Iliacus
sheath
Gluteus
medius
FIGURE 4-40 ■ Sagittal sonogram (panoramic view) of the rectus FIGURE 4-41 ■ Transverse CT of the lower abdomen at the level
abdominis muscle (RAM) showing the anatomy of the rectus sheath. of the anterior superior iliac spine (ASIS) showing the location of the
Note the posterior rectus sheath is deficient distal to the “transition iliohypogastric and ilioinguinal nerve in the fascial plane between
zone” (ie, distal to the arcuate line). Also one of the tendinous inser- the internal oblique and the transversus abdominis muscle.
tions is visible above the arcuate line in this sonogram.
Linea
Rectus abdominis alba
External oblique
Internal aponeurosis
oblique
Iliohypogastric
anterior rectus sheath is adherent to the tendinous inser- nerve
tions of the RAM. A hypoechoic space is also clearly Ilioinguinal
nerve
visualized between the posterior rectus sheath and the ASIS / Iliac
Bowel
epimysium covering the posterior surface of the RAM crest
Transversus
(Fig. 4-37). This is the potential space into which local abdominis
anesthetic is injected during a rectus sheath block. The Psoas
three tendinous insertions of the RAM may also be seen Iliacus

as hyperechoic areas within the muscle on a sagittal
Gluteus
sonogram (Figs. 4-37 and 4-40). The “transition zone” in medius
the posterior aspect of the RAM where the posterior rec-

tus sheath ends can also be clearly delineated (Figs. 4-38 FIGURE 4-42 ■ Transverse CT of the lower abdomen below the
to 4-40). Distal to the transition zone the parietal perito- level of the anterior superior iliac spine (ASIS) showing the loca-
neum is seen as a hyperechoic structure deep to the RAM tion of the iliohypogastric and ilioinguinal nerve in the fascial plane
between the internal oblique and the transversus abdominis muscle.
and easily recognized by the peristaltic movement of the
Note the external oblique muscle is only an aponeurotic layer at this
underlying bowel (Fig. 4-39). level.
Ilioinguinal and Iliohypogastric Nerve MRI Abdomen – Transverse View at the Level
Gross Anatomy of the Anterior Superior Iliac Spine
The gross anatomy of the ilioinguinal and iliohypogastric Figs. 4-43 and 4-44
nerves is described earlier.
Ultrasound Scan Technique
1. Position:
Computed Tomography Abdomen – Transverse View a. Patient: Supine with the lower abdomen exposed.
at the Level of the Anterior Superior Iliac Spine b. Operator and ultrasound machine: For an ultra-
Figs. 4-41 and 4-42 sound scan of the ilioinguinal and iliohypogastric
Ch04.indd 119 23-08-2017 19:30:45

Rectus abdominis Linea alba

Internal oblique
Iliohypogastric
nerve
Ilioinguinal
nerve
External
oblique
Bowel
ASIS /
Iliac crest
Transversus
abdominis
Iliacus Psoas
Gluteus
medius

FIGURE 4-43 ■ Transverse MRI of the lower abdomen at the level the ultrasound transducer during a transverse scan of the lower
of the anterior superior iliac spine (ASIS) showing the iliohypogas- abdomen at the level of the anterior superior iliac spine (ASIS) for
tric and ilioinguinal nerve in the fascial plane between the internal the iliohypogastric and ilioinguinal nerves.
oblique and the transversus abdominis muscle.
iliac spine (ASIS). The ultrasound transducer is positioned

External oblique
Iliohypogastric aponeurosis Rectus abdominis
close to the ASIS and parallel to a line joining the ASIS
Internal nerve and the umbilicus (Fig. 4-45).
oblique
4. Sonoanatomy: The ilioinguinal and iliohypogastric
Ilioinguinal
nerve nerves are identified as two small, rounded hypoechoic
Transversus
abdominis
structures lying side by side between the internal oblique
ASIS / iliac and transversus abdominis muscles (Fig. 4-46). Below
crest
the level of the iliac crest the aponeurosis of the external
Iliacus Bowel
iliac muscle is seen as a hyperechoic aponeurotic layer
(Fig. 4-47). Deep to the transversus abdominis muscle the
Gluteus Psoas
medius peritoneum and bowel are also visualized (Fig. 4-47).
5 . Clinical Pearls: The ilioinguinal and iliohypogastric
nerves are best visualized close to the ASIS. Also during
an ultrasound-guided ilioinguinal iliohypogastric nerve
FIGURE 4-44 ■ Transverse MRI of the lower abdomen below the
block, the authors prefer to perform an in-plane technique
level of the anterior superior iliac spine (ASIS) showing the iliohy-
with the needle inserted from a medial-to-lateral direction
pogastric and ilioinguinal nerves in the fascial plane between the
internal oblique and the transversus abdominis muscles. Note the and towards the iliac bone. This not only allows the needle
external oblique muscle is only an aponeurosis at this level. to be better visualized, but also in the event of inadvertent
deep needle insertion the iliac bone will prevent further
needle advancement. We believe this approach may also
nerves, right-handed operators who hold the ultra- prevent serious complications like bowel and visceral
sound transducer with their left hand and carry out perforation because the needle is inserted away from the
needle interventions with their right hand should peritoneum and bowel.
stand on the left side of the patient and position the
ultrasound machine directly in front on the contralat- Quadratus Lumborum Block
eral side. This is vice-versa for left-handed operators.
2. Transducer selection: High-frequency (13-8 MHz) linear Gross Anatomy
array transducer. Quadratus lumborum block (QLB) is a recently introduced
3 . Scan technique: The ilioinguinal and iliohypogastric abdominal wall field block9 in which the local anesthetic
nerves are best visualized close to the anterior superior is injected into a fascial plane that is deep to the fascia
Ch04.indd 120 23-08-2017 19:30:54

Anterior
IVC
TAM
Lumbar
Ao
plexus
IOM
External oblique QLB I
EOM
ASIS Psoas major plane
muscle L4 VB
Internal oblique
Transversus ab QLM QLB II

dominis
plane
Erector spinae Articular TM-QLB

Iliohypogastric muscle process plane
Ilioinguinal nerves
Medial Posterior Lateral
FIGURE 4-46 ■ Transverse sonogram of the lower abdomen, at the FIGURE 4-48 ■ Figure showing the facial planes in the posterior
level of the anterior superior iliac spine (ASIS) showing the iliohy- abdomen where the local anesthetic is injected during a quadra-
pogastric and ilioinguinal nerves between the internal oblique and tus lumborum block (QLB). TAM, transversus abdominis muscle;
the transversus abdominis muscles. IOM, internal oblique muscle; EOM, external oblique muscle; QLN,
quadratus lumborum muscle; VB, vertebral body; Ao, aorta; IVC,
inferior vena cava.
Anterior
External oblique Subcutaneous fat

aponeurosis
limited clinical data on QLB8,10,12 and in particular the mech-
Iliac bone anism by which it produces clinical efficacy. Preliminary
Internal oblique
reports suggest that a QLB acts by a combination of mecha-
Transve
rsus abd
ominis nisms: (a) craniocaudal spread of the local anesthetic in the
fascial plane anterior to the quadratus lumborum,10,14 (b) ipsi-
Large bowel
lateral paravertebral spread,10,14 and (c) possibly ipsilateral
Iliohypogastric epidural spread.14 There is also an anatomical plane of com-
Ilioinguinal nerves
munication between the retroperitoneal space and the thoracic
paravertebral space,16–19 which may also be involved in the
Medial Posterior Lateral
extended lumbothoracic spread of the local anesthetic after a
FIGURE 4-47 ■ Transverse sonogram of the lower abdomen, from QLB injection.
just below the level of the anterior superior iliac spine, showing the The fascia transversalis of the abdominal wall blends medi-
iliohypogastric and ilioinguinal nerves between the internal oblique ally with the anterior layer of the quadratus lumborum fascia
and the transversus abdominis muscles. Also note the external and the psoas fascia (psoas sheath, Fig. 4-49).20 The subcos-
oblique aponeurosis, which is seen as a hyperechoic layer, superfi- tal (T12), iliohypogastric (L1), and ilioinguinal (L1) nerves
cial to the internal oblique muscle.
course anterior to and in close contact with the quadratus
lumborum muscle,21 and the lateral femoral cutaneous nerve
of the thigh (L2, L3) crosses the lateral border of the psoas
transversalis (the deep fascia of the abdominal wall) and on muscle at the level of the inferior border of the L4 vertebra
the anterolateral aspect of the quadratus lumborum muscle in this fascial plane.21 The potential space behind the fascia
(Fig. 4-48).9–12 The point of injection is believed to approxi- covering the psoas major and quadratus lumborum muscles
mate to the landmark-based technique of performing a TAP in the abdomen is continuous cranially with the subendotho-
block at the lumbar triangle of Petit.8,14 Several ultrasound- racic fascial compartment of the lower thoracic paravertebral
guided techniques for QLB10–12,15 or their variations have been spaces in the thorax (Fig. 4-50).16,17,19 This continuity occurs
described in the literature (Fig. 4-48), but the optimal tech- dorsal to the diaphragm through the medial and lateral arcu-
nique or the site of injection is still not known. There are also ate ligaments (lumbocostal arch) and the aortic hiatus.16,19,22
Ch04.indd 121 23-08-2017 19:31:04

Pancreas Parietal peritoneum

Transversalis fascia
Duodenum
Descending colon
Ao IVC Anterior pararenal

space
IOM
EOM
Perirenal space
TAM
Lateral conal fascia
PM
Kidney Posterior renal
space
Transversalis fascia
Quadratus lumborum
ESM
with fascia
Subcostal nerve
Ilioinguinal nerve
FIGURE 4-49 ■ Figure showing the anatomical relationship of the transversus abdominis plane (TAP), fascia transversalis, and the fascia
of the quadratus lumborum (quadratus lumborum fascia) and psoas (psoas fascia/sheath) muscles in the retroperitoneal space. Note the
subcostal and ilioinguinal nerves are located on the anterior surface of the quadratus lumborum muscle. Ao, aorta; IVC, inferior vena cava;
PM, psoas major muscle; ESM, erector spine muscle; TAM, transversus abdominis muscle; IO, internal oblique muscle; EOM, external
oblique muscle.
Lung (20 mL of 0.375% ropivacaine on each side) produces loss of

Parietal pleura
Endothoracic
sensation to cold from T7-T12 dermatomes.12 The segmental
Endothoracic fascia
fascia Diaphragm anesthesia produced by a QLB is significantly wider than that
Adrenal gland produced by a lateral (midaxillary) TAP block (with ropiva-
Subserous
fascia
Kidney
caine 0.5%, 15 mL per side, T10-T12).12 Also the duration of
Perirenal space analgesia after a bilateral QLB in patients undergoing laparo-
Anterior scopic ovarian surgery is significantly longer than that produced
Psoas fascia renal fascia
by a bilateral lateral (midaxillary) TAP block.12 The prolonged
Posterior
Psoas muscle renal fascia duration of analgesia after a QLB has been attributed to the
paravertebral spread of the local anesthetic. QLB may also pro-
Iliac fascia duce ipsilateral sympathetic blockade because paravertebral
Psoas muscle
spread of contrast has been demonstrated.10,14 Therefore, QLB
Iliacus muscle
may be effective in relieving sympathetic mediated visceral
pain, which is otherwise not affected by a lateral (midaxillary)
FIGURE 4-50 ■ Sagittal section showing the fascial relations of TAP block. However, because there is a paucity of data on the
the lower thoracic paravertebral space and the retroperitoneal space. use of bilateral QLB for major abdominal surgery, no recom-
Note the path of communication between the subendothoracic com-
mendations can be made at this time, but QLB holds promise
partment of the lower thoracic paravertebral space and the space
behind the fascia covering the psoas muscle (psoas fascia/sheath). as a technique for perioperative pain management. The follow-
ing section briefly describes the ultrasound scan technique and
sonoanatomy relevant for QLB.
This thoracolumbar continuity is the anatomical basis for
“extended unilateral anesthesia”18 after a lower thoracic Ultrasound Scan Technique
paravertebral injection and may apply when ipsilateral 1. Position:
lumbothoracic spread of contrast10,14 or anesthesia12 occurs a. Patient: For a bilateral QLB the patient is placed in the
after a QLB injection. supine position with the abdomen exposed between
A QLB produces multidermatomal ipsilateral anesthesia of the costal margin and the iliac crest. The ultrasound
the thoracolumbar nerves.12 A bilateral single injection QLB scan for a bilateral QLB can also be performed with
Ch04.indd 122 23-08-2017 19:31:11

VB
ESM
PM
QLM Transverse
process
TAM
IOM EOM
A Position - lateral decubitus B Axis of Scan
FIGURE 4-51 ■ Figure showing the position of the patient, ultrasound transducer, and the plane of ultrasound imaging during a quadratus
lumborum block (QLB) with the patient in the lateral decubitus position. Note the anatomical relationship of the psoas major, quadratus
lumborum, and erector spinae muscle to the transverse process and the transversus abdominis plane.
EOM QLB II plane

IOM QLB I plane
Quadratus
lumborum
TAM
Psoas major
Inferior
ESM
vena cava
TP
AP
VB
Lateral
Anterior
Aorta
FIGURE 4-52 ■ Transverse sonogram, acquired with a curvilinear transducer (C5-1 MHz) showing the anatomy relevant for quadratus lum-
borum block (QLB) at the level of the transverse process. Note the site for local anesthetic during a QLB I and QLB II injection. Accompanying
photograph on the right is demonstrating the position of the patient and the ultrasound transducer during a QLB. EOM, external oblique
muscle; IOM, internal oblique muscle; TAM, transversus abdominis muscle; VB, vertebral body; TP, transverse process; ESM, erector spinae
muscle; AP, articular process.
the patient in the sitting position. For a unilateral QLB b. Operator and ultrasound machine: The operator
it may be preferable to place the patient in the lat- stands on one side of the subject, and the ultrasound
eral position (Figs. 4-51 and 4-52) because the block machine is placed directly opposite on the contralat-
needle can then be inserted from the posterior aspect eral side. For a bilateral QLB, right-handed operators
of the ultrasound transducer,11 which is otherwise not who hold the ultrasound transducer with their left
possible when the patient is in the supine position. In hand and carry out needle interventions with their
doing so the needle is inserted through the quadratus right hand should stand on the left side of the patient
lumborum muscle (transmuscular QLB)11 until the and position the ultrasound machine directly in front
needle tip is in the target site between the psoas and on the contralateral side. This is vice versa for left-
quadratus lumborum muscle (Fig. 4-48).11 handed operators.
Ch04.indd 123 23-08-2017 19:31:19

2. Transducer selection: It is preferable to use a curvilinear around the transverse process, that is, the psoas muscle
transducer (5-1 MHz, Fig. 4-51) because it provides better lying anterior, the erector spinae muscle lying posterior,
penetration and a wider field of view than a linear trans- and the quadratus lumborum muscle lying at the apex
ducer (Fig. 4-53). A high-frequency (13-8 MHz) linear (Fig. 4-52), produces a sonographic pattern that has been
transducer, which provides higher-resolution images, can likened to a “shamrock” with the muscles representing the
be used in slim individuals (Fig. 4-53).
3. Scan technique: Start the ultrasound scan by placing the
transducer in the transverse orientation in the flank imme-
QLB II plane
diately above the iliac crest (Figs. 4-51 to 4-53). Then EOM
IOM QLB I plane Quadratus
gently slide the transducer posteriorly, aiming to identify TAM
lumborum
the anterolateral surface of the vertebral body and the Psoas major Lumbar
transverse process in the transverse sonogram (Fig. 4-52). muscle plexus
Once the transverse process is located and the relevant Inferior ESM
vena cava
anatomy identified, tilt or slide the transducer slightly
AP
caudally to perform the transverse scan through the inter- VB IVF
transverse space (Fig. 4-54). The acoustic shadow of the
Lateral
transverse process will no longer be visible and will be
Cranial Spinal
replaced by the hyperechoic articular process (Fig. 4-54). Aorta
canal
4. Sonoanatomy: On the transverse sonogram the verte-
bral body and transverse process of the vertebra appear FIGURE 4-54 ■ Transverse sonogram, acquired with a curvilinear
as hyperechoic structures with a corresponding acoustic transducer (C5-1 MHz), showing the anatomy relevant for quadratus
shadow (Fig. 4-52). The psoas major, quadratus lumbo- lumborum block (QLB) at the level of the articular process (AP).
rum, and erector spinae muscles are easily recognized Note the site for local anesthetic injection during a QLB I and QLB II.
The lumbar plexus nerves are visualized on the posterior aspect of
surrounding the transverse process. Also depending on the
the psoas muscle. Also the spinal canal is visualized through the
side scanned, the inferior vena cava (on the right) and aorta intervertebral foramen (IVF). EOM, external oblique muscle; IOM;
(on the left) are visualized anterolateral to the vertebral internal oblique muscle, TAM; transversus abdominis muscle; VB,
body (Fig. 4-52). The arrangement of the three muscles vertebral body; ESM, erector spinae muscle.
QLB I plane QLB II plane
EOM
IOM
TAM TM-QLB
RPS QLM plane
ESM
PM
Lumbar TP
plexus
Lateral
VB
Anterior
FIGURE 4-53 ■ Transverse sonogram, acquired with a high-frequency (13-8 MHz) linear array transducer showing the anatomy relevant
for a quadratus lumborum block (QLB) at the level of the transverse process. The resolution of the muscles and intermuscular facial planes is
significantly improved, but the field of view is limited (compare with Fig. 4-52). Also note the sites for local anesthetic injection during a QLB.
Accompanying photograph on the right is demonstrating the position of the patient and the ultrasound transducer during a QLB. EOM, external
oblique muscle; IOM, internal oblique muscle; TAM, transversus abdominis muscle; RPS, retroperitoneal space; QLM, quadratus lumborum
muscle; PM, psoas major muscle; VB, vertebral body; TP, transverse process; ESM, erector spinae muscle; TM-QLB, transmuscular QLB.
Ch04.indd 124 23-08-2017 19:31:23

three leaves.23 Superficial and anterior to these three mus- 9. Blanco R. Tap block under ultrasound guidance: the description of a
cles the external oblique, internal oblique, and transversus “nonpopstechnique.” Reg Anesth Pain Med. 2007;32(Suppl 1):130.
10. Blanco R, Ansari T, Girgis E. Quadratus lumborum block for
abdominis muscles can be identified (Figs. 4-52 to 4-54).
postoperative pain after caesarean section: A randomised con-
In the transverse sonogram through the lumbar intertrans-
trolled trial. Eur J Anaesthesiol. 2015;32:812–818.
verse space the acoustic shadow of the transverse process 11. Borglum J, Morrigl B, Jensen K, et al. Ultrasound-guided trans-
is no longer visualized, and the intervertebral foramen muscular quadratus lumborum blockade. Br J Anaesth. (2013) 111
and spinal canal may also be visualized in addition to (eLetters Supplement) (http://bja.oxfordjournals.org/forum/topic/
the psoas major, quadratus lumborum, and erector spine brjana_el%3B9919). Accessed 14 March, 2016.
12. Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum
muscles (Fig. 4-54).
block: analgesic effects and chronological ropivacaine concen-
5 . Clinical Pearls: One must identify the lower pole of
trations after laparoscopic surgery. Reg Anesth Pain Med. 2016;
the kidney and the peritoneal cavity during the scout 41:146–150.
scan to avoid deep needle insertion and visceral injury. 13. Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P. Spread
When performing a QLB scan in individuals with a thick of injectate after ultrasound-guided subcostal transversus
abdominal wall, gentle inward pressure may be applied abdominis plane block: a cadaveric study. Anaesthesia 2009;
64:745–750.
with the transducer to compress the abdominal tissues.
14. Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc D onnell
This maneuver reduces the overall depth to the target and
JG. Studies on the spread of local anaesthetic solution in transver-
thereby may improve the overall quality of the image. sus abdominis plane blocks. Anaesthesia 2011;66:1023–1030.
15. Hansen CK, Dam M, Bendtsen TF, Borglum J. Ultrasound-
guided quadratus lumborum blocks: definition of the clinical
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block for analgesia following caesarean section. Anaesthesia. Anatomical bases for paravertebral anesthetic block: fluid
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5. Hebbard PD, Barrington MJ, Vasey C. Ultrasound-guided con- regions. Surg Radiol Anat. 1999;21:359–363.
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Ch04.indd 125 23-08-2017 19:31:24

CHAPTER 5 Ultrasound Imaging of the Spine: Basic Considerations
Introduction
Cervical
Ultrasound has revolutionized the practice of regional anes- spine
thesia, particularly peripheral nerve blockade, and it has also

been used for central neuraxial blocks (spinal and epidural
Thoracic
injections).1–3 However, the use of ultrasound for central neur- spine
axial blocks is still in its infancy and not as popular4 as that
for peripheral nerve blocks. The reasons for this are not clear,
but may be related to the high success rate of landmark-based
Lumbar
techniques, limited data on ultrasound for neuraxial blocks, spine
perceived difficulty in performing spinal sonography, limited

Sacral
acoustic window for ultrasound imaging, and poor under- spine
standing of spinal sonoanatomy. However, recently published A Coccyx B
data suggest that ultrasound is beneficial for central neuraxial

FIGURE 5-1 ■ Human vertebral (spinal) column. (A) Posterior
blocks. Identification of a given lumbar intervertebral level
view and (B) lateral view.
for central neuraxial block using surface anatomical land-
marks (Tuffier line) is often imprecise,5 and ultrasound is
more accurate than clinical assessment.6 It can also be used to Pedicle Body of vertebra
accurately measure the depth to the epidural space or thecal
sac7–9 and predict the ease of performing a neuraxial block.10
Ultrasound also offers technical advantage by reducing the
number of puncture attempts,11–14 improves the success rate Transverse
of epidural access on the first attempt,12 reduces the need to process Superior articular
process
puncture multiple levels,12–14 and improves patient comfort
during the procedure.13 Ultrasound may also be beneficial for Spinous
process
central neuraxial blocks in patients with difficult (ie, abnor-
mal or variant) spinal anatomy.15,16 Therefore, it is envisioned
that the use of ultrasound for central neuraxial blocks will Inferior articular
Lamina
grow in the near future. A sound knowledge of the anatomy process
of the spine is a prerequisite for understanding the sonoanat- FIGURE 5-2 ■ Structure of a typical vertebra with its different
omy of the spine. In this chapter, we describe general details components.
of spine anatomy and basic considerations relevant for spinal
sonography and central neuraxial blocks.
vertebra. In the cervical region there are eight spinal nerves.

Basics of Spine Anatomy The first seven spinal nerves lie above the corresponding
The human spine or vertebral column is made up of vertebra, but the eighth cervical nerve lies below the seventh
33 vertebrae—7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 cervical vertebra. In the coccygeal region there is only one
coccygeal—that are stacked on top of each other (Fig. 5-1). coccygeal nerve.
A typical vertebra has unique features (Fig. 5-2), and they dif- The spine has two primary curves (ie, the thoracic and
fer at different levels (Figs. 5-3 to 5-5). The number of spinal sacral curve) that are concave anteriorly, present at birth, and
nerves in the thoracic, lumbar, and sacral region corresponds to due to the shape of the vertebral bodies (Fig. 5-1). There are
the number of vertebra, each lying below the corresponding also two secondary curves—the cervical and lumbar curves
126
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CHAPTER 5 / Ultrasound Imaging of the Spine: Basic Considerations n 127
Spinous process
Vertebral Uncinate process SAP
arch Vertebral
foramen Posterior
Pedicle Lamina tubercle
SAF
VB
Posterior Anterior
tubercle tubercle
C4 IAF
Transverse
Sulcus for foramen Spinous process
spinal nerve Anterior tubercle
A Superior view B Anterior view
Sulcus for
spinal nerve SAF
Transverse SAP
process
Spinous process
VB
IAF IAP
C Lateral view
FIGURE 5-3 ■ A typical cervical vertebra (C4). Note the triangular spinal canal and the foramen transversarium on the transverse processes.
SAP, superior articular process; IAP, inferior articular process; SAF, superior articular facet; IAF, inferior articular facet.
Spinous process
SAP TP
Lamina
TP Costal facet on
transverse process
Superior VB
Pedicle articular facet
SC
Inferior costal SVN
Inferior costal Inferior articular
process T6
Superior costal facet facet
facet
Spinous process
Superior costal TP
facet
Costal facet on
transverse process
VB
Spinous process
Inferior costal
facet IAP
Inferior vertebral
notch
FIGURE 5-4 ■ A typical thoracic vertebra (T6). TP, transverse process; SC, spinal canal; SVN, superior vertebral notch; SC, spinal canal;
VB, vertebral body; TP, transverse process; SAP, superior articular process; IAP, inferior articular process.
(Fig. 5-1)—that are convex anteriorly and develop after birth. is formed by the supporting pedicles and laminae (Fig. 5-6).
The cervical curvature develops after the infant starts to sup- Seven processes arise from the vertebral arch: one spinous
port the weight of the head (usually between 4 and 9 months process, two transverse processes, two superior articular
of age), and the lumbar curvature develops between 12 and processes, and two inferior articular processes (Fig. 5-6).
18 months of age once the child assumes the upright posture. Adjacent vertebra articulate with each other at the facet joints
A typical vertebra is made up of two components: the between the superior and inferior articular processes and the
vertebral body and the vertebral arch (Fig. 5-6). The latter intervertebral disc between the vertebral bodies (Fig. 5-7).
Ch05.indd 127 23-08-2017 17:46:14

128 n CHAPTER 5 / Ultrasound Imaging of the Spine: Basic Considerations
Spinous process Lamina

SAP
Mamillary SAP
process TP
TP
SC
Vertebral VB
arch SVN
L4
Inferior articular
facet
IAP Spinous
process
SAP
TP
VB
Spinous
process
Inferior
vertebral notch
IAP Inferior articular
facet
FIGURE 5-5 ■ A typical lumbar vertebra (L4). Note the large vertebral body. SAP, superior articular process; IAP, inferior articular pro-
cess; SAF, superior articular facet; IAF, inferior articular facet; VB, vertebral body; TP, transverse process; SC, spinal canal; SVN, superior
vertebral notch.
Spinous process Posterior longitudinal Superior articular

Inferior articular ligament facet
process
Vertebral arch Intervertebral Ligamentum
Superior atricular disk
process flavum
Transverse process
Anterior longitudinal Vertebral arch
ligament Superior articular
process
Spinous process
Vertebral body
Interspinous
Pedicle Transverse ligament
Spinal canal process Intertransverse
ligament
Intervertebral
Vertebral body foramen Supraspinous
ligament
FIGURE 5-6 ■ The vertebral arch (highlighted in green). FIGURE 5-7 ■ Ligaments of the vertebral column.
This produces two gaps between the lamina and the spinous the interlaminar spaces and connects the lamina of adjacent
processes (ie, the “interlaminar space” and “interspinous vertebra (Figs. 5-7 to 5-9). It is archlike on cross-section and
space”). It is through these spaces that the ultrasound energy widest posteriorly in the midline and in the lumbar region.
enters the spinal canal and is therefore relevant for spinal The ligamentum flavum is attached to the anterior surface
sonography and central neuraxial blocks. The three major of the inferior margin of the lamina above, but it splits
ligaments of the spine are the ligamentum flavum, anterior longi- inferiorly to attach to both the posterior surface (superficial
tudinal ligament, and posterior longitudinal ligament (Fig. 5-7). component) and anterior surface (deep component) of the
The posterior longitudinal ligament is attached along the length lamina below. The spinous processes are attached at their tips
of the anterior wall of the vertebral canal (Figs. 5-7 and 5-8). by the supraspinous ligament (Fig. 5-7), which is thick and
The ligamentum flavum, also referred to as the “yellow cordlike, and along their length by the interspinous ligament
ligament,” is a dense layer of connective tissue that bridges (Fig. 5-9), which is thin and membranous.
Ch05.indd 128 23-08-2017 17:46:24

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

ligament process
Spinal sonography typically requires the use of low-frequency
ultrasound (5-2 MHz) and a curved array transducer because
Anterior longitudinal Inferior articular
ligament process the spine is located at a depth. Low-frequency ultrasound pro-
vides good tissue penetration, but it lacks spatial resolution at
Spinous process
the depths at which neuraxial structures are imaged (approxi-
mately 5–8 cm). The osseous framework of the spine, which
FIGURE 5-8 ■ Ligamentum flavum (yellow ligament) and its
envelopes the neuraxial structures, also reflects much of the
attachment to the laminae.
Posterior epidural
Conus space Ligamentum
Spinous flavum
medullaris process
Spinal cord Cauda Interspinous ligament
Posterior Sacral hiatus
equina Supraspinous ligament
dura
Filum terminale
Coccyx
Sacrum
Anterior epidural
Sacral promontory
space
L1 Vertebral L5 Vertebral
body Posterior longitudinal
Intervertebral body
ligament
Anterior longitudinal disc
ligament
FIGURE 5-9 ■ Sagittal section of the lumbosacral spine showing the relationship of the spinal cord, conus medullaris, cauda equina, filum
terminale, and thecal sac to the vertebral column.
Ch05.indd 129 23-08-2017 17:46:33

incident ultrasound signal. Furthermore, the acoustic window parallel to the ground. The coronal plane, also known as the
for ultrasound imaging (interlaminar and interspinous space) frontal plane, is perpendicular to the ground.
is relatively narrow, and this poses an additional challenge The spine can be imaged using ultrasound in the transverse
in obtaining high-quality images of the neuraxis. Recent (transverse scan, Fig. 5-11) or longitudinal (sagittal scan, Fig.
improvements in ultrasound technology, image processing 5-12) plane and with the patient in the sitting, lateral decubi-
capabilities of ultrasound machines, availability of advanced tus, or prone position. The latter is useful in patients present-
imaging modalities (tissue harmonic imaging [THI], tissue ing for chronic pain interventions when fluoroscopy may also
aberration correction, color B-mode imaging), and the devel- be used in conjunction with ultrasound. The transverse and
opment of new ultrasound scan protocols1 have all contributed sagittal scan planes complement each other during an ultra-
to improving our ability to image the neuraxis. Currently it sound examination of the spine. Coronal plane images are
is possible to accurately delineate the neuraxial anatomy displayed exclusively during multiplanar three-dimensional
relevant for central neuraxial blocks using ultrasound.1,3 (3-D) ultrasound imaging, and they are rendered images
Also of note is technology that was once only available in the from the acquired 3-D volume. During a transverse scan of
high-end cart-based ultrasound systems are now available in the lumbar spine, the ultrasound beam can be insonated at
portable ultrasound devices, making them practical for spinal the level of the spinous process (transverse spinous process
sonography and ultrasound-guided neuraxial blocks. view, TSPV, Fig. 5-11A) or through the interspinous space
(transverse interspinous view, TISV, Fig. 5-11B). A sagittal
Ultrasound Scan Planes scan can be performed through the midline (median sagit-
There are basically three anatomical planes: median, trans- tal scan) or through a paramedian (paramedian sagittal scan,
verse, and coronal plane (Fig. 5-10). The median plane is a PMSS) plane. The latter is more frequently used (less bone),
longitudinal plane that passes through the midline and bisects and during a paramedian sagittal scan (PMSS) the ultrasound
the body into equal right and left halves. The sagittal plane beam is insonated lateral to the midline (paramedian), and
is also a longitudinal plane but is parallel to the median ultrasound images are acquired from the level of the lamina
plane and perpendicular to the ground. Therefore, the median (paramedian sagittal lamina view, Fig. 5-12A), articular pro-
plane can also be defined as the sagittal plane that is exactly cess (paramedian sagittal articular process view, Fig. 5-12B),
in the middle of the body (median sagittal plane). The trans- or transverse process (paramedian sagittal transverse pro-
verse plane, also known as the axial or horizontal plane, is cess view, Fig. 5-12C). The neuraxial structures are better
visualized through a paramedian sagittal plane than through
the median sagittal or median transverse plane.19 The ultra-
sound visibility of neuraxial structures is further improved
when the spine is imaged in the paramedian sagittal oblique
Median plane
Transverse plane
Coronal plane
Transverse Scan - Spinous process Transverse Scan - Interspinous Space
Sagittal plane A B
FIGURE 5-11 ■ Axis of scan – transverse scan (A) at the level of

FIGURE 5-10 ■ Anatomical planes of the body. the spinous process and (B) at the level of the interspinous space.
Ch05.indd 130 23-08-2017 17:46:36

Paramedian sagittal Paramedian sagittal scan Paramedian sagittal scan

scan - Lamina - Articular process - Transverse process
A B C
FIGURE 5-12 ■ Axis of scan – paramedian sagittal scan (A) at the level of the lamina, (B) at the level of the articular process, and (C) at the
level of the transverse process.
Transverse Process
y
ne
Kid
PM PMSOS
IVC
VB PMSS
ESM
PMSS PMSOS
Paramedian Sagittal - Lamina Paramedian Sagittal Oblique - Lamina
A B Lumbar Spine - Paramedian Scan
FIGURE 5-13 ■ Axis of scan. (A) Paramedian sagittal scan at the FIGURE 5-14 ■ Axis of scan – paramedian sagittal oblique scan of
level of the lamina and (B) paramedian sagittal oblique scan at the lumbar spine. Note the medial direction of the ultrasound beam
the level of the lamina. (blue color). PMSS, paramedian sagittal scan (red color); PMSOS,
paramedian sagittal oblique scan. VB, vertebral body; IVC, inferior
vena cava; ESM, erector spinae muscle.
axis (Fig. 5-13). During a paramedian sagittal oblique scan Sonoanatomy of the Osseous Elements of the Spine
(PMSOS), the transducer is positioned 2 to 3 cm lateral to the
The bony framework of the spine, which wraps around the
midline (paramedian) in the sagittal plane, and it is also tilted
neuraxial structures, does not lend itself to optimal conditions
slightly medially, that is, towards the midline (Fig. 5-14).
for ultrasound imaging because it reflects the majority of the
The purpose of the medial tilt is to ensure that the majority of
incident ultrasound energy, except for what gets through to
the ultrasound energy (signal) enters the spinal canal through
the spinal canal through the interspinous and interlaminar
the widest part of the interlaminar space. The same applies,
spaces. This creates a narrow acoustic window for imaging
and is probably more important, during a paramedian sagittal
(Fig. 5-16) and is narrower in the thoracic region than in the
scan of the thoracic spine (Fig. 5-15).
Ch05.indd 131 23-08-2017 17:46:45

how to interpret ultrasound images of the spine. Let’s con-

sider that the spine is made up of bone and soft tissue. If one is
able to identify individual osseous elements of the spine, then
one should be able to identify the gaps in the bony framework
(ie, the interlaminar space or the interspinous space) through
which the ultrasound beam is insonated to visualize the neur-
axial structures within the spinal canal. It is also through these
same gaps that a spinal or an epidural needle is inserted dur-
ing an ultrasound-guided central neuraxial block.
The water-based spine phantom is a simple model to
study the osseous anatomy of the spine.1,3,20 It is prepared
Paramedian Sagittal Scan Paramedian Sagittal Oblique Scan by immersing a commercially available spine model in a
A B
water bath (Fig. 5-17) and imaging it in the transverse and
FIGURE 5-15 ■ Axis of scan – thoracic spine. (A) Paramedian sag- sagittal plane through the water using a low-frequency
ittal scan and (B) paramedian sagittal oblique scan. curved array transducer (Fig. 5-18). The water-based spine
Acoustic window
Lamina
Water based spine phantom

Acoustic
A Lumbar Spine shadow Ultrasound scan
A B
FIGURE 5-17 ■ The water-based lumbosacral spine phantom.

Lamina Note the lumbosacral spine is immersed in a water bath and is
imaged through the water using a curved linear transducer.
B Thoracic Spine
FIGURE 5-16 ■ Sagittal sonogram of the lumbar and thoracic spine

demonstrating the acoustic window between the acoustic shadows of
the laminae. Note the acoustic window is larger in the lumbar spine.
lumber spine (Fig. 5-16). Age-related changes in the spine

also cause narrowing of the acoustic window, making spinal
sonography more challenging in the elderly. Being able to
FIGURE 5-18 ■ Water-based thoracic spine phantom. Note the
accurately define the osseous anatomy of the spine in a spinal acute angulation of the spinous processes in the midthoracic area
sonogram is, in our opinion, the first step towards learning (seen on the ultrasound monitor).
Ch05.indd 132 23-08-2017 17:47:05

phantom, although originally developed to study the osseous for spinal sonography. Each osseous element of the spine
anatomy of the lumbosacral spine,1,3,20 can also be used for produces a characteristic (signature) sonographic pattern that
the thoracic (Fig. 5-18) and cervical spine. Ultrasonography is comparable with that seen in vivo (Figs. 5-19 to 5-24).1,3
is often a case of “pattern recognition,” and this is also true Because water produces an anechoic (black) background, the
SP
Lamina
A
Spinous process (TS)
ISS SP
AP
TP
SC
VB
B Spinous process (SS) C Articular Process (TS)
FIGURE 5-19 ■ Sonograms from the water-based lumbosacral spine phantom showing (A) the transverse spinous process (SP) view, (B) the
median sagittal spinous process view, and (C) the transverse interspinous view. An inset image has been placed next to image C to illustrate
the resemblance of the sonographic appearance of the transverse interspinous view to a cat’s head (refer to text for details). TS; transverse
scan; SP, spinous process; ISS, interspinous space; TP, transverse process; AP, articular process; VB, vertebral body; SC, spinal canal.
Posterior Lamina Needle
Cranial Caudad
Anterior
A Lamina (SS)
AP
TP
B Articular process (SS) C Transverse process (SS)
FIGURE 5-20 ■ Paramedian sagitttal sonogram of the (A) lamina, (B) articular process, and (C) transverse process frrom the lumbosacral
water-based spine phantom. A graphic overlay has been placed over the lamina in (A) to illustrate the “horse head sign” and over the articular
process in (B) to illustrate the “camel hump sign.” SS, sagittal scan; AP, articular process; TP, transverse process. Note a needle has been
placed over the lamina, which is used to validate the structure imaged.
Ch05.indd 133 23-08-2017 17:47:15

Sacrum
Sacral hiatus
Interlaminar Lamina
Coccyx space
Sacrum (SS)
Sacral cornua
Spinal canal
Sacral cornua (TS)
Paramedian sagittal oblique scan (PMSOS)

B
A
FIGURE 5-21 ■ Sonograms from a water-based lumbosacral spine

phantom showing (A) median sagittal view of the sacrum, sacral Needle
Lamina
hiatus, and coccyx and (B) transverse view of the sacral hiatus. SS,
sagittal scan; TS, transverse scan.
Posterior
L5 S1 Gap Sacrum
Lamina of L5
Cranial PMSOS - Simulated in-plane needle insertion

Caudal
B
FIGURE 5-23 ■ Paramedian sagittal sonogram of thoracic spine

at the level of the lamina. A simulated epidural needle is shown
being inserted towards the interlaminar space in (B) as one would do
with a paramedian thoracic epidural. PMSOS, paramedian sagittal
Anterior
oblique scan.
between the spinous processes represent the interspinous

FIGURE 5-22 ■ Paramedian sagittal sonogram of the lumbosacral spaces (Fig. 5-19B). The transverse interspinous view pro-
junction (L5-S1 gap) from the water-based lumbosacral spine phantom. duces a sonographic pattern that resembles a cat’s head (Fig.
5-19C) with the ears of the cat representing the articular pro-
hyperechoic reflections from the bone are clearly visualized. cesses, the head representing the spinal canal, and the whis-
Also because one can see the spine model through the water, kers the transverse processes. We refer to this as the cat’s head
it is possible to validate the sonographic appearance of a given sign. On a paramedian sagittal scan the lamina resembles the
osseous element by performing the scan with a marker (eg, a head and neck of a horse (Fig. 5-20A) and is referred to as the
needle) in contact with it (Fig. 5-20A). The water-based spine horse-head sign.3 The articular processes appear as one con-
phantom is also relatively cheap, easily prepared, requires tinuous hyperechoic wavy line with no intervening gaps (Fig.
little setup time, and can be repeatedly used without it dete- 5-20B), resembling a camel’s hump (camel hump sign). The
riorating or decomposing like animal tissues do. transverse processes are also crescent-shaped (Fig. 5-20C),
With a lumbosacral water-based spine phantom the spi- but much smaller than the spinous process, and their acous-
nous processes produce an inverted Y-shaped pattern in the tic shadows produce a sonographic pattern referred to as the
transverse spinous process view (Fig. 5-19A), but in a median trident sign.21 The sacrum is recognized as a large hyper-
sagittal scan they appear as crescent-shaped structures with echoic structure with a large acoustic shadow anterior to it on
their concavity facing anteriorly (Fig. 5-19B). The gaps a sagittal sonogram (Fig. 5-21).3 The gap between the lamina
Ch05.indd 134 23-08-2017 17:47:27

Bifid spinous Monofid spinous

process process
Lamina
Cervical spine model TS - C2 Spinous process TS - C7 Spinous process

A B C
Occiput
C1 (Atlas) Spinous Lamina Articular process
C2 process
Spinal
canal
D PMSS - Spinous process E PMSOS - Lamina F PMSS - Articular process
FIGURE 5-24 ■ Sonograms from a water-based cervical spine phantom. Note the bifid spinous process of C2 in (B), the C1 spinous process
is hypoplastic relative to C2 and recessed in (D), lamina in (E), and articular process in (F). TS, transverse scan; PMSS, paramedian sagittal
scan; PMSOS, paramedian sagittal oblique scan.
A CIRS phantom B Ultrasound imaging
C CIRS phantom - 3D rendered CT D CIRS phantom - Sagittal sonogram
FIGURE 5-25 ■ The CIRS lumbar training phantom (A) shown being imaged using ultrasound (C and D). Also shown is a 3-D reconstructed
image of the volume CT data set of the CIRS phantom (B).
of L5 and the sacrum is the L5-S1 gap (lumbosacral inter- anatomy of the spine are the CIRS lumbar training phan-
laminar space, Fig. 5-22).3 Representative ultrasound images tom (Figs. 5-25 and 5-26)3 and gelatin-agar spine phantom
of the lamina of the thoracic spine (Fig. 5-23), and the spinous (Figs. 5-27 to 5-29).22 Because the former can be imaged
process (Fig. 5-24), lamina, and articular pillars (Fig. 5-24) using computerized tomography (CT), 3-D reconstruction of
of the cervical spine are presented in Figs. 5-23 and 5-24. high-definition CT scan data (3-D volume data set) can also
Other models that are useful in understanding the osseous be used to study the osseous anatomy (Figs. 5-25 and 5-26).
Ch05.indd 135 23-08-2017 17:47:37

SP ISS L5S1 Gap Sacrum FJ AP
TP
Spinous process Articular process and Transverse process

A B
Inferior articular
Lamina ILS process
Lamina and Interlaminar space Articular process

C D
FIGURE 5-26 ■ Rendered CT images of the CIRS lumbar training phantom. (A) Median sagittal section showing the spinous processes,
interspinous space (ISS), and the L5-S1 gap. (B) Transverse interspinous section showing the articular processes (AP), facet joints (FJ),
transverse process (TP), and spinal canal. (C) Paramedian sagittal section showing the laminae and interlaminar spaces (ILS). (D) Paramedian
sagittal section at the level of the articular processes.
A B
C D
FIGURE 5-27 ■ Gelatin-agar spine phantom. (A) Lumbosacral spine model secured to the base of the plastic box. (B) Spine phantom after
being embedded in the gelatin-agar mixture. (C) Performing ultrasound scan of the gelatin-agar spine phantom. (D) Simulated in-plane needle
insertion in the gelatin-agar spine phantom.
Ch05.indd 136 23-08-2017 17:47:51

A B Spinous process
Lamina
Agar gel Spine Phantom Transverse spinous process view
C D
Interlaminar space
Lamina Articular process
Spinal canal Spinal canal
Paramedian sagittal oblique scan Transverse interspinous view
FIGURE 5-28 ■ Ultrasound scan of the gelatin-agar spine phantom (A). Transverse sonogram of the spinous process (B) and through the
interspinous space (D). Paramedian sagittal oblique scan of the L3-L4-L5 level (C).
Sacrum Lamina
L5S1 gap LF
L5 Lamina ILS
SC
AC SC
AC
A L5S1 Gap B Paramedian Sagittal oblique scan - Lamina
AP
C Paramedian Sagittal scan - Articular process D Paramedian Sagittal scan - Transverse process
FIGURE 5-29 ■ Paramedian sagittal sonogram from the gelatin-agar spine phantom. (A) L5-S1 gap, (B) the laminae, (C) articular processes,
and (D) the transverse processes at L3-L4 and L4-L5 levels. A graphic overlay has been placed over the L4 lamina in image B to illustrate
the sonographic pattern resembling the head and neck of a horse, and an inset has been placed in image C to illustrate the camel hump–like
appearance of the articular processes. SC, spinal canal; AC, anterior complex; ILS, interlaminar space; LF, ligamentum flavum; AP, articular
process; TPn transverse process.
Ch05.indd 137 23-08-2017 17:47:59

References during combined spinal and epidural anesthesia. Reg Anesth

Pain Med. 2001;26:64–67.
1. Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult 13. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy
thoracic and lumbar spine for central neuraxial blockade. Anes- of ultrasound imaging in obstetric epidural anesthesia. J Clin
thesiology. 2011;114:1459–1485. Anesth. 2002;14:169–175.
2. Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time 14. Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time
ultrasound-guided paramedian epidural access: evaluation of a ultrasonic observation of combined spinal-epidural anaesthesia.
novel in-plane technique. Br J Anaesth. 2009;102:845–854. Eur J Anaesthesiol. 2004;21:25–31.
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Sonoanatomy relevant for ultrasound-guided central neuraxial sound-guided spinal anesthesia in patients with a challenging
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using the transverse approach to the lumbar spine pro- Paramedian access to the epidural space: the optimum window
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sound imaging facilitates localization of the epidural space
Ch05.indd 138 23-08-2017 17:47:59

Sonoanatomy Relevant for Ultrasound-Guided Injections
of the Cervical Spine CHAPTER 6
Introduction Typical Cervical Vertebra (C3 to C6)
Injections of the cervical spine are frequently used for pain The third to sixth cervical vertebra are considered typical
management in chronic pain medicine. The concentration cervical vertebra (Fig. 6-4), whereas the first, second, and
of bony structures and nerves in the cervical spine, each of seventh cervical vertebra are atypical with certain unique
which can be a cause of pain, as well as vessels, requires an features (Figs. 6-5 and 6-6). The general characteristics of a
intimate knowledge of the anatomy. The relevant procedures typical cervical vertebra are described next. The upper five
in the cervical spine include facet joint and medial branch
blocks, selective nerve root injection, third occipital nerve
block, epidural steroid injection, and stellate ganglion block. Dens
In this chapter we discuss the anatomy relevant for these C1 (atlas)
procedures.
C2 (axis) Transverse
process
Intervertebral
Basic Cervical Spine Anatomy Facet joint disc
VB
The cervical spine (Figs. 6-1 to 6-3) is a column of seven Posterior tubercle
vertebrae supporting the skull and neck structures. The atlanto- Anterior tubercle
Transverse
occipital and atlantoaxial joints are unique. The former is an foramen Sulcus for
ellipsoid joint, and the atlantoaxial joint is a rotatory joint. The spinal nerve
C7 Transverse
atlantoaxial joint is bordered by the C2 dorsal root ganglion process
Inferior
and vertebral artery. The cervical vertebrae are identified by the articular facet
presence of the foramen transversarium (transverse foramen)
for the vertebral artery. FIGURE 6-2 ■ Cervical spine – anterior view. VB, vertebral body.
Posterior arch
of atlas
Dens of axis
C1 (atlas)
Posterior tubercle
C2 (axis) Atlas (C1)

Spinous process
Axis (C2)
Transverse
Sulcus for Inferior articular Superior articular
process process
spinal nerve process
Facet joint
Anterior Inferior articular Facet joint
tubercle Superior articular process
process Spinous process
Posterior
tubercle C7 Transverse
C7 Spinous
Verebral process process
body Lamina
C7 (vertebra)
C7 Spinous
Transverse foramen process
FIGURE 6-1 ■ Cervical spine – lateral view. FIGURE 6-3 ■ Cervical spine – posterior view.
139
ch06.indd 139 23-08-2017 19:33:27

140 n Chapter 6 / Sonoanatomy Relevant for Cervical Spine Injections
Spinous process
Vertebral Uncinate process SAP
arch Vertebral
foramen Posterior
Pedicle Lamina tubercle
SAF
VB
Posterior Anterior
tubercle tubercle
VB IAF
Transverse
Sulcus for foramen Spinous process
spinal nerve Anterior tubercle
Sulcus for
spinal nerve SAF
Transverse SAP
process
Spinous process
VB
IAF IAP
C Lateral view
FIGURE 6-4 ■ A typical cervical vertebra (C4 - fourth cervical vertebra). SAF, superior articular facet; SAP, superior articular process;
VB, vertebral body; IAF, inferior articular facet; IAP, inferior articular process.
Posterior
Posterior arch
tubercle SAF Anterior
Groove of arch Transverse
vertebral artery foramen
SAF
Transverse
foramen
Transverse
process IAF Anterior Transverse
Facet for dens tubercle process
Anterior tubercle
SAF
Posterior tubercle
Anterior
tubercle
Posterior arch
Transverse of atlas
foramen Transverse process
IAF
C Lateral view
FIGURE 6-5 ■ Atlas (superior, anterior, and lateral view). Note the kidney-shaped SAFs. SAF, superior articular facet; IAF, inferior articular
facet.
cervical vertebrae (C3 to C7) each have a concave s uperior foramina. The spinal canal (vertebral canal) in the cervical
surface and are convex on the inferior surface. They artic- spine is larger than the size of the body. It is also trian-
ulate with the adjacent vertebrae via uncovertebral joints gular shaped because the pedicles are directed backwards
(joints of Luschka). These are thought to be due to degener- and laterally (Fig. 6-4). The superior and inferior vertebral
ative tears in the annulus of the intervertebral disc, leading notches are usually equal sized. The laminae are relatively
to creation of the uncovertebral joint. Uncovertebral long and narrow and thinner above than below. The superior
joint osteophytes can contribute to narrowing of the exit and inferior articular processes form the articular pillars
ch06.indd 140 23-08-2017 19:33:32

