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Atlas of Pain Injection Techniques

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Atlas
of

Pain

Injection
Techniques
SECOND EDITION

Therese C. OConnor MB FFARCSI


Consultant Anesthetist, Pain Specialist
Sligo Regional Hospital
Ireland

Stephen E. Abram

MD

Professor, Department of Anesthesiology


Medical College of Wisconsin
Milwaukee, WI, USA

an imprint of Elsevier Limited


2014, Elsevier Limited. All rights reserved.
First edition 2003
The rights of Therese C. OConnor and Stephen E. Abram to be identified as authors of this work has
been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
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This book and the individual contributions contained in it are protected under copyright by the
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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to
be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN: 9780702044717
Ebook ISBN: 9780702050343
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vii

Dedication

For my Parents
Therese C. OConnor
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. OConnor

xi

PREFACE TO THE FIRST EDITION

While the role of anesthesiologists in the management of


patients with severe or intractable pain has expanded
dramatically in the past few decades, it has traditionally
been anesthesiologists ability to use regional anesthetic
techniques both diagnostically and therapeutically that has
made their contributions to pain medicine unique. This
textbook emphasizes those regional anesthetic techniques
that have been included in the anesthesiologists
armamentarium for many years. In recent years, there have
been dramatic advances in the technology of pain
management interventions. These include implantable drug
delivery devices, radiofrequency and cryoanalgesia
neuroablation techniques, spinal cord and peripheral nerve
stimulators, percutaneous nucleoplasty, annuloplasty and
vertebroplasty devices. Despite these innovations, there is
still a substantial role in acute, chronic and cancer pain
management for many of the older, more conventional
regional anesthetic techniques.
Nerve blocks play a variety of roles in the management of
pain. For acute postoperative or post-traumatic pain, they
may be continued throughout the most painful interval,
serving as the sole analgesic technique or as adjunctive
measures, reducing the need for opioids and other systemic
analgesics. For patients with chronic or cancer pain, they
may provide long-term benefit by reducing nociceptive
inputs to sensitized regions of the spinal cord or brain.
They provide periods of antinociception that facilitate
physical therapy and reconditioning. Combined with
corticosteroids, they reduce neural inflammation and

produce neuronal membrane stabilization. They provide


diagnostic information regarding sites and mechanisms of
pain. Joint and muscular injections also provide an
important contribution to the diagnosis and management
of chronic pain. In the cancer patient, neurolytic
procedures may provide extended periods of interruption
of the most active sources of nociception. Long-term
infusions of local anesthetics, often combined with opioids
and other analgesic agents, can provide weeks to months
of relief when systemic analgesics have failed.
Our aim in embarking on the preparation of this atlas was
to provide a description of many of the basic regional
anesthetic tools and the common joint and muscular
injections that may be of benefit to patients with persistent
or severe pain. It is unusual for these procedures to be
curative on their own. Their value lies in their rational use
in combination with other management techniques,
including, but by no means limited to, physical therapy,
exercise, psychotherapy, and systemic medication. All
chapters in the book have been written to a template
taking the reader through each block in a consistent and
easy-to-follow way. Step-by-step illustrations accompanied
by photographs are used to teach technique within the
context of the surrounding anatomical structures and we
have also highlighted where injections can go wrong and
offered advice on how to avoid problems. It is our hope
that this atlas will fulfill our aim of providing a strong
foundation of regional anesthetic techniques in the
treatment of pain.

MECHANISMS OF PAIN
TRANSMISSIONAN
OVERVIEW OF ANATOMY
AND PHYSIOLOGY

The term pain is used to define sensations that hurt or are


unpleasant. There are, however, different types of pain.
Pain following injury can be considered to have a useful
protective function by rendering the injured area
hypersensitive to external stimuli. Specific groups of
primary sensory neurons carry stimuli defining the quality,
duration and intensity of noxious stimuli from injured
tissue. Their organized projections to the spinal chord or
trigeminal nucleus mean that the origin of the stimuli can
be precisely located. This somatic pain is often termed
ouch pain and is usually associated with acute, direct
injury to tissue. It arises from structures that are innervated
by somatic nerves, e.g. muscle, skin, synovium, and
periosteum. Thus the pain is usually easily localized to the
distribution of the nerve supplying the injured area, and is
often sharp and intense.
On the other hand, pain arising from visceral organs is
poorly localized. It may be appreciated as being deep in the
body, often arising from the midline, or may be referred to
distant structures. The reason for this is that visceral
sympathetic afferents converge on the same dorsal horn
neuron as do somatic nociceptive afferents, and both of
these stimuli travel to the brain via the spinothalamic
pathways. Thus, pain is appreciated in the cutaneous area
corresponding to the dorsal horn neuron upon which the
visceral afferents converge, accompanied by allodynia and
hyperalgesia in this dermatome. As a result, reflex somatic
motor activity may result in the spasm of muscles.
Consequently, cutaneous nociceptors may be stimulated,
which may be partly responsible for referred pain. In
addition, there is considerable branching of peripheral
visceral afferents with resulting overlap in the territory of
individual dorsal roots. Compared with somatic nociceptor
fibers, only a small number of visceral afferents converge
on dorsal horn neurons. This overlap, combined with
convergence of visceral afferents on the dorsal horn over a
wide number of segments, means that visceral pain is
usually dull, vague, and very often poorly localized.
While damage to cutaneous or deep tissue is usually
associated with inflammation of that tissue, neuropathic

pain is significantly influenced by pathologic changes in


peripheral nerve function. Thus neuropathic pain can
persist long after the original injury has healed. Pathologic
peripheral nerve changes include generation of spontaneous
neural inputs, neuroma formation and regeneration of
nerves. An injured nerve may become mechanically
sensitive, and mild pressure or traction may produce bursts
of rapid firing followed by many minutes of afterdischarge, perceived as pain in the affected root. With
time, the dorsal horn pain projection cells (wide dynamic
range neurons) may attain lower thresholds and expanded
receptive fields, adding to the traffic from pain fibers.
The character of the pain varies and typically may be
throbbing, shooting, lancinating, burning or freezing.
Recently, it has become apparent that the receptive-field
properties of dorsal horn neurons are not fixed or hardwired, but can change. The reason for this is that sensory
input from primary sensory fibers and interneurons onto
spinal neurons is normally too low in amplitude to
generate an action-potential discharge in the postsynaptic
cell. A temporal or spatial summation of postsynaptic
action potentials is required to exceed the threshold of the
cell. The center of the receptive field usually constitutes the
firing zone, where an adequate stimulus will generate an
action-potential discharge in the cell. Surrounding this
firing zone is the subliminal zone; a peripheral stimulus
evokes a response that is subthreshold. Changes may occur
in the area because an increase in excitability of a neuron
can convert a previously subthreshold input into a
suprathreshold response, leading to receptive-field
plasticity, or central sensitization. Thus, afferent barrages
of high-frequency C fiber activity can generate changes
in sensory processing in the spinal cord, leading to a
hyperalgesic state.
Careful investigation of the likely neurologic basis of each
patients pain may help in its treatment; thus whenever
possible the following aspects should be determined: site(s),
character, radiation, temporal pattern, factors increasing or
decreasing pain, and associated factors. An attempt should
be made to determine if the pain is somatic, visceral or

CHAPTER

Mechanisms of pain transmissionan overview of anatomy and physiology

neuropathic in origin, so that a rationale for treatment may


be planned.
In addition, it should be remembered that there are other
factors that determine an individuals level of pain
perception. Psychologic factors are as important as sensory
factors in determining pain perception and are more
important in their contribution to suffering. Various
responses to painful conditions exist, but depressive
features tend to predominate in patients with chronic pain.
Analysis of the patient from a psychologic perspective will
provide a more thorough understanding of the patients
pain complaint and the ramifications thereof. Being attuned
to psychologic issues will enable the physician to plan and
execute a more comprehensive treatment plan. The
relationship between depression, anxiety and pain is
circular or reciprocal, rather than linear. The existence of
pain often has detrimental effects on the patients mood,
increasing feelings of anxiety or depression. The
development of depression or anxiety can exacerbate the
experience of pain.
There have also been many reports about the perception
and communication of pain, and its treatment may be
influenced by sociodemographic factors. These include
ethnicity and cultural background, as well as gender, age,
education, and socioeconomic class.
It is therefore important to approach the management of
pain bearing foremost in the mind the varying influences
on perception of pain.
On the other hand, repeated blockade of sympathetic
activity with local anesthetic has been shown to reduce the
severity of sympathetically maintained pain. Visceral pain
may also be reduced by local anesthetic blockade of
visceral afferent fibers that accompany the sympathetic
efferents. However, the result is short-lived if pathology
remains that will cause continued stimulation; for example,
carcinoma of the head of the pancreas causes pain
mediated through the celiac plexus. In these cases it is
reasonable to consider neurolytic visceral afferent blockade
for pain relief.

It has been demonstrated that locally applied


corticosteroids prevent development of ectopic discharge
and suppress ongoing discharge of injured nerves. Thus in
the patient with chronic nerve pain, it is reasonable to
consider injection of corticosteroid at the site of injury to a
nerve, e.g. epidural or nerve root injection for nerve injury
due to intervertebral disc pathology.
Degeneration and inflammation of joints can produce pain
that is usually somatic in character, although this may
sometimes be difficult to distinguish from neuropathic
pain; for example, facet joint pain may be very similar to
radicular pain. Joint arthropathy as a cause of pain can be
confirmed by injection of local anesthetic into the joint.
Addition of corticosteroid to the local anesthetic has been
shown to decrease inflammation in the joint and thereby
reduce pain.
The myofascial syndrome is a very common cause of
somatic pain. It is associated with marked tenderness of
discrete points (trigger points) within affected muscles, and
with pain that is often referred to an area some distance
away. In addition, the affected areas may have the
appearance of tight, ropey bands of muscle with associated
autonomic changes such as vasoconstriction. Biopsies of
such trigger points can show degenerative changes
corresponding to the severity of pain (or can show little or
no change at all). The most important aspect of the
treatment of myofascial pain is to regain the length and
elasticity of affected muscles. This is best achieved by
physical maneuvers that stretch muscle. However, these
maneuvers are often painful and may worsen muscle
contraction. Therapy aimed at reducing pain and sensitivity
in muscles is best instituted prior to stretching exercises.
Trigger-point injectionsinjection of local anesthetic
directly into the trigger pointcan confirm the diagnosis of
myofascial pain and a series of injections can markedly
reduce muscle sensitivity. These injections, combined with
stretching exercises, can produce significant analgesia for
myofascial pain.

JOINT INJECTIONS

2.1 LUMBAR FACET JOINT INJECTION


Anatomy
The zygopophyseal or facet joints (Fig. 2.1.1) are paired
articular surfaces between the posterior aspects of
adjacent vertebrae. In the cervical region, rotation and
flexion are possible as the joint surfaces lie midway
between the coronal and the axial planes. Rotation is
prevented in the lumbar region but flexion is possible as

Lumbar vertebra
Superior facet

Superior

Inferior oblique

the anterior portion of the lumbar facet joints lie in the


coronal plane and the posterior portions in the sagittal
plane. In the thoracic region, the joints inferior and
superior articular surfaces overlap each other in an almost
vertical incline.
The facet joints bear most of the shear forces when the
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
dorsal rami of the spinal nerves. These nerves also
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

Lateral

Mb

Inferior facet

Lb
Ppr
Sn

Medial branch

Zygopophyseal
joint

Fig. 2.1.1

SvN

Gr
Intervertebral disc

Fig. 2.1.2 Lumbar spine innervation. Innervation of the lumbar


spinal structures in the transverse view. Note the posterior primary
ramus (Ppr) leaving the spinal nerve (Sn) and splitting into a
lateral branch (Lb) and a medial branch (Mb). The medial branch
passes under the mamillo-accessory ligament to innervate the
facet joint and capsule, the spinous process and the multifidus
muscles. Sensory fibers traveling with the gray rami (Gr) form the
sinu-vertebral nerve (SvN) and provide sensory function to
the disc annulus. (Reproduced with permission from
Cousins and Bridenbaughs Neural Blockade in Clinical
Anesthesia and Management of Pain, 4th edition,
Wolters Kluwer/Lippincott Williams & Wilkins, 2009.)

CHAPTER

Joint injections

adjacent facet joint, and the distal branch innervates the


next facet joint below. The medial branch also innervates
the interspinous ligaments and the multifidus muscles and
the lateral branch innervates other adjacent muscles. Thus,
pain from irritation of a joint may cause generalized
sensitization of the dorsal rami with secondary
hyperactivity and spasm of the innervated muscles and may
be difficult to localize.
The facet joints contain vascular, highly innervated
intra-articular synovial inclusions, which may
become trapped and inflamed when the joint is injured,
causing pain.

Equipment






2ml and 10ml syringes


25G needle
22G spinal needle, end-opening
Non-ionic radio-opaque contrast medium
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)
C-arm fluoroscopy or ultrasound

Drugs
Lidocaine (lignocaine) 1% 10ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
25mg (or its equivalent)
Resuscitation drugs (see Appendix 3)

Position of patient
Prone.
Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 2.1.3).

Fig. 2.1.3

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The lumbar midline and an area 10cm5cm laterally
is cleaned with antiseptic solution.
The spinous processes of the vertebrae are marked.
The insertion point of the needle lies 23cm lateral to
the cephalic end of the spinous process of the vertebra
(Fig. 2.1.4 a,b).
C-arm fluoroscopy is positioned at an angle of about
30, tilted towards the side of the joint to be injected.
The angle is adjusted until the joint is well visualized. A
radio-opaque object, e.g. the tip of a hemostat, is
positioned over the joint and the skin is marked.
Thereby, with the aid of fluoroscopy, the insertion point
is identified.
A skin wheal is raised and the area is infiltrated with
lidocaine (lignocaine) 1%.
A spinal needle is introduced in a vertical direction to
the skin, until the needle is observed to enter the joint
space, preferably near the lowest aspect of the joint
(inferior recess). Confirmation of intra-articular
placement is made by observation of the needle tip
remaining on the joint line as the fluoroscope is rotated
laterally (Fig. 2.1.5).
After negative aspiration, 0.5ml of non-ionic radioopaque contrast medium (that is compatible with nerve
tissue) is injected.
The correct placement is indicated by outlining the joint
with non-ionic radio-opaque contrast medium, visible
on anteroposterior and oblique views (Fig. 2.1.6 a,b).

2.1 Lumbar facet joint injection

Fig. 2.1.4

Ultrasound may also be helpful in identifying the facet


joint (Fig. 2.1.7).
When the correct placement of the needle is confirmed,
lidocaine (lignocaine) 1% 0.5ml plus corticosteroid, e.g.
triamcinolone diacetate 25mg, may be injected and the
needle removed while clearing with lidocaine
(lignocaine) 1% 1ml.

Confirmation of a successful injection


Relief of pain.

Tips
Care must be taken to inject only a small amount of
volume as described above. A total volume of more than
1ml may damage the joint. If the joint is disrupted
anteriorly, drug may spread to the epidural space.

Fig. 2.1.5

CHAPTER

Joint injections

Potential problems

Lumbar Facet Nerve Injection

Solution may spread to the epidural space via the


anteromedial capsule.
Nerve root injection.

Facet nerve injection may be carried out by placing a


spinal needle at the point where the superior articular
and transverse processes join as the median branch
passes over the cephalad edge of the transverse process
(Fig. 2.1.8).
The direct posterior approach should be avoided as the
needle placement may be obstructed by the superior
portion of the facet joint.
Approach to the target site from a lateral oblique angle
30 to skin is recommended.
The needle is advanced towards the target site (the
posterior-superior edge of the transverse process) until
bone is encountered.
It is recommended that the transverse process be
approached first, to determine depth.
The needle is then repositioned medially until the lateral
edge of the facet joint is reached.
The needle is then moved superiorly until it just falls
off the superior edge of the transverse process (Fig.
2.1.9).
The optimum position is obtained by repositioning the
needle to the postero-superior edge of the transverse
process.
The patient may now report reproduction of back pain.
Injection of lidocaine (lignocaine) 1% 0.5ml plus
triamcinolone diacetate 25mg may be carried out for
therapeutic effect. Diagnostic blockade may be
unreliable as anesthesia of a facet joint means that both
nerves supplying the joint should be blocked. However,
this means that the joint above and the joint below will
also be partially blocked and therefore diagnosis of pain
in a particular joint using nerve block is not feasible.

Fig. 2.1.6

Potential problems
The same potential problems may occur as described for
lumbar facet joint injection (see above).

2.1 Lumbar facet joint injection

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; 100:12428 2004 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.)

Mb

Fig. 2.1.8

Fig. 2.1.9

CHAPTER

Joint injections

2.2 CERVICAL FACET JOINT INJECTION


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 C23 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
C23 facet joint is innervated by the medial branch of the
third occipital nerve, which travels beneath the tendonous
origin of the splenius capitis muscle where it may be
accessed for local anesthetic blockade (Fig. 2.2.2).

Medial branch

Equipment






2ml and 10ml syringes


25G needle
22G spinal needle, end-opening
Radio-opaque contrast medium
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)
C-arm fluoroscopy or ultrasound

Vertebral artery

Fig. 2.2.1

Drugs
Lidocaine (lignocaine) 1%, 10ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
25mg (or its equivalent)
Resuscitation drugs (see Appendix 3)

Splenius capitus
Vertebral
artery

Position of patient
Prone.
Neck slightly flexed (Fig. 2.2.3).

Needle puncture and technique

C23 joint
3rd
occipital
nerve

Caution: injection of 0.51ml of lidocaine (lignocaine)


1% into the vertebral artery may result in immediate
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 7cm5cm
laterally is cleaned with antiseptic solution.
The spinous processes are marked.

Fig. 2.2.2

2.2 Cervical facet joint injection

Fig. 2.2.3

Fig. 2.2.4

Fig. 2.2.5

The insertion point of the needle lies 23cm lateral to


the cephalic end of the spinous process of the vertebra
(Fig. 2.2.4).
C-arm fluoroscopy is positioned at an angle of about
30, tilted towards the side of the joint to be injected.
The angle is adjusted until the joint is well visualized.
A radio-opaque object, e.g. the tip of a hemostat, is
positioned over the joint and the skin is marked.
Thereby, with the aid of fluoroscopy, the insertion point
is identified.
A skin wheal is raised and the area is infiltrated with
lidocaine (lignocaine) 1%.
A spinal needle is introduced in a vertical direction to
the skin, until the needle is observed to enter the joint
space (Fig. 2.2.5). Confirmation of intra-articular
placement is made by observation of the needle tip

remaining on the joint line as the fluoroscope is rotated


(Fig. 2.2.6) or on ultrasound.
After negative aspiration, 0.5ml of non-ionic radioopaque contrast medium (that is compatible with nerve
tissue) is injected.
The correct placement is indicated by outlining the joint
with non-ionic radio-opaque contrast medium, visible
on anteroposterior and oblique views.
When the correct placement of the needle is confirmed,
lidocaine (lignocaine) 1% 0.5ml plus corticosteroid, e.g.
triamcinolone diacetate 25mg, may be injected and the
needle removed while clearing with lidocaine
(lignocaine) 1% 1ml.

Confirmation of a successful injection


Relief of pain.

10

CHAPTER

Joint injections

3rd occipital
branch
Medial branch

Fig. 2.2.6

Tips
Care must be taken to inject only a small amount of
volume, as described above. A total volume of more
than 1ml may damage the joint. If the joint is disrupted
anteriorly, a drug may spread to the epidural space.

Potential problems
Solution may spread to the epidural space via the
anteromedial capsule.
Nerve root injection.
Intrathecal injection resulting in spinal anesthesia may
occur if local anesthetic is inadvertently injected into
the nerve root sleeve. Prompt recognition of this
complication is vital during cervical procedures, because
the patients breathing may be arrested and there may be
immediate convulsion and/or loss of consciousness with
CVS collapse requiring immediate resuscitation. In
addition, the patients head should be immediately
elevated after the injection to ensure that the lidocaine
(lignocaine) flows inferiorly. Some practitioners elevate
the head of the table during all cervical injections to
help prevent this complication. Intravenous injection
may be harmless, but it results in a suboptimal or
false-negative result.
Intra-arterial injection may result in immediate
convulsion and/or loss of consciousness with possible
CVS collapse. Intrarterial injection can be dangerous if
the agent is injected into the vertebral artery or radicular
branches that enter the neural foramina at various levels

Fig. 2.2.7

and, rarely, persisting paraplegia or paraparesis have


been reported after cervical facet joint injection or nerve
root block. These complications may be due to
embolism from intra-arterial injection of particulate
corticosteroid. However, even when contrast injection
prior to steroid infiltration confirms extravascular needle
placement, nerve damage may occur, which suggests an
alternative cause for the complication, such as
vasospasm or direct arterial injury from the needle-tip.
Regardless of the cause, contrast injection is
recommended to at least potentially reduce the risk of
intravascular injection. Ultrasound will have limitations
in this regard.
Hematoma may occur (avoid performing block on
patients who have coagulopathy).

CERVICAL FACET NERVE INJECTION


Facet nerve injection may be carried out by placing a
spinal needle at the point where the superior articular and
transverse processes join as the median branch passes over
the cephalad edge of the transverse process (Fig. 2.2.7).
The direct posterior approach should be avoided as the
needle placement may be obstructed by the superior
portion of the facet joint.
Approach to the target site from a lateral oblique angle
30 to the skin is recommended.
The needle is advanced towards the target site (the
posteriorsuperior edge of the transverse process) until
bone is encountered.
It is recommended that the transverse process be
approached first, to determine depth.

2.2 Cervical facet joint injection

The needle is then repositioned medially until the lateral


edge of the facet joint is reached.
The needle is then moved superiorly until it just falls
off the superior edge of the transverse process.
The optimum position is obtained by repositioning the
needle to the posterosuperior edge of the transverse
process.
The patient may now report reproduction of back pain.

Injection of lidocaine (lignocaine) 1% 0.5ml plus


triamcinolone diacetate 25mg may be carried out for
therapeutic effect. Diagnostic blockade may be
unreliable as anesthesia of a facet joint means that both
nerves supplying the joint should be blocked. However,
this means that the joint above and the joint below will
also be partially blocked and therefore diagnosis of pain
in a particular joint using nerve block is not feasible.

11

12

CHAPTER

Joint injections

2.3 SACRO-ILIAC JOINT INJECTION


Anatomy
The surfaces of the sacrum and ilium form a synovial joint,
the sacro-iliac joint. Ligaments and connective tissue
surround the joint, conferring stability and preventing
excessive movement of the joint (Figs 2.3.1, 2.3.2). The
joint is innervated by L4, L5, S1 (the superior gluteal
nerve), S2, and L3. Localization of the pain is therefore
difficult due to this wide nerve supply to the joint.

Equipment
2ml and 10ml syringes
25G needle

22G spinal needle, end-opening


Radio-opaque contrast medium
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)
C-arm fluoroscopy or ultrasound

Drugs
Lidocaine (lignocaine) 1%, 10ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
25mg (or its equivalent)
Resuscitation drugs (see Appendix 3)

Position of patient
Prone.
Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 2.3.3).

