topics / مواضيع: ANESTHESIA Hadzic's Peripheral Nerve Blocks Hadzic parte 01

ANESTHESIA Hadzic's Peripheral Nerve Blocks Hadzic parte 01

DEDICATION

I dedicate this book to Dr. Jerry Darius Vloka,

a peerless scholar whose contribution to and teaching of

regional anesthesia have provided an educational platform and

inspiration for generations of practitioners and academicians alike.

You are a beacon of light and a paragon of scholarship and virtue.

I am profoundly privileged to number you among my closest friends.

May many generations of students slake their thirst at the well of your wisdom,

and may our friendship outpace the ravages of time.

With love and respect,

Admir

“Tell me what company thou keepst, and I’ll tell thee what thou art.”

Cervantes

CONTENTS

Contributors

reface

Acknowledgments

SECTION 1

FOUNDATIONS OF PERIPHERAL NERVE BLOCKS

Essential Regional Anesthesia Anatomy

Admir Hadzic and Carlo Franco

Local Anesthetics: Clinical Pharmacology and Rational Selection

Jeff Gadsden

Equipment for Peripheral Nerve Blocks

Ali Nima Shariat, Patrick M. Horan, Kimberly Gratenstein, Colleen McCally, and Ashton P.

Frulla

Electrical Nerve Stimulators and Localization of Peripheral Nerves

Martin Simpel and Andre van Zundert

Monitoring and Documentation

Jeff Gadsden

Indications for Peripheral Nerve Blocks

Jeff Gadsden

Continuous Peripheral Nerve Blocks in Outpatients

Brian M. Ilfeld, Elizabeth M. Renehan, and F. Kayser Enneking

Regional Anesthesia in the Anticoagulated Patient

Honorio T. Benzon

Toxicity of Local Anesthetics

Steven Dewaele and Alan C. Santos

0. Neurologic Complications of Peripheral Nerve Blocks

Jeff Gadsden

SECTION 2

NERVE STIMULATOR AND SURFACE-BASED NERVE BLOCK TECHNIQUES

1. Cervical Plexus Block

2. Interscalene Brachial Plexus Block

3. Supraclavicular Brachial Plexus Block

4. Infraclavicular Brachial Plexus Block

5. Axillary Brachial Plexus Block

6. Wrist Block

7. Cutaneous Nerve Blocks of the Upper Extremity

8. Lumbar Plexus Block

9. Sciatic Block

art 1. Transgluteal Approach

art 2. Anterior Approach

0. Popliteal Sciatic Block

art 1. Intertendinous Approach

art 2. Lateral Approach

1. Femoral Nerve Block

2. Ankle Block

3. Thoracic Paravertebral Block

4. Intercostal Block

SECTION 3

INTRAVENOUS REGIONAL ANESTHESIA

5. Bier Block

SECTION 4

FOUNDATIONS OF ULTRASOUND-GUIDED NERVE BLOCKS

6. Ultrasound Physics

Daquan Xu

7. Optimizing an Ultrasound Image

Daquan Xu

SECTION 5

ULTRASOUND-GUIDED NERVE BLOCKS

8. Ultrasound-Guided Cervical Plexus Block

9. Ultrasound-Guided Interscalene Brachial Plexus Block

0. Ultrasound-Guided Supraclavicular Brachial Plexus Block

1. Ultrasound-Guided Infraclavicular Brachial Plexus Block

2. Ultrasound-Guided Axillary Brachial Plexus Block

3. Ultrasound-Guided Forearm Blocks

4. Ultrasound-Guided Wrist Block

5. Ultrasound-Guided Femoral Nerve Block

6. Ultrasound-Guided Fascia Iliaca Block

7. Ultrasound-Guided Obturator Nerve Block

8. Ultrasound-Guided Saphenous Nerve Block

9. Ultrasound-Guided Sciatic Block

art 1. Anterior Approach

art 2. Transgluteal and Subgluteal Approach

0. Ultrasound-Guided Popliteal Sciatic Block

1. Ultrasound-Guided Ankle Block

2. Common Ultrasound-Guided Truncal and Cutaneous Blocks

art 1. Transversus Abdominis Plane Block

art 2. Iliohypogastric and Ilioinguinal Nerve Blocks

art 3. Rectus Sheath Block

art 4. Lateral Femoral Cutaneous Nerve Block

SECTION 6

ULTRASOUND-GUIDED NEURAXIAL AND PERINEURAXIAL BLOCKS

3. Introduction

Manoj Karmakar and Catherine Vandepitte

4. Spinal Sonography and Considerations for Ultrasound-Guided Central Neuraxial Blockade

Wing Hong Kwok and Manoj Karmakar

