Beruflich Dokumente
Kultur Dokumente
KADER KESKINBORA
From the Division of Pain Therapy, Department of Anesthesiology, Medical faculty of Cerrahpasa, Istanbul University, Turkey INDOANESTHESIA 2013
Ultrasonography (US) is a recent achievement in the field of regional anesthesia and it has been increasingly used for its clinical reliability and efficiency. Moreover, US guidance is nearing to become the standard of care in regional anesthesia and for postoperative pain management.
Ultrasonographic illustration of the brachial plexus (indicated by white arrows) at the supraclavicular level, adjacent to the cervical Pleura (indicated by grey arrows). SA, Subclavian artery.
The sciatic nerve (SN) at the mid-femoral level partly surrounded by local anaesthetic, resulting in a successful block. The homogenous hypoechoic (dark) zone represents the local anaesthetic (LA).
The availability of other imaging techniques like flouroscopy, CT and MRI and lack of familiarization with US imaging are some of the reasons beneath this discrepancy.
Important steps are being made lately towards the development of safe, available and clinically efficient US guided techniques for many procedures especially involving peripheral nerve.
4. Assessment of LA spread around the nerves and immediate supplementary injections in case of insufficient spread:
This may improve block effectiveness., shorten latency, prolong duration, allow LA dose reduction and lower the risk of overdose.
Marhofer P, Br J Anesth,2005
especially
allowing
visualization
of
puncture
site,
needle
tip
on the other hand, US still lacks acceptable resolution at deep levels, and
it has poor utility for areas hidden by bony structures.
Spinal
Cervical Facet Joint Injections
is frequently performed either to diagnose or to treat pain mediated by the greater ccipital nerve (GON) such as occipital neuralgia and cervicogenic headache.
Unfortunately, no US guided procedures have been described until recently completed anatomical study was published.
Greher and coworkers developed an US guided approach to block the GON. In contrast to the standard blind approach of GON block, they targeted the nerve more proximally where it was usually not divided.
Ultrasound-guided classical distal block technique Ultrasound-guided new proximal block technique
at the level of superior nuchal line at C2 where it lies superficial to the oblique capitis inferior muscle
Their findings confirmed that the GON could be visualized using US both at the level of the superior nuchal line and C2. This newly described approach superficial to the obliques capitis inferior muscle has a higher success rate and should allow a more precise blockade of the nerve.
may be used in patients suffering from vascular diseases or sympathetically maintained pain of the head or the upper extremity.
US allows direct visualization of the local anatomy which are all relevant anatomical structures of the middle cervical ganglion region at the C6 level, leading to better safety and block reliability.
So that, clear imaging of the muscles, fasciae, blood vessels, viscera, and bone surface makes US superior to fluoroscopy for image-guided stellate ganglion block.
Ultrasound imaging for stellate ganglion block: direct visualization of puncture site and local anesthetic spread. A pilot study.
Kapral S, Krafft P, Gosch M, Fleischmann D, Weinstabl C Reg Anesth1995 Jul-Aug;20(4):323-8.
case series. Compared with blind injection, the authors used a lower
volume of local anesthetic (5 mL rather than 8 mL), found no formation of hematomas (whereas 3 patients in the blind injection group had a hematoma), and rapid onset of Horner syndrome in US guided stellate ganglion block.
Shibata and coworkers suggested that subfascial injection would result in better spread of the injectate and more reliable sympathetic blockade
Ultrasound image during C6-stellate ganglion block injection beneath the prevertebral fasica in the longus colli muscle
white arrow indicates the prevertebral fascia distended with local anesthetic
Gofeld and coworkers attempted to find a pathway for needle placement away from vital neck structures
have been used in the management of a variety of painful shoulder pathologies by use of several techniques. .
In recent years, the technique for suprascapular nerve block under US guidance was defined, and a few studies using that technique have already been published. The images shown in those ultrasound-guided SSN injection reports were described as identifying the SSN within the suprascapular notch and covered by the superior transverse scapular ligament.
suprascapular
and
spinoglenoid
notches
The authors scanned 60 volunteers with US, both in the supraclavicular and the classic target area. And then they compared visibility of the SSN in both regions. They concluded that visualization of the SSN with US is better in the supraclavicular region as compared with the supraspinous fossa. The anatomic dissections confirmed that their novel supraclavicular SSN block technique was accurate.
There are very few published data on US-guided intercostal nerve blocks. Using US, the nerves are rarely seen because they lie close to or are covered by the caudal edge of the rib and are therefore masked by sonographic artifacts. In contrast, the spread of the injected solution can be seen clearly by US during the injection.