Disaligned joint
with pressure

Needle puncture and technique

Fig. 2.3.1

Intravenous access is inserted.


Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The sacral area is prepared antiseptically.
An AP image is obtained, centered over the joint to be
injected.
Two joint lines are observed. The posterior joint line is
located more medial in a direct AP view (Fig. 2.3.4a).
The image intensifier (positioned above the patient) is
rotated toward the opposite side until the two joint lines

Fig. 2.3.2

Fig. 2.3.3

Posterior
sacro-iliac
ligament

Sacrospinalis muscle

2.3 Sacro-iliac joint injection

Spine of
sacrum

Ilium

Sacro-iliac
joint

Sacrum

Fig. 2.3.5

Needle

Sacro-iliac joint injection

Fig. 2.3.4

are superimposed (usually about 1020) (Fig. 2.3.4b).


The skin is marked and a skin wheal is raised. The area
is infiltrated with lidocaine (lignocaine) 1% over the
joint line 1cm above the most caudal point of the joint.
A 22 or 25G 3in spinal needle is advanced no more
than 1cm into the joint. Some resistance is usually felt
as the needle contacts the joint.
A lateral view is then obtained. The needle should
traverse no more than half the distance across the
sacrum, and should never be advanced beyond the
anterior cortex.
Contrast dye, 0.5 to 1ml, may be injected to ensure
intra-articular spread. Intravascular injection is best
detected during live fluoroscopy injection. In the AP
view, dye should be seen within the joint space. Some

Fig. 2.3.6

extravasation outside the joint is common. If extensive,


the needle should be repositioned.
12ml lidocaine 1% is injected alone for diagnostic
purposes. Reproduction of the patients pain during
needle positioning and injection as well as pain relief
following the block will help confirm the sacro-iliac
joint as the pain generator (avoid sedation with opioids
for diagnostic procedures).
Corticosteroid, e.g. triamcinolone diacetate 25mg, plus
12ml 1% lidocaine may be injected for therapeutic
effect.
Ultrasound may also be used to identify the joint
(Fig. 2.3.5).
CT scan may also be used to identify the joint but is not
usually necessary (Fig. 2.3.6).

13

14

CHAPTER

Joint injections

Confirmation of a successful injection


Reproduction of pain during injection and relief of pain
following injection confirms correct placement.
Radiologic assessment of the X-ray image after injection
of contrast medium may demonstrate tears in the joint
capsule.

Tips
While the joint may be easily entered, injection can be
difficult where the joint is heavily invested with
connective tissue and ligaments. This is especially true in
elderly patients, where the joint is rigid and the joint
space cannot expand to accommodate a volume of
liquid. In such cases it may be possible to inject only as
the needle is being removed from the joint.

Sometimes, injection into the deep sacro-iliac ligaments


around the joint may be helpful for pain relief.
Introduction of a spinal needle just above the midline
of the upper sacrum and advanced at 45 to the
skin, under the rim of the ilium and in the direction
of the joint, will access these ligaments. Lidocaine
(lignocaine) 1% 4ml plus triamcinolone diacetate
25mg may then be injected.

Potential problems



Discomfort on injection.
Epidural injection.
Sacral nerve root blockade.
Subperiosteal injection (painful in the awake patient).

EPIDURAL INJECTION

Intervertebral disc disease may produce inflammation of


spinal nerve roots, which may be the cause of radicular pain.
The L5 and S1 nerve roots are most commonly affected,
probably because they exit the bony canal through a narrow
lateral bony recess, therefore increasing the likelihood of
nerve compression and irritation. Lumbo-sacral
radiculopathy consists of low-back pain that radiates a
varying distance into the lower extremity, and which may be
associated with motor and sensory loss consistent with
damage to the affected nerve root. If bowel and bladder
symptoms of dysfunction are present, large midline disc
protrusion is suspected and prompt surgical intervention is
indicated. Otherwise, if severe pain exists after treatment
with immobilization and mild analgesics, epidural steroid
injection may be carried out. Similarly, pain of thoracic

or cervical disc origin may respond to epidural steroid


injection.
Triamcinolone diacetate is the most commonly
administered preparation and injection should be carried
out as close to the affected nerve root as possible. Injection
of a small amount of local anesthetic with the steroid will
help to confirm drug placement and provide analgesia. In
patients with S1 pathology the drug may not spread to the
affected nerve root using the lumbar approach and the
caudal approach to the epidural space may be required.
Cervical epidural injection accesses the cervical spinal nerve
roots, while in the thoracic region a paramedian approach
is usually more successful.

16

CHAPTER

Epidural injection

3.1 LUMBAR EPIDURAL BLOCK


Anatomy

Drugs

Structures encountered when inserting an epidural needle


include skin, subcutaneous tissue, supraspinous ligament,
interspinous ligament, ligamentum flavum (56mm thick
in the midline of the lumbar region, 35mm thick in
the midline of the thoracic region), prior to reaching the
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).

Lidocaine (lignocaine) 1%, 10ml (or its equivalent)


Corticosteroid if indicated, e.g. triamcinolone diacetate
50mg (or its equivalent)
Saline (NaCl) 10ml
Resuscitation drugs (see Appendix 3)

One should expect a distance of 3.56cm from skin to the


epidural space using a midline approach. In the lumbar
region the spinous processes are generally perpendicular to
the vertebral bodies (Fig. 3.1.3). In the thoracic region the
spinous processes lie at an angle of 3045 to the thoracic
vertebral body, thus making midline epidural injection a
little more difficult, and sometimes necessitating a
paravertebral approach. Other relevant anatomy of the
vertebral bodies is illustrated in Fig. 3.1.4.

2
3
4

3
4

5
6
7

6
7
8
1

C7
T1

2
3

Equipment







1
2

C1

2ml and 10ml syringes


18G, 20G, and 25G needles
ECG, BP, and SpO2 monitors
18G epidural set (Fig. 3.1.5)
Filter aspiration needle
Resuscitation equipment (see Appendix 3)
Fluoroscopy (optional)
Ultrasound (optional)

6
7

10

10

11

11

12
1

Subcutaneous
tissues

Epidural
space

Ligamentum
flavum

12

5
1

1
5

L1

2
3
4
5

S1
1

Skin

Fig. 3.1.1

Supraspinous Interspinous
ligament
ligament

Fig. 3.1.2

3.1 Lumbar epidural block


Superior
articular process
(a) Cervical

Pedicle
Transverse process
Spine
Inferior articular
process

Facet

(b) Thoracic

Facet
Superior articular
process

Transverse process
(c) Lumbar

Inferior articular
process
Lamina
Inferior and superior
articular facets

Fig. 3.1.3

Transverse
process

Position of patient

Pedicle

Lateral, usually lying on the side of the radiculopathy.


Shoulders and buttocks parallel to the edge of the bed,
perpendicular to the floor, with spine flexed.

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The midline and an area 10cm 5cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
Lidocaine (lignocaine) 1% 2ml is drawn up into three
2ml syringes.
Lidocaine (lignocaine) 1% 2ml, plus corticosteroid, e.g.
triamcinolone diacetate 50mg is drawn up into the
10ml syringe.
NaCl 10ml is drawn up into the 10ml loss-ofresistance syringe.
The iliac crest is palpated and the intercrestal line (this
corresponds with the inferior aspect of the spinous
process of L4 or may lie in the L45 interspace) is
identified (Fig. 3.1.6).
The spinous processes are palpated, and the level
requiring injection is identified.
This may be confirmed by fluoroscopy or ultrasound.

Vertebral
foramen

Fig. 3.1.4

Fig. 3.1.5

MIDLINE APPROACH FOR


THE RIGHT-HANDED OPERATOR
With the left hand
The fore- and middle fingers are placed each side of the
interspace.

17

18

CHAPTER

Epidural injection

Vertebra
prominens C7

Root of spine
of scapula T3
A

Inferior angle
of scapula T7

Rib margin 10cm


from midline L1
Superior aspect
of iliac crest L4
Posterior superior
iliac spine S2

Fig. 3.1.6

These fingers are kept in place until the epidural needle


is gripped by the interspinous ligament.

With the right hand


The interspinous ligament is infiltrated with lidocaine
(lignocaine) 1% 2ml.
The epidural needle is inserted, bevel facing the side of
the radiculopathy, between the fore- and middle fingers
of the left hand in a direction 60 cephalad,
perpendicular to the spine, parallel to the floor, until it
is gripped by the interspinous ligament (Fig. 3.1.7 a,b).
In the case of thoracic epidural injection (midline
approach), the point of entry of the needle should be as
close as possible to the caudal end of the interspinous
space and the needle directed 3045 cephalad to enter
between the spinous processes.
The hub of the needle is gripped with the fore- and
middle fingers of the left hand and this hand is steadied
by leaning the wrist against the patients back.
The stylet is removed and the loss-of-resistance syringe
is applied.

Fig. 3.1.7

The needle is slowly and carefully advanced, while


constant pressure is applied to the plunger, the left hand
aiding the advance, while at the same time applying a
brake if required (Fig. 3.1.8 a,b).
At the point at which the needle enters the ligamentum
flavum, absolute resistance to injection is experienced.
At this point the needle is advanced very slowly until a
sudden loss of resistance to the pressure on the plunger
is experienced, the point at which the epidural space is
entered.
After negative aspiration for blood or cerebrospinal fluid
(CSF), lidocaine (lignocaine) 1% 3ml is injected.
After 5 minutes the patient is questioned about any
changes in sensation or power, and any changes in heart
rate or blood pressure are noted.
If the injection is for diagnostic purposes only, the
needle may be removed at this point.
If therapeutic effect is required, lidocaine (lignocaine)
1% 2ml, plus corticosteroid if indicated, e.g.
triamcinolone diacetate 50mg (or its equivalent), may
be injected. Alternatively, a catheter may be inserted
through the needle if indicated.
The needle is flushed with NaCl 1ml and removed.
The patient is allowed to lie in the lateral position, on
the side of the pain.

3.1 Lumbar epidural block


A

Fig. 3.1.9

Fig. 3.1.8

Monitors should be left attached and i.v. access left in


situ for at least 30 minutes.
The patient is advised to contact the hospital should the
anesthesia remain after several hours.

FLUOROSCOPIC GUIDED LUMBAR


EPIDURAL INJECTION
Position the patient prone with a pillow under the lower
abdomen to increase lumbar flexion.
The interlaminar space for the desired segmental level is
identified fluoroscopically using a straight AP view.
Angling the fluoroscope slightly cephalad may open the
space if it appears very narrow.
Prepare skin with antiseptic and sterile drape.
Raise a local anesthetic skin wheal just below the
interlaminar space, about 0.5cm from the midline
toward the symptomatic side.
Advance the Tuohy needle, angling slightly toward the
midline until resistance of the ligamentum flavum is
encountered, keeping the trajectory just lateral to the
midline to avoid contacting the spinous process. Repeat
imaging periodically to ensure that the needle is
approaching the space, not the lamina or spinous
process (see Fig. 3.1.9). Advance the needle through the

Fig. 3.1.10

ligamentum flavum using a loss of resistance technique


with air or saline. Once loss of resistance is achieved,
obtain a lateral view to ensure the needle is barely into
the bony spinal canal.
Attach a low volume extension set to the needle,
aspirate to ensure there is no blood return, and inject
0.51ml of non-ionic contrast medium during live
fluoroscopy. Dye should be seen spreading within the
bony canal (see Fig. 3.1.10). Prior to injecting local
anesthetic or steroid, obtain an AP view to reconfirm
epidural spread.

19

20

CHAPTER

Epidural injection

Aspirate again, then inject local anesthetic (12ml) and


50mg triamcinolone diacetate or equivalent.
Loss of resistance is occasionally encountered with the
needle superficial to the epidural space. Dye will be seen
dorsal to the epidural space on the lateral view, and
spread lateral to the spinal canal will be seen on the AP
view. The needle can then be advanced through the
ligamentum flavum, again using loss of resistance,
followed by dye confirmation.

Confirmation of a successful block


Relief of pain.
Anesthesia in the distribution of the blocked nerves.
For lumbar epidural steroid injection, improvement in
straight-leg raising may be evident.

Tips
Air may be used instead of NaCl to determine loss of
resistance. If this technique is used it is advisable to
avoid constant pressure on the plunger, as the air is
compressible; instead it should be bounced intermittently
with the thumb to test for resistance and loss of
resistance.
Advocates claim identification of CSF is easier with this
technique.
Advocates of the use of NaCl point out that absolute
resistance to pressure identifies the ligamentum flavum,
and that by applying constant pressure to the plunger
one can identify loss of resistance earlier, thereby more
easily avoiding the possibility of dural tap.
An epidural catheter may be inserted through the needle
and the needle removed, taking care not to withdraw
the catheter when removing the needle. However, a test
dose of lidocaine (lignocaine) 1% 4ml with/without
epinephrine (adrenaline) 1:200000 is given after
insertion, before any injection through the catheter is
carried out.
Ultrasound may guide the insertion of the needle as
spinous proccesses are easily visible on ultrasound
(optional) (Fig. 3.1.11).

Fig. 3.1.11

Injection of radio-opaque dye under direct fluoroscopy


can confirm epidural placement.
Insertion of a radio-opaque epidural catheter may be
carried out also under fluoroscopy.

Potential problems
IMMEDIATE
Failure to locate epidural space (sitting position may be
successful).
Intravascular injection (test dose important); addition of
epinephrine (adrenaline) to test dose may help
identification of intravascular injection.
Intrathecal injection (test dose important).
Hypotension due to sympathetic blockade (give i.v. fluid;
consider ephedrine).
Headache (possible dural puncture).
Allergic reaction.

LATER
Infection (epidural abscess; bacterial meningitis).
Aseptic meningitis; usually a result of intrathecal
injection (test dose important).
Cushingoid symptoms; usually as a result of repeated
steroid injections.

3.2 Thoracic epidural block

3.2 THORACIC EPIDURAL BLOCK


Anatomy

Position of patient

In the thoracic region, the spinous processes lie at an angle


of 3045 to the thoracic vertebral body (Fig. 3.2.1 a,b)
thus making midline epidural injection a little more
difficult, and sometimes necessitating a paramedian
approach (Fig. 3.2.2 ad).

Lateral, usually lying on the side of the radiculopathy.


Shoulders and buttocks parallel to the edge of the bed,
perpendicular to the floor, with spine flexed.

Equipment





2ml and 10ml syringes


18G, 20G, and 25G needles
ECG, BP, and SpO2 monitors
18G epidural set
Resuscitation equipment (see Appendix 3)
Fluoroscopy or ultrasound (optional)

Drugs
Lidocaine (lignocaine) 1%, 10ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
50mg (or its equivalent)
Saline (NaCl) 10ml
Resuscitation drugs (see Appendix 3)

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The midline and an area 10cm 5cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
Lidocaine (lignocaine) 1% 2ml is drawn up into three
2ml syringes.
Lidocaine (lignocaine) 1% 2ml, plus corticosteroid, e.g.
triamcinolone diacetate 50mg, is drawn up into the
10ml syringe.
NaCl 10ml is drawn up into the 10ml loss-ofresistance syringe.
The spinous processes are palpated, and the level
requiring injection is identified.
This may be confirmed by fluoroscopy or ultrasound.

T14 T5

T6

Lateral
C7
C7

T58
T10
T10

L3

T912

Fig. 3.2.1

L3

Oblique

Posterior

21

22

CHAPTER

Epidural injection
Thoracic epidural

Lumbar epidural
(a) Midline

(a) Midline

(b) Paraspinous

(b) Paraspinous

L3

1cm

T3
T4

L4
10

10

45

T5
1cm

(a)

L5
(b)

25
35

(a)
(b)

T7

45

55

Fig. 3.2.2

Paramedian approach
FOR THE RIGHT-HANDED OPERATOR
With the left hand
The fore- and middle fingers are placed each side of the
interspace.
These fingers are kept in place until the epidural needle
is gripped by the interspinous ligament.

With the right hand


The interspinous ligament is infiltrated with lidocaine
(lignocaine) 1% 2ml.
The insertion point of the epidural needle in the
paravertebral approach lies 1cm lateral to the
midline, at the lower border of the spinous process
(Fig. 3.2.3 a,b). The epidural needle is inserted, bevel
facing the side of radiculopathy, between the fore- and
middle fingers of the left hand, perpendicular to the
spine, parallel to the floor, until it is gripped by the
interspinous ligament.
The direction of the needle is 130 cephalad and 15
medial to the midline. Care must be taken as the
ligamentum flavum is not as thick laterally, and may not
be identified as easily. Therefore, it is usually easiest to
first identify the lamina and walk the needle off the

lamina in a cephalad direction until the needle enters the


ligamentum flavum. At that point the loss-of-resistance
technique may be performed.
The hub of the needle is gripped with the fore- and
middle fingers of the left hand and this hand is steadied
by leaning the wrist against the patients back.
The stylet is removed and the loss-of-resistance syringe
is applied.
The needle is slowly and carefully advanced until the
osseous endpoint of the lamina is encountered.
It is then walked off the lamina in the cephalad
direction until it enters the ligamentum flavum.
At the point at which the needle enters the ligamentum
flavum, absolute resistance to injection is experienced.
It is then carefully advanced further while constant
pressure is applied to the plunger, the left hand aiding
the advance, while at the same time applying a brake if
required (Fig. 3.2.4, viewed from above).
The needle is advanced very slowly until a sudden loss
of resistance to the pressure on the plunger is
experienced, the point at which the epidural space is
entered.
After negative aspiration for blood or cerebrospinal
fluid, lidocaine (lignocaine) 1% 2ml is injected.

3.2 Thoracic epidural block

Transverse
process

Facet
Lamina
Spinous process

Paramedian
approach
(spinal or epidural)

Fig. 3.2.4
15
Midline approach
(spinal or epidural)

The patient is advised to contact the hospital should


anesthesia remain after several hours.

Confirmation of a successful block


L3

Relief of pain.
Anesthesia in the distribution of blocked nerves.
For lumbar epidural steroid injection, improvement in
straight-leg raising may be evident.

Tips

15
1cm
L4

L5
B

Fig. 3.2.3

After 5 minutes the patient is questioned about changes


in sensation or power, and any changes in heart rate or
blood pressure are noted.
If the injection is for diagnostic purposes only, the
needle may be removed at this point.
If therapeutic effect is required, lidocaine (lignocaine)
1% 2ml plus corticosteroid, e.g. triamcinolone diacetate
50mg, may be injected.
The patient is allowed to lie in the lateral position, on
the side of the pain.
Monitors should be left attached and i.v. access should
remain in situ for at least 30 minutes.

Air may be used instead of NaCl to determine loss of


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
technique.
Advocates of the use of NaCl point out that absolute
resistance to pressure identifies the ligamentum flavum,
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.
An epidural catheter may be inserted through the needle
and the needle removed, taking care not to withdraw
the catheter when removing the needle. However, a test
dose of lidocaine (lignocaine) 1% 4ml with epinephrine
(adrenaline) 1:200000 is given after insertion, before
any injection through the catheter is carried out.
Identification of the insertion point may be aided by
ultrasound (Fig. 3.2.5).
Injection of radio-opaque dye under direct fluoroscopy
can confirm epidural placement.
Insertion of a radio-opaque epidural catheter may be
carried out also under fluoroscopy.

23

24

CHAPTER

Epidural injection

Intravascular injection (test dose important); addition of


epinephrine (adrenaline) to test dose may help
identification of intravascular injection.
Intrathecal injection (test dose important).
Hypotension due to sympathetic blockade (give i.v. fluid,
consider ephedrine).
Headache (possible dural puncture).
Allergic reaction.
Spinal cord injury may occur if the epidural space is not
recognized. Deep sedation should be avoided during
needle insertion and drug injection.

LATER
Fig. 3.2.5

Potential problems
IMMEDIATE
Failure to locate epidural space (sitting position may be
successful).

Infection (epidural abscess, bacterial meningitis).


Aseptic meningitis, usually the result of intrathecal
injection (test dose important).
Cushingoid symptoms (usually as a result of repeated
injections).
Epidural hematoma. This complication should be
suspected when sensory or motor function loss occurs
minutes to hours after the procedure. Immediate
diagnostic imaging (CT or MRI) is essential. Prompt
surgical decompression may be required.

3.3 Cervical epidural block

3.3 CERVICAL EPIDURAL BLOCK


Anatomy
In the cervical region, the spinous processes are almost
perpendicular to the vertebral bodies, especially in the
lower part. They also widen and become bifid. As a result,
insertion of the needle is often easy. However, it must be
remembered that the epidural space is relatively narrow in
this area (24mm), and that the spinal cord lies very close
to it (Fig. 3.3.1 a,b). Most workers prefer to use the
hanging drop technique when accessing the cervical
epidural space, as there exists a significant negative
pressure in the cervical region in the sitting position.

Epidural space
Spinal cord
Dura matter
Ligament
Subarachnoid space

Ligamentum
flavum
Interspinous
ligament

Equipment





Supraspinous
ligament

2ml, 5ml, and 10ml syringes


18G, 20G, and 25G needles
ECG, BP, and SpO2 monitors
18G epidural set
Resuscitation equipment (see Appendix 3)
Fluoroscopy or ultrasound (optional)

Drugs

Lidocaine (lignocaine) 1%, 10ml (or its equivalent)


Corticosteroid if indicated, e.g. triamcinolone diacetate
50mg (or its equivalent)
Saline (NaCl) 10ml
Resuscitation drugs (see Appendix 3)

Atlas
Axis
C3

Position of patient

C4

Sitting.
Head flexed forward.

C5
C6

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The midline and an area 10cm 5cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
Lidocaine (lignocaine) 1% 2ml is drawn up into two
2ml syringes.
Lidocaine (lignocaine) 1% 1ml plus corticosteroid, e.g.
triamcinolone diacetate 50mg, is drawn up into a 5ml
syringe.
NaCl 10ml is drawn up into a 10ml syringe.
The patient is allowed to sit up straight for a moment,
and the spinous process of T3, which lies opposite the

C7

Fig. 3.3.1

root of the spine of the scapula, is identified and


marked. The prominent spinous process of C7 (vertebra
prominens) is identified (Fig. 3.3.2) and marked
(Fig. 3.3.3 a,b). Ultrasound can be used to guide needle
placement (Fig. 3.3.3 c,d). The interspace to be used for
epidural injection is also marked.

25

26

CHAPTER

Epidural injection
1
2

C1

2
3
4

3
4

5
6
7

6
7
8
1

C7
T1

2
3

4
5
6

3
4
5

6
7

8
9
10

8
9

Fig. 3.3.2

FOR THE RIGHT-HANDED OPERATOR


With the left hand
The fore- and middle fingers are placed each side of the
interspace.
These fingers are kept in place until the epidural needle
is gripped by the interspinous ligament.

