Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12 doi:10.1111/j.1365-2044.2009.06200.

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Ultrasound in regional anaesthesia

J. Griffin1 and B. Nicholls2
1 Specialist Registrar in Anaesthesia, South West School of Anaesthesia, Derriford Hospital, Plymouth, Devon, UK
2 Consultant in Anaesthesia and Pain Management, Taunton & Somerset NHS Foundation Trust, Musgrove Park
Hospital, Taunton, Somerset, UK

Summary
Ultrasound guidance is rapidly becoming the gold standard for regional anaesthesia. There is an
ever growing weight of evidence, matched with improving technology, to show that the use of
ultrasound has significant benefits over conventional techniques, such as nerve stimulation and loss
of resistance. The improved safety and efficacy that ultrasound brings to regional anaesthesia will
help promote its use and realise the benefits that regional anaesthesia has over general anaesthesia,
such as decreased morbidity and mortality, superior postoperative analgesia, cost-effectiveness,
decreased postoperative complications and an improved postoperative course. In this review we
consider the evidence behind the improved safety and efficacy of ultrasound-guided regional
anaesthesia, before discussing its use in pain medicine, paediatrics and in the facilitation of neuraxial
blockade. The Achilles’ heel of ultrasound-guided regional anaesthesia is that anaesthetists are far
more familiar with providing general anaesthesia, which in most cases requires skills that are
achieved faster and more reliably. To this ends we go on to provide practical advice on ultrasound-
guided techniques and the introduction of ultrasound into a department.
. ......................................................................................................
Correspondence to: Dr B. Nicholls
E-mail: barrynicholls@doctors.org.uk

The use of ultrasound imaging techniques in regional If the use of ultrasound is to become more widespread
anaesthesia is rapidly becoming an area of increasing amongst anaesthetists, then it must be shown to be
interest. It represents one of the largest changes that the clinically effective, practical and cost-effective. The use of
field of regional anaesthesia has seen. For the first time, ultrasound guidance in daily clinical practice requires a
the operator is able to view an image of the target nerve degree of training and an understanding of the equipment
directly, guide the needle under real-time observation, and technology. This article will address the benefits and
navigate away from sensitive anatomy, and monitor the widespread uses of ultrasound in regional anaesthesia. It
spread of local anaesthetic (LA). This comes at a time will provide practical tips on how to achieve success in its
when an ageing population presents with an increasing use. It will review the evidence that support its use and
range of comorbidities, thereby demanding a wider provide advice on the introduction of ultrasound into a
choice of surgical and anaesthetic options to ensure department.
optimal clinical care and a decreased risk of complica-
tions. The key to successful regional anaesthesia is
Background
deposition of LA accurately around the nerve structures.
In the past, electrical stimulation or paraesthesia, both of Regional anaesthesia, when used alone or in combination
which relied on surface landmark identification, was with general anaesthesia, offers several potential benefits
used for this. However, landmark techniques have over general anaesthesia alone: a decrease in morbidity
limitations; variations in anatomy [1] and nerve and mortality [3–6]; superior postoperative analgesia [7–
physiology [2], as well as equipment accuracy have 10]; cost-effectiveness [11]; a decrease in postoperative
had an effect on success rates and complications. The complications [12–14]; and an improved postoperative
introduction of ultrasound may go some way to course (decreased use of opioids and anti-emetics, faster
changing this. recovery and discharge, increased patient satisfaction)

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Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 1
J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12
. ....................................................................................................................................................................................................................

