Professional Documents
Culture Documents
Stephen E. Abram MD
Professor, Department of Anesthesiology
Medical College of Wisconsin
Milwaukee, WI, USA
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Dedication
For my Parents
Therese C. O’Connor
To my teachers, my colleagues, my patients and my family
Stephen Abram
ix
ACKNOWLEDGMENT
I would like to acknowledge Florence Grehan, photographer, and the nursing staff of the Day Services Unit,
Sligo Regional Hospital.
Therese C. O’Connor
xi
While the role of anesthesiologists in the management of produce neuronal membrane stabilization. They provide
patients with severe or intractable pain has expanded diagnostic information regarding sites and mechanisms of
dramatically in the past few decades, it has traditionally pain. Joint and muscular injections also provide an
been anesthesiologists’ ability to use regional anesthetic important contribution to the diagnosis and management
techniques both diagnostically and therapeutically that has of chronic pain. In the cancer patient, neurolytic
made their contributions to pain medicine unique. This procedures may provide extended periods of interruption
textbook emphasizes those regional anesthetic techniques of the most active sources of nociception. Long-term
that have been included in the anesthesiologist’s infusions of local anesthetics, often combined with opioids
armamentarium for many years. In recent years, there have and other analgesic agents, can provide weeks to months
been dramatic advances in the technology of pain of relief when systemic analgesics have failed.
management interventions. These include implantable drug Our aim in embarking on the preparation of this atlas was
delivery devices, radiofrequency and cryoanalgesia to provide a description of many of the basic regional
neuroablation techniques, spinal cord and peripheral nerve anesthetic tools and the common joint and muscular
stimulators, percutaneous nucleoplasty, annuloplasty and injections that may be of benefit to patients with persistent
vertebroplasty devices. Despite these innovations, there is or severe pain. It is unusual for these procedures to be
still a substantial role in acute, chronic and cancer pain curative on their own. Their value lies in their rational use
management for many of the older, more conventional in combination with other management techniques,
regional anesthetic techniques. including, but by no means limited to, physical therapy,
Nerve blocks play a variety of roles in the management of exercise, psychotherapy, and systemic medication. All
pain. For acute postoperative or post-traumatic pain, they chapters in the book have been written to a template
may be continued throughout the most painful interval, taking the reader through each block in a consistent and
serving as the sole analgesic technique or as adjunctive easy-to-follow way. Step-by-step illustrations accompanied
measures, reducing the need for opioids and other systemic by photographs are used to teach technique within the
analgesics. For patients with chronic or cancer pain, they context of the surrounding anatomical structures and we
may provide long-term benefit by reducing nociceptive have also highlighted where injections can go wrong and
inputs to sensitized regions of the spinal cord or brain. offered advice on how to avoid problems. It is our hope
They provide periods of antinociception that facilitate that this atlas will fulfill our aim of providing a strong
physical therapy and reconditioning. Combined with foundation of regional anesthetic techniques in the
corticosteroids, they reduce neural inflammation and treatment of pain.
MECHANISMS OF PAIN
TRANSMISSION—AN
OVERVIEW OF ANATOMY
AND PHYSIOLOGY 1
The term pain is used to define sensations that hurt or are pain is significantly influenced by pathologic changes in
unpleasant. There are, however, different types of pain. peripheral nerve function. Thus neuropathic pain can
Pain following injury can be considered to have a useful persist long after the original injury has healed. Pathologic
protective function by rendering the injured area peripheral nerve changes include generation of spontaneous
hypersensitive to external stimuli. Specific groups of neural inputs, neuroma formation and regeneration of
primary sensory neurons carry stimuli defining the quality, nerves. An injured nerve may become mechanically
duration and intensity of noxious stimuli from injured sensitive, and mild pressure or traction may produce bursts
tissue. Their organized projections to the spinal chord or of rapid firing followed by many minutes of after-
trigeminal nucleus mean that the origin of the stimuli can discharge, perceived as pain in the affected root. With
be precisely located. This somatic pain is often termed time, the dorsal horn pain projection cells (wide dynamic
“ouch” pain and is usually associated with acute, direct range neurons) may attain lower thresholds and expanded
injury to tissue. It arises from structures that are innervated receptive fields, adding to the traffic from pain fibers.
by somatic nerves, e.g. muscle, skin, synovium, and The character of the pain varies and typically may be
periosteum. Thus the pain is usually easily localized to the throbbing, shooting, lancinating, burning or freezing.
distribution of the nerve supplying the injured area, and is Recently, it has become apparent that the receptive-field
often sharp and intense. properties of dorsal horn neurons are not fixed or hard-
On the other hand, pain arising from visceral organs is wired, but can change. The reason for this is that sensory
poorly localized. It may be appreciated as being deep in the input from primary sensory fibers and interneurons onto
body, often arising from the midline, or may be referred to spinal neurons is normally too low in amplitude to
distant structures. The reason for this is that visceral generate an action-potential discharge in the postsynaptic
sympathetic afferents converge on the same dorsal horn cell. A temporal or spatial summation of postsynaptic
neuron as do somatic nociceptive afferents, and both of action potentials is required to exceed the threshold of the
these stimuli travel to the brain via the spinothalamic cell. The center of the receptive field usually constitutes the
pathways. Thus, pain is appreciated in the cutaneous area firing zone, where an adequate stimulus will generate an
corresponding to the dorsal horn neuron upon which the action-potential discharge in the cell. Surrounding this
visceral afferents converge, accompanied by allodynia and firing zone is the subliminal zone; a peripheral stimulus
hyperalgesia in this dermatome. As a result, reflex somatic evokes a response that is subthreshold. Changes may occur
motor activity may result in the spasm of muscles. in the area because an increase in excitability of a neuron
Consequently, cutaneous nociceptors may be stimulated, can convert a previously subthreshold input into a
which may be partly responsible for referred pain. In suprathreshold response, leading to receptive-field
addition, there is considerable branching of peripheral plasticity, or central sensitization. Thus, afferent barrages
visceral afferents with resulting overlap in the territory of of high-frequency C fiber activity can generate changes
individual dorsal roots. Compared with somatic nociceptor in sensory processing in the spinal cord, leading to a
fibers, only a small number of visceral afferents converge hyperalgesic state.
on dorsal horn neurons. This overlap, combined with Careful investigation of the likely neurologic basis of each
convergence of visceral afferents on the dorsal horn over a patient’s pain may help in its treatment; thus whenever
wide number of segments, means that visceral pain is possible the following aspects should be determined: site(s),
usually dull, vague, and very often poorly localized. character, radiation, temporal pattern, factors increasing or
While damage to cutaneous or deep tissue is usually decreasing pain, and associated factors. An attempt should
associated with inflammation of that tissue, neuropathic be made to determine if the pain is somatic, visceral or
1
CHAPTER
2
Mechanisms of pain transmission—an overview of anatomy and physiology
neuropathic in origin, so that a rationale for treatment may It has been demonstrated that locally applied
be planned. corticosteroids prevent development of ectopic discharge
In addition, it should be remembered that there are other and suppress ongoing discharge of injured nerves. Thus in
factors that determine an individual’s level of pain the patient with chronic nerve pain, it is reasonable to
perception. Psychologic factors are as important as sensory consider injection of corticosteroid at the site of injury to a
factors in determining pain perception and are more nerve, e.g. epidural or nerve root injection for nerve injury
important in their contribution to suffering. Various due to intervertebral disc pathology.
responses to painful conditions exist, but depressive Degeneration and inflammation of joints can produce pain
features tend to predominate in patients with chronic pain. that is usually somatic in character, although this may
Analysis of the patient from a psychologic perspective will sometimes be difficult to distinguish from neuropathic
provide a more thorough understanding of the patient’s pain; for example, facet joint pain may be very similar to
pain complaint and the ramifications thereof. Being attuned radicular pain. Joint arthropathy as a cause of pain can be
to psychologic issues will enable the physician to plan and confirmed by injection of local anesthetic into the joint.
execute a more comprehensive treatment plan. The Addition of corticosteroid to the local anesthetic has been
relationship between depression, anxiety and pain is shown to decrease inflammation in the joint and thereby
circular or reciprocal, rather than linear. The existence of reduce pain.
pain often has detrimental effects on the patient’s mood, The myofascial syndrome is a very common cause of
increasing feelings of anxiety or depression. The somatic pain. It is associated with marked tenderness of
development of depression or anxiety can exacerbate the discrete points (trigger points) within affected muscles, and
experience of pain. with pain that is often referred to an area some distance
There have also been many reports about the perception away. In addition, the affected areas may have the
and communication of pain, and its treatment may be appearance of tight, ropey bands of muscle with associated
influenced by sociodemographic factors. These include autonomic changes such as vasoconstriction. Biopsies of
ethnicity and cultural background, as well as gender, age, such trigger points can show degenerative changes
education, and socioeconomic class. corresponding to the severity of pain (or can show little or
It is therefore important to approach the management of no change at all). The most important aspect of the
pain bearing foremost in the mind the varying influences treatment of myofascial pain is to regain the length and
on perception of pain. elasticity of affected muscles. This is best achieved by
physical maneuvers that stretch muscle. However, these
On the other hand, repeated blockade of sympathetic
maneuvers are often painful and may worsen muscle
activity with local anesthetic has been shown to reduce the
contraction. Therapy aimed at reducing pain and sensitivity
severity of sympathetically maintained pain. Visceral pain
in muscles is best instituted prior to stretching exercises.
may also be reduced by local anesthetic blockade of
Trigger-point injections—injection of local anesthetic
visceral afferent fibers that accompany the sympathetic
directly into the trigger point—can confirm the diagnosis of
efferents. However, the result is short-lived if pathology
myofascial pain and a series of injections can markedly
remains that will cause continued stimulation; for example,
reduce muscle sensitivity. These injections, combined with
carcinoma of the head of the pancreas causes pain
stretching exercises, can produce significant analgesia for
mediated through the celiac plexus. In these cases it is
myofascial pain.
reasonable to consider neurolytic visceral afferent blockade
for pain relief.
JOINT INJECTIONS
2
2.1 LUMBAR FACET JOINT INJECTION
Anatomy the anterior portion of the lumbar facet joints lie in the
coronal plane and the posterior portions in the sagittal
The zygopophyseal or facet joints (Fig. 2.1.1) are paired
plane. In the thoracic region, the joints’ inferior and
articular surfaces between the posterior aspects of
superior articular surfaces overlap each other in an almost
adjacent vertebrae. In the cervical region, rotation and
vertical incline.
flexion are possible as the joint surfaces lie midway
between the coronal and the axial planes. Rotation is The facet joints bear most of the shear forces when the
prevented in the lumbar region but flexion is possible as spine is flexed. In addition, when the intervertebral discs
are degenerated, the facet joints carry increased load and
weight, especially when the spine is extended. Innervation
of the facet joints is via the medial branches of the
Lumbar vertebra dorsal rami of the spinal nerves. These nerves also
Superior facet innervate the muscles and ligaments surrounding the joints.
Each medial branch divides into proximal and distal
branches (Fig. 2.1.2). The proximal branch innervates the
Articular surfaces
of facet joints
Superior Inferior oblique Lateral
Mb
A Inferior facet
Lb
Ppr
SvN
Sn
Gr
Medial branch Intervertebral disc
adjacent facet joint, and the distal branch innervates the Needle puncture and technique
next facet joint below. The medial branch also innervates
• Intravenous access is inserted.
the interspinous ligaments and the multifidus muscles and
the lateral branch innervates other adjacent muscles. Thus, • Monitors are attached.
pain from irritation of a joint may cause generalized • Resuscitation equipment and drugs are checked and
sensitization of the dorsal rami with secondary made ready for use.
hyperactivity and spasm of the innervated muscles and may • The lumbar midline and an area 10 cm × 5 cm laterally
be difficult to localize. is cleaned with antiseptic solution.
The facet joints contain vascular, highly innervated • The spinous processes of the vertebrae are marked.
intra-articular synovial inclusions, which may • The insertion point of the needle lies 2–3 cm lateral to
become trapped and inflamed when the joint is injured, the cephalic end of the spinous process of the vertebra
causing pain. (Fig. 2.1.4 a,b).
• C-arm fluoroscopy is positioned at an angle of about
Equipment 30°, tilted towards the side of the joint to be injected.
The angle is adjusted until the joint is well visualized. A
• 2 ml and 10 ml syringes
radio-opaque object, e.g. the tip of a hemostat, is
• 25 G needle positioned over the joint and the skin is marked.
• 22 G spinal needle, end-opening • Thereby, with the aid of fluoroscopy, the insertion point
• Non-ionic radio-opaque contrast medium is identified.