With the right hand


The interspinous ligament is infiltrated with lidocaine
(lignocaine) 1% 2ml.
The epidural needle is inserted, bevel facing caudad,
between the fore- and middle fingers of the left hand in
a direction 60 cephalad, until it is gripped firmly by the
interspinous ligament.
The hub of the needle is gripped with the fore- and
middle fingers of the left hand and this hand is steadied
by leaning the wrist against the patients spine.
The stylet is removed.
The hub of the epidural needle is filled with saline
(Fig. 3.3.4) such that a hanging drop appears (Fig. 3.3.5).

With both hands


The wings of the epidural needle are gripped with each
hand, steadying the hands by resting the wrists against
the posterior thoracic wall (Fig. 3.3.6).
The needle is slowly and carefully advanced with both
hands.
It is prudent periodically to confirm high resistance of
the needle in the ligament by testing with an air-filled
syringe, then replace the stylet to make sure there is no
tissue blocking the needle before resuming the hanging
drop technique.

Fig. 3.3.3

3.3 Cervical epidural block

Fig. 3.3.3, contd

Fig. 3.3.4

Fig. 3.3.5

The hanging drop at the hub of the needle is watched


closely, and the patient is asked periodically about the
presence of paresthesia.
At the point at which the epidural needle enters the
epidural space, the drop should appear to be sucked
into the needle (Figs 3.3.7, 3.3.8).
After negative aspiration for blood or CSF, lidocaine
(lignocaine) 1% 2ml is injected.
After 12 minutes the patient is questioned about
changes in sensation or power, and any changes in heart
rate or blood pressure are noted.
If the injection is for diagnostic purposes only, the
needle may be removed at this point.
If therapeutic effect is required, lidocaine (lignocaine)
1% 1ml plus corticosteroid, e.g. triamcinolone diacetate
50mg, may be injected.
The patient is allowed to lie in the lateral position, on
the side of the pain.
Monitors should be left attached and i.v. access kept in
situ for at least 30 minutes.

27

28

CHAPTER

Epidural injection

Fig. 3.3.6

Fig. 3.3.7

Ultrasound may aid in identifying the interspinous space


as spinous processes are easily visible.

FLUOROSCOPIC GUIDED CERVICAL


EPIDURAL INJECTION
Check MRI to ensure that the spinal cord is not
displaced posteriorly. If the posterior epidural space is
compromised or the spinal cord is shifted posteriorly,
it is safer to enter the upper thoracic epidural space
and advance a radio-opaque catheter to the low
cervical level.
Position patient prone, with pillow under shoulders,
neck flexed, arms at sides, shoulders as far downward as
possible.

Fig. 3.3.8

Identify targeted interlaminar space (T12, C7T1, or


C67) in direct AP fluoroscopic view. Adjust angle
upward or downward slightly to maximize view of
interlaminar space.
Mark skin over lower border of T12, C7T1
(preferred) or C67 interlaminar space just lateral to
the midline. Do not perform epidural injection above
C67 because of absence of midline epidural fat at
higher levels.
Prepare skin with antiseptic and sterile drape.
Provide only minimal sedation or no sedation. Instruct
patient to report any pain or paresthesia during the
procedure.
Infiltrate skin and subcutaneous tissue with lidocaine
(lignocaine) 1%.
Advance the Tuohy needle through the insertion point
into the interspinous ligament and check the fluoroscopy
image to ensure the needle tip is directed toward the
midline (Fig. 3.3.9).
Begin to advance through the ligament using loss of
resistance with air or saline. Check lateral view if
possible (may be obscured by the shoulders). Proceed
with needle advancement. When loss of resistance

3.3 Cervical epidural block

Fig. 3.3.9

Fig. 3.3.10

occurs, recheck the lateral view. If unable to visualize the


spinal canal, obtain slightly oblique view (Fig. 3.3.10).
Attach a low volume extension set to the needle and
inject a small volume (1ml or less) of non-ionic contrast
medium under live fluoroscopy, preferably in lateral
view (AP or oblique view is used if this is not possible)
(Fig. 3.3.11), then observe the AP view to confirm
epidural dye spread.
Aspirate to ensure there is no blood return, then inject
12ml lidocaine (lignocaine) 1% followed by 2550mg
triamcinolone diacetate or equivalent.

Confirmation of a successful block

Fig. 3.3.11

Relief of pain.

Tips
Loss-of-resistance techniques may also be used to access
the cervical epidural space.
The steroid may be given soon after the test dose, as
hypotension may be a problem if the patient remains in
the sitting position.

Potential problems
IMMEDIATE
Failure to locate epidural space (lateral position with
loss of resistance technique may be successful).
Pain on injection (caution: close proximity to
spinal cord).
Intrathecal injection (test dose important).
Hypotension bradycardia due to sympathetic blockade
(maximum 3ml local anesthetic administered in this
technique).
Vasovagal syncope is common in young adult patients.

Intravascular injection; addition of epinephrine


(adrenaline) 1:200000 to the test dose may aid
identification of intravascular injection.
Headache (possible dural puncture).
Allergic reaction.
Spinal cord injury may occur if the epidural space is not
recognized. Deep sedation should be avoided during
needle insertion and drug injection.

LATER
Infection (epidural abscess, bacterial meningitis).
Aseptic meningitis, usually the result of intrathecal
injection (test dose important).
Cushingoid symptoms (usually as a result of repeated
injections).
Epidural hematoma. This complication should be
suspected when sensory or motor function loss occurs
minutes to hours after the procedure. Immediate
diagnostic imaging (CT or MRI) is essential. Prompt
surgical decompression may be required.

29

30

CHAPTER

Epidural injection

3.4 CAUDAL EPIDURAL BLOCK


Anatomy
Injection of anesthetic through the sacral hiatus allows
access to the sacral epidural space or caudal anesthesia.
The sacrum is roughly triangular in shape and is made up
of five fused sacral vertebrae (Fig. 3.4.1). Its dorsal aspect
is convex and there is a midline sacral canal that allows
passage of the sacral nerves through four pairs of foramen,
anteriorly and posteriorly. At the caudal end lies the
coccyx, and at the cephalad end lies the fifth lumbar
vertebra. The posterior wall of S5, and sometimes S4, is
unfused. The thick fibrous sacro-coccygeal membrane or
sacral hiatus covers the defect. This may be variable in size
as the posterior wall of other sacral vertebrae may also be
unfused. Penetration of this membrane allows access to the
sacral epidural space.

Equipment





2ml, 5ml, and 20ml syringes


18G, 20G, and 25G needles
22G, 35cm short-bevel needle, with stylet
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)
Fluoroscopy or ultrasound (optional)

Saline (NaCl) 10ml


Resuscitation drugs (see Appendix 3)

Position of patient
Prone.
Pillow under abdomen and/or operating table broken to
allow flexion of the lumbo-sacral spine.
Lower limbs abducted 15, toes rotated to point
towards the opposite foot (Fig. 3.4.2).

Needle puncture and technique (adult)


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The midline and an area 10cm 5cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.

Drugs
Lidocaine (lignocaine) 1%, 10ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
50mg (or its equivalent)

Sacral cornua
Sacro-coccygeal
ligament

Fig. 3.4.1

Fig. 3.4.2

3.4 Caudal epidural block

Lidocaine (lignocaine) 1% 2ml is drawn up into three


2ml syringes.
Lidocaine (lignocaine) 1% 15ml plus corticosteroid, e.g.
triamcinolone diacetate 50mg, is drawn up into the
20ml syringe.
NaCl 10ml is drawn up into the 10ml syringe.

FOR THE RIGHT-HANDED OPERATOR


With the left hand
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.

After 5 minutes the patient is questioned about changes


in sensation or power of the lower limbs, and any
changes in heart rate or blood pressure are noted.
Then lidocaine (lignocaine) 1% 515ml plus
corticosteroid, e.g. triamcinolone diacetate 50mg, may
be injected in order to promote spread to upper sacral
and lower lumbar segments (a volume of at least 10ml
should be used if the symptoms are at the level of S1
nerve root or higher) (Fig. 3.4.6). The needle is then

With the right hand


The insertion point is infiltrated with lidocaine
(lignocaine) 1% 2ml.
The 22G 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).
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 1520 (Fig. 3.4.5). This should allow further
advancement of 12cm, as the needle enters the long
axis of the caudal epidural space.
After negative aspiration, lidocaine (lignocaine) 1% 2ml
is injected.

Sacral cornua

Fig. 3.4.3

Fig. 3.4.4

31

32

CHAPTER

Epidural injection

Fig. 3.4.5

Fig. 3.4.6

Fig. 3.4.7

removed while clearing it with lidocaine (lignocaine) 1%


2ml.
Monitors should be left attached and i.v. access kept in
situ for at least 30 minutes.
It is prudent to warn the patient about possible loss of
sensation and or power of one or both lower limbs.

Advance a Tuohy needle at a 45 angle to the skin


through the sacral hiatus, checking a lateral fluoroscopic
view to make sure the needle has entered the spinal
canal. Lower the needle angle and advance the needle
slightly. Recheck lateral fluoroscopy to ensure the needle
is in the spinal canal.

FLUOROSCOPIC GUIDED CAUDAL


EPIDURAL INJECTION
This approach may be used for treating L5 or S1
radiculopathy. It is a reasonable alternative to the
interlaminar approach when surgery has disrupted the
posterior spinal anatomy.
Position the patient prone.
Locate the sacral hiatus using the sacral cornua as
landmarks.
Prepare skin with antiseptic and sterile drape.
Place the tip of a sterile blunt instrument over the sacral
hiatus and obtain a lateral fluoroscopic view of the
sacrum.
Raise a skin wheal with 1% lidocaine (lignocaine) just
below the sacral hiatus and infiltrate with lidocaine
down to the sacral hiatus with a small gauge needle.

Aspirate to rule out intravascular placement and


inject 0.51ml contrast medium under live
fluoroscopy. Check a lateral and AP image to ensure
epidural spread.
If no epidural catheter is used, inject a mixture of local
anesthetic and steroid. Inject 10ml 0.5% lidocaine plus
50mg triamcinolone diacetate. This volume should be
sufficient to reach the L5 or S1 nerve roots.
Alternatively, a radio-opaque catheter can be inserted
through the needle and advanced to the desired level.
Check the catheter position in both AP and lateral
views (Fig. 3.4.7). Attach the injection hub to the
catheter and inject 0.51ml contrast medium
under live fluoroscopy, rechecking dye spread in both
AP and lateral views (Fig. 3.4.8). Inject 12ml 1%
lidocaine plus 50mg triamcinolone diacetate or
equivalent.

3.4 Caudal epidural block

Fig. 3.4.9

Fig. 3.4.10

Fig. 3.4.8
Fig. 3.4.11

Confirmation of a successful block

Potential problems

Relief of pain.
Anesthesia or diminished sensation in distribution of
blocked nerves.
Improvement in straight-leg raising (although for sacral
nerve root-related pain, this may not have been positive
prior to caudal blockade).

IMMEDIATE

Tips
After location of the caudal epidural space, the left hand
may be placed over the sacral hiatus while 10ml saline
is rapidly injected (Fig. 3.4.6). Misplacement of the
needle in the subcutaneous tissue (Fig. 3.4.9) should be
evident if the injection is appreciated by the palpating
left hand.
Subperiosteal injection in the awake patient will cause
pain (Fig. 3.4.10). The needle angle is important as the
tip may come to lie anterior to the sacrum (Fig. 3.4.11).
Anatomic variations exist in many patients, making
access to the caudal epidural space difficult or impossible.
Fluoroscopy using lateral views is useful to confirm the
epidural needle position. Ultrasound may also be helpful
in identifying the sacro-coccygeal membrane.

Failure to locate epidural space.


Intravascular injection (test dose important); addition of
epinephrine (adrenaline) to test dose may help
identification of intravascular injection.
Intrathecal injection, rare but possible (test dose
important).
Hypotension due to sympathetic blockade (give i.v. fluid,
consider ephedrine).
Transient exacerbation of radiculopathic pain (caution
patient).
Headache (possible dural puncture, rare).
Allergic reaction.

LATER
Infection (epidural abscess, bacterial meningitis).
Aseptic meningitis, usually the result of intrathecal
injection (test dose important).
Cushingoid symptoms (usually as a result of repeated
injections).
Infection (epidural abscess).
Epidural hematoma.

33

34

CHAPTER

Epidural injection

3.5 LONG-TERM EPIDURAL CATHETER INSERTION


Anatomy
As described for lumbar epidural block in Section 3.1.

Equipment







2ml and 10ml syringes


18G, 20G, and 25G needles
ECG, BP, and SpO2 monitors
18G epidural set
Epidural catheter passer
A surgical pack, including small scalpel and suture set
Resuscitation equipment (see Appendix 3)
Fluoroscopy or ultrasound (optional)

Drugs
Lidocaine (lignocaine) 1% (preservative free) 20ml (or
its equivalent)
Lidocaine (lignocaine) 1% (preservative free) 4ml plus
epinephrine (adrenaline) 1:200000
Saline (NaCl) 10ml

Position of patient
Lateral, lying on side of radiculopathy (Fig. 3.5.1).
Shoulders and buttocks parallel to the edge of the bed,
perpendicular to the floor, with spine flexed.

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The midline and an area 10cm 5cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
Lidocaine (lignocaine) 1%, 2ml is drawn up into three
2ml syringes.
Lidocaine (lignocaine) 1% 10ml is drawn up into one
10ml syringe.

NaCl 10ml is drawn up into the 10ml loss-ofresistance syringe.


An epidural catheter is inserted through the needle as
previously described, 56cm into epidural space (see
Section 3.1).
The needle is withdrawn 11.5cm, but is not removed.
After negative aspiration, a test dose of lidocaine
(lignocaine) 1% 4ml, with epinephrine (adrenaline)
1:200000, is given. After 5 minutes the patient is
questioned about changes in sensation or power, and
any changes in heart rate or blood pressure are noted.
After a negative reaction lidocaine (lignocaine) 1%
10ml is injected slowly over 10 minutes. Assessment of
the level of blockade is carried out after a further
15 minutes.
Subcutaneous infiltration around the epidural needle
with lidocaine (lignocaine) 1% is carried out. Note: a
small incision is made to include the epidural needle
(Fig. 3.5.2).
A purse string suture is placed around the epidural
needle, but is not tied (Fig. 3.5.3).
Another small incision in the lateral abdominal wall is
made after subcutaneous infiltration with lidocaine
(lignocaine) 1% (Fig. 3.5.4). A catheter passer is
tunneled through the subcutaneous tissue between the
two incision sites.
A catheter is manually bent to a curve and tunneled
through the subcutaneous tissue between the two
incision sites in the direction from the abdominal site to
the epidural needle site (Fig. 3.5.5).
The epidural needle is carefully removed (Figs 3.5.6,
3.5.7).
The catheter is secured to subcutaneous tissue in the
midline by tightening the purse string suture (Fig. 3.5.8).
The catheter is further secured using an angle piece and
then threaded in a lateral direction through the catheter

L4

Fig. 3.5.1

Fig. 3.5.2

L3

L2

3.5 Long-term epidural catheter insertion

Fig. 3.5.3

Fig. 3.5.6

7cm
2cm

Fig. 3.5.4

Fig. 3.5.5

Fig. 3.5.7

35

36

CHAPTER

Epidural injection

Fig. 3.5.8

Fig. 3.5.9

passer from the needle site to the abdominal wall site


and connections are secured (Fig. 3.5.9).
A pump may be placed in the abdominal wall site and
the skin incisions closed.

Insertion of a radio-opaque epidural catheter may be


carried out also under fluoroscopy.
Ultrasound may aid insertion

Confirmation of a successful block


Relief of pain.
Anesthesia or diminished sensation in the distribution of
affected nerves.

Tips
Injection of radio-opaque dye under direct fluoroscopy
can confirm epidural placement.

Potential problems
As described for lumbar epidural block in Section 3.1.
However, in view of the long-term nature of epidural
catheter implantation, any symptoms of infection should
be immediately investigated and treated.
Epidural catheters should not be inserted or removed
during anticoagulation. Coagulation and platelet
function should be normalized before catheter removal.

SOMATIC NERVE BLOCKADE

Mechanical nerve root compression was originally thought


to be the cause of pain in discogenic radiculopathy.
However, it has been found that many asymptomatic
patients demonstrate substantial disc protrusion on
magnetic resonance (MR) imaging, myelography and
subsequent autopsy examination. In addition, surgical
decompression does not result in uniform success in the
relief of such pain. Following a period of mechanical
nerve-root compression it is likely that an acute
inflammatory process ensues, resulting in intraneural
accumulation of serum proteins and fluid, raised
intraneural pressure, ischemia and axonal degeneration.
Degenerating glycoprotein material from the
nucleus pulposis may also contribute to the
inflammatory process.

There are many situations in which injection of spinal


nerve roots with local anesthetic may be helpful in the
diagnosis of radicular pain. These include those where
investigations including electromyography, computer
tomography (CT) or MR imaging are not consistent with
the clinical findings, where there are multiple levels of
pathology, and after spinal surgery with subsequent
scarring in the area of the surgery. In addition, the
contribution of the somatic nerve root may be elucidated
in pain of uncertain origin, e.g. chest pain or abdominal
pain, by specific nerve root local anesthetic injection.
It may be used therefore to determine the level of surgery,
if indicated, and the addition of steroid may produce
longer-lasting pain relief.

38

CHAPTER

Somatic nerve blockade

4.1 INTERCOSTAL NERVE BLOCK


Anatomy

Equipment

The intercostal nerve is made up of several types of nerves:


sympathetic white and grey rami communicantes,
cutaneous and motor fibers supplied by dorsal rami,
sensory fibers to the chest wall, anterior and posterior, via
the lateral cutaneous branch, and further sensory fibers to
the anterior chest wall via the anterior cutaneous branch.
The lateral cutaneous branch exits just distal to the angle
of the rib. Just below the inferior edge of the rib, in the
intercostal groove, lie the intercostal nerve, artery and vein,
the latter lying superior to the nerve. The optimal site to
block the intercostal nerve is the most posterior point at
which the rib is palpable, usually the angle of the rib
(Fig. 4.1.1 a,b).

2ml and 5ml syringes


30G needle
22G 34cm short-bevel needle
Extension set (optional)
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)
Ultrasound (optional)

Drugs
Lidocaine (lignocaine) 1% 2ml for skin
infiltration
Lidocaine (lignocaine) 1% 5ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
50mg (or its equivalent)
Resuscitation drugs (see Appendix 3)

Position of patient

Inferior angle
of rib

Prone (this allows best access, although a lateral or


supine position may also be used).
Pillow under mid-abdomen to widen the intercostal
spaces.
Arms hanging over sides of table to rotate the scapulae
laterally.

Needle puncture and technique

Skin
A

Rib

Vein
Nerve
Artery

Intercostal
muscle

Intravenous access is inserted.


Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
Sedation may be administered if multiple blocks are
being performed.
The midline and an area 10cm 10cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
The midline is palpated and marked.
The inferior edge of the rib is palpated and marked at
the most posterior point at which the rib is palpable;
this is the insertion point (Fig. 4.1.2). If multiple blocks
are planned these marks will form a line that becomes
more medial towards the cephalad end as the scapulae
are avoided laterally (Fig. 4.1.2).

FOR THE RIGHT-HANDED OPERATOR


B

Fig. 4.1.1

With the left hand


The inferior edge of the rib is palpated with the foreand middle fingers (Fig. 4.1.3).

4.1 Intercostal nerve block

Fig. 4.1.4

The skin is drawn up over the rib itself.


The fingers of the left hand will grip the needle-hub for
controlled advancement of the needle once contact with
the rib is made during injection.

With the right hand

Fig. 4.1.2

Fig. 4.1.3

The insertion point is infiltrated with lidocaine


(lignocaine) 1% using a 2ml syringe and a 30G needle.
The 22G short-bevel needle with syringe attached is
inserted between fore- and middle finger of the left hand
in a direction 1520 cephalad, until it makes contact
with the rib (Figs 4.1.4, 4.1.5).
The needle-hub is gripped with the fingers of the left
hand and this hand is steadied by leaning the wrist
against the patients posterior chest wall.
With the right and left hands acting as one unit, the
needle is walked off the edge of the rib until it enters
the intercostal space immediately below the rib (Fig
4.1.6). Alternatively, a catheter may be inserted between
the needle and syringe and injection may then be carried
out by a second operator, while the first maintains the
needle steady in the correct position (Fig. 4.1.7).
It is then advanced 2mm.
After negative aspiration, 34ml of local anesthetic, plus
corticosteroid if indicated, is injected and the needle is
withdrawn.
Monitors are left attached and i.v. access left in situ for
at least 30 minutes.
Chest X-ray is performed if pneumothorax is suspected.

39

40

CHAPTER

Somatic nerve blockade

Fig. 4.1.7

Confirmation of a successful block


Relief of pain.
Anesthesia in the distribution of the blocked nerve.

Tips

Fig. 4.1.5

Fig. 4.1.6

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 > 2mm deeper than the rib
when intercostal space is reached is avoided. This
will minimize the risk of pneumothorax, as the
average distance from the rib to the pleura is
8mm. If patient coughs on injection, pneumothorax
is suspected.
Neurolytic intercostal nerve block, e.g. with alcohol
50% 3ml (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 3cm of catheter through an 18G
epidural needle after the intercostal neurovascular
bundle has been identified as above.

4.1 Intercostal nerve block

Fig. 4.1.9

Potential problems
Fig. 4.1.8

Radiofrequency lesioning
Radiofrequency lesioning of the intercostal nerve is
simple and has a low level of side effects. The lesioning
is carried out using the same method of placement of
the needle as described for intercostal nerve block with
local anesthetic.
However, after placement of the needle and confirmation
of accuracy by fluoroscopy (as described above), a trial
of stimulation is carried out using 2V at 50Hz. If the
needle has been placed accurately the patient should
experience paresthesiae in the distribution of that
intercostal nerve. A pulsed radiofrequency lesion may
then be produced at 4045C for 5 minutes or 4960C
for 90 seconds.

Injection within the nerve sheath can result in the spread


of anesthetic to the subarachnoid space.
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
insertion.
Because of the vascularity of the intercostal space, there
may be rapid absorption of local anesthetic and systemic
effects can occur quickly, especially with multiple
blocks. However, peak plasma concentration of local
anesthetic may occur 1520 minutes after the block is
performed, when systemic toxicity effects may develop.
Addition of epinephrine (adrenaline) to the anesthetic
solution may decrease the peak plasma concentration of
local anesthetic.
If aspiration of blood occurs, the needle should be
removed, keeping the left fore- and middle fingers in
place. The needle is cleared, reinserted to contact the rib
again, and the block is continued as above.

41

42

CHAPTER

Somatic nerve blockade

Care of the airway must be remembered if sedation is


administered to a patient in the prone position.
Complications of neurolytic intercostal nerve block
include pneumothorax, infection (especially in the
immunocompromised patient) as well as post-lesioning

intercostal nerve neuritis. The frequency of the latter in


radiofrequency lesioning increases as higher temperatures
are used. Intercostal nerve neuritis usually responds to
local injection of lidocaine (lignocaine) 1% 3ml plus
triamcinolone diacetate 20mg to the lesion site.

