HSS Journal

, Volume 7, Issue 1, pp 64–71 | Cite as

Musculoskeletal Sonopathology and Ultrasound-Guided Regional Anesthesia

  • Alan J. R. Macfarlane
  • Brian D. Sites
  • Vincent R. Sites
  • Ali M. Naraghi
  • Vincent W. S. Chan
  • Mandeep Singh
  • John G. Antonakakis
  • Richard Brull
Review Article


The use of real-time ultrasound guidance has revolutionized the practice of regional anesthesia. Ultrasound is rapidly becoming the technique of choice for nerve blockade due to increased success rates, faster onset, and potentially improved safety. In the course of ultrasound-guided regional anesthesia, unexpected pathology may be encountered. Such anomalous or pathological findings may alter the choice of nerve block and occasionally affect surgical management. This case series presents a variety of musculoskeletal conditions that may be encountered during ultrasound-guided regional anesthesia practice.


anesthesia ultrasound regional anesthesia 



The authors wish to thank Mr. James Liang, BMSc, Research Fellow, Department of Anesthesia, Toronto Western Hospital, Toronto for his assistance in formatting and editing of images during the preparation of this manuscript.


  1. 1.
    Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2009;102:408–417.CrossRefPubMedGoogle Scholar
  2. 2.
    Anderson MA, Newmeyer WL, 3rd, Kilgore ES, Jr. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg. 1982;144:63–67.CrossRefPubMedGoogle Scholar
  3. 3.
    Bianchi S, Abdelwahab IF, Zwass A, et al. Sonographic findings in examination of digital ganglia: retrospective study. Clin Radiol. 1993;48:45–47.CrossRefPubMedGoogle Scholar
  4. 4.
    Chan VWS. Ultrasound Imaging for Regional Anesthesia. A Practical Guide. 2nd ed. Toronto, ON: Toronto Publishing Company; 2008.Google Scholar
  5. 5.
    Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care. 2007;23:528–531.CrossRefPubMedGoogle Scholar
  6. 6.
    Cheng P KH, Grubb D. Diagnostic neural sonography (sonopathology): is there a role for the anesthesiologists. Reg Anesth Pain Med. 2008;32:9. http://www.asra.com/education/display_fall_2008.php?id=41. Accessed October 11, 2009.
  7. 7.
    Chin KJ, Chan V. Ultrasound-guided peripheral nerve blockade. Curr Opin Anaesthesiol. 2008;21:624-631.CrossRefPubMedGoogle Scholar
  8. 8.
    Chin KJ, Niazi A, Chan V. Anomalous brachial plexus anatomy in the supraclavicular region detected by ultrasound. Anesth Analg. 2008;107:729–731.CrossRefPubMedGoogle Scholar
  9. 9.
    Dash S, Bheemreddy SR, Tiku ML. Posterior tibial neuropathy from ruptured Baker's cyst. Semin Arthritis Rheum. 1998;27:272–276.CrossRefPubMedGoogle Scholar
  10. 10.
    Duggan E, Brull R, Lai J, Abbas S. Ultrasound-guided brachial plexus block in a patient with multiple glomangiomatosis. Reg Anesth Pain Med. 2008;33:70–73.PubMedGoogle Scholar
  11. 11.
    Fielding JR, Franklin PD, Kustan J. Popliteal cysts: a reassessment using magnetic resonance imaging. Skeletal Radiol. 1991;20:433–435.CrossRefPubMedGoogle Scholar
  12. 12.
    Horton LK, Jacobson JA, Powell A, Fessell DP, Hayes CW. Sonography and radiography of soft-tissue foreign bodies. Am J Roentgenol. 2001;176:1155–1159.Google Scholar
  13. 13.
    Kainberger F, Mittermaier F, Seidl G, Parth E, Weinstabl R. Imaging of tendons--adaptation, degeneration, rupture. Eur J Radiol. 1997;25:209–222.CrossRefPubMedGoogle Scholar
  14. 14.
    Martinoli C, Bianchi S, Derchi LE. Tendon and nerve sonography. Radiol Clin North Am. 1999;37:691–711.CrossRefPubMedGoogle Scholar
  15. 15.
    McManus JG, Morton MJ, Crystal CS, et al. Use of ultrasound to assess acute fracture reduction in emergency care settings. Am J Disaster Med. 2008;3:241–247.PubMedGoogle Scholar
  16. 16.
    National Institute for Health and Clinical Excellence. Ultrasound-guided catheterization of the epidural space: Full guidance. Available at: http://guidance.nice.org.uk/IPG249. Accessed October 13th, 2009.
  17. 17.
    National Institute for Health and Clinical Excellence. Ultrasound-guided regional nerve block: guidance. Available at: http://guidance.nice.org.uk/IPG285. Accessed October 13th, 2009.
  18. 18.
    Orebaugh SL, Williams BA, Vallejo M, Kentor ML. Adverse outcomes associated with stimulator-based peripheral nerve blocks with versus without ultrasound visualization. Reg Anesth Pain Med. 2009;34:251–255.CrossRefPubMedGoogle Scholar