• ECG, BP, and SpO2 monitors • A skin wheal is raised and the area is infiltrated with
• Resuscitation equipment (see Appendix 3) lidocaine (lignocaine) 1%.
• C-arm fluoroscopy or ultrasound • A spinal needle is introduced in a vertical direction to
the skin, until the needle is observed to enter the joint
Drugs space, preferably near the lowest aspect of the joint
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent) (inferior recess). Confirmation of intra-articular
placement is made by observation of the needle tip
• Corticosteroid if indicated, e.g. triamcinolone diacetate
remaining on the joint line as the fluoroscope is rotated
25 mg (or its equivalent)
laterally (Fig. 2.1.5).
• Resuscitation drugs (see Appendix 3)
• After negative aspiration, 0.5 ml of non-ionic radio-
opaque contrast medium (that is compatible with nerve
Position of patient tissue) is injected.
• Prone. • The correct placement is indicated by outlining the joint
• Pillow under anterior superior iliac spine to flatten the with non-ionic radio-opaque contrast medium, visible
normal lumbar lordosis (Fig. 2.1.3). on anteroposterior and oblique views (Fig. 2.1.6 a,b).
Fig. 2.1.3
5
2.1 • Lumbar facet joint injection
A B
Fig. 2.1.4
Tips
• Care must be taken to inject only a small amount of
volume as described above. A total volume of more than
1 ml may damage the joint. If the joint is disrupted
anteriorly, drug may spread to the epidural space.
Fig. 2.1.5
2
CHAPTER
6
Joint injections
B
Potential problems
• The same potential problems may occur as described for
Fig. 2.1.6 lumbar facet joint injection (see above).
7
2.1 • Lumbar facet joint injection
A B
Fig. 2.1.7 A High-resolution sonogram (15-MHz linear transducer) of vertebral bone L3 immersed in water in the cross-axis view.
B Corresponding anatomic cross-sectional cadaver preparation. Circles indicate targets. ESM erector spinae muscle; N needle; PM
psoas muscle; SAP superior articular process; SC spinal channel; TP transverse process; VB vertebral body. (From Greher M, Scharbert
G, Kamolz LP, et al, Ultrasound-guided lumbar facet nerve block: a sonoanatomic study of a new methodologic approach.
Anesthesiology 2004; 100:1242–8 © 2004 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.)
Mb
Anatomy
The anatomy relevant to injection of the cervical facet
joints is similar to that relevant to the lumbar facet joints.
The cervical facet joints below the C2–3 level are
innervated by the medial branches of the cervical posterior
primary rami. These divide into lateral and medial
branches after leaving the posterior spinal canal and the
splenius capitis muscles cover the medial branch
posteriorly. The medial branches lie in close proximity to
the vertebral artery and the epidural space is in close
proximity to the anterior joint capsule (Fig. 2.2.1). The
C2–3 facet joint is innervated by the medial branch of the
third occipital nerve, which travels beneath the tendonous Medial branch
origin of the splenius capitis muscle where it may be
accessed for local anesthetic blockade (Fig. 2.2.2).
Equipment
• 2 ml and 10 ml syringes
• 25 G needle
• 22 G spinal needle, end-opening
• Radio-opaque contrast medium
• ECG, BP, and SpO2 monitors Vertebral artery
• Resuscitation equipment (see Appendix 3)
Fig. 2.2.1
• C-arm fluoroscopy or ultrasound
Drugs
• Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate Splenius capitus
25 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3) Vertebral
artery
Position of patient
• Prone.
• Neck slightly flexed (Fig. 2.2.3).
C2–3 joint
Needle puncture and technique
3rd
Caution: injection of 0.5–1 ml of lidocaine (lignocaine) occipital
1% into the vertebral artery may result in immediate nerve
convulsion and/or loss of consciousness with possible
cardiovascular system (CVS) collapse.
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The cervical midline and an area of 7 cm × 5 cm
laterally is cleaned with antiseptic solution.
• The spinous processes are marked. Fig. 2.2.2
9
2.2 • Cervical facet joint injection
Fig. 2.2.3
• The insertion point of the needle lies 2–3 cm lateral to remaining on the joint line as the fluoroscope is rotated
the cephalic end of the spinous process of the vertebra (Fig. 2.2.6) or on ultrasound.
(Fig. 2.2.4). • After negative aspiration, 0.5 ml of non-ionic radio-
• C-arm fluoroscopy is positioned at an angle of about opaque contrast medium (that is compatible with nerve
30°, tilted towards the side of the joint to be injected. tissue) is injected.
The angle is adjusted until the joint is well visualized. • The correct placement is indicated by outlining the joint
A radio-opaque object, e.g. the tip of a hemostat, is with non-ionic radio-opaque contrast medium, visible
positioned over the joint and the skin is marked. on anteroposterior and oblique views.
• Thereby, with the aid of fluoroscopy, the insertion point • When the correct placement of the needle is confirmed,
is identified. lidocaine (lignocaine) 1% 0.5 ml plus corticosteroid, e.g.
• A skin wheal is raised and the area is infiltrated with triamcinolone diacetate 25 mg, may be injected and the
lidocaine (lignocaine) 1%. needle removed while clearing with lidocaine
• A spinal needle is introduced in a vertical direction to (lignocaine) 1% 1 ml.
the skin, until the needle is observed to enter the joint
space (Fig. 2.2.5). Confirmation of intra-articular Confirmation of a successful injection
placement is made by observation of the needle tip • Relief of pain.
2
CHAPTER
10
Joint injections
3rd occipital
branch
Medial branch
• The needle is then repositioned medially until the lateral • Injection of lidocaine (lignocaine) 1% 0.5 ml plus
edge of the facet joint is reached. triamcinolone diacetate 25 mg may be carried out for
• The needle is then moved superiorly until it just “falls therapeutic effect. Diagnostic blockade may be
off” the superior edge of the transverse process. unreliable as anesthesia of a facet joint means that both
• The optimum position is obtained by repositioning the nerves supplying the joint should be blocked. However,
needle to the posterosuperior edge of the transverse this means that the joint above and the joint below will
process. also be partially blocked and therefore diagnosis of pain
• The patient may now report reproduction of back pain. in a particular joint using nerve block is not feasible.
2
CHAPTER
12
Joint injections
Spine of
sacrum
Needle
are superimposed (usually about 10–20°) (Fig. 2.3.4b). extravasation outside the joint is common. If extensive,
The skin is marked and a skin wheal is raised. The area the needle should be repositioned.
is infiltrated with lidocaine (lignocaine) 1% over the • 1–2 ml lidocaine 1% is injected alone for diagnostic
joint line 1 cm above the most caudal point of the joint. purposes. Reproduction of the patient’s pain during
• A 22 or 25 G 3½ in spinal needle is advanced no more needle positioning and injection as well as pain relief
than 1 cm into the joint. Some resistance is usually felt following the block will help confirm the sacro-iliac
as the needle contacts the joint. joint as the pain generator (avoid sedation with opioids
• A lateral view is then obtained. The needle should for diagnostic procedures).
traverse no more than half the distance across the • Corticosteroid, e.g. triamcinolone diacetate 25 mg, plus
sacrum, and should never be advanced beyond the 1–2 ml 1% lidocaine may be injected for therapeutic
anterior cortex. effect.
• Contrast dye, 0.5 to 1 ml, may be injected to ensure • Ultrasound may also be used to identify the joint
intra-articular spread. Intravascular injection is best (Fig. 2.3.5).
detected during “live” fluoroscopy injection. In the AP • CT scan may also be used to identify the joint but is not
view, dye should be seen within the joint space. Some usually necessary (Fig. 2.3.6).
2
CHAPTER
14
Joint injections
Confirmation of a successful injection • Sometimes, injection into the deep sacro-iliac ligaments
around the joint may be helpful for pain relief.
• Reproduction of pain during injection and relief of pain
Introduction of a spinal needle just above the midline
following injection confirms correct placement.
of the upper sacrum and advanced at 45° to the
• Radiologic assessment of the X-ray image after injection skin, under the rim of the ilium and in the direction
of contrast medium may demonstrate tears in the joint of the joint, will access these ligaments. Lidocaine
capsule. (lignocaine) 1% 4 ml plus triamcinolone diacetate
25 mg may then be injected.
Tips
• While the joint may be easily entered, injection can be
difficult where the joint is heavily invested with
Potential problems
connective tissue and ligaments. This is especially true in • Discomfort on injection.
elderly patients, where the joint is rigid and the joint • Epidural injection.
space cannot expand to accommodate a volume of • Sacral nerve root blockade.
liquid. In such cases it may be possible to inject only as • Subperiosteal injection (painful in the awake patient).
the needle is being removed from the joint.
EPIDURAL INJECTION
3
Intervertebral disc disease may produce inflammation of or cervical disc origin may respond to epidural steroid
spinal nerve roots, which may be the cause of radicular pain. injection.
The L5 and S1 nerve roots are most commonly affected, Triamcinolone diacetate is the most commonly
probably because they exit the bony canal through a narrow administered preparation and injection should be carried
lateral bony recess, therefore increasing the likelihood of out as close to the affected nerve root as possible. Injection
nerve compression and irritation. Lumbo-sacral of a small amount of local anesthetic with the steroid will
radiculopathy consists of low-back pain that radiates a help to confirm drug placement and provide analgesia. In
varying distance into the lower extremity, and which may be patients with S1 pathology the drug may not spread to the
associated with motor and sensory loss consistent with affected nerve root using the lumbar approach and the
damage to the affected nerve root. If bowel and bladder caudal approach to the epidural space may be required.
symptoms of dysfunction are present, large midline disc Cervical epidural injection accesses the cervical spinal nerve
protrusion is suspected and prompt surgical intervention is roots, while in the thoracic region a paramedian approach
indicated. Otherwise, if severe pain exists after treatment is usually more successful.
with immobilization and mild analgesics, epidural steroid
injection may be carried out. Similarly, pain of thoracic
3
CHAPTER
16
Epidural injection
Anatomy Drugs
Structures encountered when inserting an epidural needle • Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
include skin, subcutaneous tissue, supraspinous ligament, • Corticosteroid if indicated, e.g. triamcinolone diacetate
interspinous ligament, ligamentum flavum (5–6 mm thick 50 mg (or its equivalent)
in the midline of the lumbar region, 3–5 mm thick in • Saline (NaCl) 10 ml
the midline of the thoracic region), prior to reaching the • Resuscitation drugs (see Appendix 3)
epidural space itself (Fig. 3.1.1). Beyond this space lies
the dura mater, the arachnoid mater and intrathecal space
containing the cerebrospinal fluid. The spinal cord usually
ends at the L2 level (Fig. 3.1.2).
One should expect a distance of 3.5–6 cm from skin to the 1
1
epidural space using a midline approach. In the lumbar C1
2 2
region the spinous processes are generally perpendicular to 3 3
the vertebral bodies (Fig. 3.1.3). In the thoracic region the 4
4
5
spinous processes lie at an angle of 30–45° to the thoracic
6 5
vertebral body, thus making midline epidural injection a 7 6
little more difficult, and sometimes necessitating a 8
7
C7 1
paravertebral approach. Other relevant anatomy of the 1
2
vertebral bodies is illustrated in Fig. 3.1.4. T1
3
2
4
3
Equipment 5
4
• 2 ml and 10 ml syringes 6
5
• 18 G, 20 G, and 25 G needles 7
6
• ECG, BP, and SpO2 monitors
8 7
• 18 G epidural set (Fig. 3.1.5)
• Filter aspiration needle 9
8
L1 2
5
S1
1
2
3
4
Supraspinous Interspinous 5
Skin ligament ligament
Superior
articular process
(a) Cervical
Pedicle
Transverse process
Spine
Inferior articular
(b) Thoracic Facet process
Facet
Superior articular
process
Transverse process
(c) Lumbar
Inferior articular
process
Lamina
Inferior and superior
articular facets
Fig. 3.1.3
Transverse
process
Vertebra
prominens C7
Root of spine
of scapula T3
Inferior angle
of scapula T7
Superior aspect
of iliac crest L4 B
Fig. 3.1.7
Posterior superior
iliac spine S2
Fig. 3.1.9
Fig. 3.1.8
T1–4 T5
T6
Lateral Oblique Posterior
C7
C7
T5–8
T10
T10
L3 L3
T9–12
B
A
Fig. 3.2.1
3
CHAPTER
22
Epidural injection
L3 1cm T3
T4
L4 T5
10 10 (a) 1cm
L5 25
(a)
(b) 35 (b) T7
45
45
A B 55
C D
Fig. 3.2.2
Paramedian approach lamina in a cephalad direction until the needle enters the
ligamentum flavum. At that point the loss-of-resistance
FOR THE RIGHT-HANDED OPERATOR technique may be performed.