4.2 Interpleural block

4.2 INTERPLEURAL BLOCK


Anatomy

Position of patient

The parietal pleura lines the thoracic wall, the thoracic


surface of the diaphragm and the lateral mediastinum. The
visceral pleura completely covers the surface of the lung.
Both the pleural layers become contiguous at the root
of the lung. Between the two pleural layers lies the
interpleural space (Fig. 4.2.1). Injection of local anesthetic
into this space produces an interpleural block by topical
contact with free nerve endings within the pleura,
and by local diffusion to nerves in the vicinity of the
injection site. These include the intercostal nerves, the
sympathetic chain, and the inferior part of the brachial
plexus. Local anesthetic solution may also track
to the epidural and subarachnoid spaces producing
blockade.

The technique described here relies on negative


interpleural pressure to identify the interpleural space.
Therefore the patient should be breathing spontaneously
for this technique.
Semi-prone.
Side to be blocked uppermost, supported by a pillow
(Fig. 4.2.2).
The arm should be allowed to fall forwards in front of
the body to rotate the scapula anterolaterally.

Equipment





2ml and 10ml syringes


18G, 20G, and 25G needles
ECG, BP, and SpO2 monitors
18G epidural set
Well-lubricated 5ml glass syringe
Resuscitation equipment (see Appendix 3)

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The midline and an area 15cm 12cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
Lidocaine (lignocaine) 2%, 2ml is drawn up.
Levobupivacaine 0.25% 20ml is drawn up.
Air is drawn up into a well-lubricated 5ml syringe.
The seventh and eighth ribs are palpated and marked.

Drugs



Lidocaine (lignocaine) 1% 10ml


Levobupivacaine 0.25%, 20ml (or its equivalent)
Saline (NaCl) 10ml
Resuscitation drugs (see Appendix 3)

Interpleural space

Fig. 4.2.1

Fig. 4.2.2

43

44

CHAPTER

Somatic nerve blockade

Fig. 4.2.3

A point approximately 10cm from the midline,


immediately superior to the eighth rib, is marked; this is
the insertion point (Fig. 4.2.3).

FOR THE RIGHT-HANDED OPERATOR


With the left hand
The fore- and middle fingers are placed each side of the
insertion point, palpating the superior aspect of the
eighth rib.
These fingers are kept in place until the epidural needle
passes through the subcutaneous tissue.

With the right hand


A skin wheal is raised at the insertion point.
The epidural needle is inserted between the fore- and
middle fingers of the left hand, taking care that the
point of entry of the needle is as close as possible to the
superior aspect of the eighth rib. This helps to avoid
damage to the neurovascular bundle, which lies
immediately inferior to the seventh rib.
After passage through the subcutaneous tissue, the hub
of the needle is gripped with the fore- and middle fingers
of the left hand and this hand is steadied by leaning the
wrist against the patients posterior chest wall.
The stylet is removed and the well-lubricated glass
syringe containing 3ml air is applied (Fig. 4.2.4).
The needle is slowly and carefully advanced, with no
pressure applied to the plunger, the left hand aiding the
advance, while at the same time applying a brake if
required.
Resistance from the tissues prevents the plunger from
advancing.
At the point at which the needle enters the interpleural
space a definite click is experienced, negative pressure
draws the air in and the barrel drops (Fig. 4.2.5).

Fig. 4.2.4

Taking care not to allow air entry into the interpleural


cavity, a catheter is inserted approximately 10cm
into the interpleural space (Fig. 4.2.6). Once the
catheter is in position it is best to place the patient
supine, tilted slightly, with the side to be blocked
upwards (Fig. 4.2.7 a,b). (If blockade of the upper
thoracic segments is required the patient is tilted
head-down).
After negative aspiration and a test dose, 1015ml
levobupivacaine 0.25% (or its equivalent) in divided
doses of 5ml is injected.
Infusion of local anesthetic may be set up for continuous
analgesia.
Monitors should be left attached and i.v. access left in
situ while the catheter is in place.
Chest radiograph may be performed to rule out
pneumothorax.

Confirmation of a successful block


Relief of pain.
Anesthesia in the distribution of the blocked nerves.

4.2 Interpleural block

Pleural
reflection

810 cm
A

Air

Parietal
pleura

Visceral pleura C

Fig. 4.2.5

Epidural
needle

Intercostal
muscle

Skin

Rib
Neurovascular bundle
Parietal pleura
Visceral pleura
Lung
Epidural catheter

Fig. 4.2.6

Supine

Pleural cavity Pericardial cavity

Local anesthetic Sympathetic


solution
chain

Fig. 4.2.7

Splanchnic
nerve

Lung

Phrenic nerve

Local anesthetic
solution

45

46

CHAPTER

Somatic nerve blockade

Tips

Potential problems

As an alternative technique, the barrel of the syringe


may be removed and the open syringe filled with NaCl
or local anesthetic and advanced until the fluid level
begins to fall as the solution is sucked into the
interpleural space (Fig. 4.2.8).
Also, a bag containing NaCl 500ml may be attached to
the epidural needle via a giving set, and drops observed
on entry to the interpleural space (Fig. 4.2.9).
Ultrasound may aid placement of the needle (Fig. 4.2.10).

Pneumothorax.
Unpredictable analgesia. The mechanism of action of
interpleural block is still unproven and spread of the
local anesthetic solution may be unpredictable. The
duration of the block may be decreased when a
thoracotomy drainage tube is present.

Fig. 4.2.8

Fig. 4.2.9

Fig. 4.2.10

4.3 Lumbar nerve root block

4.3 LUMBAR NERVE ROOT BLOCK


Anatomy
The lumbar nerves are made up of sensory and motor
fibers to the trunk and lower limbs, and sympathetic white
and grey rami communicantes. Each lumbar nerve exits via
the intervertebral foramen which lies just inferior to the
caudad edge of the transverse process of the respective
vertebral body, and passes anteriorly over the lateral aspect
of the transverse process of the vertebral body below
(Fig. 4.3.1). It then branches into posterior and anterior
branches. The posterior branch supplies the paravertebral
muscles and cutaneous fibers to the back. The anterior
branch passes through the substance of the psoas muscle
and branches further, communicating with the other
anterior branches to form the lumbar plexus. As a result
there is significant overlap of nerve supply. The fascial
layers of the psoas muscle prevent spread of local
anesthetic to the sympathetic lumbar chain. It may be
helpful to consider blockade of a lumbar nerve root to be
similar to intercostal nerve block except that the transverse
process is present instead of a rib and the insertion site is
therefore more medial.

Equipment
2ml and 10ml syringes
25G needle

Fig. 4.3.1

22G spinal needle, end-opening


Radio-opaque contrast medium
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)
Fluoroscopy or ultrasound

Drugs
Lidocaine (lignocaine) 1% 10ml (or its
equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
25mg (or its equivalent)
Resuscitation drugs

Position of patient
Prone.
Pillow under the anterior superior iliac spine to flatten
the normal lumbar lordosis (Fig. 4.3.2).

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The lumbar midline and an area 10cm 5cm laterally
is cleaned with antiseptic solution and a fenestrated
drape is placed over the sterile area.
The iliac crests are palpated and the intercrestal line is
identified. This corresponds with the inferior aspect of
the spinous process of L4 or may lie in the L45
interspace (Fig. 4.3.3 a).
The spinous processes are counted until the level to
be blocked is identified and confirmed with
fluoroscopy.
The spinous processes of the vertebrae are marked
(Fig. 4.3.3 b).
The insertion point of the needle lies 23cm lateral to
the cephalic end of the spinous process of the vertebra.
The nerve corresponding to each vertebra emerges just
below the transverse process of that vertebra at this site
(see Appendix 6).
Therefore, with the aid of fluoroscopy, the insertion
point is identified.
A skin wheal is raised and the area is infiltrated with
lidocaine (lignocaine) 1%.
A spinal needle is introduced in a vertical direction to
the skin, until the needle contacts bone at an
approximate depth of 35cm, the transverse process of
that vertebra (Fig. 4.3.4 a,b).

47

48

CHAPTER

Somatic nerve blockade

Fig. 4.3.2

L1
L2
L3
L4

Fig. 4.3.3

The needle is then walked off the transverse process


in the caudad direction and advanced 1.52cm, the site
of the emerging nerve root (Fig. 4.3.5).
It is useful to confirm the needle tip over the
intervertebral foramen with fluoroscopy.
Paresthesia in the distribution of the nerve may be
experienced.
After aspiration, non-ionic radio-opaque contrast
medium 1ml is injected.
The correct placement is indicated by outlining the nerve
root with non-ionic radio-opaque contrast medium,

visible on anteroposterior and lateral fluoroscopic views


(Fig. 4.3.6).
After further aspiration, lidocaine (lignocaine) 1%
0.51ml is injected.
After 5 minutes the patient is questioned about changes
in pain, sensation and power of the lower limb.
For diagnostic nerve root blockade, the needle
may be removed when the level causing pain is
identified.
Ultrasound may also aid placement of the needle
(Fig. 4.3.7).

4.3 Lumbar nerve root block

Fig. 4.3.4

Confirmation of a successful block


Relief of pain and anesthesia in distribution of the
blocked nerve.

Tips
As in the case of thoracic nerve root block, it has also
been recommended that the needle is angled 20
medially after entering the paravertebral space. However
care must be taken, with the aid of fluoroscopy, not to
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.

However, even small volumes of epidural spread may


confound the diagnostic value of the block.
Sympathetic blockade is unlikely, but it may occur and
cause hemodynamic changes.
Intravascular injection. Injection of particulate steroids
into a radicular artery can cause spinal cord infarction.
Particulate steroids should never be injected near the
foramen unless intravascular placement has been ruled
out using live fluoroscopy contrast dye injection,
preferably with digital subtraction technique.

49

50

CHAPTER

Somatic nerve blockade

2
3cm

Sympathetic chain

Lumbar nerve

Fig. 4.3.5

Fig. 4.3.7

Fig. 4.3.6

4.4 Thoracic nerve root block

4.4 THORACIC NERVE ROOT BLOCK


Anatomy
The anatomy relevant to thoracic paravertebral nerve root
blockade is very similar to the anatomy relevant to lumbar
paravertebral nerve root block, except that:
ribs are present instead of the rudimentary ribs of the
lumbar spine, the transverse processes;
the lung and pleura are in close proximity to the injection
site, therefore the risk of pneumothorax is significant;
unlike the lumbar region, where the needle passes
through the substance of the psoas muscle, the needle
passes through connective tissue only in the thoracic
region (Fig. 4.4.1 a,b);
the fascial layers of the psoas muscle prevent spread to
the sympathetic lumbar chain. However, such layers do
not exist in the thoracic region, and paravertebral
injection usually results in sympathetic blockade.

Drugs
Lidocaine (lignocaine) 1% 10ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
25mg (or its equivalent)
Resuscitation drugs (see Appendix 3)

Position of patient
Prone (the block requires localization of the transverse
process and can be performed in a lateral, sitting or
prone position) (Fig. 4.4.2).

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The thoracic midline and an area 10cm 5cm laterally
is cleaned with antiseptic solution.

Equipment



ECG, BP, and SpO2 monitors


Resuscitation equipment and drugs (see Appendix 3)
Fluoroscopy or ultrasound

2ml and 10ml syringes


25G needle
22G spinal needle, end-opening
Radio-opaque contrast medium

Pleura

Sympathetic ganglion
Anterior
costotransverse
ligament

Anterior
costotransverse
ligament
Nerve
Rib

Fig. 4.4.1

Lamina

51

52

CHAPTER

Somatic nerve blockade

Fig. 4.4.2

The inferior angle of the scapula is identified; this lies


at the level of the spinous process of T7.
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
blocked is identified, and confirmed with fluoroscopy.
The spinous processes of vertebrae are then marked.
The insertion point of the needle lies 1.53cm lateral to
the cephalic end of the spinous process of the vertebra,
usually midway between the ribs (Fig. 4.4.3 a,b).
The nerve corresponding to each vertebra emerges just
below the transverse process of that vertebra at this site.
Therefore, with the aid of fluoroscopy, the insertion
point is identified.
A skin wheal is raised and the area is infiltrated with
lidocaine (lignocaine) 1%.
The transverse process is identified under fluoroscopy
and the spinal needle is introduced in a direction
perpendicular to the skin until the needle contacts bone.
A slightly mesiad inclination avoids the pleura and
increases the chances of placing the needle tip near the
nerve root.
Care must be taken to avoid the pleura by not
advancing the needle any further than is necessary to
locate the transverse process, approximately 3cm. If the
needle does not contact the transverse process by 3cm,
it should be withdrawn and re-advanced in a more
caudad, and subsequently more cephalic, direction,
again taking care not to advance beyond 3cm.
The needle is then walked off the caudad edge
of the transverse process until it slips off the edge
(Fig. 4.4.4 a,b). It is then advanced 1cm, the site
of the emerging nerve root at that level.
It is useful to confirm the needle tip over the
intervertebral foramen with fluoroscopy.
Paresthesia in the distribution of the nerve may be
experienced.

Anterior
costotransverse
ligament

Posterior
costotransverse
ligament

Azygos vein
Thoracic
duct

Lung

Esophagus
Aorta
Greater
splanchnic
nerve
Thoracic
sympathetic
chain
1.5cm

Superior
costotransverse ligament

Fig. 4.4.3

After aspiration, radio-opaque contrast medium 1ml, is


injected.
The correct placement is indicated by outlining the nerve
root with non-ionic radio-opaque contrast medium,
visible on anteroposterior and lateral views (as in
the description of lumbar somatic nerve injection in
Section 4.3).
Ultrasound may aid placement of needle.

4.4 Thoracic nerve root block

Fig. 4.4.4

After further aspiration, lidocaine (lignocaine) 1%


0.11ml is injected.
After 5 minutes the patient is questioned about
changes in pain and sensation in the distribution of the
nerve root.
For diagnostic nerve root blockade the needle may be
removed when the level causing pain is identified.

Confirmation of a successful block


Relief of pain and anesthesia in distribution of the
blocked nerve.

Tips
An alternative approach is to advance the needle in a
mesiad direction until the lamina is contacted. The
needle is inserted more medially, 1.5cm lateral to the
cephalad edge of the spinous process and then walked
laterally off the edge of the lamina until it slips into the
costovertebral ligament and is advanced 1cm.

Some workers advocate applying an air-filled loss-ofresistance syringe to the needle after it has been walked
off the transverse process or lamina, and advancing the
needle while applying pressure to the plunger. Loss of
resistance has been described as the needle pops through
the costotransverse ligament to enter the thoracic
paravertebral space.
A catheter may be passed into the paravertebral space
via an epidural needle, with the bevel medial, by using
this technique.

Potential problems
Pneumothorax.
While it has been recommended that the needle be
angled 20 medially after entering the paravertebral
space, care must be taken with the aid of fluoroscopy
that the local anesthetic solution is not injected into the
nerve sheath causing the solution to track centrally to
produce intrathecal blockade.

53

54

CHAPTER

Somatic nerve blockade

Epidural blockade usually occurs with this block, but


this is not a problem once low volumes are used.
However, even small volumes of epidural spread may
confound the diagnostic value of the block.
Sympathetic blockade may cause hemodynamic changes.
Neuritis may occur with catheter placement.

Intravascular injection. Injection of particulate steroids


into a radicular artery can cause spinal cord infarction.
Particulate steroids should never be injected near the
foramen unless intravascular placement has been ruled
out using live fluoroscopy contrast dye injection,
preferably with digital subtraction technique.

4.5 Sacral nerve root block

4.5 SACRAL NERVE ROOT BLOCK


Anatomy

Equipment

Each of the five sacral nerves is accessible by passing a


needle into the sacral foramen via the posterior opening at
the level of the nerve. The sacral canal is the caudal
extension of the epidural space and nerves of the cauda
equina leave via the sacral foramina (Fig. 4.5.1). The distal
dural sac ends at S2, the level of the posterior superior iliac
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.

2ml and 10ml syringes


25G needle
22G spinal needle, end-opening
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3) and drugs
Fluoroscopy or ultrasound

Drugs
Lidocaine (lignocaine) 1% 10ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
50mg (or its equivalent)
Resuscitation drugs (see Appendix 3)

Position of patient

Conus medullaris

Prone.
Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 4.5.3).

Dura matter
Spinous process

Transverse
process

1
L1

Termination of the
spinal cord at the
level of L1

2
L2
3

Cauda equina
L3

Termination
of the
subarachnoid
space at S2

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The sacral midline and an area10cm 5cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.

L4

L5

S1

Subarachnoid
space (CSF)
Sacral nerves
in the caudal
epidural space
Posterior sacral
foramen

S2
S3
Filum
terminale

Sacral
hiatus

S4

First
coccygeal
vertebra

S5
Coccygeal nerve

Fig. 4.5.1

Fig. 4.5.2

Cornu of sacrum
Coccygeal cornu

55

56

CHAPTER

Somatic nerve blockade

Fig. 4.5.3

1cm

S1
S2
S3
S4

Posterior
superior
iliac spine
Sacral cornu

Fig. 4.5.4

Iliac crests are palpated and an intercrestal line is


identified.
This corresponds with the inferior aspect of the spinous
process of L4 or may lie in the L45 interspace.
For this block, it is almost essential that the posterior
opening of the sacral foramina is identified with
fluoroscopy. The X-ray beam is used to guide the needle
tip into the foramen. It is important to note that when
the anteroposterior X-ray view is used, it is usually the
anterior opening of the foramen that is the most
prominent.
The insertion point of the needle lies 23cm lateral
to the midline (variable) and approximately 1cm medial
to the posterior iliac spine (Figs 4.5.4, 4.5.5 a,b).
Therefore, with the aid of fluoroscopy, the insertion
point is identified.
A skin wheal is raised and the area is infiltrated with
lidocaine (lignocaine) 1%.

Fig. 4.5.5

A spinal needle is introduced in a vertical direction to


the skin, and aimed slightly cephalad until bone is
contacted (Fig. 4.5.6).
The needle is then walked off the sacrum in a caudad
direction until it slips into the foramen. After
confirmation with the aid of fluoroscopy it is then
advanced 1cm.

4.5 Sacral nerve root block

Fig. 4.5.7

Tips

Fig. 4.5.6

Paresthesia may be produced.


After aspiration, non-ionic radio-opaque contrast
medium 0.5ml is injected.
The correct placement is indicated by a needle tip flush
with the anterior surface of the spinal canal in the
lateral fluoroscopic view.
Injection of 0.5ml non-ionic contrast should spread
diagonally along the S1 spinal nerve (Fig. 4.5.7).
After further aspiration, lidocaine (lignocaine) 1%
0.5ml is injected.
After 5 minutes, the patient is questioned about changes
in pain, sensation and power of the lower limb.
For diagnostic nerve root blockade the needle may be
removed when the level causing pain is identified.
Ultrasound may also aid placement.

Confirmation of a successful block


Relief of pain.
Anesthesia in the distribution of the blocked nerve.

Some workers advocate drawing a line from a point


23cm medial to the posterior superior iliac spine to a
point 12cm 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
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.
Optimally, the needle makes gentle contact with the
spinal nerve in the middle of the canal (Figs 4.5.9,
4.5.10) and produces paresthesia in the distribution of
the nerve.
While all sacral nerve roots are accessible, using this
technique for blockade of S5 is achieved by walking the
needle caudally off the inferior edge of the bony plate of
the sacrum and advancing the needle 1cm.

Potential problems
Caudal epidural blockade may occur with this block,
but this is not a problem once low volumes are used.
However, even small volumes of epidural spread may
confound the diagnostic value of the block.
Intravascular injection. Injection of particulate steroids
into a radicular artery can cause spinal cord infarction.
Particulate steroids should never be injected near the
foramen unless intravascular placement has been ruled
out using live fluoroscopy contrast dye injection,
preferably with digital subtraction technique.

57

58

CHAPTER

Somatic nerve blockade

S5

S4

S3
S2
S1

Fig. 4.5.8

Fig. 4.5.9

S5

S4

S3
S2
S1

Fig. 4.5.10

4.6 Occipital nerve block

4.6 OCCIPITAL NERVE BLOCK


Anatomy
The greater occipital nerve arises from the dorsal rami of
the second cervical nerve. From here it passes through the
muscles of the neck and becomes subcutaneous at the
superior nuchal line, where it emerges with the occipital
artery (Fig. 4.6.1). The superior nuchal line extends from
the mastoid process to the greater occipital protuberance
bilaterally (Fig. 4.6.2).

ECG, BP, and SpO2 monitors


Resuscitation equipment (see Appendix 3)

Drugs
Lidocaine (lignocaine) 1% 10ml (or its equivalent)
Corticosteroid if indicated, e.g. triamcinolone diacetate
50mg (or its equivalent)
Resuscitation drugs (see Appendix 3)

Equipment

Position of patient

10ml syringe
25G needle

Sitting.
Neck flexed.
Greater occipital
protuberance
Mastoid process

Needle puncture and technique


The superior nuchal line is cleaned with antiseptic
solution (no drape is required) (Fig. 4.6.3).

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

Fig. 4.6.2

Fig. 4.6.3

59

60

CHAPTER

Somatic nerve blockade

The occipital artery is palpated 2cm lateral to the


greater occipital protuberance on the superior nuchal
line (Fig. 4.6.4).
A 25G needle is inserted subcutaneously at this point.
After negative aspiration, 35ml of lidocaine
(lignocaine) 1% or its equivalent, plus corticosteroid if
indicated, is injected to surround the occipital artery.
It is often difficult to feel an occipital artery pulse. If
this is the case, it is best to pick a point midway
between the occipital protuberance and the mastoid
bone and fan out the injection in both directions,
medially and laterally from that site (Fig. 4.6.5).

Tips
Bone should be contacted at a depth no greater than
12cm.
The lesser occipital nerve is blocked by redirecting the
needle towards the mastoid process along the greater
nuchal line and injecting a further 3ml of solution.

Potential problems
Injection into the cerebrospinal fluid (CSF) of the
cisterna magna is possible and will produce a total
spinal block.

Confirmation of a successful block


Relief of pain and anesthesia in distribution of nerve.

Fig. 4.6.4

Fig. 4.6.5

4.7 Trigeminal ganglion (Gasserian) block

4.7 TRIGEMINAL GANGLION (GASSERIAN) BLOCK


Anatomy
The trigeminal ganglion gives rise to the fifth cranial nerve
and divides into three branches, the ophthalmic, maxillary,
and mandibular nerves (Fig. 4.7.1). These provide the
sensory nerve supply to the ipsilateral face and the anterior
two-thirds of the head (Fig. 4.7.2). The mandibular nerve
also provides motor supply to the muscles of mastication.
The trigeminal ganglion is located at the apex of the
petrous temporal bone in a fold of dura mater, Meckels
cave. This dural invagination covers the posterior

two-thirds of the ganglion and contains cerebrospinal fluid


(CSF). Posterior to Meckels cave lies the brainstem,
superior to it lies the temporal lobe, and medially lies the
cavernous sinus which contains the internal carotid artery
and cranial nerves III, IV, and VI. Accordingly, extreme
care must be taken when carrying out this block, especially
if neurolytic agents are used. Blockade of the ganglion is
carried out by passage of a needle through the foramen
ovale, which lies immediately below it (Fig. 4.7.3).

