Ultrasound Guided

Nerve Blocks:
Raymond Graber, MD
University Hospitals Case Medical Center
Case Western Reserve University School of Medicine
Goals:
Discuss rationale for US guidance.
Learn proper techniques of US guidance.
Discuss interesting findings seen with US.
Discuss specific nerve blocks.

Landmark Technique For
Nerve Blocks:
Traditional nerve block
techniques are based on the
ability to palpate muscles,
bones, and pulses.
A normal consistent
anatomic relationship
between nerves and these
other structures is assumed.
Problems with Landmark Techniques:
Anatomic Variations
There are normal variations in anatomy.
Some patients have landmarks that are difficult to palpate.
History of US Guidance
1989: Ting et al used US to examine spread
of local anesthetic after axillary blocks.
1994: Reed & Leighton used doppler to
identify the axillary artery in an obese patient,
and marked the skin prior to axillary block.
1994 (Kapral et al): supraclavicular blocks.
1998 ( Marhoffer): femoral blocks.

Benefits of US Guidance
Ability to see nearby vascular structures
Ability to see nerves (sometimes!)
Ability to visualize the needle approaching the
nerve.
Ability to see local anesthetic spread.
Possibility of reducing complications.
Can do postop without nerve stim.
Less painful to use US instead of nerve stim when
patient has a fracture.
Can perform rescue blocks without nerve stim.
Spread of Local:
US guidance has demonstrated one possible cause of
patchy blocks incomplete surrounding of the nerve
with local anesthetic.
If after half the volume of local is injected, inadequate
spread is seen, the needle can be repositioned.
How Accurate is Nerve Stimulation?
We used to assume a linear relationship between the
threshold stimulating current (the lowest current you
can still achieve a twitch at) and the distance from the
needle tip to the nerve.
Many authors recommend a current of 0.2-0.5 ma as a
goal. Higher threshold currents would lead to more
searching with the needle. Lower currents would mean
increased risk of intraneural injection.
The 2 following studies called this dogma into question.
In this study, interscalene blocks were done with
paresthesia technique. Paresthesia is assumed to indicate
contact with the nerve. When a paresthesia was obtained,
the nerve stimulator was turned on.
Results: All patients had easily elicited paresthesias Only
30% of patients exhibited any motor response to electrical
stimulation up to 1.0 mA
Conclusion: Elicitation of paresthesia does not translate to
an ability to elicit a motor response to a peripheral nerve
stimulator in the majority of patients.

In this study, needles were placed into pig
nerves, then nerve stim turned on to see at what
current motor response occurred.
Thus, intraneural placement occurred despite
presumed safe nerve stim currents in 66% of
the nerves.
Demonstration of Intraneural
Injection with US:
Does US Improve Success Rate?
RAPM May-June 2008:
US guidance improves success rate of interscalene
brachial plexus blockade (99% vs 91%). (Kapral et al)
US guidance improves the success of sciatic nerve
block at the popliteal fossa (89.2% vs 60.6%). (Perlas et
al)
Both these studies allowed the US group to reposition
to needle to ensure good spread of local anesthetic,
whereas the nerve stim groups were singe injection.
US Guided Nerve Blocks:
Equipment, Terminology
& Technical Aspects
The equipment is evolving. High resolution imaging is now
available in laptop size equipment. The better the resolution,
the easier it is to image nerves. Some equipment examples
follow, but more systems are coming on the market.
Sonosite 180+
C11 Probe
11-mm broadband curved array
transducer.
Imaging modes: 2D, M-mode,
color power Doppler, directional
color power Doppler
Physical characteristics:
Frequency: broadband 7-4
MHz
Maximum Depth: 10 cm
Maximum Field of View: 90
Our original device images
hard to interpret. Good for IJ
placements.
Sonosite C11
HFL38 Probe
38 mm broadband flat array
transducer.
Imaging modes: 2D, M-mode,
color power Doppler, directional
color power Doppler
Physical characteristics:
Frequency: broadband 10-
5MHz
Maximum Depth: 6 cm
GE 12L-RS
US Probe
42 x 7 mm broadband flat array
transducer.
Imaging modes: 2D, M-mode,
color Doppler, harmonic and
compound imaging.
Physical characteristics:
Frequency: 5-13 MHz
Maximum Depth: 6-8 cm
Maximum width of View: 39
mm.
Most of the images in this
talk are from this device.
Equipment & Supplies
Block kit.
Needles block, skin wheal
Nerve stimulator
Sterile sheath kit (contains gel, sleeve, rubber
bands.)
Local anesthetic
US machine
SAX Imaging
Most commonly used.
LAX Imaging
Rarely used.
SAX Out of Plane (OOP) Approach:
Needle is at best seen only in cross section. More commonly,
tissue movement is seen as the needle approaches the target.
SAX In Plane (IP) Approach
With this approach, one can see the needle approach the target.
However, be aware that it is easy to be a little oblique, and to not
actually see the needle tip.
Needle Type:
Typical 22 g insulated block needles can be used.
Alternatively, 18 g Touhy needles sometimes are
used, because are easier visualized, or for catheter
placement.
OOP approach: Needle diameter would not matter,
since the needle is not visualized with this technique.
IP approach: A larger diameter needle can be
helpful, especially if the nerve is relatively deeper, and
a longer needle is required.
Technique (1)
IP approach: line up needle in middle of US plane. Penetrate
skin and enter under probe. If needle not seen, move probe
slightly and slowly to find needle.
Move needle to desired location.
Inject 1 ml to verify needle location.
Reposition needle if needed.

Technique (2)
Technique (3)
Local Anesthetic Spread
Examine spread of local.
Reposition to next location if desired.
With US guidance, is
nerve stimulation still
required?
As you get better with US, you rely less and less on nerve stim.
However, may be advantageous to leave nerve stim on at low
current for extra feedback on needle tip location.
Femoral Nerve Block