[7, 15, 16]. Unfortunately, despite these clinical benefits, compared with the traditional landmark and nerve
regional anaesthesia remains less popular than general stimulation techniques. Chan et al. [36] undertook a
anaesthesia. Its use is associated with a number of randomised, controlled trial of 188 patients undergoing
shortcomings. Perhaps the greatest is that general anaes- axillary brachial plexus blocks, comparing ultrasound with
thesia is far more successful and reliable than regional nerve stimulation techniques. Block success rate was
anaesthesia [17, 18]. Even in experienced hands and with higher with ultrasound (82.8%, p = 0.01) and combined
the use of nerve stimulation, there is an inherent failure ultrasound and nerve stimulation (80.7%, p = 0.03),
rate. Anaesthetists are more familiar with providing compared with nerve stimulation alone (62.9%). They
general anaesthesia [19], which is generally achieved faster reported the additional benefits of less axillary pain and
and using skills that are easier to attain. However, regional bruising. None of the groups reported any major
anaesthesia does not compete with general anaesthesia, in complications. However, one must be mindful that this
much the same way as ultrasound-guided regional tech- ultrasound success rate, in the hands of experienced
niques do not compete with nerve stimulation techniques. operators using high-end ultrasound machines, was well
What ultrasound can bring to regional anaesthesia is a short of 100%. The authors commented that this was
number of potential advantages that serve to redress some most likely due to mistakes in nerve identification and
of the shortcomings of the current techniques: direct misinterpretation of circumferential spread of LA.
observation of nerves [21, 24–28]; direct observation of Orebaugh et al. [37], in a larger but non-randomised
surrounding structures (vessels, muscles, tendons), facili- study of 248 patients requiring any one of four different
tating the identification of nerves [24–28]; direct observa- peripheral nerve blocks (interscalene, axillary, femoral,
tion of LA deposition and spread [24, 25, 27, 29]; popliteal), compared ultrasound plus nerve stimulation
avoidance of painful evoked muscle contractions [25]; a with nerve stimulation alone. They found a significantly
decrease in complications such as accidental intraneural or shorter time was needed to perform the blocks with fewer
intravascular injection [21, 24, 25, 27, 29, 31, 32]; faster attempts (both p < 0.001) when ultrasound was used.
onset of block [24, 25, 27, 28, 30]; longer duration of However, they failed to show a statistical difference in the
block [25]; improved block quality [24, 28, 30, 34, 35]; failure rate between the two groups: 2% (3 ⁄ 124) in the
and decreased dose of LA [23, 30]. A number of recent ultrasound plus nerve stimulation group and 6% (8 ⁄ 124)
editorials [20–22] have agreed that ultrasound guidance in the nerve stimulation group (p = 0.334). Pearlas et al.
will become the gold standard for regional anaesthesia, but [35], in a prospective, randomised trial, assigned 74
that this transition will take another 5–10 years. patients undergoing major elective foot or ankle surgery
to receive a sciatic block in the popliteal fossa. Half of the
blocks were guided by real-time ultrasound and half by
Advantages
nerve stimulation. Sensory and motor function were
The single most important advantage that ultrasound assessed by a blinded observer at predetermined intervals
brings to regional anaesthesia is the ability to confirm the for up to 1 h. Block success was identified as loss of
exact placement and spread of LA; it is the LA that blocks sensation to pinprick within 30 min in the distribution of
the nerve and not the needle. The needle can be both tibial and common peroneal nerves. They found that
manipulated under real-time observation to the target the ultrasound group had a significantly higher block
nerve, and LA placed directly around the nerve, resulting success rate compared with the nerve stimulation group
in a faster onset, longer duration and improved quality (89.2% vs 60.6% respectively, p = 0.005). Onset and
block using less LA. Hazardous structures such as blood progression time for the block was faster in the ultrasound
vessels, pleural and viscera can be avoided, and compli- group, without an increase in block procedure time or
cations can thereby be minimised. Ultrasound frees the complications.
operator from using the classically described landmarks. Casati et al. [38] undertook a prospective, randomised,
Nerves can be targeted at any point along their course blinded study to test the hypothesis that ultrasound
where they can be seen. ‘Blind techniques’ relying on guidance can shorten the onset time of axillary brachial
pops, clicks, twitches and the need for multiple trial and plexus blocks compared with nerve stimulation when
error needle passes, with their lack of accuracy, reliability, using a multiple injection technique. Thirty patients were
longer placement times, patient discomfort and injury, randomised to each group. The average number of needle
can now, for many blocks, be dispensed with. passes was four in the ultrasound group and eight in the
nerve stimulation group. Mean (SD), sensory block onset
Efficacy and safety time was shorter in the ultrasound group (14 (6) vs 18 (6)
Several studies have shown increased efficacy and safety min respectively, p = 0.01). However, no difference was
when using ultrasound to aid regional anaesthesia when seen in the onset time of the motor block or readiness for