With the left hand • The hub of the needle is gripped with the fore- and
• The fore- and middle fingers are placed each side of the middle fingers of the left hand and this hand is steadied
interspace. by leaning the wrist against the patient’s back.
• These fingers are kept in place until the epidural needle • The stylet is removed and the loss-of-resistance syringe
is gripped by the interspinous ligament. is applied.
With the right hand • The needle is slowly and carefully advanced until the
• The interspinous ligament is infiltrated with lidocaine osseous endpoint of the lamina is encountered.
(lignocaine) 1% 2 ml. • It is then walked off the lamina in the cephalad
• The insertion point of the epidural needle in the direction until it enters the ligamentum flavum.
paravertebral approach lies 1 cm lateral to the • At the point at which the needle enters the ligamentum
midline, at the lower border of the spinous process flavum, absolute resistance to injection is experienced.
(Fig. 3.2.3 a,b). The epidural needle is inserted, bevel • It is then carefully advanced further while constant
facing the side of radiculopathy, between the fore- and pressure is applied to the plunger, the left hand aiding
middle fingers of the left hand, perpendicular to the the advance, while at the same time applying a brake if
spine, parallel to the floor, until it is gripped by the required (Fig. 3.2.4, viewed from above).
interspinous ligament. • The needle is advanced very slowly until a sudden loss
• The direction of the needle is 130° cephalad and 15° of resistance to the pressure on the plunger is
medial to the midline. Care must be taken as the experienced, the point at which the epidural space is
ligamentum flavum is not as thick laterally, and may not entered.
be identified as easily. Therefore, it is usually easiest to • After negative aspiration for blood or cerebrospinal
first identify the lamina and walk the needle off the fluid, lidocaine (lignocaine) 1% 2 ml is injected.
23
3.2 • Thoracic epidural block
Transverse
process
Facet
Lamina
Spinous process
Paramedian
approach
(spinal or epidural) Fig. 3.2.4
15
15 Tips
1cm • Air may be used instead of NaCl to determine loss of
L4 resistance. If this technique is used it is advisable to
avoid constant pressure on the plunger, as the air is
compressible; instead the plunger should be bounced
intermittently with the thumb to test for resistance and
loss of resistance.
• Advocates claim identification of CSF is easier with this
L5 technique.
• Advocates of the use of NaCl point out that absolute
B resistance to pressure identifies the ligamentum flavum,
Fig. 3.2.3 and that by applying constant pressure to the plunger
one can identify loss of resistance more immediately,
thereby avoiding the possibility of dural tap more
easily.
• After 5 minutes the patient is questioned about changes • An epidural catheter may be inserted through the needle
in sensation or power, and any changes in heart rate or and the needle removed, taking care not to withdraw
blood pressure are noted. the catheter when removing the needle. However, a test
• If the injection is for diagnostic purposes only, the dose of lidocaine (lignocaine) 1% 4 ml with epinephrine
needle may be removed at this point. (adrenaline) 1 : 200 000 is given after insertion, before
• If therapeutic effect is required, lidocaine (lignocaine) any injection through the catheter is carried out.
1% 2 ml plus corticosteroid, e.g. triamcinolone diacetate • Identification of the insertion point may be aided by
50 mg, may be injected. ultrasound (Fig. 3.2.5).
• The patient is allowed to lie in the lateral position, on • Injection of radio-opaque dye under direct fluoroscopy
the side of the pain. can confirm epidural placement.
• Monitors should be left attached and i.v. access should • Insertion of a radio-opaque epidural catheter may be
remain in situ for at least 30 minutes. carried out also under fluoroscopy.
3
CHAPTER
24
Epidural injection
Equipment Supraspinous
• 2 ml, 5 ml, and 10 ml syringes ligament
Position of patient C4
• Sitting.
C5
• Head flexed forward.
C6
Needle puncture and technique C7
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The midline and an area 10 cm × 5 cm laterally is
cleaned with antiseptic solution and a fenestrated drape
B
is placed over the sterile area.
• Lidocaine (lignocaine) 1% 2 ml is drawn up into two Fig. 3.3.1
2 ml syringes.
• Lidocaine (lignocaine) 1% 1 ml plus corticosteroid, e.g. root of the spine of the scapula, is identified and
triamcinolone diacetate 50 mg, is drawn up into a 5 ml marked. The prominent spinous process of C7 (vertebra
syringe. prominens) is identified (Fig. 3.3.2) and marked
• NaCl 10 ml is drawn up into a 10 ml syringe. (Fig. 3.3.3 a,b). Ultrasound can be used to guide needle
• The patient is allowed to sit up straight for a moment, placement (Fig. 3.3.3 c,d). The interspace to be used for
and the spinous process of T3, which lies opposite the epidural injection is also marked.
3
CHAPTER
26
Epidural injection
1 1
C1
2 2
3 3
4
5
4
6 5
7 6
8
7
C7 1
2 1
T1
3
2
4
3
5
4
6
5
7
6
8 7
A
9
8
10
9
Fig. 3.3.2
C D
Fig. 3.3.11
Confirmation of a successful block
• Relief of pain.
Drugs
• Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)
Sacral cornua
Sacro-coccygeal
ligament
• Lidocaine (lignocaine) 1% 2 ml is drawn up into three • After 5 minutes the patient is questioned about changes
2 ml syringes. in sensation or power of the lower limbs, and any
• Lidocaine (lignocaine) 1% 15 ml plus corticosteroid, e.g. changes in heart rate or blood pressure are noted.
triamcinolone diacetate 50 mg, is drawn up into the • Then lidocaine (lignocaine) 1% 5–15 ml plus
20 ml syringe. corticosteroid, e.g. triamcinolone diacetate 50 mg, may
• NaCl 10 ml is drawn up into the 10 ml syringe. be injected in order to promote spread to upper sacral
and lower lumbar segments (a volume of at least 10 ml
FOR THE RIGHT-HANDED OPERATOR
should be used if the symptoms are at the level of S1
With the left hand nerve root or higher) (Fig. 3.4.6). The needle is then
• The posterior superior iliac spines are identified.
• The sacral cornua (the unfused spinous processes of S5)
are also identified and marked.
• Between the cornua lies the base of the sacral hiatus, a
roughly triangular fibroelastic structure.
• The index and middle fingers of the left hand are placed
on each of the sacral cornua (Fig. 3.4.3).
• The insertion point lies between these two fingers.
With the right hand
• The insertion point is infiltrated with lidocaine
(lignocaine) 1% 2 ml.
• The 22 G short-bevel needle with stylet is inserted at an
angle of 45° to the skin (Fig. 3.4.4. a,b). Ultrasound can
be used to guide needle placement (Fig. 3.4.4c).
A
• As the needle passes through the fibroelastic sacral
hiatus, a “pop” may be experienced, although this is not
always evident in adults, and bone may be contacted.
• After passing through the sacral hiatus, the needle is
withdrawn a little, and redirected to an angle to the skin
of 15–20° (Fig. 3.4.5). This should allow further
advancement of 1–2 cm, as the needle enters the long
axis of the caudal epidural space.
• After negative aspiration, lidocaine (lignocaine) 1% 2 ml
is injected.
Sacral cornua
Fig. 3.4.5
removed while clearing it with lidocaine (lignocaine) 1% • Advance a Tuohy needle at a 45° angle to the skin
2 ml. through the sacral hiatus, checking a lateral fluoroscopic
• Monitors should be left attached and i.v. access kept in view to make sure the needle has entered the spinal
situ for at least 30 minutes. canal. Lower the needle angle and advance the needle
• It is prudent to warn the patient about possible loss of slightly. Recheck lateral fluoroscopy to ensure the needle
sensation and or power of one or both lower limbs. is in the spinal canal.
• Aspirate to rule out intravascular placement and
FLUOROSCOPIC GUIDED CAUDAL
inject 0.5–1 ml contrast medium under live
EPIDURAL INJECTION fluoroscopy. Check a lateral and AP image to ensure
• This approach may be used for treating L5 or S1 epidural spread.
radiculopathy. It is a reasonable alternative to the • If no epidural catheter is used, inject a mixture of local
interlaminar approach when surgery has disrupted the anesthetic and steroid. Inject 10 ml 0.5% lidocaine plus
posterior spinal anatomy. 50 mg triamcinolone diacetate. This volume should be
• Position the patient prone. sufficient to reach the L5 or S1 nerve roots.
• Locate the sacral hiatus using the sacral cornua as • Alternatively, a radio-opaque catheter can be inserted
landmarks. through the needle and advanced to the desired level.
• Prepare skin with antiseptic and sterile drape. Check the catheter position in both AP and lateral
• Place the tip of a sterile blunt instrument over the sacral views (Fig. 3.4.7). Attach the injection hub to the
hiatus and obtain a lateral fluoroscopic view of the catheter and inject 0.5–1 ml contrast medium
sacrum. under live fluoroscopy, rechecking dye spread in both
• Raise a skin wheal with 1% lidocaine (lignocaine) just AP and lateral views (Fig. 3.4.8). Inject 1–2 ml 1%
below the sacral hiatus and infiltrate with lidocaine lidocaine plus 50 mg triamcinolone diacetate or
down to the sacral hiatus with a small gauge needle. equivalent.
33
3.4 • Caudal epidural block
Fig. 3.4.9
Fig. 3.4.10
Fig. 3.4.8
Fig. 3.4.11
L2
L3
L4
Fig. 3.5.1 Fig. 3.5.2
35
3.5 • Long-term epidural catheter insertion
7cm
2cm
Fig. 3.5.4
passer from the needle site to the abdominal wall site • Insertion of a radio-opaque epidural catheter may be
and connections are secured (Fig. 3.5.9). carried out also under fluoroscopy.
• A pump may be placed in the abdominal wall site and • Ultrasound may aid insertion
the skin incisions closed.
Potential problems
Confirmation of a successful block • As described for lumbar epidural block in Section 3.1.
• Relief of pain. • However, in view of the long-term nature of epidural
• Anesthesia or diminished sensation in the distribution of catheter implantation, any symptoms of infection should
affected nerves. be immediately investigated and treated.
• Epidural catheters should not be inserted or removed
Tips during anticoagulation. Coagulation and platelet
• Injection of radio-opaque dye under direct fluoroscopy function should be normalized before catheter removal.
can confirm epidural placement.
SOMATIC NERVE BLOCKADE
4
Mechanical nerve root compression was originally thought There are many situations in which injection of spinal
to be the cause of pain in discogenic radiculopathy. nerve roots with local anesthetic may be helpful in the
However, it has been found that many asymptomatic diagnosis of radicular pain. These include those where
patients demonstrate substantial disc protrusion on investigations including electromyography, computer
magnetic resonance (MR) imaging, myelography and tomography (CT) or MR imaging are not consistent with
subsequent autopsy examination. In addition, surgical the clinical findings, where there are multiple levels of
decompression does not result in uniform success in the pathology, and after spinal surgery with subsequent
relief of such pain. Following a period of mechanical scarring in the area of the surgery. In addition, the
nerve-root compression it is likely that an acute contribution of the somatic nerve root may be elucidated
inflammatory process ensues, resulting in intraneural in pain of uncertain origin, e.g. chest pain or abdominal
accumulation of serum proteins and fluid, raised pain, by specific nerve root local anesthetic injection.
intraneural pressure, ischemia and axonal degeneration. It may be used therefore to determine the level of surgery,
Degenerating glycoprotein material from the if indicated, and the addition of steroid may produce
nucleus pulposis may also contribute to the longer-lasting pain relief.
inflammatory process.
4
CHAPTER
38
Somatic nerve blockade
Anatomy Equipment
The intercostal nerve is made up of several types of nerves: • 2 ml and 5 ml syringes
sympathetic white and grey rami communicantes, • 30 G needle
cutaneous and motor fibers supplied by dorsal rami, • 22 G 3–4 cm short-bevel needle
sensory fibers to the chest wall, anterior and posterior, via • Extension set (optional)
the lateral cutaneous branch, and further sensory fibers to
• ECG, BP, and SpO2 monitors
the anterior chest wall via the anterior cutaneous branch.
• Resuscitation equipment (see Appendix 3)
The lateral cutaneous branch exits just distal to the angle
of the rib. Just below the inferior edge of the rib, in the • Ultrasound (optional)
intercostal groove, lie the intercostal nerve, artery and vein,
the latter lying superior to the nerve. The optimal site to Drugs
block the intercostal nerve is the most posterior point at • Lidocaine (lignocaine) 1% 2 ml for skin
which the rib is palpable, usually the angle of the rib infiltration
(Fig. 4.1.1 a,b). • Lidocaine (lignocaine) 1% 5 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3)
Position of patient
• Prone (this allows best access, although a lateral or
supine position may also be used).