5. Sonography of Thoracic Paravertebral Space and Considerations for Ultrasound-Guided Thoracic

Paravertebral Block

Catherine Vandepitte, Tatjana Stopar Pintaric, and Philippe E. Gautier

6. Ultrasound of the Lumbar Paravertebral Space and Considerations for Lumbar Plexus Block

Manoj Karmakar and Catherine Vandepitte

SECTION 7

ATLAS OF ULTRASOUND-GUIDED ANATOMY

SECTION 8

ATLAS OF SURFACE ANATOMY

Index

CONTENTS FOR DVD

5 NERVE BLOCKS FOR 95% OF INDICATIONS

Ultrasound-Guided Interscalene Block

Ultrasound-Guided Supraclavicular Block

Ultrasound-Guided Axillary Block

Ultrasound-Guided Femoral Nerve Block

Ultrasound-Guided Popliteal Block

CONTRIBUTORS

Marina Alen, MD

Fellow, Regional Anesthesia

St. Luke’s–Roosevelt Hospital Center

New York, New York

Honorio T. Benzon, MD

Professor

Department of Anesthesiology

Feinberg School of Medicine

Northwestern University

Chicago, Illinois

Rafael Blanco, MD

MBBS, F.R.C.A., D.E.A.A. & Intensive Care

Consultant Anaesthesiologist

Complexo Hospitalario Universitario A Coruña

Spain

Ana Carrera, PhD, MD

Lecturer of Human Anatomy

Faculty of Medicine

University of

Girona Girona, Spain

Lorenzo Casertano, CSCS

Physical Therapy

Columbia University, New York, New York

Junping Chen, MD

Fellow, Regional Anesthesia

St. Luke’s–Roosevelt Hospital Center

New York, New York

Thomas B. Clark, DC, RVT

Adjunct Professor of Radiology

Department of Radiology

Logan College of Chiropractic

St. Louis, Missouri

Adam B. Cohen, MD

Attending Physician

Department of Orthopedic Surgery

St. Luke’s–Roosevelt Hospital Center

New York, New York

Jose De Andrés, MD, PhD

Head of Department

Department of Anesthesia

Hospital General Universitario

Valencia. Spain

Belen De Jose Maria, MD, PhD

Senior Pediatric Anesthesiologist

Department of Pediatric Anesthesia

Hospital Sant Joan de Deu

Barcelona, Spain

Jeffrey Dermksian, MD

Assistant Clinical Professor

Department of Orthopaedic Surgery

Columbia University

New York, New York

Steven A. Dewaele, MD

Associate Consultant

Department of Anesthesiology and Intensive Care

AZ St Lucas

Ghent, Belgium

Tomás Domingo, MD

Pain Unit, Department of Anaesthesiology

Hospital Universitari de Bellvitge

Associate Professor, Human Anatomy

Universitat de Barcelona, Campus de Bellvitge

Barcelona, Spain

F. Kayser Enneking, MD

Professor and Chair

Department of Anesthesiology

University of Florida

Gainesville, Florida

Carlo D. Franco, MD

Professor

Department of Anesthesiology and Anatomy

J.H.S. Hospital Cook County

Rush University Medical Center

Chicago, Illinois

Ashton P. Frulla, BS

Research Assistant

Department of Anesthesiology

St. Luke’s–Roosevelt Hospital

New York, New York

Jeff Gadsden, MD, FRCPC, FANZCA

Assistant Professor of Clinical Anesthesiology

Department of Anesthesiology

College of Physicans and Surgeons

Columbia University

New York, New York

Philippe E. Gautier, MD

Head of Department

Department of Anaesthesia

Clinique Ste Anne-St Remi

Brussels, Belgium

Kimberly Gratenstein, MD

Regional Anesthesia Fellow

Department of Anesthesiology

St. Luke’s–Roosevelt Hospital

New York, New York

Fermin Haro-Sanz, MD

Associate Professor

Anestesiologia Reanimación Terapia del Dolor

Universidad de Navarra

Navarra, Spain

Paul Hobeika, MD

Assistant Professor of Orthopedic Surgery

Department of Orthopedics and Orthopedic Surgery

St. Luke’s–Roosevelt Hospital

College of Physicians and Surgeons Columbia University

New York, New York

Patrick Horan, MPH

Research Fellow

Department of Anesthesiology

St. Luke’s–Roosevelt Hospital

Center New York, New York

Brian M. Ilfeld, MD, MS (Clinical Investigation)