Equipment






Ophthalmic

2ml and 10ml syringes


25G needle
22G 810cm needle
Non-ionic radio-opaque contrast medium
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)
Fluoroscopy

Drugs

Maxillary

Lidocaine (lignocaine) 2% 10ml


Lidocaine (lignocaine) 1% 10ml (or its equivalent)
Neurolytic agent, e.g. phenol 6% plus glycerol (or its
equivalent)
Sedative, e.g. midazolam, propofol
Resuscitation drugs (see Appendix 3)

Mandibular

Fig. 4.7.1

Position of patient
Supine.
Eyes directed straight ahead.
Ophthalmic
Meckel's cave
Maxillary

C2

Mandibular

Gasserian
ganglion
Zygomatic arch
Foramen ovale

C3

C4
Posterior
primary rami

Fig. 4.7.2

Anterior
primary rami

Fig. 4.7.3

61

62

CHAPTER

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Needle puncture and technique


Caution: Injection of 0.25ml of lidocaine (lignocaine) 1%
into the CSF may result in immediate convulsion and/or
loss of consciousness with possible cardiovascular system
(CVS) collapse.
The cheek on the side of the block is cleaned with
antiseptic solution or saline.
Mild sedation is induced.
It is best to stand on the side of the block, just below
the shoulder.
The insertion point lies 13cm posterior to the lateral
margin of the mouth, at the medial edge of the masseter
muscle (located by asking the patient to clench the jaw)
and is marked.
In edentulous patients the insertion point should be
more caudad as sufficient angle towards the
infratemporal surface of the sphenoid bone may not be
achieved.
One finger is placed inside the upper lip to avoid
injection into the buccal cavity and possible bacterial
contamination, and a skin wheal is raised at this site.
Viewed from above, a 22G 810cm needle is advanced
towards the ipsilateral pupil (Figs 4.7.44.7.6), 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. 4.7.4

the needle is reinserted to walk off the bone and


enter the foramen ovale (Fig. 4.7.7).
Paresthesia in the distribution of the mandibular nerve
(sometimes the other branches of the trigeminal nerve)
or contraction of the muscles of mastication may be
experienced at this point.
The needle is advanced a further 1cm to bring the tip
to lie in the trigeminal ganglion. The correct placement
is indicated by a visible outline of Meckels cave on
injection of 0.25ml non-ionic radio-opaque contrast
medium under fluoroscopy (Figs 4.7.8, 4.7.9).
The patient is allowed to awaken from sedation and is
questioned about the presence and distribution of
paresthesia and pain.
A stimulating device may aid placement in patients who
are not able to locate the paresthesia with accuracy.
If necessary, analgesia may be administered, although
this may affect accurate assessment of the blockade.
Adjustment of the needle may be required to place the
needle near the appropriate nerve division.

Fig. 4.7.5

4.7 Trigeminal ganglion (Gasserian) block

Fig. 4.7.8

Fig. 4.7.6

Roof of
infratemporal
fossa
Zygomatic arch
Foramen ovale

2
1

Fig. 4.7.7

Fig. 4.7.9

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64

CHAPTER

Somatic nerve blockade

After careful negative aspiration for CSF or blood,


lidocaine (lignocaine) 1% 0.25ml is injected (Caution:
injection into CSF may cause loss of consciousness.)
This is followed by further boluses of lidocaine
(lignocaine) 1% 0.25ml until a total of 1ml is given.
After 5minutes the patient is questioned about pain
relief and changes in sensation.
When the desired analgesia has been achieved for
diagnostic blockade the needle may be removed.

Confirmation of a successful block


Relief of pain and anesthesia in the distribution of the
trigeminal nerve or its desired branches.

Gangliolysis using thermocoagulation may be employed


for trigeminal-nerve division destruction after location
of the ganglion using this technique. Further intravenous
anesthesia using a short-acting agent, e.g. propofol, may
be induced after placement of the insulated needle to
facilitate this painful procedure.
Injection of glycerol alone may produce pain relief with
this injection technique. This involves placement of the
needle in the cul-de-sac of CSF, positioning the patient
face-down or supine, with the head extended to prevent
spill-over into the posterior cranial fossa. After entry
into the CSF, and positive aspiration of CSF, 0.10.3ml
of glycerol may be injected.

Tips

Potential problems

Intravenous anesthesia using a short-acting agent, e.g.


propofol, may be induced to allow placement of the
needle. The patient is then allowed to awaken and a
stimulating device may aid accurate placement of the
needle.
The needle is advanced beyond the infratemporal bone
by 0.5cm for location of the mandibular division,
1.0cm for the maxillary division, and 1.5cm for the
ophthalmic division.

Injection of 0.25ml of lidocaine (lignocaine) 1% into


the CSF may result in immediate convulsion and/or loss
of consciousness with possible CVS collapse.
Spread of hyperbaric neurolytic solution may immediately
affect cranial nerves VI, VIII, IX, X, XI, and XII.
Spread of hypobaric neurolytic solution may
immediately affect the oculomotor and trochlear nerves.
Neurolytic blocks of the trigeminal ganglion commonly
produce corneal and hemifacial anesthesia.

AUTONOMIC BLOCKADE

Autonomic blockade is useful in the diagnosis and


treatment of pain of autonomic origin. In cases of thoracic,
abdominal or pelvic pain, it is often difficult to distinguish
between that of visceral origin and that of somatic. Pain of
visceral origin, e.g. pancreatic cancer or pelvic cancer, may
cause pain that responds to celiac or hypogastric plexus
blockade, respectively. A prognostic block may be carried
out prior to neurolytic blockade for relief of cancer pain.
Pain of the upper abdominal viscera may also be relieved
by celiac plexus block, proceeding to neurolytic blockade
as appropriate for cancer-related pain. The retrocrural
approach to the celiac plexus also targets the splanchnic
nerves to produce a splanchnic nerve block if required.
Chest pain may be of somatic origin, e.g. intercostal
neuralgia and costochondritis, or visceral origin, e.g.
pulmonary or cardiac-related pain. Stellate ganglion
blockade may be helpful in the diagnosis and management
of the latter.
In addition, increased sympathetic activity is thought to
contribute to a large number of pain states. These are

generally grouped under the term Complex Regional Pain


Syndrome Type I and II. In these cases, trophic changes
and alterations in blood flow are often obvious but the
pathophysiologic origin is not. Blockade of sympathetic
innervation may therefore help in diagnosis and
management of such pain. This may also indicate other
therapies that could be beneficial, e.g. sympathetically
active drugs or destructive therapies. Similarly, these
therapies would not be indicated if sympathetic blockade
failed to relieve the pain. If blockade did succeed in
relieving this type of pain, further blocks may effect lasting
relief.
There are a number of other conditions in which the
diagnosis is clear but there is a possible contribution of
sympathetic activity in the pathogenesis of the pain. These
conditions include central pain, post-herpetic neuralgia,
trigeminal neuralgia, peripheral vascular disease and
others. Blockade of sympathetic activity may help to clarify
the sympathetic contribution to the pain and therefore help
to indicate management options.

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Autonomic blockade

5.1 STELLATE GANGLION BlockC6


(CLASSIC) APPROACH
Anatomy

Position of patient

The cervical sympathetic trunkthe superior, middle, and


stellate gangliasupplies the sympathetic innervation of
the head, neck, and upper limbs. The stellate ganglion is
made up of a combination of the lower cervical and first
thoracic ganglia. It lies on the prevertebral fascia of the
seventh cervical and first thoracic vertebrae (Fig. 5.1.1).
However, as the sixth cervical anterior tubercle
(Chassaignacs tubercle) is easy to palpate, injection of a
large volume of local anesthetic is made at this level and
allowed to track caudally along the prevertebral fascia to
block the stellate ganglion. The vertebral and carotid
arteries, the pleura, and the brachial plexus are in close
proximity to the stellate ganglion.

Equipment






10ml syringe
22G short-bevel needle
Extension set (optional)
ECG, BP, SpO2 monitors
Skin temperature monitor
Resuscitation equipment (see Appendix 3)
Ultrasound (optional)

Supine.
Thin pillow under head.
Roll under neck.
Eyes directed at ceiling.
Mouth slightly open.

Needle puncture and technique


Caution: Injection of 0.51ml of lidocaine (lignocaine)
1% into the vertebral artery may result in immediate
convulsion and/or loss of consciousness with possible
cardiovascular system (CVS) collapse.
Intravenous access is inserted.
Monitors are attached, each temperature probe is
attached to the palmar aspect of the middle finger of
each hand (Fig. 5.1.2).
Resuscitation equipment and drugs are checked and
made ready for use.
The side of the neck is cleaned with antiseptic solution.
It is best to stand at the same side of the neck as the
ganglion to be blocked.

FOR THE RIGHT-HANDED OPERATOR


With the left hand

Drugs

The thyroid cartilage is located and marked.


The cricoid cartilage is identified and marked
(Figs 5.1.3, 5.1.4).

Lidocaine (lignocaine) 1%, 10ml


Resuscitation drugs (see Appendix 3)

Temperature probe

Stellate
ganglion
C6
C7

Fig. 5.1.1

Fig. 5.1.2

5.1 Stellate ganglion blockC6 (classic) approach

Fig. 5.1.6

Fig. 5.1.3

Thyroid cartilage
Cricoid cartilage

C6 anterior
tubercle

Fig. 5.1.4

Fig. 5.1.7
Muscles

Chassaignacs tubercle is palpated with the middle finger,


just lateral to the cricoid cartilage (Fig. 5.1.5).
The sternocleidomastoid (SCM) muscle is gently pulled
laterally and the carotid pulse is palpated (Fig. 5.1.6).
Chassaignacs tubercle is palpated again and positioned
between the fore- and middle fingers.

With the right hand

Fig. 5.1.5

The needle is inserted between the fore- and middle


fingers of the other hand, directly perpendicular
to the floor, aiming for Chassaignacs tubercle
(Figs 5.1.7, 5.1.8).
When contact with the tubercle is reached, the injecting
hand is steadied and the needle is withdrawn 2mm.
The hub of the needle is held in place with the
other hand.

67

68

CHAPTER

Autonomic blockade

Fig. 5.1.8

Fig. 5.1.9

After negative aspiration, lidocaine (lignocaine) 1%,


0.5ml, is injected.
The patient is questioned about sensation and any
change in level of consciousness is noted.
If negative, the same procedure is repeated as 0.5ml
boluses are given until 10ml is injected.
The needle is withdrawn and the patient is immediately
put in the sitting position.
Monitors should be left attached and i.v. access left in
situ for at least 30 minutes. The patient is requested not
to eat or drink for 2 hours, as the recurrent laryngeal
nerve may be blocked.
Note: if aspiration of blood occurs during the block the
needle is removed and cleared, keeping left fore- and
middle fingers in place. It is then reinserted and the
block is continued as above.
If hematoma occurs before the solution is injected
it may be worth performing the block at the
C7 level.
If there is pain on injection and/or paresthesia, it is
likely that the brachial plexus may have been contacted,
the needle is withdrawn and the landmarks are
rechecked.

Blockade of the upper sympathetic chain can occur in


the absence of sympathetic denervation of the upper
extremity, resulting in Horners syndrome without a rise
in skin temperature in the hand.

Confirmation of a successful block


Skin temperature, measured over the palmar aspect
of the hand or fingers on the blocked side, should begin
to rise within 23 minutes. Extensive sympathetic
blockade is confirmed by a rise in skin temperature to
>33C.
Ptosis of eyelid.
Miosis of pupil.
Unilateral blockage of nose on side of block.
Unilateral flushing of conjunctiva of eye on side of
block.

Tips
The external jugular vein usually crosses the SCM
muscle at the level of C6.
Skin infiltration prior to block should be avoided if
possible, as this will make landmarks more difficult to
locate.
If palpation is painful or difficult it may be helpful to
try to bounce the middle finger off the tubercle during
identification.
An extension set may be inserted between the needle
and syringe for better stability of needle (Fig. 5.1.9), but
an assistant is then required to continue the procedure
as described above.
Consideration should be given to performance of the
block under fluoroscopy or CT control if the landmarks
are difficult to locate.
Lidocaine (lignocaine) 1% 15ml may be given if a
previous block failed to relieve sympathetically
maintained pain in the presence of correctly placed
solution. This may improve tracking of the solution
caudally to produce more effective blockade of the
stellate ganglion.
Ultrasound may aid placement of needle
(Fig. 5.1.10 a,b).

Potential problems
Intra-arterial injection or intrathecal injection may result
in immediate convulsion and/or loss of consciousness
with possible CVS collapse.

5.1 Stellate ganglion blockC6 (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


patients who have coagulopathy).
Pneumothorax may occur.
Recurrent laryngeal nerve block may occur and it is
prudent to advise the patient about possible hoarseness

post-blockade. Bilateral stellate ganglion blockade


should be avoided for the same reason.
Phrenic nerve block may occur and it is prudent to
caution the patient about possible shortness of breath
post blockade of the stellate ganglion.

69

70

CHAPTER

Autonomic blockade

5.2 STELLATE GANGLION BLOCKC7 APPROACH


Anatomy
As for stellate ganglion block (C6 approach) in Section 5.1
(Figs 5.2.1 a,b).

Equipment





Position of patient




C6

Middle
cervical
ganglion
Stellate
ganglion
Vertebral
artery

T1

Supine.
Thin pillow under head.
Roll under neck.
Eyes directed at ceiling.
Mouth slightly open.

Needle puncture and technique

C5

Common
carotid
artery
Right subclavian
artery

Drugs
Lidocaine (lignocaine) 1%, 10ml
Resuscitation drugs (see Appendix 3)

10ml syringe
22G short-bevel needle
Extension set (optional)
ECG, BP, SpO2 monitors
Skin temperature monitor
Fluoroscopy or CT (optional)

Resuscitation equipment (see Appendix 3)


Ultrasound (optional)

Caution: injection of 0.51ml of lidocaine (lignocaine)


1% into the vertebral artery may result in immediate
convulsion and/or loss of consciousness with possible
cardiovascular (CVS) collapse. The risk of pneumothorax
is greater with this approach.
Intravenous access is inserted.
Monitors are attached.
Each temperature probe is attached to the palmar aspect
of the middle finger of each hand. (Fig. 5.2.2).
Resuscitation equipment and drugs are checked and
made ready for use.
The side of the neck is cleaned with antiseptic solution.

Lung

Temperature probe

Longus colli

Superior stellate
ganglion

C2
C3
C4

Anterior
scalenus

C5

Middle ganglion

C6
C7

Stellate
ganglion

Medius
scalenus

T1

Subclavian
artery
Dome of pleura
1st rib

Fig. 5.2.1

Carotid artery

Fig. 5.2.2

5.2 Stellate ganglion blockC7 approach

It is best to stand at the same side of the neck as the


ganglion to be blocked.

FOR THE RIGHT-HANDED OPERATOR


With the left hand
The thyroid cartilage is located and marked.
The cricoid cartilage is identified and marked
(Figs 5.2.3, 5.2.4).
The sternoclavicular junction is palpated and marked
(Fig. 5.2.5).
The SCM muscle is gently pulled laterally and the
carotid pulse is palpated (Fig. 5.2.6).
The site of insertion of the needle lies 3cm above the
sternoclavicular junction or one to two finger-breadths
below the level of the cricoid cartilage.

With the right hand


The patient is requested to exhale deeply before needle
insertion to minimize the risk of pneumothorax.
The needle is inserted between the fore- and middle
fingers of the other hand, directly perpendicular to the
floor.
When contact with the transverse process of C7 is
reached, the injecting hand is steadied and the needle is
withdrawn 2mm.
The hub of the needle is held in place with the
other hand.
After negative aspiration, lidocaine (lignocaine) 1%,
0.5ml, is injected.
The patient is questioned about sensation, and any
change in level of consciousness is noted.
If negative, the same procedure is repeated and 0.5ml
boluses are given until 58ml is injected.
The needle is withdrawn and the patient is immediately
put in the sitting position.

Muscles

Fig. 5.2.3

Fig. 5.2.5

Thyroid cartilage
Cricoid cartilage

C6 anterior
tubercle

Fig. 5.2.4

Fig. 5.2.6

71

72

CHAPTER

Autonomic blockade

Monitors should be left attached and i.v. access left in


situ for at least 30 minutes. Blockade of the recurrent
laryngeal nerve is less likely with the C7 approach but
it is wise to advise the patient not to eat or drink for
2 hours.
Note: if aspiration of blood occurs during the block, the
needle is removed and cleared, keeping the left fore- and
middle fingers in place. It is then reinserted and the
block is continued as above.
If there is pain on injection and/or paresthesia, it is
likely that the brachial plexus may have been contacted,
the needle is withdrawn and the landmarks are
rechecked.
Ultrasound may aid placement of the needle.

Confirmation of a successful block


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.
Ptosis of eyelid.
Miosis of pupil.
Unilateral blockage of nose on side of block.
Unilateral flushing of conjunctiva of eye on side
of block.
Relief of sympathetically maintained pain.

Tips
Some workers advocate targeting the ventrolateral
aspect of the C7 vertebral body instead of its transverse
process. The needle is directed 1520 medially. With
the aid of fluoroscopy, ultrasound or CT, the vertebral
body is contacted just medial to the insertion of the
longus colli muscle. The needle is then withdrawn

2mm, stabilized, and 1ml of non-ionic contrast


medium is injected.
The external jugular vein usually crosses the SCM
muscle at the level of C6.
Skin infiltration prior to block should be avoided if
possible, as this will make landmarks more difficult
to locate.
An extension set may be inserted between the needle
and syringe for better stability of needle, but an assistant
is then required to continue the procedure as described
above.
Lidocaine (lignocaine)1% 10ml may be given if a
previous block failed to relieve sympathetically
maintained pain in the presence of correctly placed
solution. This may improve tracking of the solution
caudally to produce more effective blockade of the
stellate ganglion.

Potential problems
Intra-arterial injection or intrathecal injection may result
in immediate convulsion and/or loss of consciousness
with possible CVS collapse.
Hematoma may occur (avoid performing block on
patients who have coagulopathy).
Pneumothorax may occur (more likely with C7
approach).
Recurrent laryngeal nerve block may occur and it is
prudent to advise the patient about possible hoarseness
post blockade. Bilateral stellate ganglion blockade
should be avoided for the same reason.
Phrenic nerve block may occur and it is prudent to
caution the patient about possible shortness of breath
following blockade of the stellate ganglion.

5.3 Lumbar sympathetic block

5.3 LUMBAR SYMPATHETIC BLOCK


Anatomy

Position of patient

The lumbar sympathetic chain is located in the prevertebral


fascia, which lies on the anterolateral aspects of the
vertebral bodies. The psoas muscle separates the lumbar
sympathetic chain from the lumbar somatic nerves. A
single injection of local anesthetic at the level of L2 will
usually provide a complete block of postganglionic
sympathetic efferents to the lower extremity because the
lowest preganglionic sympathetic outflow to the chain is at
the level of L2.

Prone.
Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.3.1).

Equipment







2ml, 5ml, and 10ml syringes


30G needle
Two 15cm 22G needles
Extension set (optional)
ECG, BP, SpO2 monitors
Skin temperature monitor (two probes)
Resuscitation equipment (see Appendix 3)
Fluoroscopy

Drugs
Lidocaine (lignocaine) 1%, 5ml for skin infiltration
Lidocaine (lignocaine) 1%, 1520ml (or its equivalent)
for block
Phenol 6%
Radio-opaque contrast medium
Resuscitation drugs (see Appendix 3)

Fig. 5.3.1

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Each temperature probe is attached to the plantar aspect
of the big toe (Fig. 5.3.2).
Resuscitation equipment and drugs are checked and
made ready for use.
The thoracolumbar midline and an area 10cm5cm
laterally is cleaned with antiseptic solution and a
fenestrated drape is placed over the sterile area.
The twelfth rib is identified and a line is drawn along its
inferior border (Fig. 5.3.3 a,b).
The iliac crests are palpated and the intercrestal line is
identified (this corresponds with the inferior aspect of the
spinous process of L4 or may lie in the L45 interspace).
The spinous processes are counted until L2 is identified
and confirmed with fluoroscopy.
The insertion point lies 8cm lateral to the L2 spinous
process and is also marked (Fig. 5.3.4).
A skin wheal is raised at one of the marked sites and
the area is infiltrated with lidocaine (lignocaine) 1%.
At a 30 angle to the frontal plane, a 22G 15cm
needle is advanced slightly cephalad towards the lower

73

74

CHAPTER

Autonomic blockade
Temperature probe

Fig. 5.3.2

portion of the L2 vertebral body (Fig. 5.3.5), until its


vertebral body is contacted at a depth of about 79cm
and confirmed with fluoroscopy. If the needle contacts
bone at a more superficial level, it is probable that it has
come into contact with the transverse process and it will
need to be repositioned.
The needle depth is noted.
The needle is then withdrawn to the subcutaneous tissue
and, with the aid of fluoroscopy, it is re-advanced, this
time at an angle 45 to the frontal plane, until the
previous depth (as noted) is reached. It should slip past
the vertebral body at a depth about 12cm deeper than
the first depth mark (Fig. 5.3.6).
After negative aspiration, the fluoroscopic image is
observed as a small amount of non-ionic radio-contrast
medium is injected. The correct placement of the needle
is indicated by the presence of a layer of contrast
medium in a thin line along the anterior border of the
vertebral column (Figs 5.3.75.3.9).
After further negative aspirations, 5ml of lidocaine
(lignocaine) 1% is injected. The patient is questioned
about pain relief and observations of skin temperature
are made. There should be little resistance to injection,
similar to resistance felt when injecting through an
epidural needle. If resistance is encountered, or if the
injection is painful, the needle should be repositioned. A
unilateral rise in skin temperature indicates a successful
block.
After 10 minutes the patient is questioned about pain
relief and any symptoms of somatic nerve blockade.
Sensory and motor functioning of the lower extremities
is checked. The procedure should be abandoned if there
is evidence of somatic blockade.

L2

Fig. 5.3.3

5.3 Lumbar sympathetic block


8 cm

8cm

10cm

Kidney

Sympathetic chain

Vena cava
Aorta
Thoracic duct

Fig. 5.3.6

Fig. 5.3.4

Neurolysis may be achieved by leaving the needle in


place after block has been confirmed and injecting 5ml
phenol 6%. To avoid leaving alcohol in the needle tract,
the needle is then cleared with air or local anesthetic
1ml, and removed. However, because of the very high
incidence of genitofemoral neuralgia that can occur
post-neurolytic lumbar sympathetic block, the benefit
versus risk should be considered carefully.
Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.

