Illustrated Manual of Regional Anesthesia: Conception, Realization, Consultation, Organization: Bureaux Bassler, Karlsruhe, FRG Artist: Wolfgang Rost, Graphic-Design

105 Pages·1988·3.89 MB·English

by  Professor P. Prithvi Raj M.D.

Prithvi Raj . Hans Nolte . Michael Stanton-Hicks
Illustrated Manual of
Regional Anesthesia
Coneeption, Realization, Consultation, Organization: Bureaux Bassier, Karlsruhe, FRG
Artist: Wolfgang Rost, Graphie-Design
With 300 transparencies, mostly in color,
and text brochure with 96 figures
Springer -Verlag
Berlin Heidelberg New York London Paris Tokyo
Professor P. Prithvi Raj, M. D.
Department of Anesthesiology, University of Texas Medical School
5020 MSMB 6471 Fannin, Houston, Texas 77030, U.SA
Univ. Professor Dr. med. Hans Nolte
Klinikum Minden, Institut für Anästhesiologie
Friedrichstraße 17, 4950 Minden, FRG
Professor Dr. med. Michael Stanton·Hicks, M.B., B.S., F.FAR.C.S.
Klinikum der Johannes Gutenberg-Universität, Klinik für Anästhesiologie
Langenbeckstraße 1, 6500 Mainz 1, FRG
ISBN 978-3-642-52261-1 ISBN 978-3-642-71221-0 (eBook)
DOI 10.10071978-3-642-71221-0
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of transla
tion, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in otherways, and storage in data banks. Duplication
of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its version of
June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law.
© Springer-Verlag Berlin Heidelberg 1988
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book.ln every
individual case the respective user must check its accuracy by consulting other pharmaceutical literature.
Typesetting: Hagedom-Satz, Berlin, FRG
Reproduction of transpareneies: JUP, Industrie- und Presseklischee, Berlin, FRG
2119/3020-543210
We dedicate this book to all of our loved ones
Contents
Foreword by P. Bromage ..................... IX B. Subarachnoid (Spinal) Block ...................... 24
1. General Aspects ............................. 24
Foreword by H. Killian. . . . . . . . . . . . . . . . . .. .. .. . . XI 2. Types and Methods of Subarachnoid Block
(Transparency 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 24
Foreword by A. Fortuna. . . . . . . . . . . . . . . . . . . . . .. XIII
C. Epidural Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
1. General Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Preface ...................................... XV
2. Cervical Approach (Transparency 3) .............. 27
3. Thoracic Approach (Transparency 4) . . . . . .. . . . . . .. 28
4. Lumbar Approach (Transparency 5) .............. 30
Chapter I: Principles of Management
5. Caudal Approach (Transparency 6) ............... 32
A. Preparation of the Surgical Patient for Regional Anesthesia
1. Preoperative Phase .......................... .
2. Quality and Duration of Block .................. . Chapter 111: Upper-Extremity Blocks
3. Planning for the Recovery Period ................ 2
A. Block of the Brachial Plexus and Its Branches . . . . . . . .. 35
4. Performance of Block . . . . . . . . . . . . . . . . . . . . . . . . . 2
1. General Description . . . . . . . . . . . . . . . . . . . . . . . . . .. 35
5. Management of Patient During Surgery . . . . . . . . . . . . 4
2. Interscalene Approach (Transparency 7 a) .......... 37
6. Postoperative Management . . . . . . . . . . . . . . . . . . . . . 4
3. Supradavicular Approach (Transparency 7 b) ....... 39
B. Physiologic Changes Due to Regional Anesthesia: 4. Infradavicular Approach (Transparency 8) . . . . . . . . .. 40
Comparison with General Anesthesia . . . . . . . . . . . . . . . . 4 5. Axillary Approach (Transparency 9) . . . . . . . . . . . . . .. 42
1. Intraoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . 4 6. Suprascapular Nerve Block (Transparency 10) ...... 44
2. Immediate Postoperative Period ................. 4
3. Extended Postoperative Period .................. 5 B. Elbow Block (Transparencies 11, 12) . . . . . . . . . . . . . . .. 44
C. Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 C. Wrist Block (Transparencies 13, 14) ................ 45
1. Classification of Local Anesthetic Agents . . . . . . . . . . . 5
D. Hand and Digital Block (Transparency 15) . . . . . . . . . . .. 46
2. Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . . . . . 5
3. Active Form ................................ 5
4. Site of Action ............................... 6
5. Pharmacokinetics ............................ 6 Chapter IV: Lower-Extremity Blocks
6. Systemic Toxicity Due to Local Anesthetic Agents.. . . . 7
A. Lumbosacral Plexus and Its Branches ............... 47
7. Management of Toxicity . . . . . . . . . . . . . . . . . . . . . . . . 8
1. General Considerations ....................... 47