• Pillow under mid-abdomen to widen the intercostal
Inferior angle spaces.
of rib
• Arms hanging over sides of table to rotate the scapulae
laterally.
Fig. 4.1.4
Fig. 4.1.7
Tips
• The approximate depth to the rib may be determined
with the left fore- and middle fingers before insertion of
the needle.
• Insertion of the needle > 2 mm deeper than the rib
when intercostal space is reached is avoided. This
will minimize the risk of pneumothorax, as the
Fig. 4.1.5 average distance from the rib to the pleura is
8 mm. If patient coughs on injection, pneumothorax
is suspected.
• Neurolytic intercostal nerve block, e.g. with alcohol
1 2
50% 3 ml (made up by combining equal parts of
alcohol 100% and lidocaine (lignocaine) 1% or its
equivalent), or phenol 6%, may be carried out after
local anesthetic block confirms accurate placement of
the needle as described above. However, it is important
to note that injection may result in subarachnoid spread
of a neurolytic agent with resultant possible permanent
spinal cord damage.
• Ultrasound may aid accurate placement of the needle
(Fig. 4.1.8). Injection of non-ionic radio-constrast
medium may also aid accurate placement of the needle
in neurolytic block (Fig. 4.1.9).
• Placement of a catheter into the intercostal space can be
achieved by threading 3 cm of catheter through an 18 G
epidural needle after the intercostal neurovascular
bundle has been identified as above.
Fig. 4.1.6
41
4.1 • Intercostal nerve block
Fig. 4.1.9
Potential problems
• Injection within the nerve sheath can result in the spread
of anesthetic to the subarachnoid space.
Fig. 4.1.8
• Intercostal block in patients with severe respiratory
problems should be avoided as there is risk of a
pneumothorax. Careful observation of a small
pneumothorax is usually all that is required but
failure to re-expand the lung may require chest tube
Radiofrequency lesioning insertion.
• Radiofrequency lesioning of the intercostal nerve is • Because of the vascularity of the intercostal space, there
simple and has a low level of side effects. The lesioning may be rapid absorption of local anesthetic and systemic
is carried out using the same method of placement of effects can occur quickly, especially with multiple
the needle as described for intercostal nerve block with blocks. However, peak plasma concentration of local
local anesthetic. anesthetic may occur 15–20 minutes after the block is
• However, after placement of the needle and confirmation performed, when systemic toxicity effects may develop.
of accuracy by fluoroscopy (as described above), a trial Addition of epinephrine (adrenaline) to the anesthetic
of stimulation is carried out using 2 V at 50 Hz. If the solution may decrease the peak plasma concentration of
needle has been placed accurately the patient should local anesthetic.
experience paresthesiae in the distribution of that • If aspiration of blood occurs, the needle should be
intercostal nerve. A pulsed radiofrequency lesion may removed, keeping the left fore- and middle fingers in
then be produced at 40–45 °C for 5 minutes or 49–60 °C place. The needle is cleared, reinserted to contact the rib
for 90 seconds. again, and the block is continued as above.
4
CHAPTER
42
Somatic nerve blockade
• Care of the airway must be remembered if sedation is intercostal nerve neuritis. The frequency of the latter in
administered to a patient in the prone position. radiofrequency lesioning increases as higher temperatures
• Complications of neurolytic intercostal nerve block are used. Intercostal nerve neuritis usually responds to
include pneumothorax, infection (especially in the local injection of lidocaine (lignocaine) 1% 3 ml plus
immunocompromised patient) as well as post-lesioning triamcinolone diacetate 20 mg to the lesion site.
43
4.2 • Interpleural block
Interpleural space
Fig. 4.2.3
Pleural
reflection
8–10 cm
A Air
Parietal
pleura
B Visceral pleura C D
Fig. 4.2.5
Epidural Intercostal
needle muscle Skin
Rib
Neurovascular bundle
Parietal pleura
Visceral pleura
Lung
Epidural catheter
Fig. 4.2.6
Fig. 4.2.8
Fig. 4.3.2
L1
L2
L3
L4
A B
Fig. 4.3.3
• The needle is then walked off the transverse process visible on anteroposterior and lateral fluoroscopic views
in the caudad direction and advanced 1.5–2 cm, the site (Fig. 4.3.6).
of the emerging nerve root (Fig. 4.3.5). • After further aspiration, lidocaine (lignocaine) 1%
• It is useful to confirm the needle tip over the 0.5–1 ml is injected.
intervertebral foramen with fluoroscopy. • After 5 minutes the patient is questioned about changes
• Paresthesia in the distribution of the nerve may be in pain, sensation and power of the lower limb.
experienced. • For diagnostic nerve root blockade, the needle
• After aspiration, non-ionic radio-opaque contrast may be removed when the level causing pain is
medium 1 ml is injected. identified.
• The correct placement is indicated by outlining the nerve • Ultrasound may also aid placement of the needle
root with non-ionic radio-opaque contrast medium, (Fig. 4.3.7).
49
4.3 • Lumbar nerve root block
A B
Fig. 4.3.4
Confirmation of a successful block However, even small volumes of epidural spread may
confound the diagnostic value of the block.
• Relief of pain and anesthesia in distribution of the
• Sympathetic blockade is unlikely, but it may occur and
blocked nerve.
cause hemodynamic changes.
• Intravascular injection. Injection of particulate steroids
Tips into a radicular artery can cause spinal cord infarction.
• As in the case of thoracic nerve root block, it has also Particulate steroids should never be injected near the
been recommended that the needle is angled 20° foramen unless intravascular placement has been ruled
medially after entering the paravertebral space. However out using live fluoroscopy contrast dye injection,
care must be taken, with the aid of fluoroscopy, not to preferably with digital subtraction technique.
inject local anesthetic solution into the nerve sheath
allowing tracking of the solution centrally to produce
intrathecal blockade.
Potential problems
• Intrathecal injection.
• Epidural blockade usually occurs with this block, but
this is not a problem once low volumes are used.
4
CHAPTER
50
Somatic nerve blockade
3cm
Fig. 4.3.7
Fig. 4.3.6
51
4.4 • Thoracic nerve root block
Pleura
Sympathetic ganglion
Anterior Anterior
costotransverse costotransverse
ligament ligament
Nerve
Rib Lamina
B
A
Fig. 4.4.1
4
CHAPTER
52
Somatic nerve blockade
A
Fig. 4.4.2
Anterior
• The inferior angle of the scapula is identified; this lies costotransverse
at the level of the spinous process of T7. ligament
• The root of the spine of the scapula is identified; this
lies at the level of the spinous process of T3.
• The spinous processes are counted until the level to be Posterior
costotransverse
blocked is identified, and confirmed with fluoroscopy. ligament
• The spinous processes of vertebrae are then marked.
• The insertion point of the needle lies 1.5–3 cm lateral to
the cephalic end of the spinous process of the vertebra,
Azygos vein
usually midway between the ribs (Fig. 4.4.3 a,b).
Lung
• The nerve corresponding to each vertebra emerges just Thoracic
duct
below the transverse process of that vertebra at this site.
• Therefore, with the aid of fluoroscopy, the insertion Esophagus
point is identified. Aorta
A B
Fig. 4.4.4
• After further aspiration, lidocaine (lignocaine) 1% • Some workers advocate applying an air-filled loss-of-
0.1–1 ml is injected. resistance syringe to the needle after it has been walked
• After 5 minutes the patient is questioned about off the transverse process or lamina, and advancing the
changes in pain and sensation in the distribution of the needle while applying pressure to the plunger. Loss of
nerve root. resistance has been described as the needle pops through
• For diagnostic nerve root blockade the needle may be the costotransverse ligament to enter the thoracic
removed when the level causing pain is identified. paravertebral space.
• A catheter may be passed into the paravertebral space
Confirmation of a successful block via an epidural needle, with the bevel medial, by using
this technique.
• Relief of pain and anesthesia in distribution of the
blocked nerve.
Potential problems
Tips • Pneumothorax.
• An alternative approach is to advance the needle in a • While it has been recommended that the needle be
mesiad direction until the lamina is contacted. The angled 20° medially after entering the paravertebral
needle is inserted more medially, 1.5 cm lateral to the space, care must be taken with the aid of fluoroscopy
cephalad edge of the spinous process and then walked that the local anesthetic solution is not injected into the
laterally off the edge of the lamina until it slips into the nerve sheath causing the solution to track centrally to
costovertebral ligament and is advanced 1 cm. produce intrathecal blockade.
4
CHAPTER
54
Somatic nerve blockade
• Epidural blockade usually occurs with this block, but • Intravascular injection. Injection of particulate steroids
this is not a problem once low volumes are used. into a radicular artery can cause spinal cord infarction.
However, even small volumes of epidural spread may Particulate steroids should never be injected near the
confound the diagnostic value of the block. foramen unless intravascular placement has been ruled
• Sympathetic blockade may cause hemodynamic changes. out using live fluoroscopy contrast dye injection,
• Neuritis may occur with catheter placement. preferably with digital subtraction technique.
55
4.5 • Sacral nerve root block
Anatomy Equipment
Each of the five sacral nerves is accessible by passing a • 2 ml and 10 ml syringes
needle into the sacral foramen via the posterior opening at • 25 G needle
the level of the nerve. The sacral canal is the caudal • 22 G spinal needle, end-opening
extension of the epidural space and nerves of the cauda • ECG, BP, and SpO2 monitors
equina leave via the sacral foramina (Fig. 4.5.1). The distal
• Resuscitation equipment (see Appendix 3) and drugs
dural sac ends at S2, the level of the posterior superior iliac
• Fluoroscopy or ultrasound
spines. The epidural space ends at the sacral hiatus
(Fig. 4.5.2). While variability in the bony anatomy of the
sacrum is common, this occurs usually in the midline. Drugs
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3)
Conus medullaris
Position of patient
• Prone.
• Pillow under anterior superior iliac spine to flatten the
Dura matter normal lumbar lordosis (Fig. 4.5.3).
L4
Termination 5
of the Subarachnoid
subarachnoid space (CSF)
L5
space at S2
Sacral nerves
in the caudal
S1 epidural space
Posterior sacral
S2 foramen
S3
Sacral
S4 hiatus
Filum Cornu of sacrum
terminale First
S5 coccygeal Coccygeal cornu
vertebra
Coccygeal nerve
A
Fig. 4.5.3
1cm
S1
S2 Posterior
S3 superior
iliac spine
S4
Sacral cornu
Fig. 4.5.4
Fig. 4.5.7
Tips
• Some workers advocate drawing a line from a point
2–3 cm medial to the posterior superior iliac spine to a
point 1–2 cm lateral to the sacral cornua. The sacral
foramina usually lie along this line.
• It is best to angle the X-ray beam caudally, thereby
perpendicular to the sacrum, superimposing the anterior
Fig. 4.5.6 and posterior sacral foramina. Consequently, when the
needle is introduced in a direction perpendicular
(Fig. 4.5.8) to the skin, fluoroscopic guidance is easier.
• Paresthesia may be produced. Optimally, the needle makes gentle contact with the
spinal nerve in the middle of the canal (Figs 4.5.9,
• After aspiration, non-ionic radio-opaque contrast
4.5.10) and produces paresthesia in the distribution of
medium 0.5 ml is injected.
the nerve.
• The correct placement is indicated by a needle tip flush
• While all sacral nerve roots are accessible, using this
with the anterior surface of the spinal canal in the
technique for blockade of S5 is achieved by walking the
lateral fluoroscopic view.
needle caudally off the inferior edge of the bony plate of
• Injection of 0.5 ml non-ionic contrast should spread
the sacrum and advancing the needle 1 cm.
diagonally along the S1 spinal nerve (Fig. 4.5.7).
• After further aspiration, lidocaine (lignocaine) 1%
0.5 ml is injected.
Potential problems
• After 5 minutes, the patient is questioned about changes • Caudal epidural blockade may occur with this block,
in pain, sensation and power of the lower limb. but this is not a problem once low volumes are used.
However, even small volumes of epidural spread may
• For diagnostic nerve root blockade the needle may be
confound the diagnostic value of the block.
removed when the level causing pain is identified.
• Intravascular injection. Injection of particulate steroids
• Ultrasound may also aid placement.
into a radicular artery can cause spinal cord infarction.
Particulate steroids should never be injected near the
Confirmation of a successful block foramen unless intravascular placement has been ruled
• Relief of pain. out using live fluoroscopy contrast dye injection,
• Anesthesia in the distribution of the blocked nerve. preferably with digital subtraction technique.