Associate Professor in Residence

Department of Anesthesiology

University of California, San Diego

San Diego, California

Manoj Kumar Karmakar, MD, FRCA, FHKCA, FHKAM

Associate Professor and Director of Paediatric Anesthesia

Department of Anaesthesia and Intensive Care

The Chinese University of Hong Kong

Prince of Wales Hospital

Shatin, New Territories

Hong Kong

Kwesi Kwofie, MD

Fellow, Regional Anesthesia

St. Luke’s–Roosevelt Hospital Center

New York, New York

Wing Hong Kwok, FANZCA

The Chinese University of Hong Kong

Prince of Wales Hospital

Shatin, New Territories

Hong Kong

Manuel Llusa, MD, PhD

Associate Professor

Department of Human Anatomy and Embryology

University of Barcelona

Barcelona, Spain

Ana M. López, MD, PhD

Senior Specialist

Department of Anesthesiology

Hospital Clínic

Barcelona, Spain

Philippe B. Macaire, MD

Senior Consultant

Department of Anesthesiology and Pain Management

Rashid Hospital

Dubai, United Arab Emirates

Thomas Maliakal, MD

Resident

Department of Anesthesiology

St. Luke’s–Roosevelt Hospital Center

New York, New York

Josep Masdeu, MD

Department of Anesthesia

Hospital Moisés Broggi

Consorci Sanitari Integral

Barcelona, Spain

Colleen E. McCally, DO

Regional Anesthesia Fellow

St. Luke’s–Roosevelt Hospital Center

New York, New York

Carlos Morros, MD, PhD

Associate Professor

Department of Anesthesia

Clínica Diagonal. Barcelona. Spain

Alberto Prats-Galino, MD, PhD

Professor

Laboratory of Surgical Neuro-Anatomy

Human Anatomy and Embryology Unit

Faculty of Medicine

University of Barcelona

Barcelona, Spain

Miguel Angel Reina, MD, PhD

Associate Professor

Department of Clinical Medical Sciences and Research

Laboratory of Histology and Imaging

Institute of Applied Molecular Medicine

CEU San Pablo University

School of Medicine

Madrid, Spain

Wojciech Reiss, MD

Fellow, Regional Anesthesia

St. Luke’s–Roosevelt Hospital Center

New York, New York

Elizabeth M. Renehan, MD, MSc, FRCPC

Department of Anesthesiology

University of Florida

Gainesville, Florida

Teresa Ribalta, MD, PhD

Professor of Pathology

Department of Anatomical Pathology

Hospital Clínic

University of Barcelona Medical School, IDIBAPS

Barcelona, Spain

Vicente Roqués, MD, PhD

Consultant Anaesthetist

Anesthesia and Intensive Care

Hospital Universitario Virgen de la Arrixaca

Murcia, Spain

Xavier Sala-Blanch, MD

Staff Anesthesiologist

Department of Anesthesia

Hospital Clinic

University of Barcelona

Barcelona, Spain

Carlos H. Salazar-Zamorano, MD

Attending Anesthesiologist

Anesthesia Resident Coordinator

Department of Anesthesiology

Hospital de Figueres

Figueres, Spain

Gerard Sanchez-Etayo, MD

Department of Anesthesiology

Hospital Clinic

Barcelona, Spain

Alan C. Santos, MD, MPH

Professor of Anesthesiology

College of Physicians and Surgeons

Columbia University

New York, New York

Chairman of Anesthesiology

St. Luke’s–Roosevelt Hospital Center

New York, New York

Luc A. Sermeus, MD

Lector, Department of Anesthesiology

University of Antwerp

Wilrijk, Belgium

Ali Nima Shariat, MD

Clinical Instructor

Department of Anesthesiology

St. Luke’s–Roosevelt Hospital Center

New York, New York

Uma Shastri, MD

Fellow, Regional Anesthesia

St. Luke’s–Roosevelt Hospital Center

New York, New York

Sanjay K. Sinha, MBBS

Director of Regional Anesthesia

Department of Anesthesiology

St. Francis Hospital and Medical Center

Hartford, Connecticut

Dr. rer. nat. Martin Sippel

Senior Vice President

Center of Excellence in Pain Control and CVC

B. Braun Melsungen AG

Melsungen, Germany

Leroy Sutherland, MD

Fellow, Regional Anesthesia

St. Luke’s–Roosevelt Hospital Center

New York, New York

Douglas B. Unis, MD

Assistant Clinical Professor

Department of Orthopaedic Surgery

College of Physicians and Surgeons

Columbia University

New York, New York

Catherine F. M. Vandepitte, MD

Consultant Anesthesiologist

Katholieke Universiteit

Leuven Leuven, Belgium

André van Zundert, MD, PhD, FRCA, EDRA

Professor of Anesthesiology

Catharina Hospital

Eindhoven, Netherlands

University Maastricht

Maastricht, Netherlands

University of Ghent

Ghent, Belgium

Chi H. Wong, MS, DO

Anesthesiology Resident

Department of Anesthesiology

Yale New Haven Hospital

New Haven, Connecticut

Daquan Xu, MD, MSc, MPH

Research Associate

Department of Anesthesiology

St. Luke’s–Roosevelt Hospital Center

New York, New York

Tatjana Stopar Pintaric, MD, PhD, DEAA

Associate Professor of Anesthesiology

University Medical Center Ljubljana

Ljubljana, Slovenia

PREFACE

Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, second edition,

is being published at an exciting time in the development of regional anesthesia. Reflecting on the first

edition of the book,*

we believe its success was due largely to the tried-and-true nature of the

material taught. It would not be an overstatement to say that the first edition of this book influenced

professional lives of many colleagues and ultimately benefited patients worldwide. The success

helped garner the New York School of Regional Anesthesia (NYSORA) additional esteem that it

enjoys today. In line with the philosophy of the first edition, this second edition minimizes

presentation of theoretical considerations. Instead, the featured techniques and teachings are gleaned

directly from the trenches of the clinical practice of regional anesthesia.

In recent years, the field of regional anesthesia, and in particular peripheral nerve blockade, has

entered an unprecedented renaissance. This renaissance is due primarily to the widespread

introduction of ultrasound-guided regional anesthesia. The ability to visualize the anatomy of interest,

the needle–nerve relationship, and the spread of the local anesthetic has resulted in significant growth

of interest in and use of peripheral nerve blocks. Regardless, many aspects of ultrasound-guided

regional anesthesia still require clarification and standardization. Examples include dilemmas

regarding the ideal placement of the needle for successful and safe blockade, the number of injections

required for individual techniques, the volume of local anesthetic for successful blockade, the

integration of additional monitoring tools such as nerve stimulation and injection pressure monitoring

and many others. For these reasons, we decided to defer publication of the second edition and opted

to wait for clarification from clinical trials or collective experience to provide more solid

recommendations. As a result, just as with the first edition, the second book features only tried-andtrue descriptions of peripheral nerve block techniques with wide clinical applicability rather than a

plethora of techniques and modifications that have mere theoretical considerations. Where the

collective experience has not reached the necessary level to recommend teaching a certain technique

(e.g., neuraxial blocks), we opted to feature anatomic considerations rather than vague or

inadequately developed technique recommendations, which may lead to disappointments, or possibly

complications, if they are adopted without careful consideration.

The second edition is organized as a collection of practical introductory chapters, followed by

detailed and unambiguous descriptions of common regional anesthesia block procedures rather than

an exhaustive theoretical compendium of the literature. Although ultrasound guidance eventually may

become the most prevalent method of nerve blockade globally, most procedures world-wide are still

performed using the methods of peripheral nerve stimulation and/or surface landmarks, particularly in

the developing world. Because this book has been one of the main teaching sources internationally,

we decided to retain the section on the traditional techniques of nerve blockade in addition to the new

section on ultrasound-guided regional anesthesia. Since knowledge of surface anatomy is essential for

practice of both traditional and ultrasound regional anesthesia procedures, we decided to also add an

Atlas of Surface Anatomy (Section 8).

The book is organized in eight sections that progress from the foundations of peripheral nerve

blocks and regional anesthesia to their applications in clinical practice. Ultrasound-guided regional

anesthesia is a field in evolution, and many of its aspects still lack standardization and clear guidance.

For this reason, we decided to produce this new edition as an international collaborative effort. This

collaboration resulted in teaching that is based not only on our experience at NYSORA but also is

endorsed by a number of opinion leaders in the field from around the globe. I would like to thank themfor the contributions, enthusiasm, and passion that they invested in creating the second edition of

Peripheral Nerve Blocks. This book also would not be what it is without the large extended family of

educators and trainees, who took part in the numerous NYSORA educational programs, including our

educational outreach program in developing countries in Asia. I thank you immensely for your input,

which inspired us to deliver this updated edition, and for your multiple contributions through e-mails,

suggestions, and discussion on the NYSORA.com website.

There are no standards of care related to peripheral nerve blocks, despite their widespread use.