Case Report Ultrasound-guided intercostal nerve block for traumatic pneumothorax requiring tube thoracostomy
Stone MB, Carnell J, Fischer JW, Herring A, Nagdev A American Journal of Emergency Medicine (2011) 29
Stone and coworkers placed probe in a longitudinal parasagittal orientation to identify the ribs and pleural line. Then they visualized the needle approaching the inferior margin of the target ribs, and injected LA solution into each intercostal space with real-time ultrasound visualization of local anesthetic spread to the adjacent pleura
The area for optimal scanning of these nerves is the area posterior and cephalad to the superior iliac spine. With the probe placed in an orientation perpendicular to the inguinal
ligament, all the 3 layers of abdominal muscles (ExtObl, IntObl, and TranAbd), iliac crest, and
This investigation is the first description of an US guided approach to the ilioinguinal (II) and iliohipogastric (IH) nerve in adults. They suggested using their new injection point about 5 cm cranial and posterior to the anterior superior iliac spine. At this point all three muscle layers of the abdominal wall can easily be identified by ultrasound and facilitate orientation.
US GUIDED LATERAL FEMORAL CUTANEOUS NERVE BLOCK is used for the diagnosis and conservative management of meralgia paresthetica which is a mononeuropathy of the LFCN and characterized by paresthesia, numbness, and pain in a localized area on the anterolateral aspect of the thigh.
Lateral femoral cutaneous nerve (LFCN) is a small peripheral of nerve, and the scanning good that requires knowledge region. The literature suggests that the LFCN is experienced the personnel anatomy with
around
Bodner and coworkers assessed the feasibility of US in visualizing the lateral femoral cutaneous nerve in a cadaver and 8 volunteers. They suggested that US enables visualization of the LFCN in a cadaver and in volunteers
Because of its small size, proximity to neurovascular structures, and deep location, the piriformis muscle injection with the use of US seems more logical. Over the past few years, US has been shown to be a reliable imaging tool for needle placement during piriformis injections. US guided injection offers a technique with a direct visualization of the piriformis muscle, real-time guidance of needle insertion, and the confirmation of injectate inside or around the piriformis muscle.
Pheng and coworkers suggested in this article that the key step for US guided injection was to align the ultrasound probe in the longitudinal axis of the piriformis muscle above the ischial spine. So that they recommended another technique rather than reported technique in the literature: Scanning was performed in the transverse plane with the probe placed over posterior superior iliac spine so that the sacroiliac joint can be seen.
Chen and coworkers recommended the medial-to-lateral approach when performing the US guided piriformis muscle injection
The authors scanned deep gluteal region in two perpendicular planes as longitudinal and transverse to the internal pudendal artery. They founded that in almost one-half of the cases a direct US-guided infiltration of the pudendal nerve was possible and in the remaining cases the nerve could be detected and blocked indirectly, using the ischial spine or the internal pudendal artery as a landmark
Feasibility of real-time ultrasound for pudendal nerve block in patients with chronic perineal pain.
Rofaeel A, Peng P, Louis I, Chan V Reg Anesth Pain Med. 2008 Mar-Apr;33(2):139-45
In the literature, only this study describes the feasibility of the US guided pudental nerve injection technique.
spine to capture the transverse view of the ischial spine, the sacrospinous internal the pudendal nerve. Their findings were that pudendal nerve block at the ischial spine level could be reliably performed under real-time ultrasound guidance.
US GUIDED EXTREMITY
PERIPHERAL
NERVE
BLOCKS
OF
THE
UPPER
ISOLATED UPPER EXTREMITY NERVE BLOCK RADIAL NERVE BLOCK MEDIAN NERVE BLOCK ULNAR NERVE BLOCK US guidance is also very useful for peripheral nerve blocks in the upper limbs, as it allows the anaesthetist to minimize the dose of local
Median nerve can be blocked from the antecubital area of elbow distally to the wrist.
the
US GUIDED EXTREMITY
PERIPHERAL
NERVE
BLOCKS
OF
THE
LOWER
LUMBOSACRAL PLEXUS BLOCK FEMORAL NERVE BLOCK OBTURATOE NERVE BLOCK SCIATIC NERVE BLOCK While peripheral nerve blocks can replace neuraxial techniques, they still require two punctures. It is therefore useful to minimize the amount of LA injected by US guidance. These blocks are useful for surgical anesthesia and postoperative pain but in interventioanl pain medicine they are olso important especially for
Figure visibility
of of
four the
position sciatic
improves nerve
the
in the
There are several advantages to treat a pathologic knee with the aid of sonography. First, US can be used as an extension of the physical examination and aid in the accurate diagnosis of arthritis.
Im and coworkers showed that US-guided injections via a medial patellar portion (MPP) of the knee joint had a significantly greater accuracy rate (95.6%) than blind injections (77.3%).