  19. 19.
    Perlas A, Niazi A, McCartney C, Chan V, Xu D, Abbas S. The sensitivity of motor response to nerve stimulation and paresthesia for nerve localization as evaluated by ultrasound. Reg Anesth Pain Med. 2006;31:445–450.PubMedGoogle Scholar
  20. 20.
    Pillen S, Arts IM, Zwarts MJ. Muscle ultrasound in neuromuscular disorders. Muscle Nerve. 2008;37:679–693.CrossRefPubMedGoogle Scholar
  21. 21.
    Robertson CM, Robertson RF, Strazerri JC. Proximal dissection of a popliteal cyst with sciatic nerve compression. Orthopedics. 2003;26:1231–1232.PubMedGoogle Scholar
  22. 22.
    Schafhalter-Zoppoth I, Younger SJ, Collins AB, Gray AT. The "seesaw" sign: improved sonographic identification of the sciatic nerve. Anesthesiology. 2004;101:808–809.CrossRefPubMedGoogle Scholar
  23. 23.
    Silvestri E, Martinoli C, Derchi LE, Bertolotto M, Chiaramondia M, Rosenberg I. Echotexture of peripheral nerves: correlation between US and histologic findings and criteria to differentiate tendons. Radiology. 1995;197:291–296.PubMedGoogle Scholar
  24. 24.
    Sites BD, Brull R, Chan VW, et al. Artifacts and pitfall errors associated with ultrasound-guided regional anesthesia. Part II: a pictorial approach to understanding and avoidance. Reg Anesth Pain Med. 2007;32:419–433.PubMedGoogle Scholar
  25. 25.
    Sites BD, Chan VW, Neal JM, et al. The American Society of Regional Anesthesia and Pain Medicine and the European Society Of Regional Anaesthesia and Pain Therapy Joint Committee recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med. 2009;34:40–46.CrossRefPubMedGoogle Scholar
  26. 26.
    Sites BD, Macfarlane A.J.R, Sites V.R, Naraghi, A., Chan V.W.S., Singh, M. Antonakakis, J.G., Brull, R. Clinical sonopathology for the regional anesthesiologist. Part I: vascular and neural. Reg Anesth Pain Med. 2010;35:272–280.CrossRefPubMedGoogle Scholar
  27. 27.
    Sites BD, Macfarlane A.J.R, Sites V.R, Naraghi, A., Chan V.W.S., Singh, M. Antonakakis, J.G., Brull, R. Clinical sonopathology for the regional anesthesiologist. Part II: Bone, Viscera, Subcutaneous Tissue, And Foreign bodies. Reg Anesth Pain Med. 2010;35:281–289.CrossRefPubMedGoogle Scholar
  28. 28.
    Sites BD, Spence BC, Gallagher JD, Beach ML. On the edge of the ultrasound screen: Regional anesthesiologists diagnosing nonneural pathology. Reg Anesth Pain Med. 2006;31:555–562.PubMedGoogle Scholar
  29. 29.
    Soudack M, Nachtigal A, Gaitini D. Clinically unsuspected foreign bodies: the importance of sonography. J Ultrasound Med. 2003;22:1381–1385.PubMedGoogle Scholar
  30. 30.
    Swen WA, Jacobs JW, Hubach PC, Klasens JH, Algra PR, Bijlsma JW. Comparison of sonography and magnetic resonance imaging for the diagnosis of partial tears of finger extensor tendons in rheumatoid arthritis. Rheumatology. 2000;39:55–62.CrossRefPubMedGoogle Scholar
  31. 31.
    Toro JR, Travis LB, Wu HJ, Zhu K, Fletcher CD, Devesa SS. Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978-2001: An analysis of 26,758 cases. Int J Cancer. 2006;119:2922–2930.CrossRefPubMedGoogle Scholar
  32. 32.
    Tschirch FT, Schmid MR, Pfirrmann CW, Romero J, Hodler J, Zanetti M. Prevalence and size of meniscal cysts, ganglionic cysts, synovial cysts of the popliteal space, fluid-filled bursae, and other fluid collections in asymptomatic knees on MR imaging. Am J Roentgenol. 2003;180:1431–1436.Google Scholar

Copyright information

© Hospital for Special Surgery 2010

Authors and Affiliations

  • Alan J. R. Macfarlane
    • 1
  • Brian D. Sites
    • 2
  • Vincent R. Sites
    • 3
  • Ali M. Naraghi
    • 4
  • Vincent W. S. Chan
    • 6
  • Mandeep Singh
    • 6
  • John G. Antonakakis
    • 5
  • Richard Brull
    • 6
  1. 1.Department of AnaesthesiaGlasgow Royal InfirmaryScotlandUK
  2. 2.Department of AnesthesiologyDartmouth-Hitchcock Medical CenterLebanonUSA
  3. 3.Department of RadiologyLahey ClinicBurlingtonUSA
  4. 4.Joint Department of Medical Imaging of University Health Network and Mount Sinai Hospital, Toronto Western HospitalTorontoCanada
  5. 5.Department of AnesthesiologyUniversity of VirginiaCharlottesvilleUSA
  6. 6.Department of Anesthesia and Pain Management, Toronto Western HospitalUniversity Health NetworkTorontoCanada

Personalised recommendations