With this edition, we have tried to standardize the techniques and the monitoring approach during

local anesthetic delivery, for both greater consistency and greater safety of peripheral nerve blocks.

Different institutions naturally may have different approaches to techniques that they customize for

their own needs. The material we present in this volume however, comes from the trenches of clinical

practice, so to speak. Most procedures described are accompanied by carefully developed flowcharts

to facilitate decision making in clinical practice that the authors themselves use on an everyday basis.

The successful practice of ultrasound-guided regional anesthesia and pain medicine procedures

depends greatly on the ability to obtain accurate ultrasound images and the ability to recognize the

relevant structures. For these reasons, we decided to add an atlas of ultrasound anatomy for regional

anesthesia and pain medicine (Section 7) procedures to this volume. The anatomy examples consist of

a pictorial guide with images of the transducer position needed to obtain the corresponding ultrasound

image and the cross-sectional gross anatomy of the area being imaged. Once the practitioner absorbs

this material, he or she can extrapolate the knowledge of the practical techniques presented to

practice virtually any additional regional anesthesia technique. We have expended painstaking efforts

to provide cross-sectional anatomy examples where possible. Perfecting the matching of ultrasound

and anatomy sections is not always possible because the sonograms and cross-sectional anatomy

views are obtained from volunteers and fresh cadavers, respectively. The reader should keep in mind

that the ultrasound images are obtained from videos during dynamic scanning. For this reason, the

labeled ultrasound images are accurate to the best of our abilities and within the limitations of the

ultrasound equipment even when they do not perfectly match the available paired cross-sectional

anatomy.

Due to popular demand, we decided to include a DVD containing videos of the most common

ultrasound-guided nerve block procedures. Assuming that videos are the most beneficial method for

novices and trainees, we decided to include videos of well-established ultrasound-guided nerve

blocks that should cover most indications for peripheral nerve blocks. Once trainees have mastered

these techniques, they typically require only knowledge about the specific anatomy of the block(s) to

be performed to apply the principles learned in the videos to any other nerve block procedure. This is

another example of how the atlas of ultrasound anatomy (Section 7) included in the book will be

useful. With the wealth of information presented in a systematic fashion, we believe that the Atlas

also will be of value to anyone interested in the ultrasound anatomy of peripheral nerve and

musculoskeletal systems, including radiologists, sonographers, neurologists, and others.

With this edition of Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional

Anesthesia, we have tried to provide a wealth of practical information about the modern practice of

peripheral nerve blocks and the use of ultrasound in regional anesthesia and to present multiple

pathways to troubleshoot common clinical problems. We hope this book will continue to serve as one

of the standard teaching texts in anesthesiology, and we thank the readership of previous edition their

support and encouragement.

Sincerely,Admir Hadzic, MD

ACKNOWLEDGMENTS

This book would not be possible without the contributions and support from a number of remarkable

people and top professionals in their respective fields.

Most notably, special thanks to Professor Alan Santos, MD, the chair of the Department of

Anesthesiology at St. Luke’s–Roosevelt Hospitals, where a significant part of the clinical teaching

and research of the New York School of Regional Anesthesia (NYSORA) has taken place over the

years. Alan’s commitment to education and academics, and his leadership have created a unique

milieu where faculty and staff drawn to academics can excel and pursue their academic goals with a

remarkable departmental support.

Hats off to our current and past fellows in regional anesthesia. You have been immeasurably

helpful and a continuing source of inspiration for many projects and NYSORA endeavors, and you

have been so much fun to work with as well. In particular, thanks and love go to “NYSORA Angels”

Drs. Kim Gratenstein and Colleen Mitgang for the all-around help and positive vibe. I also extend

gratitude to our residents who have helped create teaching ideas and a multitude of didactic

algorithms through our daily interactions in clinical practice.

Many thanks to my numerous U.S. and international collaborators, whose support, relentless

challenges, and innovative didactic material have made a palpable contribution to this project. A bow

to you, my colleagues at St. Luke’s–Roosevelt Hospital, New York, and our site director, Dr. Kurian

Thomas, whose daily organizational skills and clinical leadership made many of our endeavors

possible—often magically so—in these times of increasing financial and manpower strain.

Many thanks to my family: foremost, my son Alen Hadžić, my parents Junuz and Safeta Hadžić, my

sister Admira, and the entire family for allowing me to work on this book project while depriving

them of my presence.

Special thanks to the illustrator, Lejla Hadžić. Her artistic vision and talent adorns this book with

a plethora of detailed illustrations. Lejla has been spearheading multiple projects in her own primary

area of expertise, restoration of war- and weather-ravaged cultural monuments with a Swedish-based

organization, Cultural Heritage Without Borders (CHWB), for which she has received much

international acclaim. Many thanks also to Emma Spahic for lending her artistic eye and Photoshop

skills to the project.

This book owes a great deal to a number of gifted clinicians, academicians, and regional

anesthesia teams from around the globe. Many thanks to Dr. Catherine Vandepitte, who has spent

countless hours editing and collating the material. Daquan Xu, MD, has contributed his unmatched

organizational skills and knowledge of anatomy and ultrasonography. At the peak of our efforts to

produce this book, Daquan actually moved in with me in my apartment on the Hudson River in

Lincoln Harbor, across from the Midtown section of Manhattan. While enduring 16- to 18-hour days

working on the book in the winter of 2011, Daquan would take five-minute breaks on the balcony to

gaze over the skyline of New York. We would stop working only when Daquan became so tired that

he could not see the Empire State Building any more. This sign became known as “The Daquan Sign

to Quit Working”. Boundless appreciation to Dr. Sala-Blanch and his team, Miguel Reina, Ana

Carrera, Ana Lopez, and many others, for their support, contribution in vision, and, in particular,

original anatomic material. Thank you to Dr. Manoj Karmakar and his team for their cutting-edge

contributions to various sections of the atlas of ultrasound anatomy. Thank you to Thomas Clark, who

used his unmatched skills in musculoskeletal imaging to muster some great ultrasound anatomy in the

Atlas section of the book. Many thanks to Dr. Jeff Gadsden for his contribution and best wishes for

success as he takes over the leadership of the Division of Regional Anesthesia at St. Luke’s–

Roosevelt Hospital, a position I have held for the past 15 years. As he continues to build the division

and the regional anesthesia fellowship, I have moved on to multiple other teaching and publishing

endeavors. In particular, I will focus on keeping our two textbooks on regional anesthesia current in

years to come.