4
CHAPTER
58
Somatic nerve blockade
S4 S3
S5 S2
S1
S4 S3
S5 S2
S1
Fig. 4.5.10
59
4.6 • Occipital nerve block
Greater
occipital nerve
Occipital artery
Lesser
occipital nerve
Greater
auricular nerve
posterior branch
Fig. 4.6.1
Greater
occipital
nerve
Lesser
occipital
nerve
Superior
nuchal line
Mastoid
process
Greater
occipital
protuberance
Maxillary
Drugs
• Lidocaine (lignocaine) 2% 10 ml
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent)
Mandibular
• Neurolytic agent, e.g. phenol 6% plus glycerol (or its
equivalent)
• Sedative, e.g. midazolam, propofol
• Resuscitation drugs (see Appendix 3)
Fig. 4.7.1
Position of patient
• Supine.
• Eyes directed straight ahead.
Ophthalmic
Meckel's cave
Maxillary
Gasserian
ganglion
Foramen ovale
C3
C4
Posterior Anterior
primary rami primary rami
Needle puncture and technique the needle is reinserted to walk off the bone and
enter the foramen ovale (Fig. 4.7.7).
Caution: Injection of 0.25 ml of lidocaine (lignocaine) 1%
• Paresthesia in the distribution of the mandibular nerve
into the CSF may result in immediate convulsion and/or
(sometimes the other branches of the trigeminal nerve)
loss of consciousness with possible cardiovascular system
or contraction of the muscles of mastication may be
(CVS) collapse.
experienced at this point.
• The cheek on the side of the block is cleaned with • The needle is advanced a further 1 cm to bring the tip
antiseptic solution or saline. to lie in the trigeminal ganglion. The correct placement
• Mild sedation is induced. is indicated by a visible outline of Meckel’s cave on
• It is best to stand on the side of the block, just below injection of 0.25 ml non-ionic radio-opaque contrast
the shoulder. medium under fluoroscopy (Figs 4.7.8, 4.7.9).
• The insertion point lies 1–3 cm posterior to the lateral • The patient is allowed to awaken from sedation and is
margin of the mouth, at the medial edge of the masseter questioned about the presence and distribution of
muscle (located by asking the patient to clench the jaw) paresthesia and pain.
and is marked. • A stimulating device may aid placement in patients who
• In edentulous patients the insertion point should be are not able to locate the paresthesia with accuracy.
more caudad as sufficient angle towards the • If necessary, analgesia may be administered, although
infratemporal surface of the sphenoid bone may not be this may affect accurate assessment of the blockade.
achieved. • Adjustment of the needle may be required to place the
• One finger is placed inside the upper lip to avoid needle near the appropriate nerve division.
injection into the buccal cavity and possible bacterial
contamination, and a skin wheal is raised at this site.
• Viewed from above, a 22 G 8–10 cm needle is advanced
towards the ipsilateral pupil (Figs 4.7.4–4.7.6), or
viewed from the side the needle advances towards the
mid-point of the zygomatic arch (see Anatomy above)
until bone is contacted; the roof of the infratemporal
fossa. This lies just anterior to the foramen ovale and
lateral to the base of the pterygoid process. The location
of the needle tip is confirmed with fluoroscopy.
• A depth mark is set and the needle is withdrawn to
the subcutaneous tissue. With the aid of fluoroscopy
Fig. 4.7.8
Fig. 4.7.6
Roof of
infratemporal
fossa
Zygomatic arch
Foramen ovale
2
1
• After careful negative aspiration for CSF or blood, • Gangliolysis using thermocoagulation may be employed
lidocaine (lignocaine) 1% 0.25 ml is injected (Caution: for trigeminal-nerve division destruction after location
injection into CSF may cause loss of consciousness.) of the ganglion using this technique. Further intravenous
This is followed by further boluses of lidocaine anesthesia using a short-acting agent, e.g. propofol, may
(lignocaine) 1% 0.25 ml until a total of 1 ml is given. be induced after placement of the insulated needle to
• After 5 minutes the patient is questioned about pain facilitate this painful procedure.
relief and changes in sensation. • Injection of glycerol alone may produce pain relief with
• When the desired analgesia has been achieved for this injection technique. This involves placement of the
diagnostic blockade the needle may be removed. needle in the cul-de-sac of CSF, positioning the patient
face-down or supine, with the head extended to prevent
Confirmation of a successful block spill-over into the posterior cranial fossa. After entry
into the CSF, and positive aspiration of CSF, 0.1–0.3 ml
• Relief of pain and anesthesia in the distribution of the
of glycerol may be injected.
trigeminal nerve or its desired branches.
Temperature probe
Stellate
ganglion
C6
C7
Thyroid cartilage
Cricoid cartilage
C6 anterior
tubercle
• After negative aspiration, lidocaine (lignocaine) 1%, • Blockade of the upper sympathetic chain can occur in
0.5 ml, is injected. the absence of sympathetic denervation of the upper
• The patient is questioned about sensation and any extremity, resulting in Horner’s syndrome without a rise
change in level of consciousness is noted. in skin temperature in the hand.
• If negative, the same procedure is repeated as 0.5 ml
boluses are given until 10 ml is injected.
Tips
• The needle is withdrawn and the patient is immediately
put in the sitting position. • The external jugular vein usually crosses the SCM
muscle at the level of C6.
• Monitors should be left attached and i.v. access left in
situ for at least 30 minutes. The patient is requested not • Skin infiltration prior to block should be avoided if
to eat or drink for 2 hours, as the recurrent laryngeal possible, as this will make landmarks more difficult to
nerve may be blocked. locate.
• Note: if aspiration of blood occurs during the block the • If palpation is painful or difficult it may be helpful to
needle is removed and cleared, keeping left fore- and try to bounce the middle finger off the tubercle during
middle fingers in place. It is then reinserted and the identification.
block is continued as above. • An extension set may be inserted between the needle
• If hematoma occurs before the solution is injected and syringe for better stability of needle (Fig. 5.1.9), but
it may be worth performing the block at the an assistant is then required to continue the procedure
C7 level. as described above.
• If there is pain on injection and/or paresthesia, it is • Consideration should be given to performance of the
likely that the brachial plexus may have been contacted, block under fluoroscopy or CT control if the landmarks
the needle is withdrawn and the landmarks are are difficult to locate.
rechecked. • Lidocaine (lignocaine) 1% 15 ml may be given if a
previous block failed to relieve sympathetically
maintained pain in the presence of correctly placed
Confirmation of a successful block
solution. This may improve tracking of the solution
• Skin temperature, measured over the palmar aspect caudally to produce more effective blockade of the
of the hand or fingers on the blocked side, should begin stellate ganglion.
to rise within 2–3 minutes. Extensive sympathetic
• Ultrasound may aid placement of needle
blockade is confirmed by a rise in skin temperature to
(Fig. 5.1.10 a,b).
> 33 °C.
• Ptosis of eyelid.
• Miosis of pupil. Potential problems
• Unilateral blockage of nose on side of block. • Intra-arterial injection or intrathecal injection may result
• Unilateral flushing of conjunctiva of eye on side of in immediate convulsion and/or loss of consciousness
block. with possible CVS collapse.
69
5.1 • Stellate ganglion block—C6 (classic) approach
Fig. 5.1.10 From Gupta Prashant K, Gupta Kumkum, Dwivedi Amit Nandan D, Jain Manish. Potential role of ultrasound in anesthesia
and intensive care, Anesthesia Essays and Research, 2011 Volume 5, Issue Number 1, Page: 11-19.
• Hematoma may occur (avoid performing block on post-blockade. Bilateral stellate ganglion blockade
patients who have coagulopathy). should be avoided for the same reason.
• Pneumothorax may occur. • Phrenic nerve block may occur and it is prudent to
• Recurrent laryngeal nerve block may occur and it is caution the patient about possible shortness of breath
prudent to advise the patient about possible hoarseness post blockade of the stellate ganglion.
5
CHAPTER
70
Autonomic blockade
C5
Needle puncture and technique
Caution: injection of 0.5–1 ml of lidocaine (lignocaine)
1% into the vertebral artery may result in immediate
Middle
cervical convulsion and/or loss of consciousness with possible
C6 ganglion cardiovascular (CVS) collapse. The risk of pneumothorax
is greater with this approach.
Stellate • Intravenous access is inserted.
ganglion • Monitors are attached.
• Each temperature probe is attached to the palmar aspect
Vertebral of the middle finger of each hand. (Fig. 5.2.2).
T1 artery
• Resuscitation equipment and drugs are checked and
made ready for use.
Common
• The side of the neck is cleaned with antiseptic solution.
carotid
artery
Longus colli
C2
Superior stellate
ganglion C3 Anterior
C4 scalenus
C5
Middle ganglion C6 Medius
C7
scalenus
Stellate T1
ganglion
Subclavian
artery
Dome of pleura
1st rib
B Carotid artery
Fig. 5.2.1 Fig. 5.2.2
71
5.2 • Stellate ganglion block—C7 approach
• It is best to stand at the same side of the neck as the With the right hand
ganglion to be blocked. • The patient is requested to exhale deeply before needle
insertion to minimize the risk of pneumothorax.
FOR THE RIGHT-HANDED OPERATOR
• The needle is inserted between the fore- and middle
With the left hand fingers of the other hand, directly perpendicular to the
• The thyroid cartilage is located and marked. floor.
• The cricoid cartilage is identified and marked • When contact with the transverse process of C7 is
(Figs 5.2.3, 5.2.4). reached, the injecting hand is steadied and the needle is
• The sternoclavicular junction is palpated and marked withdrawn 2 mm.
(Fig. 5.2.5). • The hub of the needle is held in place with the
• The SCM muscle is gently pulled laterally and the other hand.
carotid pulse is palpated (Fig. 5.2.6). • After negative aspiration, lidocaine (lignocaine) 1%,
• The site of insertion of the needle lies 3 cm above the 0.5 ml, is injected.
sternoclavicular junction or one to two finger-breadths • The patient is questioned about sensation, and any
below the level of the cricoid cartilage. change in level of consciousness is noted.
• If negative, the same procedure is repeated and 0.5 ml
boluses are given until 5–8 ml is injected.
• The needle is withdrawn and the patient is immediately
put in the sitting position.
Muscles
Fig. 5.2.3
Cricoid cartilage
C6 anterior
tubercle
• Monitors should be left attached and i.v. access left in 2 mm, stabilized, and 1 ml of non-ionic contrast
situ for at least 30 minutes. Blockade of the recurrent medium is injected.
laryngeal nerve is less likely with the C7 approach but • The external jugular vein usually crosses the SCM
it is wise to advise the patient not to eat or drink for muscle at the level of C6.
2 hours. • Skin infiltration prior to block should be avoided if
• Note: if aspiration of blood occurs during the block, the possible, as this will make landmarks more difficult
needle is removed and cleared, keeping the left fore- and to locate.
middle fingers in place. It is then reinserted and the • An extension set may be inserted between the needle
block is continued as above. and syringe for better stability of needle, but an assistant
• If there is pain on injection and/or paresthesia, it is is then required to continue the procedure as described
likely that the brachial plexus may have been contacted, above.
the needle is withdrawn and the landmarks are • Lidocaine (lignocaine) 1% 10 ml may be given if a
rechecked. previous block failed to relieve sympathetically
• Ultrasound may aid placement of the needle. maintained pain in the presence of correctly placed
solution. This may improve tracking of the solution
caudally to produce more effective blockade of the
Confirmation of a successful block
stellate ganglion.
• Temperature increase >1° on the side of block. The
temperature should begin to rise in the finger of the
blocked side within 3 minutes of injection. Potential problems
• Ptosis of eyelid.
• Intra-arterial injection or intrathecal injection may result
• Miosis of pupil. in immediate convulsion and/or loss of consciousness
• Unilateral blockage of nose on side of block. with possible CVS collapse.
• Unilateral flushing of conjunctiva of eye on side • Hematoma may occur (avoid performing block on
of block. patients who have coagulopathy).
• Relief of sympathetically maintained pain. • Pneumothorax may occur (more likely with C7
approach).
Tips • Recurrent laryngeal nerve block may occur and it is
• Some workers advocate targeting the ventrolateral prudent to advise the patient about possible hoarseness
aspect of the C7 vertebral body instead of its transverse post blockade. Bilateral stellate ganglion blockade
process. The needle is directed 15–20° medially. With should be avoided for the same reason.
the aid of fluoroscopy, ultrasound or CT, the vertebral • Phrenic nerve block may occur and it is prudent to
body is contacted just medial to the insertion of the caution the patient about possible shortness of breath
longus colli muscle. The needle is then withdrawn following blockade of the stellate ganglion.