Chapter 6 / Sonoanatomy Relevant for Cervical Spine Injections n 141
Spinous Dens
process
Vertebral arch
AAF
Vertebral Transverse
foramen IAP process
SAF
Transverse
process
Transverse VB
foramen
IAF
Dens SAF
AAF
AA Superior view B Anterior view
Dens
PAF Transverse
AAF
foramen
SAF Spinous
process
Transverse
process VB
IAF
C Lateral view
FIGURE 6-6 ■ Axis (superior, anterior, and lateral view). SAF, superior articular facet; VB, vertebral body; IAF, inferior articular facet;
AAF, anterior articular facet; IAP, inferior articular process; PAF, posterior articular facet.
and project laterally at the junction of the pedicle and trans- Dens Lateral atlantoaxial
verse process. The superior articular facets are directed joint
backwards and upwards, whereas the inferior articular fac- C1 spinal Atlas (C1)
ets are directed forwards and downwards (Fig. 6-1). The nerve
Axis (C2)
transverse process of each vertebra is pierced by the fora-
Uncinate
men transversarium (Fig. 6-4) to allow for the passage of Vertebral artery in process
transverse foramen
the vertebral arteries on their upward course to the foramen
magnum (Fig. 6-7). Each transverse process has an anterior C5 spinal nerve
Spinal nerve
and a posterior tubercle with the groove for the spinal nerve in sulcus C6 anterior
tubercle
between them (Figs. 6-1 and 6-2). The anterior tubercle of C7 transverse C7 Posterior
the sixth cervical vertebra is large and called the “carotid process tubercle
Vertebral artery C7 spinal nerve
tubercle” (tubercle of Chassaignac). The posterior tubercles
of C3 to C5 are located lower and laterally (Figs. 6-1 and 6-2).
Vertebral body (C7)
The spinous processes of C3 to C6 can be bifid (Figs. 6-3
and 6-8), and the two divisions can be of unequal size. The FIGURE 6-7 ■ Cervical spine (anterior view) showing the rela-
first bifid spinous process is C2, and this landmark is used to tionship of the cervical spinal nerves and the vertebral artery to the
transverse processes of the vertebra. Note the transverse processes of
identify the remaining cervical vertebrae. The facet joints are
the C7 vertebra lack an anterior tubercle and the relationship of the
oriented at 45 degrees to the axial plane and allow sliding of vertebral artery to the C7 spinal nerve and the transverse processes.
one articular facet on another (Figs. 6-9 and 6-10).
The cervical spinal canal measures about 14 to 20 mm in
the mediolateral dimension and 15 to 20 mm in the anteropos- and posterolaterally by the facet joints. The pedicles border
terior dimension. The spinal nerves (formed by the anterior the exit foramina superior and inferiorly. The spinal nerves
and posterior nerve roots) exit through the neural foramina. exit above their corresponding vertebral bodies. The C1 nerve
These foramina are largest at C2 to C3 and progressively exits above the C1 vertebra (atlas). The next spinal nerve is
decrease in size to the C6 to C7 levels. The spinal nerve and C2, exiting above the C2 vertebra (axis). Following this nam-
ganglion take up about 33% of the foraminal space. The fora- ing convention, the last cervical nerve root is C8, and it exits
men is bordered anteromedially by the uncovertebral joints between the C7 and T1 vertebrae (Figs. 6-11 and 6-12).
ch06.indd 141 23-08-2017 19:33:34

Ligamentum
Bifid C2 spinous flavum Dura
process C3C4 articular
C2 lamina C3C4 articular
process process
Spinal canal Spinal cord

VB
Posterior
Right
FIGURE 6-8 ■ Cross-sectional cadaver anatomic section through FIGURE 6-10 ■ Cross-sectional cadaver anatomic section through
the C2 vertebral body showing the bifid spinous process of C2. This the cervical spine demonstrating the facet joints. Note that the facet
is an anatomical landmark used to identify the C2 vertebra as it is joints are orientated at about 45 degrees to the horizontal plane in
the first cervical vertebra with a bifid spinous process. The spinous transverse section.
process may be tilted to the right or left. Gentle left and right angula-
tion of the probe in the longitudinal sagittal plane may be required to
visualize these spinous processes.
C5 TP anterior
Sternocleidomastoid tubercle
Anterior
scalene
C4 lamina C6 lamina Vertebral
C5 lamina Middle
scalene artery
C7 lamina
C5 TP posterior
tubercle
VB
C7
Posterior C5 nerve root

Anterior
Left
Cranial
FIGURE 6-9 ■ Paramedian sagittal cadaver anatomic section FIGURE 6-11 ■ Cross-sectional cadaver anatomic section through
through the cervical spine demonstrating the lamina of the cervical the cervical spine demonstrating the exiting C5 nerve root. The
vertebrae. VB, vertebral body. C5 nerve root exits the neural foramen and is in close relation to
the vertebral artery posteriorly. Both these structures are bound by
the larger anterior tubercle and the smaller posterior tubercle. TP,
transverse process.
The anterior spinal artery is located in the central sul- arise from the cervicomedullary junction portion of the
cus of the cord, with paired posterior arteries running on vertebral arteries. This anatomy is relevant for epidural ste-
the posterolateral aspect of the cord dorsally. The anterior roid injections. The radicular arteries also supply the nerve
spinal artery is an important artery: it supplies the anterior roots and spinal cord. These radicular arteries arise from
two-thirds of the cervical spinal cord. The artery receives the aorta. In the lower cervical spine, they arise from the
blood supply from the paired anterior spinal branches that vertebral arteries and run in an anteromedial direction with
ch06.indd 142 23-08-2017 19:33:47

Sternocleidomastoid
C1 Atlas
C2 SP Dura C3 SP
C4 SP
C5 Nerve
root
Spinal
cord Spinal cord
VB
Anterior C4 Transverse C5 Transverse Posterior

process process Anterior complex
Cranial Cranial
FIGURE 6-12 ■ Sagittal cadaver anatomic section of the exit neu- FIGURE 6-13 ■ Median sagittal cadaveric anatomic section through
ral foramina demonstrating the C5 nerve root exiting between the the cervical spine demonstrating C1 in relation to the occiput and the
transverse processes (TP) of C4 superiorly (C4 TP) and C5 (C5 TP) rest of the cervical vertebrae. Note how closely the dura and the cervi-
inferiorly. The bulk of sternocleidomastoid muscle lies anteriorly cal spinal cord are to the spinous processes. The vertebral bodies (VB)
and may be traversed during procedures in the cervical spine. are labeled as anterior complex to demonstrate that sonographically, the
individual components (including the posterior longitudinal ligament
complex) are difficult to distinguish individually. SP, spinous process.
respect to the neural foramina. In the lower cervical spine, mass is a facet (zygapophyseal) joint. The superior articu-
large radiculomedullary branches contribute blood supply to lar facets are kidney shaped (Fig. 6-5), concave, and face
the anterior spinal artery as well. Branches of the ascend- upwards and inwards (imagine your hands cupping water
ing and deep cervical arteries anastomose with the vertebral from a running tap). The inferior articular facets are flat and
artery branches and contribute to the anterior spinal artery. face downwards and outwards. The transverse processes
The ascending cervical artery arises from the thyrocervical project laterally from each lateral mass and are longer than all
trunk or subclavian artery. the others (Figs. 6-2 and 6-3).
The posterior subclavian artery also gives off the deep cervi-
cal artery and the superior intercostal artery. The deep cervical Axis (C2)
artery gives spinal branches from levels C7 to T1, known as
The second cervical vertebra (Fig. 6-6) is recognized by
the cervical radiculomedullary arteries. As mentioned earlier,
the presence of the dens (odontoid process), which is a
these arteries can contribute supply to the anterior spinal artery.
strong toothlike process that projects upwards from the
These radiculomedullary arteries are found along the length of
body (Fig. 6-6). The dens is believed to represent the body
the intervertebral foramina and can be compromised during
(centrum) of the atlas, which has fused with the body of the
injection, potentially leading to damage to the anterior spinal
axis. The odontoid process articulates with the atlas to form
artery. The posterior third of the cervical spinal cord is supplied
the rotatory atlantoaxial joint. The joint is strengthened by
by small paired posterior spinal branches.
periarticular ligaments (the apical, alar, and transverse liga-
ments). The axis is made up of a vertebral body, pedicles,
Atlas (C1) lamina, and transverse and spinous processes. The atlas artic-
The atlas is the first cervical vertebra (Fig. 6-5) and forms the ulates with the axis (Fig. 6-2) at the superior articular facets
joint that connects the spine to the skull (Fig. 6-13). It is ring of C2. In order to meet the inferior articular processes of C1,
shaped and lacks both a vertebral body and spinous process the C2 superior articular facets face upwards and outwards.
(Fig. 6-5). It also lacks a true facet joint and has two arches: There is an extensive and densely packed network of blood
anterior and posterior. The posterior arch is usually quite vessels around the dens. These are supplied by the paired
small. A thick anterior arch, lateral masses, and transverse anterior and posterior ascending arteries (which arise from
processes on either side make up the rest of the atlas ring. the vertebral arteries at the C3 level, carotid wall vessels, and
It also has a rudimentary posterior tubercle. On each lateral the ascending pharyngeal arteries).
ch06.indd 143 23-08-2017 19:33:55

The transverse ligament secures the odontoid process to

the posterior atlas and acts to prevent subluxation of C1 on
C2. Accessory ligaments arise posterior to the transverse
ligament and insert on the lateral aspects of the atlantoaxial
joint. The apical ligament, part of the accessory ligaments C6 Articular
process
mentioned earlier, connect the anterior lip of the foramen
magnum to the tip of the dens. Paired alar ligaments also
C5 VB
attach the tip of the dens to the anterior foramen magnum. C5/6 Facet
joint
The tectorial membrane is a cranial continuation of the poste-
rior longitudinal ligament, attaching to the anterior lip of the
C5 Articular
foramen magnum. A broad accessory atlantoaxial ligament process
connects C1 and C2 and connects to the occiput. They con-
tribute to craniocervical stability. The lack of bony borders
at the atlantoaxial joint results in wider acoustic windows at
this level, but this is countered by the tortuous course of the
ascending vertebral arteries.
FIGURE 6-14 ■ Transverse CT section through the cervical spine
demonstrating the facet joints at the C5 to C6 level. The inferior articu-
Seventh Cervical Vertebra (C7) lar pillar of the C6 (vertebra inferior to the joint) is located anterior
This is also known as the “vertebral prominence” because it to the joint space. The superior articular pillar of the C5 (vertebra
superior to the joint) is located posterior to the joint space.
has a long and prominent spinous process (Fig. 6-1) that is
palpable from the skin surface. The spinous process is also
thick, nearly horizontal, and is not bifid but ends in a tubercle.
The transverse process of C7 is relatively large and lacks an
anterior tubercle (Fig. 6-7). The foramen transversarium on
the transverse processes of C7 are small but may be duplicated C7 Articular
or even absent. process
C6/7 Facet
Computed Tomography Anatomy of the joint
Cervical Spine C6 Articular
process
Figs. 6-14 to Fig. 6-21
Magnetic Resonance Anatomy of the

Cervical Spine
C6 Spinous
Figs. 6-22 to 6-38 process
FIGURE 6-15 ■ Transverse CT section through the cervical spine

Ultrasound for Cervical Facet Joint demonstrating the facet joints at the C6 to C7 level. Note the rela-
tively horizontal orientation of the facet joint as opposed to the
Injection obliquity of the C5 to C6 facet superiorly.

1a. Patient position: b. Posterior approach: The posterior approach has
a. Lateral approach: The patient is placed in the lateral the distinct advantage of allowing the patient to be
decubitus position. The head is placed on a pillow placed prone and both joints being accessible without
so that the shoulders are square to the examination having to change position. It can be uncomfortable
couch. Hair should be tied and lifted clear from the to the patient if multiple levels are blocked, so this
side of the neck to prevent contamination during the position is suited for faster access to both sides of the
procedure (Fig. 6-39). neck (Fig. 6-40).
ch06.indd 144 23-08-2017 19:33:57

C1 Posterior
arch
C2 Lamina
C7 Transverse
process C3 Lamina
C7 Lamina Interlaminar
space
C4 Lamina
FIGURE 6-18 ■ Sagittal CT section of the cervical spine demon-

FIGURE 6-16 ■ Transverse CT section through the cervical spine. strating the posterior arch of C1 and the corresponding laminae of
The lamina on the posterolateral aspect of the vertebra flows into the the vertebrae inferiorly.
transverse process. The longus colli muscle lies on the anteromedial
aspect of the transverse process.
T1 Transverse C4 Articular
process process
C7 VB C4 Transverse C4/5 Facet
process joint
C5 Transverse C5 Articular
process process
C7 Lamina
C7 Spinous process
FIGURE 6-17 ■ Transverse CT section through the body of the FIGURE 6-19 ■ Sagittal CT section of the cervical spine more
seventh cervical spine demonstrating its large and prominent spinous laterally in the cervical spine demonstrating the overlapping articu-
process (vertebra prominence). VB, vertebral body. lar pillars that form the facet joints. In the same cut, transverse
processes may also be visualized on CT. The transverse processes
may be obscured on ultrasound by the bony reflections of the facet
joints.
1b. Position of operator and ultrasound machine: 2. Transducer selection:

The operator sits or stands facing the patient’s back in the Due to the density of muscular structures around the cer-
lateral position or on the side of the patient for the pos- vical spine, a curvilinear probe (5–2 MHz) is used for
terior approach. It is more comfortable for the operator imaging and blocks in the cervical spine (facet blocks
if the nondominant hand anchors the transducer and the and occipital nerve blocks). The in-plane resolution of
dominant hand manipulates the needle. the images is reduced compared with a linear probe, but
ch06.indd 145 23-08-2017 19:34:01

C1
C1 posterior arch
C2 Spinous
process
C2 lamina
Dura
C3 lamina
C5 Spinous Dura
C4 lamina
process
Anterior complex
C7 Spinous
process
FIGURE 6-22 ■ Sagittal T2-weighted MRI section of the cervical

spine demonstrating the posterior arch of C1 and the correspond-
ing laminae of the vertebrae inferiorly. Note the slight overlap of
FIGURE 6-20 ■ Sagittal CT section of the cervical spine in the mid-
the laminae, which is seen on ultrasound as a “horse head” configu-
line demonstrating the spinous processes aligned with the occiput.
ration. Cerebrospinal fluid (hyperintense signal) bathes the small
The tips of the spinous processes are echogenic on ultrasound.
nerve roots in the spinal canal.
Starting with the broad echogenic base of the occiput, these echogenic
points can be used to identify the levels of the cervical spine. Note that
the spinous process of C1 is hypoplastic relative to C2 and recessed. It
is important to identify this recess to avoid mislabeling C2 as the first
cervical vertebra on ultrasound.
C4 Transverse
process C3 lamina
C4 Articular
Vertebral pillar Facet joint
artery
C4/5 facet C4 lamina
C5 Transverse joint
Facet joint
process C5 Articular C5 lamina
pillar
FIGURE 6-21 ■ Sagittal CT section of the cervical spine demon- FIGURE 6-23 ■ Sagittal T2-weighted MRI section of the cervical
strating the relationships of the articular pillars, facet joints, and the spine more laterally in the cervical spine demonstrating the overlap-
vertebral artery within the foramen transversarium. Also note the ping articular pillars that form facet joints.
oblique angulation of the facet joints in the sagittal plane. In order
for successful facet joint injection, the needle should be parallel to
the angulation of the joint.
ch06.indd 146 23-08-2017 19:34:08

Vertebral artery C4 root
C5 root
FIGURE 6-24 ■ Sagittal MRI section of the cervical spine demon-

strating the vertebral artery within the foramen transversarium. The
exiting nerve roots are well demonstrated as ovoid hypointense foci
as they are seen en face. The nerve roots are closely related to the
vertebral artery.
FIGURE 6-26 ■ Sagittal MRI section of the cervical spine demon-

strating the broad base of the occiput. Note that the spinous process
of C1 is hypoplastic relative to C2 and recessed. It is important
to identify this recess to avoid mislabeling C2 as the first cervical
vertebra on ultrasound.
C2 spinous process
C3 spinous process
Spinal cord C4 lamina

C4 spinous process Vertebral body
C5 spinous process (anterior complex) Epidural space
Vertebral body C6 spinous process Spinal cord and dura
(anterior complex)
C7 spinous
Ligamentum flavum process
and dura
FIGURE 6-25 ■ Sagittal MRI section of the cervical spine in FIGURE 6-27 ■ Sagittal oblique MRI section of the cervical spine
the midline demonstrating the spinous processes aligned with the demonstrating the epidural space and the dura posteriorly. The e pidural
occiput. The tips of the spinous processes are echogenic on ultra- space in the cervical spine is a potential space (unlike the lumbar spine,
sound. Starting with the broad echogenic base of the occiput, these where fat fills the epidural space).
echogenic points can be used to identify the levels of the cervical
spine. Note that the spinous process of C1 is hypoplastic relative to
C2 and recessed. It is important to identify this recess to avoid mis-
labeling C2 as the first cervical vertebra on ultrasound. MRI demon-
strates the relationship of the cervical spine relative to the dura, with
surrounding cerebrospinal fluid.
ch06.indd 147 23-08-2017 19:34:17

Sternocleidomastoid muscle
C4 nerve root
C5 nerve root
C2 laminae
FIGURE 6-28 ■ Transverse MRI section through the cervical spine FIGURE 6-30 ■ Paramedian sagittal MRI of the cervical spine
demonstrating the laminae of C2. The cervical spinal cord is well demonstrating the almost vertical oblique course of the cervi-
visualized centrally, with nerve roots exiting on either side of the cal nerve roots of C4 and C5 as they plunge toward the intersca-
cord, extending beyond through the exit foramina. lene groove. The large overlying sternocleidomastoid muscle is
demonstrated.
Vertebral body
(anterior complex)
Spinal cord
C4 NR C4 TP
C5 NR
C5 TP
C2/3 articular facet C2/3 articular facet
C6 NR
C7 NR
FIGURE 6-29 ■ Transverse MRI section through the cervical FIGURE 6-31 ■ Paramedian sagittal MRI section of the cervical
spine demonstrating the facet joints. The facets are angled posteri- spine demonstrates the C5 nerve root beyond the exit foramen. It
orly at this level and gradually assume a more horizontal orienta- runs between the transverse processes of C4 and C5 en route to
tion in the lower cervical spine. The vertebral body and anterior the interscalene groove (between the anterior and middle scalene
and posterior longitudinal ligaments are collectively referred to muscles).
as the anterior complex in sonography as they are not separately
distinguishable.
ch06.indd 148 23-08-2017 19:34:30

Sternocleidomastoid C6 nerve root

Anterior scalene C5 Anterior tubercle Carotid artery
Sternocleidomastoid Anterior scalene
Middle scalene Anterior tubercle
C5 nerve root
FIGURE 6-34 ■ Transverse MRI section through the cervical spine

demonstrating the prominent anterior tubercle of C6 (Chassaignac’s
tubercle). This is a sonoanatomical landmark to identify C6 and the
FIGURE 6-32 ■ Transverse MRI section through the cervical spine exiting C6 nerve root immediately posterior to the tubercle. The lon-
demonstrating the exiting C5 nerve root. The C5 nerve root exits the gus colli muscle lies anteromedial to the Chassaignac tubercle in
neural foramen and is in close relation to the vertebral artery poste- close relationship with the carotid artery on its lateral aspect.
riorly. Both these structures are bound by the larger anterior tubercle
and the smaller posterior tubercle.
C7 articular processes
C6 articular processes
Vertebral body
(anterior complex)
C6 spinous process
Articular processes FIGURE 6-35 ■ Transverse MRI section through the cervical spine
Spinal cord demonstrating the C6 to C7 facet joints. In comparison with the C5
to C6 level, the facets are orientated in a more horizontal plane.
IJV Carotid artery

Sternocleidomastoid
Vertebral artery
Anterior scalene

demonstrating the facet joints at the C5 to C6 level. The inferior
articular pillar of the C6 (vertebra inferior to the joint) is located
anterior to the joint space. The superior articular pillar of the C5 C7 nerve root
(vertebra superior to the joint) is located posterior to the joint space.
Note that at C5 to C6, the facets remain oblique relative to the hori-
zontal plane. They take a more horizontal course from the C6 to-C7
and C7 to T1 levels.

at the C6 to C7 foramen demonstrating the exiting C7 nerve root
running immediately posterior to the vertebral artery. The nerve root
is en route between the anterior and middle scalene to form the bra-
chial plexus. Note the presence of the internal jugular vein (IJV),
carotid artery, and the vertebral artery.
ch06.indd 149 23-08-2017 19:34:38

Vertebral body (anterior complex)
C7 transverse processes

demonstrating the C7 transverse processes. The anterior complex
(vertebral body) is flanked by the vertebral arteries on both sides.
FIGURE 6-39 ■ Position of the patient and ultrasound transducer
during a paramedian sagittal scan of the cervical facet joints. The
transducer is placed about 1 to 2 cm away from the midline and
angulated medially toward the facet joints. A similar position is used
for performing third occipital nerve blocks (refer to text).
Longus colli Trachea

Carotid artery
Vertebral body
Sternocleidomastoid
Vertebral
artery
FIGURE 6-38 ■ Transverse MRI section through the cervical FIGURE 6-40 ■ Position of the patient and ultrasound transducer
spine demonstrating the longus colli muscles running anterior to the during a paramedian sagittal scan of the cervical facet joints. The
transverse processes. Note that the vertebral arteries lie immediately transducer is placed about 1 to 2 cm away from the midline and
posterior to the longus colli at the C7 level. The carotid artery is angulated medially toward the facet joints. The posterior approach
located on the anterolateral aspect of the muscle, and the thyroid allows more room to maneuver the needle and probe. It also allows
gland forms the anterior border of the muscle. With ultrasound, a simultaneous access to both sides of the spine, but is generally more
safe trajectory between the artery and thyroid gland toward the lon- uncomfortable for patients.
gus colli can be planned. The sternocleidomastoid muscle overlies
the anterolateral aspect of the neck and may be traversed during a
stellate ganglion block.
spatial compound imaging and tissue harmonic imaging
this is often necessary due to the depth of the facet joints on new ultrasound machines enable us to examine tissues
in relation to the skin. The probe footprint is often large, at those depths with reasonable clarity. Beam steering
and maneuvering the transducer into the correct position technology (which is an offshoot of compound imaging)
requires practice. Although visualization of small (2 mm enhances needle visualization, and color B-mode imag-
and below) structures is compromised by using a curvi- ing (such as indigo or sepia hue) aids the human eye for
linear probe traditionally, processing techniques such as image visualization when image contrast is poor.
ch06.indd 150 23-08-2017 19:34:43

3. Scanning technique for facet joint blocks: the level, the transducer should be shifted slightly laterally
A sagittal plane scan is performed in the midline, using along the lamina by about 1 to 2 cm from the midline.
the spinous processes to identify the level to inject. Align From there, a slight lateral shift of the transducer will
the transducer in a craniocaudal direction with respect reveal facet joints, which appear with a characteristic
to the cervical spine, starting at the occiput and sliding “saw sign.” The probe may have to be angled medially
inferiorly. C1 has a very small or absent spinous process to produce a slightly paramedian sagittal oblique image.
(Figs. 6-41 and 6-42), and the first bifid spinous process The needle is inserted in a posterior-to-anterior plane and
will be C2. The transducer can be slid inferiorly until the followed in real time (Fig. 6-43).1
desired level for the injection is reached. Having identified 4 . Sonoanatomy of the facet joint:
On ultrasound, cervical segments can be identified
with respect to the occiput by counting the echogenic
points, which represent the spinous processes. The first
echogenic point located inferior to the occiput is the C1
cervical vertebra. The C2 vertebra is located immediately
C1 Atlas inferior to that and has a characteristic bifid appearance.
Dura This presents as two echogenic points on ultrasound per-
C4 SP
formed in the transverse plane. The spinous processes
C2 SP C3 SP
in the cervical spine can appear bifurcated and can be
asymmetrical. They can also deviate to the right or left
Spinal cord (Figs. 6-8 and 6-13).
The occipitoatlantal and atlantoaxial joints may
Posterior be demonstrated once these levels are identified. The
Anterior complex articular processes are echogenic, and the facet joint is
Cranial
represented as a hypoechoic gap between the articular
processes. The needle can then be inserted from infe-
FIGURE 6-41 ■ Median sagittal sonogram of the cervical spine. rior to superior in plane to the transducer. This approach
The broad echogenic base of the occiput is immediately followed by allows the needle to be inserted parallel to the facet joint
the recessed spinous process of C1. The C2 spinous process is larger
(Fig. 6-43).
and appears as a step superficially relative to the C1 vertebra.
C4 Lamina C5 Lamina
Occiput C3 Lamina
Ligamentum C6 Lamina
C1 Atlas flavum
Spinal
cord
Facet joints
Posterior Posterior
Anterior
Cranial complex
Cranial
FIGURE 6-42. ■ Coned (zoomed) sagittal view of the cervical FIGURE 6-43 ■ Paramedian sagittal sonogram of the cervical
spine. The occiput and C1 articulation is clearly demonstrated. spine lateral to the laminae demonstrating the overlying echogenic
“hills” of the facet joints.
ch06.indd 151 23-08-2017 19:34:48

C2 Articular
process
Articular processes
Spinal
cord
Facet joint
Posterior Anterior
complex Posterior
Right Left
Right
Anterior
FIGURE 6-44 ■ Transverse sonogram of the cervical spine at the FIGURE 6-46 ■ Transverse sonogram clearly demonstrating the
C2 articular pillars level. With the probe orientated in a transverse facet joint of C5 to C6. Sometimes, this joint is obscured by osteo-
plane and angulated superiorly between the spinous processes, the phyte formation.
spinal cord and anterior complex can be visualized.
has a fibrous capsule and is lined by synovial membrane.

The joint capsules are lax in the lower cervical spine,
allowing the spine to glide smoothly during movement
C3C4 articular C3C4 articular (Figs. 6-9, 6-14, 6-29, and 6-46).
process
process The facet joint capsules contain dense mechanorecep-
tors, which play a role in proprioception and pain sensation.
Spinal This is thought to neuromodulate the cervical spine and
cord prevent excessive joint movement.3 The facet joints are
innervated by articular branches derived from the medial
branches of the cervical ventral and dorsal rami. The
Anterior
Posterior
complex atlanto-occipital and atlantoaxial joints are innervated by
Right Left the anterior rami of the first and second cervical spinal
Anterior
nerves. The C2 to C3 facet joint is innervated by the two
FIGURE 6-45 ■ Transverse sonogram at the C2 to C4 articulation branches of the posterior ramus of the third cervical spi-
demonstrating the facet joints on either side of the central canal con- nal nerve: a communicating branch and the third occipital
taining the spinal cord. The echogenic lines denoting the apposing nerve (Fig. 6-9).
articular surfaces can be seen. Whereas an in-plane injection technique The C3 to C7 dorsal rami arise from their respective
is frequently used with cross-sectional imaging, ultrasound-guided
spinal nerves and pass dorsally over the root of the cor-
facet injections are usually performed in the longitudinal plane rela-
tive to the patient.
responding transverse processes. The medial branches of
the cervical dorsal rami run transversely across the cen-
troid of the corresponding articular pillars (Fig. 6-47).
They are bound to the periosteum by investing fascia and
The facet joints are angled at about 45 degrees to secured by the tendon of semispinalis capitis. The articu-
the transverse plane in the cervical spine.2 They start to lar branches arise as the nerve approaches the posterior
assume a more vertical position in the upper thoracic aspect of that articular pillar, one innervating the zyg-
spine. The superior articular process faces more postero- apophyseal joint above and the other innervating the joint
medial in the upper cervical levels, and it becomes more below. Hence each typical cervical facet joint below C2
posterolateral at the lower cervical level (Figs. 6-44 and and C3 has dual innervation from the medial branch above
6-45). The facet joints are synovial joints. Each facet joint and below.
ch06.indd 152 23-08-2017 19:35:03

The skin entry point of the needle is usually about

2 to 3 cm inferior to the end of the probe, rather than at
Articular process
Medial branch Facet joint the probe itself. This allows the needle to enter at a shal-
dorsal rami
lower angle and to be inserted parallel to the facet joint.
Confirmation of injectate can be done by watching out
for a hyperechoic flush (representing a small pocket of
air trapped within the needle). However, once the air has
been expelled, it can be difficult to visualize the injectate.
Turning on the Color Doppler function on the ultrasound
machine allows flow to be visualized, and injection can
Posterior be done under continuous Doppler monitoring.
Cranial
FIGURE 6-47 ■ Coned down (zoomed) ultrasound view of the Ultrasound for Third Occipital Nerve Block
facet joints and articular pillars. Echogenic medial branch rami
Gross Anatomy of the Third Occipital Nerve
are visualized in apposition to the echogenic bone cortex. These
superficial structures are well visualized and can be targeted for As described in the facet joint section, the joints are inner-
radiofrequency ablation and injection. vated by articular branches derived from medial branches of
the cervical dorsal rami. The C3 to C7 dorsal rami arise from
the corresponding spinal nerves and travel dorsally over the
transverse processes posteriorly. Now, the C3 medial branches
have a different anatomy. A deep medial branch passes around
the waist of the C3 articular pillar to supply the C3 to C4 facet
The medial branches of the C3 dorsal ramus differ in
(similar to the other levels caudally). The superficial medial
their anatomy. A deep medial branch passes around the
branch of C3 (the TON) curves laterally and around the pos-
waist of the C3 articular pillar, similar to other typical
terior aspect of the C2 to C3 facet. It supplies branches to
medial branches, and supplies the C3 to C4 zygapophy-
the joint prior to traveling dorsal to the semispinalis obliquus
seal joint. The superficial medial branch of C3 is large
capitis muscle. So, each facet joint is innervated by the medial
and known as the third occipital nerve (TON). It curves
branch at the levels inferior and superior to it (dual innerva-
around the lateral and then the posterior aspect of the C2
tion), with the exception of C2 to C3, which is innervated by
to C3 zygapophyseal joint, giving articular branches to
a single nerve (TON). The TON is the only nerve that crosses
the joint. Beyond the C2 to C3 zygapophyseal joint, the
over the facet joint. The TON measures about 2 mm in diam-
TON becomes cutaneous over the suboccipital region.
eter (range of 1–3 mm) and is located about 2 cm (range 1.4–
Another anatomical exception is the course of the medial
2.7 cm) from the skin.
branch of C7. The C7 medial branch passes more cranial,
closer to the foramen of C7, crossing the triangular supe-
rior articular process of C7 vertebrae. Ultrasound Scan Technique
5 . Clinical Pearls: 1. Position:
Do not introduce too much craniocaudal rocking move- a. Patient: The patient is placed in the lateral decubitus
ment of the transducer as it increases the chances of position, similar to a lateral facet injection position
losing one’s position. Axial scans of the cervical spine (Fig. 6-39). The head is placed on a pillow so that the
to identify the facet joints are usually not practiced shoulders are square to the examination couch. Hair
routinely. The reason is that rotating the transducer to should be tied and lifted clear from the side of the
produce an axial image increases the chances of losing neck to prevent contamination during the procedure.
one’s position along the cervical vertebrae, requiring a b. Operator and ultrasound machine: The operator
recount. Furthermore, visualization of the facet joint in sits or stands facing the patient’s back in the lateral
the axial plane does not facilitate needle positioning, as position. It is more comfortable for the operator if
the sonographic technique uses a craniocaudal approach the nondominant hand anchors the transducer and the
(as opposed to a lateral-to-median approach). dominant hand manipulates the needle.
ch06.indd 153 23-08-2017 19:35:05

2. Transducer selection: proximal level, prior to branching of the nerve, increasing

A high-frequency (15–12 MHz) linear transducer is the treated area. Using Doppler prior to injection is impor-
generally used. This allows visualization of the greater tant to identify aberrant vessels in the suboccipital area.
occipital nerve at the level of the obliquus capitis inferior
muscle. Imaging techniques like beam steering technol-
ogy and compound and harmonic imaging are available
Ultrasound for Selective Nerve Root Block
on most new ultrasound machines. These generally Ultrasound Scan Technique
improve visualization of the anatomy and the needle. 1. Position:
A lower-frequency curvilinear transducer (3–5 MHz) can a. Patient:
be used in obese patients, but nerve visualization will be i. Lateral approach: The patient is placed in the
more difficult compared with the linear transducer. The lateral decubitus position (Fig. 6-48). The head
footprint of the curvilinear transducer is also bigger than is placed on a pillow so that the shoulders are
the linear transducer. Circumstances will usually dictate square to the examination couch. Hair should be
the appropriate transducer to use. tied and lifted clear from the side of the neck to
3. Scanning technique and sonoanatomy: prevent contamination during the procedure.
Starting in the midline of the posterior spine, the probe Posterior approach: The posterior approach
ii.
can be slid anteriorly and laterally to the level of the mas- has the distinct advantage of allowing the patient
toid process. This will allow identification of the occipital to be placed prone and both sides being acces-
bone and the C1 and C2 transverse processes. Turning on sible without having to change position. It can be
the Color Doppler function at this level is useful to iden- uncomfortable to the patient if multiple levels are
tify aberrant branches of the vertebral artery. The probe blocked, so this position is suited for faster access
can be slid inferiorly and posteriorly, and the articular to both sides of the neck.
pillars of C2 and C3 will come into view. The TON runs b. Position of operator and ultrasound machine:
perpendicular to the probe at this point and is located The operator sits or stands facing the patient’s back
dorsal to the C2 to C3 articulation. Sonographically, the in the lateral position or on the side of the patient for
fibrillar ovoid nerve can be seen overlying the C2 to C3 the posterior approach. It is more comfortable for the
facet joint. The TON crosses the C2 to C3 articular pillars operator if the nondominant hand anchors the trans-
about 1 mm from the bone, and the operator can identify ducer and the dominant hand manipulates the needle.
the typical fibrillar pattern of the nerve on ultrasound by
angling the probe slightly back and forth. The facets can
also be confirmed by visualizing the echogenic “hills”
representing the facet joints caudally. The medial branch
nerves are located in the troughs or valleys of these echo-
genic “hills”4 (Figs. 6-43 and 6-47).
Another technique to detect the TON involves placing
the transducer in an oblique transverse orientation, with
the cranial end of the transducer anchored to the occipi-
tal bone. The caudal end of the transducer can then be
tilted inferiorly (keeping the cranial end anchored to the
mastoid), until the semispinalis obliquus capitis muscle
comes into view in the longitudinal plane. The third
occipital nerve can be seen as an ovoid fibrillar structure
overlying the muscle. This corresponds to the traditional
suboccipital landmark used in palpation-based injection
FIGURE 6-48 ■ Position of the patient and ultrasound transducer
techniques.
during a scan for selective nerve root injection. The high-frequency
4. Clinical Pearls: linear array transducer is placed in a transverse oblique plane with
The ultrasound technique is a modification of the blind respect to the long axis of the cervical spine, allowing visualization
palpation technique. The nerve is blocked at a more of the nerve root.
ch06.indd 154 23-08-2017 19:35:06

2. Transducer selection:
For selective nerve root blocks, a high-frequency (15–12
MHz) linear array transducer can be used. The linear foot-
print is smaller than the curvilinear transducer and can be Sternocleidomastoid
placed at the base of the neck for the lower cervical nerve Middle scalene
roots. Imaging techniques like beam steering technology Anterior scalene
C5 TP
and compound and harmonic imaging are generally avail- Posterior
able on most new ultrasound machines and improve visu- tubercle
C5 TP
alization of the anatomy and the needle point. Anterior
tubercle
3. Scanning technique: C5 Nerve
root
Locating the correct cervical vertebral level has been Anterior
described in the section on facet joint injection. This Lateral

involves identifying the C1 vertebra (with a small or non-
existent spinous process) and the C2 vertebra inferiorly FIGURE 6-49 ■ Transverse sonogram demonstrating the exited C5
(the first bifid cervical spinous process, Fig. 6-8). The nerve root between the anterior and posterior tubercles of the C5
levels are then labeled sequentially from C2 (Fig. 6-41). transverse process. The nerve will proceed between the anterior and
Another technique of identifying the cervical vertebral middle scalene muscles with the other brachial plexus roots. The
overlying sternocleidomastoid muscle is hypoechoic with fibrofatty
levels on a lateral image is to count upwards (cephalad
striations.
direction) from C6. The C6 vertebral anterior tubercle is
the largest in the cervical spine (Chassaignac’s tubercle).
The transducer is maintained in the same axial orientation
and gently moved upwards. The anterior tubercles of the
respective cervical vertebrae are identified and counted.
The vertebral artery must be identified at the same time
Sternocleidomastoid
and documented. The vessel runs anteriorly at C7 before Anterior scalene
it enters the foramen transversarium from C6 in about Middle scalene

90% of cases (Fig. 6-7). In the remaining cases, the ver-
C6 TP
tebral artery enters the foramen transversarium at C5 or Posterior C6 TP
tubercle Anterior
at a higher vertebral level. The ultrasound transducer is tubercle
positioned to obtain an oblique axial image of the cervi-
cal spine. The landmark structures are the transverse pro- C6 Nerve root
cesses and their anterior and posterior tubercles, resulting Carotid

Posterior
artery
in a camel hump sign. The nerve root is visualized as an Lateral
oval hypoechoic punctate structure between the tubercles
(Figs. 6-49 and 6-50). Subsequently, a 22-G needle can be FIGURE 6-50 ■ Transverse sonogram demonstrating the exited C6
introduced in a posterior-to-anterior direction. The needle nerve root between the anterior and posterior tubercles. The nerve
is slowly advanced toward the oval hypoechoic target will proceed between the anterior and middle scalene muscles, with
the other brachial plexus roots. The overlying sternocleidomastoid
located between the “camel humps.”5 This approach is
muscle is hypoechoic, with fibrofatty striations.
extraforaminal, but it provides a margin of safety given
the density of radicular arteries in the foramen itself.
The anterior tubercle at C7 is hypoplastic. Hence, there is
no bony landmark to indicate the anteriormost extent of the 4. Sonoanatomy:
nerve root. More importantly, the vertebral artery at C7 runs The cervical spinal nerves exit primarily through the
in close proximity to the exited nerve root. It takes a verti- lower part of the foramen (Figs. 6-11, 6-12, 6-31, and
cal course toward the subclavian artery, and the C7 nerve 6-52). Epiradicular veins generally occupy the upper part
root eventually runs laterally as part of the brachial plexus of the foramen. Radicular arteries also lie in close approx-
(Fig. 6-51). Due to the inherent risks of cervical spine pro- imation to the cervical spine nerves within the foramen.
cedures, monitoring with fluoroscopy is still advisable.6–12 Hoeft showed that radicular branches from the vertebral
ch06.indd 155 23-08-2017 19:35:12

Sternocleidomastoid
Posterior tubercle Anterior scalene

of C7 Sternocleidomastoid
C6 nerve root
Anterior scalene C6 TP anterior
Middle scalene tubercle
IJV
VB
C7 TP
C6 TP posterior
Carotid Anterior tubercle
Vertebral artery
Anterior C7 Nerve artery Left
root
Lateral
FIGURE 6-51 ■ Transverse sonogram demonstrating the exited FIGURE 6-53 ■ Transverse cadaver anatomic section through the
C7 nerve root. The anterior tubercle of C7 is hypoplastic and barely cervical spine demonstrating the prominent anterior tubercle of
seen. C6 (Chassaignac’s tubercle). This is a sonoanatomical landmark
to identify C6 and the exiting C6 nerve root immediately posterior
to the tubercle. The longus colli muscle lies anteromedial to the
Chassaignac tubercle.
the anterior ones. The transverse processes lie beside the

vertebral bodies slightly directed downward and anteri-
Sternocleidomastoid orly. The transverse processes in the cervical spine are
C5 Nerve root relatively short, with the exception of the atlas and C7.
The transverse processes at C1 project more laterally
then all the others. The anterior tubercle at C2 is not well
developed, resulting in a small transverse process. This
C4 TP
feature can be used to differentiate C1 from C2 vertebrae
C5 TP
on the axial plane. The anterior tubercle at C6 is usually
the largest (tubercle of Chassaignac). This is an impor-
Anterior tant sonographic landmark as the prominent anterior
Cranial tubercle allows identification of C6 and location of the
stellate ganglion in relation to the longus colli muscles.
FIGURE 6-52 ■ Sagittal sonogram demonstrating the exited C5 The transverse process of C7 has no anterior tubercle.
nerve root running lateral to the transverse process. The C4 trans- This is an important characteristic to note as it helps to
verse process superiorly is demonstrated on the left of the image. identify the vertebra. More importantly, injections per-
formed around C7 should be done with caution, as the
vertebral artery course is more variable then the other
artery course over the anteromedial aspect of the fora- levels of the cervical spine (Figs. 6-8, 6-28, 6-34, 6-37,
men and the branches arising from the ascending or deep 6-53, and 6-54).
cervical arteries run medially throughout the foramen.13 Cervical ribs of various lengths and size may also
These arteries are at risk for inadvertent injury during occur and are usually bilateral when present. They can
transforaminal injections.9 indent or impinge on the brachial plexus nerve roots.
The C3 to C6 vertebrae constantly demonstrate an The foramen transversarium at C1 to C7 contain verte-
anterior (usually bigger) and a posterior tubercle with the bral arteries and sympathetic nervous plexus from C6
groove for the spinal nerve between them. The posterior upwards. Intervertebral foramina are largest at C2 and C3
tubercles of C3 to C5 are situated lower and lateral to (Figs. 6-55 and 6-56).
ch06.indd 156 23-08-2017 19:35:20

Nerve root Sternocleidomastoid

Nerve root Sternocleidomastoid
C4 Transverse
C5 Transverse process
C5 Transverse
C4 Transverse process process
process
Vertebral artery
Anterior Vertebral artery
Posterior
Cranial
Cranial
FIGURE 6-54 ■ Anterior sagittal sonogram of the cervical spine FIGURE 6-56 ■ Anterior sagittal sonogram of the cervical spine at
at the tips of the transverse processes. The nerve is a hypoechoic the level of the C4 and C5 transverse processes demonstrating the
structure located between the transverse processes. A linear tubular hypoechoic nerve roots. The vertebral arteries within the foramen
structure located deep to the nerve with echogenic walls is the verte- transversarium are well demonstrated with Color Doppler mode.
bral artery. It can be confirmed using Color Doppler.
Vertebral
artery C4 Transverse Sternocleidomastoid Ultrasound for Stellate Ganglion
process C5 Transverse
process
(Cervical Sympathetic Chain) Block
Gross Anatomy
The cervical sympathetic chain is composed of the supe-
rior, middle, intermediate, and inferior cervical ganglia. In
80% of cases, the inferior cervical ganglion is fused with
the first thoracic ganglion, forming the stellate (cervicotho-
racic) ganglion. It measures approximately 2.5 cm in length,
1 cm in width, and 0.5 cm in anteroposterior depth. The
ganglion is usually found between the inferior border of the
Anterior
C7 transverse process to T1 (especially if the lower cervical
Cranial and upper thoracic ganglia remained separate) or adjacent to
the pleural dome. It is contained within the fascial plane of
FIGURE 6-55 ■ Sagittal cadaver anatomic section of the cervi- the prevertebral fascia, overlying the longus colli muscles,
cal spine showing the vertebral artery immediately posterior to the
on either side of the cervical vertebrae. The postganglionic
transverse processes of C4 and C5. The relative positions of the ver-
tebral bodies and cervical spinal cord are also demonstrated. The
fibers from the stellate ganglion and seventh and eighth cer-
large belly of the sternocleidomastoid muscle is located anteriorly. vical nerves to the first thoracic nerve provide sympathetic
innervation to the upper limbs. The preganglionic fibers
5. Clinical Pearls: travel in a cephalad direction to the superior and middle cer-
Although ultrasound guidance is useful in identifica- vical ganglia through the cervical sympathetic trunk. Hence,
tion of the vertebral and inferior thyroid arteries, spinal injection of local anesthetic at the level of the stellate gan-
radicular arteries are often too small in caliber to visual- glion blocks the sympathetic supply to a larger area (the
ize consistently with ultrasound. Hence, using a smaller head, neck, and upper limbs) than injection of the cervical
volume of injectate and continuous sonographic and sympathetic trunk (which results in sympathetic blockade of
Doppler monitoring are suggested. Epidural extension of the head and neck regions only).
the injectate through a transforaminal approach can result The vertebral artery is relatively free floating at the C7
in a wider area of pain relief. level prior to entering the foramen transversarium at C6 as
ch06.indd 157 23-08-2017 19:35:26

it ascends the neck. This is true in about 90% of cases. It 2. Transducer selection:
can enter the foramen transversarium at C5 or higher instead For cervical sympathetic chain blocks, a high-frequency
in the remaining 10% of cases and is vulnerable to injury.14 (15–12 MHz) linear array transducer can be used. The
The inferior thyroid artery is also exposed at the base of the linear footprint is smaller than the curvilinear probe
neck. It arises from the thyrocervical trunk of the subclavian and can be placed at the base of the neck. Imaging tech-
artery (running anterior to the vertebral artery and the longus niques like beam steering technology and compound and
colli muscle) and has a tortuous and variable course.15 These harmonic imaging are generally available on most new
vascular structures can be visualized with Color Doppler and ultrasound machines. These improve visualization of the
avoided during ultrasound-guided injections. anatomy and the needle.
3. Scanning technique:
Ultrasound Scan Technique The ultrasound transducer is placed in transverse orienta-
1. Position: tion with respect to the cervical spine, in a paramedian
a. Patient: The patient is placed in a supine position, position, at the base of the neck, above the prominence
with the neck slightly extended (Fig. 6-57). A high- of the medial clavicle. From there, the probe is angled in
resolution linear transducer (17–9 MHz) is placed a craniocaudal direction gently until the anterior tubercle
slightly lateral to the midline at the base of the neck.16 of C6 (Chassaignac’s tubercle) transverse process comes
b. Position of operator and ultrasound machine: into view. At this point, Color Doppler should be used to
With the patient supine, the operator sits or stands on identify the important vessels and esophagus described
the side to be blocked. The ultrasound display should later. A lateral-to-medial approach can be planned
be placed diametrically opposite the operator. The through the sternocleidomastoid muscle or lateral to it.
operator can also sit or stand cephalad to the patient The needle track must avoid the vascular structures and
(at the head end). This gives access to both sides of should run posterior to the vessels. The fluoroscopic
the neck without the need to shift position. This posi- technique of touching bone with the needle followed by
tion helps if the side to be blocked is ipsilateral to the gentle retraction can also be followed here. With ultra-
operator’s dominant hand (ie, right stellate ganglion sound, the needle can be finessed into the space between
for right-handed individuals). It is more comfortable the prevertebral fascia superficial to the muscle and
for the operator if the nondominant hand anchors the reduce the amount of injection into the muscle. Usually
transducer and the dominant hand manipulates the 5 to 10 mL of local anesthetic is adequate (as opposed to
needle. larger quantities when the injection was performed with-
out imaging guidance). Injection should be monitored
with Color Doppler.
4. Sonoanatomy:
On axial sections, the twin anechoic circular structures
denoting the internal jugular vein and carotid artery are
visible. The vein is differentiated from the artery by
their compressibility. On computed tomography (CT)
and magnetic resonance imaging (MRI), differentiation
is based on relative locations of the vessels with respect
to each other (the internal jugular vein is superficial to
the carotid artery) and by scrolling in a craniocaudal
direction. The thickness of the overlying sternocleido-
mastoid can be gauged in cross-section. The longus colli
muscle runs anterior to the cervical transverse process at
this level. It appears as an ovoid hypoechoic structure in
FIGURE 6-57 ■ Position of the patient and the ultrasound trans-
transverse section, with fibrous tissue giving rise to inter-
ducer during a cervical sympathetic (stellate ganglion) block. The
stellate ganglion is best visualized with the patient’s neck gently nal striations (Fig. 6-58). These fibrous strands are also
extended. The transducer is orientated in a transverse oblique plane associated with fatty tissue, which adds to the striated
relative to the long axis of the cervical spine. hyperechoic appearance. On CT fibrous strands present
ch06.indd 158 23-08-2017 19:35:26

Sternohyoid contained in the foramen transversarium at this level).