2. Lumbar Plexus Block (Transparency 16) . . . . . . . . . .. 47
D. Aids to Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1. Fluoroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 3. Psoas Compartment Block (Transparency 17) . . . . . .. 48
2. Peripheral Nerve Stimulation . . . . . . . . . . . . . . . . . . . . 9
B. Hip and Gluteal Region .......................... 49
Appendix .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12 1. Sciatic Nerve Block (Transparencies 18-21) . . . . . . .. 49
Suggestions for Further Reading ..................... 16 2. Femoral Nerve Block (Transparency 22) ........... 51
3. Obturator Nerve Block (Transparency 23) . . . . . . . . .. 53
4. Lateral Femoral Cutaneous Nerve Block
(Transparency 24) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 54
Chapter 11: Central Nerve Blocks
C. Blocks of the Knee Region ....................... 54
A. General Considerations (Transparency 1) . . . . . . . . . . . . .. 17 1. Common Peroneal and Tibial Nerve Block
1. Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 17 (Transparency 25) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 54
2. Preliminary Remarks on Subarachnoid and 2. Saphenous Nerve Block at the Knee
Epidural Block. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 22 (Transparency 26) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 55
VIII
D. Ankle Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 56 Chapter VII: Blocks of the Trunk
1. Anterior Ankle and Metatarsal Block (Transparency 27) 56 and Perineum
2. Posterior Ankle Block (Transparency 28) . . . . . . . . . .. 57
A. Intercostal Nerve Block (Transpareneies 43, 44) 77
B. Thoraeie Paravertebral Nerve Block (Transparency 45) .. 78
Chapter V: Intravenous Regional Anesthesia C. Lumbar Paravertebral Nerve Block (Transparency 46) . .. 79
A. General Considerations (Transparency 29) . . . . . . . . . . .. 59 D. Trans-sacral Nerve Block (Transparency 47) . . . . . . . . .. 80
B. Standard Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 60 E. Pudendal Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . .. 81
1. Transperineal Approach (Transparency 48) ......... 82
C. Pharmacokinetics of Local Anesthetics with
2. Transvaginal Approach (Transparency 49) . . . . . . . . .. 83
Intravenous Regional Anesthesia ................... 64
F. Paracervical Nerve Block (Transparency 50) .......... 84
D. Complications ................................. 64
G. Sacrococcygeal Plexus Block (Transparency 51) 84
Chapter VI: Head and Neck Blocks Chapter VIII: Autonomie Nerve Blocks
A. Trigeminal Nerve and Its Branches . . . . . . . . . . . . . . . . .. 67 A. Stellate Ganglion Block . . . . . . . . . . . . . . . . . . . . . . . . . .. 85
1. Trigeminal Ganglion Block (Transparency 30) ....... 67 1. Anterior Approach (Transparency 52) ............. 86
2. Ophthalmie Nerve Block (Retrobulbar) 2. Lateral Approach (Transparency 53) .............. 87
(Transparency 31) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 68
3. Supraorbital and Supratrochlear Nerve Block B. Thoraeie Sympathetic Block (Transparency 54) ........ 87
(Transparency 32) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 69
C. Splanchnic Nerve and Celiac Plexus Block
4. Maxillary Nerve Block (Transparency 33) . . . . . . . . . .. 69
(Transparency 55) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 89
5. Infraorbital Nerve Block (Transparency 34) ......... 70
6. Mandibular Nerve Block (Transparency 35) . . . . . . . .. 70 D. Lumbar Sympathetic Block ....................... 90
7. Mental Nerve Block (Transparency 36) ............ 71 1. General Considerations ........................ 90
2. Paramedian (Classic, or Mandl) Approach
B. Sphenopalatine Ganglion Block (Transparency 37) . . . . .. 71 (Transparency 56) . . . . . . . . . . . . . . . . . . . . . . . . . . .. 91
3. Lateral (Reid's) Approach (Transparency 57) . . . . . . .. 92
C. Glossopharyngeal Nerve Block (Transparency 38) ...... 72
Chapter IX: Field Blocks
D. Laryngeal Nerve Block (Transparency 39) ............ 73
A. Mammoplasty (Transparency 58) .................. 93
E. Block of the Cervical Plexus and its Branches .. . . . . . .. 74
1. General Aspects ............................. 74
B. Upper and Lower Abdomen (Transparency 59) ........ 94
2. Superficial Cervical Plexus Block (Transparency 40) .. 74
3. Deep Cervical Plexus Block (Transparency 40) ...... 74 C. Inguinal Region (Transparency 60) . . . . . . . . . . . . . . . . .. 94
4. Greater Occipital Nerve Block .. . . . . . . . . . . . . . . . .. 75
D. Penile Block (Transparency 61) .................... 95
5. Spinal Accessory Nerve Block (Transparency 41) .... 75