73
5.3 • Lumbar sympathetic block
Fig. 5.3.1
5
CHAPTER
74
Autonomic blockade
Temperature probe
Fig. 5.3.2
8 cm 2 1
8cm
10cm
Tips
• If fluoroscopy is not available ultrasound may aid
placement of the needle. A line 10 cm from the midline
is drawn parallel to the midline; the lowest rib is
identified and a line is drawn along its inferior border.
• The point of intersection of these lines should be lateral
to the L2 vertebral body.
• Consideration should be given to performance of the
block under CT control if the block is unsuccessful.
• Repeated blocks may bring about gradual improvement
in sympathetically maintained pain.
• Immediate physiotherapy after blockade may improve
Fig. 5.3.5 the outcome.
5
CHAPTER
76
Autonomic blockade
Fig. 5.3.7
Fig. 5.3.9
Potential problems
• If the needle tip is placed too superficially, the tip may
come to lie in the intervertebral foramen and injection
may result in a subarachnoid block, an epidural block,
or a somatic nerve block. Confirmation of needle
position using lateral fluoroscopy is therefore
recommended.
• Genitofemoral neuralgia may occur in 5–10% of
patients post-neurolytic block causing pain in the groin.
• Perforation of the aorta or the inferior vena cava is
possible and retroperitoneal hematoma may occur.
Consequently the block should be avoided in patients
with coagulopathy.
• Intravascular injection may occur.
• Perforation of the kidney or ureter is usually of no
clinical significance unless neurolytic agents are used.
• Perforation of the intervertebral disc may occur. This
also is usually of no clinical significance but may produce
a septic discitis if bacterial contamination occurs.
• Postural hypotension, secondary to sympathetic
blockade, may occur.
• Injection of neurolytic solution into the psoas muscle
may cause rhabdomyolysis.
Fig. 5.3.8 • Patients in the prone position should be monitored
carefully when intravenous sedation is administered.
77
5.4 • Celiac plexus block—retrocrural approach
Anatomy that have synapsed in the celiac ganglia (Fig. 5.4.2). The
vagus nerve also supplies parasympathetic nerve fibers. Via
The celiac plexus is flat and lies against the crus of the
the celiac plexus dorsal root, ganglion cells innervate the
diaphragm, surrounding the root of the celiac and
whole of the abdominal viscera, including the liver, spleen,
mesenteric arteries and anterior to three vertebral bodies
kidneys, suprarenal glands, and intestines, with the
centered at L1. Posteriorly on the left side is the aorta, and
exception of the pelvic organs, the rectum, and the left half
on the right is the inferior vena cava. The kidneys lie
of the colon.
lateral and the pancreas anterior to the celiac plexus
(Fig. 5.4.1 a,b). Pain originating from the viscera is often vague and poorly
localized as a result of convergence of neurons in the
The celiac plexus is made up of pre- and postganglionic
dorsal horn and crossing over the midline of some of the
sympathetic and parasympathetic nerve fibers.
visceral afferents.
Postganglionic sympathetic fibers are supplied from the
paired celiac ganglia. Preganglionic sympathetic efferents There are two main approaches to celiac plexus blockade.
from the thoracic sympathetic chain are supplied via the One approach places the two needles posterior to the crura
greater and lesser splanchnic nerves. The intra-abdominal of the diaphragm, the retrocrural approach. The
viscera are supplied by postganglionic sympathetic fibers retrocrural approach to the celiac plexus also targets the
splanchnic nerves to produce a splanchnic nerve block if
Celiac artery
required. The other approach places a needle anterior to
the crus of the diaphragm on the right, the anterocrural
Celiac plexus approach (Fig. 5.4.3), as discussed in Section 5.5.
Liver
Sympathetic chain
Dorsal root
Inferior Thoracic
Aorta vena cava spinal cord
Splanchnic
nerve
Somatic nerve
Kidney Kidney
Aorta
Ventral root
Diaphragm White ramus Vagus nerve
Retrocrural spread
Splanchnic nerve
Celiac plexus
Celiac
ganglion
Anterocrural
spread Viscus
Splanchnic nerves
Diaphragmatic
crus
Superior
B B mesenteric ganglion
Fig. 5.4.1 Fig. 5.4.2
5
CHAPTER
78
Autonomic blockade
T12
Celiac axis
L1 Superior
mesenteric
artery
L2
Classic Aorta
celiac block
R L
L1
L3 L2 L1
Pancreas Inferior
A B vena cava
C Fig. 5.4.5
A B
Fig. 5.4.6
5
CHAPTER
80
Autonomic blockade
C D
E
Fig. 5.4.6, cont’d
be seen to expand superiorly, spreading to the • Injection near the mid-point of the body is more likely
thoracic levels to contact the splanchnic nerves to result in dorsal spread of the drug toward the neural
(see Fig. 5.4.6 d). foramen. More cephalad placement is a bit more
• After confirming negative aspiration for blood, difficult technically, but places the needle closer to the
15–20 ml alcohol or phenol is injected. The needle is splanchnic nerves.
cleared with 1 ml lidocaine prior to removal. • The procedure is repeated in an identical manner on the
• Alternatively, the needle can be advanced more left side.
cephalad to a position at the anterior border of T12
preferably near either the lower or upper endplate Confirmation of a successful block
(Fig. 5.4.6 e). • Relief of upper abdominal pain.
81
5.4 • Celiac plexus block—retrocrural approach
Aorta
Diaphragm
Retrocrural spread
Celiac plexus
Anterocrural
spread
Splanchnic nerves
Diaphragmatic
crus
Fig. 5.5.1
83
5.5 • Celiac plexus block—anterocrural approach
Fig. 5.5.2
• The thoracolumbar midline and area 10 cm × 5 cm • 1 ml 1% lidocaine is injected before removing the needle
laterally is cleaned with antiseptic solution and a to clear it.
fenestrated drape is placed over the sterile area.
• The twelfth rib and L1 are identified and confirmed Left side
with fluoroscopy. • The same procedure is repeated on the left.
ANTEROCRURAL APPROACH • The needle is positioned 1.5–2 cm anterior to the
anterior border of the L1 body. It is then usually
Right side within the aorta, and aspiration is positive for arterial
• A 15 cm 22 G spinal needle is selected. A slight curve at blood.
the needle tip, away from the bevel direction, may be
• The needle is advanced forward until aspiration is
created which allows the needle to be redirected during
negative for blood (Fig. 5.5.3 b).
placement.
• 1 ml contrast is injected. The pattern is generally
• An AP view of the upper lumbar/low thoracic spine is amorphous anteriorly, but a straight border of dye along
obtained and the C-arm is adjusted to superimpose the the anterior surface of the aorta may be seen (Fig. 5.4.4).
T12–L1 endplates. • Aspiration is repeated and, if negative, 3 ml 1%
• A skin wheal is raised at the lower border of the twelfth lidocaine (lignocaine) is injected. If no nerve block is
rib on the right just above the level of the L1 transverse noted after 10 minutes, this is followed by 15–20 ml
process. The needle is inserted at this site and advanced alcohol. If phenol is used, the lidocaine is not needed.
at an angle 30° from perpendicular inward until the L1 • 1 ml 1% lidocaine is injected before removing the needle
body is contacted just below the upper endplate. to clear it.
• The curve of the needle is turned laterally and the needle • Monitors should be left attached and i.v. access left in
is advanced along the upper portion of the body. situ for at least 30 minutes.
• Once the needle has slipped a few millimeters past
the lateral aspect of the L1 body, a lateral view is
obtained.
Confirmation of a successful block
• Relief of upper abdominal pain.
• The needle is advanced until the tip is 1.5–2 cm anterior
to the anterior border of the L1 body. The needle is
aspirated and if negative, 1 ml non-ionic contrast is Tips
injected. Dye spread should be in an amorphous pattern • After injection of non-ionic radio-contrast medium, a
(Fig. 5.5.3). blush will indicate injection into muscle. If visible
• If aspiration is negative, 3 ml 1% lidocaine (lignocaine) contrast medium disappears immediately it is likely that
is injected. If no nerve block is noted after 10 minutes, intravascular injection has occurred.
this is followed by 15–20 ml alcohol. If phenol is used, • Consideration should be given to performance of the
the lidocaine is not needed. block under CT control if the block is unsuccessful.
5
CHAPTER
84
Autonomic blockade
R L
L1
L3 L2 L1
Pancreas Inferior
A B vena cava
T12
Celiac axis
L1 Superior
mesenteric
artery
L2
Classic
Aorta
celiac block
• Pneumothorax may occur. • The thoracic duct may be damaged (possibly causing
• Transient motor paralysis and paraplegia may occur chylothorax, or lymphedema).
after the block, probably as a result of spasm of • Abdominal and chest discomfort may be experienced for
segmental arteries. 30 minutes after injection of alcohol.
• Perforation of the intervertebral disc may occur, but this • There may be a detectable odor from the breath after
also is usually of no clinical significance. alcohol injection.
• Perforation of the kidney or ureter is usually of no • Patients in the prone position should be monitored
clinical significance unless neurolytic agents are injected. carefully when intravenous sedation is administered.
5
CHAPTER
86
Autonomic blockade
Anatomy Equipment
The superior hypogastric plexus is formed from pelvic • 2 ml, 5 ml, and 10 ml syringes
sympathetic fibers of the aortic plexus and L2 and L3 • 30 G needle
splanchnic nerves. These afferent and efferent fibers • Two 15 cm 22 G needles
innervate the pelvic viscera, including the uterus, bladder, • Extension set (optional)
vagina, and prostate. The plexus is located between the
• ECG, BP, and SpO2 monitors
upper third of the first sacral vertebral body and the lower
• Resuscitation equipment (see Appendix 3)
third of the fifth lumbar vertebral body, at the sacral
promontory, in the retroperitoneal space (Fig. 5.6.1 a,b). • Fluoroscopy
Parasympathetic nerve fibers from S2–S4 pass through the
inferior hypogastric plexus.
Superior
hypogastric plexus
Psoas major
muscle
Superior
rectal artery
Internal iliac
artery and vein
External iliac
artery and vein
Fig. 5.6.1
87
5.6 • Hypogastric plexus block
Tips
• After injection of non-ionic radio-contrast medium, a
blush will indicate injection into muscle. If this
disappears immediately it is likely that intravascular
Fig. 5.6.2 injection has occurred.
5
CHAPTER
88
Autonomic blockade
B C
Fig. 5.6.3
• Consideration should be given to performance of the intervertebral foramen and injection may result in an
block under CT control if the block is unsuccessful epidural block or a somatic nerve block. Injection of
(Fig. 5.6.10). neurolytic solution into the psoas muscle may cause
rhabdomyolysis.
• Perforation of the aorta or the inferior vena cava is
Potential problems possible and consequently the block should be avoided
• The position of each needle tip should always be in patients with coagulopathy. Dissection of the aorta
confirmed with fluoroscopy prior to injection of may occur as a result of direct damage during the block.
neurolytic agents as it may lie in the peritoneal cavity, Retroperitoneal hematoma may occur and for this
within a viscus or intravascularly. If a needle tip is reason also the block should be avoided in patients with
placed too superficially, the tip may come to lie in the coagulopathy.
89
5.6 • Hypogastric plexus block
Superior
hypogastric
plexus
Bifurcation of Psoas
iliac vessels major muscle
Fig. 5.6.8
Anatomy Equipment
The ganglion impar is a retroperitoneal sympathetic • 2ml, 5 ml, and 10 ml syringes
ganglion located at the level of the sacrococcygeal junction • 30 G needle
(Fig. 5.7.1). Above the level of this ganglion the • 22 G spinal needle
sympathetic chains are paired. Sympathetic afferents from • Extension set (optional)
the perineum, distal rectum and anus, distal urethra, vulva
• ECG, BP, and SpO2 monitors
and the distal third of the vagina converge in the ganglion
• Resuscitation equipment (see Appendix 3)
impar.
Drugs
• Lidocaine (lignocaine) 1%, 5 ml for skin infiltration
• Lidocaine (lignocaine) 1%, 15–20 ml (or its equivalent)
for block
L5 • Phenol 6%
• Non-ionic radio-opaque contrast medium
• Resuscitation drugs (see Appendix 3)
S1
Position of patient
S2
• Prone.
S3 • Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.7.2).
S4
S5
Needle puncture and technique
Sacrococcygeal • Intravenous access is inserted.
Coccyx junction • Monitors are attached.