Confirmation of a successful block


Increase in skin temperature on the plantar surface of
the foot to about 35C; temperature should begin to
rise in the foot on the side of the block within 3 minutes
of injection of local anesthetic.
Relief of sympathetically maintained pain in the
lower limb.

Tips

Fig. 5.3.5

If fluoroscopy is not available ultrasound may aid


placement of the needle. A line 10cm 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
the outcome.

75

76

CHAPTER

Autonomic blockade

Fig. 5.3.7
Fig. 5.3.9

Potential problems

Fig. 5.3.8

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 510% 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.
Patients in the prone position should be monitored
carefully when intravenous sedation is administered.

5.4 Celiac plexus blockretrocrural approach

5.4 CELIAC PLEXUS BLOCKRETROCRURAL APPROACH


Anatomy
The celiac plexus is flat and lies against the crus of the
diaphragm, surrounding the root of the celiac and
mesenteric arteries and anterior to three vertebral bodies
centered at L1. Posteriorly on the left side is the aorta, and
on the right is the inferior vena cava. The kidneys lie
lateral and the pancreas anterior to the celiac plexus
(Fig. 5.4.1 a,b).
The celiac plexus is made up of pre- and postganglionic
sympathetic and parasympathetic nerve fibers.
Postganglionic sympathetic fibers are supplied from the
paired celiac ganglia. Preganglionic sympathetic efferents
from the thoracic sympathetic chain are supplied via the
greater and lesser splanchnic nerves. The intra-abdominal
viscera are supplied by postganglionic sympathetic fibers
Celiac artery

Celiac plexus

Liver

that have synapsed in the celiac ganglia (Fig. 5.4.2). The


vagus nerve also supplies parasympathetic nerve fibers. Via
the celiac plexus dorsal root, ganglion cells innervate the
whole of the abdominal viscera, including the liver, spleen,
kidneys, suprarenal glands, and intestines, with the
exception of the pelvic organs, the rectum, and the left half
of the colon.
Pain originating from the viscera is often vague and poorly
localized as a result of convergence of neurons in the
dorsal horn and crossing over the midline of some of the
visceral afferents.
There are two main approaches to celiac plexus blockade.
One approach places the two needles posterior to the crura
of the diaphragm, the retrocrural approach. The
retrocrural approach to the celiac plexus also targets the
splanchnic nerves to produce a splanchnic nerve block if
required. The other approach places a needle anterior to
the crus of the diaphragm on the right, the anterocrural
approach (Fig. 5.4.3), as discussed in Section 5.5.
Sympathetic chain
Dorsal root
Thoracic
spinal cord

Inferior
vena cava

Aorta

Splanchnic
nerve
Kidney
A

Kidney
L1

Somatic nerve
Grey
ramus

Diaphragmatic crus
Aorta
White ramus

Diaphragm

Ventral root
Vagus nerve

Retrocrural spread
Splanchnic nerve
Celiac plexus

Celiac
ganglion
Anterocrural
spread

Viscus

Splanchnic nerves
Diaphragmatic
crus
B

Fig. 5.4.1

Fig. 5.4.2

Superior
mesenteric ganglion

77

78

CHAPTER

Autonomic blockade

Equipment






RETROCRURAL APPROACH

2ml, 5ml, and 10ml syringes


30G needle
Two 15cm 22G needles
Extension set (optional)
ECG, BP, SpO2 monitors
Resuscitation equipment (see Appendix 3)
Fluoroscopy

Drugs
Mild sedative
Lidocaine (lignocaine) 1%, 5ml for skin infiltration
Lidocaine (lignocaine) 1%, 1520ml (or its equivalent)
for block
6% aqueous phenol or 5075% alcohol (ethanol). Our
suggestion: mix 2 parts absolute alcohol with one part
1% lidocaine. This will help reduce the incidence and
severity of pain following injection. In addition, precede
all alcohol injections with 34ml 1% lidocaine
Non-ionic radio-opaque contrast medium
Resuscitation drugs (see Appendix 3)

Position of patient
Prone.
Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.4.4).

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
Mild sedation may be induced.
Greater splanchnic nerve
Paravertebral
sympathetic trunk
Lesser splanchnic
nerve

A 15cm 22G spinal needle is selected. A slight curve at


the needle tip, away from the bevel direction, may be
created, which allows the needle to be redirected during
placement.
An AP view of the upper lumbar/low thoracic spine is
obtained and the C-arm is adjusted to superimpose the
T12L1 endplates.
A skin wheal is raised at the lower border of the
twelfth rib on the right just above the level of the L1
transverse process (Fig. 5.4.5 a). The needle is inserted
at this site and advanced at an angle 30 from
perpendicular inward until the L1 body is contacted
just below the upper endplate (Fig. 5.4.5). The curve
of the needle is turned laterally and the needle is
advanced along the upper portion of the body. Once the
needle has slipped a few millimeters past the lateral
aspect of the L1 body, a lateral view is obtained.
The curve of the needle is directed inward toward the
body and advanced until the tip lies at the anterior
border of the body, near the upper endplate, in a direct
lateral view.
Using live fluoroscopy, 1ml non-ionic contrast
medium is injected. The dye should remain against the
anterior aspect of the bodies in the lateral view
(Fig. 5.4.6 a).
If dye is seen spreading dorsally toward the neural
foramina (see Fig. 5.4.6 b), the needle should be
withdrawn and repositioned at a higher level.
An AP view is obtained, which should demonstrate dye
spread against the lateral aspect of the bodies
(Fig. 5.4.6 c).
Spread more laterally indicates injection within the
psoas muscle, in which case the needle should be
repositioned more medially and anteriorly. 3 ml
1% lidocaine is then injected. The dye shadow will

Thoracic duct
Azygos vein

T10

Diaphragm
Celiac plexus

T11

T12

Celiac axis
Superior
mesenteric
artery

L1

L2

Classic
celiac block

Aorta

Prevascular celiac block

Fig. 5.4.3

Fig. 5.4.4

5.4 Celiac plexus blockretrocrural approach

L1
12th Rib

L3

L2

12th Rib

L1

Kidney

Aortic
artery
Pancreas

Fig. 5.4.6

Kidney
Inferior
vena cava

Fig. 5.4.5

Liver

79

80

CHAPTER

Autonomic blockade

be seen to expand superiorly, spreading to the


thoracic levels to contact the splanchnic nerves
(see Fig. 5.4.6 d).
After confirming negative aspiration for blood,
1520ml alcohol or phenol is injected. The needle is
cleared with 1ml lidocaine prior to removal.
Alternatively, the needle can be advanced more
cephalad to a position at the anterior border of T12
preferably near either the lower or upper endplate
(Fig. 5.4.6 e).

Fig. 5.4.6, contd

Injection near the mid-point of the body is more likely


to result in dorsal spread of the drug toward the neural
foramen. More cephalad placement is a bit more
difficult technically, but places the needle closer to the
splanchnic nerves.
The procedure is repeated in an identical manner on the
left side.

Confirmation of a successful block


Relief of upper abdominal pain.

5.4 Celiac plexus blockretrocrural approach

Tips
After injection of non-ionic radio-contrast medium, a
blush will indicate injection into muscle. If visible
contrast medium disappears immediately it is likely that
intravascular injection has occurred.
Consideration should be given to performance of
the block under CT control if the block is
unsuccessful.
Placement of the needle anterior to the diaphragmatic
crus can also be achieved via insertion through the
abdominal wall.

Potential problems
The position of each needle tip should always be
confirmed with fluoroscopy before injection of neurolytic
agent as it may lie in the peritoneal cavity, within a
viscus or intravascularly. If a needle tip is placed too
superficially, the tip may come to lie in the intervertebral
foramen and injection may result in an epidural block or
a somatic nerve block. Injection of neurolytic solution
into the psoas muscle may cause rhabdomyolysis.
Perforation of the aorta or the inferior vena cava is
possible and consequently the block should be avoided
in patients with coagulopathy. Dissection of the aorta

may occur as a result of direct damage during the block.


Retroperitoneal hematoma may occur and for this
reason also the block should be avoided in patients with
coagulopathy.
Orthostatic hypotension may occur as a result of
sympathetic blockade for up to 3 days after a neurolytic
block. Diarrhea may occur also and hydration of the
patient should be monitored.
Pneumothorax may occur.
Transient motor paralysis and paraplegia may occur
after the block, probably as a result of spasm of the
segmental arteries.
Perforation of the intervertebral disc may occur, but this
also is usually of no clinical significance.
Perforation of the kidney or ureter is usually of
no clinical significance unless neurolytic agent is
injected.
The thoracic duct may be damaged (possibly causing
chylothorax, or lymphedema).
Abdominal and chest discomfort may be experienced for
30 minutes after injection of alcohol.
There may be a detectable odor from the breath after
alcohol injection.
Patients in the prone position should be monitored
carefully when intravenous sedation is administered.

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5.5 CELIAC PLEXUS BLOCKANTEROCRURAL APPROACH


Anatomy
The anterocrural approach places a needle anterior to each
crus of the diaphragm. The needles are inserted more
medially and directed at a larger angle towards the midline
until they come to lie in the retroperitoneal compartment
between the aorta, and the inferior vena cava dorsally, and
the pancreas ventrally (Fig. 5.5.1). Fluoroscopic imaging is
necessary for accurate placement of the anterocrural needles
using this approach.

Lidocaine (lignocaine) 1%, 1520ml (or its equivalent)


for block
6% aqueous phenol or 5075% alcohol (ethanol).
Our suggestion: mix 2 parts absolute alcohol with
one part 1% lidocaine. This will help reduce the
incidence and severity of pain following injection. In
addition, precede all alcohol injections with 34ml 1%
lidocaine
Non-ionic radio-opaque contrast medium
Resuscitation drugs (see Appendix 3)

Equipment
Position of patient

2ml, 5ml, and 10ml syringes


30G needle
15cm 22G needle (penetration of the diaphragmatic
crus is easier with a large gauge needle)
Extension set (optional)
ECG, BP, SpO2 monitors
Resuscitation equipment (see Appendix 3)
Fluoroscopy

Prone.
Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.5.2).

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
Mild sedation may be induced.

Drugs
Mild sedative
Lidocaine (lignocaine) 1%, 5ml for skin infiltration

Aorta
Diaphragm
Retrocrural spread
Celiac plexus

Anterocrural
spread

Splanchnic nerves
Diaphragmatic
crus

Fig. 5.5.1

5.5 Celiac plexus blockanterocrural approach

Fig. 5.5.2

The thoracolumbar midline and area 10cm5cm


laterally is cleaned with antiseptic solution and a
fenestrated drape is placed over the sterile area.
The twelfth rib and L1 are identified and confirmed
with fluoroscopy.

ANTEROCRURAL APPROACH
Right side
A 15cm 22G spinal needle is selected. A slight curve at
the needle tip, away from the bevel direction, may be
created which allows the needle to be redirected during
placement.
An AP view of the upper lumbar/low thoracic spine is
obtained and the C-arm is adjusted to superimpose the
T12L1 endplates.
A skin wheal is raised at the lower border of the twelfth
rib on the right just above the level of the L1 transverse
process. The needle is inserted at this site and advanced
at an angle 30 from perpendicular inward until the L1
body is contacted just below the upper endplate.
The curve of the needle is turned laterally and the needle
is advanced along the upper portion of the body.
Once the needle has slipped a few millimeters past
the lateral aspect of the L1 body, a lateral view is
obtained.
The needle is advanced until the tip is 1.52cm anterior
to the anterior border of the L1 body. The needle is
aspirated and if negative, 1ml non-ionic contrast is
injected. Dye spread should be in an amorphous pattern
(Fig. 5.5.3).
If aspiration is negative, 3ml 1% lidocaine (lignocaine)
is injected. If no nerve block is noted after 10 minutes,
this is followed by 1520ml alcohol. If phenol is used,
the lidocaine is not needed.

1ml 1% lidocaine is injected before removing the needle


to clear it.

Left side
The same procedure is repeated on the left.
The needle is positioned 1.52cm anterior to the
anterior border of the L1 body. It is then usually
within the aorta, and aspiration is positive for arterial
blood.
The needle is advanced forward until aspiration is
negative for blood (Fig. 5.5.3 b).
1ml contrast is injected. The pattern is generally
amorphous anteriorly, but a straight border of dye along
the anterior surface of the aorta may be seen (Fig. 5.4.4).
Aspiration is repeated and, if negative, 3ml 1%
lidocaine (lignocaine) is injected. If no nerve block is
noted after 10 minutes, this is followed by 1520ml
alcohol. If phenol is used, the lidocaine is not needed.
1ml 1% lidocaine is injected before removing the needle
to clear it.
Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.

Confirmation of a successful block


Relief of upper abdominal pain.

Tips
After injection of non-ionic radio-contrast medium, a
blush will indicate injection into muscle. If visible
contrast medium disappears immediately it is likely that
intravascular injection has occurred.
Consideration should be given to performance of the
block under CT control if the block is unsuccessful.

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Autonomic blockade
R

L
L1
12th Rib

L3

L2

12th Rib

L1

Kidney

Pancreas

Lesser splanchnic
nerve

Liver

Inferior
vena cava

Azygos vein

T10

Diaphragm

Celiac plexus

T11

T12

L1

Classic
celiac block

Kidney

Thoracic duct

Greater splanchnic nerve


Paravertebral
sympathetic trunk

Aortic
artery

Celiac axis

Superior
mesenteric
artery

L2

Aorta

Prevascular celiac block

Fig. 5.5.3

Potential problems
The position of each needle tip should always be
confirmed with fluoroscopy prior to injection of
neurolytic agent as it may lie in the peritoneal cavity,
within a viscus or intravascularly. If a needle tip is
placed too superficially, the tip may come to lie in the
intervertebral foramen and injection may result in
epidural block or a somatic nerve block. Injection of
neurolytic solution into the psoas muscle may cause
rhabdomyolysis.

Perforation of the aorta or the inferior vena cava is


possible and consequently the block should be avoided
in patients with coagulopathy. Dissection of the aorta
may occur as a result of direct damage during the block.
Retroperitoneal hematoma may occur and for this
reason also the block should be avoided in patients with
coagulopathy.
Orthostatic hypotension may occur as a result of
sympathetic blockade for up to three days after a
neurolytic block. Diarrhea may occur also and hydration
of the patient should be monitored.

5.5 Celiac plexus blockanterocrural approach

Pneumothorax may occur.


Transient motor paralysis and paraplegia may occur
after the block, probably as a result of spasm of
segmental arteries.
Perforation of the intervertebral disc may occur, but this
also is usually of no clinical significance.
Perforation of the kidney or ureter is usually of no
clinical significance unless neurolytic agents are injected.

The thoracic duct may be damaged (possibly causing


chylothorax, or lymphedema).
Abdominal and chest discomfort may be experienced for
30 minutes after injection of alcohol.
There may be a detectable odor from the breath after
alcohol injection.
Patients in the prone position should be monitored
carefully when intravenous sedation is administered.

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5.6 HYPOGASTRIC PLEXUS BLOCK


Anatomy

Equipment

The superior hypogastric plexus is formed from pelvic


sympathetic fibers of the aortic plexus and L2 and L3
splanchnic nerves. These afferent and efferent fibers
innervate the pelvic viscera, including the uterus, bladder,
vagina, and prostate. The plexus is located between the
upper third of the first sacral vertebral body and the lower
third of the fifth lumbar vertebral body, at the sacral
promontory, in the retroperitoneal space (Fig. 5.6.1 a,b).
Parasympathetic nerve fibers from S2S4 pass through the
inferior hypogastric plexus.

2ml, 5ml, and 10ml syringes


30G needle
Two 15cm 22G needles
Extension set (optional)
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)
Fluoroscopy

A
Inferior vena cava
Aorta

Superior
hypogastric plexus

Superior
rectal artery
Internal iliac
artery and vein

External iliac
artery and vein

Fig. 5.6.1

Psoas major
muscle

5.6 Hypogastric plexus block

Drugs
Lidocaine (lignocaine)1%, 5ml for skin infiltration
Lidocaine (lignocaine)1%, 1520ml (or its equivalent)
for block
Phenol6%
Non-ionic radio-opaque contrast medium
Resuscitation drugs (see Appendix 3)

Position of patient
Prone.
Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.6.2).

Needle puncture and technique


Intravenous access is inserted.
Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The lumbosacral midline and area 10cm5cm
laterally is cleaned with antiseptic solution and a
fenestrated drape is placed over the sterile area.
The iliac crests are palpated and the intercrestal line is
identified (this corresponds with the inferior aspect of
the spinous process of L4 or may lie in the L45
interspace).
The spinous processes are counted until the L5S1
interspace is identified and confirmed with fluoroscopy.
The insertion points lie 2cm lateral and 2cm cephalad
to the space between the L5 transverse process and the
sacrum (Fig. 5.6.3 a,b).
A skin wheal is raised at one of the marked sites and
the area is infiltrated with lidocaine (lignocaine)1%.
At a 30 angle to the frontal plane, a 22G 15cm
needle is advanced, aimed slightly caudad towards the
L5S1 interspace (Fig. 5.6.3 c), until the lower part of

the L5 vertebral body is contacted at a depth of about


79cm and confirmed with fluoroscopy. If the needle
contacts bone at a more superficial level, it is probable
that it has come into contact with the L5 transverse
process or the sacrum and needs to be repositioned.
The needle depth is noted.
The needle is then withdrawn to the subcutaneous tissue
and, with the aid of fluoroscopy, it is re-advanced, this
time at an angle 45 to the frontal plane (or with slight
concavity of the needle) until the previous depth (as
noted) is reached. It should slip past the vertebral body
at a depth about 12cm deeper than the first depth
mark, to lie just anterior to the upper portion of the
sacrum (Fig. 5.6.4).
After negative aspiration, the fluoroscopic image is
observed as a small amount of non-ionic radio-contrast
medium is injected (Fig. 5.6.5). The correct placement of
the needle is indicated by the presence of a collection of
contrast medium just anterior to the upper portion of
the sacrum or the L5S1 interspace (Fig. 5.6.6). The
contrast medium usually spreads in all directions, not
usually along the sacrum.
The procedure is repeated on the other side in a
mirrored fashion (Figs 5.6.7, 5.6.8).
After further negative aspirations, 5ml of lidocaine
(lignocaine) 1% is injected bilaterally and the patient is
questioned about pain relief. There should be little
resistance to injection, similar to that felt when injecting
through an epidural needle. If resistance is encountered,
or if the injection is painful, the needle should be
repositioned.
After 10 minutes the patient is questioned about pain
relief and any symptoms of somatic nerve blockade.
Sensory and motor functioning of the lower extremities
is checked. The procedure should be abandoned if there
is evidence of somatic blockade.
After confirmation of pain relief and lack of somatic
block, 6ml phenol 6% is injected through each needle
using glass syringes. The needles are then cleared with
air or local anesthetic 1ml, and removed.
Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.
Ultrasound may help placement of the needle
(Figs 5.6.95.6.10).

Confirmation of a successful block


Relief of lower abdominal pain.

Tips

Fig. 5.6.2

After injection of non-ionic radio-contrast medium, a


blush will indicate injection into muscle. If this
disappears immediately it is likely that intravascular
injection has occurred.

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Fig. 5.6.3

Consideration should be given to performance of the


block under CT control if the block is unsuccessful
(Fig. 5.6.10).

Potential problems
The position of each needle tip should always be
confirmed with fluoroscopy prior to injection of
neurolytic agents as it may lie in the peritoneal cavity,
within a viscus or intravascularly. If a needle tip is
placed too superficially, the tip may come to lie in the

intervertebral foramen and injection may result in an


epidural block or a somatic nerve block. Injection of
neurolytic solution into the psoas muscle may cause
rhabdomyolysis.
Perforation of the aorta or the inferior vena cava is
possible and consequently the block should be avoided
in patients with coagulopathy. Dissection of the aorta
may occur as a result of direct damage during the block.
Retroperitoneal hematoma may occur and for this
reason also the block should be avoided in patients with
coagulopathy.

5.6 Hypogastric plexus block

Fig. 5.6.4

Fig. 5.6.6

Fig. 5.6.5

Fig. 5.6.7

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Autonomic blockade

Orthostatic hypotension may occur as a result of


sympathetic blockade for up to three days after a
neurolytic block. Diarrhea may occur also and hydration
of the patient should be monitored.
Transient motor paralysis and paraplegia may occur
after the block, probably as a result of spasm of
segmental arteries.
Perforation of the intervertebral disc may occur, but this
is usually of no clinical significance.

Superior
hypogastric
plexus
Bifurcation of
iliac vessels

Psoas
major muscle

Fig. 5.6.8

Fig. 5.6.9

Fig. 5.6.10

5.7 Ganglion impar block

5.7 GANGLION IMPAR BLOCK


Anatomy

Equipment

The ganglion impar is a retroperitoneal sympathetic


ganglion located at the level of the sacrococcygeal junction
(Fig. 5.7.1). Above the level of this ganglion the
sympathetic chains are paired. Sympathetic afferents from
the perineum, distal rectum and anus, distal urethra, vulva
and the distal third of the vagina converge in the ganglion
impar.

2ml, 5ml, and 10ml syringes


30G needle
22G spinal needle
Extension set (optional)
ECG, BP, and SpO2 monitors
Resuscitation equipment (see Appendix 3)

Drugs
Lidocaine (lignocaine) 1%, 5ml for skin infiltration
Lidocaine (lignocaine) 1%, 1520ml (or its equivalent)
for block
Phenol 6%
Non-ionic radio-opaque contrast medium
Resuscitation drugs (see Appendix 3)

L5

S1

Position of patient

S2

Prone.
Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.7.2).

S3
S4

Needle puncture and technique

S5
Sacrococcygeal
junction

Coccyx

Ganglion impar

Anococcygeal
ligament

Marks entrance
point of needle

Fig. 5.7.1

Fig. 5.7.2

Intravenous access is inserted.


Monitors are attached.
Resuscitation equipment and drugs are checked and
made ready for use.
The midline along the intergluteal groove and an area
10cm5cm laterally is cleaned with antiseptic

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solution and a fenestrated drape is placed over the


sterile area.
A skin wheal is raised at the superior aspect of the
intergluteal groove, just above the anus, over the
anococcygeal ligament (Fig. 5.7.3).
The stylet from the 22G spinal needle is removed, and
the needle is bent with the fingers to form a 30 angle,
approximately 2cm from the hub.
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).

After negative aspiration, the fluoroscopic image is


observed as a small amount of non-ionic radio-contrast
medium is injected. The correct placement of the needle
is indicated by the presence a small round blob of
contrast medium at the anterior border of the vertebral
column (Fig. 5.7.5 a,b).
Lidocaine (lignocaine) 1% 5ml is injected for ganglion
blockade.

Iliac crest
Posterior suprior
iliac spine
Sacral cornua
Sacral hiatus
Coccyx
Anococcygeal
ligament

Anus

Fig. 5.7.3

Sacrococcygeal junction
Ganglion impar
Retroperitoneal
space

Anococcygeal
ligament

Sacrum

Anus
Rectum

Fig. 5.7.4

Fig. 5.7.5

5.7 Ganglion impar block

After 10 minutes the patient is questioned about pain


relief and any somatic blockade. Sensory and motor
functioning of the lower extremities is checked. The
procedure should be abandoned if there is evidence of
somatic blockade.
After confirmation of pain relief and lack of somatic
block, 5ml of phenol 6% is injected using a glass
syringe. To avoid leaving alcohol in the needle tract the
needle is then cleared with air or local anesthetic 1ml,
and removed.
Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.