6. Phrenic Nerve Block (Transparency 42) ........... 76 E. Anal Block (Transparency 62) ..................... 96
Foreword
Professor Philip Bromage
From the earliest stirrings of modern surgical anesthesia, novice surgeons struggling to learn from the living what
there was a strong intuitive feeling that anesthesia of part they were denied an opportunity to learn from the dead_
of the body would be better for the patient than complete But that is largely nostalgia for a past era_ Today, the visual
anesthesia of the whole organism. In 1848, James Young arts and the plastics industry have united to give us superb
Simpson spent some time and effort seeking this elusive teaching models and techniques that did not exist a few
goal, but after a few ingenious though unsuccessful experi decades ago, and they have developed two- and three
ments, he gave up the search and turned back to general dimensional surrogate cadavers that are imbued with a
anesthesia as the only practical solution to surgical pain more vivid artistry than ever existed on the marble slabs
relief at that time_ amid the formalin reek of our old dissecting rooms_
earl Koller's simple but brilliant application of cocaine to This book is a fresh and highly successful attempt to repair
the eye in 1884 opened the door to a whole new universe some of the bridges that were burnt with the passing of the
of neural anatomy and pharmacology_ Within a decade or old anatomy days_ Together, the authors have contributed
so, practically every nerve, plexus, and bony orifice in the their technical skills and the artist his inward eye to rebuild
body had been explored and exploitedto provide regional the three-dimensional sense_ Essential to locating invisible
anesthesia in the conscious patient Those early pioneers targets at some depth beneath the surface of the body, this
knew their anatomy weil, and for the most part, they were three-dimensional sense is aprerequisite of successful
ski lied, swift, and deft surgical technicians, who could open regional anesthesia_ The plastic overlays presented in this
and close a wound without a wasted movement volume conjure up in a few minutes salient features that
It took almost a century to unravel the mysteries of the might take days or weeks to learn by orthodox methods of
pharmacologic bases of regional anesthesia, and even gross dissection_ The neophyte is set upon the right road,
today we are not entirely certain of the differential effects and the old-timer's knowledge of anatomical detail is re
of local anesthetics on axons of varying size and character_ freshed_ All practitioners of regional anesthesia will find this
During this long interval, anatomical teaching changed its work an invaluable guide to successful technique and the
methods and emphasis_ Medical students no longer spend prevention of complications that arise from anatomical
hundreds of hours dissecting cadavers and memorizing the inaccuracies_ If regional anesthesia is to survive as a practi
minutiae of muscle attachments and their influence on cal art, it must be performed impeccably_ This work will
bony configuration_ Embryology is almost a lost art among contribute not only to the survival of the art, but more
practicing physicians, and those of us who were brought importantly, to the well-being of the patients who reap its
up in the old ways sigh as we watch the faltering steps of benefits_
Foreword
Professor Dr. H. Killian1
Anyone who has ever taken an interest in the history of duction anesthesia. Unfortunately, these attempts miscar
regional anesthesia knows that its genesis and develop ried, as all three experimenters became addicted as a
ment were no less dramatic than those of general anesthe result of studying the analeptic property of cocaine. The
sia and that it experienced several major crises. experiments led to no practical conclusions, but the hypo
It was mainly due to the great insight and tenacity of a cou thesis persisted, instigating bold men again and again to
rageous surgeon that this method of eliminating pain for use cocaine infiltrations as a local anesthetic on nerve path
operative and, occasionally, therapeutic purposes has not ways. Since they used concentrations of cocaine that were
only been preserved but has become an indispensable part much too high, e.g., 5 %-10 % and more, this inevitably led
of anesthesiology. to serious consequences. The number of registered co
Once Carl Koller had been made aware of the pain-killing caine poisonings rose rapidly everywhere, as did the num
effect of cocaine by Sigmund Freud in Vienna and had ber of deaths attributed to cocaine. Alarm spread; the pros
recognized that its chief value lay not in the field of therapy, pect of having to abandon cocaine anesthesia loomed.