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2 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12 J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia
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surgery. An insufficient block was seen in one patient in guided regional nerve block, published in January 2009
the ultrasound group and two in the nerve stimulation [44].
group. However, procedure-related pain was seen in 14
patients (48%) in the nerve stimulation group compared
Epidural and spinal anaesthesia
with only six patients (20%) in the ultrasound group
(p = 0.48). In conclusion, the group commented that In January 2008 NICE published guidelines [45] that
with multiple injection axillary blocks, ultrasound pro- suggested that ultrasound could be used in two different
vided a similar success rate and had a comparable ways to facilitate catheterisation of the epidural space.
incidence of complications when compared with nerve One method is the use of real-time ultrasound imaging to
stimulation. Marhofer et al. [30] conducted a prospective observe the passage of the needle towards the epidural
randomised controlled trial comparing ultrasound with space. The second method (pre-puncture ultrasound) is
nerve stimulation in 60 patients receiving femoral ‘three- the use of ultrasound as a guide to the conventional
in-one’ blocks for hip surgery following trauma. The technique, using an initial scan of the patient’s lumbar
onset time of sensory block in each nerve was significantly spine to identify the midline, interspinous spaces and
shorter with ultrasound guidance when compared with depth of the epidural space. The guidance relates to
nerve stimulation. The quality of the nerve block was also children, neonates, pregnant women and patients with
significantly better in the ultrasound group (p < 0.01). scoliosis. Neuraxial imaging with ultrasound is particu-
The femoral nerve could be viewed in 95% of the larly challenging as the structures in which we are
ultrasound group in which there were no cases of vascular interested (ligamentum flavum, epidural space and dura)
puncture compared with 10% in the nerve stimulation are mostly encased in bone, through which ultrasound
group. In a large retrospective study by Sandhu et al. [39], will not pass. Visibility is via one or two acoustic
1146 patients underwent ultrasound-guided infraclavicu- windows, the interspinous space and the intralaminar
lar blocks. These were carried out by 88 different junior space. These are best imaged when scanning transversely
doctors who were supervised by 37 different anaesthetists, in the midline and longitudinally in the paramedian area
and hence this represented a ‘real world’ scenario. respectively (Figs 1 and 2). To understand spinal ultra-
Ninety-nine per cent of the blocks were successful sound, a thorough knowledge of lumbar spine anatomy is
(1138 ⁄ 1146), arterial puncture occurred in < 1% of cases necessary, as certain bony landmarks can be easily
and no patients had accidental intravascular injection, identified: sacrum, spinous processes, articular processes
local toxicity or symptoms of peripheral nerve injury. (facet joints) and vertebral bodies. The epidural space is
Furthermore, the use of ultrasound has shed some light hypo-echoic and often not seen clearly. The ligamentum
on the failings of nerve stimulation. A study by Beach flavum and posterior dura are commonly seen as a single
et al. [40] showed that for adequately imaged nerves, a
positive motor response to nerve stimulation did not
improve the success of the block. In addition, they found
that a block could be successful without positive nerve
stimulation. Indeed, muscle stimulation and paraesthesia
may not occur even when ultrasound confirms the
SP
correct needle position [2]. Other papers have shown that
the needle can be intraneural and there can still be failure AP
to provoke muscle contractions by the nerve stimulator
[41]. In diabetic patients, it has been demonstrated that PD
nerve stimulation and paraesthesia may be impossible to SC
elicit at currents < 2.4 mA [42]. Biegeleisen [43], in a AD

prospective study of US-guided axillary blocks, found VB

that nerve puncture and intraneural injection of LA does
not always lead to nerve injury.
In the last year alone there has been a large number of
excellent studies published that provide more evidence
that ultrasound will soon become the main method of
guidance in regional anaesthesia. This has been sup- Figure 1 Midline ultrasound view of the lumbar spine and the
epidural space. The depth to the epidural space is marked (A).
ported by the recent publication of the UK National SP, spinous process; AP, articular process; AD, anterior dura –
Institute for Health and Clinical Excellence (NICE) ligamentum flavum complex; PD, posterior dura; SC, spinal
Interventional Procedure Guidance 285 on ultrasound- canal; VB, vertebral body.

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Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 3
J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12
. ....................................................................................................................................................................................................................