Ganglion impar • Resuscitation equipment and drugs are checked and
Anococcygeal
ligament Marks entrance made ready for use.
point of needle • The midline along the intergluteal groove and an area
Fig. 5.7.1 10 cm × 5 cm laterally is cleaned with antiseptic
Fig. 5.7.2
5
CHAPTER
92
Autonomic blockade
solution and a fenestrated drape is placed over the • After negative aspiration, the fluoroscopic image is
sterile area. observed as a small amount of non-ionic radio-contrast
• A skin wheal is raised at the superior aspect of the medium is injected. The correct placement of the needle
intergluteal groove, just above the anus, over the is indicated by the presence a small round blob of
anococcygeal ligament (Fig. 5.7.3). contrast medium at the anterior border of the vertebral
• The stylet from the 22 G spinal needle is removed, and column (Fig. 5.7.5 a,b).
the needle is bent with the fingers to form a 30° angle, • Lidocaine (lignocaine) 1% 5 ml is injected for ganglion
approximately 2 cm from the hub. blockade.
• The needle is inserted through the skin wheal, with the
concave curvature facing posteriorly.
• With the aid of fluoroscopy, the needle is advanced deep
into the coccyx, closely approximating its anterior
surface, until the tip reaches the level of the
sacrococcygeal junction (Fig. 5.7.4).
Iliac crest
Posterior suprior
iliac spine
Sacral cornua
Sacral hiatus
Coccyx
Anococcygeal
ligament A
Anus
Fig. 5.7.3
Sacrococcygeal junction
Ganglion impar
Retroperitoneal Anococcygeal
space ligament
Sacrum
Anus
B
Rectum
Fig. 5.7.4 Fig. 5.7.5
93
5.7 • Ganglion impar block
A B
Fig. 5.8.1
95
5.8 • Intravenous regional sympathetic block—upper limb
Temperature probe
Fig. 5.8.3
Tips
• Resuscitation equipment and drugs are checked and
• If i.v. access to the affected limb is difficult due to
made ready for use.
vasoconstriction, a smear of glycerol trinitrate cream on
• The limb is raised above the level of the heart for 2
the dorsum of the hand will usually aid i.v. insertion.
minutes (Fig. 5.8.1 b).
• A single or double cuff may be employed for this block
• With the limb raised, it is exsanguinated by applying a
but a double tourniquet may make the block more
tight wrap, e.g. Esmarch bandage.
comfortable. The proximal cuff is inflated first. A few
• A thin layer of padding is applied, e.g. Velband, under minutes after injection the distal cuff is inflated and
the tourniquet site. when inflation is complete the proximal cuff is released.
• The tourniquet is applied and the cuff is inflated to a • Retrograde cannulation, i.e. towards the periphery
pressure 100 mmHg higher than the systolic blood (Figs 5.8.4, 5.8.5) rather than proximally (Figs 5.8.6,
pressure (Fig. 5.8.2). 5.8.7), may help direct the spread of bretylium to the
• The limb is then lowered. A mixture of lidocaine periphery.
(lignocaine) 0.5% 15 ml (without epinephrine/ • Active or passive movements of the limb may hasten
adrenaline), bretylium 1.5 mg/kg (or guanethidine the distribution of bretylium to the periphery.
0.25 mg/kg), and NaCl to make a total volume of 40 ml
(a final lidocaine (lignocaine) solution of 0.25%), is • If the tourniquet inflation is painful, inhalation of
injected through the i.v. cannula in the affected limb. nitrous oxide–oxygen mixture may improve comfort.
• The tourniquet is allowed to remain inflated for at least • Repeated blocks may bring about gradual improvement
30 minutes. in sympathetically maintained pain.
5
CHAPTER
96
Autonomic blockade
• Immediate physiotherapy after block may improve circulation. Systemic toxicity of lidocaine (lignocaine) may
outcome. also occur, possibly causing seizures. Blood pressure may
decrease after deflation of the cuff later in the procedure.
• The tourniquet inflation may be painful.
Potential problems • A sensation of burning may occur after injection due to
• Accidental deflation of the tourniquet early in the release of endogenous norepinephrine.
procedure may cause a precipitous rise in blood pressure • Neuropraxia may occur (rarely) with a very tight
due to the general release of endogenous norepinephrine/ tourniquet.
noradrenaline when unfixed bretylium enters the • Avoid in sickle cell anemia.
97
5.9 • Intravenous regional sympathetic block—lower limb
Drugs
• Lidocaine (lignocaine) 0.5% without epinephrine
(adrenaline), or its equivalent
• Bretylium 1.5 mg/kg (or its equivalent, e.g. guanethedine
0.5 mg/kg)
• Saline (NaCl) 30 ml
• Resuscitation drugs (see Appendix 3)
Position of patient
• Supine.
Technique
• Intravenous access is inserted in the contralateral limb.
• Peripheral i.v. access is inserted in the limb to be
blocked.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The limb is raised above the level of the heart for 2
minutes (Fig. 5.9.1).
• With the limb raised, it is exsanguinated by applying a
tight wrap (Fig. 5.9.2).
• A thin layer of padding is applied, e.g. Velband, under
the tourniquet site.
• The tourniquet is applied and inflated to a pressure
100 mmHg higher than the systolic blood pressure. A
second tourniquet may be applied to the calf of patients
with no known predispositions to deep venous Fig. 5.9.1
5
CHAPTER
98
Autonomic blockade
Tips
• If i.v. access to the affected limb is difficult due to
vasoconstriction, a smear of glycerol trinitrate cream on
the dorsum of the foot will usually aid i.v. insertion.
• A single or double cuff may be employed for this block
but a double tourniquet may make the block more
comfortable. The proximal cuff is inflated first. A few
minutes after injection the distal cuff is inflated and
when inflation is complete the proximal cuff is released.
• Retrograde cannulation, i.e. towards the periphery
(Fig. 5.9.5) rather than proximally (see Fig. 5.9.3), may
help direct the spread of bretylium to the periphery.
• Active or passive movements of the limb may hasten the
distribution of bretylium to the periphery.
• If the tourniquet inflation is painful, inhalation of
nitrous oxide–oxygen mixture may improve comfort.
• Repeated blocks may bring about gradual improvement
in sympathetically maintained pain.
• Immediate physiotherapy after block may improve
outcome.
Fig. 5.9.2
Temperature probe
Single cuff
Potential problems
• Accidental deflation of the tourniquet early in the
procedure may cause a precipitous rise in blood pressure
due to the general release of endogenous norepinephrine
or epinephrine when unfixed bretylium enters the
circulation. Systemic toxicity of lidocaine (lignocaine)
may also occur in high doses possibly causing seizures.
Blood pressure may decrease after deflation of the cuff
later in the procedure.
• The tourniquet inflation may be painful.
• A sensation of burning may occur after injection due to
release of endogenous norepinephrine.
• Neuropraxia may occur (rarely) with a very tight
tourniquet.
• Avoid in sickle cell anemia.
Fig. 5.9.5
MUSCLE INJECTIONS
6
Myofascial pain occurs commonly in the muscles of Fibromyalgia is a pain syndrome characterized by
the upper and lower back. It is characterized by pain widespread, diffuse and usually symmetrical tender areas of
associated with movement of the affected muscles that muscles. Bony structures, such as costochondral junctions
develop areas of extreme tenderness, termed trigger points. and lateral epicondyles, produce local pain, but not
Palpation of these points is usually perceived as a tight referred, on palpation of tender points. Injection of these
band or firm nodule in the muscle and reproduces pain tender areas typically does not improve the pain of
that may be referred some distance from the site of fibromyalgia.
palpation. Involuntary muscular contraction can occur on Usually a dilute solution of local anesthetic suffices for
palpation, and snapping palpation can result in a local beneficial effect. Bupivacaine produces more muscle
twitch response. Electromyography (EMG) is not reliable degeneration than any other local anesthetic when injected
in diagnosing myofascial pain syndrome and it is worth into a muscle, and consequently it is usually avoided,
remembering that this syndrome may occur in association lidocaine (lignocaine) being the usual local anesthetic of
with underlying painful disorders of the spine. choice.
Injection of trigger points with local anesthetic, especially The optimum number of trigger-point injections required
if repeated several times and combined with stretching to produce pain relief is variable. The injection sites may
exercises, may have a beneficial therapeutic effect on the themselves be painful after the local anesthetic wears off.
pain of myofascial pain syndrome. Pain reproduction This may exacerbate muscle spasm if too many trigger-
during injection, followed by relief of pain after injection, point injections are performed. Consideration should be
that lasts at least as long as the expected local anesthetic given to the severity of the muscle spasm, the number of
effect, indicates that these painful points contribute to trigger points, and to the sensitivity of the patient to pain
myofascial pain syndrome. when deciding on the number of injections.
6
CHAPTER
102
Muscle injections
Anatomy Equipment
The muscles most often involved in myofascial pain • 10 ml syringe
syndrome of the neck include the trapezius, rhomboid • 25 G needle
minor and major, latissimus dorsi, levator scapulae and
splenius capitis (Fig. 6.1.1; see also Fig. 2.1.2).
Drugs
• Lidocaine (lignocaine) 1% 10 ml
Position of patient
• Prone.
• Pillow under chest to allow the neck to flex.
Trapezius
• The sitting position is also used, but vasovagal response
Levator
scapula
may follow trigger-point injections especially in young
adults, and it is probably more prudent to use the prone
Rhomboid position.
minor
Rhomboid
major
Needle puncture and technique
• The neck, shoulders, and upper posterior thorax are
cleaned with antiseptic solution.
• Trigger points in the muscles are palpated (Fig. 6.1.2)
and marked (Fig. 6.1.3).
Latissimus • A 25 G needle with syringe attached is inserted into a
dorsi
trigger point (Fig. 6.1.4).
• After negative aspiration, 2–3 ml of lidocaine
(lignocaine) 1% is injected into the trigger point while
Fig. 6.1.1 moving the needle back and forth through the muscle.
• After injection, the next trigger point is injected in the
Relaxed muscle
same manner (Fig. 6.1.5 a,b).
fibers
Trigger point Confirmation of a successful injection
• Pain reproduction when the needle enters the muscle
confirms correct placement.
Local twitch
Tips
• For best results, injection is carried out in a fan-like
manner by repeatedly withdrawing the needle slightly
and redirecting it.
• Stretching of the involved muscles by physiotherapy
within the duration of the local anesthesia improves
results.
• Some workers advocate massage of the area immediately
after injection.
Potential problems
• Pain on injection.
• Vasovagal response (especially in young adults in the
Fig. 6.1.4 sitting position).
• Pneumothorax (especially in thin patients).
Skin
Subcutaneous
tissue
Muscle
Trapezius
Supraspinatus
(under trapezius)
Infraspinatus
Teres minor
Teres major
A B
Fig. 6.1.5
6
CHAPTER
104
Muscle injections
Anatomy Drugs
The muscles most often involved in myofascial pain • Lidocaine (lignocaine) 1% 10 ml
syndrome of the back include the erector spinae (the
longissimus, iliocostalis, and spinalis columns) and the Position of patient
deep transversospinal (semispinalis, multifidus, and • Prone.
rotatores) muscles (Fig. 6.2.1 a,b). In the buttocks,
• Pillow under abdomen to straighten the normal lumbar
spasm of the gluteus medius muscle may also cause
lordosis (Fig. 6.2.2 a).
significant pain.
• The sitting position is also used, but vasovagal response
may follow trigger-point injections, and it is probably
Equipment more prudent to use the prone position.
• 10 ml syringe • Alternatively, the semiprone position will also allow
• 25 G needle access to affected muscles (Fig. 6.2.2 b).
Psoas major
Quadratus
External oblique lumborum Quadratus
Latissimus dorsi Internal oblique lumborum
Longissimus
and iliocostalis
Interspinalis
Multifidus
A B Iliocostalis Longissimus
Fig. 6.2.1
B
Fig. 6.2.2
105
6.2 • Trigger-point injections—back
Needle puncture and technique • After injection, the next trigger point is injected in the
same manner.
• The midline and the surrounding area are cleaned with
antiseptic solution.
• Trigger points in the muscles are identified by palpation
Confimation of a successful injection
and marked (Fig. 6.2.3). • Pain reproduction when the needle enters the muscle
• A 25 G needle with syringe attached is inserted into a confirms correct placement.
trigger point (Fig. 6.2.4).
• After negative aspiration, 2–3 ml of lidocaine Tips
(lignocaine) 1% is injected into the trigger point while • For best results, injection is carried out in a fan-like
moving the needle back and forth through the muscle manner by repeatedly withdrawing the needle slightly
(Fig. 6.2.5). and redirecting it.
• Stretching of the involved muscles by physiotherapy within
the duration of the local anesthetic improves results.
• Some workers advocate massage of the area immediately
after injection.
Potential problems
• Pain on injection.
• Vasovagal response (especially young adults in the
sitting position).
• Pneumothorax (especially in thin patients) is also a
possibility when injecting the upper back.