but rather in its capacity to block nerve pathways in order This serious crisis was overcome by the courage of Paul
to produce painlessness, he proved - partly through ex Reclus. With unbelievable energy, industry, and conscien
periments on himself, partly through research on the eyes tiousness, he set about progressively reducing the concen
of animals - the effectiveness of topical anesthesia. In so tration of cocaine to as little as 0.1 % in order to eliminate
doing, he made it possible for ophthalmologists to perform from the procedure the dangers of too great a decrease in
cataract operations under local anesthesia with the patient concentration and too rapid an absorption rate. Only after
in a conscious state. This epochal discovery was presented 7000 successful operations using cocaine as an anesthetic
in a lecture to the convention of ophthalmologists in Heidel did he risk making public his technique in a book which was
berg on September 15, 1884. The lecture itself was given to set a standard for the practice of regional anesthesia.
by Dr. Brettauer of Trieste and the technique demonstrated Unfortunately, his publication came a year too late for him
by others because Koller lacked the necessary funds to to receive the full credit he deserved.
travel to Heidelberg himself. Nevertheless, the lecture was Meanwhile, having tried his method of local anesthesia on
an unqualified success, and his technique was adopted by 1000 cases, Carl Ludwig Schleich presented his work at
ophthalmologists all over the world. the Berlin Convention of Surgeons in 1892. A dramatic
William Steward Halsted, who studied aseptic surgery with scene culminating in the unfounded rejection of the
Ernst von Bergmann in Berlin, Richard von Volkmann in method was instigated by Prof. Bardelleben of Berlin, who
Halle, and Karl Thiersch in Leipzig in order to introduce it was president of the convention. Meanwhile, Schleich con
in America, heard of the success of cocaine as an an tinued to apply with great success his method of local
esthetic in eye operations. This made a deep impression on anesthesia using weak concentrations of cocaine in combi
him, and he began to take a greater interest in cocaine. nation with local supercooling of tissue - which took the
Reading the reports of pioneers in the field, he came upon a form of layered infiltration anesthesia. He was thereby able
publication by the Peruvian physician Thomas Moreno y to avoid the greater risks of chloroform anesthesia.
Malz, which had been printed in Paris in 1868. Moreno y Schleich continued to demonstrate his methods in a wide
Malz had injected cocaine solution into the thighs of bull variety of operations to visitors from all over the world, but
frogs and observed that the response to a weak solution the injustice done to him was never officially made good.
was only painlessness with maintenance of muscle power, However, Johannes von Miculicz of Breslau followed his
but that with higher concentrations, it was possible to example and proved with excellent results that Schleich's
observe complete anesthesia accompanied by para lysis. assertions were correct. Eventually, Ernst von Bergmann
His results suggested that the pathway of the sciatic nerve overcame this skepticism concerning Schleich's method
must have been blocked by the cocaine. Therefore, Moreno and asked Schleich to induce anal anesthesia on one of his
y Malz recommended that this method be evaluated for patients; von Bergmann was then able to operate pain
surgical purposes. Together with his colleagues Hall and lessly. He acknowledged later in a confidential conversa
Heathley, Halsted experimented on himself using cocaine tion that while he, von Bergmann, had simply made use of
solution, with a view toward developing a technique of con- existing knowledge of surgery, Schleich had conceived of
1 Deceased.
XII
new ideas and had succeeded in transforming them into a sia, depending on the ability or the inclination of the sur
viable technique. geon. However, its development did not stop there.
Progress in the development of regional anesthesia was In the U.SA before 1939, the use of local anesthetics was
interrupted until Basil von Anrep and Richard Willstädter advocated by only a few individual surgeons and anesthe
succeeded in determining the chemical structure of siologists, such as Lundy and Labat. Its great advantages
cocaine. Only then were systematic experiments under were recognized there only during World War 11, after which
taken to modify the cocaine molecule and produce new it became a universally used method.