If the injectate only stays at C6, then the middle cervical
Sternocleidomastoid
Sternothyroid sympathetic ganglion is treated and not the stellate gan-
glion. The traditional practice of stellate ganglion block
IJV
Transverse Carotid avoided bilateral injections. The reasons for this included
artery
Cervical artery potential for local anesthetic toxicity with the use of high
volumes of local anesthetic (and hence higher plasma
Trachea
concentration) and recurrent laryngeal nerve palsy (up to
10% of cases).17 With real-time ultrasound monitoring,
longus colli
Anterior Vertebral flow of the injectate between the carotid sheath, thyroid,
artery
Lateral Medial and esophagus may be detected, and needle positioning
Vertebral body
Posterior can be adjusted if necessary.
FIGURE 6-58 ■ Transverse sonogram of the cervical spine demon- References

strating the longus colli muscle. Note it is surrounded by the internal
jugular vein, the carotid artery, the transverse cervical artery, and the 1. Galiano K, Obwegeser AA, Bodner G, et al. Ultrasound-guided
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controlled sonoanatomic study. Clin J Pain. 2006;22:538–543.
2. Pal GP, Routal RV, Saggu SK. The orientation of the articular
as hypodense streaks within the muscle. On T1-weighted facets of the zygapophyseal joints at the cervical and upper tho-
MRI images, the muscles appear hypointense with the racic region. J Anat. 2001;198:431–441.
3. Lord SM, McDonald GJ, Bogduk N. Percutaneous radiofre-
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This relationship is preserved on T2-weighted sequences. treatment for cervical zygapophyseal joint pain. Neurosurgery
Whereas palpation and fluoroscopy are techniques used Quaterly. 1998;8:288–308.
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the additional advantage of real-time visualization of the ization and ultrasound-guided block of the third occipital nerve:
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joint pain. Anesthesiology. 2006;104:303–308.
Structures like the thyroid gland and esophagus can also
5. Galiano K, Obwegeser AA, Bodner G, et al. Ultrasound-guided
be demonstrated with ultrasound and avoided during the periradicular injections in the middle to lower cervical spine:
procedure. The esophagus has a variable course at the level an imaging study of a new approach. Reg Anesth Pain Med.
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5 . Clinical Pearls: 9. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforam-
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11. Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P.
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ch06.indd 160 23-08-2017 19:35:29

Ultrasound of the Thoracic Spine for Thoracic
Epidural Injections CHAPTER 7
Introduction the 11th and 12th vertebrae, for articulation with the tubercle
of the ribs (Fig. 7-1). The thoracic vertebrae are intermediate in
Ultrasound imaging of the thoracic spine can be challenging
size between the cervical and lumbar vertebrae, with the lower
due to peculiarities in its anatomy. The osseous framework
thoracic vertebrae being a lot larger than the upper thoracic
of the thoracic spine makes up for a narrow acoustic window
vertebrae (Fig. 7-4) and the upper thoracic vertebrae (T1–T2)
with limited ultrasound visibility of the spinal canal and neur-
being similar in size to the cervical vertebrae (Fig. 7-2). The
axial structures.1,2 Ultrasound visibility of the thoracic spine
thoracic spine has a primary curvature, which is concave
also varies depending on the plane1 of the ultrasound imag-
ing and which part of the thoracic spine is being imaged.1
Ultrasound visibility progressively decreases as one moves
up the thoracic spine.1 Currently data are limited on the use
Superior articular
of ultrasound to guide or assist thoracic epidural injections.3,4 T1 process
This chapter briefly outlines the anatomy, the technique of Spinous process
Inferior articular
ultrasound imaging, and sonoanatomy of the thoracic spine process
relevant for thoracic epidural injection. Superior costal Costal facet on
facet transverse process
Inferior costal VB Transverse process
facet
Basic Anatomy of the Thoracic Spine Facet joint
Intervertebral Inferior vertebral

The thoracic spine is made up of a column of 12 vertebrae foramen notch
(Fig. 7-1) that makes up the midsection of the vertebral col- Superior vertebral
notch
umn. The thoracic vertebrae are identified by the presence of T12
articular facets on the lateral surface of the vertebral bodies
for articulation with the head of the ribs (Figs. 7-1 to 7-4).
There are also facets on the transverse processes of all, except FIGURE 7-1 ■ Thoracic spine (lateral view). VB, vertebral body.
Spinous process
SAP TP
Lamina TP
Costal facet
on TP
SC Superior articular VB
Pedicle facet
T2 Inferior articular
Inferor costal facet
facet
VB Spinous process
Superior costal SAP Superior

facet articular facet
Costal facet on TP
VB TP
Spinous process
Inferior costal IVN
facet IAP
FIGURE 7-2 ■ Second thoracic vertebra (superior, anterior, and lateral view). TP, transverse process; VB, vertebral body; SC, spinal canal;
SAP, superior articular process; IAP, inferior articular process; IVN, inferior vertebral notch.
161
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162 n Chapter 7 / Ultrasound of the Thoracic Spine for Thoracic Epidural Injections
Spinous process
SAP
Lamina TP
TP Costal facet on
transverse process
Superior VB
Pedicle articular facet
SC
Inferior costal SVN
Inferior costal Inferior articular
process T6
Superior costal facet facet
facet
Spinous process
Superior costal TP
facet
Costal facet on
transverse process
VB
Spinous process
Inferior costal
facet IAP
Inferior vertebral
notch
FIGURE 7-3 ■ Sixth thoracic vertebra (superior, anterior, and lateral view). TP, transverse process; SVN, superior vertebral notch;
SC, spinal canal; SAP, superior articular process; IAP, inferior articular process.
Spinous process
SAP
Lamina
IAP
SAP
TP TP
Costal
facet SC SVN VB
T12
Inferior
SAP articular facet
TP
Spinous process
VB
Costal facet
Inferior Inferior articular
vertebral notch facet
FIGURE 7-4 ■ Twelfth thoracic vertebra (superior, anterior, and lateral view). TP, transverse process; SC, spinal canal; SAP, superior articular
process; IAP, inferior articular process; SVN, superior vertebral notch; VB, vertebral body.
anteriorly, but also has a lateral curvature that is slightly con- five vertebrae (1st, 9th, 10th, 11th, and 12th) are atypical
cave to the left, most likely from greater use of the right upper as they have certain unique features. The body of a typical
extremity and pressure from the aorta. thoracic vertebra is heart-shaped (Fig. 7-3) with its antero-
posterior and lateral diameters being roughly the same
Typical Thoracic Vertebrae (Fig. 7-3). Also the distance between the two lamina of
The 2nd to 8th thoracic vertebrae are considered typical tho- the vertebra is greater than the width of the vertebral body
racic vertebrae (Figs. 7-2 and 7-3), whereas the remaining (Fig. 7-3).5 On either side of the vertebral body are two
ch07.indd 162 23-08-2017 17:59:57

Chapter 7 / Ultrasound of the Thoracic Spine for Thoracic Epidural Injections n 163
Superior articular
process
Costotransverse
Superior costal TP junction
facet
Costal facet on Transverse
transverse process process
VB Rib
Spinous process
Inferior articular
Inferior costal process
facet IAP
Inferior vertebral
notch Lamina
Spinous process
FIGURE 7-5 ■ Lateral view of the sixth thoracic vertebra. VB, ver-
tebral body; TP, transverse process; IAP, inferior articular process.
FIGURE 7-6 ■ Articulation of the thoracic vertebrae and the rib with
the transverse process (costotransverse junction) in the midthoracic
region. Note the acute angulation of the spinous processes and the
costal (superior and inferior) facets (Fig. 7-3). The superior posteriorly directed transverse processes.
costal facets are larger, located on the superior border of the
vertebra near the pedicle, and articulate with the head of
the numerically identical rib (Figs. 7-2 and 7-3). The inferior
costal facets are smaller in size, they are located near the
inferior border of the vertebra and in front of the inferior the neck of the rib being hidden anteriorly by the transverse
vertebral notch, and they articulate with the next lower rib. process at the vertebral levels T1 to T4, but from there on until
The spinal canal is relatively small and circular (Fig. 7-3) T9 the neck of the rib progressively projects above the trans-
and contains the spinal cord and meninges. verse process.5 The spinous processes are long and directed
The pedicles of the thoracic vertebra are short and directed backwards, downwards (Figs. 7-1, 7-6 and 7-7), and often
backwards (Fig. 7-2). The superior vertebral notch is shal- slightly obliquely. Therefore even in a perfectly normal spine,
low, whereas the inferior vertebral notch is large and deep the tips of the spinous processes may be slightly deviated
(Figs. 7-1 and 7-5). The laminae are broad and thick, overlap from the midline (ie, paramedian in location, Fig. 7-7). The
the one from the adjacent vertebrae (Fig. 7-6), and are con- spinous processes are longest between T2 and T9 levels and
nected to the pedicle anteriorly (Fig. 7-5). The interlaminar overlap each other like “tiles on a roof.” This creates an acute
spaces are also narrow, and using ultrasound they measure angle for epidural needle insertion or insonation of the ultra-
approximately 0.9 cm at the lower thoracic spine to 0.8 cm sound beam if one were to do so through the midline. The spi-
and 0.6 cm at the mid- and upper thoracic spine, respectively.1 nous processes are less oblique above T2 and below T9. The
The transverse processes are large and are directed laterally spinous processes of T11 and T12 are directed backwards as
and backwards (Figs. 7-3 and 7-6) from the junction of the with the lumbar spinous processes. The orientation of the T10
lamina and pedicle (Fig. 7-5). The costal facets on the anterior spinous process varies, with it being only slightly caudally
surface of the transverse process of the upper six vertebrae directed to resemble that of the T11 and T12.
are concave (Fig. 7-3), facing forward, and articulate with The ligamentum flavum is attached to the upper border
the tubercle of the corresponding rib. The inferior articular and the upper part of the anterior surface of the laminae.
processes are fused to the laminae, and their articular facets The transverse process gives attachment to the follow-
are directed forwards and slightly downwards and medially ing ligaments (Fig. 11-3): (i) lateral costotransverse liga-
(Fig. 7-5). The superior articular processes in contrast project ment at the tip, (ii) superior costotransverse ligament to
from the junction of the pedicle and laminae and are directed the lower border, (iii) the inferior costotransverse ligament
backwards and slightly laterally and upwards. The articula- to the anterior surface, (iv) intertransverse ligament to the
tion of the rib to the transverse process anteriorly results in superior and inferior borders, and (v) the levator costae to
ch07.indd 163 23-08-2017 18:00:03

CE
T3 VB
A B C
T3 Rib Costotransverse
T3 Transverse process junction
T2 Spinous process
D E F
FIGURE 7-8 ■ Cross-sectional cadaver anatomic section through
FIGURE 7-7 ■ Different views of the thoracic spine that were the third thoracic vertebra demonstrating the relationship of the spi-
rendered from a single 3-D volume CT data set. Note that although nous process of the T2 vertebra with the posterior elements of the
there is no scoliosis in this patient, the spinous processes of the T3 thoracic vertebra. Also note the posteriorly directed transverse
vertebrae are slightly deviated from the midline (Fig. 7-7F). process and the costotransverse articulation. VB, vertebral body; CE,
cervical esophagus.
the posterior surface (T1–T11). The spinous processes give

Ligamentum
Interlaminar flavum
attachment to the supraspinous and interspinous ligaments. space
Also the superior and inferior borders of the vertebral bod- Lamina
T6
ies give attachment in front and behind to the anterior and Intrathecal space T5
posterior longitudinal ligaments, respectively. There are also Spinal cord T4
several muscles attached to the spine of the thoracic verte- T3
brae, including the latissimus dorsi, trapezius, rhomboids, T2

and many deep muscles of the back.
T1 T4 VB
Gross Anatomy of the Upper Thoracic

Spine (T1–T4)
Figs. 7-8 and 7-9
FIGURE 7-9 ■ Paramedian sagittal cadaver anatomic section

Computed Tomography Anatomy
through the thoracic spine demonstrating the lamina and the inter-
of the Upper Thoracic Spine (T1–T4) laminar spaces of the thoracic vertebrae. VB, vertebral body.
Figs. 7-10 to 7-13
Computed Tomography Anatomy of the Midthoracic

Spine (T5–T8)
of the Upper Thoracic Spine (T1–T4)
Figs. 7-20 to 7-23
Figs. 7-14 to 7-17
Magnetic Resonance Imaging Anatomy of the
Gross Anatomy of the Midthoracic Spine (T5–T8) Midthoracic Spine (T5–T8)
Figs. 7-18 and 7-19 Figs. 7-24 to 7-27
ch07.indd 164 23-08-2017 18:00:30

T1 lamina
T1 VB
T2 VB
Spinal ILS
cord
Ligamentum
flavum
T4 VB T4 lamina
Epidural space
Spinal cord
T3 Spinous 4th Rib
process
FIGURE 7-10 ■ Transverse CT section through the lower part of FIGURE 7-13 ■ Paramedian sagittal CT section of the upper tho-
the body of the second thoracic vertebra. VB, vertebral body. racic spine. ILS, interlaminar space; VB, vertebral body.
T3/4 VB Spinal cord
CSF
Epidural space
Spinal T3 VB
cord
TP
Base of T3
Epidural space Spinous process
Ligamentum
flavum
T2 Spinous
process
FIGURE 7-11 ■ Transverse CT section through the interspinous FIGURE 7-14 ■ Transverse MRI section of the upper thoracic spine
space of the T2 to T3 thoracic vertebrae. VB, vertebral body; TP, through the base of the T3 spinous process. VB, vertebral body; CSF,
transverse process. cerebrospinal fluid.
T1 Spinous
process
T1 VB ISS Spinal cord
T3 VB
CSF
Spinal cord
Epidural space Epidural Ligamentum

T4 VB
space flavum
T4 Spinous
process
T2 Spinous
process
FIGURE 7-12 ■ Median sagittal CT section of the upper thoracic FIGURE 7-15 ■ Transverse MRI section of the upper thoracic
spine (T1–T4). VB, vertebral body; ISS, interspinous space. spine through the interspinous space of the T2 to T3 vertebrae. VB,
vertebral body; CSF, cerebrospinal fluid.
ch07.indd 165 23-08-2017 18:01:04

T2 Spinous
process
T1 VB Ligamentum
ISS flavum
Epidural Intrathecal space
Lamina
space Interlaminar
space
Ligamentum T8
flavum T7
T6
T4 VB T4 Spinous T5
process T4
Spinal cord
T6 VB Spinal cord
FIGURE 7-16 ■ Median sagittal MRI section of the upper thoracic

spine (T1–T4). VB, vertebral body; ISS, interspinous space.
FIGURE 7-19 ■ Paramedian sagittal cadaver anatomic section of

the midthoracic spine. Note the acute caudal angulation of the lami-
nae and the narrow interlaminar spaces. VB, vertebral body.
T1 VB
T2 lamina
Ligamentum
flavum
ILS T6 VB
Spinal cord
Epidural
space Epidural
space
T4 lamina
T4 VB
Spinal cord
T5 Spinous Base of T6
process Spinous process
FIGURE 7-17 ■ Paramedian sagittal MRI section of the upper tho- FIGURE 7-20 ■ Transverse CT section of the midthoracic spine
racic spine (T1–T4). VB, vertebral body; ILS, interlaminar space. through the base of the T6 spinous process. VB, vertebral body.
T7 VB
Spinal T7 VB
cord
Rib
TP
Epidural Ligamentum
space flavum
T7 Transverse T6 Spinous
T7 Rib process process
FIGURE 7-18 ■ Cross-sectional cadaver anatomic section through FIGURE 7-21 ■ Transverse CT section of the midthoracic spine through
the midthoracic spine (7th thoracic vertebra). VB, vertebral body. the T6 to T7 interspinous space. VB, vertebral body; TP, transverse process.
ch07.indd 166 23-08-2017 18:01:40

T5
T5 Spinous process
T7 VB
Spinal cord
ISS
Epidural space
Spinal
cord Epidural
space
T8 Ligamentum T6 Spinous
flavum process
T8 Spinous process
FIGURE 7-22 ■ Median sagittal CT section of the midthoracic FIGURE 7-25 ■ Transverse MRI section of the midthoracic spine
spine (T5–T8). Note the acute caudal angulation of the spinous pro- through the T6 to T7 interspinous space. VB, vertebral body.
cesses and the narrow interspinous spaces (ISS).
T5 lamina T5 VB T5 Spinous
T5 process
ILS
Interspinous
Spinal space
cord Spinal
cord
Epidural Epidural.
space space
T8 Ligamentum T8 VB
Ligamentum
flavum flavum
T8 lamina
T8 Spinous
process
FIGURE 7-23 ■ Paramedian sagittal CT section of the midthoracic FIGURE 7-26 ■ Median sagittal MRI section of the midthoracic
spine. Note the narrow interlaminar spaces (ILS). spine. Note the sharp acute caudal angulation of the spinous pro-
cesses and the narrow interspinous spaces. VB, vertebral body.
T5 lamina
T5 VB
T6 VB Interlaminar
Spinal cord
space
Epidural space
Ligamentum
flavum
Spinal cord
Ligamentum Base of T6
Epidural space
flavum Spinous process
T8 VB
T8 lamina
T5 Spinous
process
FIGURE 7-24 ■ Transverse MRI section of the midthoracic spine FIGURE 7-27 ■ Paramedian sagittal MRI section of the midthoracic
through the base of the T6 spinous process. VB, vertebral body. spine. VB, vertebral body.
ch07.indd 167 23-08-2017 18:02:11

Gross Anatomy of the Lower Thoracic

Spine (T9–T12)
Figs. 7-28 and 7-29
T10 VB
Computed Tomography Anatomy
of the Lower Thoracic Spine (T9–T12) Spinal
cord
Figs. 7-30 to 7-33
Magnetic Resonance Imaging Anatomy Lamina

of the Lower Thoracic Spine (T9–T12)
Figs. 7-34 to 7-37 T10 Spinous process
FIGURE 7-30 ■ Transverse CT section of the lower thoracic spine

through the base of the T10 spinous process. VB, vertebral body.
T11 T10 VB
Spinal
cord
T11 Rib T11 Transverse

process
T11 lamina
T11 TP
11th Rib
the lower thoracic spine (11th thoracic vertebra). VB, vertebral
body.
FIGURE 7-31 ■ Transverse CT section of the lower thoracic spine
through the T10 to T11 interspinous space. VB, vertebral body; TP,
transverse process.
Spinal cord
Lamina
Ligamentum flavum
Epidural space T9
T9
T10 Interlaminar
space Spinous
process
T12
T10
ITS
Spinal
cord
T11
T11 VB
Cauda equina Epidural

space
T12
FIGURE 7-29 ■ Paramedian sagittal cadaver anatomic section of FIGURE 7-32 ■ Median sagittal CT section of the lower thoracic
the lower thoracic spine (T9–T12). Note the acute caudal angula- spine (T9–T12). Note the spinous process of T11 and T12 are broad,
tion of the laminae and the narrow interlaminar spaces. VB, vertebral directed backwards, and similar to the lumbar spinous processes.
body; ITS, intrathecal space.
ch07.indd 168 23-08-2017 18:02:44

T9 lamina T9 VB
ILS T9 Spinous process
T10 lamina
Ligamentum
flavum
Spinal cord Interspinous space
T11 lamina
T12 VB Spinal cord
Epidural
space T12 Spinous process
T12 lamina
Epidural space
FIGURE 7-33 ■ Paramedian sagittal CT section of the lower thoracic FIGURE 7-36 ■ Median sagittal MRI section of the lower thoracic
spine. ILS, interlaminar spaces. spine (T9–T12). VB, vertebral body.
T9 VB
T9 lamina
T11/T12
disc Epidural space
Spinal cord
CSF T11/T12
facet joint
Ligamentum Ligamentum
flavum Epidural space flavum
T12 VB
T12 lamina
T11 Spinous
process
FIGURE 7-34 ■ Transverse MRI section of the lower thoracic spine FIGURE 7-37 ■ Paramedian sagittal MRI section of the lower tho-
through the T10 to T11 interspinous space. VB, vertebral body; CSF, racic spine (T9–T12). VB, vertebral body.
cerebrospinal fluid.
Ultrasound Imaging of the Thoracic

Spine – Basic Considerations
T11 VB
Because of the peculiarities of the anatomy of the thoracic spine,
Spinal cord as described earlier, we will be considering ultrasound imaging
CSF of the thoracic spine under three sections: (a) upper (T1–T4),
(b) middle (T5–T8), and (c) lower (T9–T12) (Fig. 7-38).
Ligamentum Epidural space
Ultrasound imaging of the thoracic spine can be performed
flavum in the transverse or sagittal plane. Because the depth from
the skin to the lamina and epidural space in the mid- and
lower thoracic regions—where the majority of thoracic epi-
T10 Spinous
process dural catheters are placed in clinical practice—is relatively
shallow (median distance approx. 3.3–4 cm)1,4 the use of a
FIGURE 7-35 ■ Transverse MRI section of the lower thoracic spine high-frequency linear (12–8 MHz) transducer may suffice
through the T10 spinous process. VB, vertebral body; CSF, cerebro- for ultrasound imaging. However, although the ultrasound
spinal fluid. images are generally of high resolution, the field of view
ch07.indd 169 23-08-2017 18:03:04

Upper Thoracic (T1-4)
Mid-thoracic (T5-8)
Lower Thoracic (T9-12)
Thoracic Spine - Transverse Scan
FIGURE 7-38 ■ Thoracic spine and its division into the upper FIGURE 7-39 ■ Figure illustrating the osseous structures insonated
(T1–T4), mid (T5–T8), and lower (T9–T12) thoracic regions. during a median transverse scan of the thoracic spine at the level of
the spinous process. Note the angle formed between the spinous pro-
cess and the lamina and the posteriorly directed transverse process.
with a high-frequency linear transducer is narrow and it gets

Thoracic Spine - Paramedian Sagittal Scan
progressively narrower with increasing depth of imaging.
Therefore, it is desirable to use a curvilinear transducer,
which emits a divergent beam and provides both high-quality
images and a wide field of view (Fig. 7-39).1,4 The authors
prefer to use a high-frequency (9–4 MHz) curvilinear trans-
ducer for imaging the thoracic spine, but a low frequency
(5–2 MHz) is perfectly fine.
Ultrasound visibility of the neuraxial structures decreases
progressively as one moves up the thoracic spine, with ultra-
sound visibility being best in the lower thoracic region.1 The
acute angulation of the spinous processes and the overlap-
A Paramedian Sagittal Scan B Paramedian Sagittal Oblique Scan
ping laminae in the midthoracic region make it difficult to
image the neuraxis through the median plane in the trans- FIGURE 7-40 ■ Axis of scan – thoracic spine. (A) paramedian sag-
verse axis (median transverse scan). Ultrasound visualiza- ittal scan and (B) paramedian sagittal oblique scan.
tion of the spinal canal and neuraxial structures is better
through the paramedian sagittal plane than through the
median transverse plane.1 Therefore, the thoracic spine is
generally imaged via the paramedian plane (Fig. 7-40) and ultrasound imaging is significantly narrower than that in the
through the interlaminar spaces.1 The laminae of the thoracic lumbar region (Fig. 7-42). Therefore, ultrasound visibility of
vertebrae are hyperechoic and relatively flat (Fig. 7-41) com- the neuraxial structures in the thoracic spine is not as good
pared to the “horse head–like appearance” of the laminae in as in the lumbar region. For optimal imaging, it is also nec-
the lumbar spine (Fig. 5-20).6,7 Due to the narrow interlami- essary to tilt the ultrasound transducer slightly medially, that
nar spaces in the thoracic spine,1 the acoustic window for is, insonate the beam slightly medially (paramedian sagittal
ch07.indd 170 23-08-2017 18:03:09

oblique scan, Fig. 7-40), so that the majority of the ultra- beam, (c) the spinal cord is inherently hypoechoic, and
sound energy enters the spinal canal through the widest part (d) the spinal cord is surrounded by anechoic cerebrospi-
of the interlaminar space, similar to that in the lumbar region. nal fluid (Fig. 7-44).8 Therefore, in the thoracic region one
The spinal cord, which lies within the thoracic spi- has to rely on recognizing the osseous structures of the
nal canal, can be clearly defined in newborns and young vertebral arch, interspinous and interlaminar spaces, liga-
infants8 using ultrasound (Figs. 7-43 and 7-44) but cannot mentum flavum, and the anterior complex (AC).3 The latter
be delineated in adults with currently available ultrasound represents the composite echo created by the posterior sur-
technology. The central canal is also seen as an echo-
face of the vertebral body, posterior longitudinal ligament,
genic line in the center of the spinal cord in young infants and the anterior dura. Also because it is often difficult to
(Fig. 7-43).8 Various factors may contribute to the inability define the ligamentum flavum and posterior dura as two
to visualize the spinal cord in adults: (a) a narrow acous- separate structures in a thoracic sonogram, they are col-
tic window for imaging, (b) attenuation of the ultrasound lectively referred to as the ligamentum flavum–dura matter
complex,1 or the posterior complex (PC).3
Ultrasound Imaging of the Upper Thoracic

Interlaminar
Spine (T1–T4)
space Lamina
1. Position:
a. Patient: The patient is positioned comfortably in the
sitting position with the arms hanging down and rest-
ing on the thigh or on a pillow or support in front.
The patient is also asked to slightly flex the head
anteriorly. However, if the patient is unable to sit
or is unwell, then the patient can be positioned in
the lateral decubitus position with the head flexed
anteriorly.
FIGURE 7-41 ■ Water-based thoracic spine phantom with a sagittal stands behind the patient, and the ultrasound machine
sonogram showing the lamina and interlaminar spaces. is placed directly in front of the patient.
Lumbar Spine Thoracic Spine
Lamina
Lamina
Posterior
Cranial Caudal
Anterior
A
Acoustic shadow Acoustic window B
FIGURE 7-42 ■ Acoustic window for ultrasound imaging in the (A) lumbar and (B) thoracic spine. Note the narrow interlaminar spaces and
acoustic window for ultrasound imaging in the thoracic spine.
ch07.indd 171 23-08-2017 18:03:18

Cephalad Posterior Caudad
Posterior epidural Posterior dura

space
CSF
Spinal cord Central echo Anterior dura
complex
Anterior epidural
space
Anterior FIGURE 7-45 ■ Position and orientation of the ultrasound trans-

ducer during a transverse scan of the upper thoracic spine with the
FIGURE 7-43 ■ Sagittal sonogram of the thoracic spine in a neo- subject in the sitting position.
nate to illustrate the hypoechoic spinal cord, hyperechoic central
canal, hyperechoic anterior and posterior dura, and the epidural
spaces. CSF, cerebrospinal fluid.
Posterior
Transverse Lamina
Paraspinal Epidural
process
muscle space
CSF
Posterior Dura Spinal

cord
Pleura
Dentate Anterior dura

ligament
Anterior
complex
Anterior
FIGURE 7-44 ■ Transverse sonogram of the thoracic spine in a FIGURE 7-46 ■ Position and orientation of the ultrasound trans-
neonate to illustrate the hypoechoic spinal cord, the thecal sac, den- ducer during a paramedian sagittal oblique scan of the upper thoracic
tate ligaments, dura (anterior and posterior), and the epidural space. spine with the subject in the sitting position.
CSF, cerebrospinal fluid.
obtain a transverse spinous process view (TSPV, Fig. 7-47)

2. Transducer selection: Due to the thick musculature of or a transverse interspinous view (TISV, Fig. 7-48).
the nape of the neck and relatively greater depth from Because the spinous processes in the upper thoracic
the skin to the neuraxial structures, curvilinear transduc- region are not inclined as steeply as in the midthoracic
ers are best for imaging the upper thoracic spine. The region, especially above the T3 levels, it may be feasible
authors prefer to use a high-frequency (9–4 MHz) curvi- to obtain a TISV. Below this level it gets increasingly dif-
linear transducer, but it is feasible to use a low-frequency ficult to obtain a TISV. For a sagittal scan the ultrasound
(5–2 MHz) curvilinear transducer for the ultrasound scan. transducer is placed 2 to 3 cm lateral to the midline and
3. Scanning technique: The upper thoracic spine can be gently tilted medially (paramedian sagittal oblique scan,
imaged in the transverse (Fig. 7-45) or sagittal (Fig. 7-46) PMSOS) until the thoracic lamina and the interlaminar
planes. During the median transverse scan, the aim is to spaces are visualized (Fig. 7-49).
ch07.indd 172 23-08-2017 18:03:33

Posterior Posterior
Articular Spinous
process process
Pleura Interlaminar Lamina

Ligamentum space
flavum
Posterior dura
Right Left Cranial Caudal
Spinal canal
Anterior
complex
Anterior Anterior
FIGURE 7-47 ■ Transverse sonogram demonstrating the spinous FIGURE 7-49 ■ Paramedian sagittal oblique sonogram of the upper
process view of the upper thoracic spine. thoracic spine. Note the narrow acoustic window for ultrasound
imaging and the anterior complex.
Posterior
are visualized as linear hyperechoic shadows, one on each
side of the midline, and they are also directed slightly
Transverse backwards and outwards (Fig. 7-48). The AC is visual-
process
ized anteriorly as a hyperechoic shadow (Fig. 7-48). The
outlines of the spinal canal can be recognized, but the
Right Left spinal cord is not visualized for reasons described earlier
(Fig. 7-48).
On a PMSOS of the upper thoracic region the lamina
Spinal canal and interlaminar spaces are clearly visualized posteriorly
(Fig.7-49). The intervening gaps between the lamina of
Anterior the adjacent vertebrae are the interlaminar spaces, and
complex
Anterior
they are relatively narrow (width approximately 0.6 mm)1
compared to that at the lower thoracic (width approxi-
FIGURE 7-48 ■ Transverse sonogram demonstrating the interspi- mately 0.9 mm)1 or lumbar spine (Fig. 7-42). This results
nous view of the upper thoracic spine. in a narrow acoustic window for imaging, and thus ultra-
sound visibility of the neuraxial structures is also lim-
ited when compared to that at the mid or lower thoracic
4. Sonoanatomy of the upper thoracic spine: On a median region.1 Nevertheless it may still be possible to visualize
TSPV the spinous process is visualized as a hyperechoic the ligamentum flavum, epidural space, posterior dura,
structure with an acoustic shadow anteriorly (Fig. 7-47). spinal canal, and AC from a posterior-to-anterior direc-
Laterally the lamina and transverse process or the inferior tion within the acoustic window (Fig. 7-49).
articular processes of the thoracic vertebra with their cor-
responding acoustic shadow are visualized. Because the Ultrasound Imaging of the Midthoracic
spinal canal and neuraxis are obscured by the acoustic
shadow of the spinous process and lamina in this view,
Spine (T5-T8)
it is only useful for locating the midline if the spinous 1. Position:
processes are not palpable. If one now slides the trans- a. Patient: Sitting (Figs. 7-50 and 7-51) or lateral decu-
ducer slightly caudally and/or gently inclines the ultra- bitus (Fig. 7-52) position.
sound beam cranially, the acoustic shadow of the spinous b. Operator and ultrasound machine: The operator
process disappears and the median TISV is obtained sits or stands behind the patient, and the ultrasound
(Fig. 7-48). On a median TISV the transverse processes machine is positioned directly in front of the patient.
ch07.indd 173 23-08-2017 18:03:52

Thoracic Spine - Paramedian Sagittal Oblique Scan

FIGURE 7-50 ■ Position and orientation of the ultrasound transducer
during a transverse scan of the midthoracic spine with the subject in
the sitting position. FIGURE 7-52 ■ Paramedian sagittal oblique sonogram of the mid-
thoracic spine with the patient in the lateral position.
Posterior
Spinous process
Transverse
process
Lamina
Right Left
Pleura
Anterior
FIGURE 7-51 ■ Paramedian sagittal oblique sonogram of the FIGURE 7-53 ■ Transverse sonogram demonstrating the spinous
idthoracic spine with the subject in the sitting position.
m process view of the midthoracic spine.
2. Transducer selection: Curved array transducer. The (Fig. 7-50) or sagittal (Figs. 7-51 and 7-52) axis. The
authors prefer to use a high-frequency (9–4 MHz) curvilin- median transverse scan (median TSPV, Fig. 7-53) is not
ear transducer, but a low-frequency (5–2 MHz) curvilinear very useful, as it provides little information relevant for
transducer will suffice. neuraxial blockade other than identifying the midline
3. Scanning technique: Ultrasound imaging is more demand- and measuring the depth to the lamina. Also acquiring
ing in the midthoracic region than at the lower thoracic a median TISV (Fig. 7-54) at the midthoracic region is
region due to the acute caudal angulation of the spinous challenging, and in some individuals it may be impossi-
processes and the overlapping lamina. The narrow inter- ble. Because the paramedian sagittal axis provides better
spinous and interlaminar spaces (approximately 0.8 cm)1 visualization of the neuraxis than the transverse axis,1 it
create a narrow acoustic window for imaging with
is the preferred route for imaging. Also for optimal para-
variable quality of ultrasound images of the neuraxis. median sagittal imaging one has to perform a PMSOS
The midthoracic spine can be imaged in the transverse (Fig. 7-52) as described earlier.
ch07.indd 174 23-08-2017 18:04:06

Posterior
Thoracic Spine - Transverse Scan
Transverse
process
Right Left
Spinal canal
Anterior complex
Anterior
FIGURE 7-54 ■ Transverse sonogram demonstrating the interspi-

nous view of the midthoracic spine. Note the posteriorly directed
transverse processes. FIGURE 7-55 ■ Figure highlighting the osseous structures insonated
during a transverse scan of the midthoracic spine at the spinous
process level (transverse spinous process view).
4. Sonoanatomy of the midthoracic spine: On a median

TSPV the spinous process, lamina, transverse processes,
the costotransverse junction, and the ribs produce a sono-
graphic pattern that we describe as the “flying swan sign” Lamina Interlaminar Ligamentum
space flavum
due to its resemblance to a swan in flight. The posteriorly
directed transverse processes are also easily recognized,
and they are symmetrically located. One must note that
due to the acute angulation of the spinous processes in Posterior dura
the midthoracic region, when one performs a median
transverse scan to obtain a median TSPV, the osseous ele-
Acoustic shadow Posterior
ments in the sonogram look congruous, but the spinous of lamina
Anterior Cranial Caudal
process shadow is from the vertebra one level higher than complex
Anterior
that from which the shadows of the laminae and trans-
verse processes arise (Fig. 7-55). The exact clinical sig- FIGURE 7-56 ■ Paramedian sagittal oblique sonogram of the mid-
nificance of this observation for central neuraxial blocks thoracic spine.
is not clear.
On a PMSOS in the midthoracic region the laminae and
interlaminar spaces are clearly visualized posteriorly Ultrasound Imaging of the Lower Thoracic
(Fig. 7-56). The laminae appear relatively flat (Figs. 7-56
and 7-57), and the interlaminar spaces are also relatively
Spine (T9–T12)
narrow (width approximately 0.8 mm).1 However, despite 1. Position:
the narrow acoustic window, it may be possible to define a. Patient: Sitting (Fig. 7-58) or lateral decubitus
the ligamentum flavum, epidural space, posterior dura, position.
spinal canal, and AC from a posterior-to-anterior direc- b. Operator and ultrasound machine: The operator
tion within the acoustic window (Fig. 7-56). Age-related stands behind the patient, and the ultrasound machine
changes in the vertebral column and/or ossification of the is positioned directly in front of the patient.
ligamentum flavum can make visualization of the neur- 2. Transducer selection: Curved array transducer. The
axial structures difficult in the elderly. authors prefer to use a high-frequency (9–4 MHz)
ch07.indd 175 23-08-2017 18:04:14

Lamina ILS
Lamina ILS
SC LF
VB
PD
Lung
A B AC
Lamina ILS LF
ITS ILS LF Epidural
Lamina space
Spinal cord
AC
VB
T5 VB T8
C Lung D
FIGURE 7-57 ■ Correlative sagittal (A) CT, (B) sonogram, (C) cadaver anatomic, and (D) MRI (T1 weighted) images of the midthoracic
spine. ILS, interlaminar space; SC, spinal canal; VB, vertebral body; LF, ligamentum flavum; PD, posterior dura; AC, anterior complex; ITS,
intrathecal space.
FIGURE 7-58 ■ Position and orientation of the ultrasound trans- FIGURE 7-59 ■ Position and orientation of the ultrasound trans-
ducer during a transverse scan of the lower thoracic spine with the ducer during a paramedian sagittal oblique scan of the lower thoracic
subject in the sitting position. spine with the subject in the sitting position.
curvilinear transducer (Figs. 7-58 and 7-59), but a low- and because of the relatively larger acoustic window it is
frequency (5–2 MHz) curvilinear transducer is perfectly possible to acquire high-quality images of the neuraxis
adequate. (Figs. 7-60 to 7-62).
3 . Scanning technique: Ultrasound imaging is less demand- 4 . Sonoanatomy of the lower thoracic spine: On a median
ing in the lower thoracic region than at the upper and mid- TSPV the spinous process, lamina, and transverse processes
thoracic regions due to the wider acoustic window for produce a typical acoustic shadow (Fig. 7-60). Although this
ultrasound imaging. Ultrasound imaging at the lower two view is not useful for visualizing the neuraxial structures,
to three thoracic intervertebral levels is similar to imaging it is useful for locating the midline. Laterally the parietal
the lumbar spine. The lower thoracic spine can be imaged pleura and underlying lung are visualized and recognized
in the transverse (Fig. 7-58) or sagittal (Fig. 7-59) axis, by the characteristic “lung-sliding sign” (Fig. 7-60).9
ch07.indd 176 23-08-2017 18:04:25

Posterior
Spinous Posterior
process
Ligamentum Interlaminar
Thoracic paravertebral Transverse flavum space
space Lamina Epidural
Internal intercostal process space
membrane
Right Left Cranial Caudal
Posterior
dura
Pleura ? Cauda equina
Anterior
complex
Anterior Anterior
FIGURE 7-60 ■ Transverse sonogram demonstrating the trans- FIGURE 7-62 ■ Paramedian sagittal oblique sonogram of the lower
verse spinous process view of the midthoracic spine. thoracic spine. The white linear streak in the middle of the acoustic
window probably represents one of the cauda equina nerves.
Posterior
Identification of Thoracic Intervertebral
Spaces Using Ultrasound
Transverse process Accurate identification of a given thoracic intervertebral level
using anatomical landmarks is inaccurate.11 Ultrasound has
Right Left
been used to identify a given thoracic intervertebral space by
“counting up” from the L5 to S1 junction.1,11 Identification
errors can be expected with this method because lumbosa-
cral transitional anomalies (lumbarization of S1 or sacraliza-
Spinal canal
tion of L5) are present in approximately 4% to 21% of the
Anterior complex general population.12,13 Therefore to enhance accuracy, others
have elected to include identification of the 12th rib and its
Anterior
articulation with the T12 vertebra as a secondary ultrasound
FIGURE 7-61 ■ Transverse sonogram demonstrating the trans- landmark to the “counting up” method.1,14 It is not known if
verse interspinous view of the midthoracic spine. this combined method improves accuracy because an acces-
sory L1 rib can also be present in approximately 2% of indi-
viduals.15 An alternative sonographic method, which has been
used to identify the level of thoracic paravertebral injection,
relies on identifying the first rib.16 However, a limitation of
On a median TISV the spinal canal and anterior com- this method is that the presence of a cervical rib can affect its
plex are clearly defined in the midline with the transverse accuracy. Therefore, although various sonographic methods
processes laterally (Fig. 7-61). The posterior dura or the have been described, they have inherent inaccuracies. More
posterior complex may also be visualized in a median importantly, none of these methods have been tested against
TISV in some individuals. The PMSOS provides better a gold-standard imaging modality such as computed tomog-
visibility of the neuraxial structures (Fig. 7-62), relevant raphy (CT) or magnetic resonance imaging (MRI). Despite
for central neuraxial blocks, than the median TISV.6,7,10 these limitations it is our opinion that for day-to-day prac-
One can clearly recognize the wide interlaminar spaces tice of thoracic epidural catheter placement, the sonographic
and the posterior and anterior complexes (Fig. 7-62). methods described earlier are clinically useful because sono-
Outlines of the cauda equina fibers may also be rarely graphic methods are generally more accurate than methods
visualized (Fig. 7-62). that solely reply on anatomical landmarks.11
ch07.indd 177 23-08-2017 18:04:34

Clinical Pearls 4. Salman A, Arzola C, Tharmaratnam U, Balki M. Ultrasound

imaging of the thoracic spine in paramedian sagittal oblique
Currently there are limited published data on ultrasound plane: the correlation between estimated and actual depth to the
imaging of the thoracic spine or on the use of ultrasound for epidural space. Reg Anesth Pain Med. 2011;36:542–547.
thoracic epidural catheter placement. Based on published 5. Moriggl B. Spine anatomy and sonoanatomy for pain physi-
cians. In: Narouze S, ed. Atlas of Ultrasound Guided Procedures
data, it is most frequently used to preview the anatomy of the
in Interventional Pain Management. New York, NY: Springer;
spine before thoracic epidural catheter placement.4 During the 2010:79–105.
preprocedural or scout scan, ultrasound can be used to iden- 6. Karmakar MK. Ultrasound guided central neuraxial blocks. In:
tify the midline, determine the presence of any underlying Narouze S, ed. Atlas of Ultrasound Guided Procedures in Inter-
spinal abnormality (eg, scoliosis,17 underlying spinal instru- ventional Pain Management. 1st ed. New York, NY: Springer;
mentation), determine the degree of axial rotation of the tho- 2010:161–178.
7. Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD.
racic spine in scoliosis,17 accurately measure the depth to the
Sonoanatomy relevant for ultrasound-guided central neuraxial
lamina or posterior dura,4 and determine the optimal site for blocks via the paramedian approach in the lumbar region. Br J
epidural needle placement. During a median transverse (for Radiol. 2012;85:e262–e269.
midline approach) or PMSOS (for a paramedian approach), 8. Unsinn KM, Geley T, Freund MC, Gassner I. US of the spinal
the angle of insonation that produces the best ultrasound visu- cord in newborns: spectrum of normal findings, variants, con-
alization of the neuraxial structures or the anterior complex genital anomalies, and acquired diseases. Radiographics. 2000;
20:923–938.
closely mirrors the angle or trajectory for needle insertion.
9. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out
Currently there are no published data on the use of ultrasound pneumothorax in the critically ill. Lung sliding. Chest. 1995;
to guide or assist real-time epidural needle placement in the 108:1345–1348.
thoracic region. In the authors’ experience ultrasound can 10. Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time
be used to assist epidural catheter placement in the thoracic ultrasound-guided paramedian epidural access: evaluation of a
region, especially in patients with obesity or difficult backs, novel in-plane technique. Br J Anaesth. 2009;102:845–854.
11. Arzola C, Avramescu S, Tharmaratnam U, Chin KJ, Balki M.
by guiding the tip of the epidural needle to the target inter-
Identification of cervicothoracic intervertebral spaces by surface
laminar space before the traditional loss-of-resistance method landmarks and ultrasound. Can J Anaesth. 2011;58:1069–1074.
is used to confirm correct epidural needle placement. This 12. Hughes RJ, Saifuddin A. Imaging of lumbosacral transitional
may translate into reduced needle passes and higher success vertebrae. Clin Radiol. 2004;59:984–991.
rates on the first attempt. Future research to establish the util- 13. Bron JL, van Royen BJ, Wuisman PI. The clinical significance
ity of ultrasound for thoracic epidural catheter placement is of lumbosacral transitional anomalies. Acta Orthop Belg. 2007;
73:687–695.
warranted.
14. Arzola C, Davies S, Rofaeel A, Carvalho JC. Ultrasound
using the transverse approach to the lumbar spine provides
reliable landmarks for labor epidurals. Anesth Analg. 2007;
References 104:1188–1192.
1. Avramescu S, Arzola C, Tharmaratnam U, Chin KJ, Balki M. 15. Tyl RW, Chernoff N, Rogers JM. Altered axial skeletal devel-
Sonoanatomy of the thoracic spine in adult volunteers. Reg opment. Birth Defects Res B Dev Reprod Toxicol. 2007;
Anesth Pain Med. 2012;37:349–353. 80:451–472.
2. Grau T, Leipold RW, Delorme S, Martin E, Motsch J. Ultra- 16. Bouzinac A, Delbos A, Rontes O. [Ultrasound location of the
sound imaging of the thoracic epidural space. Reg Anesth Pain first rib confirm the level of realization of thoracic paravertebral
Med. 2002;27:200–206. block]. Ann Fr Anesth Reanim. 2012;31:571–572.
3. Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult 17. McLeod A, Roche A, Fennelly M. Case series: Ultrasonogra-
thoracic and lumbar spine for central neuraxial blockade. phy may assist epidural insertion in scoliosis patients. Can J
Anesthesiology. 2011;114:1459–1485. Anaesth. 2005;52:717–720.
ch07.indd 178 23-08-2017 18:04:34

Ultrasound Imaging of the Lumbar Spine
for Central Neuraxial Blocks CHAPTER 8
Introduction ultrasound imaging, and sonoanatomy relevant for CNBs in

the lumbar region.
Central neuraxial blocks (CNBs), which include spinal,
epidural, and combined spinal epidural (CSE) injections,
are frequently performed in the lumbar region for anesthesia Basic Lumbar Spine Anatomy
and analgesia and for managing chronic pain.1 Traditionally,
The lumbar spine makes up the lower back and is made up of
they are performed using a combination of surface anatomic
five vertebra, numbered L1 to L5 (Figs. 8-1 and 8-2). It con-
landmarks, the operator’s tactile perception of “loss of resis-
nects with the thoracic spine above and with the sacrum below
tance” during needle advancement through the ligamentum
at the lumbosacral joint. L1 to L4 are typical lumbar vertebrae
flavum, and/or visualizing the efflux of cerebrospinal fluid.
because they share common characteristics, but L5 is atypi-
Anatomic landmarks (eg, the spinous processes) are use-
cal because it has certain peculiarities. The lumbar vertebral
ful but they are not always easily palpable in patients with
body is designed to bear weight, and therefore the size of the
edema, obesity,2 underlying spinal deformity, or previous
lumbar vertebrae increases from L1 to L5. The lumbar spine
back surgery. The “Tuffier’s line,” which is a line joining the
also has a curvature, being slightly convex anteriorly, and this
highest points of the iliac crests, is another surface anatomi-
is referred to as lordosis.
cal landmark that is widely used to estimate the location of
the L4 to L5 interspace; however, the correlation is incon- Typical Lumbar Vertebra
sistent.3 Even in the absence of spine abnormalities, estima-
A typical lumbar vertebra (L1–L4) is identified by its large
tion of a specific intervertebral level may not be accurate in
vertebral body and the absence of costal facets on the body
many patients4,5 and may result in needle placement one or
(Fig. 8-3). The body of a typical lumbar vertebra is wider in
two spinal levels higher than intended.4–7 This inaccuracy is
the transverse axis than in the anteroposterior axis (Fig. 8-3).
exaggerated in the obese and in the upper spinal levels.4,6,8
The height of the vertebral body is also greater anteriorly
Furthermore, using surface anatomical landmarks alone,
than posteriorly, and this difference contributes to the for-
it is not possible to predict the ease or difficulty of needle
ward convexity of the lumbar spine. The vertebral foramen
placement prior to skin puncture. Unanticipated technical
is triangular in shape (Fig. 8-3) and larger than that in the
difficulty, multiple attempts at needle placement, and failure
thoracic region but smaller than that in the cervical region.
of CNB are therefore prevalent in clinical practice.9,10
Recently, ultrasound imaging of the spine11–13 has emerged
as a useful tool to overcome many of the shortcomings of
the traditional approach to CNBs, and it has been used with Superior articular
great success. Ultrasound is most frequently used as a pre- process
First Lumbar
procedural tool,11 but can also be used to guide the epidural vertebra (L1)
Transverse
process
or spinal needle in real time during CNBs.14 Advantages of L2
Spinous process
the preprocedural scan include being able to accurately locate
Zygapophyseal
the midline,15 identify a given lumbar interspace, predict the Intervertebral disk
joint
depth to the epidural space, detect any vertebral rotational Intervertebral
L5 foramen
defects (eg, in scoliosis), and identify patients with a poten- Median sacral
crest
tially difficult CNB.11,16 In expert hands the use of ultrasound Sacral promontory Sacrum
for epidural needle insertion reduces the number of puncture
attempts,17–22 improves the success rate of epidural access on Articular surface Coccyx
of sacrum
the first attempt,18 reduces the need to puncture multiple lev-
els,18–20 and improves patient comfort during the procedure.19
This chapter briefly outlines the anatomy, the technique of FIGURE 8-1 ■ Lumbosacral spine – lateral view.
179
ch08.indd 179 23-08-2017 18:13:53

180 n Chapter 8 / Ultrasound Imaging of the Lumbar Spine for Central Neuraxial Blocks
The pedicles are short and strong and directed posteriorly from and directed laterally and slightly backwards (Fig. 8-4). The
the upper part of the body (Figs. 8-2 and 8-3). This results in width of the transverse process increases from L1 to L3 after
an inferior vertebral notch that is significantly deeper than the which it decreases as one moves caudally. In a typical lumbar
superior vertebral notch (Figs. 8-2 and 8-3). The laminae are vertebra, the superior articular processes lie farther apart from
short and thick, directed backwards and medially, and form each other than the inferior articular processes (Fig. 8-4). The
the posterior part of the vertebral arch. The spinous process superior articular processes face backwards and medially,
is thick, wide, and quadrilateral in shape, and directed back- whereas the inferior articular process faces laterally and for-
wards (Figs. 8-1 to 8-3). The transverse processes are thin ward (Figs. 8-3 and 8-4).
Superior articular facet
Transverse
Transverse process process
L1
Inferior vertebral
notch Interspinous space Body of vertebra
Spinous process
Intervertebral Zygapophyseal joint Facet joint
foramen
Superior vertebral Spinous process
notch Superior articular
Interlaminar process
Inferior articular process
space
Vertebral body
Superior articular process
Interspinous Spinal canal
Intervertebral disc L5
Inferior articular facet space Inferior articular
process
FIGURE 8-2 ■ Lumbar spine – lateral view. FIGURE 8-4 ■ Posterior articulation of the lumbar vertebra. Note
the superior and inferior articular processes and the facet joints on
either side of the midline.