icant difference in aspiration of blood, backache or

sensory problems. Dural puncture was seen in 0.7% of the
ultrasound group and 1.3% of the control group. Patient
satisfaction was higher in the ultrasound group.
On the premise that epidural anaesthesia may be
AP
difficult in pregnancy, Grau et al. [48] went on to evaluate
the teaching possibilities of ultrasonography as a diagnos-
PD
tic approach to the epidural region. Two groups of
SC
residents performed their first 60 obstetric epidurals under
AD
supervision. The control group used a conventional loss
of resistance technique while the ultrasound group
proceeded in the same way but were supported by
pre-puncture ultrasound imaging, giving them informa-
tion about optimum puncture point, depth and angle.
Success was defined as using fewer than three attempts,
Figure 2 Paramedian ultrasound view of the lumbar spine and not changing space or anaesthetic technique, and achiev-
epidural space. The depth of the epidural space is marked (A). ing adequate epidural anaesthesia. In the control group,
AP, articular process; AD, anterior dura – ligamentum flavum the success rate for the first 10 epidurals was 60%,
complex; PD, posterior dura; SC, spinal canal. increasing to 84% over the next 50 epidurals. In the
ultrasound group, success rate started at 86% and
bright hyperechoic line. Anterior and deep to these increased to 94%. The authors concluded that the study
structures, the anterior dura and posterior longitudinal showed the possible value of ultrasound imaging for
ligament can often be seen as being distinct from the teaching and learning obstetric regional anaesthesia.
vertebral body; the spinal canal lies between these Arzola et al. [49] imaged 61 pregnant women undergoing
superficial and deeper structures. In neonates and children epidural analgesia with a midline, transverse ultrasound
under six months, the internal architecture of the spinal approach. They found a good level of success in the
cord can be clearly seen; this is not so in older children ultrasound determined insertion point (91.8%) and in the
and adults. measured and actual depth to the epidural space. The
mean (SD) ultrasound determined depth of the space was
Efficacy and safety 4.66 (0.68) cm; the actual depth of the space as measured
In a randomised controlled trial of 64 children, Willschke by the epidural needle was 4.65 (0.72) cm.
et al. [46] compared real-time ultrasound with pre- It is unsurprising that NICE have targeted the use of
puncture ultrasound. Catheter placement was successful ultrasound in these groups. In children, the quality of
in all children but was quicker to perform in the real-time image is superior because of the lesser depths involved,
ultrasound group: a mean of 162 s compared with 234 s the relatively larger acoustic windows and the reduced
(p < 0.01). None of the children in the real-time ultra- ossification of the surrounding bony structures [50].
sound group required supplementary intra-operative or While in pregnancy it has been shown [51] that the
postoperative analgesia, compared with 6% (2 ⁄ 34) in the optimum puncture site available on the skin for lumbar
pre-puncture group. Furthermore, in a case series of 35 epidural space cannulation is smaller, the soft-tissue
neonates, he demonstrated that the tip of the needle and channel between the spinal processes is narrower, and
spread of LA could be clearly seen in all cases. the skin–epidural space distance is greater than in the
Grau et al. [31, 47] conducted two randomised, non-pregnant patient. Furthermore, the visibility of the
controlled studies of a total of 372 pregnant women ligamentum flavum, dura mater and epidural space is
receiving obstetric epidurals. They compared the use of decreased during pregnancy. An increased incidence of
pre-puncture ultrasound with no ultrasound. The mean obesity and oedema obscures anatomical landmarks (the
numbers of puncture attempts were 1.3 and 1.5, spinous processes and the midline), and hormonal changes
compared with 2.2 and 2.6 respectively (p < 0.013 and result in softer ligaments, making the loss of resistance
p < 0.001). In the larger of these studies (n = 300), they technique less reliable.
showed a faster onset time for the block (4.6 min vs Ultrasound can be used to pre-scan the lumbar spine in
5.3 min, p < 0.027) and a lower incidence of severe difficult cases, confirming both the midline and the depth
headaches (2.7% vs 10.0%, p < 0.011) in the ultrasound to the ligamentum flavum and epidural space, decreasing
group. However, preparation time was increased at 6 min the failure rate and the incidence of complications. Real-
compared with 4 min (p < 0.001). There was no signif- time epidural guidance is not routinely used; both

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4 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12 J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia
. ....................................................................................................................................................................................................................