Confirmation of a successful block


Relief of perineal pain.

Tips
To aid access to the anococcygeal ligament an assistant
may be asked to retract the skin of the buttock; after
penetration of the skin, this is no longer required.
Exaggerated anterior curvature of the sacrococcygeal
vertebral column may inhibit access and it may be
necessary to bend the needle to a more acute angle.

Potential problems
The position of each needle tip should always be
confirmed with fluoroscopy prior to injection of
neurolytic agent as it may lie in the peritoneal cavity,
within a viscus or intravascularly. Caudal epidural
placement of the needle is possible, therefore it is
essential that spread of contrast material is observed
to be restricted to the retroperitoneum, and that
a test dose produces no somatic nerve blockade.
Perforation of the rectum or periosteal injection is
also possible.
Local tumor invasion may inhibit spread
of solution.
Retroperitoneal hematoma may occur and the block
should be avoided in patients with coagulopathy.
Diarrhea may occur also and hydration of the patient
should be monitored.
There may be a detectable odor from the breath after
alcohol injection.
Patients in the prone position should be
monitored carefully when intravenous sedation is
administered.

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5.8 INTRAVENOUS REGIONAL SYMPATHETIC


BLOCKUPPER LIMB
Anatomy

Drugs

Peripheral sympathetic blockade is achieved by limiting the


effect of the sympatholytic agent to the tissues of the
affected limb using a tourniquet. Intravenous injection of
an agent that releases endogenous norepinephrine
(noradrenaline) from sympathetic nerve endings causes
depletion of this neurotransmitter, and thereby chemical
sympathetic blockade.

Lidocaine (lignocaine) 0.5% without epinephrine/


adrenaline, or its equivalent
Bretylium 1.5mg/kg (or its equivalent, e.g. guanethedine
0.25mg/kg)
Saline (NaCl) 20ml
Resuscitation drugs (see Appendix 3)

Equipment





20ml syringe
Two i.v. cannulae
Pneumatic tourniquet
ECG, BP, and SpO2 monitors
Skin temperature monitor
Resuscitation equipment (see Appendix 3)

Fig. 5.8.1

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 (Fig. 5.8.1 a).
Monitors are attached.

5.8 Intravenous regional sympathetic blockupper limb


Temperature probe

Fig. 5.8.3

It is then deflated in one step, but left in place.


Re-inflation may be required if there is a precipitous
change in blood pressure.
Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.

Confirmation of a successful block

Fig. 5.8.2

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. 5.8.1 b).
With the limb raised, it is exsanguinated by applying a
tight wrap, e.g. Esmarch bandage.
A thin layer of padding is applied, e.g. Velband, under
the tourniquet site.
The tourniquet is applied and the cuff is inflated to a
pressure 100mmHg higher than the systolic blood
pressure (Fig. 5.8.2).
The limb is then lowered. A mixture of lidocaine
(lignocaine) 0.5% 15ml (without epinephrine/
adrenaline), bretylium 1.5mg/kg (or guanethidine
0.25mg/kg), and NaCl to make a total volume of 40ml
(a final lidocaine (lignocaine) solution of 0.25%), is
injected through the i.v. cannula in the affected limb.
The tourniquet is allowed to remain inflated for at least
30 minutes.

Relief of sympathetically maintained pain.


Measurements of skin temperature of the affected limb
before and after the block should demonstrate
temperature increase. However, the sympatholytic effect
of the drug may not be immediate (Fig. 5.8.3).

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 hand 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
(Figs 5.8.4, 5.8.5) rather than proximally (Figs 5.8.6,
5.8.7), 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 oxideoxygen mixture may improve comfort.
Repeated blocks may bring about gradual improvement
in sympathetically maintained pain.

95

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Autonomic blockade

Fig. 5.8.4

Fig. 5.8.6

Fig. 5.8.5

Fig. 5.8.7

Immediate physiotherapy after block may improve


outcome.

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/
noradrenaline when unfixed bretylium enters the

circulation. Systemic toxicity of lidocaine (lignocaine) may


also occur, 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.

5.9 Intravenous regional sympathetic blocklower limb

5.9 INTRAVENOUS REGIONAL SYMPATHETIC


BLOCKLOWER LIMB
Anatomy
As in the case of the upper limb, peripheral sympathetic
blockade is achieved by limiting the effect of the
sympatholytic agent to the tissues of the affected limb
using a tourniquet. Intravenous injection of an agent
releases endogenous norepinephrine (noradrenaline) from
sympathetic nerve endings, which causes depletion of this
neurotransmitter, and may bring about a chemical
sympathetic block.

Equipment





50ml syringe
Two i.v. cannulae
Pneumatic tourniquet
ECG, BP, and SpO2 monitors
Skin temperature monitor
Resuscitation equipment (see Appendix 3)

thrombosis. Inflation of this second cuff may aid


limitation of spread of sympatholytic agent to the
periphery (Fig. 5.9.3).
The limb is then lowered and a mixture of lidocaine
(lignocaine) 0.5% 25ml (without epinephrine),
bretylium 1.5mg/kg (or its equivalent) and NaCl to
make a total volume of 40ml (a final lidocaine/
lignocaine solution of 0.25%) is injected through the i.v.
cannula in the affected limb.
The tourniquet is allowed to remain inflated for at least
30 minutes.
It is then deflated in one step, but left in place.
Re-inflation may be required if there is a precipitous
change in blood pressure.

Drugs
Lidocaine (lignocaine) 0.5% without epinephrine
(adrenaline), or its equivalent
Bretylium 1.5mg/kg (or its equivalent, e.g. guanethedine
0.5mg/kg)
Saline (NaCl) 30ml
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
100mmHg 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

97

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Autonomic blockade

Monitors should be left attached and i.v. access left in


situ for at least 30 minutes.

Confirmation of a successful block


Relief of sympathetically maintained pain.
Measurements of skin temperature of the affected limb
before and after the block should demonstrate
temperature increase (Fig. 5.9.4).

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 oxideoxygen 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

Fig. 5.9.3

Fig. 5.9.4

5.9 Intravenous regional sympathetic blocklower limb

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

99

MUSCLE INJECTIONS

Myofascial pain occurs commonly in the muscles of


the upper and lower back. It is characterized by pain
associated with movement of the affected muscles that
develop areas of extreme tenderness, termed trigger points.
Palpation of these points is usually perceived as a tight
band or firm nodule in the muscle and reproduces pain
that may be referred some distance from the site of
palpation. Involuntary muscular contraction can occur on
palpation, and snapping palpation can result in a local
twitch response. Electromyography (EMG) is not reliable
in diagnosing myofascial pain syndrome and it is worth
remembering that this syndrome may occur in association
with underlying painful disorders of the spine.

Fibromyalgia is a pain syndrome characterized by


widespread, diffuse and usually symmetrical tender areas of
muscles. Bony structures, such as costochondral junctions
and lateral epicondyles, produce local pain, but not
referred, on palpation of tender points. Injection of these
tender areas typically does not improve the pain of
fibromyalgia.

Injection of trigger points with local anesthetic, especially


if repeated several times and combined with stretching
exercises, may have a beneficial therapeutic effect on the
pain of myofascial pain syndrome. Pain reproduction
during injection, followed by relief of pain after injection,
that lasts at least as long as the expected local anesthetic
effect, indicates that these painful points contribute to
myofascial pain syndrome.

The optimum number of trigger-point injections required


to produce pain relief is variable. The injection sites may
themselves be painful after the local anesthetic wears off.
This may exacerbate muscle spasm if too many triggerpoint injections are performed. Consideration should be
given to the severity of the muscle spasm, the number of
trigger points, and to the sensitivity of the patient to pain
when deciding on the number of injections.

Usually a dilute solution of local anesthetic suffices for


beneficial effect. Bupivacaine produces more muscle
degeneration than any other local anesthetic when injected
into a muscle, and consequently it is usually avoided,
lidocaine (lignocaine) being the usual local anesthetic of
choice.

102

CHAPTER

Muscle injections

6.1 TRIGGER-POINT INJECTIONSNECK AND THORAX


Anatomy

Equipment

The muscles most often involved in myofascial pain


syndrome of the neck include the trapezius, rhomboid
minor and major, latissimus dorsi, levator scapulae and
splenius capitis (Fig. 6.1.1; see also Fig. 2.1.2).

10ml syringe
25G needle

Drugs
Lidocaine (lignocaine) 1% 10ml

Position of patient
Trapezius
Levator
scapula
Rhomboid
minor
Rhomboid
major

Latissimus
dorsi

Fig. 6.1.1
Relaxed muscle
fibers

Prone.
Pillow under chest to allow the neck to flex.
The sitting position is also used, but vasovagal response
may follow trigger-point injections especially in young
adults, and it is probably more prudent to use the prone
position.

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).
A 25G needle with syringe attached is inserted into a
trigger point (Fig. 6.1.4).
After negative aspiration, 23ml of lidocaine
(lignocaine) 1% is injected into the trigger point while
moving the needle back and forth through the muscle.
After injection, the next trigger point is injected in the
same manner (Fig. 6.1.5 a,b).

Confirmation of a successful injection

Trigger point

Pain reproduction when the needle enters the muscle


confirms correct placement.

Local twitch

Fig. 6.1.2

Fig. 6.1.3

6.1 Trigger-point injectionsneck and thorax

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
Fig. 6.1.4

Pain on injection.
Vasovagal response (especially in young adults in the
sitting position).
Pneumothorax (especially in thin patients).

Skin
Subcutaneous
tissue
Muscle

Trapezius

Supraspinatus
(under trapezius)
Infraspinatus
Teres minor
Teres major

Fig. 6.1.5

103

104

CHAPTER

Muscle injections

6.2 TRIGGER-POINT INJECTIONSBACK


Anatomy

Drugs

The muscles most often involved in myofascial pain


syndrome of the back include the erector spinae (the
longissimus, iliocostalis, and spinalis columns) and the
deep transversospinal (semispinalis, multifidus, and
rotatores) muscles (Fig. 6.2.1 a,b). In the buttocks,
spasm of the gluteus medius muscle may also cause
significant pain.

Lidocaine (lignocaine) 1% 10ml

Equipment
10ml syringe
25G needle

Position of patient
Prone.
Pillow under abdomen to straighten the normal lumbar
lordosis (Fig. 6.2.2 a).
The sitting position is also used, but vasovagal response
may follow trigger-point injections, and it is probably
more prudent to use the prone position.
Alternatively, the semiprone position will also allow
access to affected muscles (Fig. 6.2.2 b).

Psoas major
Quadratus
lumborum

External oblique
Latissimus dorsi
Longissimus
and iliocostalis

Quadratus
lumborum

Internal oblique

Interspinalis
Multifidus

Fig. 6.2.1

Fig. 6.2.2

Iliocostalis

Longissimus

6.2 Trigger-point injectionsback

Needle puncture and technique


The midline and the surrounding area are cleaned with
antiseptic solution.
Trigger points in the muscles are identified by palpation
and marked (Fig. 6.2.3).
A 25G needle with syringe attached is inserted into a
trigger point (Fig. 6.2.4).
After negative aspiration, 23ml of lidocaine
(lignocaine) 1% is injected into the trigger point while
moving the needle back and forth through the muscle
(Fig. 6.2.5).

After injection, the next trigger point is injected in the


same manner.

Confimation of a successful injection


Pain reproduction when the needle enters the muscle
confirms correct placement.

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 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

Fig. 6.2.4

Fig. 6.2.5

105

106

CHAPTER

Muscle injections

6.3 GLUTEUS MEDIUS INJECTION


Anatomy
When the buttock muscles are relaxed the quadratus
femoris, gemelli and gluteus medius muscles can be
palpated. Spasm of the gluteus medius muscle (Fig. 6.3.1)
may be the source of buttock pain and may respond to
trigger-point injection. Unlike pirformis muscle spasm, this
does not produce symptoms of sciatic nerve irritation but
causes localized pain, often referred to the posterior thigh
and calf.

The greater trochanter is palpated.


The insertion point of the needle lies approximately
2cm medial and superior to the greater trochanter
(Figs 6.3.3, 6.3.4).
A 22G needle is introduced in a direction vertical to the
skin and advanced until it is felt to be gripped by the
tense muscle (Fig. 6.3.5).

Equipment
10ml syringe
22G needle

Drugs

Fig. 6.3.2

Lidocaine (lignocaine) 1% 10ml


Gluteus minimus

Position of patient
Prone.
Pillow under abdomen to flatten the normal lumbar
lordosis (Fig. 6.3.2).

Needle puncture and technique


The surface of the buttock and hip is cleaned with
antiseptic solution.
The posterior superior iliac spine is palpated and marked.
Gluteus medius
Gluteus maximus

Fig. 6.3.3
Gluteus medius

Gluteus maximus

Fig. 6.3.1

Fig. 6.3.4

6.3 Gluteus medius injection

Skin
Subcutaneous
tissue
Muscle

Gluteus medius

Fig. 6.3.5

Fig. 6.3.6

After negative aspiration, lidocaine (lignocaine) 1%


3ml is injected in the substance of the muscle while
moving the needle back and forth in the muscle
(Fig. 6.3.6).
The procedure is repeated if other trigger points are
present in the muscle.

Tips

Confirmation of a successful injection


Pain reproduction when the needle enters the muscle
confirms correct placement of the needle.
Relief of pain on abduction of the hip.

For best results injection is carried out in a fan-like


manner by repeatedly withdrawing the needle slightly
and redirecting it (see inset in Fig. 6.3.6).

Potential problems
Sciatic nerve block: although this is unusual because the
injection site is not very close to the sciatic notch, it is
prudent to warn the patient of the possibility.
Infection or abscess formation.

107

108

CHAPTER

Muscle injections

6.4 PIRIFORMIS INJECTION


Anatomy

Needle puncture and technique

The piriformis muscle inserts into the pelvic surface of the


sacrum from the second to the fourth segments, lateral to
the anterior sacral foramina, and passes out of the pelvis
through the greater sciatic foramen to insert into the
superior aspect of the greater trochanter (Fig. 6.4.1). It
overlies the sciatic nerve in the greater sciatic foramen.
Contraction contributes to abduction of the lower limb.
Spasm of the muscle in myofascial pain syndrome often
causes pain referred to the posterior thigh and calf.

The surface of the buttock and hip is cleaned with


antiseptic solution and a fenestrated drape is placed over
the sterile area.
The posterior superior iliac spine is palpated and
marked.
The greater trochanter is palpated and marked.
The insertion points of the needle lie at the points
one-third and two-thirds along, and 13cm below the
line connecting these two marks (Figs 6.4.3 a,b,c).
The first insertion point, the medial one, is infiltrated
with lidocaine (lignocaine) 1% 2ml.
A 22G spinal needle is introduced in a direction vertical
to the skin and advanced until it is felt to be gripped by
the tense piriformis muscle, or until bone is contacted
(Figs 6.4.4, 6.4.5).
The end-point is a fascial click at a depth of about
45cm, depending on the thickness of adipose tissue.
The patient is questioned about the presence of pain,
paresthesia, and changes in sensation in the distribution
of the sciatic nerve, while the needle is being advanced.
If these symptoms arise, the needle may be in contact
with the sciatic nerve and should be repositioned. It is
also possible that spasm of the muscle on needle
insertion may produce these symptoms and often
reproduction of pain occurs with entry into the
muscle.
After negative aspiration, lidocaine (lignocaine) 1% 5ml
is injected.
Ultrasound may aid placement of the needle
(Fig. 6.4.6 a,b)

Equipment
2ml syringe and two 5ml syringes
25G needle
22G spinal needle, end-opening

Drugs
Lidocaine (lignocaine) 1% 10ml (or its equivalent)

Position of patient
Prone.
Pillow under abdomen to flatten the normal lumbar
lordosis (Fig. 6.4.2).

Confirmation of a successful injection


Relief of pain on abduction of the lower limb against
pressure on the lateral knee in the sitting position.

Tips
Piriformis
muscle

If injection is not successful in relieving the pain, it may


be repeated at the lateral insertion point. This lies at a

Sciatic nerve

Fig. 6.4.1

Fig. 6.4.2

6.4 Piriformis injection

Sacral cornua

Sacral cornu

Sciatic nerve

Posterior superior
iliac spine

Posterior superior
iliac spine

Piriformis
muscle

Piriformis
muscle
A

Fig. 6.4.3

Sciatic nerve

Gluteus
minimus

Greater
trochanter

Greater
trochanter

109

110

CHAPTER

Muscle injections

Fig. 6.4.4

Piriformis
muscle

Fig. 6.4.5

point two-thirds along and 13cm below the line


joining the posterior superior iliac spine and the greater
trochanter.

Potential problems
Sciatic nerve block.
Infection or abscess may occur (rarely).

Fig. 6.4.6

TRANSCUTANEOUS
ELECTRICAL NERVE
STIMULATION (TENS)
Transcutaneous electrical nerve stimulation is thought to
modify pain appreciation by stimulation of large fibers
thereby blocking (or closing the gate to) smaller C-fibers
carrying nociceptive impulses. There is also evidence that
high-frequency stimulation of the skin increases latency
and decreases maximum firing rates in small afferent fibers.
This can produce conduction blockade in C-fibers as the
current is increased, probably via potassium efflux from
the axon. It is thought that a combination of these actions
is responsible for the analgesia derived from the use of
TENS. This is probably not related to opiate-mediated
mechanisms when conventional parameters are used.
Not all pain responds to TENS. If the usual parameters do
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 12Hz and may also
relieve pain that is not responsive to conventional TENS.

Control settings (Figs 7.1.1, 7.1.2)


CONTINUOUS STIMULATION



Amplitude set to zero.


Pulse width set to midrange.
Switch to continuous mode.
Increase pulse amplitude level gradually to the
maximum level for comfort (sensation should be strong
but not painful).
Adjust pulse frequency to maximum level for comfort
(amplitude may be reduced as pulse width is increased).
Adjust pulse width to maximum level for comfort.
Maintain for 4560 minutes.

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
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
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
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

Rectangular

Triangular

Sine wave

Exponential

Biphasic

Asymmetric

112

CHAPTER

Transcutaneous electrical nerve stimulation (TENS)

High frequency

Low frequency

Trains of impulses

Fig. 7.1.2

Modulated settings
BURST STIMULATION



All controls set to zero.


Switch to pulsed mode.
Frequency set to 12Hz.
Increase amplitude and pulse width as with continuous
mode described above.
Maintain for 4560 minutes.

LOW-FREQUENCY HIGH-INTENSITY STIMULATION


All controls set to zero.
Increase amplitude to level where the muscle underlying
the electrodes twitches visibly but not painfully.
Increase frequency to 24Hz.
Maintain for short period (515 minutes).

All the types of stimulation should be tried for each pain,


and the effects on the pain should be compared. The
optimum parameters must be found by trial and error.
The patient is usually advised to begin by using TENS
for at least one hour three times a day. Once the effect
of TENS on the pain is known it is recommended that
stimulation should be discontinued after 30 minutes if the
patient experiences one or more hours of analgesia from
a single application. If pain relief is achieved only during
stimulation, the unit can be kept on constantly. However,
electrode sites should be changed every 24 hours.
Occasionally, skin rash under the electrodes may occur
and this problem may be minimized by frequent rotation
of the electrode sites and with topical steroids. However,
very few side effects are associated with the use of TENS.
Electrical skin burns may occur if TENS is applied to
skin with poor innervation and it is necessary to ensure
that there is normal sensation prior to applying the
electrodes. Allergic reaction to the electrodes or the
adhesive tape has also been described, but is not
common.
Use of TENS is contraindicated on areas over the
anterior neck (stimulation of carotid sinus, larynx), over
the pregnant uterus or in the presence of a cardiac
pacemaker.
Note: Description of the insertion technique of a
spinal cord stimulator or peripheral nerve stimulator is
outside the scope of this text as the techniques are specific
to the different types of stimulator.

APPENDIX

SUGGESTED
CORTICOSTEROIDS

Equivalent dosage
(mg)

Anti-inflammatory
potency (relative)

Mineralocorticoid
potency (relative)

Drug name

Duration of action

Triamcinolonea

1236h

Methylprednisolone

1236h

0.5

Dexamethasone

48h

0.75

Hydrocortisone

12h

20

25

Triamcinolone diacetate recommended for central neuroaxial injections.

Corticosteroid injection side effects


LOCAL SIDE EFFECTS



Atrophy of subcutaneous tissue


Rupture of injected tendon
Depigmentation of skin
Infection

SYSTEMIC SIDE EFFECTS (HIGHER INCIDENCE


WITH LARGER DOSES)







Skin flushing
Irregularity of the menstrual cycle
Impaired glucose tolerance
Osteoporosis
Muscle wasting and myopathy
Arthropathy
Suppression of adrenal function
Psychologic upset

APPENDIX

SUGGESTED NEUROLYTIC
AGENTS

Aqueous phenol 6%.


Alcohol 100% may be diluted to 50% (pain on injection
may be experienced and it is recommended that the
nerve is blocked with local anesthetic prior to injection).

APPENDIX

RECOMMENDED RESUSCITATION
DRUGS AND EQUIPMENT

SUGGESTED RESUSCITATION DRUGS


Drug

Suggested dosage (70kg adult)

Indication

Atropine

0.20.4mg i.v. increments

Bradycardia from vagal dominance

Ephedrine

510mg i.v. increments

Hypotension from sympathetic block

Lidocaine (lignocaine)

50100mg i.v. bolus

Ventricular arrhythmias

Midazolam

13mg i.v. increments

Local anesthetic; seizure activity

Diazepam

2.55mg i.v. increments

Local anesthetic; seizure activity

Thiopental (thiopentone)

50100mg i.v. increments

Local anesthetic; seizure activity

Succinylcholine

50100mg i.v. bolus

Muscle relaxation; airway control

It is also recommended that the full range of drugs required for advanced cardiac life support (ACLS), including pre-filled
syringes, be available in the operating room.