SAP
Mamillary SAP
process TP
TP
SC
Vertebral VB
arch SVN
L4
Inferior articular
facet
IAP Spinous
SAP process
TP
VB
Spinous
Inferior process
vertebral notch
IAP Inferior articular
facet
FIGURE 8-3 ■ A typical (fourth) lumbar vertebra – superior, anterior, and lateral views. TP, transverse process; SAP, superior articular
p rocess; SC, spinal canal; SVN, superior vertebral notch; VB, vertebral body; IAP, inferior articular process.
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Chapter 8 / Ultrasound Imaging of the Lumbar Spine for Central Neuraxial Blocks n 181
Spinous process Lamina SAP

SAP
TP
TP
Spinous
process
SC
VB
Vertebral SVN
arch L5
Inferior vertebral
SAP notch IAP
Inferior articular
facet
TP
VB
Inferior articular
facet
IAP Spinous process
FIGURE 8-5 ■ An atypical (fifth) lumbar vertebra – superior, lateral, and anterior views. TP, transverse process; SAP, superior articular
process; SC, spinal canal; SVN, superior vertebral notch; VB, vertebral body; IAP, inferior articular process.
Fifth Lumbar Vertebra (L5)

The body of the L5 vertebra is the largest of all the lum-
bar vertebrae. Its anterior surface is wider than its posterior
surface (Fig. 8-5), and this difference results in the sharp PM Intrathecal space
lumbosacral angulation (Fig. 8-1). The pedicles are short L4 VB
Cauda equina
and directed backwards and laterally (Fig. 8-5). The supe-
rior articular processes face more backwards than medially, QLM
and the inferior articular process also looks more anteriorly
Transverse
than laterally when compared to the other lumbar vertebrae Articular Ligamentum Epidural process
(Fig. 8-5). The distance between the inferior articular pro- process flavum space
cesses are also equal to or more than the distance between ESM
the superior articular processes. The transverse process of L5

is short, thick, pyramidal in shape, and attached to the entire
thickness of the pedicle (Fig. 8-5). The spine of L5 is also
relatively short and has a rounded tip. FIGURE 8-6 ■ Cross-sectional cadaver anatomic section through
The adjacent lumbar vertebrae articulate with each other the L4 vertebral body and transverse process illustrating the attach-
at the facet joints between the superior and inferior articular ment of the ligamentum flavum to the laminae, posterior epidural
space, and the relationship of the articular process to the transverse
processes and the intervertebral disc between the vertebral
process. ESM, erector spinae muscle; QLM, quadratus lumborum
bodies (Fig. 5-7). This results in two gaps—the “interspinous
muscle; PM, psoas major muscle; VB, vertebral body.
space” and the “interlaminar space”—between the adjacent
spinous processes and the laminae of the vertebrae, respec-
tively (Fig. 8-4). These gaps allow the ultrasound energy to flavum, supraspinous and interspinous ligament, and the ante-
enter the spinal canal and thereby act as acoustic windows rior and posterior longitudinal ligament), spinal canal, and the
for ultrasound imaging during spinal sonography. The reader epidural space in the lumbar region.
should refer to Chapter 5 for a detailed description of the
anatomy of the interlaminar and interspinous spaces, major Gross Anatomy of the Lumbar Spine
ligaments that support the lumbar vertebra (ie, ligamentum Figs. 8-6 to 8-11
ch08.indd 181 23-08-2017 18:14:11

Spinous process
Interspinous
space
L3
Ligamentum
Psoas major L4 VB flavum
Intrathecal L4
IVF L5
space
CE ES
QLM Cauda equina
ITS
Articuar
process
ESM Lamina
Sacrum
L4VB
L5VB
FIGURE 8-8 ■ Median sagittal cadaver anatomic section of the

FIGURE 8-7 ■ Cross-sectional cadaver anatomic section from just lumbar spine showing the spinous processes (L3–L5), interspinous
inferior to the L4 transverse process and through the lower part of spaces, ligamentum flavum, posterior epidural space, and the the-
the L4 vertebral body illustrating the lamina of the lumbar vertebra, cal sac. Also note the cauda equina (CE) within the thecal sac. ITS,
the articular processes, and the intervertebral foramina. VB, verte- intrathecal sac; VB, vertebral body.
bral body; IVF, intervertebral foramen; QLM, quadratus lumborum
muscle; ESM, erector spinae muscle.
ESM
Erector spinae
L3 Lamina Epidural muscle
Cauda equina space ILS Superior articular Inferior articular
process Facet joint
ITS process
Sacrum
L4VB L5VB
L4 VB IVD L3VB
FIGURE 8-9 ■ Paramedian sagittal cadaver anatomic section of FIGURE 8-10 ■ Paramedian sagittal cadaver anatomic section of
the lumbar spine at the level of the lamina. The laminae have been the lumbar spine at the level of the articular processes. A graphic
shaded in green, and a graphic overlay has been placed over the L3 overlay has been placed over the articular processes of the L4 ver-
lamina to illustrate the horse head–like appearance of the lamina of tebra to illustrate the camel hump–like appearance formed by the
the lumbar vertebra. ESM, erector spinae muscle; ILS, interlaminar articulations of the superior and inferior articular processes and the
space; ITS, intrathecal space; VB, vertebral body; IVD, interverte- facet joints. VB, vertebral body.
bral disc.
ch08.indd 182 23-08-2017 18:14:23

Aorta
IVC
ESM
TPL3
VB
TPL4 TPL5
PM
um
cr
ITS
Sa
L2NR QLM
L3NR ESM
Psoas major muscle Lamina
Spinous
process
Bowel
FIGURE 8-11 ■ Paramedian sagittal cadaver anatomic section of FIGURE 8-12 ■ Transverse CT image of the lumbar spine at the
the lumbar spine at the level of the transverse processes. Note the level of the spinous process. IVC, inferior vena cava; VB, vertebral
large fleshy muscle (ie, the psoas major muscle) lying anterior to the body; ITS, intrathecal space; PM, psoas major muscle; QLM, qua-
transverse processes. Also the lumbar plexus nerves can be identi- dratus lumborum muscle; ESM, erector spinae muscle.
fied within the substance of the psoas muscle. ESM, erector spinae
muscle; TP, transverse process; NR, nerve root.
Sacrum
Interspinous Epidural L4 SP L5 SP L5S1 Gap
Aorta space space
IVC
VB PM
ITS
QLM L5 VB
Facet joint
L4 VB
ESM Posterior dura
Ligamentum Articular
flavum Epidural process
space
FIGURE 8-13 ■ Transverse CT image of the lumbar spine at the FIGURE 8-14 ■ Median sagittal CT image of the lumbosacral
level of the articular process. IVC, inferior vena cava; VB, verte- spine. Note the L5 to S1 gap between the spinous processes of L5
bral body; ESM, erector spinae muscle; ITS, intrathecal space; PM, and S1 vertebra posteriorly. SP, spinous process; VB, vertebral body.
psoas major muscle; QLM, quadratus lumborum muscle.
Computed Tomography Anatomy of the Lumbar Magnetic Resonance Imaging Anatomy of the
Spine Lumbar Spine
Figs. 8-12 to 8-18 Figs. 8-19 to 8-26
ch08.indd 183 23-08-2017 18:14:32

Sacrum
Interlaminar
L5S1 Gap Erector spinae L3 TP L5 TP
space L4 TP
L5 lamina
L3 lamina L4 lamina L3 NR L4 NR
Sacrum
ITS
Psoas major
L5 VB
L4 VB
FIGURE 8-15 ■ Paramedian sagittal oblique (rendered) CT section FIGURE 8-18 ■ Paramedian sagittal CT image of the lumbosacral
of the lumbosacral spine at the level of the lamina. Note the wide spine at the level of the transverse processes. TP, transverse process;
interlaminar space (L5–S1 gap) between the lamina of L5 and the NR, nerve root.
sacrum. ITS, intrathecal space; VB, vertebral body.
IVC Aorta
Kidney
Sacrum PM
VB
L5 lamina L5S1 Gap

L4 lamina Interlaminar
space QLM ITS
ITS ESM Transverse

Ligamentum Articular process
flavum Posterior Posterior epidural process
space
dura
L5 VB
L4 VB
FIGURE 8-19 ■ Transverse T1-weighted magnetic resonance

image of the lumbar spine through the interspinous space. Note the
FIGURE 8-16 ■ Paramedian sagittal CT image of the lumbosacral attachment of the ligamentum flavum to the laminae and the wide
spine at the level of the lamina. Note the relatively narrow interlami- posterior epidural space. IVC, inferior vena cava; PM, psoas major
nar and intrathecal space (ITS) when compared to that in Fig. 8-15 muscle; VB, vertebral body; QLM, quadratus lumborum muscle;
(same subject). VB, vertebral body. ESM, erector spinae muscle; ITS, intrathecal space.
Articular PM
VB
process
LPVS
Lumbar nerve
root
ITS
QLM
L5 VB
L4 VB Articular process
Lamina
Cauda equina SP
FIGURE 8-17 ■ Paramedian sagittal CT image of the lumbar spine FIGURE 8-20 ■ Transverse T1-weighted magnetic resonance
at the level of the articular processes. Note how the articular pro- image of the lumbar spine at the level of the spinous process. Note
cesses articulate to form the facet joints. VB, vertebral body. the relationship of the articular processes to the intervertebral fora-
men and the lumbar nerve root. VB, vertebral body; LPVS, lumbar
paravertebral space; ITS, intrathecal space; PM, psoas major mus-
cle; QLM, quadratus lumborum muscle; SP, spinous process.
ch08.indd 184 23-08-2017 18:14:43

Anterior Cod liver oil

capsule
VB
Right Left
Posterior Ligamentum flavum
SP1 SP2 SP3 SP4 SP5
Subarachnoid space
Cauda equina
Facet joint
Ligamentum flavum Epidural space
Posterior dura
Posterior dura
Posterior Subarachnoid space with
Epidural space
Cauda equina
Cranial Caudal
Spinous process
Erector spinae muscle Anterior dura, posterior longitudinal
Anterior ligament and vertebral body complex
FIGURE 8-22 ■ Median sagittal magnetic resonance image of the

FIGURE 8-21 ■ Zoomed magnetic resonance image of the lumbar lumbar spine demonstrating the spinous processes (SP), interspinous
epidural and intrathecal space. Note the attachment of the ligamen- spaces, posterior epidural space, and the thecal sac. The hyperin-
tum flavum to the laminae, the posterior epidural space, and the tense oval structures on the surface of the skin posteriorly are cod
cauda equina nerves within the hyperintense cerebrospinal fluid. liver oil capsules that were used as skin markers to identify the lum-
VB, vertebral body. bar interspinous spaces.
Erector spinae muscle

Interlaminar space
Ligamentum flavum
Posterior dura
Epidural space
L5 S1 Gap
Erector Spinae muscle Ligamentum flavum L5
L2
L3 L4
L5
L2 L3 L4
Cauda equina Thecal sac

Posterior Posterior dura
Thecal sac with Anterior dura, posterior longitudinal
cauda equina ligament and vertebral body complex
Cranial Caudal
Anterior
FIGURE 8-23 ■ Sagittal magnetic resonance image of the lumbar FIGURE 8-24 ■ Sagittal oblique (rendered) T1-weighted magnetic
spine at the level of the lamina. resonance image of the lumbar spine at the level of the lamina. Note
the wide interlaminar and intrathecal spaces when compared to that
in Fig. 8-23 (same subject).
Articular
Erector spinae process
IVD L4 VB L5 VB
FIGURE 8-25 ■ Sagittal magnetic resonance image of the lumbosacral spine at the level of the lumbar articular processes. VB, vertebral
body. IVD, intervertebral disc.
ch08.indd 185 23-08-2017 18:14:56

Ultrasound Imaging of the Lumbar Spine

The lumbar spine is imaged using a low-frequency (5–2 MHz)
Erector spinae
L2 TP
muscle
L3 TP L4 TP L5 TP
curved array transducer and in the transverse or sagittal
plane. During a median transverse scan (Figs. 8-27 to 8-38)
um the “transverse spinous process view” (Figs. 8-27 to 8-29)
cr
Sa
and “transverse interspinous view” (Figs. 8-34 to 8-36) are
L3 Nerve root Psoas major acquired. During a median sagittal scan (Figs. 8-39 to 8-41)
the lumbar spinous processes and the interspinous spaces
are visualized.12,13 The lumbar spinous processes appear as
Posterior
Cranial
SP
FIGURE 8-26 ■ Sagittal T1-weighted magnetic resonance image
of the lumbosacral spine at the level of the transverse processes (TP).
Note the relationship of the psoas muscle to the TP and the steep
caudal course of the lumbar nerve roots. Lamina
ESM
Acoustic shadow
FIGURE 8-28 ■ Transverse sonogram of the lumbar spine with

the transducer positioned directly over the lumbar spinous process
(ie, the transverse spinous process view). Note the acoustic shadow
of the spinous process and lamina completely obscures the spinal
canal and the neuraxial structures. SP, spinous process; ESM, erector
spinae muscle.
FIGURE 8-27 ■ Position and orientation of the ultrasound trans-
ducer during a transverse scan of the lumbar spine with the subject
in the lateral position.
Spinous process
Lamina
Posterior
Right
Transverse Spinous Process View
FIGURE 8-29 ■ Transverse sonogram of the lumbar spine illustrating the transverse spinous process view. Photographs on the right illustrate
the position and orientation of the ultrasound transducer with the subject in the lateral position.
ch08.indd 186 23-08-2017 18:15:15

Spinous process
Spinous
process
A Transverse view
Spinous process
C Coronal view
B Sagittal view
FIGURE 8-30 ■ Multiplanar 3-D CT images of the lumbar spinous process that were rendered from a volume CT data set of the CIRS
lumbar training phantom. (A) Transverse view, (B) sagittal view, and (C) coronal view.
SP
SP Lamina
Lamina
ESM
SC
VB Acoustic shadow
A B
SP SP
Lamina Lamina
ESM
PD ESM
PD
QLM CE
CE
ITS
PM
VB
PM ITS
C D VB
FIGURE 8-31 ■ Correlative transverse (A) CT, (B) ultrasound, (C) cadaver anatomic, and (D) MRI images of the lumbar spinous process
and lamina. SP, spinous process; SC, spinal canal; VB, vertebral body; ESM, erector spinae muscle; QLM, quadratus lumborum muscle;
PM, psoas major muscle; ITS, intrathecal space; PD, posterior dura; CE, cauda equina; ITS, intrathecal space.
ch08.indd 187 23-08-2017 18:15:40

SP ISS
ITS
Spinous process
B Sagittal
SP
ISS
C Coronal
A Transverse D Slice plain
FIGURE 8-32 ■ Multiplanar 3-D ultrasound images of the lumbar spinous process with the reference marker (white crosshair) placed over
the tip of the spinous process. (A) Transverse view, (B) sagittal view, (C) coronal view, and (D) slice plane. SP, spinous process; ITS, intrathecal
space; ISS, interspinous space.
Spinous process
Lamina SP SP
Posterior dura ISS
ITS
A Transverse B Sagittal Anterior complex
Lamina
C Coronal D Slice plane
FIGURE 8-33 ■ Multiplanar 3-D ultrasound images of the lumbar spinous process with the reference marker (white crosshair) placed over
the base of the spinous process. (A) Transverse view, (B) sagittal view, (C) coronal view, and (D) slice plane. SP, spinous process; ITS, intra-
thecal space; ISS, interspinous space.
Articular process
Posterior dura
Posterior
Intrathecal
Right space Anterior complex
Transverse Interspinous Scan
FIGURE 8-34 ■ Transverse sonogram of the lumbar spine with the ultrasound beam being insonated through the lumbar interspinous space
(ie, the transverse interspinous view). The photographs on the right illustrate the position and orientation of the ultrasound transducer with
the subject in the lateral position.
ch08.indd 188 23-08-2017 18:15:47

Posterior
ESM Articular process

ESM
Epidural space Posterior dura
Epidural space
Intrathecal
Posterior dura
space AP
Right Left
ITS
Anterior
Posterior complex
VB
Right Left
Vertebral Anterior Acoustic shadow
Anterior body complex of AP
Anterior
FIGURE 8-35 ■ Transverse sonogram of the lumbar spine – coned FIGURE 8-36 ■ Transverse sonogram of the lumbar spine –
(zoomed) transverse interspinous view. The epidural space, posterior transverse interspinous view. Note the posterior epidural space is
dura, intrathecal space, and the anterior complex are visible in the clearly delineated in this sonogram. ESM, erector spinae muscle;
midline, and the articular process (AP) is visible laterally on either ITS, intrathecal space; VB, vertebral body.
side of the midline. Note how the articular processes on either side
are symmetrically located.
Spinous process Interspinous space
Spinous process
Spinal canal
A Sagittal view
Articular process Facet joint

Transverse process
Spinal
canal Vertebral C Coronal view
body
B Transverse view
FIGURE 8-37 ■ Multiplanar 3-D CT images of the lumbar spine that were rendered from a volume CT data set of the CIRS lumbar training
phantom. The reference marker (crosshair) has been placed at the L3 to L4 interspinous space. (A) Sagittal view, (B) transverse view, and
(C) coronal view.
ch08.indd 189 23-08-2017 18:15:52

FJ IAP
SAP
TP
ESM
ES PD
SC ITS AP
VB
VB AC
A B
ES
LF PD
ESM
LF IAP AP
TP
ES SAP
QL
ITS CE CE
VB ITS
PM AD
VB
C D
FIGURE 8-38 ■ Correlative transverse (A) CT, (B) ultrasound, (C) cadaver anatomic, and (D) high-definition coned (zoomed) ultrasound
images of the lumbar interspinous view. Note how the inferior and superior articular processes of the vertebrae make up the facet joints on
either side of the midline. TP, transverse process; FJ, facet joint; SC, spinal canal; IAP, inferior articular process; SAP, superior articular
process; ESM, erector spinae muscle; ES, epidural space; ITS, intrathecal space; LF, ligamentum flavum; CE, cauda equina; PM, psoas
major muscle; QLM, quadratus lumborum muscle; PD, posterior dura; AP, articular process; VB, vertebral body; AC, anterior complex;
AD, anterior dura.
Spinous process Spinous process
Interspinous space
Acoustic shadow of
spinous process
FIGURE 8-39 ■ Position and orientation of the ultrasound trans- FIGURE 8-40 ■ Median sagittal sonogram of the lumbar spine
ducer during a median sagittal scan of the lumbar spine with the showing the crescent-shaped hyperechoic reflections of the spinous
subject in the lateral position. processes. The interspinous space is interposed between the spinous
processes in the midline.
crescent-shaped structures (Figs. 8-40 and 8-41) and occupy limited view of the neuraxial structures (Fig. 8-41). In con-
most of the median plane (ie, there is a lot of bone). Therefore, trast there is less bony obstruction in the paramedian sagittal
the acoustic window for imaging is relatively narrow in the plane, particularly at the level of the lamina, which creates
midline (Fig. 8-41). Also any clinical condition that causes a large acoustic window for imaging through the interlami-
narrowing of the interspinous spaces (eg, in the elderly) nar spaces. Sonographic views of the neuraxis are also more
further compromises the acoustic window. Consequently
detailed through the paramedian sagittal plane (Figs. 8-42 to
ultrasound imaging through the median plane provides a 8-67). Therefore it is the preferred route for spinal sonography
ch08.indd 190 23-08-2017 18:15:58

L5S1 gap SP ISS

ISS
SP SP
SP
rum
Sa c
SC
VB
L4
Acoustic shadow
A IVD B of SP
ISS
LF ISS SP
SP LF ES
ES SP PD
PD SP
ITS CE
ITS
CE L5
VB AD
VB L4
IVD L5
C D IVD
FIGURE 8-41 ■ Correlative median sagittal (A) CT, (B) ultrasound, (C) cadaver anatomic section, and (D) magnetic resonance images of
the lumbar spine. SP, spinous process; ISS, interspinous space; VB, vertebral body; SC, spinal canal; IVD, intervertebral disc; LF, ligamentum
flavum; PD, posterior dura; ES, epidural space; ITS, intrathecal space; CE, cauda equina.
Posterior
ESM
Posterior dura
Lamina
Cranial L5 Caudal
L4
L3
Intrathecal
space
Anterior complex
Anterior
FIGURE 8-42 ■ Position and orientation of the ultrasound trans- FIGURE 8-43 ■ Paramedian sagittal sonogram of the lumbar spine.
ducer during a paramedian sagittal scan of the lumbar spine with the Note the narrow intrathecal space in this sonogram. ESM, erector
subject in the lateral position. spinae muscle.
Lamina of L3
B A
L5S1 Gap
Locating the L3-L4-L5 intervertebral spaces
FIGURE 8-44 ■ Position and orientation of the ultrasound trans- FIGURE 8-45 ■ Figure illustrating how to identify a given lum-
ducer during a paramedian sagittal oblique scan of the lumbar spine bar intervertebral space by performing a paramedian sagittal scan.
with the subject in the lateral position. (A) Locate the L5 to S1 gap and (B) slide the transducer cephalad
until the lamina of L3, L4, and L5 are identified.
ch08.indd 191 23-08-2017 18:16:10

L5S1 Gap
ESM Lamina LF
S1
L5
ITS
Posterior Epidural
space
Cranial Lumbosacral Junction (L5-S1) Scan
FIGURE 8-46 ■ Paramedian sagittal sonogram of the lumbosacral junction. The dip or gap between the posterior surface of the sacrum
and the lamina of L5 is the L5 to S1 gap. ESM, erector spinae muscle; LF, ligamentum flavum; ITS, intrathecal space. The photographs on
the right illustrate the position and orientation of the ultrasound transducer to locate the L5 to S1 gap with the subject in the lateral position.
Erector spinae
muscle
Epidural space
Lamina Ligamentum
flavum
L3
L4
L5
Posterior Paramedian sagittal oblique scan

Posterior
dura Cauda equina
Anterior Intrathecal IVD
space Anterior complex
FIGURE 8-47 ■ Paramedian sagittal oblique scan of the lumbar spine at the level of the lamina showing the L3 to L4 and L4 to L5 inter-
laminar spaces. Note the hypoechoic epidural space (few millimeters wide) between the hyperechoic ligamentum flavum and the posterior
dura. The intrathecal space is the anechoic space between the posterior dura and the anterior complex in the sonogram. The hyperechoic
reflections anterior of the anterior complex are from the intervertebral disc (IVD). The cauda equina nerve fibers are also seen as hyperechoic
longitudinal structures within the thecal sac. The photograph on the right illustrates the position and orientation of the ultrasound transducer
during a paramedian sagittal oblique scan of the lumbar spine with the subject in the lateral position.
Ligamentum
Epidural space Interlaminar
flavum Lamina space
L3 L4 L5
Intrathecal
space
Cauda equina
Anterior complex
Anterior
FIGURE 8-48 ■ Paramedian sagittal oblique sonogram of the lumbar spine demonstrating the L3 to L4 and L4 to L5 interlaminar spaces.
The posterior epidural space is clearly delineated between the hyperechoic ligamentum flavum and the posterior dura in this sonogram. Also
note the cauda equina nerves within the thecal sac at the L4 to L5 level.
ch08.indd 192 23-08-2017 18:16:17

Sacrum
Posterior Blood vessels L5S1 Gap
Intrathecal space
Posterior dura
Lamina Cauda equina
Interlaminar space
ESM
L5
L4
L1 L3
L3 L4 L5 L2
Sacral canal
Intrathecal space
Anterior complex
FIGURE 8-50 ■ Panoramic view of a paramedian sagittal oblique

Cranial Anterior Caudal scan of the lumbosacral spine.
FIGURE 8-49 ■ Paramedian sagittal oblique sonogram of the lum-

bar spine at the L3 to L5 level demonstrating color Doppler signals
from the vasculature within the erector spinae muscle (ESM).
Lamina
Lamina
A Transverse view
Lamina
C Coronal view
B Sagittal view
phantom. The reference marker (crosshair) has been placed over the L4 lamina. (A) Transverse view, (B) sagittal view, and (C) coronal view.
ch08.indd 193 23-08-2017 18:16:23

Needle L3 Lamina ESM ILS LF ES

L3 Lamina ILS
PD
SC
AC
ITS
A Lamina (phantom) B Lamina (volunteer)

ESM
L3 Lamina ILS
ES
Posterior
Cranial Caudal
Anterior CE
ITS
L4 VB IVD
C Lamina (cadaver)
FIGURE 8-52 ■ Paramedian sagittal oblique sonogram of the lumbar spine at the level of the laminae (L3–L5) from (A) the water-based
spine phantom and (B) volunteers and a representative anatomical section from (C) a representative cadaver anatomical section from the
Visible Human Server. In the latter, the lamina has been shaded in green (C). Note the marker (needle) in contact with the lamina in
the water-based spine phantom (A). This was done to ensure that the lamina was being scanned and also helped in validating its sonographic
appearance. A graphic overlay has been placed over the lamina in (A) to illustrate the “horse head sign.” AC, anterior complex; CE, cauda
equina; ES, epidural space; ESM, erector spinae muscle; ILS, interlaminar space; ITS, intrathecal space; IVD, intervertebral disc; LF, liga-
mentum flavum; PD, posterior dura; SC, spinal canal; VB, vertebral body.
Lamina ESM Lamina

ILS ILS LF ES
L3 L4 L5
SC
ITS PD
L5
VB Sacrum CE
L4
AC
A IVD B IVD
Lamina Lamina ILS

ESM ILS LF ESM LF ES PD
ES
m
cru ITS
Sa
AC
CE
VB ITS CE L5
L5 VB L4
L4 IVD IVD
C D
FIGURE 8-53 ■ Correlative paramedian sagittal (A) CT, (B) ultrasound, (C) cadaver anatomic section, and (D) magnetic resonance
images of the lumbar spine. ILS, interlaminar space; ESM, erector spinae muscle; ES, epidural space; SC, spinal canal; VB, vertebral body;
IVD, intervertebral disc; LF, ligamentum flavum; ITS, intrathecal space; CE, cauda equina; PD, posterior dura; AC, anterior complex.
ch08.indd 194 23-08-2017 18:16:29

Posterior
ES
LF LF
ES
L5
L4
L5
L4
Cranial Caudal
Dura Dura
CE CE
ITS
ITS
A Spinal Sonogram L45 Interspace B T2 MRI L45 Interspace
Anterior
FIGURE 8-54 ■ Correlative paramedian sagittal (A) sonogram and (B) T2-weighted magnetic resonance images of the neuraxis via the
L4 to L5 interlaminar space. LF, ligamentum flavum; ES, epidural space; ITS, intrathecal space; CE, cauda equina.
Lamina Lamina Interlaminar

space
AP
ITS
Interthecal Anterior
space complex
C Coronal
FIGURE 8-55 ■ Multiplanar 3-D ultrasound images of the lumbar spine with the reference marker (green crosshair) placed over the lamina.
(A) Transverse view, (B) sagittal view, and (C) coronal view. AP, articular process; ITS, intrathecal space.
ch08.indd 195 23-08-2017 18:16:33

Articular process
Erector spinae
muscle
Posterior
Cranial
Paramedian sagittal articular process scan
FIGURE 8-56 ■ Paramedian sagittal sonogram of the lumbar spine showing the articular processes. The photographs on the right illustrate
the position and orientation of the ultrasound transducer during a paramedian sagittal scan of the lumbar spine at the level of the articular
processes of the vertebra with the subject in the lateral position.
Erector spinae
muscle
Articular process
Anterior
FIGURE 8-57 ■ Paramedian sagittal sonogram of the lumbar spine at the level of the articular processes of the vertebra. A graphic overlay
has been placed in this image to illustrate the camel hump–like appearance of the articular processes.
and for real-time ultrasound-guided CNBs.11–13 For a detailed On a TSPV, the spinous process and the lamina on either side
ultrasound examination of the lumbar spine, it must be imaged are seen as hyperechoic reflections anterior to which there is an
in both the transverse and sagittal planes because the informa- acoustic shadow that completely conceals the underlying spinal
tion obtained from either plane complements the other. canal and thus the neuraxial structures (Figs. 8-28 and 8-29).
Therefore, the TSPV is not suitable for imaging the neuraxial
Transverse Ultrasound Imaging structures but can be used to identify the midline when the spi-
of the Lumbar Spine nous processes cannot be palpated (eg, in patients with edema
For a transverse scan of the lumbar spine, the ultrasound trans- over the back or obese patients). From this position, by sliding
ducer is positioned in the midline and initially over the spinous the transducer slightly cranially or caudally, a transverse scan
process (transverse spinous process view, TSPV, Figs. 8-27 to of the lumbar spine through the interspinous/interlaminar space
8-29) with the patient in the sitting, lateral, or prone position. (transverse interspinous view, TISV, Figs. 8-34 to 8-38) is
ch08.indd 196 23-08-2017 18:16:36

AP
AP
A Sagittal view
AP
C Coronal view
B Transverse view
phantom. The reference marker (crosshair) has been placed over the articular process (AP) of the L4 vertebra. (A) Sagittal view, (B) transverse
view, and (C) coronal view.
AP
AP ESM
A Articular process (phantom) B Articular process (volunteer)
AP ESM FJ
Posterior
Cranial Caudal
Anterior L4 VB
C Articular process (cadaver)
FIGURE 8-59 ■ Paramedian sagittal sonogram of the articular process from the (A) water-based spine phantom, (B) volunteer, and
(C) a representative cadaver anatomical section. A graphic overlay has been placed in (B) to illustrate the camel hump–like appearance of the
articular processes. AP, articular process; ESM, erector spinae muscle; FJ, facet joint; VB, vertebral body.
obtained.12,15 A slight tilt of the ultrasound transducer cranially the spinal canal in the midline, and the articular processes and
or caudally may be needed to align the ultrasound beam with the transverse processes are visualized laterally (Figs. 8-34 to
the interspinous space and optimize the TISV. In the TISV, 8-36).12,15 The osseous elements produce a sonographic pattern
the posterior dura, thecal sac, and the anterior complex can that resembles a “cat’s head,” with the spinal canal represent-
be visualized (from a posterior-to-anterior direction) within ing the head, the articular processes representing the ears of
ch08.indd 197 23-08-2017 18:16:41

IAP SAP AP ESM AP
L5
VB
A IVD B
IAP ESM SAP FJ

ESM AP
VB L4 L5
IVD L4VB
C D
FIGURE 8-60 ■ Correlative sagittal (A) CT, (B) ultrasound, (C) cadaver anatomic section, and (D) magnetic resonance images of the
lumbar spine at the level of the articular processes (AP). IAP, inferior articular process; SAP, superior articular process; VB, vertebral body;
IVD, intervertebral disc; ESM, erector spinae muscle; FJ, facet joint.
Articular process
Posterior dura
AP
ITS
AP
Slice plane
C Coronal D
FIGURE 8-61 ■ Multiplanar 3-D ultrasound images of the lumbar spine with the reference marker (white crosshair) placed over the articular
process of the vertebra. (A) Transverse view, (B) sagittal view, and (C) coronal view. AP, articular process; ITS, intrathecal space.
ch08.indd 198 23-08-2017 18:16:47

ESM
TP L3
TP L4 TP L5
PM
PM
RPS
Posterior
Cranial
Paramedian sagittal scan - Transverse process
FIGURE 8-62 ■ Paramedian sagittal sonogram of the lumbar spine at the level of the transverse processes. Note the hyperechoic reflections
of the transverse processes with their acoustic shadows that produce the “trident sign.” The psoas major muscle is seen in the acoustic window
between the transverse processes and is recognized by its typical hypoechoic and striated appearance. Hyperechoic longitudinal striations
within the substance of the psoas muscle may represent intramuscular tendons of the psoas muscle. The photographs on the right illustrate
the position and orientation of the ultrasound transducer during a paramedian sagittal scan of the lumbar spine at the level of the transverse
processes of the vertebra with the subject in the lateral position. ESM, erector spinae muscle; TP, transverse process; PM, psoas major muscle;
RPS, retroperitoneal space.
the cat, and the transverse processes representing the whiskers Posterior
(Figs. 8-35 to 8-38). The ligamentum flavum is rarely visual- Cranial Caudal
ized in the TISV (Figs. 8-35 and 8-36), possibly due to anisot- ESM Anterior
Lumbar plexus
ropy caused by the archlike attachment of the ligamentum
flavum to the lamina (Fig. 8-38). The epidural space is also TPL2
TPL3 TPL4
less frequently visualized in the TISV (Fig. 8-6) than in the
Psoas major
paramedian sagittal oblique scan (PMSOS). In the TISV the muscle
depth of the posterior dura from the skin can be easily mea-
Psoas major
sured using the internal caliper of the ultrasound system. The Intramuscular muscle
tendon
TISV can also be used to examine for rotational defects of the
vertebra, such as in scoliosis. Normally, both the lamina and
the articular processes on either side are symmetrically located Retroperitoneal
space
(Figs. 8-35 and 8-36). However, if there is asymmetry, then a
rotational deformity of the vertebral column23 should be sus- FIGURE 8-63 ■ Paramedian sagittal sonogram of the lumbar spine
pected and a difficult CNB should be anticipated. at the level of the transverse processes. The acoustic shadows of the
transverse processes produce the “trident sign.” In this sonogram the
Sagittal Ultrasound Imaging of the lumbar plexus is visualized as a hyperechoic shadow in the posterior
Lumbar Spine part of the psoas muscle between the L3 and L4 transverse process
(TP). Intramuscular tendons of the psoas muscle are also seen within
For a sagittal scan (Figs. 8-39 to 8-67) the patient is posi- the substance of the psoas muscle and should not to be confused with
tioned in the sitting, lateral (Fig. 8-39), or prone position with the lumbar plexus nerves. ESM, erector spinae muscle.
the lumbosacral spine maximally flexed. The transducer is
placed 1 to 2 cm lateral to the spinous process (paramedian
sagittal scan, PMSS) at the lower back with its orientation that majority of the ultrasound signal enters the spinal canal
marker directed cranially (Fig. 8-39). For optimal imaging through the widest part of the interlaminar space.
the transducer is also tilted slightly medially during the scan The sagittal scan routine begins by locating the sacrum
(paramedian sagittal oblique scan, PMSOS, Fig. 8-44) so as a flat hyperechoic structure with a large acoustic shadow
ch08.indd 199 23-08-2017 18:16:50

Transverse process
Transverse
process
A Transverse view
Transverse process
C Coronal view
B Sagittal view
phantom. The reference marker (crosshair) has been placed over the transverse process of the L4 vertebra. (A) Transverse view, (B) sagittal
view, and (C) coronal view.
ESM
TPL3 TPL5
TPL4 TPL3
TPL4 TPL5
PM
PM PM
A B RPS
ESM
ESM TPL3 TPL4
TPL3
TPL4 TPL5
PM
L2NR
L3NR LP
PM
RPS RPS
C D
FIGURE 8-65 ■ Correlative sagittal (A) CT, (B) ultrasound, (C) cadaver anatomic section, and (D) magnetic resonance images of the lumbar
spine at the level of the transverse processes (TP). PM, psoas muscle; ESM, erector spinae muscle; RPS, retroperitoneal space; NR, nerve
root; LP, lumbar plexus.
anteriorly (Figs. 8-45 to 8-47, details in Chapter 9). When the transducer cranially and counting upward (Figs. 8-45 and
transducer is gently manipulated in a cranial direction, a gap 8-47).13,14 The erector spinae muscles are hypoechoic and lie
is seen between the sacrum and the lamina of the L5 verte- superficial to the laminae. The lamina appears hyperechoic and
bra, which is the L5 to S1 interlaminar space, also referred is the first osseous structure visualized (Figs. 8-47 and 8-48).
to as the L5 to S1 gap (Fig. 8-46).13,24 The L3 to L4 and L4 Because bone impedes the penetration of ultrasound, there is
to L5 interlaminar spaces can now be located by moving the an acoustic shadow anterior to each lamina. The sonographic
ch08.indd 200 23-08-2017 18:16:55

appearance of the lamina produces a pattern that resem-

bles the head and neck of a horse (the “horse head sign”)
Transverse AP
process Transverse (Fig. 8-52).13 The interlaminar space is the gap between the
process
adjoining lamina (Fig. 8-48) and is the “acoustic window”
ESM
through which the neuraxial structures are visualized within
the spinal canal. The ligamentum flavum appears as a hyper-
TP
PM
echoic band across adjacent lamina (Figs. 8-47 to 8-50). The
posterior dura is the adjoining hyperechoic structure ante-
rior to the ligamentum flavum, and the epidural space is the
hypoechoic area (a few millimeters wide) between the liga-
mentum flavum and the posterior dura (Figs. 8-47 and 8-48).
The ligamentum flavum and posterior dura may also be seen as
a single linear hyperechoic structure, which is referred to as the
“posterior complex”11 or “ligamentum flavum-posterior dura
complex.”25 The posterior dura is generally more hyperechoic
than the ligamentum flavum.13 The thecal sac with the cere-
TP brospinal fluid is the anechoic space anterior to the posterior
dura (Fig. 8-53). The cauda equina, which is located within
C Coronal the thecal sac, may also be seen as multiple horizontal, hyper-
echoic shadows within the anechoic thecal sac. Pulsations of
FIGURE 8-66 ■ Multiplanar 3-D ultrasound images of the lumbar the cauda equina are also identified in some individuals.13,14
spine with the reference marker (green crosshair) placed over the The anterior dura is also hyperechoic, but it is often difficult
transverse process of the vertebra. (A) Transverse view, (B) sagittal
to differentiate it from the posterior longitudinal ligament and
view, and (C) coronal view. AP, articular process; PM, psoas major
the posterior surface of the vertebral body because they are of
muscle; TP, transverse process; ESM, erector spinae muscle.
SP
Lamina
Articular process
FIGURE 8-67 ■ A sagittal iSlice display that was rendered from a 3-D ultrasound data set of the lumbar spine. In this figure, 16 contiguous
sagittal ultrasound images of the lumbar spine that are approximately 1.8 mm apart from the level of the spinous process (SP) to the articular
process (AP) are displayed. Note the change in the sagittal sonoanatomy of the lumbar spine from a medial to lateral direction.
ch08.indd 201 23-08-2017 18:16:59

similar echogenicity (isoechoic) and closely apposed to each patients younger than 50 years of age. Anesth Analg. 1994;78:
other. What results is a single, composite, hyperechoic reflec- 667–673.
10. Tarkkila P, Huhtala J, Salminen U. Difficulties in spinal needle
tion anteriorly, which is referred to as the “anterior complex”
use. Insertion characteristics and failure rates associated with
(Figs. 8-53 and 8-54).13,14
25-, 27- and 29-gauge Quincke-type spinal needles. Anaesthe-
If the transducer is now slid laterally from the level of sia. 1994;49:723–725.
the lamina, the paramedian sagittal articular process view 11. Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult
(Figs. 8-56 and 8-57) is seen. The articular processes of the thoracic and lumbar spine for central neuraxial blockade. Anes-
vertebrae appear as one continuous, hyperechoic wavy line thesiology. 2011;114:1459–1485.
12. Karmakar MK. Ultrasound for central neuraxial blocks. Tech
with no intervening gaps (Figs. 8-56 to 8-61).12,13 This pro-
Reg Anesth Pain Manag. 2009;13:161–170.
duces a sonographic pattern that resembles multiple camel
13. Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD.
humps—the “camel hump sign” (Fig. 8-59).12,13 A sagittal Sonoanatomy relevant for ultrasound-guided central neuraxial
scan lateral to the articular processes brings the transverse blocks via the paramedian approach in the lumbar region. Br J
processes of the L3 to L5 vertebrae into view and produces Radiol. 2012;85:e262–e269.
the paramedian sagittal transverse process view (Figs. 8-62 14. Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time
ultrasound-guided paramedian epidural access: evaluation of a
and 8-63). The transverse processes (Figs. 8-62 to 67) are
novel in-plane technique. Br J Anaesth. 2009;102:845–854.
recognized by their crescent-shaped, hyperechoic reflections
15. Carvalho JC. Ultrasound-facilitated epidurals and spinals in
and fingerlike acoustic shadows anteriorly (Figs. 8-62 and obstetrics. Anesthesiol Clin. 2008;26:145–158.
8-63).13,26 This produces a sonographic pattern that is referred 16. Chin KJ, Ramlogan R, Arzola C, Singh M, Chan V. The utility
to as the “trident sign” because of its resemblance to the tri- of ultrasound imaging in predicting ease of performance of spi-
dent (Latin tridens or tridentis) that is often associated with nal anesthesia in an orthopedic patient population. Reg Anesth
Pain Med. 2013;38:34–38.
Poseidon, the god of the sea in Greek mythology, and the
17. Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control
Trishula of the Hindu God Shiva.26
for presumed difficult epidural puncture. Acta Anaesthesiol
Scand. 2001;45:766–771.
18. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Ultra-
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ing combined spinal and epidural anesthesia. Reg Anesth Pain
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Project of the Royal College of Anaesthetists. Br J Anaesth. of ultrasound imaging in obstetric epidural anesthesia. J Clin
2009;102:179–190. Anesth. 2002;14:169–175.
2. Stiffler KA, Jwayyed S, Wilber ST, Robinson A. The use of 20. Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time
ultrasound to identify pertinent landmarks for lumbar puncture. ultrasonic observation of combined spinal-epidural anaesthesia.
Am J Emerg Med. 2007;25:331–334. Eur J Anaesthesiol. 2004;21:25–31.
3. Hogan QH. Tuffier’s line: the normal distribution of anatomic 21. Perlas A, Chaparro LE, Chin KJ. Lumbar neuraxial ultrasound
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Gawne-Cain M, Russell R. Ability of anaesthetists to identify 22. Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging
a marked lumbar interspace. Anaesthesia. 2000;55:1122–1126. for lumbar punctures and epidural catheterisations: systematic
5. Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound review and meta-analysis. BMJ. 2013;346:f1720.
imaging for identification of lumbar intervertebral level. Anaes- 23. Suzuki S, Yamamuro T, Shikata J, Shimizu K, Iida H.
thesia. 2002;57:277–280. Ultrasound measurement of vertebral rotation in idiopathic sco-
6. Holmaas G, Frederiksen D, Ulvik A, Vingsnes SO, Ostgaard G, liosis. J Bone Joint Surg Br. 1989;71:252–255.
Nordli H. Identification of thoracic intervertebral spaces by 24. Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound
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ch08.indd 202 23-08-2017 18:16:59

Ultrasound Imaging of Sacrum and Lumbosacral
Junction for Central Neuraxial Blocks CHAPTER 9
Introduction into a median section and a pair of lateral masses (Fig. 9-1).
The median section is traversed by the sacral canal, which con-
Ultrasound imaging of the sacrum1,2 and lumbosacral (L5–S1)
tains adipose tissue, cauda equina nerves (including the filum
interlaminar space3–7 is frequently performed to identify the
terminale), epidural space, spinal meninges (dura and arach-
sonoanatomy relevant for central neuraxial blocks, that is,
noid), and the thecal sac. The thecal sac ends at the level of the
spinal and epidural (lumbar and caudal) injection.1–7 Because
S2 but can vary from S1 to S3. The sacral canal also contains
the lumbosacral interlaminar space and sacrum are relatively
the epidural venous plexus, which generally ends at the level
superficial structures, they lend themselves well to ultrasound
of the S4 but may extend more caudally. The lateral masses
imaging.3–5,7 This chapter briefly outlines the anatomy, tech-
are formed by fusion of the transverse processes posteriorly
nique of ultrasound imaging, and sonoanatomy of the sacrum
and the costal elements anteriorly. The base is formed by the
and lumbosacral interlaminar space relevant for c entral neur-
superior surface of the body of the S1 vertebra, which is large,
axial blocks.
lumbar in type, and articulates with the L5 vertebra at the lum-
bosacral junction. The vertebral foramen of the S1 vertebra is
triangular in shape and continuous cranially with the lumbar
Basic Anatomy of the Sacrum spinal canal and caudally with the sacral canal. The spine of
The sacrum is a large, triangular bone formed by the fusion the S1 vertebra forms the first spinous tubercle. The apex of
of the five sacral vertebrae (Figs. 9-1 and 9-2). It makes up the sacrum is formed by the body of the S5 vertebra (inferior
the posterior aspect of the bony pelvis and articulates with surface) that articulates with the coccyx (Figs. 9-1 and 9-2).
the corresponding hip bones laterally at the sacroiliac junc- The pelvic surface of the sacrum (Fig. 9-1), although
tions. Because it is triangular in shape it has a base, an apex, not visualized during ultrasound imaging, is concave and
and four surfaces (right and left lateral surfaces, dorsal and directed downwards and forward. Four transverse ridges on
ventral or pelvic surface). Anatomically the pelvic surface of the median area indicate the lines of fusion of the bodies of
the sacrum faces downwards and forward, whereas the dorsal the four sacral vertebrae (Fig. 9-1). These transverse ridges
surface faces backwards and slightly upwards. The sacrum connect the four pelvic sacral foramina on either side of the
is divided by a row of foramina on either side of the midline midline and are continuous with the sacral canal through the
Base of sacrum SAP

Sacral Ala of
promontory sacrum Sacral canal
Fused laminae SAP
Sacral
Ala of
tuberosity
sacrum
Lateral part
Lateral mass Articular
Median sacral surface
crest
Lateral sacral
crest
Transverse lines Dorsal sacral
Anterior sacral
foramina
foramina Intermediate sacral
Sacral crest
Apex of hiatus
sacrum Sacrococcygeal Sacral cornua
joint
Coccyx Coccyx Sacrococcygeal joint
FIGURE 9-1 ■ The sacrum – ventral or pelvic surface. SAP, superior FIGURE 9-2 ■ The sacrum – dorsal surface. SAP, superior articular
articular process. process.
203
ch09.indd 203 23-08-2017 18:48:28

204 n Chapter 9 / Ultrasound Imaging of Sacrum and Lumbosacral Junction for Central Neuraxial Blocks
intervertebral foramen. The pelvic sacral foramen decrease in Gross Anatomy of the Sacrum
size in a craniocaudal direction consistent with the decrease
Fig. 9-4
in size of the sacral vertebra. In contrast the dorsal surface
(Fig. 9-2), which can be visualized using ultrasound, is con-
vex, irregular in appearance, narrower than the pelvic surface, Computed Tomography Anatomy
and directed backwards and slightly upwards (Fig. 9-2). The of the Sacrum
median area bears the median sacral crest with three to four Figs. 9-5 to 9-7
spinous tubercles representing the fused spines of the upper
four sacral vertebrae (Fig. 9-2). A ridge joining the articu-
lar tubercles forms the intermediate sacral crest. Four dor-
of the Sacrum
sal sacral foramina lie lateral to the intermediate sacral crest
(Fig. 9-2) and communicate with the sacral canal through Figs. 9-8 and 9-9
the intervertebral foramina (Fig. 9-3). The lateral sacral crest
lies lateral to the dorsal sacral foramina. Below the fourth
sacral tubercle there is an inverted U-shaped defect on the Median sacral crest
posterior aspect of the sacrum: the “sacral hiatus” (Fig. 9-2).