local anesthetics. Regional anesthesia owes its fresh impetus following World
In 1905, Einhorn made the important discovery of novo War 11, especially in the developed countries, to several
caine, a relatively harmless agent, thus signalling a break authors, including H. Killian, H. Nolte, H. G. Auberger, and
through in regional anesthesia. A fortunate coincidence O. Schulte-Steinberg of Germany; Sir Robert Macintosh
played the decisive role here. The effectiveness of novo of England; H. Bergmann of Austria; J. J. Bonica, P. Brom
caine, or procaine, which is a relatively weak local anesthe age, D. and P. Bridenbaugh, D.C. Moore, and others of the
tic, can be increased and prolonged when tissue is super U.s.A.; J. Lassner, P. Gauthier-Lafaye of France; and
cooled or when vasoconstriction is achieved by some other Th. Gordh, E. Eriksson, and others of Sweden. In Russia,
means. Owing to a delay in its absorption, the toxicity of the owing to the severe scarcity of narcotics after the revo
agents is thus markedly reduced. This is also true, although lution, regional anesthesia became more widespread
to varying degrees, for many drugs derived from procaine. and was promoted by Wischnewsky and later by his
This mechanism was grasped by Heinrich Braun in Zwickau son during World War 11. There, lobectomies, pneumec
through self-experimentation. Braun was striving to achieve tomies, and operations on the esophagus were performed
this vasoconstriction by pharmacologic means when he using layer-by-Iayer infiltration anesthesia with a mixture of
read the first reports of the vasoconstrictive effect of adren novocaine and epinephrine, without use of the intubation
aline. Braun was also exceptionally lucky in that the combi technique.
nation of novocaine with traces of adrenaline produced the A new crisis for regional anesthesia arose with the introduc
most favorable conditions for surgery, i.e., the transforma tion of the intubation technique using curare, later succinyl
tion of the vascular dilatation caused by local anesthetic choline, and narcotics.
agent into vasoconstriction. With other preparations from In Europe and particularly in Germany, the use of regional
the same se ries of local anesthetics, this change proved anesthesia decreased noticeably to barely 10 % of all
much slighter or failed to take place at all. Supercooling of cases after the introduction of the intubation technique
tissue was no longer necessary, and this fact decided the around 1945-1946. Knowledge of techniques of regional
fate of novocaine and the further development of local anesthesia declined, and they were no longer taught in
anesthesia for many decades. medical schools, to the point where many anesthesiolo
In the meantime, Heinrich Braun and his pupils von Härtei, gists could no longer administer regional anesthesia at all.
Kappis, and others developed techniques of regionallocal In an effort to remedy this unfortunate situation, a few
anesthesia and peripheral nerve blocks. people made a serious attempt to re-establish regional
August Bier attempted centrallumbar anesthesia, although anesthesia. The battle has now been won; in 30 %-40 % of
this method had so many side effects at the beginning that cases today, regional and major conduction anesthesia are
he could not recommend it for general use. Despite these used, not to mention minor local anesthesia performed by
initial observations, Tuffier risked using the technique sev surgeons, dentists, and others. These methods have finally
eral times and, by observing the physiologic changes, was gained adefinite place in the field of analgesia.
able to salvage the method. Blocks of other, larger nerves I am sure that this atlas will make learning techniques of
and plexus anesthesia followed. regional anesthesia easier and will contribute toward pre
Even before World War I, the use of regional anesthesia had serving this method of anesthesia and guaranteeing its
spread worldwide, accounting for up to 60 % of all anesthe- availability for future generations.
Foreword
Professor Armando Fortuna
During the last 40 years, several outstanding textbooks blocks can be employed in the c1inical management of
have appeared in the field of regional anesthesia, including patients.
Maclntosh's Spinal Anesthesia, Bonica's The Management By means of a completely new state-of-the-art printing
of Pain, Moore's Regional Block, and Bromage's Epidural process employing laser beams to color the transparen
Analgesia, to mention only a few. eies, Springer-Verlag has kept the price within reasonable
Even with all these masterly volumes, there is still a need at limits in spite of the large number of color plates and illus
the present time for a new textbook which includes all the trations. With traditional methods, the cost would have
latest developments in techniques, drugs, and c1inical indio been prohibitive. In publishing this atlas, every effort has
cations for methods of local anesthesia. been made to make the subject simple, c1ear, and easy to
This extraordinary publication, the lIIustrated Manual of understand for the interested physician or medical student.
Regional Anesthesia, by Prithvi Raj, Hans Nolte, and Each type of block is described according to the same step
Michael Stanton-Hicks, represents to me the "book of the by-step format, with seetions on history, anatomy, equip
1980s," appearing at a time when local analgesia is enjoy ment, drugs, technique, practical aspects, indications,
ing arevival, especially in Europe and the U.SA Both the contraindications, and complications.
American Society of Regional Anesthesia and the European I am sure that this atlas will maintain its position as one of
Society of Regional Anesthesia have been very active in the standard texts in regional anesthesia for many years to
promoting the safety, simplicity, usefulness, and economy come.
of these methods. It was a great pleasure and honor for me to have seen this
Prof. Raj and his colleagues have been among the leaders work in its prepublication stage. I am sure that it will playa
of this movement. This atlas embodies their philosophy and great role in promoting techniques of regional anesthesia
experience and shows how various types of anesthetic and their clinical applications.