Ultrasound-Guided Peripheral Nerve Blockade

  • Alan Bielsky
  • David M. Polaner


Ultrasound imaging has become an essential tool for today’s regional anesthesiologist. Ultrasound-guided nerve blocks are as or more effective, safe, and efficient as surface landmark base or neurostimulation techniques and have enhanced and increased the use of peripheral nerve blockade in clinical practice. The overall safety of peripheral nerve blockade has been repeatedly established in multiple retrospective and prospective studies (Ecoffey, Safety in pediatric regional anesthesia. Pediatric anesthesia. Blackwell, 2012; Neal et al. Reg Anesth Pain Med, 35(Suppl 1), S1–S9, 2010; Polaner et al. Anesth Analg, 115(6), 1353–64, 2012; Neal, Reg Anesth Pain Med 41(2), 195–204, 2016).


Ultrasound physics Safety Peripheral nerve block Upper extremity block Lower extremity block Abdominal wall block Paravertebral block 


  1. 1.
    Ecoffey C. Safety in pediatric regional anesthesia. Pediatric anesthesia. Blackwell, Oxford; 2012;22(1):25–30.Google Scholar
  2. 2.
    Neal JM, Brull R, VWS C, Grant SA, Horn J-L, Liu SS, et al. The ASRA evidence-based medicine assessment of ultrasound-guided regional anesthesia and pain medicine. Reg Anesth Pain Med. 2010;35(Suppl 1):S1–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Polaner DM, Taenzer AH, Walker BJ, Bosenberg A, Krane EJ, Suresh S, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg. 2012;115(6):1353–64.PubMedCrossRefGoogle Scholar
  4. 4.
    Neal JM. Ultrasound-guided regional anesthesia and patient safety: update of an evidence-based analysis. Reg Anesth Pain Med. 2016;41(2):195–204.PubMedCrossRefGoogle Scholar
  5. 5.
    McNaught A, Shastri U, Carmichael N, Awad IT, Columb M, Cheung J, et al. Ultrasound reduces the minimum effective local anaesthetic volume compared with peripheral nerve stimulation for interscalene block. Br J Anaesth. 2011;106(1):124–30. Oxford University Press.PubMedCrossRefGoogle Scholar
  6. 6.
    Liu SS, Zayas VM, Gordon MA, Beathe JC, Maalouf DB, Paroli L, et al. A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109(1):265–71.PubMedCrossRefGoogle Scholar
  7. 7.
    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(3):251–5.PubMedCrossRefGoogle Scholar
  8. 8.
    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(3):408–17.PubMedCrossRefGoogle Scholar
  9. 9.
    Casati A, Baciarello M, Cianni SD, Danelli G, De Marco G, Leone S, et al. Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth. 2007;98(6):823–7. Oxford University Press.PubMedCrossRefGoogle Scholar
  10. 10.
    Suresh S, Schaldenbrand K, Wallis B, De Oliveira GS. Regional anaesthesia to improve pain outcomes in paediatric surgical patients: a qualitative systematic review of randomized controlled trials. Br J Anaesth. 2014;113(3):375–90. Oxford University Press.PubMedCrossRefGoogle Scholar
  11. 11.
    Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev. 2016;(2):CD011436.Google Scholar
  12. 12.
    Marhofer P. Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks*1. Reg Anesth Pain Med. 1998;23(6):584–8.PubMedGoogle Scholar
  13. 13.
    Willschke H, Marhofer P, Bösenberg A, Johnston S, Wanzel O, Cox SG, et al. Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children. Br J Anaesth. 2005;95(2):226–30. Oxford University Press.PubMedCrossRefGoogle Scholar
  14. 14.
    Novelline RA, Squire LF. Squire’s fundamentals of radiology. 6th ed. Cambridge: Harvard University Press; 2004.Google Scholar
  15. 15.
    Brull R, Macfarlane AJR, Tse CCH. Practical knobology for ultrasound-guided regional anesthesia. Reg Anesth Pain Med. 2010;35(2 Suppl):S68–73.PubMedCrossRefGoogle Scholar
  16. 16.
    Sites BD, Brull R, Chan VWS, Spence BC, Gallagher J, Beach ML, 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(5):419–33.PubMedGoogle Scholar
  17. 17.
    Sites B, Brull R, Chan V, Spence B, Gallagher J, Beach M, et al. Artifacts and pitfall errors associated with ultrasound-guided regional anesthesia. Part I: understanding the basic principles of ultrasound physics and machine operations. Reg Anesth Pain Med. 2007;32(5):412–8.PubMedGoogle Scholar
  18. 18.