This results from a failure of fusion of the laminae of the
fourth and fifth sacral vertebrae. The inferior articular pro-
cesses of the fifth sacral vertebra form the sacral cornua and
lie lateral to the sacral hiatus (Fig. 9-2). The sacral hiatus is
roofed by a firm elastic membrane, the sacrococcygeal liga- Sacral hiatus
ment, which is an extension of the ligamentum flavum. The
terminal end of the filum terminale exits through the sacral
Dorsal sacral Coccyx
hiatus and traverses the dorsal surface of the S5 vertebra and foramen Sacral canal
sacrococcygeal joint to end at the coccyx. The fifth spinal

nerve also exits through the sacral hiatus lying medial to the FIGURE 9-3 ■ Sagittal section of the sacrum showing the sacral
sacral cornua. canal and the sacral foraminae.
Sacrococcygeal
Sacral cornua membrane Sacral hiatus
Sacral hiatus
Sacral canal
Sacral vertebra
FIGURE 9-4 ■ Transverse (upper images) and sagittal (lower images) cadaver anatomic sections of the sacrum at the level of the sacral
hiatus that was rendered from the Visible Human Server male data set.
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Chapter 9 / Ultrasound Imaging of Sacrum and Lumbosacral Junction for Central Neuraxial Blocks n 205
Sacral Sacrum Cauda equina

Gluteus canal
medius
Gluteus
medius
ESM
Sacral Sacroiliac Erector
canal SIJ
joint spinae
Iiac crest
Median sacral
crest
Median sacral Iliac crest
crest
FIGURE 9-5 ■ Transverse CT image of the sacrum. Note the sacral
canal and the sacroiliac joints. ESM, erector spinae muscle. FIGURE 9-8 ■ Transverse MRI image of the midsection of the
sacrum. Note the cauda equina nerves within the fat-filled sacral
canal. SIJ, sacroiliac joint.
Sacral hiatus Superficial posterior

Posterior sacrococcygeal sacrococcygeal ligament
ligament Deep posterior
Sacral canal sacrococcygeal ligament Sacral hiatus
S5 Caudal epidural
S4 space
Coccyx S5
Coccyx
S4
S3
S2
ITS
Sacral cornua Sacral hiatus
Sacral S1
Sacral
cornua hiatus
L5
FIGURE 9-6 ■ Median sagittal CT image of the sacrum. Inset image

is a transverse CT section of the sacrum at the level of the sacral hiatus. FIGURE 9-9 ■ Median sagittal MRI image of the sacrum. The
superficial and deep components of the sacrococcygeal ligament are
L5-S1 Gap Median sacral seen in this image. Inset image is a transverse MRI section of the sacrum
crest at the level of the sacral hiatus.
Iliac
crest
Ultrasound Imaging of the Sacrum

for Caudal Epidural Injection – Basic
Considerations
Dorsal sacral
foramen Sacro iliac The caudal epidural space is the continuation of the lumbar
joint
Sacral
Sacral epidural space and can be accessed via the sacral hia-
hiatus
cornua
tus. Ultrasound imaging of the sacrum and sacral hiatus
Coccyx can be performed in the transverse or sagittal axis (Fig.
9-10).1,2,5 Because the sacral hiatus is a superficial structure,
FIGURE 9-7 ■ 3-D CT reconstruction demonstrating the dorsal it can be imaged using a high-frequency linear transducer
surface of the sacrum. Note the large L5 to S1 interlaminar space,
dorsal sacral foramina, and the sacral hiatus.
ch09.indd 205 23-08-2017 18:48:48

(12–5 MHz).1,2,5 Ultrasound imaging of the sacrum for a cau- in chronic pain medicine, then the patient may be
dal epidural injection produces a typical sonographic appear- positioned in the prone position with a pillow under
ance of the osseous structures that are illustrated in Fig. 9-11. the abdomen.
stands behind the patient, and the ultrasound machine
Ultrasound Imaging of the Sacrum is placed directly in front of the patient.
for Caudal Epidural Injection 2. Transducer selection: High-frequency linear transducer
(12–5 MHz).
1. Position:
3. Scanning technique: Ultrasound scan for the sacral hiatus
a. Patient: The patient is positioned in the lateral
is commenced by placing the ultrasound transducer at the
decubitus position for a caudal epidural injection
lower end of the sacrum and over the coccyx. Thereafter
(Fig. 9-12). When fluoroscopy is used in conjunction
the transducer is gradually moved cranially until the
with ultrasound for the caudal epidural injection, as
sacral cornua and hiatus are visualized (Fig. 9-12).
4. Sonoanatomy: The sacral hiatus is covered by the
sacrococcygeal ligament. Its lateral margins are formed
by the two sacral cornua. On a transverse sonogram of
the sacrum at the level of the sacral hiatus, the sacral
cornua are seen as two hyperechoic reversed U-shaped
structures, one on either side of the midline (Figs. 9-12
and 9-13). Connecting the two sacral cornua and deep
to the skin and subcutaneous tissue is a hyperechoic
band, the sacrococcygeal ligament (Figs. 9-12 and
9-13). Anterior to the sacrococcygeal ligament is another
hyperechoic linear structure, which represents the dorsal
A Transverse scan B Sagittal scan
surface of the sacrum (Fig. 9-12). The hypoechoic space
FIGURE 9-10 ■ Figure illustrating the position of the ultrasound between the sacrococcygeal ligament and the bony
transducer during a (A) transverse and (B) sagittal scan of the sacrum. dorsal surface of the sacrum is the caudal epidural space
A B
Sacrum Sacral cornua
Sacral hiatus
Coccyx
Sacrum (SS) Sacral cornua (TS)

Sacrum
L5-S1Gap
Lamina of L5
C L5-S1 Gap (SS)
FIGURE 9-11 ■ Sonograms of the sacral hiatus (A, sagittal view and B, transverse view) and lumbosacral interlaminar space (L5–S1 gap,
sagittal view) from the water-based spine phantom. SS, sagittal scan; TS, transverse scan.
ch09.indd 206 23-08-2017 18:48:54

(Figs. 9-12 and 9-13). The two sacral cornua and the (Fig. 9-14). On a sagittal sonogram of the sacrum at the
posterior surface of the sacrum produce a sonographic level of the sacral cornua, the sacrococcygeal ligament,
pattern that we refer to as the “frog eye sign” because the base of sacrum, and the sacral hiatus are also clearly
of its resemblance to the eyes of a frog (Figs. 9-12 and visualized (Figs. 9-15 and 9-16). However, due to the
9-13). If one moves the transducer slightly cephalad acoustic shadow of the posterior surface of the sacrum,
to the midsection of the sacrum, the dorsal surface of only the lower part of the caudal epidural space is seen
the sacrum with the median sacral crest is visualized (Fig. 9-16).
Sacral cornua Sacrococcygeal Sacral hiatus

ligament
Transverse sonogram Position of patient and transducer

A B
FIGURE 9-12 ■ (A) Transverse sonogram of the sacrum at the level of the sacral hiatus that was acquired with the patient in the (B) lateral
position.
Sacral cornua Sacrococcygeal ligament
Sacral hiatus
C
Sacrum
FIGURE 9-13 ■ (A) Transverse sonogram of the sacrum at the level of the sacral hiatus. Note the two sacral cornua and the hyperechoic
sacrococcygeal ligament that extends between the two sacral cornua. The hypoechoic space between the sacrococcygeal ligament and the pos-
terior surface of the sacrum is the sacral hiatus. Inset images in the figure: (B) shows the sacral cornua from the water-based spine phantom,
(C) shows a 3-D reconstructed image of the sacrum at the level of the sacral hiatus from a 3-D CT data set from the author’s archive, and (D)
shows a transverse CT slice of the sacrum at the level of the sacral cornua.
ch09.indd 207 23-08-2017 18:48:59

Median sacral
Sacrum crest
FIGURE 9-14 ■ Transverse sonogram of the midsection of the sacrum showing the median sacral crest and the large acoustic shadow of the sacrum.
Sacrum Sacrococcygeal
ligament
Acoustic shadow
of sacrum
Sacral hiatus
Posterior
Cranial
A Sacral Hiatus: Sagittal scan
B Position: Patient & Transducer
FIGURE 9-15 ■ (A) Sagittal sonogram of the sacrum at the level of the sacral hiatus that was acquired with the patient in the (B) lateral position.
Sacrum Sacrococcygeal ligament
Coccyx
C
Sacral hiatus
A
Acoustic shadow
of sacrum Posterior
Cranial Caudal
D Anterior
FIGURE 9-16 ■ (A) Sagittal sonogram of the sacrum at the level of the sacral hiatus. Note the hyperechoic sacrococcygeal ligament that
extends from the sacrum to the coccyx and the acoustic shadow of the sacrum that completely obscures the sacral canal. Inset images in the
figure: (B) shows the sacral hiatus from the water-based spine phantom, (C) shows a 3-D reconstructed image of the sacrum at the level of the
sacral hiatus from a 3-D CT data set from the author’s archive, and (D) shows a sagittal CT slice of the sacrum at the level of the sacral cornua.
ch09.indd 208 23-08-2017 18:49:09

Clinical Pearls
1. There is marked variability in the anatomy of the sacral
hiatus.
2. Age-related changes in the sacral hiatus (ie, thickening L4 Transverse
L4-L5 interspinous process
and calcification of the sacrococcygeal ligament and space
cornua) can lead to significant narrowing of the hiatus. L5 Transverse
IAP L5 process
3. Avoid advancing the epidural needle too deep into the
caudal epidural space during an ultrasound-guided caudal L5-S1 Gap
SAP S1
epidural injection because the acoustic shadow of the Lamina S1 Median sacral
crest
sacrum obscures ultrasound visualization of the needle Articular surface
Dorsal sacral
tip and injectate. Therefore, unintentional intravascular foramen
Intermediate sacral
injection may be missed. crest Sacral hiatus
4. Color Doppler ultrasound should be used to confirm
Sacral cornua Coccyx
correct position of the needle tip and injection into the
caudal epidural space.8 FIGURE 9-17 ■ The lumbosacral spine – dorsal view. IAP, inferior
articular process; SAP, superior articular process.
Basic Anatomy of the Lumbosacral

Interlaminar Space
The lumbosacral (L5–S1) interlaminar space, also referred to
as the L5 to S1 gap,5,7 is the intervertebral space between the intervertebral (L3–L4 or L4–L5) space during CNB.6,7,13 This
lamina of L5 and S1 vertebrae (Fig. 9-17). It is one of the method relies on identifying the L5 to S1 interlaminar space
routes (paramedian approach) for needle insertion during cen- or the L5 to S1 gap in a paramedian sagittal scan and then
tral neuraxial blocks (CNBs, spinal and epidural injection), sliding the transducer cephalad to locate the lamina of the L3,
and spinal injections via the L5 to S1 interlaminar space origi- L4, and L5 vertebrae3,6,7,13 and thereby the L4 to L5 and L3 to
nally described by Taylor in 1940.9 However, a review of the L4 intervertebral spaces.3,6,7,13
literature indicates that CNBs are most frequently performed There are certain peculiarities in the anatomy of the
via the L3 to L4 or L4 to L5 intervertebral space and rarely L5 to S1 interlaminar space that deserve attention as a route
via the L5 to S1 interlaminar space. The exact reason for this for CNB. As described earlier, the L5 to S1 interlaminar
practice is not known, although the interlaminar space at the space is wider than the interlaminar spaces at the L4 to L5
L5 to S1 is wider than that at the other lumbar interverte- and L3 to L4 intervertebral levels.10 Also, because the dor-
bral levels.10 This may be due to a poor understanding of the sal surface of the sacrum is directed backwards and slightly
anatomy of the L5 to S1 interlaminar space or a lack of data upwards in vivo (Figs. 9-7, 9-18, and 9-19), the L5 to S1
comparing CNBs via the L3 to L4 or L4 to L5 and L5 to S1 interlaminar space may be closer to the skin than the L4 to
intervertebral spaces. However, with recent improvements in L5 intervertebral space. At the L5 to S1 intervertebral level,
our understanding of the sonoanatomy of the spine,3,7 there the ligamentum flavum is also relatively thinner, there is a
are several reports on the use of ultrasound for CNB via the lack of posterior epidural fat,14 and there is a greater amount
L5 to S1 interlaminar space in patients with difficult spine of epidural fat in the midline superficial (external) to the
(eg, scoliosis, instrumented or operated backs).11,12 Ultrasound epidural space,14 when compared to that at the other lumbar
has also been successfully used to accurately locate the lumbar intervertebral spaces.
ch09.indd 209 23-08-2017 18:49:14

L5-S1 IVD
A
Sacral canal
Sacrum Sacrum
L5-S1 L5-S1 Gap
Spinous Lamina
process
ILS
L4 L5
L4 L5
ITS CE
S1 S1
IVD
L5 L5
B C
FIGURE 9-18 ■ Cadaver anatomic section showing the lumbosacral interlaminar space (L5–S1 gap) in the (A) transverse, (B) median
(sagittal), and (C) paramedian sagittal axis. IVD, intervertebral disc; ILS, interlaminar space; ITS, intrathecal space; CE, cauda equina.
Dorsal surface
of sacrum
ESM L5-S1 Gap
Lamina Ligamentum Epidural space

flavum
Cauda
equina
L4 L5
Sacrum
L5 VB
IVD
FIGURE 9-19 ■ Sagittal cadaver anatomic section of the lumbosacral spine, through the laminae of L4 and L5 vertebrae and the L5 to S1
interlaminar space that was rendered from the Visible Human Server male data set. The lamina and dorsal surface of the sacrum are high-
lighted in green. Also note how the dorsal surface of the sacrum is directed backwards and slightly upwards. ESM, erector spinae muscle;
IVD, intervertebral disc; VB, vertebral body.
Gross Anatomy of the Lumbosacral Interlaminar Computed Tomography Anatomy of the Lumbosacral
Space Interlaminar Space
Figs. 9-18 and 9-19 Figs. 9-20 to 9-22
ch09.indd 210 23-08-2017 18:49:42

Sacrum
L5 VB L5 lamina
Ligamentum
flavum L5-S1 Gap
L4 lamina
Dura
Facet joint
ESM
Iliac Ligamentum
crest flavum Articular
process
L5 VB
FIGURE 9-20 ■ Transverse CT image of the lumbosacral inter-

vertebral space (junction). VB, vertebral body; ESM, erector spinae
muscle.
FIGURE 9-22 ■ Paramedian sagittal CT image of the lumbosacral

interlaminar space (L5–S1 gap). VB, vertebral body.
L5-S1 Gap
L5 Spinous
process Sacrum
Intrathecal sac with
cauda equina
L4 Spinous ESM L5 VB
process
Sacral canal
Iliac crest Posterior Ligamentum Articular Facet joint

dura flavum process
FIGURE 9-21 ■ Median sagittal CT image of the lumbosacral FIGURE 9-23 ■ Transverse MRI image of the lumbosacral interve-
intervertebral space. ESM, erector spinae muscle. rebral space. VB, vertebral body.
Magnetic Resonance Imaging Anatomy but it can also be imaged with the patient in the prone
of the Lumbosacral Interlaminar Space position.
Figs. 9-23 to 9-25
stands behind the patient, and the ultrasound machine
Ultrasound Imaging of the Lumbosacral is placed directly in front of the patient.
2. Transducer selection: Because the L5 to S1 interlaminar
Interlaminar Space space is relatively superficial, it can be imaged using a
1. Position: high-frequency linear transducer (12–5 MHz). However,
a. Patient: The L5 to S1 interlaminar space is imaged with because the L5 to S1 interlaminar space is imaged as part
the patient in the lateral decubitus position (Fig. 9-26), of a “scan routine” during spinal sonography for CNB,
ch09.indd 211 23-08-2017 18:49:47

S1 SP Sacrum
L5 lamina L5-S1 Gap
L4 SP L5-S1 Gap
Epidural L5 SP L4 lamina
space
Ligamentum
flavum
ITS
ITS
Epidural L5 VB
space
FIGURE 9-25 ■ Paramedian sagittal MRI image of the lumbosa-

FIGURE 9-24 ■ Median sagittal MRI image of the lumbosacral cral spine illustrating the laminae of L4 and L5 and the lumbosacral
spine. Note the tapered thecal sac and its termination at the level interlaminar space (L5–S1 gap). ITS, intrathecal space. VB, verte-
of S1 in this subject. Also note the cauda equina nerves within the bral body.
thecal sac. ITS, intrathecal sac. SP, spinous process.
Cauda equina Posterior

L5 Articular Transverse
dura process
process
ITS
Posterior L5 VB
Right
Median Transverse scan
FIGURE 9-26 ■ Transverse sonogram illustrating the transverse interspinous view of the L5 to S1 intervertebral space. ITS, intrathecal
space; VB, vertebral body.
a low-frequency (5–2 MHz) curvilinear transducer is moved in a cephalad direction until the a coustic shadow
most frequently used. of the dorsal surface of the sacrum disappears and the
3. Scanning technique: For a transverse scan the ultrasound spinal canal with the thecal sac, posterior surface of the
transducer is placed over the midsection of the sacrum L5 vertebral body (anterior complex), and the articular
(Fig. 9-26). Once the sacrum with the median sacral process of L5 (laterally) at the L5 to S1 intervertebral
crest (Fig. 9-14) is visualized, the transducer is slowly space are clearly visualized (Figs. 9-26 and 9-27).
ch09.indd 212 23-08-2017 18:49:52

For a sagittal scan the ultrasound transducer is placed round-to-oval anechoic structure within the spinal canal
over the sacrum in the sagittal orientation (Fig. 9-28) and (Figs. 9-26 and 9-27). The anterior complex of the pos-
then slowly moved in a cranial direction until the L5 to terior surface of the L5 vertebral body produces a hyper-
S1 interlaminar space is visualized (Figs. 9-28 and 9-29). echoic shadow anterior to the thecal sac (Figs. 9-26 and
During image optimization it may be necessary to tilt the 9-27). The ligamentum flavum with the posterior epidural
transducer slightly medially to produce a paramedian space may also be seen in some individuals (Fig. 9-27).
sagittal oblique scan (Fig. 9-28). The cauda equina nerves appear as small hyperechoic
4 . Sonoanatomy: On a transverse sonogram of the L5 shadows within the thecal sac (Fig. 9-27). The articular
to S1 intervertebral space the thecal sac is seen as a processes are seen laterally (Figs. 9-27 and 9-28). If one
now slowly slides the transducer in a cephalad direction,
one can easily recognize the transition of the anatomy
from the L5 to S1 intervertebral space to the spinous pro-
Epidural space cess of L5, the L4 to L5 intervertebral space, L4 spinous
process, and the L3 to L4 intervertebral space, respec-
Articular ESM Ligamentum flavum
tively (Figs. 9-30 to 9-32). The transverse scan sequence
process
Cauda equina described earlier is rarely used to identify a given lumbar
intervertebral space, but it may be used.
On a paramedian sagittal sonogram (Figs. 9-33 and 9-34)
the dorsal surface of the sacrum appears as a linear hyper-
Intrathecal echoic structure with a large acoustic shadow anteriorly
space
(Fig. 9-33). The osseous structure visualized immediately
Anterior dura cranial to the sacrum is the lamina (horse-head appear-
L5 VB
ance) of the L5 vertebra, and the intervening gap is the
L5 to S1 interlaminar space (Figs. 9-33 and 9-34). One
must not confuse this with a median sagittal scan through
FIGURE 9-27 ■ Transverse sonogram (zoomed view) illustrating
the L5 to S1 intervertebral space when the spinous pro-
the transverse interspinous view of the L5 to S1 intervertebral space.
Note the posterior epidural space and cauda equina nerves are visible cesses of the L5 and S1 are visualized (Fig. 9-35). At
in this image. ESM, erector spinae muscle. the L5 to S1 interlaminar space and within the acoustic
L5-S1 Gap
L5 Lamina Sacrum
LF S1
Paramedian sagittal oblique scan
ITS
Posterior
Posterior
dura
Anterior
A Paramedian sagittal oblique sonogram B Position of patient and transducer
FIGURE 9-28 ■ (A) Paramedian sagittal oblique ultrasound scan of the lumbosacral interlaminar space (L5–S1 gap) (B) with the patient in
the lateral position. Note the slight oblique tilt in the ultrasound transducer in the inset image.
ch09.indd 213 23-08-2017 18:49:57

FIGURE 9-29 ■ Correlative image of the lumbosacral interlaminar space (L5–S1 gap) anatomy. (A) sagittal sonogram from the water-based
spine phantom, (B) sagittal sonogram in vivo, and (C) cadaver anatomical section. ESM, erector spinae muscle; PD, posterior dura; CE, cauda
equina; ITS, intrathecal space.
MSC L5 SP
SIJ
Dura
AP
TP
ITS
A Sacrum B L5-S1 Gap C L5 Spinous process
L4 SP Dura
FJ Dura
AP Lamina AP ESM
ITS
AC ITS
D L4-L5 interspace E L4 Spinous process F L3-L4 Interspace
FIGURE 9-30 ■ A sequence of transverse sonogram (same subject) from (A) midsection of sacrum, (B) lumbosacral (L5–S1) intervertebral
space, (C) L5 spinous process, (D) L4 to L5 intervertebral space, (E) L4 spinous process, and (F) L3 to L4 intervertebral space. MSC, median
sacral crest; SIJ, sacroiiac joint; TP, transverse process; AP, articular process; ITS, intrathecal sac; SP, spinous process; FJ, facet joint; AC,
anterior complex; ES, erector spinae muscle.
ch09.indd 214 23-08-2017 18:50:04

Sacral canal
Sacrum
SIJ Dura AP ESM
ESM L5 SP
A Sacrum MSC Iliac crest B L5-S1 Gap C L5 Spinous process
Dura Dura AP
FJ L4 SP
D L4-L5 Interspace E L4 Spinous process F L3-L4 Interspace
FIGURE 9-31 ■ A sequence of transverse CT images of the lumbosacral spine (same subject) from (A) midsection of sacrum, (B) lum-
bosacral (L5–S1) intervertebral space, (C) L5 spinous process, (D) L4 to L5 intervertebral space, (E) L4 spinous process, and (F) L3 to L4
intervertebral space. ESM, erector spinae muscle; MSC, median sacral crest; SIJ, sacroiliac joint; AP, articular process; SP, spinous process;
FJ, facet joint.
Cauda equina
Thecal sac
ESM SIJ
L5 SP FJ
MSC AP
A Sacrum B L5-S1 Gap C L5 Spinous process
Thecal sac
TP LF Thecal sac
ESM LF TP
L4 SP
D L4-L5 Interspace E L4 Spinous process F L3-L4 Interspace
FIGURE 9-32 ■ A sequence of transverse MRI images of the lumbosacral spine (same subject) from (A) midsection of sacrum, (B) lumbosa-
cral (L5–S1) intervertebral space, (C) L5 spinous process, (D) L4 to L5 intervertebral space, (E) L4 spinous process, and (F) L3 to L4 interver-
tebral space. ESM, erector spinae muscle; MSC, median sacral crest; SIJ, sacroiliac joint; AP, articular process; SP, spinous process; FJ, facet
joint; LF, ligamentum flavum; TP, transverse process.
ch09.indd 215 23-08-2017 18:50:17

window, the following structures are visualized in a pos- Clinical Pearls

terior-to-anterior direction: erector spinae muscle, liga-
mentum flavum, posterior epidural space, posterior dura, 1. Identification of a given lumbar intervertebral space
thecal sac, and the anterior complex, respectively (Figs. using anatomical landmark (intercristal or Tuffier’s
9-33 and 9-34). Occasionally the tapered distal end of the line) is imprecise15 and often results in identification
thecal sac can be seen. The cauda equina nerves may also of an intervertebral space one or two spinal levels
be seen as hyperechoic streaks within the anechoic cere- higher.16,17
brospinal fluid–filled thecal sac (Fig. 9-33). 2. Cumulative evidence suggests that ultrasound is more
accurate than anatomical landmarks in locating a given
lumbar intervertebral space.13
3. To identify a given lumbar intervertebral space using
ultrasound, one has to rely on locating the L5 to S1
Posterior
interlaminar space on a paramedian sagittal scan
Sacrum
(described earlier). Therefore, inaccuracies can result in
ESM
L5-S1 Gap
individuals with lumbosacral transitional vertebra, that
Epidural space
Ligamentum is, lumbarized S1 (Figs. 9-36 and 9-37) or sacralized L5
flavum
L4
(Figs. 9-38 and 9-39) that is present in 4% to 21% of
Acoustic shadow
Cranial L5 of sacrum Caudal individuals.18
Lamina 4. The anatomy of the L5 to S1 intervertebral space is
Cauda equina rarely altered during spinal instrumentation or scoliosis
Intrathecal space (particularly idiopathic scoliosis) surgery. Therefore,
Anterior complex
it should be considered as a route for CNB in such
patients.
Anterior 5. Dry taps are common during spinal access through

the L5 to S1 interlaminar space. This is particularly
FIGURE 9-33 ■ Paramedian sagittal oblique sonogram of the lumbo-
true when the spinal puncture is performed with the
sacral (L5–S1) interlaminar space. Note the wide interlaminar space,
and correspondingly, the wide acoustic window for ultrasound imaging
patient in the lateral decubitus position and the spinal
at this level. The posterior surface of the sacrum is identified as a flat needle is inserted from the nondependent side (personal
hyperechoeic structure with a large acoustic shadow anterior to it. The experience).
dip or gap between the sacrum and the lamina of L5 is the L5 to S1
intervertebral space or the L5 to S1 gap. ESM, erector spinae muscle.
Posterior Posterior
Lumbosacral (L5-S1) Interlaminar Space Cranial Caudal
Anterior L4 Spinous
process ESM Interspinous
L5-S1 Gap Sacrum space L5 Spinous L5-S1 Gap
process
Sacrum S1
L5-S1 Gap
Cranial Caudal
Posterior dura
L5 Cauda equina
Subarachnoid
space
Intrathecal space with
Subarachnoid Posterior dura cauda equina
space Anterior complex
Sonogram T2 MRI
A B Anterior
FIGURE 9-34 ■ Correlative images (A) paramedian sagittal oblique FIGURE 9-35 ■ Median sagittal sonogram of the lumbosacral
sonogram and (B) sagittal MRI of the lumbosacral interlaminar space interlaminar (L5–S1 gap) space. ESM, erector spinae muscle.
(L5–S1 gap).
ch09.indd 216 23-08-2017 18:50:22

L5
L4
S1 L5 L4
L5 S1
L5
S1
S1
Radiographs showing lumbarization of S1 vertebra Radiographs showing sacralization of L5 vertebra
FIGURE 9-36 ■ Lumbosacral transitional vertebra I: Lumbariza- FIGURE 9-38 ■ Lumbosacral transitional vertebra III: Sacraliza-
tion of the S1 vertebra is seen on the plain radiographs (anteroposte- tion of the L5 vertebra is seen on the plain radiographs (anteroposte-
rior and lateral views). rior and lateral views).
L1
L2
L3
L4
L5 L4
L5
S1
S1 L4
L5
S1 L5
S1
CT scan images showing lumbarization of S1 vertebra CT scan images showing sacralization of L5 vertebra
FIGURE 9-37 ■ Lumbosacral transitional vertebra II: Lumbariza- FIGURE 9-39 ■ Lumbosacral transitional vertebra IV: Sacralization
tion of the S1 vertebra is seen on the CT scan images (sagittal and of the L5 vertebra is seen on the CT scan images (sagittal and 3-D
3-D reconstructed views). reconstructed views).
References 6. Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time

ultrasound-guided paramedian epidural access: evaluation of a
1. Chen CP, Tang SF, Hsu TC, et al. Ultrasound guidance in caudal novel in-plane technique. Br J Anaesth. 2009;102:845–854.
epidural needle placement. Anesthesiology. 2004;101:181–184. 7. Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD.
2. Chen CP, Wong AM, Hsu CC, et al. Ultrasound as a screening Sonoanatomy relevant for ultrasound-guided central neuraxial
tool for proceeding with caudal epidural injections. Arch Phys blocks via the paramedian approach in the lumbar region. Br J
Med Rehabil. 2010;91:358–363. Radiol. 2012;85:e262–e269.
3. Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult 8. Yoon JS, Sim KH, Kim SJ, Kim WS, Koh SB, Kim BJ. The
thoracic and lumbar spine for central neuraxial blockade. Anes- feasibility of color doppler ultrasonography for caudal epidural
thesiology. 2011;114:1459–1485. steroid injection. Pain. 2005;118:210–214.
4. Karmakar MK. Ultrasound for central neuraxial blocks. Tech 9. Taylor JA. Lumbosacral subarachnoid tap. J Urology.
Reg Anesth Pain Manag. 2009;13:161–170. 1940;43:561–564.
5. Karmakar MK. Ultrasound guided central neuraxial blocks. 10. Ebraheim NA, Miller RM, Xu R, Yeasting RA. The location
In: Narouze S, ed. Atlas of Ultrasound Guided Procedures in of the intervertebral lumbar disc on the posterior aspect of the
Interventional Pain Management. New York: Springer; 2010. spine. Surg Neurol. 1997;48:232–236.
ch09.indd 217 23-08-2017 18:50:43

11. Costello JF, Balki M. Cesarean delivery under ultrasound- 15. Broadbent CR, Maxwell WB, Ferrie R, Wilson DJ,
guided spinal anesthesia [corrected] in a parturient with Gawne-Cain M, Russell R. Ability of anaesthetists to identify
poliomyelitis and harrington instrumentation. Can J Anaesth. a marked lumbar interspace. Anaesthesia. 2000;55:1122–1126.
2008;55:606–611. 16. Whitty R, Moore M, Macarthur A. Identification of the lumbar
12. Yamauchi M, Honma E, Mimura M, Yamamoto H, Takahashi E, interspinous spaces: Palpation versus ultrasound. Anesth Analg.
Namiki A. Identification of the lumbar intervertebral level using 2008;106:538–540, table.
ultrasound imaging in a post-laminectomy patient. J Anesth. 17. Pysyk CL, Persaud D, Bryson GL, Lui A. Ultrasound assessment
2006;20:231–233. of the vertebral level of the palpated intercristal (Tuffier’s) line.
13. Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound Can J Anaesth. 2010;57:46–49.
imaging for identification of lumbar intervertebral level. 18. Hughes RJ, Saifuddin A. Imaging of lumbosacral transitional
Anaesthesia. 2002;57:277–280. vertebrae. Clin Radiol. 2004;59:984–991.
14. Hameed F, Hunter DJ, Rainville J, Li L, Suri P. Prevalence of
anatomic impediments to interlaminar lumbar epidural steroid
injection. Arch Phys Med Rehabil. 2012;93:339–343.
ch09.indd 218 23-08-2017 18:50:43

Sonoanatomy Relevant for Thoracic Interfascial Nerve
Blocks: Pectoral Nerve Block and Serratus Plane Block CHAPTER 10
Introduction or without axillary clearance.2 The SPB3 is a more recent

addition to the family of thoracic interfascial nerve blocks
Blanco and colleagues1–3 have recently described novel ultra-
and involves a single injection of 0.4 mL/kg of local anes-
sound-guided thoracic interfascial nerve blocks, the pectoral
thetic into the myofascial plane between the latissimus dorsi
nerve block (PECS)1,2 and serratus plane block (SPB),3 for
and the serratus anterior muscle more posteriorly and at the
anesthesia and/or analgesia of the anterior/anterolateral chest
level of the fifth rib.3 Local anesthetic spreads in the serratus
wall.1–4 The SPB may also anesthetize the axilla via blockade
plane, deep to the latissimus dorsi, and along the lateral chest
of the intercostobrachial nerve.3 These blocks were originally
wall to affect the lateral cutaneous branches of the second to
developed for breast surgery in an attempt to avoid some of
ninth intercostal nerves and possibly the long thoracic and
the rare but serious complications of thoracic paravertebral
thoracodorsal nerves.3,4 A clear understanding of the sono-
and neuraxial blocks. During a PECS-I block, the local anes-
anatomy of the thoracic wall is a prerequisite to effectively
thetic (0.4 mL/kg or approximately 20–30 ml)1 is injected as
using a PECS or SPB. The following section describes the
a single injection into the myofascial plane between the pec-
gross anatomy, ultrasound scan technique, and sonoanatomy
toralis major and minor muscle, aiming to block the medial
of the thoracic wall relevant for the thoracic interfascial nerve
and lateral pectoral nerves.1 PECS-II block is a modification
blocks. Because these blocks are frequently used for breast
of the PECS-I block (modified PECS-I block) and involves
surgery, a brief description of the innervation of the breast is
two injections.2 The first injection is the same as that for a
also included.
PECS-I block (but with 10 mL of local anesthetic),2 but the
second injection is performed deep to the pectoralis minor
muscle, at the level of the third and fourth rib, into the inter-
Gross Anatomy
fascial plane between the pectoralis minor and serratus ante- 1. Muscles: Muscles involved with thoracic interfascial
rior muscle (with 20 mL of local anesthetic).2 The aim of the nerve blocks are pectoralis major, pectoralis minor, serra-
PECS-II block is to anesthetize the pectoral nerves, inter- tus anterior, intercostal muscles, and the latissimus dorsi.
costobrachial nerve, third to sixth intercostal nerves, and the a. Pectoralis major: The pectoralis major muscle is a
long thoracic nerve.2,4 The PECS-II block is therefore used triangular, fan-shaped muscle that makes up the bulk
for more extensive breast surgery, including mastectomy with of the anterior chest wall (Figs. 10-1 and 10-2). It has
Supraclavicular nerves
(C3, C4)
Clavicle Platysma
Deltoid
Deltopectoral
Pectoralis major
triangle
(clavicular head)
Cephalic vein
Pectoralis major
Intercostobrachial (sternocostal head) Pectoral fascia
nerve (T2)
Lateral mammary and posterior

branches of the lateral cutaneous
branch of ICN (T3–T6)
Lateral mammary
branches of the lateral
cutaneous branch of ICN
Medial mammary branches
of the anterior cutaneous
branch of ICN
FIGURE 10-1 ■ Figure showing the anatomy of the anterior chest wall and arrangement of the lateral and medial mammary branches of the
lateral cutaneous and anterior cutaneous branches of the intercostal nerve (ICN), respectively.
219
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220 n Chapter 10 / Sonoanatomy Relevant for Thoracic Interfascial Nerve Blocks
two parts: the clavicular head and the sternocos- is innervated by the lateral pectoral nerve, and the
tal head (Fig. 10-1). The clavicular head originates sternocostal head is innervated by both the lateral
from the medial half of the clavicle, and the sterno- and medial pectoral nerve. It is involved with flex-
costal head arises from the anterior surface of the ion, adduction, and medial rotation of the humerus;
lateral margin of the sternum, the first seven costal depression of the arm and shoulder; and elevation of
cartilages, and aponeurosis of the external oblique the ribs.
muscle. Muscle fibers from the two heads converge b. Pectoralis minor: The pectoralis minor muscle is
laterally to form a flat tendon that is inserted into a thin, triangular-shaped muscle located deep to
the lateral lip of the bicipital groove (intertubercular the pectoralis major muscle (Figs. 10-3 to 10-5). It
sulcus) of the humerus. It also forms the anterior fold is significantly smaller in size than the pectoralis
of the axilla. The pectoralis major muscle receives major muscle and originates from the outer surface
its innervation from the lateral and medial pectoral of the third to fifth ribs (Fig. 10-4). The muscle fibers
nerves of the brachial plexus. The clavicular head converge superolaterally to form a flat tendon that
is attached to the coracoid process of the scapula
(Fig. 10-4). It also forms part of the anterior wall of
the axilla. The p ectoralis minor also receives its inner-
vation from the lateral and medial pectoral nerves of
Pectoralis major
Latissimus dorsi the brachial plexus. It is involved with depression
Serratus anterior 5 of the elevated shoulder, and along with the serratus
6 Rectus abdominis
External oblique 7 anterior muscles, pulls the scapula forward.
aponeurosis (cut) 8 Anterior rectus
9 sheath (cut) c. Serratus anterior: The serratus anterior muscle cov-
External oblique (cut) 10
Tendinous insertion
Internal oblique ers most of the lateral thoracic wall (Fig. 10-2) and
Anterior rectus
sheath
Umbilicus originates as 9 to 10 muscular slips from the external
Inguinal ligament surface of the first to eighth or ninth ribs (Fig. 10-2).
Because two slips originate from the second rib, the
number of slips is usually greater than the number
FIGURE 10-2 ■ Figure showing the anatomical arrangement of the of ribs from which they arise. The muscle fibers
pectoralis major, serratus anterior, and latissimus dorsi muscles. converge posteriorly to be inserted into the medial
Thoracoacromial artery
Superior branch of
pectoral nerve
Pectoralis major
(sternocostal head)
Intercostobrachial Middle branch of

nerve pectoral nerve
Pectoral branch of Pectoralis minor
thoracoacromial artery
Medial mammary branches of
Thoracodorsal artery anterior cutaneous branch of ICN
Thoracodorsal nerve
Long thoracic nerve
Serratus anterior
FIGURE 10-3 ■ Figure showing the anatomical arrangement of the pectoral nerves and their relation to the pectoralis major (cutout view)
and minor muscles, thoracoacromial artery and its branches, the chest wall, and breast in a female. Note the medial mammary branches of the
anterior cutaneous branch of the intercostal nerve (ICN) on the anteromedial aspect of the breast.
ch10.indd 220 23-08-2017 18:21:28

Chapter 10 / Sonoanatomy Relevant for Thoracic Interfascial Nerve Blocks n 221
border of the scapula. It contributes to forming the throwing a punch. It is also involved with upward
medial wall of the axilla. It is also called the “boxer’s rotation of the scapula that occurs while lifting a load
muscle” because it causes protraction of the scapula overhead. The serratus anterior muscle is innervated
around the rib cage—a movement that occurs when by the long thoracic nerve, which travels caudally on
the outer surface of the muscle. Injury to the long
thoracic nerve can lead to a “winged scapula.”
d. Latissimus dorsi: The latissimus dorsi muscle is a
large, flat muscle located on the dorsum of the trunk.
Pectoralis major
It originates from the spinous processes of the last
Thoracoacromial (clavicular head)
six thoracic vertebra (T7–T12), the thoracolumbar
artery
fascia, and the posterior third of the external lip of
Pectoral nerve
(superior branch) the iliac crest. The muscle fibers converge crani-
Ansa pectoralis ally to form a flattened tendon that is inserted into
the floor of the bicipital (intertubercular) groove
Pectoral nerve
anterior to the attachment of the teres major muscle.
(middle branch)
It is involved with adduction, extension, and inter-
Pectoral nerve
nal rotation of the arm at the shoulder and innervated
(inferior branch)
by the thoracodorsal nerve. The thoracodorsal artery
descends inferiorly with the thoracodorsal nerve and
supplies the latissimus dorsi muscle.
Pectoralis major
e. Teres major: The teres major muscle is a rounded mus-
(sternocostal head)
cle that is attached between the scapula and humerus.
It originates from the posterior surface of the inferior
angle and lower part of the lateral border of the s capula.
The fibers converge laterally to a flat tendon that is
inserted into the medial lip of the bicipital groove.
The teres major is located superior to the latissimus
FIGURE 10-4 ■ Figure showing the pectoral nerves and their rela-
tion to the pectoral muscles (cutout view of the pectoralis major dorsi, and the muscle fibers run parallel to each other
muscle), thoracoacromial artery, and its pectoral branch. to its insertion in the humerus. It is innervated by the
Omohyoid Clavicle
Trapezius Subclavius
Cephalic vein
Lateral cord
Thoracoacromial
Ansa pectoralis
artery
Posterior cord
Clavipectoral fascia
Supraspinatus
Lateral pectoral nerve
Axillary artery
Medial cord Pectoralis major
Infraspinatus
Subscapular Pectoralis minor
artery
Subscapularis
Suspensory (Gerdy’s)
Teres minor ligament of axilla
Teres major Axillary fascia
Latissimus dorsi
FIGURE 10-5 ■ Figure showing the sagittal anatomy of the right axilla. Note the relation of the pectoral nerves and ansa pectoralis to the
thoracoacromial artery and pectoral muscles. Also note the attachment of the clavipectoral fascia and suspensory (Gerdy’s) ligament of the
axilla.
ch10.indd 221 23-08-2017 18:21:37

lower subscapular and thoracodorsal nerves, which Each typical intercostal nerve (Fig. 10-6) passes
are branches of the posterior cord of the brachial below the neck of the rib (with the same number)
plexus, and receives spinal contributions from the C5 to enter the costal groove. At the posterior part of
to C8 spinal nerves. It is involved with extension and the costal groove, the intercostal nerve lies between
medial rotation of the humerus. the parietal pleura (with the endothoracic fascia)
2. Nerves: The nerves involved with thoracic interfascial and the internal intercostal membrane (Fig. 10-6).
nerve blocks are intercostal nerves, pectoral nerves, long Otherwise, throughout its course through the inter-
thoracic nerve, and thoracodorsal nerve. costal space, the intercostal nerve lies between the
a. Intercostal nerve: The intercostal nerves are the innermost intercostal and the internal intercostal
anterior primary rami of the spinal nerves T1 to T11. muscle (Figs. 10-6 and 10-7). The lateral cutane-
The anterior primary rami of the 12th spinal nerve ous branch pierces the intercostal and serratus
form the subcostal nerve. The first and second inter- anterior muscle complex at the level of the midax-
costal nerve, in addition to supplying the intercostal illary line and gives off its anterior and posterior
spaces, provide innervation to the upper limb. The branches (Figs. 10-6, 10-8, and 10-9). The anterior
lower five intercostal nerves (T7–T11) also sup- branch (T2–T6) courses forward and supplies the
ply the abdominal wall and are therefore called the skin on the lateral and anterior aspect of the chest
thoracoabdominal nerves. The intercostal nerves. T3 wall (Figs. 10-1, 10-6, and 10-9). In females they
to T6 are typical intercostal nerves because they only form the lateral mammary branches of the inter-
supply the thoracic wall. The anterior division of the costal nerve (same number) and supply the breast
first thoracic spinal nerve divides into two branches: (Figs. 10-6 and 10-10). The posterior branch courses
a larger branch that exits the thorax close to the neck backwards and supplies the skin over the scapula
of the first rib, and a smaller branch, the first intercos- and the latissimus dorsi muscle. The anterior cuta-
tal nerve, that runs through the intercostal space and neous branch of the intercostal nerve (ie, the main
ends close to the sternum as the anterior cutaneous intercostal nerve) courses forward through the inter-
branch of T1. The first intercostal nerve also receives costal space and emerges close to the sternum by
a small communication from the second intercostal crossing anterior to the internal thoracic (mammary)
nerve posteriorly along the neck of the rib. This is the artery (Fig. 10-6). It then pierces the internal inter-
“nerve of Kuntz,” which is present in 40% to 80% of costal muscle, the external intercostal membrane,
individuals. and the pectoralis major muscle to terminate as the
Medial mammary branch

Anterior cutaneous branch
of ICN
Internal thoracic
artery
Transversus thoracis Pectoralis major
External intercostal
Internal intercostal
Sympathetic Innermost intercostal
ganglion Visceral
pleura Lateral mammary branch
Rami communicantes
Lateral cutaneous branch
of ICN
Parietal pleura
Endothoracic fascia
Intercostal nerve
(ventral ramus)
Posterior primary ramus
FIGURE 10-6 ■ Transverse section of the thorax showing a typical intercostal nerve and its relation to the intercostal and pectoral muscles.
Note the formation of the medial and lateral mammary nerves from the intercostal nerve (ICN).
ch10.indd 222 23-08-2017 18:21:39

anterior cutaneous nerve of the thorax and innervate the lateral cutaneous branch of the second intercos-
the overlying skin after dividing into its medial and tal nerve (T2), emerges from the intercostal space
lateral branches (Fig. 10-6). The lateral branch sup- and runs oblique towards the arm to supply the
plies the medial and anterior aspect of the chest wall axilla and upper part of the medial aspect of the arm
and in females the medial and anterior aspect of the (Figs. 10-3, 10-8, and 10-10). The intercostobrachial
breast and thus is referred to as the medial mam- nerve may also receive contributions from the first,
mary nerves (T2–T6) (Figs. 10-3, 10-6, and 10-10). third, and fourth intercostal nerves.5
The intercostobrachial nerve, which corresponds to
Visceral
pleura Intercostobrachial Anterior cutaneous
Rib nerve nerves of thorax
Interpleural
space
Parietal Lateral cutaneous

pleura nerves of thorax
External Neurovascular Anterior cutaneous

intercostal bundle nerves of abdomen
Innermost
intercostal
Internal
intercostal
Subserous
fascia
Rib
Endothoracic
fascia
FIGURE 10-7 ■ Figure showing the anatomy of the intercostal FIGURE 10-8 ■ Figure showing the emergence of the lateral cuta-
space. neous branch of the intercostal nerve (lateral cutaneous nerve of the
thorax) and its branching along the lateral chest wall. Note the forma-
tion of the intercostobrachial nerve from the second intercostal nerve.
T1
T2 T2
T3
T3
T4
T4 Serratus anterior
Long thoracic nerve T5 T5
T6 External oblique (cut)
Latissimus dorsi T6
Posterior rectus
T7 T7
sheath
Lateral cutaneous branch of
T8 T8 Rectus abdominis (cut)
intercostal nerve (T2–T11)
T9
Anterior rectus
T10 sheath (cut)
Anterior cutaneous branch of
intercostal nerve (T2–T11) T9 Transversus abdominis
T11
Internal oblique and
Lateral cutaneous branch of T10 aponeurosis
subcostal nerve (T12) Anterior cutaneous branch
T11 of subcostal nerve (T12)
Lateral cutaneous branch of Anterior cutaneous branch
iliohypogastric nerve (L1) of iliohypogastric nerve (L1)
Lateral femoral cutaneous Ilioinguinal nerve
nerve (L2,3) External oblique
aponeurosis (cut)
FIGURE 10-9 ■ Figure showing the innervation of the trunk and abdominal wall. Note the anatomical arrangement of the typical intercostal
nerves (T3–T6) and the areas innervated by their lateral and anterior cutaneous branches. In females, the anterior branch of the lateral cutane-
ous branch of the intercostal nerve (T2–T7) form the lateral mammary nerve, and the medial branch of the anterior cutaneous branch of the
intercostal nerve (T1–T6) form the medial mammary nerve.
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Subclavius Pectoralis major

Cephalic vein muscle (clavicular head)
Axillary artery Clavicle
(1st part)
Supraclavicular nerve Thoracoacromial Long thoracic
Medial cutaneous (medial and intermediate) artery nerve
nerve Pectoral nerve
Deltoid (superior branch)
Intercostobrachial
nerve Pectoralis Pectoral nerve
2 minor (middle branch)
Thoracodorsal 3
nerve 4 Medial mammary Pectoralis major
Lateral cutaneous branch branches (sternocostal head)
5
of ICN Pectoral branch of
Lateral mammary 6 thoracoacromial artery
branches 7 Pectoral nerve
Long thoracic (inferior branch)
nerve
FIGURE 10-11 ■ Figure showing the anatomical structures that are

FIGURE 10-10 ■ Sensory innervation of the female breast – lateral
relevant for thoracic interfascial nerve blocks at the medial infracla-
(T2–T7) and medial (T1–T6) mammary nerves and supraclavicu-
vicular fossa (ie, between the inferior border of the clavicle and the
lar nerve (medial and intermediate). The axilla is innervated by the
medial border of the pectoralis minor muscle). Note how the cephalic
intercostobrachial nerve. Also note the course of the long thoracic
vein arches over the cords of the brachial plexus and axillary artery
and thoracodorsal nerve along the lateral chest wall. ICN, intercostal
from a lateral-to-medial direction to join the axillary vein. Also note
nerve.
the relations of the superior, medial, and inferior branches of the
pectoral nerve to the axillary artery, the thoracoacromial artery, and
pectoralis minor muscle.
b. Pectoral nerves: The pectoral nerves are frequently 23.4%, and T1 in 3.3%) have been described.10 After its
described as “pure motor nerves,” but there is grow- origin the LPN crosses anterior to the axillary vessels,
ing evidence that they are also involved with affer- pierces the clavipectoral fascia, and supplies the pecto-
ent nociception6 and proprioception, similar to that ralis major muscle (Fig. 10-5).6,8 The LPN also shares
with other pure motor nerves.7 Afferent nociception a constant course with the thoracoacromial vessels and
may be transferred by the pectoral nerves from the lies on the deep surface of the pectoralis major, beneath
acromioclavicular joint, coracoclavicular ligaments, the muscle fascia, with the pectoral branch of the tho-
subacromial bursa, articular capsule of the shoulder racoacromial artery (TAA) (Figs. 10-3, 10-4, and 10-
joint, periosteum of the clavicle, and pectoral mus- 11).6,8,11 After its origin, the MPN courses downwards
cles, and via cutaneous branches they may innervate lying anterior to the axillary artery and deep to the pec-
the anterior chest wall and anterior margin of the toralis minor muscle (Figs. 10-3, 10-4, and 10-11).8,11 It
deltoid muscle.6 then pierces the pectoralis minor muscle from beneath
The pectoral nerves are also traditionally described at about the midclavicular line and over the third inter-
as two nerves, the medial and lateral pectoral nerves, costal space.8 A few branches of the MPN may also
with the lateral pectoral nerve (LPN) being larger than loop around the inferior border of the pectoralis minor
the medial pectoral nerve (MPN).8,9 The ansa pectora- muscle to enter the pectoralis major.8
lis is a loop of communication between the LPN and The pectoral nerves may also be present as three
MPN (Figs. 10-3 and 10-4). Published data suggest constant branches (Figs. 10-3, 10-4, and 10-11),10–12
that the LPN most frequently arises from the anterior that is, a superior branch that supplies the clavicular
divisions of the upper and middle trunk (33.8%), but fibers of the pectoralis major, the middle branch that
it may also arise from the lateral cord (23.4%), of the courses on the undersurface of the pectoralis major
brachial plexus.6 The MPN also has a variable origin muscle (beneath its fascia) with the pectoral branch
and may arise from the medial cord (49.3%) or ante- of the TAA to innervate the sternal part of the pecto-
rior division of the lower trunk (43.8%) or lower trunk ralis major muscle, and the inferior branch that passes
(4.7%).6 Spinal contribution to the LPN and MPN also under the pectoralis minor muscle to innervate it and
varies.10 Two types of spinal origin of the LPN (C5– the costal part of the pectoralis major muscle.11 Given
C7 in 50% and C6 and C7 in 50%) and three types of the variable spinal origin and formation of the pec-
spinal origin of the MPN (C8 and T1 in 73,3%, C8 in toral nerves, a “subpectoral plexus”10 (Fig. 10-12) of
ch10.indd 224 23-08-2017 18:21:54

first part lies between the lateral border of the first

Superior branch rib and the medial border of the pectoralis minor
Lateral pectoral nerve
muscle and gives off the superior thoracic artery; the
C5
second part lies deep to the pectoralis minor muscle
C6
and gives off the lateral thoracic and TAA; the third
part lies between the lateral border of the pectoralis
C7 minor muscle and the lower border of the teres major
Middle branch
muscle and gives off three branches: the subscapular
Ansa pectoralis
artery, the anterior circumflex humeral artery, and the
C8 posterior circumflex humeral artery.
Inferior branch
T1 b. Thoracoacromial artery: The TAA, after its origin
(Figs. 10-3 and 10-4), runs a short course along the
upper margin of the pectoralis minor muscle, pene-
Subpectoral Plexus of Nerves trates the clavipectoral fascia (Fig. 10-5), and divides
into its terminal branches: the clavicular, acromial,
FIGURE 10-12 ■ Schematic diagram showing the formation of deltoid, and pectoral branches. The TAA is impor-
the “subpectoral plexus”10 of nerves with both the medial and lat- tant for a PECS block because, as described earlier,
eral pectoral nerve and the three terminal branches (ie, the superior, the pectoral nerves and the ansa pectoralis have a
middle, and inferior branches). The superior and middle branches constant relationship with the artery (Fig. 10-11).8,9
are derived from the lateral pectoral nerve, and the inferior branch is
The LPN also runs parallel to the pectoral branch of
derived from the ansa pectoralis (C7 spinal nerve root) and medial
the TAA in the myofascial plane between the pec-
pectoral nerve.
toralis major and minor muscles (Figs. 10-4 and
10-11), lying deep to the muscle fascia.8,9 The ansa
nerves with the C5–T1 nerve roots, the two pecto- pectoralis nerve is also formed immediately distal to
ral nerves, and the three terminal branches has been the origin of the TAA (Fig. 10-4).6
described.10,12 With this arrangement the superior and c. Thoracodorsal artery: The thoracodorsal artery
middle branches are divisions of the LPN, and the infe- (Fig. 10-3) is a branch of the subscapular artery and
rior branch is formed by fusion of the MPN and ansa travels inferiorly along the lateral chest wall (Fig. 10-3),
pectoralis from the C7 (Figs. 10-11 and 10-12).10,12 lying deep to the latissimus dorsi muscle initially and
c. Long thoracic nerve: The long thoracic nerve, also then on the external surface of the serratus anterior
known as the Bell’s nerve, originates from the ventral muscle. It is accompanied by the thoracodorsal nerve
rami of the C5, C6, and C7 and descends to the lat- (Fig. 10-3) and supplies the latissimus dorsi.
eral thoracic wall (Fig. 10-9) where it innervates the 4. Fascia
serratus anterior muscle. a. Clavipectoral fascia: This is a fascial layer that is
d. Thoracodorsal nerve: The thoracodorsal nerve origi- interposed between the clavicle and upper border of
nates from the posterior cord of the brachial plexus the pectoralis minor muscle (Fig. 10-5). The portion
with spinal contributions from the C6 to C8. As it of the clavipectoral fascia that is attached between the
descends along the posterior wall of the axilla, it is first costosternal articulation and the coracoid process
accompanied by the thoracodorsal artery and inner- is usually denser than the rest and is referred to as the
vates the latissimus dorsi muscle. “costocoracoid ligament.” Inferiorly it is thin, and at the
3. Blood vessels: The following blood vessels are of inter- upper border of the pectoralis minor muscle it splits to
est while performing thoracic interfascial nerve blocks: invest the muscle (Fig. 10-5). Below the inferior border
axillary, thoracoacromial, and thoracodorsal artery. of the pectoralis minor muscle the clavipectoral fascia
a. Axillary artery: The axillary artery is a continuation continues downwards as a single layer, the suspensory
of the subclavian artery into the axilla. It begins at the ligament of axilla, or Gerdy’s ligament, and attaches to
lateral border of the first rib and ends at the lower bor- the axillary fascia (Fig. 10-5). The clavipectoral fascia
der of the teres major muscle after which it continues is pierced by the cephalic vein, lateral pectoral nerve,
distally as the brachial artery. It has three parts: the TAA, and lymphatics (Fig. 10-5).
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Innervation of the Breast nerves (C3 and C4, Figs. 10-10 and 10-14). The lateral supra-
clavicular nerve mainly provides sensory supply to the upper
The sensory and glandular innervation of the female breast and posterior aspect of the shoulder, but may also contribute
comes from multiple sources. Medially it is innervated by to sensory innervation of the breast (Fig. 10-14). Sympathetic
the anterior cutaneous branches (medial mammary nerves) nerves reach the breast via the somatic nerves (described ear-
of the first to sixth intercostal nerves (Figs. 10-6 and 10-13) lier) and blood vessels. There is no parasympathetic nerve
and laterally by the lateral cutaneous branches (lateral mam- supply to the breast. When breast surgery involves the axilla
mary nerves) of the second to seventh intercostal nerves (eg, axillary dissection) and pectoral muscles (eg, modified
(Fig. 10-10).13 The nipple–areola complex is supplied mainly radical mastectomy), the intercostobrachial and pectoral
by the anterior and lateral cutaneous branches of the fourth nerves (LPN and MPN) may also be involved in afferent noci-
intercostal nerve (Fig. 10-13), with additional contributions ception (discussed earlier).
from the cutaneous branches of the third and fifth intercostal
nerves.13 The skin of the superior part of the breast (infracla-
vicular region) receives innervation from the superficial cer- Ultrasound Imaging for Thoracic
vical plexus via the medial and intermediate supraclavicular
Interfascial Blocks
1. Position:
a. Patient: Supine with the arm abducted and the head
turned away slightly to the contralateral side. Blanco
2
Pectoralis major 1 describes using the supine position for both the
3 Lateral mammary
3
2 nerve (T2–T7)
PECS1,2 and SPB,3,4 but we prefer the lateral posi-
4
4 tion for the SPB because it allows easy placement of
3
5 the ultrasound transducer along the lateral chest wall
5 4
for the coronal scan (described later) and also allows
5
6 easy needle manipulation.
Medial mammary b. Operator and ultrasound machine: With the
nerve (T1–T6)
patient in the supine position, the operator stands
at the head end of the patient, and the ultrasound
FIGURE 10-13 ■ Figure showing the arrangement of the lateral
and medial mammary nerves of the female breast. Note the breast machine is positioned ipsilateral to the side to be
is supplied medially by the medial mammary nerves (T1–T6) and examined and directly in front of the operator. With
laterally by the lateral mammary nerve (T2–T7).13 the patient in the lateral position and with the side
Trapezius
Clavicle
Deltoid
Lateral supraclavicular
nerve Medial supraclavicular
Intermediate supraclavicular nerve
nerve Pectoralis major
(sternocostal head)
Lateral mammary branches of the Medial mammary branches of the
lateral cutaneous branch of ICN anterior cutaneous branch of ICN
(T2–T7) (T1–T6)
FIGURE 10-14 ■ Figure showing the contribution of the supraclavicular nerves to the sensory innervation of the breast. ICN, intercostal
nerve.
ch10.indd 226 23-08-2017 18:22:00

to be scanned uppermost, the operator stands behind Steps II to V: From the earlier position the ultrasound
the patient, and the ultrasound machine is positioned transducer is moved laterally in small steps until the
on the contralateral side and directly in front of the anatomy of the thoracic wall at the level of the third
operator. to fourth (Figs. 10-22 to 10-24), fourth to fifth (Figs.
2. Transducer selection: High-frequency (13–15 MHz) 10-25 to 10-27), fifth to sixth (Figs. 10-28 to 10-30),
linear array transducer. and seventh to eighth (Figs. 10-31 to 10-33) ribs is
3. Scan technique: The ultrasound scan can be performed visualized.
in the sagittal, transverse, and coronal axis. The sagittal b. Coronal scan sequence: The coronal scan is per-
scan is performed in five sequential steps (Steps I–V) formed at the lateral chest wall and for an SPB.
over five contiguous sites starting immediately below The ultrasound transducer is placed in the coronal
the midsection of the clavicle and ending at the lateral
chest wall. This is done to better understand the anatomy
of the thoracic wall (Fig. 10-15) and the myofascial Clavicle Pectoralis major
Subclavius PECS-I plane Pectoralis minor
planes (Fig. 10-16) for local anesthetic injection during a Serratus plane
thoracic interfascial nerve block. Serratus anterior
a. Sagittal scan sequence:

