Atlas of Sonoanatomy for Regional Anesthesia and Pain Medicine

563 Pages·2017·55.18 MB·English

by  Manoj Karmakar

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CONTENTS
Preface
Acknowledgments
1. Basics of Musculoskeletal and Doppler Ultrasound Imaging for Regional
Anesthesia and Pain Medicine
2. Sonoanatomy Relevant for Ultrasound-Guided Upper Extremity Nerve Blocks
3. Sonoanatomy Relevant for Ultrasound-Guided Lower Extremity Nerve Blocks
4. Sonoanatomy Relevant for Ultrasound-Guided Abdominal Wall Nerve Blocks
5. Ultrasound Imaging of the Spine: Basic Considerations
6. Sonoanatomy Relevant for Ultrasound-Guided Injections of the Cervical Spine
7. Ultrasound of the Thoracic Spine for Thoracic Epidural Injections
8. Ultrasound Imaging of the Lumbar Spine for Central Neuraxial Blocks
9. Ultrasound Imaging of Sacrum and Lumbosacral Junction for Central Neuraxial
Blocks
10. Sonoanatomy Relevant for Thoracic Interfascial Nerve Blocks: Pectoral Nerve
Block and Serratus Plane Block
11. Sonoanatomy Relevant for Ultrasound-Guided Thoracic Paravertebral Block
12. Sonoanatomy Relevant for Ultrasound-Guided Lumbar Plexus Block
Index
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PREFACE
This Atlas is intended to illustrate the aspects of sonoanatomy that are important in the
performance of ultrasound guided nerve blocks for acute and chronic pain medicine. The use
of ultrasound has increased exponentially in the area of regional anesthesia and pain medicine
in the last decade. During this time of evolution, learning sonoanatomy was hampered with
the need to refer to various resources for the technical aspects of machine optimization,
correlating sonoanatomy with gross anatomy and other imaging modalities and discovering
the ergonomic aspects of imaging and intervention.
For regional anesthesia, transitioning from landmark based techniques for nerve blocks to
real time ultrasound image guided nerve blocks required the development of the ability to
visualize and understand the cross sectional anatomy of the area of interest outside the
traditional transverse, sagittal and coronal axis views presented by current modalities such as
computed tomography and magnetic resonance imaging.
For pain medicine, transitioning from fluoroscopy guided interventions to real time
ultrasound image guided or assisted interventions required the development of new points of
reference for interventions and a move away from traditional fluoroscopic guided endpoints
for intervention.
This book is divided into chapters that present the sonoanatomy specific for interventions
in the area of interest. With a total of 768 illustrations this book is designed to be the
complete resource for gross anatomy, CT, MR and sonoanatomy of the specific area of
interest for easy cross-reference between gross anatomy and the various modalities allowing
users to better understand the sonoanatomy. These cross-referenced images are presented
with the relevant anatomy in the same cross sectional plane of the ultrasound image. Within
each area of interest, users are guided to acquire the ideal ultrasound image for targeted
intervention with attention to the required ergonomics for operator safety and comfort.
Each approach to the relevant sonoanatomy is accompanied by clinical pearls to aid
readers acquire ultrasound images of the area of interest with ease, provide guidance for
successful intervention and avoid pitfalls.
This Atlas has been written both as an introduction for new users to ultrasonography and
as a review and instruction aid for users familiar with the subject. It is our sincere hope that
the users of this book will develop an appreciation of the ease and usefulness of
ultrasonography and the beauty of sonoanatomy.
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ACKNOWLEDGMENTS
We would like to express our deepest gratitude to Philips Medical for their assistance, with
special appreciation to – Inainee binte Abu Bakar, Lynette Barss, Cheong Yew Keong, Doxie
Davis, Nicolaas Delfos, Cellinjit Kaur, William Kok, Nah Lee Tang and Wayne Spittle. And,
of course, our families for their support and encouragement.
The anatomic images are courtesy of the Visible Human Server at Ecole Polytechnique
Fédérale de Lausanne, Visible Human Visualization Software (http://visiblehuman.epfl.ch),
and Gold Standard Multimedia www.gsm.org. All figures and illustrations in this book are
reproduced with the kind permission from www.aic.cuhk.edu.hk/usgraweb of the Department
of Anesthesia and Intensive care of The Chinese University of Hong Kong.
Manoj K. Karmakar, MD, FRCA, DA(UK), FHKCA, FHKAM
Edmund Soh, MD
Victor Chee, MD
Kenneth Sheah, MD
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CHAPTER 1
Basics of Musculoskeletal and Doppler Ultrasound
Imaging for Regional Anesthesia and Pain Medicine
A sound knowledge of the basic concepts of musculoskeletal ultrasound is essential to obtain
optimal images during ultrasound-guided regional anesthesia (USGRA). This chapter briefly
summarizes the ultrasound principles that the operator should be aware of when performing
USGRA.
Ultrasound Transducer Frequency
Spatial resolution is the ability to distinguish two closely situated objects as separate. Spatial
resolution includes axial resolution (the ability to distinguish two objects at different depths
along the path of the ultrasound beam) and lateral resolution (the ability to distinguish two
objects that are side by side perpendicular to the ultrasound beam). Higher transducer
frequencies increase spatial resolution but penetrate poorly into the tissues. Lower transducer
frequencies penetrate deeper into the tissues at the expense of lower spatial resolution. Spatial
resolution and beam penetration have to be balanced when choosing the transducer
frequency.
Examples: A high-frequency (6–13 MHz) ultrasound transducer is used to image
superficial structures such as the brachial plexus in the interscalene groove or supraclavicular
fossa. A lower-frequency transducer (5–10 MHz) is suitable for slightly deeper structures
such as the brachial plexus in the infraclavicular fossa, and a low-frequency transducer (2–5
MHz) is used to image deep structures such as the lumbar paravertebral region or the sciatic
nerve. High-frequency (6–13 MHz) linear transducers with a small footprint (25–26 mm) are
particularly suited for regional blocks in young children.
Scanning Plane
Scans can be performed in the transverse (axial) or longitudinal plane. During a transverse
scan, the transducer is oriented at right angles to the long axis of the target, producing a
cross-sectional display of the structures (Fig. 1-1A). During a longitudinal (sagittal) scan, the
transducer is oriented parallel to the long axis of the target (eg, a blood vessel or nerve) (Fig.
1-1B). During USGRA, ultrasound scans are most commonly performed in the transverse
plane in order to easily visualize the nerves, the adjacent structures, and the circumferential
spread of the local anesthetic.
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FIGURE 1-1 Axis of scan.
Transducer and Image Orientation
The ultrasound image must be correctly oriented in order to accurately identify the
anatomical relationships of the various structures on the display monitor. Ultrasound
transducers have an orientation marker (eg, a groove or a ridge) on one side of the transducer,
which corresponds to a marker on the monitor (eg, a dot or logo) (Fig. 1-2). There are no
accepted standards on how to orient a transducer, but it is common to have the orientation
marker on the transducer directed cephalad when performing a longitudinal scan, and
directed towards the right side of the patient when performing a transverse scan (Fig. 1-3). In
this way, the monitor “marker” should be at the upper-left corner of the screen representing
the cephalad end during a longitudinal scan, or the right side of the patient during a transverse
scan (Fig. 1-3). The top of the monitor represents superficial structures, and the bottom of the
monitor deep structures.
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