Special thanks to a truly inspiring video team, the Ceho Brothers of Film Productions Division of

Stone Tone Records, Inc. Aziz and Mirza Ceho are award-winning documentary filmmakers who

have contributed their immense artistic talent to the accompanying DVD, 5 Nerve Blocks for 95% of

Indications. Making a good instructional DVD has proved to be an incredibly time-consuming task.

However, we believe our efforts have been justified and we have created a uniquely detailed and

true-to-life educational tool. This DVD should be particularly helpful to clinicians who need to adopt

a few, uniquely effective nerve block techniques that can be used to provide regional anesthesia to a

wide variety of patients.

Many thanks to Brian Belval, senior editor at McGraw-Hill Medical. Brian is one of the most

inspirational and insightful managing editors I have ever worked with. I will admit without

reservation that this book would not be what it is without his vision and personal touch. Likewise, the

unmatchable attention to detail of Robert Pancotti, senior project development editor, has much to do

with the quality of this project.

Special thanks to Lorenzo Casertano for loaning his ripped fencing body for the Atlas of Surface

Anatomy that adorns Section 8 at the end of the book. Likewise, thank you to Alecia Yufa and Alen

Hadž;ić for modeling for the Atlas and the techniques.

Finally, a word of gratitude to my bandmates from Big Apple Blues Band

(www.bigappleblues.com), who contributed the original music on all tracks on the 5 Nerve Blocks

for 95% of Indications DVD. Barry Harrison, Anthony Kane, Hugh Pool, Zach Zunis, Rich Cohen,

Tom Papadatos, and Bruce Tylor are some of the very top cats in the NYC music scene. Their talent

and passion have been an important source of inspiration for me on the band stage, in the studio, and

in life in general.

Disclosure

I have served as an industry advisor over the course of my career and have received consulting

honoraria and research grants in the past from GE, Baxter, Glaxo Smith-Kline Industries SkyPharma,

Cadence, LifeTech, and others. I hold an equity position at Macosta Medical USA. Macosta Medical

USA owns intellectual property related to injection pressure monitoring and several other patents

related to the field of anesthesiology. Finally, I have invested a lifetime’s worth of energy and love

into building NYSORA over the past 15 years. My passion for regional anesthesia and undying

commitment to these multiple endeavors undoubtedly has created biases that may have influenced the

teaching in this book; I take full responsibility and stand by all of them.

SECTION 1

Foundations of Peripheral Nerve Blocks

Chapter 1 Essential Regional Anesthesia Anatomy

Chapter 2 Local Anesthetics: Clinical Pharmacology and Rational Selection

Chapter 3 Equipment for Peripheral Nerve Blocks

Chapter 4 Electrical Nerve Stimulators and Localization of Peripheral Nerves

Chapter 5 Monitoring and Documentation

Chapter 6 Indications for Peripheral Nerve Blocks

Chapter 7 Continuous Peripheral Nerve Blocks in Outpatients

Chapter 8 Regional Anesthesia in the Anticoagulated Patient

Chapter 9 Toxicity of Local Anesthetics

Chapter 10 Neurologic Complications of Peripheral Nerve Blocks

Essential Regional Anesthesia Anatomy

Admir Hadzic and Carlo Franco

A good practical knowledge of anatomy is important for the successful and safe practice of regional

anesthesia. In fact, just as surgical disciplines rely on surgical anatomy, regional anesthesiologists

need to have a working knowledge of the anatomy of nerves and associated structures that does not

include unnecessary details. In this chapter, the basics of regional anesthesia anatomy necessary for

successful implementation of various techniques described later in the book are outlined.

Anatomy of Peripheral Nerves

All peripheral nerves are similar in structure. The neuron is the basic functional unit responsible for

the conduction of nerve impulses (Figure 1-1). Neurons are the longest cells in the body, many

reaching a meter in length. Most neurons are incapable of dividing under normal circumstances, and

they have a very limited ability to repair themselves after injury. A typical neuron consists of a cell

body (soma) that contains a large nucleus. The cell body is attached to several branching processes,

called dendrites, and a single axon. Dendrites receive incoming messages; axons conduct outgoing

messages. Axons vary in length, and there is only one per neuron. In peripheral nerves, axons are very

long and slender. They are also called nerve fibers.

FIGURE 1-1. Organization of the peripheral nerve.

Connective Tissue

The individual nerve fibers that make up a nerve, like individual wires in an electric cable, are

bundled together by connective tissue. The connective tissue of a peripheral nerve is an important part

of the nerve. According to its position in the nerve architecture, the connective tissue is called the

epineurium, perineurium, or endoneurium (Figure 1-2). The epineurium surrounds the entire nerve

and holds it loosely to the connective tissue through which it runs. Each group of axons that bundles

together within a nerve forms a fascicle, which is surrounded by perineurium. It is at this level that the

nerve–blood barrier is located and constitutes the last protective barrier of the nerve tissue. The

endoneurium is the fine connective tissue within a fascicle that surrounds every individual nerve

fiber or axon.

FIGURE 1-2. Histology of the peripheral nerve and connective tissues. White arrows: External

epineurium (epineural sheath), 1 = Internal epineurium, 2 = fascicles, Blue arrows: Perineurium, Red

arrow: Nerve vasculature Green arrow: Fascicular bundle.

Nerves receive blood from the adjacent blood vessels running along their course. These feeding

branches to larger nerves are macroscopic and irregularly arranged, forming anastomoses to become

longitudinally running vessel(s) that supply the nerve and give off subsidiary branches.