R3
Step I: The ultrasound transducer is positioned R2
Lung R4 Latissimus
dorsi
with its proximal end resting on the midsection of
R5
the clavicle and with its orientation marker directed Pleura
cephalad (Fig. 10-17). The distal end of the trans- R6

Anterior
ducer is pivoted slightly laterally (directed slightly
outwards) towards the anterior axillary fold to pro- Cranial
R7
duce a sagittal oblique scan of the thoracic wall. The
clavicle is visualized as a hyperechoic structure with
an underlying acoustic shadow. The second rib is
FIGURE 10-16 ■ Sagittal oblique panoramic ultrasound image
seen lying posterior and distal to the acoustic shadow of the chest wall highlighting the PECS-I (in blue) and serratus
of the clavicle (Fig. 10-18), and the third rib is visual- plane (in green) that are targets for local anesthetic injection during
ized immediately caudal to it (Figs. 10-19 to 10-21). thoracic interfascial nerve blocks. R, rib.
Clavicle Pectoralis major

Subclavius Pectoralis minor
Serratus anterior
Gerdy’s ligament
R3
R2 Lung R4 Latissimus
dorsi
R5
Pleura
Inercostal muscles R6
Se
rra
Anterior
tu
sa
R2 R3
nt
Cranial
er
io
R7
r
FIGURE 10-15 ■ A sagittal oblique panoramic ultrasound image FIGURE 10-17 ■ Figure showing the position of the patient and
of the chest wall extending from the midsection of the clavicle to the ultrasound transducer during Step I of the sagittal scan sequence.
posterior axillary line showing the musculature and fascial planes Inset sagittal sonogram shows the plane of ultrasound imaging (blue
relevant for thoracic interfascial nerve blocks. R, rib. color) over the second intercostal space. R, rib.
ch10.indd 227 23-08-2017 18:22:05

Clavipectoral fascia
Subclavius Pectoralis major
MICF Pectoralis minor
Serratus anterior
Clavicle
Axillary vein R3
R2 Lung
Pleura B Position: Patient and transducer
Anterior
A Sagittal oblique sonogram
Cranial
FIGURE 10-18 ■ A. Sagittal oblique sonogram of the medial infraclavicular fossa (MICF), near the midsection of the clavicle, acquired
during Step I of the sagittal scan sequence. Note the second rib lies immediately posteroinferior to the clavicle, and the medial border of
the pectoralis minor muscle extends to the upper border of the third rib. B. Position of patient and ultrasound transducer during Step I of the
sagittal scan sequence. R, rib.
Pectoralis major
PECS-I plane
Subclavius MICF Pectoralis minor
CV
AV
AA
R3
R2
Serratus anterior
(upper slip)
Pleura
Anterior
B Position: Patient and transducer
A Cranial Sagittal oblique sonogrram
FIGURE 10-19 ■ A. Sagittal oblique sonogram of the anterior chest wall with the ultrasound transducer positioned slightly lateral to that
in Fig. 10-18. The axillary artery (AA) is visualized deep to the subclavius muscle and cranial to the axillary vein (AV). Also note how
the cephalic vein (CV) joins the axillary vein from above in the medial infraclavicular fossa (MICF). B. Position of patient and ultrasound
transducer during the sagittal oblique scan. R, rib.
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Axillary artery Pectoralis major

Subclavius TAA
(first part) Pectoralis minor
Clavicle
Brachial plexus
(cords) LC
AV
CCS
PC MC
R3
Serratus anterior
(upper slip) B Position: Patient and transducer
Pleura
Anterior
A Sagittal oblique sonogram Cranial
FIGURE 10-20 ■ A. Sagittal oblique sonogram of the anterior chest wall acquired during Step I of the sagittal scan sequence with the
ultrasound transducer positioned over the axillary artery (midclavicular point). Note the cords of the brachial plexus are clustered together
cranial to the axillary artery and within the costoclavicular space (CCS), which is between the clavicular head of the pectoralis major and
subclavius muscle anteriorly and the upper slips of the serratus anterior muscle overlying the second rib posteriorly. The axillary vein (AV)
lies caudal to the a xillary artery in this sonogram. Also note parts of the thoracoacromial artery (TAA) can be seen near the upper border of
the pectoralis minor muscle. B. Position of the patient and ultrasound transducer during the scan. R, rib; PC, posterior cord; MC, medial cord;
LA, lateral cord.
Subclavius Thoracoacromial artery

(origin) PECS-I plane
Pectoralis major
Clavicle
Pectoralis minor
Axillary artery
Axillary artery
(1st part)
(2nd part)
R3
R3 R4
Serratus anterior
Anterior (upper slip)
Pleura
Cranial
FIGURE 10-21 ■ Sagittal oblique sonogram of the anterior chest FIGURE 10-22 ■ Figure showing the position of the patient and
wall acquired during Step I of the sagittal scan sequence with the ultra- ultrasound transducer during Step II of the sagittal scan sequence.
sound transducer lying parallel to the axillary artery. Note the origin The inset sagittal sonogram shows the plane of ultrasound imaging
of the thoracoacromial artery from the anterior wall of the first part of (green) over the third intercostal space. R, rib.
the axillary artery in this subject. R, rib.
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PECS-I plane Serratus plane
Pectoralis major
Pectoralis minor
R3
Intercostal R4
muscles
Pleura Serratus anterior B Position: Patient and transducer
A Sagittal oblique sonogram Anterior
Cranial
FIGURE 10-23 ■ Sagittal oblique sonogram of the anterior chest wall acquired during Step II of the sagittal scan sequence. Note the PECS-I
plane lies between the posterior surface of the pectoralis major muscle and the anterior surface of the pectoralis minor muscles (interpectoral
plane), and the serratus plane lies between the posterior surface of the pectoralis minor muscle and the outer surface of the serratus anterior
muscle. During a PECS-I and PECS-II block, the local anesthetic is injected into their respective planes at this level. B. Position of the patient
and ultrasound transducer during the sagittal oblique scan. R, rib.
Pectoralis major
R4
Serratus plane PECS-I plane R5
Pectoralis minor
terio r
Serratus an
R3
Serratus anterior
R4
Pleura Intercostal muscles

Anterior
Cranial
FIGURE 10-24 ■ A zoomed sagittal oblique sonogram of the ante- FIGURE 10-25 ■ Figure showing the position of the patient and
rior chest wall acquired during Step II of the sagittal scan sequence. ultrasound transducer during Step III of the sagittal scan sequence.
The serratus plane is highlighted in green color. During a PECS-II The inset sagittal sonogram shows the plane of ultrasound imaging
block local anesthetic is injected into both the PECS-I and serratus (purple color) over the fourth intercostal space. R, rib.
plane at this level. R, rib.
orientation over the lateral chest wall (Fig. 10-34) the inferolateral margin of the latissimus dorsi muscle
and close to the posterior–axillary line. The aim at is seen overlying the serratus anterior muscle (Fig.
this stage is to identify the underlying ribs and the 10-36). The thoracodorsal artery is consistently seen
overlying serratus anterior muscle (Fig. 10-35). in the myofascial plane between the latissimus dorsi
The transducer is then gently moved posteriorly until and serratus anterior muscle at this level (Fig. 10-37).
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Pectoralis major Pectoralis minor
Serratus plane
R5
R4
Intercostal
muscles Serratus anterior
Pleura B Position: Patient and transducer
Anterior
Cranial
FIGURE 10-26 ■ A. Sagittal oblique sonogram of the anterior chest wall acquired during Step III of the sagittal scan sequence. Note the infe-
rior border of the pectoralis minor lies over the fifth rib. B. Position of patient and ultrasound transducer during the sagittal oblique scan. R, rib.
Serratus plane Gerdy’s ligament Axillary fascia
Pectoralis major R5
Serratus anterior R6
R6
Pectoralis minor R5
Serratus anterior
R4
Pleura
Anterior
Cranial
FIGURE 10-27 ■ Sagittal oblique sonogram of the anterior chest FIGURE 10-28 ■ Figure showing the position of the patient and
wall acquired with the transducer positioned slightly caudal to that ultrasound transducer during Step IV of the sagittal scan sequence.
in Figure 10-26 (same subject). Note the sixth rib is now visualized The inset sagittal sonogram shows the plane of ultrasound imaging
and the lateral border of the pectoralis minor muscle ends at the level (yellow color) over the fifth intercostal space. R, rib.
of the fifth rib. R, rib.
The ultrasound image is optimized, after which the c. Transverse scan sequence: In Blanco’s origi-
transducer is gently moved cranially along the same nal descriptions of the thoracic interfascial nerve
coronal plane until the inferolateral margin of the blocks, only the sagittal ultrasound scan technique
teres major muscle and the serratus plane (Fig. 10-38), is described.1,3,4 We have found the transverse ultra-
between the latissimus dorsi and serratus anterior sound scan window to be useful for both the PECS-I
muscle, are clearly visualized. This is the target ultra- and PECS-II blocks. For a transverse scan the patient
sound window for a SPB.4 is positioned supine with the head turned to the
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Pectoralis major Serratus anterior
R7
R6
R5
Pleura

Anterior
Cranial
FIGURE 10-29 ■ A. Sagittal oblique sonogram of the anterolateral chest wall acquired during Step IV of the sagittal scan sequence. Note
the inferior border of the pectoralis major muscle ends at the upper border of the sixth rib, and only the serratus anterior muscle overlies the
ribs below that. The lateral cutaneous branch of the intercostal nerve emerges from the intercostal space by passing through the intercostal
and serratus anterior muscle, along the midclavicular line, and lies subcutaneously at this level. B. Position of the patient and ultrasound
transducer during the sagittal oblique scan. R, rib.
Pectoralis major Serratus plane Subcutaneous fat
rior
s ante Serratu
Serratu R6 s anteri
or
R7
Pleura Intercostal muscles
Lateral
R6
Cranial R7
FIGURE 10-30 ■ Sagittal oblique sonogram of the lateral chest FIGURE 10-31 ■ Figure showing the position of the patient and
wall acquired during Step IV of the sagittal scan sequence. Note the ultrasound transducer during Step V of the sagittal scan sequence
lower slips of the serratus anterior muscle are much more bulky than near the posterior axillary line. The inset sagittal sonogram shows
the upper slips. R, rib. the plane of ultrasound imaging (dark green) over the sixth intercos-
tal space. R, rib.
contralateral side. The ipsilateral arm is also abducted (outwards). The medial end of the transducer is also
(Fig. 10-39) and flexed at the elbow, and the hand is pivoted slightly downwards (inferiorly) such that it
tucked behind the head. A linear ultrasound trans- is directed towards the midsection of the sternum
ducer (13–15 MHz) is positioned in the transverse (Fig. 10-39). The ultrasound image acquired is a
orientation slightly above and medial to the coracoid transverse oblique view of the underlying thoracic
process with its orientation marker directed laterally wall anatomy (Figs. 10-40 to 10-45).
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4. Sonoanatomy of the thoracic wall: midsection of the clavicle (Figs. 10-18 to 10-21) or
a. Sagittal sonoanatomy: The sagittal sonoanatomy of inferolaterally from the midsection of the clavicle to
the thoracic wall changes as one moves the ultrasound the lateral chest wall (Figs. 10-22 to 10-33).
transducer from a medial-to-lateral direction near the i. Sonoanatomy with Step I of the sagittal scan
sequence: With the upper end of the ultrasound
transducer positioned medial to the mid-point of
the clavicle during the sagittal scan one is able
Latissimus dorsi
to visualize the anechoic and compressible axil-
lary vein lying immediately below the clavicle
Serratus anterior
and between the pectoralis major and subclavius
R6
muscle anteriorly and the upper slips of the ser-
ratus anterior muscle, overlying the second rib,
R7
posteriorly (Fig. 10-18). This represents the cos-
Pleura toclavicular space,14–16 through which the neuro-
vascular structures pass from the neck to the arm
Lateral
and vice versa. Distally the clavicular head of the
Cranial
pectoralis major muscle and upper border of the
pectoralis minor muscle are seen lying anterior
to the serratus anterior muscle and the second
FIGURE 10-32 ■ Sagittal oblique sonogram of the lateral chest intercostal space with the second and third ribs,
wall acquired during Step V of the sagittal scan sequence. Note intervening intercostal muscles, the hyperechoic
the thick serratus anterior muscle overlying the sixth and seventh
pleura, and lung (Fig. 10-18). The space between
ribs and the inferolateral aspect of the latissimus dorsi muscle lying
superficial to the serratus anterior muscle caudally. The myofascial
the undersurface of the clavicle and subclavius
plane between the latissimus dorsi and serratus anterior muscle is the muscle cranially, the pectoral muscles anteriorly,
serratus anterior plane posteriorly. and the second and third ribs with the serratus
Thoracodorsal artery
Latissimus dorsi
R6 Serratus anterior
R7
Pleura Lateral
Cranial
A Power Doppler sonogram
FIGURE 10-33 ■ A. Doppler ultrasound demonstrating the thoracodorsal artery in the myofascial plane between the latissimus dorsi and
the serratus anterior muscle close to the posterior axillary line. The thoracodorsal nerve accompanies the thoracodorsal artery at this level,
but is more difficult to delineate with current ultrasound technology. B. Position of the patient and ultrasound transducer during the sagittal
scan. R, rib.
ch10.indd 233 23-08-2017 18:23:05

Serratus plane
Intercostal muscles
Serratus anterior
Lung
Pleura
Lateral
Cranial
FIGURE 10-34 ■ Figure showing the position of the patient and FIGURE 10-35 ■ Coronal sonogram of the lateral chest wall show-
ultrasound transducer during a coronal scan of the lateral chest wall ing the serratus anterior muscle overlying the ribs. Note the serratus
for a serratus plane block. Note the orientation marker of the ultra- anterior muscle is relatively thick at this location.
sound transducer is directed cranially.
Latissimus dorsi Serratus plane

Thoracodorsal artery
anterior
Serratus
Rib
Rib
Pleura Intercostal
muscles
B Position: Patient and Transducer
A Coronal sonogram
Lateral
Cranial
FIGURE 10-36 ■ A. Coronal sonogram of the lateral chest wall with the transducer positioned slightly posterior to that in Fig. 10-35. The
inferolateral border of the latissimus dorsi muscle is now seen lying superficial to the serratus anterior muscle at the cranial end of the sonogram.
The thoracodorsal artery is also seen lying superficial to the serratus anterior muscle in this sonogram. B. Position of the patient and ultrasound
transducer during the coronal scan.
anterior muscle posteriorly is the medial infra- minor muscle (Figs. 10-5 and 10-18). Slightly
clavicular fossa (MICF, Fig. 10-18).15,16 The lateral to the earlier position (ie, at the midclavic-
clavipectoral fascia is seen as a hyperechoic lin- ular point), the axillary artery is visualized as an
ear structure interposed between the subclavius anechoic and pulsatile structure within the cos-
muscle and the upper border of the pectoralis toclavicular space (Fig. 10-19).15,16 The cephalic
ch10.indd 234 23-08-2017 18:23:14

Thoracodorsal artery Serratus plane

Subcutaneous fat
Latissimus dorsi
Latissimus dorsi
Teres major or
s anteri
Serratus anterior Serratu
Teres major
Rib
terior Rib
tus an
Rib Serra
Rib
Pleura
Lateral Pleura Lateral
Cranial Cranial
FIGURE 10-37 ■ Color Doppler sonogram showing the thora- FIGURE 10-38 ■ Coronal sonogram of the lateral chest wall near
codorsal artery in the myofascial plane between the latissimus dorsi the posterior axillary line showing the serratus plane between the
and serratus anterior muscle along the lateral chest wall near the pos- latissimus dorsi and the serratus anterior muscle. Note the position
terior axillary line. of the teres major muscle at the cranial end of the sonogram. The
myofascial plane between the latissimus dorsi and serratus anterior
muscle at this level is our target for local anesthetic injection during
a serratus plane block.
of the pectoralis minor muscle (Fig. 10-20). The

TAA in most cases originates from the axillary
artery deep to the pectoralis minor muscles, but it
may also originate above the medial border of the
pectoralis minor muscle (Fig. 10-21). Deep to the
serratus anterior muscle, outlines of the anterior
intercostal space with the hyperechoic parietal
pleura are clearly delineated (Fig. 10-20). The
arrangement of the brachial plexus in the sagittal
sonogram is also consistent with the lateral cord
lying anterior to the medial cord and the poste-
rior cord lying superior to the lateral and medial
cord (Fig. 10-20).15,16
FIGURE 10-39 ■ Figure showing the position of the patient and Sonoanatomy with Step II of the sagittal scan
ii.
ultrasound transducer during a transverse oblique scan of the a nterior sequence: During Step II of the sagittal scan
chest wall for a PECS block. Note the medial end of the ultrasound sequence, the ultrasound transducer is placed
transducer has been pivoted slightly caudally for the scan. over the third intercostal space (Fig. 10-22).
The third and fourth ribs with the intercostal
vein joins the axillary vein from above within the muscles, pleura, and lung are clearly delineated
MICF (Fig. 10-19). Lateral to the midpoint of the (Fig. 10-23). The pectoralis major and minor
clavicle the cords of the brachial plexus are seen muscles overlie the serratus anterior muscle, and
as multiple round-to-oval structures, each with a the latter is closely attached to the adjoining ribs
hyperechoic rim, within the costoclavicular space (Fig. 10-23). The myofascial plane between the
and lying superior to the pulsatile axillary artery pectoralis major and minor muscles at the level
(Fig. 10-20). The axillary vein is located caudal of the fourth rib may be referred to as the PECS-I
to the axillary artery (Fig. 10-20). Branches of plane (Fig. 10-24) because it is the target site for
the TAA are also seen close to the upper border local anesthetic injection during a PECS-I block.1
ch10.indd 235 23-08-2017 18:23:22

PECS-I plane Pectoral branch of

Pectoralis major
Pectoralis minor
Axillary
vein

Pleura
Anterior
Serratus anterior
A Transverse oblique sonogram
Lateral
FIGURE 10-40 ■ A. Transverse oblique sonogram of the anterior chest wall showing the myofascial plane between the pectoralis major and
minor muscles (PECS-I plane). The pectoral branch of the thoracoacromial artery is seen as a hypoechoic and pulsatile structure within the
PECS-I plane. B. Position of the patient and ultrasound transducer during the transverse oblique scan.
Pectoral branch of
PECS-I plane thoracoacromial artery
Pectoralis major
Pectoralis minor
Axillary terior
vein Serratus an
Rib
Anterior
A Transverse oblique sonogram
Lateral
FIGURE 10-41 ■ A. Power Doppler sonogram showing the pectoral branch of the thoracoacromial artery in the myofascial plane between
the pectoralis major and minor muscles (PECS-I plane). B. Position of the patient and ultrasound transducer during the scan.
Sonoanatomy with Step III of the sagittal scan

iii. earlier), the pectoralis major and minor muscles
sequence: During Step III of the sagittal scan overlie the serratus anterior muscle (Figs. 10-26
sequence, the ultrasound transducer is placed and 10-27). The myofascial plane between the
over the fourth intercostal space (Fig. 10-25) and pectoralis minor and the serratus anterior muscle
the fourth and fifth ribs are clearly visualized is the target site for local anesthetic injection dur-
(Fig. 10-26). As seen during Step II (described ing a PECS-II injection.2 The inferior border of
ch10.indd 236 23-08-2017 18:23:30

Pectoral branches of the

Pectoral branch of PECS-I plane

PECS-I plane
the TAA
Pectoralis major
Pectoralis major
Cords of the Thoracoacromial Pectoralis minor

brachial plexus Pectoralis minor artery
TAA
Axillary Axillary vein
Axillary vein artery
Axillary
artery r
nterio Pleura
rior Cords of the tus a
te Serra
s an Rib Brachial plexus
ratu Anterior
Ser Anterior
Lateral
Lateral
FIGURE 10-42 ■ Transverse oblique sonogram of the anterior FIGURE 10-43 ■ Transverse oblique sonogram of the anterior
chest wall showing the PECS-I plane and the origin of the thora- chest wall showing the thoracoacromial artery lying deep to the pec-
coacromial artery (TAA) from the anterior wall of the axillary artery toralis minor muscle, and its pectoral branches in the PECS-I plane.
(second part). The cords of the brachial plexus are seen as a cluster
of nerves lying lateral to the axillary artery in this sonogram.
Sonoanatomy with Step IV of the sagittal scan

iv.
sequence: During Step IV of the sagittal scan
Bifurcation of the
sequence, the ultrasound transducer overlies the
thoracoacromial artery fifth intercostal space along the lateral chest wall
(Fig. 10-28) and at the level of the anterior axil-
Pectoralis major
lary line. With the lower border of the pectoralis
minor muscle having attached to the fifth rib, only
the pectoralis major and serratus anterior muscles
Cords of the are seen overlying the fifth rib (Fig. 10-29), and
brachial plexus Axillary vein
Axillary
only the serratus anterior muscle overlies the
artery
terior
sixth rib (Fig. 10-29). The lateral branches of
us an
Serrat the intercostal nerves pierce the intercostal and
serratus anterior muscle complex and emerge to
Anterior Rib
Pleura
lie subcutaneously at this location and along the
Lateral
midaxillary line (Fig. 10-6). Slightly more infer-
FIGURE 10-44 ■ Transverse oblique sonogram of the anterior olaterally, the serratus anterior muscle becomes
chest wall, above the superior border of the pectoralis minor mus- thicker and is the only muscle overlying the lat-
cle, showing the bifurcation of the thoracoacromial artery. Note the eral chest wall (Fig. 10-30).
pectoralis minor muscle is not visualized in this ultrasound window Sonoanatomy with Step V of the sagittal scan
v.
and the neurovascular structures lie directly on the serratus anterior sequence: During Step V of the sagittal scan
muscle at this site.
sequence, the transducer overlies the sixth inter-
costal space close to the posterior axillary line
(Fig. 10-31). The inferolateral aspect of the latis-
the pectoralis minor muscle can also be defined simus dorsi muscle overlies the thick serratus
at the level of the fifth rib (Fig. 10-27). Distal anterior muscle (Fig. 10-32), and the thoracodor-
to that and at the level of the sixth rib there is sal artery lies in the myofascial plane between
a hyperechoic layer of connective tissue which the latissimus dorsi and serratus anterior muscle
probably represents the Gerdy’s ligament (sus- (Fig. 10-33). The thoracodorsal nerve, which
pensory ligament of the axilla) fusing with the innervates the latissimus dorsi muscle, accompa-
axillary fascia (Fig. 10-5). nies the thoracodorsal artery (Fig. 10-3).
ch10.indd 237 23-08-2017 18:23:35

Thoracoacromial artery
(bifurcation) PECS-I plane Pectoralis major
Pectoralis minor
AV
AA

A Color Doppler sonogram Anterior
Lateral
FIGURE 10-45 ■ A. Color Doppler sonogram showing the bifurcation of the thoracoacromial artery near the upper border of the pectoralis
minor muscle. B. Position of the patient and ultrasound transducer during the transverse oblique scan.
b. Sonoanatomy of the thoracic wall: Coronal sono- vein (Fig. 10-42). The cords of the brachial plexus
anatomy: During the coronal scan (Fig. 10-34) the are clustered together lateral to the axillary artery
ultrasound transducer is placed along the lateral (Fig. 10-42). The origin of the TAA from the axil-
chest wall and near the posterior–axillary line. The lary artery (Figs. 10-42 and 10-43) and its bifurcation
serratus anterior muscle is seen overlying the ribs (Figs. 10-44 and 10-45) can also be visualized near
(Fig. 10-35). As one gently moves the transducer the upper border of the pectoralis minor muscle. The
posteriorly, the inferolateral border of the latissimus TAA is an important anatomical landmark because
dorsi muscle is seen lying superficial to the serratus the LPN, MPN, and ansa pectoralis are all closely
anterior muscle at the cranial end of the sonogram related to the artery (Fig. 10-11).8,9
(Fig. 10-36). The thoracodorsal artery is consistently
visualized in the serratus plane between the latissi-
mus dorsi and serratus anterior muscle (Figs. 10-36
Clinical Pearls
and 10-37). The myofascial plane between the latis- 1. Locating the second rib under the clavicle on the sagit-
simus dorsi and the serratus anterior muscle at the tal scan (Figs. 10-15 and 10-18) is a useful sonographic
level of the fifth rib (Fig. 10-38) is the target site for landmark for counting the ribs along the anterior and
local anesthetic injection during a SPB.3 anterolateral chest wall.
c. Sonoanatomy of the thoracic wall: Transverse 2. Due to the complex spinal origin and anatomical arrange-
sonoanatomy: On the transverse sonogram the pec- ment of the pectoral nerves (noted earlier), a single injec-
toralis major and minor muscles lie anterior to the tion of local anesthetic into the myofascial plane between
axillary vein, serratus anterior muscle, and the pleura the pectoralis major and minor muscles (PECS-I plane)
(Fig. 10-40) or the third to fourth ribs (Fig. 10-40) is unlikely to consistently block all the pectoral nerves or
medially. The pectoral branch of the TAA lies in the the “subpectoral plexus” of nerves. Cadaver data suggest
myofascial plane between the pectoral major and that a 10-mL injection at three sites: (a) deep and lateral
minor muscles (Figs. 10-40 and 10-41). With the aspect of the pectoralis minor muscle (3.3 mL), (b) in
transducer positioned slightly lateral to the earlier between the pectoralis major and minor muscle (3.3 mL),
position, the axillary artery is also visualized deep and (c) superficial to the posterior fascia of the pectora-
to the pectoral muscles and lateral to the axillary lis major muscle (3.4 mL), is adequate in affecting all
ch10.indd 238 23-08-2017 18:23:39

the pectoral nerves.17 However, this observation has not 6. Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS,
been clinically validated, and there are no data evaluat- De CR. Surgical anatomy of the pectoral nerves and the pectoral
musculature. Clin Anat. 2012;25:559–575.
ing pectoral nerve block dynamics after a PECS-I and or
7. Bremner-Smith AT, Unwin AJ, Williams WW. Sensory
PECS-II block. Future research in this area is warranted.
pathways in the spinal accessory nerve. J Bone Joint Surg Br.
3. Age-related changes in musculoskeletal structures18 can 1999;81:226–228.
make it difficult to accurately define the PECS-I plane in 8. Macchi V, Tiengo C, Porzionato A, Parenti A, Stecco C,
the elderly. Doppler (Color or Power) ultrasound helps Mazzoleni F, De CR. Medial and lateral pectoral nerves: course
locate the pectoral branch of the TAA (Fig. 10-41) and and branches. Clin Anat. 2007;20:157–162.
9. Kg P, K S. Anatomical study of pectoral nerves and its implica-
facilitates accurate injection of local anesthetic into the
tions in surgery. J Clin Diagn Res. 2014;8:AC01–AC05.
PECS-I plane during a PECS-I block.
10. Lee KS. Anatomic variation of the spinal origins of lateral and
4. Doppler ultrasound can also be used to locate the thora- medial pectoral nerves. Clin Anat. 2007;20:915–918.
codorsal artery in the serratus plane during a SPB. 11. David S, Balaguer T, Baque P, Peretti F, Valla M, Lebreton E,
5. A SPB affects the lateral cutaneous branches of the ipsi- Chignon-Sicard B. The anatomy of the pectoral nerves and its
lateral T2 to T9 intercostal nerves and possibly also the significance in breast augmentation, axillary dissection and
pectoral muscle flaps. J Plast Reconst Aesthet Surg. 2012;
long thoracic and thoracodorsal nerves.3,4 However, it
65:1193–1198.
does not affect the anterior cutaneous branch of the main
12. Aszmann OC, Rab M, Kamolz L, Frey M. The anatomy of the
intercostal nerve, and therefore the anteromedial aspect of pectoral nerves and their significance in brachial plexus recon-
the thorax, or the breast in females, is spared by an SPB. struction. J Hand Surg Am. 2000;25:942–947.
6. The long thoracic and thoracodorsal nerve may be anes- 13. Jaspars JJ, Posma AN, van Immerseel AA, Gittenberger-de
thetized by an SPB, but their role in afferent nociception Groot AC. The cutaneous innervation of the female breast and
nipple-areola complex: implications for surgery. Br J Plast
after major breast or thoracic surgery is still not known.
Surg. 1997;50:249–259.
14. Demondion X, Herbinet P, Boutry N, Fontaine C, Francke JP,
References Cotten A. Sonographic mapping of the normal brachial plexus.
AJNR Am J Neuroradiol. 2003;24:1303–1309.
1. Blanco R. The ‘pecs block’: a novel technique for providing 15. Karmakar MK, Sala-Blanch X, Songthamwat B, Tsui BC.
analgesia after breast surgery. Anaesthesia. 2011;66:847–848. Benefits of the costoclavicular space for ultrasound-guided

2. Blanco R, Fajardo M, Parras MT. Ultrasound description of infraclavicular brachial plexus block: description of a costocla-
Pecs II (modified Pecs I): a novel approach to breast surgery. vicular approach. Reg Anesth Pain Med. 2015;40:287–288.
Rev Esp Anestesiol Reanim. 2012;59:470–475. 16. Sala-Blanch X, Reina MA, Pangthipampai P, Karmakar MK.
3. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus Anatomic basis for brachial plexus block at the costoclavicu-
plane block: a novel ultrasound-guided thoracic wall nerve lar space: a cadaver anatomic study. Reg Anesth Pain Med.
block. Anaesthesia. 2013;68:1107–1113. 2016;41(3):387–391.
4. Blanco R. Thoracic interfascial nerve blocks: PECS (I and II) 17. Desroches J, Grabs U, Grabs D. Selective ultrasound guided
and serratus plane block, musculoskeletal ultrasound for regional pectoral nerve targeting in breast augmentation: How to spare
anaesthesia and pain medicine. In: Karmakar MK, ed. 2nd ed. the brachial plexus cords? Clin Anat. 2013;26(1):49–55.
Hong Kong: Department of Anaesthesia and Intensive Care, The 18. Li X, Karmakar MK, Lee A, Kwok WH, Critchley LA,
Chinese University of Hong Kong; 2016:377–82. Gin T. Quantitative evaluation of the echo intensity of the
5. Loukas M, Hullett J, Louis RG Jr., Holdman S, Holdman D. median nerve and flexor muscles of the forearm in the young
The gross anatomy of the extrathoracic course of the intercosto- and the elderly. Br J Radiol. 2012;85:e140–e145.
brachial nerve. Clin Anat. 2006;19:106–111.
ch10.indd 239 23-08-2017 18:23:39

Chapter 11 Thoracic Paravertebral Block
Introduction by the vertebral body, intervertebral disc, and the interverte-

bral foramen with its contents (Fig. 11-1).21,23 The superior
Thoracic paravertebral block (TPVB) is the technique of
costotransverse ligament (SCTL), which extends from the
injecting local anesthetic alongside the thoracic vertebral
lower border of the transverse process above to the upper
body close to where the spinal nerves emerge from the inter-
border of the transverse process below (Figs. 11-2 and 11-4),
vertebral foramen. This produces unilateral (ipsilateral), seg-
forms the posterior wall of the TPVS. Also interposed
mental, somatic, and sympathetic nerve blockade in multiple
between two transverse processes is the intertransverse liga-
contiguous thoracic dermatomes,1,2 which is effective for
ment (Figs. 11-2 and 11-4). The SCTL is continuous laterally
managing acute and chronic pain of unilateral origin from
the thorax and abdomen.2 TPVB can also be used for surgical
anesthesia in patients undergoing inguinal herniorrhaphy3 and Transverse process
Neck of rip
breast surgery4–6 with improved postoperative outcomes.2,5
Extrapleural
TPVB is traditionally performed using surface anatomical Endothoracic compartment
fascia
landmarks.2 Recently there has been an increase in interest Subendothoracic
in the use of ultrasound for peripheral nerve blocks,7–9 includ- PLEURA compartment
Visceral
Superior costotransverse
ing TPVB.10–18 However, published data on ultrasound-guided Parietal
ligament
(USG) TPVB are limited.10–20 This chapter describes the sono- Subserous Lateral costotransverse
fascia ligament
anatomy relevant for USG TPVB.
Intertransverse
Interpleural
ligament
space
Gross Anatomy Lung Paraspinal muscle
The thoracic paravertebral space (TPVS) is a wedge-shaped

space2,21 that lies on either side of the vertebral column (Fig.
11-1). It is wider on the left than on the right.22 The parietal FIGURE 11-2 ■ Sagittal anatomy of the thoracic paravertebral
pleura forms the anterolateral boundary. The base is formed region.
Esophagus
Subserous
fascia Thoracic duct
PLEURA Azygos
Visceral vein Descending aorta
Endothoracic Parietal Sympathetic chain
fascia
Interpleural
space
Extrapleural
Left compartment
Right lung
lung
Subendothoracic
compartment
Intercostal
nerve
Posterior
primary rami
Iternal intercostal membrane
FIGURE 11-1 ■ Transverse anatomy of the thoracic paravertebral region.
240
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Chapter 11 / Sonoanatomy Relevant for Thoracic Paraverebral Block n 241
with the internal intercostal membrane, which is the medial PLEURA:

Parietal
extension of the internal intercostal muscle, medial to the Interpleural space
Subserous fascia Visceral pleura
angle of the rib (Fig. 11-4). The apex of the TPVS is continu-
ous with the posterior intercostal space lateral to the tips of Subendothoracic space
the transverse processes (Fig. 11-4).21,23 Endothoracic fascia

Interposed between the parietal pleura anteriorly and the
superior costotransverse ligament posteriorly is a fibroelastic Hemiazygos vein
structure,24 the “endothoracic fascia”25–30 (Figs. 11-1 and 11-2),
Anterior
which is the deep fascia of the thorax2,25–27 and lines the inter- longitudinal
nal aspect of the thoracic cage (Figs. 11-5 and 11-6).24–30 ligament
The presence of the endothoracic fascia in the TPVS was
Descending
aorta
Lateral costotransverse Sympathetic

ligament
trunk Thoracic
Azygos duct
Intercostal vein,
Superior costotransverse vein
ligament artery and nerve
Intertransverse
ligament
FIGURE 11-5 ■ The endothoracic fascia and its anatomical

Rib relationship to the thoracic paravertebral space. Note the fascial
Transverse
process
compartments and the location of the neurovascular structures in
Anterior
Articular process
Radiate longitudinal relation to the endothoracic fascia.
ligament ligament
FIGURE 11-3 ■ Paravertebral ligaments relevant for thoracic para-

vertebral block.
Thoracic paravertebral space
Superior costotransverse ligament
Intertransverse ligament
Costotransverse ligament
Lateral costotransverse ligament
Internal intercostal muscle

Internal intercostal membrane
FIGURE 11-4 ■ Anatomy of the thoracic paravertebral region showing the various paravertebral ligaments and their anatomical relationship
to the thoracic paravertebral space.
ch11.indd 241 23-08-2017 18:30:05

242 n Chapter 11 / Sonoanatomy Relevant for Thoracic Paraverebral Block
Clavicle T1 Transverse process
1st Rib Endothoracic fascia Aorta

ligament
(2) VB
Lateral costotransverse
ligament
(3) Lung
Intercostal nerve Costotransverse
junction
and vessels
(4)
Parietal pleura Rib
(5) Subendothoracic space
(6) Subserous fascia Lamina

Spinous
(7) Costodiaphragmatic process Transverse
Central tendon of process
recess
diaphragm
Psoas muscle
FIGURE 11-7 ■ Transverse CT of the thoracic spine showing the ana-

FIGURE 11-6 ■ Paravertebral sagittal section of the thorax show- tomical relationship of the transverse process, rib, and the costotrans-
ing how the endothoracic fascia lines the internal aspect of the tho- verse junction to the thoracic paravertebral space. VB, vertebral body.
racic cage.
until recently ignored in the paravertebral literature. We have and prevertebral space.2,26,27,29 The cranial extension of the TPVS
drawn attention to the presence of the endothoracic fascia in is still not defined, but we have observed direct paravertebral
the TPVS27 and proposed that it may play a role in explain- spread of radio-opaque contrast medium from the thoracic to
ing the variable expressions of a TPVB.27 In the paraverte- the cervical region (unpublished data) indicating that there is
bral location, the endothoracic fascia is loosely applied to a direct anatomical continuity between the thoracic and cer-
the ribs23 (Fig. 11-2) and fuses medially with the periosteum vical paravertebral regions. Ipsilateral Horner syndrome after
at the midpoint of the vertebral body28 (Fig. 11-1). There is thoracic paravertebral injections has also been reported.29,36,39,40
an intervening layer of loose areolar connective tissue, “the The anatomical pathway for cranial spread of an injectate from
subserous fascia,”25–28 between the parietal pleura and the the thoracic to the cervical paravertebral space is still not clear.
endothoracic fascia (Figs. 11-1 and 11-2). The endothoracic The caudal boundary of the TPVS is formed by the ori-
fascia therefore divides the TPVS into two potential fascial gin of the psoas major muscle,41 and inferior (lumbar) spread
compartments,30 the anterior “extrapleural paravertebral com- through the TPVS is thought to be unlikely.41 Ipsilateral lum-
partment,” and the posterior “subendothoracic paravertebral bar spinal nerves are also occasionally involved after a lower
compartment” (Figs. 11-1 and 11-2).2,27,30 The TPVS contains thoracic paravertebral injection1,42 Saito and colleagues have
fatty tissue2,23,24 within which lie the intercostal (spinal) nerve, demonstrated ipsilateral thoracolumbar spread of colored
the dorsal ramus, intercostal vessels, rami communicantes, dye in cadavers.43 We have also reported ipsilateral thoraco-
and anteriorly the sympathetic chain (Figs. 11-1 and 11-5).2,23 lumbar anesthesia and radiological spread of contrast below
The spinal nerves in the TPVS are segmented into small bun- the diaphragm.44 These observations challenge the concept
dles lying freely among the fat and devoid of a fascial sheath, of lumbar nerve root sparing following TPVB.41 The exact
which make them susceptible to local anesthetic block.31 The mechanism for the ipsilateral thoracolumbar spread of local
intercostal nerve and vessels are located behind the endotho- anesthetic or contrast medium is not clear, but we have pro-
racic fascia,2,30,32,33 and the sympathetic trunk is located ante- posed that it occurs via the subendothoracic fascial compart-
rior to it2,28,30,33 in the TPVS (Figs. 11-1 and 11-5). ment44 to the retroperitoneal space anterior to the psoas major
and quadratus lumborum muscle where the ilioinguinal and
iliohypogastric nerves are located (Fig. 4-50).44
Communications of the Thoracic
Paravertebral Space
Computed Tomography Anatomy of the
The TPVS is continuous with the epidural space medially via
the intervertebral foramen,23,34–36 the intercostal space later-
Thoracic Paravertebral Region
ally,26,28,31,34,35,37,38 and the contralateral TPVS via the epidural23 Figs. 11-7 to 11-10.
ch11.indd 242 23-08-2017 18:30:11

Magnetic Resonance Imaging

Anatomy of the Thoracic Paravertebral
Region
Figs. 11-11 to 11-14.
Aorta
SCTL
TP
Rib
Aorta TPVS
TP
VB
Rib
IVF
Paraspinal
TPVS CTJ muscle
Lung Apex of TP
TPVS
Rib
Spinous Transverse
Lamina
process process
FIGURE 11-8 ■ Transverse CT of the thoracic spine showing the FIGURE 11-10 ■ Sagittal CT of the thorax through the thoracic
anatomical relationship of the vertebral body (VB) and transverse paravertebral space (TPVS). Note the anatomical relationship of the
process to the thoracic paravertebral space (TPVS). IVF, interver- neck of the rib to the transverse process (TP) and the costotransverse
tebral foramen. junction (CTJ). SCTL, superior costotransverse ligament.
Aorta
Aorta
VB
IVF VB
Lung Pleura
TPVS
Lung Pleura
Rib Lung
TP TP
Rib
Lamina Rib
PSM
Articular SCTL
Spinous
process
process
FIGURE 11-9 ■ Transverse CT of the thoracic spine showing the FIGURE 11-11 ■ Transverse T2-weighted MRI of the thoracic
anatomical relationship of the inferior articular process of the verte- spine showing the anatomical relationship of the transverse process,
bra to the intervertebral foramen (IVF) and the thoracic paravertebral rib, and the costotransverse junction to the thoracic paravertebral
space (TPVS). VB, vertebral body; SCTL, superior costotransverse space. VB, vertebral body; TP, transverse process; PSM, paraspinal
ligament. muscle.
ch11.indd 243 23-08-2017 18:30:20

Aorta
VB
TPVS
Pleura TP
Lung Lung
TP PSM
Pleura
Lamina PSM Rib SCTL
SCTL TP
Neurovascular
bundle
Spinous process
TP
FIGURE 11-12 ■ Transverse T2-weighted MRI of the thoracic
spine showing the anatomical relationship of the vertebral body Lung
(VB) and transverse process (TP) to the thoracic paravertebral space TPVS
(TPVS). PSM, paraspinal muscle; SCTL, superior costotransverse
ligament.
FIGURE 11-14 ■ Sagittal T2-weighted MRI of the thorax through

Aorta the thoracic paravertebral space (TPVS). Note the intercostal neuro-
vascular bundle in the TPVS. TP, transverse process; PSM, paraspi-
VB Spinal nerve
nal muscle; SCTL, superior costotransverse ligament.
root
IVF
TPVS Apex of TPVS
Lung Pleura
Lung (axial scan) or longitudinal (sagittal scan) axis with
the patient in the sitting (Fig. 11-15), lateral decubi-
PSM Articular
SP SCTL tus (Fig. 11-16), or prone position. The prone posi-
process
tion is useful in patients presenting for a chronic
pain procedure when fluoroscopy can also be used
in conjunction with ultrasound imaging. Currently
FIGURE 11-13 ■ Transverse T2-weighted MRI of the thoracic
there are no data demonstrating an optimal axis or
spine showing the anatomical relationship of the inferior articular
process of the vertebra to the intervertebral foramen (IVF) and the position for the ultrasound scan or the paravertebral
thoracic paravertebral space (TPVS). Note the spinal nerve root as it injection. It is often a matter of individual preference
exits the IVF. SP, spinous process; VB, vertebral body; PSM, para- and experience.
spinal muscles; SCTL, superior costotransverse ligament. b. Operator and ultrasound machine: The operator
sits or stands behind the patient, and the ultrasound
machine is placed directly in front on the contralat-
Sonoanatomy of the Thoracic eral side (Fig. 11-17) for an USG TPVB.
Paravertebral Region 2. Transducer selection: The transducer used for the ultra-
sound scan depends on the body habitus of the patient.
Ultrasound Scan Technique High-frequency ultrasound provides better resolution
1. Position: than low-frequency ultrasound, but its penetration is
a. Patient: An ultrasound scan of the thoracic para- poor. Moreover if one has to scan at a depth using high-
vertebral region can be performed in the transverse frequency ultrasound, then the field of vision is also
ch11.indd 244 23-08-2017 18:30:27

C7
Sagittal scan line
T1
T2
T3
FIGURE 11-15 ■ Transverse ultrasound scan of the thoracic FIGURE 11-17 ■ Figure demonstrating the ergonomics during an
paravertebral region with the patient in the sitting position. Note the ultrasound scan of the thoracic paravertebral region with the patient
position of the ultrasound transducer (linear) relative to the spine. in the right lateral position. Note a low-frequency curved array trans-
ducer is being used for the ultrasound scan.
Spine of Scapula
is not similar at all thoracic levels, and high-frequency
transducers are generally not suitable in the upper tho-
3 cm lateral racic region. Recently we have used a low-frequency
to midline curved array transducer (5–2 MHz) to perform a trans-
Sagittal scan line T4 verse scan of the thoracic paravertebral region (at all lev-
T5 els) with great success (Fig. 11-17, see details later).
3. Sonoanatomy:
a. Transverse sonoanatomy of the thoracic paraver-
tebral region:
A transverse scan of the thoracic paravertebral region
FIGURE 11-16 ■ Transverse ultrasound scan of the thoracic para- can be performed using a linear (high-frequency) or
vertebral region with the patient in the right lateral position. Note curved (low-frequency) array transducer. In slim
the position of the ultrasound (curved array) transducer relative to individuals a high-frequency linear array transducer
the spine. will suffice, but in those with a larger body habitus,
a curved array transducer is preferable. The high-
frequency linear array transducer is positioned lat-
significantly narrow. Under such circumstances it may eral to the thoracic spinous process at the target level
be preferable to use a low-frequency curved array trans- (Figs. 11-15 and 11-18). On a transverse sonogram
ducer (5–2 MHz) with a divergent beam and a wider field the paraspinal muscles are clearly delineated and lie
of vision. Published data suggest that a high-frequency superficial to the transverse process (Figs. 11-19 to
linear transducer (13–6 MHz) is frequently used for scan- 11-21). The transverse process is seen as a hyper-
ning the thoracic paravertebral region.10,11,14,18 This may echoic structure, anterior to which there is a dark
be because the transverse process, costotransverse liga- acoustic shadow that completely obscures the TPVS
ment, and the pleura in the midthoracic region are located (Figs. 11-19 and 11-20). Lateral to the transverse
at a relatively shallow depth and lend themselves to ideal process, the hyperechoic pleura that moves with res-
conditions for imaging with a high-frequency linear array piration and exhibits the typical “lung sliding sign,”45
transducer. However, ultrasound imaging of the TPVS which is the sonographic appearance of the pleural
ch11.indd 245 23-08-2017 18:30:35

Esophagus
Subserous
Thoracic duct
fascia PLEURA Azygos
Visceral Descending aorta
Endothoracic vein
fascia Parietal Sympathetic chain
Interpleural
space
Extrapleural
compartment
Right
lung
Subendothoracic
compartment
Intercostal
nerve
Posterior
US Transducer primary rami
Internal intercostal membrane
FIGURE 11-18 ■ Figure illustrating the orientation of the ultrasound transducer and how the ultrasound beam is insonated during a transverse
scan of the thoracic paravertebral region with a linear transducer. The TP (transverse process) usually casts an acoustic shadow (represented
in black), which obscures the ultrasound visibility of the thoracic paravertebral space.
Posterior
Paraspinal muscles
Internal intercostal
membrane TP
Lateral
Posterior
Lung
Medial Lateral
Apex of TPVS
Anterior
Pleura
Anterior
FIGURE 11-19 ■ Transverse sonogram of the right thoracic para- FIGURE 11-20 ■ Transverse sonogram of the left thoracic para-
vertebral region using a high-frequency linear transducer with the vertebral region using a high-frequency linear transducer with the
ultrasound beam being insonated over the transverse process. Note ultrasound beam being insonated over the transverse process. Note
how the acoustic shadow of the transverse process (TP) obscures the how the acoustic shadow of the transverse process (TP) obscures
thoracic paravertebral space (TPVS). The hypoechoic space poste- the TPVS. The hypoechoic space between the parietal pleura and
rior to the parietal pleura and anterolateral to the TP is the apex of the the internal intercostal membrane laterally represents the apex of the
TPVS, or the medial limit of the posterior intercostal space. TPVS, or the medial limit of the posterior intercostal space.
surfaces moving relative to each other within the tho- (Figs. 11-19 to 11-21), which is the medial extension
rax. Comet tail artifacts, which are reverberation arti- of the internal intercostal muscle and is continuous
facts, may also be seen deep to the pleura and within medially with the superior costotransverse ligament
the lung tissue, and are often synchronous with respi- (SCTL, Fig. 11-4). This hypoechoic space represents
ration.45 A hypoechoic space is also seen between the the medial limit of the posterior intercostal space or
parietal pleura and the internal intercostal membrane the apex of the TPVS, and the two communicate with
ch11.indd 246 23-08-2017 18:30:41