    Suresh S, Taylor LJ, De Oliveira GS. Dose effect of local anesthetics on analgesic outcomes for the transversus abdominis plane (TAP) block in children: a randomized, double-blinded, clinical trial. Pediatr Anesth. 2015;25(5):506–10.CrossRefGoogle Scholar
  19. 19.
    Sites BD, Taenzer AH, Herrick MD, Gilloon C, Antonakakis J, Richins J, et al. Incidence of local anesthetic systemic toxicity and postoperative neurologic symptoms associated with 12,668 ultrasound-guided nerve blocks. Reg Anesth Pain Med. 2012;37(5):478–82.PubMedCrossRefGoogle Scholar
  20. 20.
    Fredrickson MJ, Ball CM, Dalgleish AJ. A prospective randomized comparison of ultrasound guidance versus neurostimulation for interscalene catheter placement. Reg Anesth Pain Med. 2009;34(6):590–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Kapral S, Greher M, Huber G, Willschke H, Kettner S, Kdolsky R, et al. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Reg Anesth Pain Med. 2008;33(3):253–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Lombard TP, Couper JL. Bilateral spread of analgesia following interscalene brachial plexus block. Anesthesiology. 1983s;58(5):472.PubMedCrossRefGoogle Scholar
  23. 23.
    Borgeat A. All roads do not lead to Rome. Anesthesiology. 2006;105(1):1–2.PubMedCrossRefGoogle Scholar
  24. 24.
    Benumof JL. Permanent loss of cervical spinal cord function associated with interscalene block performed under general anesthesia. Anesthesiology. 2000;93(6):1541–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Clendenen SR, Robards CB, Wang RD, Greengrass RA. Continuous interscalene block associated with neck hematoma and postoperative sepsis. Anesth Analg. 2010;110(4):1236–8.PubMedGoogle Scholar
  26. 26.
    Taenzer AH, Walker BJ, Bosenberg AT, Martin L, Suresh S, Polaner DM, et al. Asleep versus awake: does it matter?: pediatric regional block complications by patient state: a report from the Pediatric Regional Anesthesia Network. Reg Anesth Pain Med. 2014;39(4):279–83.PubMedCrossRefGoogle Scholar
  27. 27.
    Perlas A, Lobo G, Lo N, Brull R, Chan VWS, Karkhanis R. Ultrasound-guided supraclavicular block. Reg Anesth Pain Med. 2009;34(2):171–6.PubMedCrossRefGoogle Scholar
  28. 28.
    Fingerman M, Benonis JG, Martin G. A practical guide to commonly performed ultrasound-guided peripheral-nerve blocks. Curr Opin Anaesthesiol. 2009;22(5):600–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Chan VWS, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg. 2003;97:1514–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Perlas A, Lobo G, Lo N, Brull R, Chan VWS, Karkhanis R. Ultrasound-guided supraclavicular block: outcome of 510 Consecutive cases. Reg Anesth Pain Med. 2009;34(2):171–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Neal JM. Ultrasound-guided regional anesthesia and patient safety: an evidence-based analysis. Reg Anesth Pain Med. 2010;35(2):S59–67.PubMedCrossRefGoogle Scholar
  32. 32.
    Tran DQH, Clemente A, Tran DQ, Finlayson RJ. A comparison between ultrasound-guided infraclavicular block using the “double bubble” sign and neurostimulation-guided axillary block. Anesth Analg. 2008;107(3):1075–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Tedore TR, YaDeau JT, Maalouf DB, Weiland AJ, Tong-Ngork S, Wukovits B, et al. Comparison of the transarterial axillary block and the ultrasound-guided infraclavicular block for upper extremity surgery. Reg Anesth Pain Med. 2009;34(4):361–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Bigeleisen P, Wilson M. A comparison of two techniques for ultrasound guided infraclavicular block. Br J Anaesth. 2006;96(4):502–7. Oxford University Press.PubMedCrossRefGoogle Scholar
  35. 35.
    Sauter AR, Smith H-JR, Stubhaug A, Dodgson MS, Klaastad I. Use of magnetic resonance imaging to define the anatomical location closest to all three cords of the infraclavicular brachial plexus. Anesth Analg. 2006;103(6):1574–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Retzl G, Kapral S, Greher M, Mauritz W. Ultrasonographic findings of the axillary part of the brachial plexus. Anesth Analg. 2001;92:1271–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Koscielniak-Nielsen ZJ. Multiple injections in axillary block. Reg Anesth Pain Med. 2006;31(3):192–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Handoll HHG, Koscielniak-Nielsen ZJ. Single, double or multiple injection techniques for axillary brachial plexus block for hand, wrist or forearm surgery. In: Koscielniak-Nielsen ZJ, editor. Cochrane Database Syst Rev. Chichester: Wiley; 2006;(1):CD003842.Google Scholar
  39. 39.