Organization of the Spinal Nerves

The nervous system consists of central and peripheral parts. The central nervous system includes the

brain and spinal cord. The peripheral nervous system consists of the spinal, cranial, and autonomic

nerves, and their associated ganglia. Nerves are bundles of nerve fibers that lie outside the central

nervous system and serve to conduct electrical impulses from one region of the body to another. The

nerves that make their exit through the skull are known as cranial nerves, and there are 12 pairs of

them. The nerves that exit below the skull and between the vertebrae are called spinal nerves, and

there are 31 pairs of them. Every spinal nerve has its regional number and can be identified by its

association with the adjacent vertebrae (Figure 1-3). In the cervical region, the first pair of spinal

nerves, C1, exits between the skull and the first cervical vertebra. For this reason, a cervical spinal

nerve takes its name from the vertebra below it. In other words, cervical nerve C2 precedes vertebra

C2, and the same system is used for the rest of the cervical series. The transition from this

identification method occurs between the last cervical and first thoracic vertebra. The spinal nerve

lying between these two vertebrae has been designated C8. Thus there are seven cervical vertebrae

but eight cervical nerves. Spinal nerves caudal to the first thoracic vertebra take their names from the

vertebra immediately preceding them. For instance, the spinal nerve T1 emerges immediately caudal

to vertebra T1, spinal nerve T2 passes under vertebra T2 and so on.

FIGURE 1-3. Organization of the spinal nerve.

Origin and Peripheral Distribution of Spinal Nerves

Each spinal nerve is formed by a dorsal and a ventral root that come together at the level of the

intervertebral foramen (Figure 1-3). In the thoracic and lumbar levels, the first branch of the spinal

nerve carries visceral motor fibers to a nearby autonomic ganglion. Because preganglionic fibers are

myelinated, they have a light color and are known as white rami (Figure 1-4). Two groups of

unmyelinated postganglionic fibers leave the ganglion. Those fibers innervating glands and smooth

muscle in the body wall or limbs form the gray ramus that rejoins the spinal nerve. The gray and white

rami are collectively called the rami communicantes. Preganglionic or postganglionic fibers that

innervate internal organs do not rejoin the spinal nerves. Instead, they form a series of separate

autonomic nerves and serve to regulate the activities of organs in the abdominal and pelvic cavities.

FIGURE 1-4. Organization and function of the segmental (spinal nerve).

The dorsal ramus of each spinal nerve carries sensory innervation from, and motor innervation to,

a specific segment of the skin and muscles of the back. The region innervated resembles a horizontal

band that begins at the origin of the spinal nerve. The relatively larger ventral ramus supplies the

ventrolateral body surface, structures in the body wall, and the limbs. Each spinal nerve supplies a

specific segment of the body surface, known as a dermatome.

Dermatomes

A dermatome is an area of the skin supplied by the dorsal (sensory) root of the spinal nerve (Figures

1-5 and 1-6). In the head and trunk, each segment is horizontally disposed, except C1, which does not

have a sensory component.

FIGURE 1-5. Dermatomes and corresponding peripheral nerves: front.

FIGURE 1-6. Dermatomes and corresponding peripheral nerves: back.

The dermatomes of the limbs from the fifth cervical to the first thoracic nerve, and from the third

lumbar to the second sacral vertebrae, form a more complicated arrangement due to rotation and

growth during embryologic life. There is considerable overlapping of adjacent dermatomes; that is,

each segmental nerve overlaps the territories of its neighbors. This pattern is variable among

individuals, and it is more of a guide than a fixed map.

Myotomes

A myotome is the segmental innervation of skeletal muscle by a ventral root of a specific spinal nerve

(Figure 1-7).

FIGURE 1-7. Motor innervation of the major muscle groups. (A) Medial and lateral rotation of

shoulder and hip. Abduction and adduction of shoulder and hip. (B) Flexion and extension of elbow

and wrist. (C) Pronation and supination of forearm. (D) Flexion and extension of shoulder, hip, and

knee. Dorsiflexion and plantar flexion of ankle, lateral views.

TIPS

Although the differences between dermatomal, myotomal, and osteotomal innervation are often

emphasized in regional anesthesiology textbooks, it is usually impractical to think in those terms when

planning a regional block.

Instead, it is more practical to think in terms of areas of the body that can be blocked by a specific

technique.

Osteotomes

The innervation of the bones follows its own pattern and does not coincide with the innervation of

more superficial structures (Figure 1-8).

FIGURE 1-8. Osteotomes.

Nerve Plexuses

Although the dermatomal innervation of the trunk is simple, the innervation of the extremities, part of

the neck, and pelvis is highly complex. In these areas, the ventral rami of the spinal nerves form an

intricate neural network; nerve fibers coming from similar spinal segments easily reach different

terminal nerves. The four major nerve plexuses are the cervical plexus, brachial plexus, lumbar

plexus, and sacral plexus.

The Cervical Plexus

The cervical plexus originates from the ventral rami of C1-C5, which form three loops (Figures 1-9

and 1-10). Branches from the cervical plexus provide sensory innervation of part of the scalp, neck,

and upper shoulder and motor innervation to some of the muscles of the neck, the thoracic cavity, and

the skin (Table 1-1). The phrenic nerve, one of the larger branches of the plexus, innervates the

diaphragm.

TABLE 1-1 Organization and Distribution of the Cervical Plexus

FIGURE 1-9. Organization of the cervical plexus.

FIGURE 1-10. Superficial cervical plexus branches. ct, transverse cervical; ga, greater auricular; lo,

lesser occipital; sc, supraclavicular. Also shown is the spinal accessory nerve (SA).

The Brachial Plexus

The brachial plexus is both larger and more complex than the cervical plexus (Figures 1-11, 1-12, 1-

13, 1-14A,B, 1-15A,B, and 1-16). It innervates the pectoral girdle and upper limb. The plexus is

formed by five roots that originate from the ventral rami of spinal nerves C5-T1. The roots converge

to form the superior (C5-C6), middle (C7), and inferior (C8-T1) trunks (Table 1-2). The trunks give

off three anterior and three posterior divisions as they approach the clavicle. The divisions rearrange

their fibers to form the lateral, medial, and posterior cords. The cords give off the terminal branches.