Superior articular process

PSM PSM SCTL Superior costal
Transverse process
facet
SCTL
TP TP
Rib
TPVS TPVS Position of transducer
1. Transverse view 2. Sagittal view VB
Inferior articular
process
TP
PSM
SCTL Lamina Inferior vertebral
notch
Spinous process Inferior articular
process
TP
Pleura
3. Coronal view 4. Slice planes
FIGURE 11-21 ■ A multiplanar 3-D view of the thoracic paraver- FIGURE 11-22 ■ Figure illustrating the osseous structures that are
tebral region with the reference marker placed immediately lateral insonated during a transverse ultrasound scan of the thoracic para-
to the transverse process and over the superior costotransverse liga- vertebral region through the thoracic intertransverse space and at the
ment (SCTL). Note how the three slice planes (red – transverse, level of the inferior articular process. Note the relationship of the
green – sagittal, and blue – coronal) are obtained. PSM, paraspinal inferior articular process to the inferior vertebral notch and the inter-
muscles; TPVS, thoracic paravertebral space; TP, transverse process. vertebral foramen. VB, vertebral body.
each other (Figs. 11-19 to 11-21). Therefore, local

anesthetic injected medially into the TPVS can often
be seen to spread laterally to distend this space; vice
versa, local anesthetic injected laterally into the pos-
Posterior intercostal
terior intercostal space can also spread medially to PSM
space Internal intercostal
Articular process Apex of TPVS membrane
the paravertebral space and is the basis of the inter-
SCTL
costal approach for USG TPVB10,18 where the needle
is inserted in the plane of the ultrasound beam from
a lateral-to-medial direction. From the scan position
described earlier (ie, over the transverse process), if Pleura
one now slides the transducer slightly cranially or Posterior Lung
caudally, it is possible to perform a transverse scan Medial Lateral

Intervertebral Outline of pleura
TPVS
of the paravertebral region with the ultrasound beam Anterior foramen medially
being insonated between the two transverse pro-

cesses (intertransverse space) and over the inferior
articular process medially (Fig. 11-22). The ultra- FIGURE 11-23 ■ Transverse sonogram of the left thoracic para-
vertebral region using a high-frequency linear transducer. The
sound signal is now not impeded by the transverse
ultrasound beam is being insonated through the intertransverse space
process or the costotransverse junction, and parts and at the level of the articular (inferior) process. Note the acoustic
of the parietal pleura and the “true” TPVS can be shadow of the transverse process is no longer visible and parts of the
faintly visualized (Fig. 11-23). However, one must thoracic paravertebral space (TPVS) and the anteromedial reflection
note that the inferior vertebral notch and the interver- of the pleura are now partly visible. The superior costotransverse
tebral foramen are located immediately anterior to ligament (SCTL), which forms the posterior border of the TPVS, is
also visible posteriorly, and it blends laterally with the internal inter-
the inferior articular process (Figs. 11-22 and 11-23).
costal membrane, which forms the posterior border of the posterior
The SCTL, which forms the posterior border of the intercostal space. The communication between the TPVS and the
TPVS, is also visible and it blends laterally with posterior intercostal space is also clearly delineated. PSM, paraspi-
the internal intercostal membrane, which forms the nal muscle.
ch11.indd 247 23-08-2017 18:30:46

posterior border of the posterior intercostal space

(Fig. 11-23). The communication between the TPVS
and the posterior intercostal space is also clearly
visualized (Figs. 11-19 and 11-23).
A low-frequency (5–2 MHz) curved array trans-
ducer (authors’ choice) can also be used to perform
a transverse scan of the thoracic paravertebral region
and USG TPVB. To the best of our knowledge there 2
are limited published data describing the use of a 3
1
low-frequency ultrasound transducer for sonogra- 4
phy during TPVB,17 and there are no published data
describing the detailed sonoanatomy of the thoracic
paravertebral region using a low-frequency curved
array transducer. Our preliminary experience is that
satisfactory ultrasound images of the paravertebral
region are obtained using a low-frequency trans-
ducer. Also the wide field of vision produced by the
divergent ultrasound beam is an added advantage
when compared to the narrow rectangular field of
view produced by a linear array transducer during
USG TPVB. Furthermore the ability to image at a
FIGURE 11-24 ■ The thoracic spine in the midthoracic region and
depth with a low-frequency curved array transducer the various transducer positions for a transverse scan of the thoracic
is an advantage in the upper thoracic region because paravertebral region using a low-frequency curved array transducer.
the thoracic paravertebral space is at a greater depth. Position 1 – midline over the spinous process, position 2 – at the
Using a curved array transducer the transverse scan level of the transverse process and rib, position 3 – at the level of
the transverse process, and position 4 – at the level of the articular
can be performed with the ultrasound beam being
process.
insonated at four different locations (Fig. 11-24): (1)
midline over the spinous process, (2) at the level of
the rib and costotransverse articulation/junction, (3)
at the level of the transverse process, and (4) at the
level of the articular process. Corresponding cadaver
anatomical sections are presented in Figs. 11-25 to Spinous process
11-27 to demonstrate the anatomy visualized during Rib
Transverse process Lamina
the ultrasound scan. CTJ
Each of these four ultrasound scan windows

produces a distinct sonogram reflecting the differ-
ent osseous and musculoskeletal structures that are
visualized in the sonograms. On a transverse sono-
gram in the midline (position 1, Fig. 11-24), the spi- Lung
nous process is visualized as a bright hyperechoic T4
dot with a corresponding acoustic shadow anteriorly
(Fig. 11-28). Due to the steep caudal angulation of
the thoracic spinous processes in the midthoracic
region, the spinous process that is visualized on the
FIGURE 11-25 ■ Cross-sectional cadaver anatomic section of the
sonogram arises from the vertebra above rather than
thoracic spine through the T4 vertebral body, transverse process, and
that from which the transverse process, lamina, and the rib corresponding to the level at which the transverse scan is
the articular process arise (Fig. 11-29). Because the performed in the midline (position 1 in Fig. 11-24). Note the costo-
spinous process and transverse process cast a large transverse junction (CTJ) on either side.
ch11.indd 248 23-08-2017 18:30:50

Transverse process Spinous

process Lamina
TPVS CTJ Rib TP
Posterior
Lung
Lateral
T3
FIGURE 11-28 ■ Median transverse scan of the thoracic spine
Eo
(midthoracic region) using a low-frequency curved array transducer
with the ultrasound beam being insonated over the spinous process
(position 1 in Fig. 11-24). Note the hyperechoic spinous process
thoracic spine through the T3 vertebral body and transverse process
with its acoustic shadow in the midline. The hyperechoic lamina and
corresponding to the level at which the transverse scan is performed
the posteriorly directed transverse process (TP) are also seen later-
at the level of the transverse process (position 3 in Fig. 11-24). CTJ,
ally on either side of the midline. The acoustic shadow of the SP, TP,
costotransverse junction; TPVS, thoracic paravertebral space; Eo,
and the lamina produces a sonographic pattern that resembles a “fly-
esophagus.
ing swan” (details in text) and completely obscures the spinal canal
and the paravertebral space.
Spinous process
Articular process
TPVS IVF Spinal nerve root
Lung
T4

thoracic spine through the T4 vertebral body and inferior articular
process of the vertebra corresponding to the level at which the trans-
FIGURE 11-29 ■ Figure illustrating the structures that are
verse scan is performed at the level of the articular process (posi-
insonated during a median transverse scan of the midthoracic spine.
tion 4 in Fig. 11-24). Note the position of the intervertebral foramen
Note the posteriorly directed transverse processes. Also due to the
(IVF) relative to the inferior articular process and the spinal nerve
acute caudal angulation of the thoracic spinous processes, the poste-
root as it exits the IVF. TPVS, thoracic paravertebral space.
rior elements of the vertebra (ie, the lamina and transverse process),
which are insonated, are from the vertebra one level below.
acoustic shadow, visualization of the paravertebral sign” due to its close resemblance to a swan in flight
anatomy is limited in this ultrasound scan window. (Fig. 11-30).
Also the acoustic shadow of the spinous process, With the ultrasound transducer positioned
lamina, transverse process, and ribs produce a sono- slightly laterally (position 2, Fig. 11-24), the hyper-
graphic pattern that we refer to as the “flying swan echoic outlines of the lamina, transverse process, and
ch11.indd 249 23-08-2017 18:30:58

the rib with their corresponding acoustic shadows costotransverse articulation, and the rib are identified,
are clearly delineated (Fig. 11-31). However, unlike one can gently slide or tilt the transducer caudally
the transverse process of the lumbar vertebra, which until the acoustic shadow of the rib is no longer visu-
are more or less at right angles to the vertebral body, alized (position 3, Fig. 11-24), and the hyperechoic
the transverse processes in the thoracic spine are outline of the lamina and transverse process with
directed posteriorly (Fig. 11-32), and this posterior their acoustic shadow are seen (Fig. 11-33). Lateral
angulation can be clearly delineated in the transverse to the transverse process, the hyperechoic pleura and
sonogram (Fig. 11-31). Once the transverse process, lung are visualized anteriorly, the thick hyperechoic
SP SP
Lamina
TP Lamina
AP
AP
TP
SC
SC
A B
VB VB
Lumbar vertebra (L2) Thoracic vertebra (T6)
FIGURE 11-30 ■ Figure demonstrating the outlines of the bony FIGURE 11-32 ■ Figure showing the difference in the size, shape,
elements that are insonated during a median transverse ultrasound and orientation of the transverse process (TP) of a thoracic and lum-
scan of the thoracic spine and how the acoustic shadow produced bar vertebra. Note how the TP of a thoracic vertebra is directed pos-
resembles a swan in flight (“flying swan sign”). teriorly. SP, spinous process; AP, articular process; TP, transverse
process; SC, spinal canal; VB, vertebral body.
Spinous process
Rib Posterior intercostal

TP space SCTL
Apex of TPVS TP Lamina
Lamina
Pleura
Lung
Posterior Posterior
Lateral Medial Lateral Medial
Anterior Anterior
FIGURE 11-31 ■ Paramedian transverse scan of the right thoracic FIGURE 11-33 ■ Paramedian transverse scan of the right thoracic
paravertebral region using a low-frequency curved array transducer paravertebral region using a low-frequency curved array transducer
with the ultrasound beam being insonated over the transverse pro- with the ultrasound beam being insonated over the transverse pro-
cess (TP) and the rib (position 2 in Fig. 11-24). Note the posteriorly cess (TP, position 3 in Fig. 11-24). Note the hyperechoic TP and
directed TP and how the acoustic shadow of the TP and rib com- its acoustic shadow. The apex of the thoracic paravertebral space
pletely obscures the underlying paravertebral anatomy. (TPVS), parietal pleura, and the superior costotransverse ligament
are seen lateral to the TP. SCTL, superior costotransverse ligament.
ch11.indd 250 23-08-2017 18:31:04

SCTL posteriorly, and the hypoechoic apical part of and the hyperechoic articular process (inferior) with
the TPVS is interposed between the two (Fig. 11-33). its acoustic shadow is seen medially (Fig. 11-34). As
If one now gently slides or tilts the ultrasound trans- in the ultrasound scan at the level of the transverse
ducer slightly caudally (position 4, Fig. 11-24), the process (Fig. 11-33), the SCTL, parietal pleura, lung,
acoustic shadow of the transverse process disappears, and the apical part of the paravertebral space are also
clearly delineated. However, because the acoustic
shadow of the transverse process is no longer pres-
ent, outlines of the true TPVS can now be visualized
(Fig. 11-34). Currently the majority of the published
Posterior data describing the use of a transverse scan for TPVB
Lateral Medial have used the ultrasound scan window at the level of
Anterior
the transverse process (position 3, Fig. 11-24),17,18,20
Internal intercostal SCTL
Apex of
membrane PSM
TPVS Articular process and there are limited published data describing the
use of the transverse ultrasound scan window at the
level of the articular process for TPVB. Because
Pleura there is less bony obstruction through the intertrans-
Lung
verse space and at the level of the articular process
IVF (position 4, Fig. 11-24), it is our preferred route for
imaging and needle insertion during an USG TPVB.
However, ultrasound visibility of the paravertebral
anatomy is more challenging in the upper thoracic
FIGURE 11-34 ■ Paramedian transverse scan of the right thoracic
region (Figs. 11-35 to 11-37). This may be related
paravertebral region using a low-frequency curved array transducer
with the ultrasound beam being insonated through the intertransverse to the increased depth to the paravertebral space and
space, that is, between two adjoining thoracic transverse processes anisotropy, from the pleura reflecting away from the
(position 4 in Fig. 11-24). Note the hyperechoic inferior articular paravertebral space, in the upper thoracic region (Fig.
process and its acoustic shadow medially, which obscures the under- 11-36). Despite some of these limitations, it is pos-
lying intervertebral foramen (IVF). As with the paramedian trans- sible to perform a transverse scan of the TPVS at all
verse scan at position 3, the apex of the thoracic paravertebral space
segments of the thoracic spine for TPVB (Figs. 11-35
(TPVS), parietal pleura, and the superior costotransverse ligament
(SCTL) are visualized laterally, but the area of the acoustic shadow to 11-44). We have successfully used this approach
is smaller in this ultrasound scan window (compare with Fig. 11-33). for both single-injection and multi-injection TPVB
PSM, paraspinal muscle. at all levels of the thoracic spine.
TP T1
CTJ Lamina
1st Rib
Posterior
Lateral
FIGURE 11-35 ■ Paramedian transverse scan of the right upper thoracic paravertebral region (T1 level), using a low-frequency curved array
transducer, with the ultrasound beam being insonated at the level of the transverse process (TP) and rib. CTJ, costotransverse junction.
ch11.indd 251 23-08-2017 18:31:08

Articular process
Apex of
TPVS
Pleura
Posterior
Lateral
FIGURE 11-36 ■ Paramedian transverse scan of the right upper thoracic paravertebral region (T1 level) using a low-frequency curved array
transducer, with the ultrasound beam being insonated at the level of the articular process. Note the pleura is not clearly delineated in the
transverse sonogram, and it is also located at a depth at this level (compare with that in the midthoracic region, Fig. 11-41). TPVS, thoracic
paravertebral space.
TP
Lamina
SCTL
Pleura
Lung
Posterior
Lateral
transducer with the ultrasound beam being insonated at the level of the transverse process (TP). Note the slight caudal orientation of the
ultrasound transducer. SCTL, superior costotransverse ligament.
Articular
process
Pleura SCTL TPVS
Lung
Posterior
Lateral
transducer with the ultrasound beam being insonated at the level of the articular process. Once again, note the slight caudal orientation of the
ultrasound transducer. SCTL, superior costotransverse ligament; TPVS, thoracic paravertebral space.
ch11.indd 252 23-08-2017 18:31:13

CTJ TP Lamina
SP
Rib
Posterior
Lateral
FIGURE 11-39 ■ Paramedian transverse scan of the right midthoracic paravertebral region using a low-frequency curved array transducer,
with the ultrasound beam being insonated at the level of the transverse process (TP) and rib. SP, spinous process; CTJ, costotransverse junction.
Apex of TP
SCTL Lamina
Pleura TPVS
Lung
Posterior
Lateral
FIGURE 11-40 ■ Paramedian transverse scan of the right midthoracic paravertebral region using a low-frequency curved array transducer,
with the ultrasound beam being insonated at the level of the transverse process (TP). SCTL, superior costotransverse ligament; TPVS, tho-
racic paravertebral space.
Articular
process
SCTL
Pleura TPVS
Lung IVF
Posterior
Lateral
FIGURE 11-41 ■ Paramedian transverse scan of the right midthoracic paravertebral region using a low-frequency curved array transducer
with the ultrasound beam being insonated at the level of the articular process and rib. IVF, intervertebral foramen; TPVS, thoracic paraverte-
bral space; SCTL, superior costotransverse ligament.
ch11.indd 253 23-08-2017 18:31:18

TP Spinous
process
Rib CTJ
Posterior
Lateral
FIGURE 11-42 ■ Paramedian transverse scan of the right lower thoracic paravertebral region using a low-frequency curved array trans-
ducer with the ultrasound beam being insonated at the level of the transverse process (TP) and rib. CTJ, costotransverse junction.
Spinous process
TP
Apex of
TPVS
Pleura
Posterior
Lateral
FIGURE 11-43 ■ Paramedian transverse scan of the right lower thoracic paravertebral region using a low-frequency curved array transducer
with the ultrasound beam being insonated at the level of the transverse process (TP). TPVS, thoracic paravertebral space.
Articular
process
SCTL
Pleura TPVS
Lung
IVF
Posterior
Lateral
FIGURE 11-44 ■ Paramedian transverse scan of the right lower thoracic paravertebral region using a low-frequency curved array transducer
with the ultrasound beam being insonated at the level of the articular process. IVF, intervertebral foramen; SCTL, superior costotransverse
ligament; TPVS, thoracic paravertebral space.
ch11.indd 254 23-08-2017 18:31:22

b. Sagittal sonoanatomy of the thoracic paraverte- muscles, and they cast an acoustic shadow anteriorly
bral region: (Fig. 11-48). In between the acoustic shadows of two
Published data on sagittal sonography of the thoracic adjacent transverse processes, an acoustic window
paravertebral region in the clinical setting are limited is produced by reflections from the SCTL and inter-
and have been described with the use of a high-fre- transverse ligaments, the paravertebral space and its
quency linear array transducer.11,15 During a sagittal contents, the parietal pleura, and lung tissue (in a
scan of the thoracic paravertebral region, the ultra- posterior-to-anterior direction) (Fig. 11-48).
sound transducer is positioned 2 to 3 cm lateral to Ultrasound visibility of the paravertebral struc-
the midline (paramedian) with its orientation marker tures is relatively poor in a true sagittal scan (Figs.
directed cranially (Figs. 11-45 to 11-47). On a sagittal 11-49 and 11-50), and this is true with both high-fre-
sonogram the transverse processes are seen as hyper- quency (Fig. 11-49) and low-frequency (Fig. 11-50)
echoic and rounded structures deep to the paraspinal transducers. This may be due to the loss of spatial
Neck of rib Transverse process
Extrapleural
Endothoracic compartment
fascia
Subendothoracic
PLEURA compartment
Visceral
Parietal Superior costotransverse
ligament
Subserous Lateral costotransverse
fascia ligament
Interpleural Intertransverse
space ligament
Lung Paraspinal muscle
FIGURE 11-45 ■ Figure demonstrating the position of the patient FIGURE 11-47 ■ Figure illustrating the various anatomical struc-
(lateral in this image) and how the ultrasound transducer is oriented tures that are insonated during a paramedian sagittal ultrasound scan
during a paramedian sagittal scan of the thoracic paravertebral region. of the thoracic paravertebral region.
Esophagus
Subserous
PLEURA Azygos
Visceral Descending aorta
vein
fascia
Interpleural
space
Extrapleural
Left compartment
Right lung
lung
Subendothoracic
compartment
Intercostal
nerve
Posterior
primary rami
Internal intercostal membrane US beam Ultrasound transducer
FIGURE 11-46 ■ Figure showing how the ultrasound beam is insonated during a paramedian sagittal scan of the thoracic paravertebral
region.
ch11.indd 255 23-08-2017 18:31:27

resolution at the depth at which the paravertebral

Posterior
structures are located. Also anisotropy from the ultra-
sound beam not being at right angles to the pleura
due to its anteromedial reflection close to the verte-
Paraspinal ligament bral bodies (Fig. 11-46) may play a part. Ultrasound
muscles visibility of the paravertebral structures can be
Cranial Pleura Caudal
improved by gently tilting the ultrasound transducer
laterally (ie, outward) during the sagittal scan (para-
TP TP
median sagittal oblique axis, Figs. 11-51 and 11-52).
This maneuver improves imaging by reducing the
Lung
Paravertebral space Anterior distance from the skin to pleura (reduced attenua-
tion), and the ultrasound beam is also more at right
FIGURE 11-48 ■ Paramedian sagittal sonogram of the thoracic
angles to the pleura (reduced anisotropy (Fig. 11-51).
paravertebral region. Note that although the superior costotransverse It is difficult to define an optimal angle of lateral tilt
ligament, pleura, and the paravertebral space are visible, they are not for the paramedian sagittal oblique scan, but in clini-
clearly delineated (compare with Fig. 11-52 from the same patient). cal practice we recommend that one should gently tilt
TP, transverse process.
SCTL TPVS SCTL

Pleura
TPVS
TP TP
TP TP
Lung Pleura
Posterior
Posterior
Cranial
Cranial
FIGURE 11-49 ■ Paramedian sagittal scan of the right midtho- FIGURE 11-50 ■ Paramedian sagittal scan of the right midthoracic
racic paravertebral region using a high-frequency linear transducer. paravertebral region using a low-frequency curvilinear transducer.
Note the paravertebral structures, including the parietal pleura and Note the paravertebral structures, including the parietal pleura and
the paravertebral space, are not clearly delineated in this image. TP, the paravertebral space, are not clearly delineated in the sagittal
transverse process; SCTL, superior costotransverse ligament; TPVS, sonogram. TP, transverse process; SCTL, superior costotransverse
thoracic paravertebral space. ligament; TPVS, thoracic paravertebral space.
Esophagus
Subserous
PLEURA Azygos
Visceral vein Descending aorta
fascia
Interpleural
space
Extrapleural
Left compartment
Right lung
lung
Subendothoracic
compartment
Intercostal
nerve
Posterior
primary rami
Internal intercostal membrane US beam Ultrasound transducer
FIGURE 11-51 ■ Figure illustrating how the ultrasound beam is insonated during a paramedian sagittal oblique scan of the thoracic para-
vertebral region.
ch11.indd 256 23-08-2017 18:31:34

the transducer outward (laterally) until the parietal The clinical implication is that one may unknow-
pleura is clearly visualized (Fig. 11-52). A pitfall of ingly perform a posterior intercostal injection instead
the lateral tilt maneuver is that one may see the same of a paravertebral injection, and depending on the
result if the ultrasound transducer is inadvertently approach used the potential for pleural puncture
manipulated or tilted too far laterally so that it is now may be greater with the intercostal injection. Also
insonating the rib and the posterior intercostal space segmental spread of anesthesia is limited with an
(Figs. 11-53 and 11-54) instead of the transverse pro- intercostal injection. Therefore, it is important to dif-
cess and the apical part of the paravertebral space. ferentiate the transverse process (Fig. 11-55) from a
Posterior
Posterior
intercostal space
Pleura
Intercostal
muscles
Paraspinal ligament
muscles Pleura Rib
Cranial Caudal
Lung
TP TP
Posterior
Lung Cranial
Paravertebral
space
Anterior FIGURE 11-54 ■ Paramedian sagittal oblique scan of the right mid-
thoracic paravertebral region using a low-frequency curved array
FIGURE 11-52 ■ Paramedian sagittal oblique sonogram of the tho- transducer whereby the ribs instead of the transverse processes are
racic paravertebral region. Note the pleura, superior costotransverse being insonated. Note the pleura is clearly delineated in this sonogram.
ligament, and the paravertebral space are now clearly delineated
(same patient as in Fig. 11-48). TP, transverse process.
Posterior Intercostal
intercostal space Pleura muscles
Rib
Rib
Lung 2. Sagittal plane

1. Transverse plane
Posterior
Cranial
FIGURE 11-53 ■ Paramedian sagittal oblique scan of the right

midthoracic paravertebral region, using a high-frequency linear 3. Coronal plane 4. Slice plane
transducer, whereby the ribs instead of the transverse process are
being insonated. Note the intercostal muscles (not the superior cos- FIGURE 11-55 ■ A multiplanar 3-D view of the thoracic paraver-
totransverse ligament), pleura, and the posterior intercostal space are tebral region with the reference marker, or “marker dot,” placed over
clearly delineated in this sonogram. the transverse process (TP). Note how the three slice planes (red –
transverse, green – sagittal, and blue – coronal) have been obtained
and how the superior costotransverse ligament (SCTL) is continuous
with the internal intercostal membrane (IICM) laterally in the coro-
nal plane. TPVS, thoracic paravertebral space; CTJ, costotransverse
junction.
ch11.indd 257 23-08-2017 18:31:39

rib (Fig. 11-56) in the sagittal sonogram of the tho-

racic paravertebral region (Fig. 11-57).
SCTL We are not aware of any published data validat-
SCTL
ing the sonoanatomy of the thoracic paravertebral
Rib Rib
region, but it is our experience that there is good
Pleura Apex of TPVS Pleura
Apex of TPVS correlation between structures that are visualized
1. Transverse plane 2. Sagittal plane
in a thoracic paravertebral sonogram and that in
TP corresponding anatomical sections, CT, and MRI

Rib images of the thoracic paravertebral region (Figs.
11-58 to Fig. 11-60). However, irrespective of the
TP
plane of ultrasound imaging, we still have not been
Pleura
able to delineate the intercostal nerve or its branches
Rib
3. Coronal plane 4. Slice plane with currently available ultrasound technology. The
intercostal blood vessels are more readily visualized
FIGURE 11-56 ■ A multiplanar 3-D view of the thoracic para- close to the inferior border of the transverse pro-
vertebral region in color (sepia tone) with the reference marker, cess using Color or Power Doppler ultrasound (Figs.
or “marker dot,” placed over the apex of the thoracic paravertebral
11-61 and 11-62).
space (TPVS). Note the hyperechoic pleura in the coronal plane.
SCTL, superior costotransverse ligament; TPVS, thoracic paraver-
tebral space; TP, transverse process.
A B C
Lamina
ILS LF SCTL SCTL

ES
Pleura TPVS Pleura
TP TP TP TP
Lamina Posterior Transverse process Transverse process
Cranial
ICM ICS ICM

SCTL Apex of TPVS Pleura
TPVS CTJ
Pleura
Rib Rib Rib Rib
TP
Rib
CT junction Rib Rib

D E F
FIGURE 11-57 ■ A sequence of sagittal sonograms of the thoracic paravertebral region (from the same subject) showing the transition of
the anatomy from the level of the lamina to the ribs. Note the difference in the sonographic appearance of the lamina, transverse process (TP),
and the ribs. Also note the relative depths at which each structure is located. The articulation of the rib with the transverse process at the CTJ
(costotransverse junction) is clearly delineated in Fig. 11-57D. Also note that the pleura is not clearly visualized at the level of the TP, but it is
at the level of the ribs. ES, epidural space; ILS, interlaminar space; LF, ligamentum flavum; SCTL, superior costotransverse ligament; TPVS,
thoracic paravertebral space; ICM, intercostal muscles; ICS, intercostal space.
ch11.indd 258 23-08-2017 18:31:43

A B
Aorta
VB
Costotransverse
Lung junction
Rib
Lamina
Spinous
process Transverse
process
C D Spinous process
Lamina
Transverse
Rib process
FIGURE 11-58 ■ Correlative transverse cadaver anatomic (Fig. 11-58A), CT (Fig. 11-58B), MRI (T2-weighted, Fig. 11-58C), and ultra-
sound (Fig. 11-58D) images of the thoracic paravertebral region from the level of the thoracic vertebral body, transverse process, and the rib
corresponding to the level at which the transverse scan was performed in the midline (position 1, Fig. 11-24). PSM, paraspinal muscle; VB,
vertebral body; TP, transverse process.
A B
C D
sound (Fig. 11-59D) images of the thoracic paravertebral region from the level of the vertebral body and transverse process corresponding to
the level at which the transverse scan was performed (position 3, Fig. 11-24). E0, esophagus; CTJ, costotransverse junction; TPVS, thoracic
paravertebral space; VB, vertebral body; PSM, paraspinal muscle; IVF, intervertebral foramen; TP, transverse process; SCTL, superior cos-
totransverse ligament.
ch11.indd 259 23-08-2017 18:31:54

A B
C D
sound (Fig. 11-60D) images of the thoracic paravertebral region from the level of the vertebral body and inferior articular process correspond-
ing to the level at which the transverse scan was performed (position 4, Fig. 11-24). TPVS, thoracic paravertebral space; IVF, intervertebral
foramen; SCTL, superior costotransverse ligament; VB, vertebral body; PSM, paraspinal muscle; SP, spinous process.
Posterior
Posterior
Cranial Caudal
Anterior
Paraspinal PSM SCTL Articular Lamina
Pleura
muscles process
Pleura
TP TP
Lung
Cranial Caudal
TPVS
Intercostal
Lung
artery
Intercostal
vessel Anterior
FIGURE 11-61 ■ Paramedian sagittal oblique sonogram of the tho- FIGURE 11-62 ■ Paramedian transverse sonogram of the thoracic
racic paravertebral region showing the Color Doppler signal from paravertebral region at the level of the inferior articular process
the intercostal artery at the apex of the paravertebral space. TP, trans- showing the Power Doppler signal from the intercostal artery in the
verse process. paravertebral space. PSM, paraspinal muscle; SCTL, superior costo-
transverse ligament; TPVS, thoracic paravertebral space.
Three-Dimensional Sonography of the the operator to rotate the ultrasound transducer through 90
degrees. Three-dimensional ultrasound imaging technology is
Thoracic Paravertebral Region currently available (Fig. 11-63) and allows one to simultane-
As described earlier, it is possible to obtain high-resolution ously visualize the anatomy of a volume or area of interest
2-D ultrasound images of the paravertebral anatomy in the in the transverse, sagittal, and coronal planes without hav-
transverse10,14,17,18 and sagittal11,15 axes. However, this requires ing to move or rotate the transducer.46 Using traditional 2-D
ch11.indd 260 23-08-2017 18:32:05

A B
Cranial surface Caudal surface Lateral surface

C
Medial surface Posterior surface Caudal, lateral, and

posterior surfaces
FIGURE 11-63 ■ 3-D ultrasound scan. (A). The Philips iU22 FIGURE 11-64 ■ Rendered 3-D volumes of the thoracic paraverte-
Ultrasound System, (B) the high-frequency 3-D and 4-D integrated bral region showing the cranial, caudal, lateral, medial, and posterior
mechanical volume linear array transducer (VL13, 13–5 MHz) used surfaces of the acquired paravertebral volume.
for the scan, and (C) the position of the volunteer and the orientation
of the transducer during the data acquisition.
Skin
ultrasound it is not possible to obtain ultrasound images of Subcutaneous tissue
the paravertebral anatomy in the coronal axis. The coronal Paraspinal
muscles
view presents the anatomy as though one were looking down
on to the surface being imaged, analogous to a “bird’s-eye
view” and has also been referred to as the “architectural” or
TP
“plan view.”47 The potential utility of the coronal view during SCTL
TP SCTL
USG regional anesthesia is not clear, but has been used to
visualize the spread of a local anesthetic on either side of a
nerve47 during peripheral nerve blockade. We have recently Lung
demonstrated that it is feasible to perform volumetric 3-D Paravertebral space Pleura
ultrasound imaging of the thoracic paravertebral region and
study the acquired data set in various 3-D formats.46 FIGURE 11-65 ■ A rendered 3-D volume of the thoracic paraver-
In a multiplanar view of the thoracic paravertebral vol- tebral region. The acquired paravertebral volume has been rendered
ume (anatomy) it is possible to simultaneously visualize the such that the sagittal anatomy is being visualized from the lateral
transverse (x-axis), sagittal (y-axis), and coronal (z-axis) (intercostal space) side. Note the apical part of the TPVS (thoracic
paravertebral space) is clearly delineated between the SCTL (supe-
images of the paravertebral anatomy46 (Figs. 11-21, 11-55, and
rior costotransverse ligament) and the parietal pleura. TP, transverse
11-56). Moreover, when the “reference marker,” a point process.
where all the three orthogonal planes intersect, is moved in
any of the 2-D images of the multiplanar display, it automati-
cally updates its position in the other 2-D images. This allows ultrasound image is more detailed than that seen in a 2-D ultra-
one to navigate through or electronically dissect through the sound image.46 Structures such as the costotransverse junction
paravertebral volume, which helps in better understanding the (Fig. 11-55)46 and all six surfaces (faces) (Fig. 11-64) or a
3-D anatomy of the paravertebral region. Also, by using the given surface (Fig. 11-65) of the paravertebral volume, which
reference marker it is possible to visualize a specific point or are otherwise not visualized using 2-D ultrasound imaging,
anatomical structure in all three planes simultaneously. This are clearly delineated using 3-D ultrasound. One is also able
feature facilitates validation of the sonographic appearance of to display and study the acquired data set like a computerized
a given anatomical structure in the paravertebral region (Figs. tomogram (Figs. 11-66 and 11-67). Overall, volumetric 3-D
11-55 and 11-56) and to exclude artifacts. We have also dem- ultrasound imaging allows the anesthesiologists to develop a
onstrated that the anatomical information obtained in a 3-D better spatial awareness of the paravertebral anatomy.46
ch11.indd 261 23-08-2017 18:32:14

FIGURE 11-66 ■ A transverse iSlice display of the thoracic paravertebral region in color (blue tone). In this figure, 16 contiguous transverse
ultrasound images of the acquired paravertebral volume that are 1 mm apart are displayed. CTJ, costotransverse junction; SCTL, superior
costotransverse ligament; TPVS, thoracic paravertebral space; TP, transverse process.
FIGURE 11-67 ■ A sagittal iSlice display of the thoracic paravertebral region in color (sepia tone). In this figure, 16 contiguous sagittal
ultrasound images of the acquired paravertebral volume that are 1 mm apart are displayed. CTJ, costotransverse junction; SCTL, superior
costotransverse ligament; TPVS, thoracic paravertebral space; TP, transverse process.
ch11.indd 262 23-08-2017 18:32:21

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ch11.indd 264 23-08-2017 18:32:21

Lumbar Plexus Block Chapter 12
Introduction 12th rib

Lumbar plexus block (LPB), also referred to as a psoas
1,2 L1
Subcostal
compartment block (PCB),3,4 is frequently used on its own nerve L2 Sympathetic chain
or in combination with a sciatic nerve block for anesthesia Iliohypogastric L3
and/or analgesia during hip or lower extremity surgery.1,3,5,6 nerve Lumbar plexus
During an LPB the local anesthetic is injected into a fascial Ilioinguinal L4
nerve
plane within the posterior aspect of the psoas muscle.7 This L5
Lateral femoral
produces complete blockade of the major components of the Lumbosacral
cutaneous nerve
trunk
ipsilateral lumbar plexus, namely the femoral nerve (FN), lat-
eral femoral cutaneous nerve (LFC), and the obturator nerve Femoral nerve
Sacral plexus
(OBN).8 The term PCB was originally coined by Chayen
and colleagues.4 They believed that branches of the lumbar Genitofemoral nerve
plexus and parts of the sacral plexus were located close to Sciatic nerve
Obturator nerve
each other in a “compartment,” between the psoas and qua-
dratus lumborum muscle (an “intermuscular compartment”) FIGURE 12-1 ■ Anatomy of the lumbar plexus with its three major
at the level of the L4 vertebra, which could be identified using components: the lateral femoral cutaneous nerve, obturator nerve,
a “loss of resistance” technique.4 However, recent research and the femoral nerve. Note the anatomical relation of the lumbar
has demonstrated that the lumbar plexus is located within plexus to the transverse processes.
the substance of the psoas muscle.7 PCB is also referred to
as posterior lumbar plexus block,1 and several variations of
this technique have been described in the literature.2,3 LPB is
traditionally performed using peripheral nerve stimulation,8 Subcostal nerve L1
but with the recent widespread use of ultrasound guidance for Iliohypogastric nerve L2 Lumbar plexus
regional anesthesia ultrasound-guided (USG) LPB has also Quadratus lumborum
L3
been described.9,10 A clear understanding of the sonoanatomy Ilioinguinal nerve
Lateral femoral L4
of the lumbar paravertebral region9–11 is a prerequisite to cutaneous nerve
safely performing USG LPB.9,10 Psoas major L5
Genitofemoral nerve
Femoral nerve
Gross Anatomy
The lumbar plexus is formed by the union of the anterior pri-
mary rami of the L1, L2, and L3 spinal nerves and the greater
part of the L4 nerve (Figs. 3-1 and 12-1). The L1 nerve root
may also receive contribution from the T12 spinal nerve. In
the majority of individuals the lumbar plexus is located in FIGURE 12-2 ■ Figure showing the anatomical relation of the
a fascial plane or compartment within the substance of the lumbar plexus to the psoas muscle and how the nerves of the lum-
bar plexus (iliohypogastric, ilioinguinal, lateral femoral cutaneous,
psoas muscle (Figs. 12-2 to 12-4).7,11 We will henceforth refer
femoral, and obturator) emerge from the psoas muscle.
to this intramuscular fascial compartment as the psoas com-
partment. Anatomically the psoas compartment is located
between the fleshy anterior two-thirds of the psoas muscle and transverse processes (Figs. 12-2 to 12-8). The bulkier ante-
the posterior one-third of the muscle (Figs. 12-3 and 12-4).7,11 rior (fleshy) part of the psoas muscle originates from the
Therefore, the lumbar plexus is sandwiched between two por- anterolateral surface of the lumbar vertebral bodies and their
tions of the psoas muscle and closely related to the lumbar intervertebral disc, whereas the thinner posterior (accessory)
265
ch12.indd 265 23-08-2017 18:38:53

266 n Chapter 12 / Sonoanatomy Relevant for Ultrasound-Guided Lumbar Plexus Block
Anterior longitudinal
ligament
Psoas major
Lumbar sympathetic Lumbar paravertebral
ganglion space
Rami communicantes PM
Tendinous arch
L4 VB
Transverse process
Sympathetic chain
Lumbar spinal nerve root
Intertransverse QLM
ligament
L4 TP
LF ES ESM
AP
FIGURE 12-3 ■ Location of the lumbar nerve root within the sub-
stance of the psoas muscle and their relation to the transverse process.

IVC the L4 vertebral body and transverse process corresponding to the
IOM
Ao
EOM
TAM
Lumbar artery
PM RPS level at which the PMTOS-TP (paramedian transverse oblique scan
Spinal artery L4VB L4NR PC at the level of the transverse process) was performed. ESM, erec-
LPVS
tor spinae muscle; PM, psoas muscle; QLM, quadratus lumborum
IVF
DBLA muscle; AP, articular process; LF, ligamentum flavum; ES, epidural
LPlx QLM
AP space; VB, vertebral body; TP, transverse process.
Lamina
ESM
FIGURE 12-4 ■ Transverse anatomy of the lumbar paravertebral

region at the L4 vertebral level. Note the origin and branching of the
lumbar artery. Ao, aorta; IVC, inferior vena cava; RPS, retroperitoneal PM L4 VB L3 Nerve root
space; EOM, external oblique muscle; IOM, internal oblique muscle; IVF
TAM, transversus abdominis muscle; PM, psoas muscle; QLM, qua-
dratus lumborum muscle; IVF, intervertebral foramen; DBLA, dor- QLM LPVS
sal branch of lumbar artery; LPVS, lumbar paravertebral space; NR,
AP
nerve root; PC, psoas compartment; LPlx, lumbar plexus; VB, verte- L4 Nerve root
ESM
bral body; AP, articular process; ESM, erector spinae muscle. Lamina
Lumbar plexus
FIGURE 12-7 ■ Cross-sectional cadaver anatomical section from

Psoas major just inferior to the L4 transverse process and through the lower part
of the L4 vertebral body corresponding to the level at which the
PMTOS-ITS (paramedian transverse oblique scan through the space
between two adjacent transverse processes) was performed. Note the
intervertebral foramen (IVF) and the L4 spinal nerve root as it exits
the IVF to enter the lumbar paravertebral space (LPVS). Also note
the relation of the L3 nerve of the lumbar plexus to the L4 nerve root
close to the L4 IVF. This is because the L3 lumbar nerve root after it
exits the IVF takes a steep caudal course through the posterior part
FIGURE 12-5 ■ Cadaver dissection image showing the lumbar of the psoas muscle. PM, psoas muscle; QLM, quadratus lumborum
plexus nerves within the substance of the psoas muscle. The psoas muscle; IVF, intervertebral foramen; AP, articular process; LPVS,
muscle has been split longitudinally to expose the lumbar plexus lumbar paravertebral space; ESM, erector spinae muscle; VB, ver-
nerves within the posterior aspect of the muscle. tebral body.
ch12.indd 266 23-08-2017 18:39:10

Chapter 12 / Sonoanatomy Relevant for Ultrasound-Guided Lumbar Plexus Block n 267
L2 VB
PM
PM PM
L2 TP
L3 VB
ESM
L3 TP Lumbar plexus L3 NR
ITS with CE
L4 TP Psoas
compartment L4 NR
PM
L5 NR
Sacrum
FIGURE 12-8 ■ Sagittal cadaver anatomic section showing the FIGURE 12-9 ■ Coronal cadaver anatomic section showing how
relation of the lumbar plexus to the transverse process (TP) and the the lumbar nerve roots after they exit the intervertebral foramen take
psoas muscle (PM). The reference marker of the Java application, a steep caudal course and enter the substance of the psoas muscle
seen in this figure as a green cross-hair, is over the L3 nerve of the (PM) more caudally. Also seen is the formation of the lumbar plexus
lumbar plexus (same as in Fig. 8-7). The L3 nerve of the lumbar within the substance of the psoas muscle (PM). The reference marker
plexus is seen in a fat-filled “intramuscular compartment,” that is, of the Java application, seen in this figure as a green cross-hair, is
the psoas compartment between the thick fleshy anterior and a thin over the L3 nerve of the lumbar plexus (same as in Figs. 8-7 and
posterior part of the psoas muscle between the L3 and L4 TP. ESM, 8-8). VB, vertebral body; ITS, intrathecal space; CE, cauda equina;
erector spinae muscle. NR, nerve root.
portion of the muscle originates from the anterior aspect of muscle. Outlines of the psoas compartment with the lumbar
the lumbar transverse processes (Fig. 12-3).7 Also the anterior plexus can also be delineated in the transverse anatomic section
and posterior parts of the psoas muscle fuse to form the main (Fig. 12-7). Once the plexus is formed it displays a triangular
muscle bulk, but close to the vertebral bodies these two parts shape, narrow in its superior portion and wider in its lower por-
are separated by a fascia7 or space within which the lumbar tion (Fig. 12-1). The nerves that originate from the plexus also
nerve roots, branches of the lumbar artery, and the ascending exhibit a fanned-out distribution with the LFC being outermost,
lumbar veins are located (Figs. 12-2 to 12-6).7,11 This wedge- the OBN innermost, and the femoral nerve in between (Fig.
shaped space close to the intervertebral foramen is the lumbar 12-1). Being a fusiform muscle (ie, shaped like a spindle), the
paravertebral space (LPVS) (Fig. 12-7).11 width of the psoas muscle is wider at its belly, close to the lower
The lumbar nerve root after it exits the intervertebral fora- lumbar region, than at its origin and insertion. There are also
men enters the fat-filled LPVS (Fig. 12-7). However, the lum- gender- (male > female)12 and race- (black > white)13 related
bar nerve root, instead of entering the psoas muscle at the same differences in the width and cross-sectional area of the psoas
vertebral level, takes a steep caudal course and enters the sub- muscle. The position of the lateral femoral cutaneous nerve and
stance of the psoas muscle at the vertebral level below (Fig. femoral nerve within the psoas compartment is relatively con-
12-9). This explains why the L3 nerve of the lumbar plexus lies sistent,7 but the position of the obturator can be variable and
opposite the L4 intervertebral foramen and the L4 nerve root may even lie in a fold of the psoas muscle separate from that
(Fig. 12-7). Also as seen in the sagittal anatomic section (Fig. enclosing the other two nerves (Fig. 12-10).7 The depth from
12-8), the L3 nerve of the lumbar plexus is located in an intra- the skin to the lumbar plexus also varies with gender and body
muscular compartment (ie, the psoas compartment) between mass index (BMI). Such differences in anthropometric param-
the thick fleshy anterior and a thin posterior part of the psoas eters may be relevant when performing an LPB.
ch12.indd 267 23-08-2017 18:39:14

Aorta
Psoas major Psoas compartment Inferior
vena cava
1 1 Psoas major
2 2 3 muscle
3
A Anterior B
L4 VB
Medial
1 2 1 Quadratus lumborum L4 Nerve root

2 LPVS
3 muscle Erector spinae muscle Articular process
3
C D
FIGURE 12-12 ■ Transverse CT of the abdomen at the level of the
body and articular process (inferior) of the L4 vertebra correspond-
FIGURE 12-10 ■ Figure showing the position of the (1) lateral ing to the level at which the PMTOS-ITS (paramedian transverse
femoral cutaneous nerve, (2) femoral nerve, and (3) obturator nerve oblique scan through the intertransverse space) is performed. VB,
in the psoas compartment. Note that whereas the position of 1 and 2 vertebral body; LPVS, lumbar paravertebral space.
are fairly consistent, the position of 3 can vary and may even lie in
a separate intramuscular fold (C) or compartment separate from the
psoas compartment (D).
Aorta
IVC
Inferior Aorta
vena cava
L4 VB PM
Psoas major
L3 NR L3 NR
ITS
L4 VB
QLM
QLM
Transverse
process Articular ESM
Transverse process
process Quadratus lumborum Ligamentum
Epidural
Articular Spinous Erector spinae muscle flavum
space
process process muscle
FIGURE 12-11 ■ Transverse CT of the abdomen at the level of the FIGURE 12-13 ■ Transverse T1-weighted MRI at the level of the
body and transverse process of the L4 vertebra corresponding to the L4 vertebral body and the transverse process corresponding to the
level at which the PMTOS-TP (paramedian transverse oblique scan level at which the PMTOS-TP (paramedian transverse oblique scan
at the level of the transverse process) is performed. Note the position at the level of the transverse process) is performed. The L3 nerve
of the inferior vena cava and the aorta relative to the vertebral body. root of the lumbar plexus is seen as the hypointense nerve outlined
VB, vertebral body. by a layer of hyperintense fat in the posterior aspect of the psoas
muscle close to the angle between the vertebral body and the trans-
verse process. PM, psoas major muscle; QLM, quadratus lumborum
muscle; ESM, erector spinae muscle; IVC, inferior vena cava; NR,
nerve root; ITS, intrathecal space; VB, vertebral body.
Computed Tomography Anatomy of the Lumbar Magnetic Resonance Imaging Anatomy of the
Paravertebral Region Lumbar Paravertebral Region
Figs. 12-11 and 12-12 Figs. 12-13 to 12-16
ch12.indd 268 23-08-2017 18:39:22

PM PM
L4 VB
L3 NR L3 NR
LPVS
ITS L3 TP
IVF L3 Nerve root
QLM
L4 NR
Articular L4 TP
process Epidural
space ESM PM
L5 TP
L4 Nerve root
L5 Nerve root
FIGURE 12-14 ■ Transverse T1-weighted MRI image from just
below the L4 transverse process and through the lower half of the
body of L4 vertebra and the articular process (inferior) correspond-
ing to the level at which the PMTOS-ITS (paramedian transverse
oblique scan through the intertransverse space) is performed. Note
the hypointense L4 nerve root as it exits the intervertebral foramen
(IVF) and enters the hyperintense fat-filled lumbar paravertebral
space (LPVS). Also seen in the posterior aspect of the psoas muscle
is the L3 nerve of the lumbar plexus, which is surrounded by a layer
FIGURE 12-15 ■ Sagittal T1-weighted MRI image of the lumbar
of hyperintense fat, and in an intramuscular compartment (ie, the
paravertebral region at the L3-L4-L5 vertebral level showing the
“psoas compartment”). PM, psoas major muscle; QLM, quadratus
steep caudal course of the lumbar nerve roots. Note the hypointense
lumborum muscle; ESM, erector spinae muscle; VB, vertebral body;
lumbar plexus nerves are located in an intramuscular compartment
AP, articular process; LPVS, lumbar paravertebral space; ITS, intra-
in the posterior part of the psoas muscle (ie, the “psoas compart-
thecal space; NR, nerve root; IVF, intervertebral foramen.
ment”), which is filled with hyperintense fatty tissue. TP, transverse
process; PM, psoas major muscle.
PM
PM
L2 NR Lumbar Paravertebral Sonography
L3 NR IVF Ultrasound Scan Technique
1. Position:
a. Patient: The authors prefer to position the patient
L4 NR
in the lateral position with the side to be blocked
uppermost (Fig. 12-17A).9,10 The hips and knees of
L5 VB the patient are also flexed to mimic the position nor-
mally adapted during an LPB. The ultrasound scan
S1 VB can also be performed with the patient in the prone
L5 NR position, but the disadvantage is impaired visualiza-
tion of the quadriceps muscle contraction during an
LPB if nerve stimulation is used.
FIGURE 12-16 ■ Coronal T1-weighted MRI image at the L3-L4-L5 sits or stands behind the patient, and the ultrasound
vertebral level showing the steep caudal course of the lumbar spi- machine is placed directly in front on the contralat-
nal nerves after they emerge from the intervertebral foramen (IVF).
eral side.
Note the hypointense lumbar nerve roots (NR), after they emerge
from the L4 IVF, enter a hyperintense fat-filled space on the medial 2. Transducer selection: Because the lumbar plexus and
aspect of the psoas muscle (PM), that is, the lumbar paravertebral psoas muscle are located at a depth in the abdomen
space (LPVS), comparable to that seen in Figs. 12-12 and 12-14. and pelvis, it necessitates the use of a low-frequency
VB, vertebral body.
ch12.indd 269 23-08-2017 18:39:30