    Neal JM, Gerancher JC, Hebl JR, Ilfeld BM, McCartney CJ, Franco CD, Hogan QH. Upper extremity regional anesthesia: essentials of our current understanding, 2008: Erratum in Reg Anesth Pain Med. 2010;35(4):407.Google Scholar
  40. 40.
    Chan V. Ultrasound imaging for regional anesthesia: a practical guide booklet , Etobicoke; Ontario, 2008.Google Scholar
  41. 41.
    Spence B, Sites B, Beach M. Ultrasound-guided musculocutaneous nerve block: a description of a novel technique. Reg Anesth Pain Med. 2005;30(2):198–201.PubMedGoogle Scholar
  42. 42.
    Soong J, Schafhalter-Zoppoth I, Gray AT. The importance of transducer angle to ultrasound visibility of the femoral nerve. Reg Anesth Pain Med. 2005;30(5):505.PubMedCrossRefGoogle Scholar
  43. 43.
    Tsui BCH, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and adolescents. Anesthesiology. 2010;112(2):473–92.PubMedCrossRefGoogle Scholar
  44. 44.
    Saranteas T, Chantzi C, Paraskeuopoulos T, Alevizou A, Zogojiannis J, Dimitriou V, et al. Imaging in anesthesia: the role of 4 MHz to 7 MHz sector array ultrasound probe in the identification of the sciatic nerve at different anatomic locations. Reg Anesth Pain Med. 2007;32(6):537–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Chan VWS, Nova H, Abbas S, McCartney CJL, Perlas A, Quan Xu D. Ultrasound examination and localization of the sciatic nerve. Anesthesiology. 2006;104(2):309–14.PubMedCrossRefGoogle Scholar
  46. 46.
    Barrington M, Lai S, Briggs C, Ivanusic J, Gledhill S. Ultrasound-guided midthigh sciatic nerve block—a clinical and anatomical study. Reg Anesth Pain Med. 2008;33(4):369–76.PubMedCrossRefGoogle Scholar
  47. 47.
    Horn J-L, Pitsch T, Salinas F, Benninger B. Anatomic basis to the ultrasound-guided approach for saphenous nerve blockade. Reg Anesth Pain Med. 2009;34(5):486–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Krombach J, Gray AT. Sonography for saphenous nerve block near the adductor canal. Reg Anesth Pain Med. 2007;32(4):369–70.PubMedCrossRefGoogle Scholar
  49. 49.
    Kirkpatrick JD, Sites BD, Antonakakis JG. Preliminary experience with a new approach to performing an ultrasound-guided saphenous nerve block in the mid to proximal femur. Reg Anesth Pain Med. 2010;35(2):222–3.PubMedCrossRefGoogle Scholar
  50. 50.
    Wang D, Yang Y, Li Q, Tang S-L, Zeng W-N, Xu J, et al. Adductor canal block versus femoral nerve block for total knee arthroplasty: a meta-analysis of randomized controlled trials. Sci Rep. 2017;7:40721. Nature Publishing Group.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Kim DH, Lin Y, Goytizolo EA, Kahn RL, Maalouf DB, Manohar A, et al. Adductor canal block versus femoral nerve block for total knee arthroplasty a prospective, randomized, controlled trial. Anesthesiology. 2014;120(3):540–50.PubMedCrossRefGoogle Scholar
  52. 52.
    Manickam B, Perlas A, Duggan E, Brull R, Chan VWS, Ramlogan R. Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med. 2009;34(6):578–80.PubMedCrossRefGoogle Scholar
  53. 53.
    Abrahams MS, Horn J-L, Noles LM, Aziz MF. Evidence-based medicine: ultrasound guidance for truncal blocks. Reg Anesth Pain Med. 2010;35(2):S36–42.PubMedCrossRefGoogle Scholar
  54. 54.
    McDonnell J, ODonnell B, Farrell T, Gough N, Tuite D, Power C, et al. Transversus abdominis plane block: a cadaveric and radiological evaluation. Reg Anesth Pain Med. 2007;32(5):399–404.PubMedGoogle Scholar
  55. 55.
    Suresh S, Chan VWS. Ultrasound guided transversus abdominis plane block in infants, children and adolescents: a simple procedural guidance for their performance. Pediatr Anesth. 2009;19(4):296–9. Blackwell.CrossRefGoogle Scholar
  56. 56.
    Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block. Reg Anesth Pain Med. 2008;33(3):274.PubMedCrossRefGoogle Scholar
  57. 57.
    O’Donnell BD, Mannion S. A case of liver trauma with a blunt regional anesthesia needle while performing transversus abdominis plane block. Reg Anesth Pain Med. 2009;34(1):75–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Jankovic Z, Ahmad N, Ravishankar N, Archer F. Transversus abdominis plane block: how safe is it? Anesth Analg. 2008;107(5):1758–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Azemati S, Khosravi MB. An assessment of the value of rectus sheath block for postlaparoscopic pain in gynecologic surgery. J Minim Invas Gynecol. 2005;12(1):12–5.CrossRefGoogle Scholar
  60. 60.
    Dolan J, Lucie P, Geary T, Smith M, GNC K. The rectus sheath block: accuracy of local anesthetic placement by trainee anesthesiologists using loss of resistance or ultrasound guidance. Reg Anesth Pain Med. 2009;34(3):247–50.PubMedCrossRefGoogle Scholar
  61. 61.
    Willschke H. Ultrasonography-guided rectus sheath block in paediatric anaesthesia–a new approach to an old technique. Br J Anaesth. 2006;97(2):244–9.PubMedCrossRefGoogle Scholar
  62. 62.
    Carline L, McLeod GA, Lamb C. A cadaver study comparing spread of dye and nerve involvement after three different quadratus lumborum blocks. In: Colvin L, editor. Br J Anaesth. 2016;117(3):387–394. Oxford University Press.Google Scholar
  63. 63.
    Murouchi T, Iwasaki S, Yamakage M. Quadratus lumborum block: analgesic effects and chronological ropivacaine concentrations after laparoscopic surgery. Reg Anesth Pain Med. 2016;41(2):146–50.PubMedCrossRefGoogle Scholar
  64. 64.
    Barrington MJ, Ivanusic JJ, Rozen WM, Hebbard P. Spread of injectate after ultrasound-guided subcostal transversus abdominis plane block: a cadaveric study. Anaesthesia. 2009;64(7):745–50. Blackwell.PubMedCrossRefGoogle Scholar
  65. 65.
    Børglum J, Moriggl B, Jensen K, Lönnqvist PA, Christensen AF, Sauter A, et al. Ultrasound-guided transmuscular quadratus lumborum blockade. Br J Anaesth. 2013;111:(eLetters Supplement).CrossRefGoogle Scholar
  66. 66.
    Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006;96(4):418–26. Oxford University Press.PubMedCrossRefGoogle Scholar
  67. 67.
    Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001;95(3):771–80.PubMedCrossRefGoogle Scholar
  68. 68.
    Krediet AC, Moayeri N. Different approaches to ultrasound-guided thoracic paravertebral block. An illustrated review. Anesthesiology. 2015;123(2):459–74.PubMedCrossRefGoogle Scholar
  69. 69.
    Abdallah FW, Brull R. Off side! A simple modification to the parasagittal in-plane approach for paravertebral block. Reg Anesth Pain Med. 2014;39(3):240–2.PubMedCrossRefGoogle Scholar
  70. 70.
    Tsui BCH, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and adolescents. Anesthesiology. 2010;112(3):719–28.PubMedCrossRefGoogle Scholar
  71. 71.
    Ivani G, Suresh S, Ecoffey C, Bosenberg A, Lonnqvist P-A, Krane E, et al. The European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional Anesthesia and Pain Medicine Joint Committee Practice Advisory on Controversial Topics in Pediatric Regional Anesthesia. Reg Anesth Pain Med. 2015;40(5):526–32.PubMedCrossRefGoogle Scholar
  72. 72.
    Taenzer A, Walker BJ, Bosenberg AT, Krane EJ, Martin LD, Polaner DM, Wolf C, Suresh S. Interscalene brachial plexus blocks under general anesthesia in children: is this safe practice?: A report from the Pediatric Regional Anesthesia Network (PRAN). Reg Anesth Pain Med. 2014;39(6):502–5.PubMedCrossRefGoogle Scholar
  73. 73.
    Willschke H, Marhofer P, Machata AM, Lönnqvist PA. Current trends in paediatric regional anaesthesia. Anaesthesia. 2010;65(s1):97–104. Blackwell.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversity of Colorado School of Medicine, Children’s Hospital ColoradoAuroraUSA
  2. 2.Departments of Anesthesiology and PediatricsUniversity of Colorado School of Medicine, Children’s Hospital ColoradoAuroraUSA

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