visibility of the needle and the practicalities of holding the Peripheral nerve injections using ultrasound include the
probe and manipulating a loss of resistance technique occipital nerve, suprascapular nerve, intercostal nerve,
means that a minimum of three hands are necessary. The ilio-inguinal and ilio-hypogastric nerve, pudendal nerve
development of probe supports and needle guidance and lateral cutaneous nerve of thigh. Eichenberger et al.
devices may see this as a realistic possibility in the future, [59] were able to locate the occipital nerve with
but as for now, real-time guidance is reserved for experts. ultrasound and reliably block it. This compares well with
Experience with spinal anaesthesia reflects that found with the recommended three-needle fluoroscopy technique
epidurals, being used to assess the vertebral level [52] and that is used to accommodate the variable anatomy of the
to identify normal spaces in difficult cases [53], but nerve. More recent studies comparing ultrasound and
ultrasound is still not routinely used to guide the needle. fluoroscopy for piriformis injections [60] (for piriformis
syndrome) and glenohumeral joint injections [61] have
shown improved accuracy with ultrasound.
Pain medicine
Ultrasound has the potential to influence the diagnosis
The use of ultrasound in pain medicine has lagged and treatment of many pain conditions, not only with the
behind its use in regional anaesthesia, and initial studies increased accuracy of injection techniques but also with
were primarily concerned with identifying anatomy the potential to diagnose common musculoskeletal prob-
sonographically and the feasibility of performing estab- lems. Further outcome studies to confirm the benefits of
lished techniques using ultrasound. More recently, ultrasound in comparison to fluoroscopy are eagerly
comparative studies comparing fluoroscopic and com- awaited.
puterised tomography-guided techniques with ultra-
sound have begun to appear and these are now
Paediatrics
contesting the ‘gold standard’ for pain interventions.
Although X-ray gives better definition for bony struc- Regional anaesthesia is usually performed under general
tures than ultrasound, it lacks the ability to demonstrate anaesthesia in children. Absolute distances are smaller and
musculoskeletal and peripheral nerve structures. the nerves lie closer to the skin. Ultrasound would
Although limited by bony shadowing and decreased therefore seem an obvious choice in this area, improving
resolution at depth, ultrasound for spinal injections has block efficacy and safety even though the incidence of
included cervical and lumbar facet joint injections, peripheral nerve block-related complications is already
lumbar medial branch blocks, peri-radicular injections, exceptional low (1:10 000) in paediatric practice [62].
caudal and sacro-iliac joint injections. Where ultrasound offers benefits over established tech-
Greher et al. [54] first described the feasibility of niques is in fascial plane blocks such as rectus sheath, ilio-
ultrasound-guided facet joint injections and Galiano inguinal and transversus abdominis blocks, in which the
et al. [55], in a prospective, randomised clinical trial, endpoint relies on clicks and pops. Ultrasound decreases
showed that the ultrasound approach to lumbar facet the risk of intramuscular and intraperitoneal injection,
joints is clinically feasible, and results in a significant bringing science to an imperfect art. Local anaesthetic
decrease in procedure duration and radiation dose volume reduction studies as described below enhance the
compared with computerised tomography. However, safety of regional anaesthetic techniques in children.
formal comparison with fluoroscopy is still awaited. Willschke et al. [32] conducted a randomised con-
Nerve root injections are difficult with ultrasound, and trolled trial of 100 children with a mean age of
the trans-foraminal approach is limited by poor visibility; 41 months. They showed that LA could be placed
reliable needle placement within the foramina is around 100% of ilio-inguinal and iliohypogastric nerves
unachievable with present equipment and approaches. using ultrasound, but only 50% when a fascial click
Sympathetic blocks are one of the mainstays of pain technique was used, as detected by ultrasound after
medicine, and the use of ultrasound for stellate ganglion injection (p < 0.0001). Heart rate increase on incision
blocks was initially describe by Kapral et al. in 1995 was 6% and 22% in the two groups respectively
[56]. A recent case report [57] suggests improved safety (p < 0.0001). Additional analgesia was necessary in 4%
with the use of ultrasound: less risk of damage to the and 26% respectively (p = 0.004). The mean volume of
thyroid gland and vessels, vertebral artery and oesoph- LA required to produce an effective block was signifi-
agus. The ability to monitor the spread of the LA sub- cantly lower at 0.19 ml.kg)1 compared with 0.3 ml.kg)1
fascially along the longus coli muscle may help to (p < 0.0001). Furthermore, a smaller proportion of
decrease the incidence of complications such as recur- patients required postoperative rectal analgesia: 6% com-
rent laryngeal nerve palsy, and intrathecal and epidural pared with 40% (p < 0.0001). No complications were
spread [58]. reported in either group.