Fig. 6.2.3
Skin
Subcutaneous
tissue
Muscle
Equipment
• 10 ml syringe
• 22 G needle
Gluteus medius
Gluteus maximus
Fig. 6.3.3
Gluteus medius
Gluteus maximus
Skin
Subcutaneous
tissue
Muscle
Gluteus medius
Tips
• If injection is not successful in relieving the pain, it may
be repeated at the lateral insertion point. This lies at a
Piriformis
muscle
Sciatic nerve
Piriformis Piriformis
muscle muscle
Fig. 6.4.3
6
CHAPTER
110
Muscle injections
Fig. 6.4.4
Piriformis
muscle
Fig. 6.4.5
Potential problems
B
• Sciatic nerve block.
• Infection or abscess may occur (rarely). Fig. 6.4.6
TRANSCUTANEOUS
ELECTRICAL NERVE
STIMULATION (TENS)
7
Transcutaneous electrical nerve stimulation is thought to Control settings (Figs 7.1.1, 7.1.2)
modify pain appreciation by stimulation of large fibers
thereby blocking (or “closing the gate” to) smaller C-fibers CONTINUOUS STIMULATION
carrying nociceptive impulses. There is also evidence that • Amplitude set to zero.
high-frequency stimulation of the skin increases latency • Pulse width set to midrange.
and decreases maximum firing rates in small afferent fibers. • Switch to continuous mode.
This can produce conduction blockade in C-fibers as the • Increase pulse amplitude level gradually to the
current is increased, probably via potassium efflux from maximum level for comfort (sensation should be strong
the axon. It is thought that a combination of these actions but not painful).
is responsible for the analgesia derived from the use of
• Adjust pulse frequency to maximum level for comfort
TENS. This is probably not related to opiate-mediated
(amplitude may be reduced as pulse width is increased).
mechanisms when conventional parameters are used.
• Adjust pulse width to maximum level for comfort.
Not all pain responds to TENS. If the usual parameters do • Maintain for 45–60 minutes.
not produce pain relief, low frequency, high intensity
stimulation may be tried. This means that the current
amplitude is increased to a level that produces mild
discomfort and muscle stimulation. Analgesia from this
type of stimulation may be due to opiate-mediated
mechanisms. Burst stimulation means short bursts of high
frequency stimulation delivered at 1–2 Hz and may also
relieve pain that is not responsive to conventional TENS.
A TENS trial may be carried out prior to giving the unit to
the patient to use at home. This allows the patient to
become familiar with the use of TENS, and to ensure that
the pain is not aggravated by its use. A minimum of one
Rectangular Triangular
hour is recommended as the trial period. This will indicate
whether the patient is likely to respond to TENS. However,
failure to respond within this time period does not
necessarily mean that there will be no response if used for
longer periods, or with different settings. It is important to
allow the patient to use the TENS at home for a period of
Sine wave Exponential
at least 14 days.
The TENS stimulator is a battery-operated pulse generator
which has several controls. These include an on/off switch
plus amplitude control, frequency control, mode selector,
and width control. In addition, multichannel units have
amplitude controls for each channel. The pulse generator
connects to leads that then connect to electrodes, which are
Biphasic Asymmetric
applied to the skin. Electrodes are applied in pairs, and are
positioned so that they lie along the direction of the nerves
in the area being treated, e.g. longitudinally in the limbs,
but dermatomally in the trunk. Fig. 7.1.1
7
CHAPTER
112
Transcutaneous electrical nerve stimulation (TENS)
C2
C2
C3 C3
T1
C3
C4 C4
T2
C4
3
T2
C5 C5 4
3
C5 5 C5
4 6
T2 5 7
6 T2 8 T2
7 T2 9
T1 8 10
T1 11 T1
9
C6 T1 12
10
C6 L1 S1
11
C7 C6 L3 C6
C8 12
S5
L1 C7 Coc C7
S3 C7 S3
C8 L2 S4 L2 C8
C8
S3
S4
L2
L2 S2 S2
S2
L3
L3 L3
S2
L5
S1
L4 L5 L4 L5
L4
S1
L4
L5
L5
L5 S1
S1 S1 S1
L3 L3
L5 L5
S2 S2
L4 L4
L2 L2
S4
L2 L2
S3 S3
S1 S1
L5 Coc L5
S1 S1
S5
Fig. A.4.3
C2
C3
C4
C6 C5 T2 C5 C6
T1 3 T1
4
C7 5 C7
C8 C8
6
7
8
9
10
11
12
L1
L2 L3 L2
L5 L5
S2 S3 S4 S2
S1 S1
L4 L3 S5 L3 L4
Coc
C2
C3
C4 C4
C6 C5 C5 C6
T1 T2 T2 T2 T1
C7 3 C7
C8 4 C8
5
6
7
8
9
10
11
12
L2 L1 L2
S1 L3 L3 S1
L5 L4 S3 S3 L4 L5
Fig. A.4.4
121
Appendix 4
C2
C3
C4 C4
T2
C5 3 C5
4
T2 5 T2
6
L3
7
8
T1 9 T1
C3 C4 T2 3 4 5 6 7 8 9 10 11 12 L1 C6 C6
10
11
S3
C2 12
C7 L1 C7
C5
C8 S3 C8
L2 S4
L2 L2
T1
C6
L3 L3
L3 S2
C7 L4
C8
L4 L4
L5
L5 L5
S1 S1
S1
Each muscle in the body is supplied by a particular level or • T1–T12 supplies the chest wall and abdominal muscles.
segment of the spinal cord and by its corresponding spinal • L2 bends the hip.
nerve. • L3 straightens the knee.
• C5 also supplies the shoulder muscles and the muscle • L4 pulls the foot up.
that we use to bend our elbow. • L5 wiggles the toes.
• C6 is for bending the wrist back. • S1 pulls the foot down.
• C7 is for straightening the elbow. • S3, S4 and S5 supply the bladder, bowel and sex organs,
• C8 bends the fingers. and the anal and other pelvic muscles.
• T1 spreads the fingers.
C5 C6,7,8
C5 C6,7,8
L5,S1
L1,2,3
L2,3 L4,5
L5,S1
L1,2,3
L5, S1
C6
L3,4
L4,5 C7,8
S1,2
Fig. A.5.1
APPENDIX
6
LUMBO-SACRAL SPINE
ANATOMY
Spinal cord
Pia mater
Arachnoid
Dura mater
L1
Conus
medullaris
L1
L2
L2
Cauda equina
L3
Ligamentum
flavum (L3–4) L3
L4
Epidural space
L4
Internal filum
terminale L5
L5
Sacrum
Sacrum
Distal dural sac
S1
External filum
terminale S2
S3
S4
S5
Coccyx
Fig. A.6.1
127
INDEX
Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
retrocrural approach, 77–81 contrast medium, non-ionic radio-opaque dorsal nerve roots, 1
anatomy, 77, 77f–78f in celiac plexus block dural puncture, 20, 24, 29, 33
confirmation of success, 80 anterocrural approach, 83 dural sac, 55, 125f
drugs, 78 retrocrural approach, 78, 81 distal, 55, 125f
equipment, 78 in cervical epidural block, 29 dural tap, 20, 23
needle puncture and technique, 78–80, in cervical facet joint injection, 9 dura mater, 16, 125f
79f–80f in ganglion impar block, 92
position of patient, 78, 78f in hypogastric plexus block, 87–88
potential problems, 81
tips, 81
in intercostal nerve block, 40, 41f
in long-term epidural catheter insertion, 36
E
cerebrospinal fluid (CSF), 16, 60, 64 in lumbar epidural block, 19 electromyography (EMG), 37, 101
cervical anterior tubercle, sixth, 66–68 in lumbar facet joint injection, 4–5 endotracheal tubes, 117
cervical disc pain, 15 in lumbar nerve root block, 48 ephedrine, 117
cervical epidural block, 25–29 in lumbar sympathetic block, 74 epidural abscess, 33
anatomy, 25, 25f in sacral nerve root block, 57 epidural block
confirmation of success, 29 in sacro-iliac joint injection, 13 in celiac plexus block, 81, 84–85
drugs, 25 in thoracic epidural block, 23 in hypogastric plexus block, 88–90
equipment, 25 in thoracic nerve root block, 52 lumbar, 16–20
needle puncture and technique, 25–29, in trigeminal ganglion (Gasserian) block, with lumbar nerve root block, 49
26f–28f 62 in lumbar sympathetic block, 76
fluoroscopic guided, 28–29, 29f conus medullaris, 55f, 125f in thoracic nerve root block, 54
position of patient, 25 convulsion, 64, 66 epidural catheter insertion, 20, 23
potential problems, 29 corneal anesthesia, 64 long-term, 34–36
tips, 29 corticosteroids, 2 anatomy, 34
cervical epidural injection, 15 in caudal epidural block, 31–32 confirmation of success, 36
cervical epidural space, 25, 29 in cervical epidural block, 27, 29 drugs, 34
cervical facet joint injection, 8–11 in cervical facet joint injection, 9 equipment, 34
anatomy, 8, 8f in lumbar epidural block, 18 needle puncture and technique, 34–36,
confirmation of success, 9 in lumbar facet joint injection, 5 34f–36f
drugs, 8 in sacro-iliac joint injection, 13 position of patient, 34, 34f
equipment, 8 side effects, 113 potential problems, 36
needle puncture and technique, 8–9, suggested, 113 tips, 36
9f–10f in thoracic epidural block, 21, 23 epidural injection, 15–36
position of patient, 8, 9f costochondral junctions, 101 caudal, 32
potential problems, 10 costotransverse ligament, 51f–52f, 53 cervical, 15, 25
tips, 10 coughing on injection, 40 lumbar, 19–20, 19f
cervical ganglia, 66 cranial fossa, 64 epidural needle
cervical nerve, dorsal rami of second, cranial nerves, 61, 64 in autonomic blockade, 74, 87
59 cricoid cartilage, 66–67, 71 in epidural block, 16, 18, 22, 26–28,
cervical nerve roots, 15 CSF (cerebrospinal fluid), 16, 60, 64 33–34
cervical sympathetic trunk, 66 CT see computed tomography (CT) scan in somatic nerve block, 40–41, 44, 46, 53
C-fibers, 111 Cushingoid symptoms epidural space, 16, 24–25, 29, 33, 55, 125f
Chassaignac’s tubercle, 66–68 post-caudal epidural block, 33 epidural spread, 19, 32, 49, 54, 57
chest discomfort, 81, 85 post-cervical epidural block, 29 epidural steroid injection, 15, 20, 23
chest X-ray post-lumbar epidural block, 20 epinephrine
intercostal nerve block, 39 post-thoracic epidural block, 24 in intercostal nerve block, 41
interpleural block, 44 cutaneous fibers, 47 in intravenous regional sympathetic
chylothorax, 85 cutaneous nociceptors, 1 block, 99
cisterna magna, 60 CVS collapse see cardiovascular system in long-term epidural catheter insertion,
coagulopathy (CVS) collapse 34
and celiac plexus block, 81 in lumbar epidural block, 20
and facet joint injections, 10 in thoracic epidural block, 23
and hypogastric plexus block, 88
and lumbar sympathetic block, 76
D erector spinae muscles, 104
Esmarch bandage, 95
coccygeal cornu, 55f decompression, 37 exsanguination, 95
coccygeal nerve, 55f depression, 2 external filum terminale, 125f
coccygeal vertebra, 55f dermatomes, 119 external iliac artery, 86f
coccyx, 92, 125f dexamethasone, 113 external iliac vein, 86f
colon, 77 diagnostic blockade, 11, 48, 53, 57, 64 external oblique muscles, 104f
Complex Regional Pain Syndrome Type 1 diaphragm, 43, 77, 77f, 82, 82f, 84f
and II, 65 diaphragmatic crus, 77f, 82, 82f
computed tomography (CT) scan, 37
in celiac plexus block, 83
diarrhea
post-celiac plexus block, 81, 84
F
in hypogastric plexus block, 88 post-ganglion impar block, 93 facet joints
in sacro-iliac joint injection, 13, 13f post-hypogastric plexus block, 90 cervical, 8–11
in stellate ganglion block diazepam, 117 lumbar, 3–6
C7 approach, 72 discogenic radiculopathy, 37 pain, 2
C6 (classic) approach, 68 discomfort facet nerve injection, 10–11
conjunctiva, unilateral flushing, 68, 72 abdominal, 81, 85 fibromyalgia, 101
consciousness, loss of in stellate ganglion chest, 81 filum terminale, 125f
block distal dural sac, 55, 125f fluoroscopy
C7 approach, 70–72 dorsal horn neurons, 1 C-arm, 4, 9
C6 (classic) approach, 68–69 dorsal horn pain projection cells, 1 in caudal epidural block, 32, 32f–33f
129
Index