The lateral cord gives off the musculocutaneous nerve, and the lateral root of the median nerve. The

medial cord gives off the medial root of the median nerve and the ulnar nerve. The posterior cord

gives off the axillary and radial nerves.

TABLE 1-2 Organization and Distribution of the Brachial Plexus

FIGURE 1-11. Organization of the brachial plexus.

FIGURE 1-12. View of the posterior triangle of the neck, located above the clavicle between the

sternocleidomastoid (SCM) in front and the trapezius (trap) behind. It is crossed by the omohyoid

muscle (OH) and the brachial plexus (BP).

FIGURE 1-13. The brachial plexus (in yellow) at the level of the trunks (U, M, and L) occupies the

smallest surface area in its entire trajectory. Also shown are the dome of the pleura (PL) in blue, the

subclavian artery (SA) and the vertebral artery, both in red. The phrenic nerve, in yellow, is seen

traveling anterior to the anterior scalene muscle (AS).

FIGURE 1-14. (A) A thick fascia layer (sheath) covers the brachial plexus in the posterior triangle.

Also seen is part of the sternocleidomastoid muscle (SCM), the cervical transverse vessels (CT), and

the omohyoid muscle (OH). (B) Once the sheath is removed, the brachial plexus can be seen between

the anterior scalene (AS) and middle scalene (MS) muscles. (Part A reproduced with permission

from Franco CD, Rahman A, Voronov G, et al. Gross anatomy of the brachial plexus sheath in human

cadavers. Reg Anesth Pain Med. 2008;33(1):64-69. Part B reproduced from Franco CD, Clark L.

Applied anatomy of the upper extremity. Tech Reg Anesth Pain Mgmt. 2008;12(3):134-139, with

permission from Elsevier.)

FIGURE 1-15. (A) In the axilla the brachial plexus is also surrounded by a thick fibrous fascia that

here is shown partially open with a metal probe inside. The musculocutaneous nerve can be seen

exiting the sheath and entering the coracobrachialis muscle. (B) The sheath has been open. Pectoralis

minor (pec minor) has been partially resected. The takeoff of the musculocutaneous nerve from the

lateral cord (LC) inside the sheath is clearly visible. (Reproduced with permission from Franco CD,

Rahman A, Voronov G, et al. Gross anatomy of the brachial plexus sheath in human cadavers. Reg

Anesth Pain Med. 2008;33(1):64-69.)

FIGURE 1-16. Intercostobrachial nerve (T2) is the lateral branch of the second intercostal nerve that

supplies sensory innervation to the axilla and upper medial side of the arm.

The Lumbar Plexus

The lumbar plexus is formed by the ventral rami of spinal nerves L1-L3 and the superior branch of L4

(Figures 1-17, 1-18A,B, and 1-19). In about 50% of the cases, there is a contribution from T12. The

inferior branch of L4, along with the entire ventral rami of L5, forms the lumbosacral trunk that

contributes to the sacral plexus.

FIGURE 1-17. Organization of the lumbar plexus.

FIGURE 1-18. (A) Posterior view of the back to show the thoracolumbar fascia (TLF), whose

posterior layer has been open as a small window through which part of the erector spinae muscles has

been resected to show the anterior layer of the thoracolumbar fascia. (B) One step further in the

dissection shows part of the quadratus lumborum muscle.

FIGURE 1-19. Two branches of the lumbar plexus, the femoral nerve and obturator, are seen

between the quadratus lumborum and psoas muscles in the right retroperitoneal space.

Because the branches of both the lumbar and sacral plexuses are distributed to the lower limb, they

are often collectively referred to as the lumbosacral plexus. The main branches of the lumbar plexus

are the iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, obturator, and femoral

nerves (Figures 1-19, 1-20A,B; Table 1-3).

TABLE 1-3 Organization and Distribution of the Lumbar Plexus

FIGURE 1-20. (A) Frontal view of the upper anterior thigh showing the inguinal ligament and some

branches of the lumbar plexus: FN, femoral nerve; GF, femoral branch of genitofemoral nerve; LF,

lateral femoral cutaneous nerve; OB, obturator nerve. The femoral vein (V) and artery (A) are also

shown. (B) The same nerves of (A) are shown from the lateral side.

The Sacral Plexus

The sacral plexus arises from the lumbosacral trunk (L4-L5) plus the ventral rami of S1-S4 (Figures

1-21,1- 22A,B, 1-23, and 1-24). The main nerves of the sacral plexus are the sciatic nerve and the

pudendal nerve (Table 1-4). The sciatic nerve leaves the pelvis through the greater sciatic foramen to

enter the gluteal area where it travels between the greater trochanter and ischial tuberosity. In the

proximal thigh it lies behind the lesser trochanter of the femur covered superficially by the long head

of the biceps femoris muscle. As it approaches the popliteal fossa, the two components of the sciatic

nerve diverge into two recognizable nerves: the common peroneal and the tibial nerve (Figures 1-25

and 1-26).

TABLE 1-4 Organization and Distribution of the Sacral Plexus

FIGURE 1-21. Organization of the sacral plexus.

FIGURE 1-22. (A) The back and paraspinal muscles have been removed to show the transverse

processes of the last lumbar vertebra, the psoas muscle, and the femoral nerve. (B) Same as (A)

showing that the lateral edge of the psoas muscle at the iliac crest is between 4 and 5 cm from the

midline. fem, femoral.

FIGURE 1-23. Dissection of the right gluteal area demonstrates that the inferior border of the gluteus

maximus does not correspond superficially with the subgluteal fold; instead both cross each other

diagonally. (Reproduced from Franco CD. Applied anatomy of the lower extremity. Tech Reg Anesth

Pain Mgmt. 2008;12(3):140-145, with permission from Elsevier.)

FIGURE 1-24. The sciatic nerve (SN) from the gluteal area to the subgluteal fold is located about 10

cm from the midline in adults. This distance is not affected by gender or body habitus. (Reproduced

with permission from Franco CD, Choksi N, Rahman A, Voronov G, Almachnouk MH. A subgluteal

approach to the sciatic nerve in adults at 10 cm from the midline. Reg Anesth Pain Med.