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Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 5
J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia
. ....................................................................................................................................................................................................................
Cost analysis
The initial cost of a modern portable ultrasound system is
often used as an argument against ultrasound and its
introduction into a department. A typical machine costing
in the range of £15 000–£20 000 and with a conserva-
tive average life span of five years, at 1000 procedures per
year, equates to a cost of £3.00–£4.00 per patient event.
Sandhu et al. [33] compared the costs of administering
infraclavicular nerve blocks by either nerve stimulator or
ultrasound. The per case cost of the ultrasound machine
($17 000), spread over 5000 blocks, was $3.40. Time
saving in block onset and placement came to 21 min.
Theatre time at $8.00 per min meant a $168.00 saving per
nerve block. Over 5000 blocks, this is a saving of
$84 000. We know that ultrasound-guided blocks are also
safer, more efficacious and with fewer complications
(potential reduction in litigation costs); less LA is used and
the incidence of conversion to general anaesthesia is
lower. Further cost savings would be expected in day
surgery patients as they are able to bypass recovery and are
discharged sooner with a decreased incidence of postop-
erative nausea and vomiting. In addition, the ultrasound
machine can also be used for central line and arterial line
placement, and in the intensive care unit for assisting in
procedures such as drainage of pleural effusions or ascitic
fluid.
Practical tips for ultrasound-guided regional
anaesthesia
The premise of ultrasound-guided regional anaesthesia is
the visual location of the nerve, guidance of the needle to
the nerve and the spread of LA around the nerve and, in a
perfect world, if all these criteria are met, then a 100%
success rate should be achievable. Attention to detail and
the development of good practical skills can go along way
towards achieving this goal.
Visual location of the nerve
To optimise demonstration of nerves and surrounding
structures, it is important to understand the equipment
and its limitations, and to have a good, sound anatomical
knowledge of the structures being viewed. The probe
Crystal Field
Probe Array Frequency depth Resolution
Linear Linear 6–13 MHz 1.8–6 cm 0.5 mm axial
1 mm lateral
Curvilinear Curved 2–5 MHz 5–16 cm 2 mm axial
face 3 mm lateral
6 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12
used should match the procedure being performed
(Table 1). Choosing the wrong probe can make identi-
fication of the anatomy difficult (Figs 3 and 4). It is
important to use the highest frequency probe available for
the depth of image being scanned.
Needle guidance
The ‘holy grail’ in ultrasound-guided regional anaesthesia
is to find a needle that defies the laws of physics and can
be seen at any depth and at any angle. To this end, needles
have been coated and scored, the tips multifaceted and
needle guides designed [63], all to increase their reflec-
tivity and ease of use. At present, there is no single needle
that is significantly more echogenic than another. Facet-
tipped needles appear to have more ‘feel’ and may
decrease the chances of intraneural needle placement.
In general, large needles are more readily visible on
ultrasound and the visibility of all needles becomes less as
distance from the probe increases. Identification of the
needle can be improved by: rotating the needle, as
ultrasound reflecting from the bevel can improve visibil-
ity; gentle in-and-out movements (‘jiggling’); or injection
of small volumes of fluid–‘hydrolocalisation’ [64]. The
needle can be introduced using either an in-plane
approach in which the needle is passed along the long
axis of the probe, parallel to the probe face, or an out-of-
plane approach in which the needle passes at right angles
to the long axis of the probe. Use of the in-plane
technique means that the entire needle can be seen
(Fig. 5), that there is excellent visibility of the needle-
nerve interface, and that a technique such as that
described as the ‘walk-down’ can be used [65]. However,
it can be difficult to keep the whole needle within the
narrow (often < 1 mm) beam, and the method often
requires unfamiliar needle approaches to blocks and may
demand the use of a longer needle with increased passage
through muscle and other tissues, causing additional pain.
Use of the out-of-plane technique can mimic established
techniques, allows more needle movement in a larger
field of vision and provides a shorter distance for the
needle to travel between the skin and the nerve.
However, the tip of the needle may be difficult to see
(Fig. 6) and there is poorer demonstration of the nerve-
needle interface.
Table 1 Different types of probe and
their uses.
Blocks
Brachial plexus, abdominal wall,
femoral and distal sciatic,
peripheral nerves
Neuraxial,lumbar plexus
and proximal sciatic
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Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12 J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia
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BPR

SM SA

Figure 5 Block needle seen in ‘in-plane’ view.

Figure 3 View with correct linear array probe of interscalene

area. SA, anterior scalene muscle; SM, middle scalene muscle;
BPR, brachial plexus roots.

Needle

SM BPR SA

Figure 6 Block needle seen in ‘out-of-plane’ view.

Figure 4 View with incorrect curvilinear array probe of in-

terscalene area. SA, anterior scalene muscle; SM, middle scalene Needle
muscle; BPR, brachial plexus roots.
LA
UN

Local anaesthetic injection

Using ultrasound, the volume of LA needed is reduced,
and general consensus appears to suggest that at least a
50% decrease in volume is common; volumes as low as
5 ml have been used with good clinical effect in
interscalene blocks used for postoperative analgesia [66].
The ideal pattern of spread and minimum volume for
individual nerve blocks has still to be determined, but
Figure 7 Acceptable local anaesthetic (LA) spread. UN, ulnar
circumferential spread appears to be the ideal (Figs. 7 and nerve in the forearm.
8). The incidence of complications and neurological
sequelae can be decreased by not deliberately contacting
the nerve and with attention to detail as described below: • The LA should be clearly seen during injection. If it is
• Injection should be painless. not, consider intravascular injection. Look for ‘smoke’
• There should be no resistance to injection. in the vessels (the microbubbles in the injectate will