A Position and landmarks B Sagittal scan
C PMTOS - TP D PMTOS - ITS FIGURE 12-18 ■ Position of the patient and the ultrasound trans-
ducer during a paramedian sagittal scan of the lumbar paravertebral
FIGURE 12-17 ■ Position of the volunteer (Fig. 12-17A) and the region. Note the ultrasound transducer with its orientation marker
plane of ultrasound imaging during a sagittal and transverse scan of directed cranially has been placed over the sagittal scan line (refer to
the lumbar paravertebral region. A picture of the ultrasound trans- Fig. 12-17A), which is a line 4 cm lateral and parallel to the midline
ducer and the plane of the ultrasound beam (green pane) has been (paramedian), at the level of the iliac crest.
superimposed onto the transverse cadaver anatomic sections to illus-
trate how the ultrasound beam was insonated during the sagittal (Fig.
12-17B), PMTOS-TP (paramedian transverse oblique scan at the
level of the transverse process, Fig. 12-17C), and PMTOS-ITS (para- (line B, Fig. 12-17A). Thereafter a line (line C) paral-
median transverse oblique scan through the intertransverse space, lel to the midline and which intersects the intercris-
Fig. 12-17D). A – midline, B – intercristal line, C – sagittal scan line, tal line (line B) at a point 4 cm lateral to the midline,
X – a point 4 cm from the midline along the intercristal line.
corresponding to the point of needle insertion during a
landmark-based LPB, is also marked (sagittal scan line)
(Fig. 12-17A). The target vertebral level for the ultra-
ultrasound (5–2 MHz) and curved array transducer to sound scan (L3-L4-L5) is then identified as previously
image the lumbar paravertebral region.9–11 Low-frequency described.15,16 This involves visualizing the lumbosacral
ultrasound provides good penetration but lacks spatial junction (L5–S1 gap) on a sagittal sonogram and then
resolution at the depths (5–9 cm) at which the anatomy counting cranially to locate the lamina and transverse
relevant for LPB is located. The latter often compromises processes of the L3, L4, and L5 vertebrae. For a sagit-
the ability to locate the lumbar plexus within the psoas tal scan, the ultrasound transducer is positioned over the
muscle. However, recent improvements in ultrasound sagittal scan line (Fig. 12-18) with its orientation marker
technology, image processing capabilities of ultrasound directed cranially. For a transverse scan the ultrasound
machines, the availability of compound imaging and tis- transducer, with its orientation marker directed laterally,
sue harmonic imaging (THI), and the use of new scan is positioned 4 cm lateral to the midline along the inter-
protocols have significantly improved our ability to cristal line and just above the iliac crest (Fig. 12-19). The
image the lumbar paravertebral region. Today, we are not transducer is also directed slightly medially (Fig. 12-19)
only able to accurately delineate the lumbar plexus, but so as to produce a transverse oblique view of the lumbar
also the adjoining paravertebral anatomy.9–11 paravertebral region.10,11 During the paramedian trans-
3 . Scan technique: An ultrasound scan of the lumbar para- verse oblique scan (PMTOS), the ultrasound beam can
vertebral region for USG LPB can be performed in the be insonated either at the level of the transverse process
sagittal (Fig. 12-17B)9,14 or transverse (Figs. 12-15C and (PMTOS-TP, Fig. 12-17C) or through the intertransverse
12-15D)10,11,14 axis. The following anatomical landmarks space (PMTOS-ITS, Fig. 12-17D).11 Alternatively a trans-
are identified and marked on the skin of the nondepen- verse scan can be performed by placing the ultrasound
dent side of the back using a skin marking pen: posterior transducer more anteriorly in the flank and above the iliac
superior iliac spine, iliac crest, lumbar spinous processes crest (Figs. 12-15 to 12-20) as described by Sauter and
(midline, line A, Fig. 12-17A) and the intercristal line colleagues with the “shamrock technique.”17
ch12.indd 270 23-08-2017 18:39:34

4. Sonoanatomy: because of its similarity to the trident (Latin for tridens

a. Sagittal sonoanatomy: or tridentis) that is often associated with Poseidon
On a sagittal sonogram the transverse processes of (the god of the sea in Greek mythology) and the
the lumbar vertebrae (L3-L4-L5) are identified by Trishula of the Hindu god Shiva. However one must
their hyperechoic reflection and their correspond- bear in mind that because the L5 transverse process
ing acoustic shadow anteriorly (Fig. 12-21).9 This is the shortest of the lumbar transverse processes, it
produces a sonographic pattern that we refer to as may be more difficult to locate and may require some
the lumbar ultrasound trident or the “trident sign”9 degree of medial orientation of the transducer until
Posterior
Cranial Caudal
Transverse process
Anterior
L3
L4 L5
PM
PM
Acoustic shadow of
Acoustic window transverse process
FIGURE 12-19 ■ Position of the patient and the ultrasound trans- FIGURE 12-21 ■ Sagittal sonogram of the lumbar paravertebral
ducer during a paramedian transverse oblique scan of the lumbar region showing the acoustic shadows of the lumbar transverse pro-
paravertebral region. The ultrasound transducer has been placed lat- cesses (L3, L4, and L5), which produce a sonographic pattern called
eral to the sagittal scan line and over the intercristal line with its the “trident sign.” The psoas muscle (PM) is seen in the intervening
orientation marker directed laterally (outward). Also note how the acoustic window.
transducer is angled medially for the ultrasound scan.
The Shamrock Method
Quadratus lumborum
Psoas muscle muscle
Transverse process
Erector spinae
muscle
A Position - lateral decubitus B Axis of scan
FIGURE 12-20 ■ The shamrock method of ultrasound imaging of the lumbar paravertebral region for lumbar plexus block. (A) Position
of the patient and the ultrasound transducer. (B) The plane of ultrasound imaging during the shamrock method. A picture of the ultrasound
transducer and the plane of the ultrasound beam (green pane) have been superimposed onto the transverse cadaver anatomic section of the
lumbar region to illustrate how the ultrasound beam is insonated during the scan.
ch12.indd 271 23-08-2017 18:39:42

the ultrasound trident is visible. The psoas muscle

Transverse process
is seen in the acoustic window of the lumbar ultra-
sound trident (Fig. 12-21) as multiple longitudinal Lower pole of
kidney
hyperechoic striations against a hypoechoic back- ESM
Interlaminar space
ground typical of muscle (Fig. 12-22).9 The lumbar
QLM
plexus may also be visualized in the posterior aspect
of the psoas muscle (Fig. 12-22).9 It appears hyper- Dura
PM
echoic (Fig. 12-22), is sonographically distinct from
the muscle fibers, and is more posterior in location VB
than the intramuscular tendons of the psoas muscle.9
Intrathecal space
The lumbar plexus nerves are also thicker than the IVC
muscle fibers (Fig. 12-22) and take an oblique course Lateral Posterior
through the psoas muscle.9 A laterally positioned
ultrasound transducer will produce a suboptimal Anterior Medial
view without the ultrasound trident, but may visual-
ize the lower pole of the kidney, which lies anterior FIGURE 12-23 ■ Paramedian transverse oblique scan of the right
to the quadratus lumborum muscle (QLM), and can lumbar paravertebral region at the level of the transverse process
(PMTOS-TP). Note how the acoustic shadow of the transverse pro-
reach the L3 to L4 vertebral level in some individuals.
cess obscures the posterior part of the psoas muscle and the inter-
b. Transverse sonoanatomy – Paramedian trans- vertebral foramen and how parts of the spinal canal and neuraxial
verse oblique scan: structures (dura and intrathecal space) are seen through the interlami-
In a typical PMTOS–TP, the erector spinae muscle, nar space. VB, vertebral body; IVC, inferior vena cava; PM, psoas
the transverse process, the psoas muscle, quadratus muscle; QLM, quadratus lumborum muscle; ESM, erector spinae
lumborum muscle, and the anterolateral surface of the muscle.
vertebral body are visualized (Fig. 12-23).11 The psoas
muscle appears hypoechoic, but areas of hyperecho-
genicity are interspersed within the central part of the
muscle (Fig. 12-23 to 12-25). These dots or speckles ESM
Psoas compartment
represent the intramuscular tendon fibers of the psoas QLM
muscle, and they are more pronounced below the level
AP
Posterior Lumbar plexus
Cranial Caudal PM IVF
Transverse process
VB LPVS LNR
Anterior Lumbar plexus
ESM
Lateral Posterior
L3 RPS
L4 L5 IVC
Anterior Medial
PM
PM
FIGURE 12-24 ■ Paramedian transverse oblique scan of the right

IM tendon
lumbar paravertebral region through the space between two adjacent
transverse processes (PMTOS-ITS). Note the intervertebral foramen
(IVF), articular process (AP), and lumbar nerve root (LNR) after it
Anterior border of Retroperitoneal space
Psoas muscle has emerged from the IVF and the hypoechoic space surrounding
the lumbar nerve root adjacent to the IVF (ie, the LPVS: lumbar
FIGURE 12-22 ■ Sagittal sonogram of the lumbar paravertebral paravertebral space). The lumbar plexus is also seen in a separate
region showing the lumbar plexus as a hyperechoic structure in the hypoechoic intramuscular compartment, which is the psoas compart-
posterior aspect of the psoas muscle (PM) between the L4 and L5 ment, in the posterior part of the psoas muscle (PM). VB, vertebral
transverse processes. Also note the hyperechoic intramuscular tendons body; PM, psoas muscle; QLM, quadratus lumborum muscle; ESM,
within the substance of the psoas muscle. ESM, erector spinae muscle; erector spinae muscle; RPS, retroperitoneal space; IVC, inferior
IM, intramuscular. vena cava.
ch12.indd 272 23-08-2017 18:39:47

Psoas compartment
ESM
Lumbar plexus Lumbar nerve
root ESM
Psoas major
QLM
AP Psoas compartment
IVF
Lumbar plexus AP
Kidney
PM
VB
IVF
Lateral Posterior
VB
Lateral Posterior
IVC
Anterior Medial
IVC
Anterior Medial
FIGURE 12-25 ■ Paramedian transverse oblique scan of the right FIGURE 12-26 ■ Paramedian transverse oblique scan of the right
lumbar paravertebral region through the space between two adjacent lumbar paravertebral region through the space between two adjacent
transverse processes (PMTOS-ITS). The lumbar nerve root is seen transverse processes (PMTOS-ITS) showing the lumbar plexus as
emerging from the intervertebral foramen, and the lumbar plexus a discrete hyperechoic structure inside a hypoechoic intramuscu-
(hyperechoic) is located within a hypoechoic space (psoas compart- lar space (psoas compartment) in the posteromedial aspect of the
ment) in the posterior aspect of the psoas muscle. Also note the lower psoas muscle. ESM, erector spine muscle; QLM, quadratus lumbo-
pole of the right kidney is seen anterior to the psoas muscle in this rum muscle; PM, psoas muscle; AP, articular process; VB, vertebral
sonogram. ESM, erector spinae muscle; AP, articular process; VB, body; IVC, inferior vena cava.
vertebral body; IVF, intervertebral foramen; IVC, inferior vena cava.
of the iliac crest. The IVC (on the right side, Fig. 12-24) foramen (Figs. 12-24 to 12-26), and the lumbar
and the aorta (on the left side) are also identified ante- spinal nerve root can be seen exiting the foramen
rior to the vertebral body and are useful landmarks to (Figs. 12-24 and 12-25).11 The latter does not enter
look out for while performing a transverse scan.11 The the psoas muscle directly opposite the intervertebral
lower pole of the kidney, which can extend to the L3 foramen from which it emerges (Figs. 12-24 and
vertebral level, is visualized as an oval structure and 12-25), but takes a caudal course as seen in the
moves synchronously with respiration in the retro- CT (Fig. 12-12), MRI (Figs. 12-14 to 12-16), and
peritoneal space (Fig. 12-25). The acoustic shadow of cadaver anatomical section (Fig. 12-9). In some
the transverse process obscures the posterior aspect of individuals an additional hyperechoic structure
the psoas muscle (Fig. 12-23).11 Therefore, the lum- surrounded by a hypoechoic space (Figs. 12-24 to
bar nerve root or lumbar plexus are rarely visualized 12-26) is seen in the posterior aspect of the psoas
through the PMTOS-TP scan window. However, the muscle.11 Based on our observation in the anatomi-
dura, epidural space, and the intrathecal space may cal sections (Fig. 12-7) and MRI images (Fig. 12-14)
be visualized during a PMTOS-TP (Fig. 12-23).11 We we believe this represents the lumbar plexus within
believe this is because the ultrasound signal, which is the psoas compartment.11 Currently there are limited
medially directed, enters the spinal canal through the data validating the transverse sonoanatomy of the
interlaminar space (Fig. 12-17C). Being able to visu- lumbar paravertebral region, but it is our experience
alize the neuraxial structures during a lumbar para- that there is good correlation between structures that
vertebral scan may be useful in documenting epidural are visualized in a lumbar paravertebral sonogram
spread after an LPB. and that in corresponding cadaver anatomical sec-
In the PMTOS-ITS11 apart from the erector tions, CT, and MRI images of the lumbar paraver-
spinae, psoas, and quadratus lumborum muscles, tebral region (Figs. 12-27 to 12-30).11 Because the
the intervertebral foramen, articular process, and lumbar plexus and the paravertebral anatomy are
the lumbar spinal nerve root are clearly delineated clearly delineated through the PMTOS-ITS ultra-
(Figs. 12-24 to 12-26).11 The LPVS is also seen as sound scan window, it is our preferred window for
a hypoechoic space adjacent to the intervertebral imaging during an ultrasound-guided LPB.10
ch12.indd 273 23-08-2017 18:39:49

A B
C D
FIGURE 12-27 ■ Correlative sagittal (A) cadaver anatomic, (B) CT, (C) MRI (T1-weighted), and (D) ultrasound images of the lumbar
paravertebral region from the level of the L3, L4, and L5 lumbar transverse processes. ESM, erector spinae muscle; PM, psoas muscle; NR,
nerve root; RPS, retroperitoneal space; TP, transverse process.
A B
C D
FIGURE 12-28 ■ Correlative transverse (A) cadaver anatomic, (B) CT, (C) MRI (T1-weighted), and (D) ultrasound images of the lumbar
paravertebral region from the level of the L4 vertebral body (VB) and transverse process (TP). ESM, erector spinae muscle; QLM, quadratus
lumborum muscle; PM, psoas muscle; AP, articular process; LF, ligamentum flavum; ES, epidural space; IVC, inferior vena cava.
ch12.indd 274 23-08-2017 18:40:03

A B
C D
FIGURE 12-29 ■ Correlative transverse (A) cadaver anatomic, (B) CT, (C) MRI (T1-weighted), and (D) ultrasound images of the lumbar
paravertebral region from the level of the L4 vertebral body (VB) and articular process (AP). ESM, erector spinae muscle; QLM, quadratus
lumborum muscle; PM, psoas muscle; AP, articular process; LPVS, lumbar paravertebral space; VB, vertebral body; IVC, inferior vena cava.
A B
FIGURE 12-30 ■ Correlative coronal (A) cadaver anatomic and (B) MRI (T1-weighted) images of the lumbar paravertebral showing the
exit of the lumbar nerve roots (NR) from the intervertebral foramen (IVF) and the formation of the lumbar plexus within the substance of the
psoas muscle (PM). ITS, intrathecal space; CE, cauda equina.
c. Transverse sonoanatomy – Shamrock method: transverse process, that is, the psoas muscle lying
In a transverse sonogram produced by the sham- anterior, the erector spinae muscle lying posterior,
rock method (Fig. 12-20) the psoas, erector spinae, and the quadratus lumborum muscle lying at the
and quadratus lumborum muscles are also clearly apex (Fig. 12-31), produces a sonographic pattern
visualized (Figs. 12-31 and 12-32). The anatomi- that has been likened to a shamrock, with the mus-
cal arrangement of the three muscles around the cles representing its three leaves.17 The lumbar nerve
ch12.indd 275 23-08-2017 18:40:10

Transverse process
Lumbar plexus
QLM
ESM
PM
VB
IVC
Lateral
Anterior
FIGURE 12-31 ■ Transverse sonogram of the lumbar paravertebral area obtained with the shamrock method at the level of the transverse process
of the L4 vertebra. Note the prominent transverse process and the arrangement of the psoas major (PM), quadratus lumborum (QLM), and erector
spine (ESM) muscles around the transverse process that has been likened to a shamrock. The accompanying photograph on the right illustrates the
position of the patient and the ultrasound transducer during the scan. VB, vertebral body; IVC, inferior vena cava.
root is visualized close to the angle between the ver-

tebral body and the transverse process (Figs. 12-32
Posterior
TAM
and 12-33), and the lumbar plexus within the pos-
Medial
Lumbar plexus terior aspect of the psoas muscle, typically about 2
QLM cm anterior to the transverse process (Figs. 12-31 to
QLM
Lumbar nerve root
12-33).17 From this position if the transducer is gently
RPS ESM tilted caudally, the acoustic shadow of the L4 trans-
PM
TP verse process disappears and the ultrasound beam is
IVC
now insonated through the intertransverse space and
ITS Dura
VB LPVS at the level of the articular process of L4 vertebra,
Ao
similar to that with a PMTOS-AP (Fig. 12-17D).10,11,17
In the resultant sonogram the psoas, erector spinae
and quadratus lumborum muscles, the intervertebral
FIGURE 12-32 ■ Transverse sonogram of the lumbar paravertebral foramen, and lumbar plexus are now clearly visual-
region with the ultrasound beam being insonated at the level of the ized (Figs. 12-34 and 12-35). In our experience, the
transverse process during the shamrock method. Note the lumbar lumbar plexus is better visualized with the shamrock
nerve root is visualized close to the angle between the vertebral body method than with a PMTOS. This may be because
and the transverse process and the lumbar plexus nerve is located
the ultrasound beam is more at right angles to the
within the substance of the psoas muscle. TAM, transversus abdomi-
nis muscle; ESM, erector spine muscle; PM, psoas major muscle;
lumbar plexus nerves during a shamrock scan.
QLM, quadratus lumborum muscle; RPS, retroperitoneal space;
IVC, inferior vena cava; Ao, abdominal aorta; VB, vertebral body;
LPVS, lumbar paravertebral space; ITS, intrathecal space; TP, trans-
Clinical Pearls
verse process. 1. The lumbar paravertebral region is highly vascular and
contains the ascending lumbar veins and the lumbar arter-
ies (Fig. 12-36), which can be visualized using Color
ch12.indd 276 23-08-2017 18:40:13

Lumbar plexus Lumbar plexus
PM
PM
PM
AP
VB
VB
VB
ITS
A Transverse (shamrock) view B Coronal view
FIGURE 12-33 ■ Biplanar ultrasound image of the lumbar paravertebral region obtained with the shamrock method and with the ultrasound
beam being insonated through the lumbar intertransverse space and at the level of the articular process. Note the transverse axis (A) is the
primary data acquisition plane and the corresponding image along the secondary data acquisition plane (x-plane – dotted line with blue arrow
head in A) is a coronal view showing the lumbar plexus nerves within the psoas muscle. PM, psoas muscle; VB, vertebral body; ITS, intrathe-
cal space; AP, articular process.
Lateral
Anterior
Lumbar plexus
QLM
ESM
PM AP QLM
Lumbar plexus ESM
VB Articular
IVF
IVC process
PM Intervertebral
foramen
Lateral
VB ITS Dura
Anterior
IVC
FIGURE 12-34 ■ Transverse sonogram of the lumbar paravertebral

region with the ultrasound beam being insonated through the lumbar
intertransverse space and at the level of the articular process (AP) FIGURE 12-35 ■ Transverse sonogram of the lumbar paravertebral
during the shamrock method. The lumbar plexus nerves are clearly region with the ultrasound beam being insonated through the lumbar
delineated in the posterior aspect of the psoas major (PM) muscle. intertransverse space and at the level of the articular process of the
The accompanying photograph on the right illustrates the position lumbar vertebra during the shamrock scan. ESM, erector spine mus-
of the patient and the ultrasound transducer during the scan. VB, cle; PM, psoas major muscle; QLM, quadratus lumborum muscle;
vertebral body; IVC, inferior vena cava; ESM, erector spine muscle; IVC, inferior vena cava; VB, vertebral body; ITS, intrathecal space.
PM, psoas major muscle; QLM, quadratus lumborum muscle; IVC,
inferior vena cava; VB, vertebral body; IVF, intervertebral foramen.
ch12.indd 277 23-08-2017 18:40:28

Abdominal
aorta
Lumbar artery
B
A
Vertebral body
Lumbar artery
Spinous process
Intervertebral
foramina
FIGURE 12-36 ■ Three-dimensional reconstruction of a CT angiogram showing the origin of the lumbar artery from the abdominal aorta
and how it is closely related to the anterolateral surface of the lumbar vertebral body. The spinal artery, which is a branch of the lumbar artery,
is also seen entering the spinal canal through the intervertebral foramen (C).
muscle (Fig. 12-38) where the lumbar plexus is located.

Therefore, it may be at risk for needle-related injury dur-
ing an LPB, as it is directly in the path of the advancing
needle. Considering the rich vascularity of the lumbar
ESM paravertebral region, it is not surprising that inadver-
QLM
Ascending lumbar vein
tent intravascular injection of local anesthetic,2,3,18 psoas
& Lumbar artery hematoma,19 lumbar plexopathy,19 and delayed retroperi-
PM toneal hematoma20,21 have all been reported after an LPB.
VB It is for the same reason, and because the psoas muscle
lies in an incompressible area, that we recommend one
IVC
must avoid LPB in patients with coagulopathy.
Lateral Posterior
2. The echo-intensity (EI) of skeletal muscles is signifi-
Anterior Medial cantly increased in the elderly,22,23 and there is a strong
correlation between EI of muscles and age (EI of the
biceps increases 1.8% per year and EI of the quadriceps
FIGURE 12-37 ■ Color Doppler ultrasound image of the right lum- increases 1.9% per year).23 The increase in EI of skel-
bar paravertebral region showing the lumbar artery and the ascending
etal muscles with age is due to age-related changes in
lumbar vein close to the anterolateral surface of the lumbar vertebra
and medial to the psoas muscle. QLM, quadratus lumborum muscle; the muscle.23 In the elderly there is a reduction in skel-
ESM, erector spinae muscle; PM, psoas muscle; VB, vertebral body; etal muscle mass (sarcopenia),24,25 replacement of the
IVC, inferior vena cava. contractile elements in the muscle by fat and connective
tissue,23 and an increase in extracellular water content
in the muscle.26 There is also an increase in body fat.24
and Power Doppler ultrasound (Figs. 12-37 and 12-38). Normally subcutaneous fat, water, and skeletal muscle
There is also a rich network of blood vessels (arteries and fibers are hypoechoic, but infiltration of skeletal muscles
veins) within the substance of the psoas muscle. The dor- by fat results in increased muscular EI.27 This may be due
sal branch of the lumbar artery is also closely related to to a change in acoustic impedance at the surface of the
the transverse process and the posterior part of the psoas fat cells and an increase in scattering of the ultrasound
ch12.indd 278 23-08-2017 18:40:33

DBLA DBLA
PM AP
AP
LA PM
VB VB
A PMTOS-ITS: LA and its branches B PMTOS-ITS: Dorsal branch of LA
DBLA DBLA
TP TP TP TP
PM
C SS - DBLA in the acoustic trident D SS (medially positioned probe) - DBLA
FIGURE 12-38 ■ Color Doppler ultrasound images of the lumbar paravertebral region in the transverse (A and B) and sagittal (C and D)
scan planes. Note the dorsal branch of the lumbar artery (DBLA) on the posterior aspect of the psoas muscle in both the transverse and sagittal
sonograms. PMTOS-ITS, paramedian transverse oblique scan through the lumbar intertransverse space; SS, sagittal scan; LA, lumbar artery;
VB, vertebral body; AP, articular process; PM, psoas muscle; TP, transverse process.
Posterior
QLM ESM
TP TP
ESM
Cranial Caudal
Retroperitoneal
space PM
VB AP
Lateral Posterior
Anterior
Anterior Medial
FIGURE 12-40 ■ Sagittal sonogram of the lumbar paravertebral region
in a morbidly obese patient (BMI = 50 kg·m−2). Note the transverse
FIGURE 12-39 ■ Paramedian transverse oblique scan of the right processes (TP) of the lumbar vertebra are barely recognizable in this
lumbar paravertebral region through the space between two adjacent ultrasound image. There is also a marked loss of contrast between the
transverse processes (PMOTS-ITS) in an elderly subject (85 yrs.). Note various lumbar paravertebral structures. ESM, erector spinae muscle.
the relatively small psoas muscle (PM) and the loss of contrast between
the various paravertebral structures. ESM, erector spinae muscle; QLM,
quadratus lumborum muscle; VB, vertebral body; AP, articular process.
energy by the intramuscular fat. Therefore, ultrasound lumbar paravertebral sonography and ultrasound-guided
images of the lumbar paravertebral region in the elderly LPB in the elderly can be challenging. The same may
appear whiter and brighter, and there is also loss of con- also be true when LPB is performed in the obese when
trast between the muscle and the adjoining structures excessive fat and increased depth to the relevant structure
(Fig. 12-39), making it difficult to delineate the lumbar can make ultrasound imaging of the lumbar paravertebral
plexus when compared to that in the young. Therefore, region difficult (Fig. 12-40).
ch12.indd 279 23-08-2017 18:40:38

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ch12.indd 280 23-08-2017 18:40:38

Index
Note: Page numbers followed by f indicate figures; and page numbers followed by t indicate tables.
A B vertebra C1 (atlas), 143, 143f

Abdominal wall nerve blocks, 106–125 Bayonet artifacts, 12, 12f vertebra C2 (axis), 143–144
anterior abdominal wall nerve, Blood vessels, 7, 225 vertebra C3 to C6, 139–143, 139f,
109–111 Bone, Doppler ultrasound imaging 140f, 141f, 142f, 143f, 144f
ilioinguinal and iliohypogastic of, 7, 8f vertebra C7, 144
nerve, 119–120, 120f Brachial plexus cervical facet joint injection,
lateral transverse abdominis plane, axilla, 20, 21f, 42–46 ultrasound for, 144, 150–153,
111–112, 111f, 112f gross anatomy of, 18, 18f, 19f, 22f 150f, 151f, 152f, 153f
muscles of anterior abdominal wall, infraclavicular fossa computed tomography (CT)
106–109, 106f, 107f, 108f, gross anatomy, 20f, 30–31, anatomy of, 144f, 145f, 146f
109f, 110f 30f, 31f magnetic resonance imaging (MRI)
quadratus lumborum block, 120– lateral, ultrasound imaging anatomy of, 146f, 147f, 148f,
125, 121f, 122f, 123f, 124f technique for, 38–42 149f, 150f
rectus sheath, 114–119, 115f, 116f, medial, ultrasound imaging selective nerve root block,
117f, 118f, 119f technique for, 31–38 ultrasound for, 154–157, 154f,
subcostal transverse abdominis interscalene groove 155f, 156f
plane, 112–114, 113f, 114f diaphragm excursion assessment, stellate ganglion block., ultrasound
Acoustic enhancement artifacts, 12, 12f 27–28 for, 157–159, 157f, 158f, 159f
Acoustic shadowing artifacts, 12 gross anatomy, 20f, 22 third occipital nerve block.,
Aliasing in Doppler ultrasound ultrasound imaging technique for, ultrasound for, 153–154
imaging, 15–16, 15f, 16f 23–27 Color Doppler imaging display, 14,
Anechoic appearance, 3, 3f supraclavicular fossa, 20f, 28–30, 14f, 15f, 16f
Anesthesia, ultrasound-guided 28f, 29f, 30f Compound imaging, 8–9, 9f
regional. See Muscoskeletal Breast, innervation of, 226, 226f Computed tomography (CT) anatomy
and Doppler ultrasound Brightness color (B-color) mode anterior superior iliac spine, 119f
imaging imaging, 12–13 cervical spine, 144f, 145f, 146f
Anisotrophy, in Doppler ultrasound femoral nerve at inguinal region, 68f
imaging, 5–6, 6f C infraclavicular fossa, 31f, 32f
Anterior superior iliac spine (ASIS), caudal epidural injection, ultrasound lateral transverse abdominis plane,
120, 121f for, 205–208, 206f, 207f, 208f 111f
Artifacts, in Doppler ultrasound CCS (costoclavicular space), 19–20, lower thoracic spine, 169f
imaging, 10–12 21f, 36f lumbar plexus block (LPB), 268f
Atlas vertebrae, in cervical spine, 143, Central neuraxial blocks. See Lumbar lumbar spine, 183f, 184f, 185f
143f spine; Sacrum and lumbosacral midfemoral/adductor canal region,
Axial scans, 1f junction 77f
Axilla, brachial plexus, 20, 21f, 42–46, Cervical spine, 139–161. See also mid thoracic spine, 166f, 167f
43f, 45f, 46f Lumbar spine; Spine, basic neck and interscalene region,
Axis of intervention, 3, 4f considerations for; Thoracic 22–23, 23f
Axis vertebrae, in cervical spine, spine obturator nerve at inguinal
143–144 anatomy of region, 71f
281
index.indd 281 23-08-2017 18:53:42

282 n Index
Computed tomography (CT) anatomy sacral hiatus changes in, 209 Interlaminar space anatomy. See
(Cont.) spinal changes of, 132–133 Sacrum and lumbosacral
rectus abdominis muscle, 116f Epidural injections, thoracic. See junction
sacrum and lumbosacral junction, Thoracic spine Ixternal oblique muscle (IOM),
205f, 211f Equation, Doppler, 13–14, 13f 106–108
sciatic nerve External oblique muscle (EOM), Internal oblique muscle (IOM), 106,
infragluteal region, 88f 106–107, 106f, 107f, 108f 107f, 108f, 115
parasacral region, 80f Interscalene groove
popliteal fossa, 91f, 92f F Diaphragmatic excursion
subgluteal region, 84f Fascia assessment, 27–28
thigh–anterior approach, 95f Doppler ultrasound imaging of, 7 gross anatomy, 20f, 22
subcostal transverse abdominis in thoracic interfacial nerve ultrasound imaging technique for,
plane, 113f blocks, 225 23–27
terminal nerves in leg, 101f Femoral nerve at inguinal region Intervertebral spaces identified by
thoracic paravertebral blocks, computed tomography (CT) ultrasound, 177
242f, 243f anatomy of, 68f Isoechoic appearance, 3, 3f
upper thoracic spine, 165f gross anatomy, 66–67, 67f
Contact artifacts, 11 magnetic resonance imaging (MRI) L
Coronal anatomical plane, 130, 130f anatomy of, 68f Lateral cutaneous nerve of thigh
Costoclavicular space (CCS), 19–20, ultrasound scan technique for, gross anatomy, 73–74
21f, 36f 67–70 magnetic resonance imaging (MRI)
Curved array transducers, 5, 5f Field of view (FOV), in Doppler anatomy of, 74f
ultrasound imaging, 3–5, 5f ultrasound scan technique for, 74–75
D Lateral transverse abdominis plane,
Diaphragmatic excursion assessment, H 111–112, 112f
27–28, 28f Hyperechoic appearance, 3, 3f Ligaments, Doppler ultrasound
Doppler gain in ultrasound imaging, Hypoechoic appearance, 3, 3f imaging of, 8f
16–17, 17f Linear array transducers, 5, 5f
Doppler shift, 14, 14f I Longitudinal scans, 1–2, 1f
Doppler ultrasound imaging. See Ilioinguinal and iliohypogastic nerve, Lower extremity nerve blocks,
Muscoskeletal and Doppler 119–120, 120f 64–105
ultrasound imaging Image orientation, 2, 2f femoral nerve at inguinal region
Imaging, ultrasound. See computed tomography (CT)
E Muscoskeletal and Doppler anatomy of, 68f
Echogenicity, in Doppler ultrasound ultrasound imaging gross anatomy, 66–67, 67f
imaging, 3, 7f, 8f, 13f Infraclavicular fossa magnetic resonance imaging
Echo-intensity of skeletal muscles, 278 gross anatomy, 20f, 30–31, 30f, 31f (MRI) anatomy of, 68f
Elbow region: median, ulnar, and lateral, ultrasound imaging ultrasound scan technique for,
radial nerves technique for, 38–42, 38f, 39f, 67–70, 68f, 69f
gross anatomy, 52–54, 54f, 55f, 56f, 41f, 42f gross anatomy of, 64–66, 64f, 65f,
57f, 58f medial, ultrasound imaging 66f
ultrasound scan technique for, technique for, 31–38, 33f, 34f, lateral cutaneous nerve of thigh
54–58 35f, 36f, 37f, 38f, 39f, 40f gross anatomy, 73–74
Elderly patients scan of, 5f magnetic resonance imaging
Doppler ultrasound imaging of, Inguinal region. See Femoral nerve (MRI) anatomy of, 74f
12, 13f at inguinal region; Obturator ultrasound scan technique for,
echo-intensity of skeletal muscles nerve at inguinal region 74–75, 74f, 75f
increased in, 278 Innervation of breast, 226, 226f midfemoral/adductor canal region
index.indd 282 23-08-2017 18:53:42

Index n 283
Lower extremity nerve blocks (Cont.) ultrasound scan technique for, sagittal ultrasound imaging of,
computed tomography (CT) 84–86, 84f, 85f, 86f 199–202, 200f, 201f
anatomy of, 77f sciatic nerve at thigh--anterior transverse ultrasound imaging of,
magnetic resonance imaging approach 196–199, 197f, 198f, 199f
(MRI) anatomy of, 77f computed tomography (CT) ultrasound imaging of, 186–196,
ultrasound scan technique for, anatomy of, 95f 186f, 187f, 188f, 189f, 190f,
77–79, 78f, 79f gross anatomy, 94–95, 95f 191f, 192f, 193f, 194f, 195f, 196f
obturator nerve at inguinal region magnetic resonance imaging Lumbosacral junction. See Sacrum and
computed tomography (CT) (MRI) anatomy of, 95f lumbosacral junction
anatomy of, 71f ultrasound scan technique for, Lungs, Doppler ultrasound imaging
gross anatomy, 70, 70f 95–97, 96f, 97f of, 8f
magnetic resonance imaging terminal nerves in leg
(MRI) anatomy of, 71f computed tomography (CT) M
ultrasound scan technique for, anatomy of, 101f Magnetic resonance imaging (MRI)
71–73, 71f, 72f, 73f gross anatomy, 97–100, 98f, anatomy
saphenous nerve at adductor canal, 99f, 100f anterior superior iliac spine, 119f
75–77, 76f magnetic resonance imaging axilla, 44f
sciatic nerve at infragluteal (MRI) anatomy of, 101f brachial plexus, 29f
region ultrasound scan technique for, cervical spine, 146f, 147f, 148f,
computed tomography (CT) 101–104, 101f, 102f, 103f 149f, 150f
anatomy of, 88f Lumbar plexus block (LPB), 265–283 elbow region, 55f
gross anatomy, 86–87, 88f anatomy, 265–268, 265f, 266f, 267f, femoral nerve at inguinal region, 68f
magnetic resonance imaging 268f infraclavicular fossa, 32f
(MRI) anatomy of, 88f computed tomography (CT) lateral transverse abdominis plane, 111f
ultrasound scan technique for, anatomy of, 268f lower thoracic spine, 169f
87–89, 88f, 89f magnetic resonance imaging (MRI) lumbar plexus block (LPB), 268f, 269f
sciatic nerve at parasacral region anatomy of, 268f, 269f lumbar spine, 184f, 185f, 186f
computed tomography (CT) ultrasound technique for midfemoral/adductor canal region, 77f
anatomy of, 80f overview, 269–270, 270f midforearm region, 59f
gross anatomy, 79–80 paramedian transverse oblique midhumeral region, 50f, 51f
magnetic resonance imaging scan, 272–275, 273f, 274f, mid thoracic spine, 166f, 167f
(MRI) anatomy of, 80f 275f, 279f neck and interscalene region, 24f
ultrasound scan technique for, sagittal sonoanatomy, 271–272, obturator nerve at inguinal region, 71f
80–83, 81f, 82f, 83f 271f rectus abdominis muscle, 116f
sciatic nerve at popliteal fossa shamrock method for transverse sacrum and lumbosacral junction,
computed tomography (CT) sonoanatomy, 275–277, 275f, 205f, 211f, 212f
anatomy of, 91f, 92f 276f, 277f sciatic nerve
gross anatomy, 90–91, 90f, 91f Lumbar spine, 179–203. See also infragluteal region, 88f
magnetic resonance imaging Cervical spine; Sacrum and parasacral region, 80f
(MRI) anatomy of, 91f, 92f lumbosacral junction; Spine, popliteal fossa, 91f, 92f
ultrasound scan technique for, basic considerations for; subgluteal region, 84f
92–94, 93f, 94f, 95f Thoracic spine thigh–anterior approach, 95f
sciatic nerve at subgluteal region anatomy of, 179–183, 179f, 180f, subcostal transverse abdominis
computed tomography (CT) 181f, 182f, 183f plane, 113f
anatomy of, 84f computed tomography (CT) terminal nerves in leg, 101f
gross anatomy, 83–84, 84f anatomy of, 183f, 184f thoracic paravertebral blocks, 243f,
magnetic resonance imaging magnetic resonance imaging (MRI) 244f
(MRI) anatomy of, 84f anatomy of, 184f, 185f, 186f upper thoracic spine, 165f, 166f
index.indd 283 23-08-2017 18:53:42

284 n Index
Magnetic resonance neurography echogenicity, 3, 3f Neuraxial blocks, central. See Lumbar

(MRN) imaging, 18f of elderly patients, 12, 13f spine; Sacrum and lumbosacral
Median anatomical plane, 130, 130f field of view and needle visibility, junction
Median nerve 3–5, 5f
elbow region, 52–58, 54f, 55f, normal structures identification O
56f, 58f blood vessels, 7 Obese patients
midforearm region, 58–62, 59f, 60f, bone, 7, 8f Doppler ultrasound imaging of,
61f, 62f fascia, 7 12–13
midhumeral region, 46–49 muscles, 6–7, 7f lumbar paravertebral region
Midfemoral/adductor canal region nerves, 6, 7f sonogram of, 279f
computed tomography (CT) pleura, 7, 8f Obturator nerve at inguinal region
anatomy of, 77f subutaneous fat, 7 computed tomography (CT)
magnetic resonance imaging (MRI) tendons, 6 anatomy of, 71f
anatomy of, 77f of obese patients, 12–13 gross anatomy, 70
ultrasound scan technique for, optimization of, 2–3 magnetic resonance imaging (MRI)
77–79, 78f, 79f scanning plane, 1–2, 1f, 2f anatomy of, 71f
Midforearm region: median, ulnar, and science of, 13–14, 13f, 14f, 15f ultrasound scan technique for,
radial nerves, 58–62, 59f, 60f, special features 71–73, 71f, 72f, 73f
61f, 62f compound imaging, 8–9, 10f Osseous elements of spine, 131–137,
Midhumeral region panoramic imaging, 9, 9f 132f, 133f, 134f, 135f, 136f, 137f
median and ulnar nerve, 46–49, 46f, three-dimensional ultrasound,
47f, 48f, 50f, 51f, 52f 9–10, 10f P
radial nerve, 48f, 49–52, 50f, 51f, 53f tissue harmonic imaging, 7–8 Panoramic imaging, 9, 9f
Mirror image artifacts, 11, 11f spectral broadening in, 16 Paramedian sagittal oblique scan
MRI (magnetic resonance imaging) transducer and image orientation, (PMSOS), 131, 131f, 132f,
anatomy. See Magnetic 2, 2f 137f, 199
resonance imaging (MRI) ultrasound transducer frequency, 1 Paramedian transverse oblique scan,
anatomy 272–275, 273f, 274f, 275f, 279f
MRN (magnetic resonance N Pectoral nerve blocks. See Thoracic
neurography) imaging, 18f Neck and interscalene region interfacial nerve blocks
Muscles computed tomography (CT) Pleura, Doppler ultrasound imaging
of anterior abdominal wall, anatomy of, 22–23 of, 7, 8f
106–109, 106f, 107f, 108f, magnetic resonance imaging (MRI) Power Doppler imaging display,
109f, 110f of, 24f 14–15, 15f
Doppler ultrasound imaging of, sagittal sonogram of, 27f Propagation speed artifacts, 11–12, 12f
6, 7f transverse sonogram of, 25f, 26f, 27f Psoas compartment block (PCB). See
echo-intensity of skeletal, 278 Needle visibility, in Doppler Lumbar plexus block (LPB)
in thoracic interfacial nerve blocks, ultrasound imaging, 3–5
219–222, 219f, 220f, 221f Nerve blocks. See Abdominal wall Q
Muscoskeletal and Doppler ultrasound nerve blocks; Lower extremity Quadratus lumborum block (QLB),
imaging, 1–17 nerve blocks; Thoracic 120–125, 121f, 122f, 123f, 124f
aliasing in, 15–16, 15f, 16f interfacial nerve blocks; Upper
anisotrophy, 5–6, 6f extremity nerve blocks R
artifacts in, 10–12, 11f, 12f Nerves Radial nerve
axis of intervention, 3, 4f of anterior abdominal wall, 109–111 elbow region, 52–58, 54f, 55f, 56f, 58f
basic steps for, 17 Doppler ultrasound imaging of, 6, 7f midforearm region, 58–62, 59f, 62f
display of, 14–15 in thoracic interfacial nerve blocks, midhumeral region, 49–52, 50f, 51f,
Doppler gain in, 16–17, 17f 222–225, 222f, 223f, 224f, 225f 52f, 53f
index.indd 284 23-08-2017 18:53:43

Index n 285
Rectus abdominis muscle (RAM), 106, ultrasound scan technique for, sonography of, 129–131, 129f, 130f,
107f, 108f, 109, 115–116, 117f, 80–83, 81f, 82f, 83f 131f
118f, 119f popliteal fossa Stellate ganglion block, ultrasound for,
Rectus sheath, 106f, 114–119, 115f, computed tomography (CT) 157–159, 157f, 158f, 159f
116f, 117f, 118f, 119f anatomy of, 91f, 92f Subcostal transverse abdominis plane,
Reverberation artifacts, 11, 11f gross anatomy, 90–91, 90f, 91f 112–114, 113f, 114f
magnetic resonance imaging Subcutaneous fat, Doppler ultrasound
S (MRI) anatomy of, 91f, 92f imaging of, 7
Sacrum and lumbosacral junction, ultrasound scan technique for, Superior costotransverse ligament
203–219 92–94, 93f, 94f, 95f (SCTL), 240
anatomy of, 203–204, 203f, 204f subgluteal region Supraclavicular fossa, of brachial
caudal epidural injections, computed tomography (CT) plexus, 20f, 28–30, 28f, 29f, 30f
ultrasound for, 205–208, 206f, anatomy of, 84f
207f, 208f gross anatomy, 83–84, 84f T
computed tomography (CT) magnetic resonance imaging TAM (transverse abdominis muscle),
anatomy of, 205f, 211f (MRI) anatomy of, 84f 106, 107f, 108, 108f, 112
interlaminar space anatomy, ultrasound scan technique for, TAP (transverse abdominis plane),
209–210, 209f, 210f, 84–86, 84f, 85f, 86f 110–112, 111f, 122f
211f, 212f thigh–anterior approach Tendons, Doppler ultrasound imaging
magnetic resonance imaging computed tomography (CT) of, 6
(MRI) anatomy of, 205f, anatomy of, 95f Terminal nerves in leg
211f, 212f gross anatomy, 94–95, 95f computed tomography (CT)
ultrasound of interlaminar space magnetic resonance imaging anatomy of, 101f
in, 211–216, 212f, 213f, 214f, (MRI) anatomy of, 95f gross anatomy, 97–100, 98f, 99f,
215f, 216f, 217f ultrasound scan technique for, 100f
Sagittal scans, 1–2, 1f 95–97, 96f, 97f magnetic resonance imaging (MRI)
Sagittal sonoanatomy, 271–272, 271f SCTL (superior costotransverse anatomy of, 101f
Saphenous nerve at adductor canal, ligament), 240 ultrasound scan technique for, 101f,
75–77, 76f Selective nerve root block, ultrasound 102f, 103f
Scalene muscles, brachial plexus for, 154–157, 154f, 155f, 156f TGC (time gain compensation), 3
relation to, 19f Serratus plane block. See Thoracic THI (tissue harmonic imaging), 7–8,
Scanning plane, in Doppler ultrasound interfascial nerve blocks 8f, 12
imaging, 1–2 Shamrock method for transverse Third occipital nerve block., ultrasound
Sciatic nerve sonoanatomy, 275–277, 275f, for, 153–154
infragluteal region 276f, 277f Thoracic interfacial nerve blocks,
computed tomography (CT) Spectral broadening in Doppler 219–240
anatomy of, 88f ultrasound imaging, 16, 16f, 17f anatomy
gross anatomy, 86–87, 88f Spectral Doppler imaging display, blood vessels, 225
magnetic resonance imaging 15, 15f fascia, 225
(MRI) anatomy of, 88f Spine. See also Cervical spine; Lumbar muscles, 219–222, 219f, 220f,
ultrasound scan technique for, spine; Sacrum and lumbosacral 221f
87–89, 88f, 89f junction; Thoracic spine nerves, 222–225, 222f, 223f, 224f,
parasacral region basic considerations for, 126–139 225f
computed tomography (CT) anatomy of, 126–129, 126f, 127f, innervation of breast, 226, 226f
anatomy of, 80f 128f, 129f overview, 219
gross anatomy, 79–80 osseous element sonoanatomy, ultrasound for, 226–238, 227f, 228f,
magnetic resonance imaging 131–137, 132f, 133f, 134f, 229f, 230f, 231f, 232f, 233f,
(MRI) anatomy of, 80f 135f, 136f, 137f 234f, 235f, 236f, 237f, 238f
index.indd 285 23-08-2017 18:53:43

286 n Index
Thoracic paravertebral block (TPVB), Three-dimensional ultrasound, 9–10, brachial plexus: infraclavicular
240–265 10f fossa
anatomy of, 240–242, 240f, 241f, 242f Time gain compensation (TGC), 3 gross anatomy, 30–31, 30f, 31f
communications of thoracic Tissue harmonic imaging (THI), 7–8, lateral, ultrasound imaging
paravertebral space, 242 8f, 12 technique for, 38–42, 38f, 39f,
computed tomography (CT) TPVB (thoracic paravertebral block). 40f, 41f, 42f
anatomy of, 242f, 243f See Thoracic paravertebral medial, ultrasound imaging
magnetic resonance imaging (MRI) block (TPVB) technique for, 31–38, 32f, 33f,
anatomy of, 243f, 244f Transducers. See also ultrasound 34f, 35f, 36f, 37f
three-dimensional sonography of, descriptions for various body brachial plexus: interscalene groove,
260–262, 261f, 262f regions 22–28
ultrasound scan technique for, curved array, 5, 5f diaphragmatic excursion
244–260, 245f, 246f, 247f, frequency of ultrasound, 1 assessment, 27–28, 28f
248f, 249f, 250f, 251f, 252f, linear array, 5, 5f gross anatomy, 22, 23f
253f, 254f, 255f, 256f, 257f, orientation of, 2, 2f ultrasound imaging technique for,
258f, 259f, 260f Transverse abdominis muscle (TAM), 23–27, 24f, 25f, 26f, 27f
Thoracic spine, 161–179. See also 106, 107f, 108, 108f, 112 brachial plexus: supraclavicular
Cervical spine; Spine, basic Transverse abdominis plane (TAP), fossa, 28–30, 28f, 29f, 30f
considerations for 110–112, 111f, 122f elbow region: median, ulnar, and
anatomy of, 161–164, 161f, 162f, Transverse anatomical plane, radial nerves
163f, 164f, 166f, 168f 130, 130f gross anatomy, 52–54
computed tomography (CT) Transverse scans, 1, 1f, 2f ultrasound scan technique for,
anatomy 54–58
lower, 168f, 169f U gross anatomy of, 18–22, 18f, 19f,
mid, 166f, 167f Ulnar nerve 20f, 21f, 22f
upper, 165f elbow region, 52–58, 54f, 55f, 57f midforearm region: median, ulnar,
magnetic resonance imaging (MRI) midforearm region, 58–62, 59f, and radial nerves, 58–62
anatomy 61f, 62f midhumeral region
lower, 169f midhumeral region, 46–49 median and ulnar nerve, 46–49
mid, 166f, 167f Ultrasound-guided regional anesthesia radial nerve, 49–52
upper, 165f, 166f (USGRA). See Muscoskeletal USGRA (ultrasound-guided regional
ultrasound of and Doppler ultrasound anesthesia). See Muscoskeletal
intervertebral spaces identified imaging and Doppler ultrasound
by, 177 Ultrasound imaging. See imaging
lower, 175–177, 176f, 177f Muscoskeletal and Doppler
mid, 173–175, 174f, 175f ultrasound imaging V
overview, 169–171, 170f, 171f Ultrasound transducer frequency, 1 Vertebrae. See Cervical spine;
upper, 171–173, 172f, 173f Uncovertebral joint osteophytes, 140 Lumbar spine; Spine, basic
Three-dimensional sonography of Upper extremity nerve blocks, 18–63 considerations for; Thoracic
thoracic paravertebral blocks, brachial plexus: axilla, 42–46, 43f, spine
260–262, 261f, 262f 44f, 45f, 46f
index.indd 286 23-08-2017 18:53:43

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FM.indd 1 01-09-2017 11:16:48

FM.indd 2 01-09-2017 11:16:49

Edmund Soh, BSc, MRCP, FRCR

Victor Chee, MD, M.Med (Anesthesiology)

Kenneth Sheah, MBBS, FRCR, MMed (Diagnostic Radiology)

New York Chicago San Francisco Athens London Madrid

FM.indd 3 01-09-2017 11:16:49

eBook conversion by codeMantra

FM.indd 5 01-09-2017 11:16:49

FM.indd 6 01-09-2017 11:16:49

FM.indd 7 01-09-2017 11:16:49

FM.indd 8 01-09-2017 11:16:49

FM.indd 9 01-09-2017 11:16:49

FM.indd 10 01-09-2017 11:16:49

A Transverse, or Axial, or Cross-sectional, Axis of Scan

FIGURE 1-1 ■ Axis of scan.

ch01.indd 1 23-08-2017 16:01:55

Transverse Scan of Right Axilla

FIGURE 1-3 ■ Image orientation – transverse scan.

ch01.indd 2 23-08-2017 16:02:01

Contrast resolution is the ability to distinguish subtle dif-

Isoechoic Hypoechoic Hyperechoic Anechoic

FIGURE 1-4 ■ Echogenicity of tissues.

ch01.indd 3 23-08-2017 16:02:02

Axis of Intervention - Short Axis

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

Axis of Intervention - Long Axis

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

ch01.indd 4 23-08-2017 16:02:15

Infraclavicular Fossa Scan

ch01.indd 5 23-08-2017 16:02:18

ch01.indd 6 23-08-2017 16:02:21

Nerve and Muscle

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Bone, Pleura and Lung

Intercostal space - Bone, Thoracic paravertebral space - Bone,

Tissue Harmonic Imaging

Sagittal Scan - Infraclavicular Fossa

Conventional Scan Scan with THI - note the reduction

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Transverse Scan of the Axilla

Conventional Scan Compound Imaging - note the speckle

Panoramic Imaging of the Forearm

ch01.indd 9 23-08-2017 16:02:51

1. The ultrasound beam travels in a straight line with a con-

ch01.indd 10 23-08-2017 16:03:03

occur whenever there is repeated reflection of the ultra-

Transducer Subclavian artery

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A Biceps muscle scan - 28 yr B Biceps muscle scan - 94 yr

Median nerve Median nerve

C Mid-forearm scan - 28 yr D Mid-forearm scan - 94 yr

is able to distinguish a greater number of color hues. Subtle