2006;31(3):215-220.)

FIGURE 1-25. Both components of the sciatic nerve, common peroneal (CP) and tibial (T) nerves

diverge from each other at the popliteal fossa. Lateral and medial gastrocnemius muscles (GN) are

also shown.

FIGURE 1-26. The sural nerve is shown behind the lateral malleolus.

Thoracic and Abdominal Wall

Thoracic Wall

The intercostal nerves originate from the ventral rami of the first 11 thoracic spinal nerves. Each

intercostal nerve becomes part of the neurovascular bundle of the rib and provides sensory and motor

innervations (Figure 1-27). Except for the first, each intercostal nerve gives off a lateral cutaneous

branch that pierces the overlying muscle near the midaxillary line. This cutaneous nerve divides into

anterior and posterior branches, which supply the adjacent skin. The intercostal nerves of the second

to the sixth spaces reach the anterior thoracic wall and pierce the superficial fascia near the lateral

border of the sternum and divide into medial and lateral cutaneous branches. Most of the fibers of the

anterior ramus of the first thoracic spinal nerve join the brachial plexus for distribution to the upper

limb. The small first intercostal nerve is in itself the lateral branch and supplies only the muscles of

the intercostal space, not the overlying skin. The lower five intercostal nerves abandon the intercostal

space at the costal margin to supply the muscles and skin of the abdominal wall.

FIGURE 1-27. Organization of the segmental spinal nerve, intercostal nerve, and innervations of the

chest wall.

Anterior Abdominal Wall

The skin, muscles and parietal peritoneum, or the anterior abdominal wall, are innervated by the

lower six thoracic nerves and the first lumbar nerve. At the costal margin, the seventh to eleventh

thoracic nerves leave their intercostal spaces and enter the abdominal wall in a fascial plane between

the transversus abdominis and internal oblique muscles. The seventh and eighth intercostal nerves

slope upward following the contour of the costal margin, the ninth runs horizontally, and the tenth and

eleventh have a somewhat downward trajectory. Anteriorly, the nerves pierce the rectus abdominis

muscle and the anterior layer of the rectus sheath to emerge as anterior cutaneous branches that supply

the overlying skin.

The subcostal nerve (T12) takes the line of the twelfth rib across the posterior abdominal wall. It

continues around the flank and terminates in a similar manner to the lower intercostal nerves. The

seventh to twelfth thoracic nerves give off lateral cutaneous nerves that further divide into anterior

and posterior branches. The anterior branches supply the skin as far forward as the lateral edge of

rectus abdominis. The posterior branches supply the skin overlying the latissimus dorsi. The lateral

cutaneous branch of the subcostal nerve is distributed to the skin on the side of the buttock.

The inferior part of the abdominal wall is supplied by the iliohypogastric and ilioinguinal nerves,

both branches of L1.The iliohypogastric nerve divides, runs above the iliac crest, and splits into two

terminal branches. The lateral cutaneous branch supplies the side of the buttock; the anterior

cutaneous branch supplies the suprapubic region.

The ilioinguinal nerve leaves the intermuscular plane by piercing the internal oblique muscle

above the iliac crest. It continues between the two oblique muscles eventually to enter the inguinal

canal through the spermatic cord. Emerging from the superficial inguinal ring, it gives cutaneous

branches to the skin on the medial side of the root of the thigh, the proximal part of the penis, and the

front of the scrotum in males and the mons pubis and the anterior part of the labium majus in females.

Nerve Supply to the Peritoneum

The parietal peritoneum of the abdominal wall is innervated by the lower thoracic and first lumbar

nerves. The lower thoracic nerves also innervate the peritoneum that covers the periphery of the

diaphragm. Inflammation of the peritoneum gives rise to pain in the lower thoracic wall and

abdominal wall. By contrast, the peritoneum on the central part of the diaphragm receives sensory

branches from the phrenic nerves (C3, C4, and C5), and irritation in this area may produce pain

referred to region of the shoulder (the fourth cervical dermatome).

Innervation of the Major Joints

Because much of the practice of peripheral nerve blocks involves orthopedic surgery, it is important

to review the innervation of the major joints to have a better understanding of the nerves involved for

a more rational approach to regional anesthesia.

Shoulder Joint

Innervation to the shoulder joints originates mostly from the axillary and suprascapular nerves, both

of which can be blocked by an interscalene block (Figure 1-28).

FIGURE 1-28. Innervation of the shoulder joint.

Elbow Joint

Nerve supply to the elbow joint includes branches of all major nerves of the brachial plexus:

musculocutaneous, radial, median, and ulnar nerves.

Hip Joint

Nerves to the hip joint include the nerve to the rectus femoris from the femoral nerve, branches from

the anterior division of the obturator nerve, and the nerve to the quadratus femoris from the sacral

plexus (Figure 1-29).

FIGURE 1-29. Innervation of the hip joint.

Knee Joint

The knee joint is innervated anteriorly by branches from the femoral nerve. On its medial side it

receives branches from the posterior division of the obturator nerve while both divisions of the

sciatic nerve supply its posterior side (Figure 1-30).

FIGURE 1-30. Innervation of the knee joint.

Ankle Joint

The innervation of the ankle joint is complex and involves the terminal branches of the common

peroneal (deep and superficial peroneal nerves), tibial (posterior tibial nerve), and femoral nerves

(saphenous nerve). A more simplistic view is that the entire innervation of the ankle joint stems from

the sciatic nerve, with the exception of the skin on the medial aspect around the medial malleolus

(saphenous nerve, a branch of the femoral nerve) (Figure 1-31).

FIGURE 1-31. Innervation of the ankle joint and foot.

Wrist Joint

The wrist joint and joints in the hand are innervated by most of the terminal branches of the brachial

plexus including the radial, median, and ulnar nerves (Figure 1-32).

FIGURE 1-32. Innervation of the wrist and hand.

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ANESTHESIA Hadzic's Peripheral Nerve Blocks Hadzic parte 01

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