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Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 7
J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia
. ....................................................................................................................................................................................................................
Needle
LA
UN
Figure 8 Unacceptable, subfascial local anaesthetic (LA)
spread. UN, ulnar nerve in the forearm; FP, fascial plane.
appear as white hyperechoic artefacts within the
vessels). If this is seen, stop injection immediately and
reposition the needle.
• If the needle tip is not within the ultrasound beam,
move the probe to demonstrate the needle tip before
injecting.
• The nerve often appears brighter and more easily
identified after injection of LA around the nerve.
• If the nerve swells during the injection, stop immedi-
ately as the injection may be intraneural.
Introduction of ultrasound into a department
The success of the introduction of any new technique
into a department is dependant upon the availability of
the equipment and the training of the individuals using
that equipment. The purchase of an ultrasound machine
by a department has been made easier with NICE
guidance No. 285 [44, 45]. Most purchases are made on
the premise of increased success, decreased complications,
improved patient care and, importantly, cost-effective-
ness. The evidence supporting the use of ultrasound in
regional anaesthesia is growing all the time and the
majority of anaesthetic departments in the UK now have
access (although often limited) to some form of ultra-
sound machine capable of imaging nerves. The choice of
ultrasound machine is individual, often dictated by
resources and personal preferences, but they should
ideally have the following capabilities:
• Ease of use, to accommodate multiple users of varying
levels of experience.
• Portability, to allow multiple areas of use; can be cart
based or truly portable.
8 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12
• A selection of probes: linear, curvilinear and phased
array.
• Doppler facilities: colour flow and power to identify
vessels and flow.
• Harmonic imaging, beam steering or compound
FP imaging to provide improved image quality and
resolution.
• Image and video capture functionality for training,
audit and clinical governance reasons.
• A long warranty of three to five years and a long
predicted clinical life.
The successful use of ultrasound is highly operator-
dependent and as such has a distinct learning curve.
Practitioners using ultrasound without training have been
shown to have more complications and lower success
rates. For this reason, the introduction of ultrasound into
a department should be structured, and predicated on
training and supervision. Recommendations for training
and a proposed curriculum have been published by the
Royal College of Radiologists [67]. The proposed
training should be modular and it is recommended that
training should be specific to the requirements of the
trainees and to the department. It is also understood that
different specialties require different levels of training and
these can broadly be divided in levels 1, 2 and 3 [68]:
• Level 1 (basic) is training that can be achieved within
recognised postgraduate training programmes.
• Level 2 (intermediate) requires specific sub-speciality
training.
• Level 3 (advanced).
Within anaesthesia, most trainees are only likely to
achieve some of the competencies included in Level-1
training. Guidelines for ultrasound-guided regional anaes-
thesia have recently been published [69]. These propose
sensible recommendations both for training and the
competencies needed to practice the technique. In general,
all recommendations agree on the need to develop basic
ultrasound skills including: understanding the equipment
used; image acquisition and optimisation; image interpre-
tation; and needling techniques. These skills can be
achieved by a mixture of theoretical and practical training,
and should follow the suggested outline:
• Knowledge of ultrasound and equipment:
o Basic physics of ultrasound.
o Machine characteristic and use.
o Optimisation and storage of the image (resolution,
gain, focus etc.).
o Patient care, safety and infection control.
• Knowledge of anatomy relevant to commonly used
techniques:
o Brachial plexus anatomy – interscalene, supracla-
vicular, infraclavicular, axillary and terminal
peripheral nerve regional anaesthetic techniques.
 2010 The Authors
Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12 J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia
. ....................................................................................................................................................................................................................

Table 2 Training models for ultra-

sound-guided regional anaesthesia. Training model Advantages Disadvantages

Live models Readily accessible Variable anatomy and echogenicity

(anywhere) Usually compliant Not able to needle
Nerve structures seen Purely for scanning
Large numbers present –
good for anatomical
variations
Phantoms Cheap and mobile-use Poor realism, no nerves
(anywhere) anywhere, reusable Agar ⁄ gelatine preps – tracking of
Home made – (gelatine, needle path
olives, pasta) Needling techniques only
Commercial – expensive Limited life span
Animals Demonstration of nerves Animal anatomy
(Europe, North Use of nerve stimulator Unfamiliar approaches
America, Vascular landmarks present Ethical and cultural objections
Australasia – Needling techniques, single Expensive
not UK) injection and catheter
techniques
Cadaveric As close to real as possible Visibility often poorer than living
preparations Observe all nerves easily Limited access to some areas
(anatomy Good needling technique No pulsations or Doppler signal – loss
departments UK, Injection of saline, catheter of landmarks
Europe and techniques Acquisition of preparations (cost)
worldwide) Mimics normal techniques
and ergonomics

Table 3 Level of difficulty for each

block with recommendations on choice
of probe and needling technique.
Recommended Needling Level of
Techniques probe techniques difficulty

Superficial cervical plexus, HFL IP ⁄ OOP Basic

interscalene
Axillary, terminal branches HFL IP ⁄ OOP Basic
(ulnar, median, radial)
Femoral, saphenous, ankle HFL IP ⁄ OOP Basic
Rectus sheath, ilio-inguinal, HFL IP ⁄ OOP Basic
iliohypogastric
Supraclavicular HFL IP only Intermediate
Infraclavicular HFL (depth < 5 cm) IP ⁄ OOP Intermediate
LFC (depth > 5 cm)
Obturator, sciatic- (all HFL (depth < 5 cm) IP ⁄ OOP Intermediate
approaches including popliteal) LFC (depth > 5 cm)
Intercostal HFL IP recommended Intermediate
Lumbar plexus ⁄ thoracic HFL (upper thoracic IP ⁄ OOP Advanced
paravertebral ⁄ lumbar epidural paravertebral) LFC

HFL, High frequency linear > 10 MHz; LFC, Low frequency curvilinear 2–5 MHz; IP, in-plane; OOP,
out-of-plane.

o Lumbar plexus anatomy – femoral, saphenous, • Supervised performance of techniques.

obturator, sciatic, popliteal and tibial. • Independent practice.
o Abdominal wall anatomy – rectus sheath, ilio- At present all assessments during training are optional
inguinal, transversus abdominus plane. and there is no consensus on whether ultrasound-guided
o Spinal anatomy – paravertebral, intercostal, epidu- regional anaesthesia should be certificated and accredited.
ral, caudal and psoas compartment. Table 2 outlines the advantages and disadvantages of
• Practice on models and phantoms. training models. Table 3 divides blocks into levels of
• Simulation of techniques – models, animals or cadavers. difficulty.

 2010 The Authors

Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 9
J. Griffin and B. Nicholls Æ Ultrasound in regional anaesthesia Anaesthesia, 2010, 65 (Suppl. 1), pages 1–12
. ....................................................................................................................................................................................................................

6 Beattie WS, Badner NH, Choi P. Epidural analgesia reduces

Conclusions postoperative myocardial infarction: a meta-analysis.
Since the first papers on ultrasound in regional anaesthesia Anesthesia & Analgesia 2001; 93: 853–8.
were published in 1994, there is now an overwhelming 7 Hadzic A, Karaca PE, Hobeika P, et al. Peripheral nerve
blocks result in superior recovery profile compared with
weight of evidence (> 1500 papers) supporting its use.
general anesthesia in outpatient knee arthroscopy. Anesthesia
We are now at a point at which worldwide opinion is
& Analgesia 2005; 100: 976–81.
shifting behind the use of ultrasound as the main method 8 Hadzic A, Arliss J, Kerimoglu B, et al. A comparison of
for needle guidance in regional anaesthesia. Indeed, direct infraclavicular nerve block versus general anesthesia for hand
ultrasound observation improves the outcome in most and wrist day-case surgeries. Anesthesiology 2004; 101: 127–
peripheral nerve techniques in adults and children. 32.
Anaesthetists can now directly see relevant nerve struc- 9 Chelly JE, David B, Williams BA, Kentor ML. Anesthesia
tures in both the upper and lower limb at all levels. and postoperative analgesia: outcomes following orthopedic
For neuraxial techniques, further studies are needed to surgery. Orthopedics 2003; 26: 865–71.
establish whether ultrasonography can lead to improve- 10 Buist RJ. A survey of the practice of regional anesthesia.
ment in performance. However, there have been prom- Journal of the Royal Society of Medicine 1990; 83: 709–12.
11 Chan VW, Peng PW, Kaszas Z, et al. A comparative study
ising results in children, neonates and in pregnancy. In
of general anesthesia, intravenous regional anesthesia, and
pain medicine, ultrasound guidance is still a technique in
axillary block for outpatient hand surgery: clinical outcome
evolution. However, for an increasing number of blocks, and cost analysis. Anesthesia & Analgesia 2001; 93: 1181–4.
evidence is now appearing with regard to feasibility and 12 Moen V, Dahlgren N, Irestedt L. Severe neurological
improved outcome. Safety and efficacy aside, for ultra- complications after central neuraxial blockades in Sweden
sound to be truly embraced there are still mental obstacles 1990–1999. Anesthesiology 2004; 101: 950–9.
to overcome, financial resources to provide and training 13 Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and
to be delivered. It is when these are achieved that the full nonacute complications associated with interscalene block
list of potential advantages that ultrasound brings to and shoulder surgery: a prospective study. Anesthesiology
regional anaesthesia will be seen. 2001; 95: 875–80.
14 Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K.
Serious complications related to regional anesthesia: results
Conflicts of interest of a prospective survey in France. Anesthesiology 1997; 87:
479–86.
Dr Nicholls has received honoraria and equipment loans 15 McCartney CJ, Brull R, Chan VW, et al. Early but no long-
from Sonosite, B Braun and GE. Dr Griffin declares no term benefit of regional compared with general anesthesia
conflicts of interest. for ambulatory hand surgery. Anesthesiology 2004; 101: 461–
7.
16 Hadzic A, Williams BA, Karaca PE, et al. For outpatient
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