Suggested resuscitation equipment







Oxygen source
Bag and masks (full range)
Breathing system for positive pressure ventilation
Oro- and nasopharangeal airways (full range)
Laryngoscopes and blades (full range)
Endotracheal tube stylets and forceps, e.g. Magills
forceps

APPENDIX

DERMATOMES

C2
C2

C3

C3

C4

T2
T1
C6
C7
C8

C5

C5
T2
T2
T1
C6

T1
C6

L1
C7
C8

S3

C5
T2
T1
S1

L3
S5
C7

S3

T1
C4

T2
3
4
5
6
7
8
9
10
11
12
L1

C4
T2
3
4
5
6
7
8
9
10
11
12

C5

C3

L2

C8

S3

C6

Coc
L2

S4

C7
C8

S4

L2
L2

S2

S2

S2

L3

L3

L3
S2

L4

L5

L5

S1

L4

L5
L4

L5
L5

S1
S1

Fig. A.4.1

S1

Fig. A.4.2

S1

L4
S1
L5

120

Appendix 4

L3

L3

L5

L5
S2

S2

L4

L2

L2

L4

L2

S4
S3

S3

L2

S1

S1
L5

Coc

S1

L5

S1

S5

Fig. A.4.3

C2

C3
C4
C5

C6
C7

C8

L2
L5

S2

S1
L4

C5

T2
3
4
5
6
7
8
9
10
11
12
L1
L3

T1

S3

C8

C7

L2
S4
S5

L3

C6
T1

L5

S2

S1
L3

L4

Coc

C2

C3
C6
T1
C8

C4

C5

C4

T2

C5
T2

T2
3
4
5
6
7
8
9
10
11

C7

C6
T1
C7

C8

12
S1
L5

Fig. A.4.4

L2
L4

L3

L1
S3

S3

L2
L3

L4

S1
L5

Appendix 4

C2
C3
C4

C4
T2
3
4
5
6

C5
T2
L3

C3 C4 T2 3 4

C6

6 7 8 9 10 11 12 L1

T1

C7

C5

T2

7
8
9
10
11
12

S3

C2

C5

T1

C7

L1
S3
S4

C8

L2

L2

C6

L2

T1
L3

C7
C8

L3

S2

L3

L4
L4

L4

L5
L5

S1
S1

Fig. A.4.5

Fig. A.4.6

C6

L5

S1

C8

121

APPENDIX

SPINAL CORD SEGMENTAL


MYOTOMES

Each muscle in the body is supplied by a particular level or


segment of the spinal cord and by its corresponding spinal
nerve.

C5 also supplies the shoulder muscles and the muscle


that we use to bend our elbow.
C6 is for bending the wrist back.
C7 is for straightening the elbow.
C8 bends the fingers.
T1 spreads the fingers.

C5

T1T12 supplies the chest wall and abdominal muscles.


L2 bends the hip.
L3 straightens the knee.
L4 pulls the foot up.
L5 wiggles the toes.
S1 pulls the foot down.
S3, S4 and S5 supply the bladder, bowel and sex organs,
and the anal and other pelvic muscles.

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
S1,2

Fig. A.5.1

C7,8

APPENDIX

LUMBO-SACRAL SPINE
ANATOMY

Spinal cord
Pia mater
Arachnoid
Dura mater
L1
Conus
medullaris

L1
L2
L2

Cauda equina

L3

Ligamentum
flavum (L34)

L3
L4

Epidural space

L4
Internal filum
terminale

L5
L5

Sacrum
Sacrum

Distal dural sac


S1

External filum
terminale

S2
S3
S4

Coccyx

Fig. A.6.1

S5

127

INDEX
Page numbers followed by f indicate figures, t indicate tables, and b indicate boxes.

A
abdominal discomfort, 81, 85
abdominal viscera, 77
abscess
epidural, 33
post-gluteus medius injection, 107
ACLS (advanced cardiac life support),
117
action potentials, 1
adipose tissue, 108
adrenal function suppression, 113
adrenaline see epinephrine
advanced cardiac life support (ACLS),
117
air
in interpleural block, 43
in lumbar epidural block, 20
in thoracic epidural block, 23
in thoracic nerve root block, 53
alcohol, 115
in celiac plexus block
anterocrural approach, 83, 85
retrocrural approach, 8081
in ganglion impar block, 93
allergic reaction
caudal epidural block, 33
cervical epidural block, 29
lumbar epidural block, 20
thoracic epidural block, 24
allodynia, 1
analgesia
opiate-mediated mechanisms and, 111
unpredictable, 46
analgesics, mild, 15
anemia, sickle cell, 96, 99
anesthetics, local see local anaesthetics
anococcygeal ligament, 93
anterior costotransverse ligament,
51f52f
anterior scalenus, 70f
anterior superior iliac spine
in autonomic blockade, 73, 78, 82, 87,
91
in joint injections, 4, 12
in somatic nerve blockade, 47, 55
anterocrural spread, 77f, 82f
anteromedial capsule, 6, 10
anus, 9192, 92f
anxiety, 2
aorta
anatomy, 77
dissection, 84, 88
perforation, 76, 81, 84, 88
aortic artery, 79f, 84f
aortic plexus, 86
arachnoid mater, 16
arteries
aortic, 79f, 84f

carotid, 66, 70f


celiac, 77f
external iliac, 86f
intercostal, 38f
internal iliac, 86f
mesenteric, 77
occipital, 60
segmental, 81, 85, 90
subclavian, 70f
superior mesenteric, 78f, 84f
vertebral, 66, 7071, 70f
arthropathy, 113
aseptic meningitis
after caudal epidural block, 33
after cervical epidural block, 29
after lumbar epidural block, 20
after thoracic epidural block, 24
atlas, 25f
atropine, 117
autonomic blockade, 6599
autopsy, 37
axis, 25f
axon, potassium efflux from, 111
axonal degeneration, 111
azygos vein, 52f

B
bacterial contamination, 62, 76
bilateral stellate ganglion block, 69
bladder, 15, 86
blood aspiration
intercostal nerve block, 4142
stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68
blood pressure changes, 18, 2223, 27, 31,
34
fall, 96, 99
rise, 68, 96, 99
systolic, 95, 97
bowel dysfunction, 15
brachial plexus, 43, 66, 68, 72
bradycardia, 29, 117
brainstem, 61
breath
after alcohol injections, 81, 85, 93
shortness of, 69, 72
breathing systems, 117
bretylium in intravenous regional
sympathetic block
lower limb, 9798
upper limb, 68, 95
buccal cavity, 62
bupivacaine, 44, 101
burning sensation, 96, 99
buttock pain, 106

C
calf, 97, 106, 108
cancer
pain, 65
pancreatic, 2, 65
pelvic, 65
cannulation, retrograde see retrograde
cannulation
carcinoma of the head of the pancreas, 2
cardiac pacemaker, 112
cardiovascular system (CVS) collapse,
stellate ganglion block
C7 approach, 7072
C6 (classic) approach, 66, 6869
carotid arteries, 66, 70f
carotid pulse, 67, 71
carotid sinus, 112
catheter
epidural see epidural catheter, long-term
intercostal, 4041
interpleural, 44
passer, 3436
thoracic nerve root block, 53
cauda equina, 55, 125f
caudal anesthesia, 30
caudal epidural block, 3033
anatomy, 30, 30f
confirmation of success, 33
drugs, 30
equipment, 30
needle puncture and technique, 31f
adult, 3032
fluoroscopic-guided, 32, 32f33f
right-handed operator, 3132, 31f32f
position of patient, 30, 30f
potential problems, 33
with sacral nerve root block, 57
tips, 33, 33f
caudal epidural space, 31, 33
cavernous sinus, 61
celiac artery, 77f
celiac axis, 78f, 84f
celiac block
classical, 78f, 84f
prevascular, 78f, 84f
celiac ganglia, 77
celiac plexus, 77
celiac plexus block
anterocrural approach, 8285
anatomy, 82, 82f
confirmation of success, 83
drugs, 82
equipment, 82
needle puncture and technique, 8283,
84f
position of patient, 82, 83f
potential problems, 8485
tips, 83

128

Index
retrocrural approach, 7781
anatomy, 77, 77f78f
confirmation of success, 80
drugs, 78
equipment, 78
needle puncture and technique, 7880,
79f80f
position of patient, 78, 78f
potential problems, 81
tips, 81
cerebrospinal fluid (CSF), 16, 60, 64
cervical anterior tubercle, sixth, 6668
cervical disc pain, 15
cervical epidural block, 2529
anatomy, 25, 25f
confirmation of success, 29
drugs, 25
equipment, 25
needle puncture and technique, 2529,
26f28f
fluoroscopic guided, 2829, 29f
position of patient, 25
potential problems, 29
tips, 29
cervical epidural injection, 15
cervical epidural space, 25, 29
cervical facet joint injection, 811
anatomy, 8, 8f
confirmation of success, 9
drugs, 8
equipment, 8
needle puncture and technique, 89,
9f10f
position of patient, 8, 9f
potential problems, 10
tips, 10
cervical ganglia, 66
cervical nerve, dorsal rami of second,
59
cervical nerve roots, 15
cervical sympathetic trunk, 66
C-fibers, 111
Chassaignacs tubercle, 6668
chest discomfort, 81, 85
chest X-ray
intercostal nerve block, 39
interpleural block, 44
chylothorax, 85
cisterna magna, 60
coagulopathy
and celiac plexus block, 81
and facet joint injections, 10
and hypogastric plexus block, 88
and lumbar sympathetic block, 76
coccygeal cornu, 55f
coccygeal nerve, 55f
coccygeal vertebra, 55f
coccyx, 92, 125f
colon, 77
Complex Regional Pain Syndrome Type 1
and II, 65
computed tomography (CT) scan, 37
in celiac plexus block, 83
in hypogastric plexus block, 88
in sacro-iliac joint injection, 13, 13f
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68
conjunctiva, unilateral flushing, 68, 72
consciousness, loss of in stellate ganglion
block
C7 approach, 7072
C6 (classic) approach, 6869

contrast medium, non-ionic radio-opaque


in celiac plexus block
anterocrural approach, 83
retrocrural approach, 78, 81
in cervical epidural block, 29
in cervical facet joint injection, 9
in ganglion impar block, 92
in hypogastric plexus block, 8788
in intercostal nerve block, 40, 41f
in long-term epidural catheter insertion, 36
in lumbar epidural block, 19
in lumbar facet joint injection, 45
in lumbar nerve root block, 48
in lumbar sympathetic block, 74
in sacral nerve root block, 57
in sacro-iliac joint injection, 13
in thoracic epidural block, 23
in thoracic nerve root block, 52
in trigeminal ganglion (Gasserian) block,
62
conus medullaris, 55f, 125f
convulsion, 64, 66
corneal anesthesia, 64
corticosteroids, 2
in caudal epidural block, 3132
in cervical epidural block, 27, 29
in cervical facet joint injection, 9
in lumbar epidural block, 18
in lumbar facet joint injection, 5
in sacro-iliac joint injection, 13
side effects, 113
suggested, 113
in thoracic epidural block, 21, 23
costochondral junctions, 101
costotransverse ligament, 51f52f, 53
coughing on injection, 40
cranial fossa, 64
cranial nerves, 61, 64
cricoid cartilage, 6667, 71
CSF (cerebrospinal fluid), 16, 60, 64
CT see computed tomography (CT) scan
Cushingoid symptoms
post-caudal epidural block, 33
post-cervical epidural block, 29
post-lumbar epidural block, 20
post-thoracic epidural block, 24
cutaneous fibers, 47
cutaneous nociceptors, 1
CVS collapse see cardiovascular system
(CVS) collapse

D
decompression, 37
depression, 2
dermatomes, 119
dexamethasone, 113
diagnostic blockade, 11, 48, 53, 57, 64
diaphragm, 43, 77, 77f, 82, 82f, 84f
diaphragmatic crus, 77f, 82, 82f
diarrhea
post-celiac plexus block, 81, 84
post-ganglion impar block, 93
post-hypogastric plexus block, 90
diazepam, 117
discogenic radiculopathy, 37
discomfort
abdominal, 81, 85
chest, 81
distal dural sac, 55, 125f
dorsal horn neurons, 1
dorsal horn pain projection cells, 1

dorsal nerve roots, 1


dural puncture, 20, 24, 29, 33
dural sac, 55, 125f
distal, 55, 125f
dural tap, 20, 23
dura mater, 16, 125f

E
electromyography (EMG), 37, 101
endotracheal tubes, 117
ephedrine, 117
epidural abscess, 33
epidural block
in celiac plexus block, 81, 8485
in hypogastric plexus block, 8890
lumbar, 1620
with lumbar nerve root block, 49
in lumbar sympathetic block, 76
in thoracic nerve root block, 54
epidural catheter insertion, 20, 23
long-term, 3436
anatomy, 34
confirmation of success, 36
drugs, 34
equipment, 34
needle puncture and technique, 3436,
34f36f
position of patient, 34, 34f
potential problems, 36
tips, 36
epidural injection, 1536
caudal, 32
cervical, 15, 25
lumbar, 1920, 19f
epidural needle
in autonomic blockade, 74, 87
in epidural block, 16, 18, 22, 2628,
3334
in somatic nerve block, 4041, 44, 46, 53
epidural space, 16, 2425, 29, 33, 55, 125f
epidural spread, 19, 32, 49, 54, 57
epidural steroid injection, 15, 20, 23
epinephrine
in intercostal nerve block, 41
in intravenous regional sympathetic
block, 99
in long-term epidural catheter insertion,
34
in lumbar epidural block, 20
in thoracic epidural block, 23
erector spinae muscles, 104
Esmarch bandage, 95
exsanguination, 95
external filum terminale, 125f
external iliac artery, 86f
external iliac vein, 86f
external oblique muscles, 104f

F
facet joints
cervical, 811
lumbar, 36
pain, 2
facet nerve injection, 1011
fibromyalgia, 101
filum terminale, 125f
fluoroscopy
C-arm, 4, 9
in caudal epidural block, 32, 32f33f

Index
in celiac plexus block
anterocrural approach, 82
needle puncture and technique, 78
in cervical epidural injection, 2829, 29f
in ganglion impar block, 9293
in hypogastric plexus block, 87
in lumbar epidural injection, 1920, 19f
in lumbar sympathetic block, 7374
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68
foramen ovale, 61
forceps, 117

G
gangliolysis, 64
ganglion blockade see stellate ganglion
block
ganglion impar, 91
ganglion impar block, 9193
anatomy, 91, 91f
confirmation of success, 93
drugs, 91
equipment, 91
needle puncture and technique, 9193, 92f
position of patient, 91, 91f
potential problems, 93
tips, 93
Gasserian block see trigeminal ganglion
(Gasserian) block
Gasserian ganglion, 61f
gemelli muscles, 106
genitofemoral neuralgia, 76
glucose tolerance, impaired, 113
gluteus medius injection, 106107
anatomy, 106
confirmation of success, 107
drugs, 106
equipment, 106
needle puncture and technique, 106107,
106f107f
position of patient, 106, 106f
potential problems, 107
tips, 107
gluteus muscles, 104
glycerol injection, 64
glycerol trinitrate cream, 98
greater auricular nerve, 59f
greater occipital nerve, 59
greater occipital protuberance, 5960, 59f
greater sciatic foramen, 108
greater trochanter
gluteus medius injection, 106
piriformis injection, 108
grey rami, 38, 47
guanethedine, 9495, 97

H
hanging drop technique, 2527, 27f
headache
post-caudal epidural block, 33
post-cervical epidural block, 29
post-lumbar epidural block, 20
post-thoracic epidural block, 24
heart rate changes, 18, 2223, 27, 31, 34
hematoma
post-caudal epidural block, 33
post-cervical epidural block, 29
post-cervical facet joint injection, 10

post-stellate ganglion block


C7 approach, 72
C6 (classic) approach, 6869
post-thoracic epidural block, 24
retroperitoneal, 76, 81, 84, 88, 93
hemifacial anesthesia, 64
hoarseness, 69
hydrocortisone, 113
hyperalgesia, 1
hyperbaric neurolytic solution, 64
hypogastric plexus, 86
hypogastric plexus block, 8690
anatomy, 86, 86f
confirmation of success, 87
drugs, 87
equipment, 86
needle puncture and technique, 87,
88f90f
position of patient, 87, 87f
potential problems, 8890
tips, 8788
hypotension
orthostatic, 81, 84, 90
post-caudal epidural block, 33
post-cervical epidural block, 29
post-lumbar epidural block, 20
post-thoracic epidural block, 24

I
iliac crest, 73
hypogastric plexus block, 87
lumbar epidural block, 17
lumbar nerve root block, 47
sacral nerve root block, 56
iliac vessels, bifurcation of, 90f
iliocostalis muscle, 104
ilium, 12, 13f, 14
infection
post-caudal epidural block, 33
post-cervical epidural block, 29
post-corticosteroid injection, 113
post-gluteus medius injection, 107
post-long-term epidural catheter insertion,
36
post-lumbar epidural block, 20
post-thoracic epidural block, 24
inferior articular process, 17f
inferior hypogastric plexus, 86
inferior vena cava
anatomy, 77
perforation, 76, 81, 84, 88
infraspinatus muscle, 103f
infratemporal bone, 64
infratemporal fossa, 62
injections
cervical facet joint, 811
epidural, 1536
joint, 314
lumbar facet joint, 36
sacro-iliac joint, 1214
sacroiliac ligaments, 14
trigger point, 2
intercostal artery, 38f
intercostal muscle, 38f, 45f
intercostal nerve block, 3842
anatomy, 38, 38f
confirmation of success, 40
drugs, 38
equipment, 38
needle puncture and technique, 3839, 39f
right-handed operator, 3839, 39f40f

neurolytic, 40, 41f, 42


position of patient, 38
potential problems, 41
radiofrequency lesioning, 41
tips, 4041, 41f
intercostal nerves, 43
intercostal neuralgia, 65
intercostal space, 3941
intercostal vein, 38f
intercrestal line, 73
hypogastric plexus block, 87
lumbar epidural block, 17
lumbar nerve root block, 47
sacral nerve root block, 56
intergluteal groove, 9192
internal carotid artery, 61
internal filum terminale, 125f
internal iliac artery, 86f
internal iliac vein, 86f
internal oblique muscles, 104f
interpleural block, 4346
anatomy, 43, 43f
confirmation of success, 44
drugs, 43
equipment, 43
needle puncture and technique, 4344,
44f
right-handed operator, 44, 44f45f
position of patient, 43, 43f
potential problems, 46
tips, 46, 46f
interpleural space, 43
interspinalis muscle, 104f
interspinous ligament, 16
in cervical epidural block, 26, 2829
in lumbar epidural block, 1819
in thoracic epidural block, 2223
intervertebral disc
disease, 15
pain, 15
perforation, 76, 81, 85, 90
intervertebral foramen, 47, 76
intestines, 77
intra-arterial injection, 10, 6869, 72
intraneural pressure, raised, 111
intrathecal blockade, 49
intrathecal injection, 10
in caudal epidural block, 33
in cervical epidural block, 29
in lumbar epidural block, 20
in lumbar nerve root block, 49
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 6869
in thoracic epidural block, 24
intrathecal space, 16
intravascular injection
in caudal epidural block, 33
in cervical epidural block, 29
in lumbar epidural block, 20
in lumbar nerve root block, 49
in lumbar sympathetic block, 76
in sacral nerve root block, 57
in thoracic epidural block, 24
in thoracic nerve root block, 54
intravenous injection, 10
intravenous regional sympathetic block
lower limb, 9799
anatomy, 97
confirmation of success, 98
drugs, 97
equipment, 97
position of patient, 97

129

130

Index
potential problems, 99
technique, 9798, 97f99f
tips, 98
upper limb, 9496
anatomy, 94
confirmation of success, 95
drugs, 94
equipment, 94
position of patient, 94
potential problems, 96
technique, 9495, 94f96f
tips, 9596
ipsilateral face, 61
ipsilateral pupil, 62
ischemia, 111

J
joint(s)
arthropathy, 2
degeneration, 2
information, 2
injections, 314
pain, 2
jugular vein, 68, 72

K
kidneys, 77
anatomy, 77
perforation, 76, 81, 85

L
lamina, 22
laryngeal nerve block, recurrent, 69,
72
laryngoscope, 117
lateral epicondyles, 101
latissimus dorsi muscle, 102
lesser occipital nerve, 59f, 60
levator scapulae muscle, 102
levobupivacaine, 43
lidocaine
caudal epidural block, 3132
celiac plexus block
anterocrural approach, 83
retrocrural approach, 7880
cervical epidural block, 2529
cervical facet joint injection, 810
facet nerve injection, 11
ganglion impar block, 92
gluteus medius injection, 107
hypogastric plexus block, 87
intercostal nerve block, 3940
interpleural block, 43
intravenous regional sympathetic block
lower limb, 97, 99
upper limb, 68, 95
long-term epidural catheter insertion,
34
lumbar epidural block, 1719
lumbar facet joint injection, 45
lumbar nerve root block, 4748
lumbar sympathetic block, 74
occipital nerve block, 60
piriformis injection, 108
for resuscitation, 117
sacral nerve root block, 5657
sacro-iliac joint injection, 1213

stellate ganglion block


C7 approach, 7072
C6 (classic) approach, 66, 68
thoracic epidural block, 2123
thoracic nerve root block, 5253
toxicity, 68, 99
trigeminal ganglion (Gasserian) block,
6264
trigger point injections, 101102, 105
ligaments
anococcygeal, 93
anterior costotransverse, 51f52f
costotransverse, 51f52f, 53
posterior sacro-iliac, 12f
sacro-coccygeal, 30f
sacroiliac, 14
supraspinous, 16
ligamentum flavum, 16, 125f
lumbar epidural block, 1819
thoracic epidural block, 2223
lignocaine see lidocaine
liver, 77
local anaesthetics, 2
in lumbar epidural block, 20
rapid absorption in intercostal nerve
block, 41
longissimus muscle, 104
longus colli muscle, 72
loss-of-resistance technique, 22, 29
lumbar epidural block, 1620
anatomy, 16, 16f17f
confirmation of success, 20
drugs, 16
equipment, 16, 17f
needle puncture and technique, 1720
fluoroscopic guided lumbar epidural
injection, 1920, 19f
midline approach, right-handed
operator, 1719, 18f19f
position of patient, 17
potential problems, 20
tips, 20, 20f
lumbar epidural steroid injection, 23
lumbar facet joint injections, 36
anatomy, 34, 3f
confirmation of success, 5
drugs, 4
equipment, 4
needle puncture and technique, 45,
5f7f
position of patient, 4, 4f
potential problems, 6
tips, 5
lumbar nerve root block, 4749
anatomy, 47, 47f
confirmation of success, 49
drugs, 47
equipment, 47
needle puncture and technique, 4748,
48f50f
position of patient, 47, 48f
potential problems, 49
tips, 49
lumbar nerve roots, 15
lumbar nerves, 47
lumbar plexus, 47
lumbar radiculopathy, 32
lumbar somatic nerves, 73
lumbar spine innervation, 3f
lumbar sympathetic block, 7376
anatomy, 73
confirmation of success, 75
drugs, 73

equipment, 73
needle puncture and technique, 7375,
73f76f
position of patient, 73, 73f
potential problems, 76
tips, 75
lumbar sympathetic chain, 73
lumbo-sacral radiculopathy, 15
lumbo-sacral spine anatomy, 125
lungs, 51
lymphedema, 85

M
Magills forceps, 117
magnetic resonance imaging (MRI), 37
mandibular nerve, 6162
masseter muscle, 62
mastication muscles, 6162
mastoid process, 5960, 59f
maxillary nerve, 61
mechanical nerve root compression, 37
Meckels cave, 61
medius scalenus muscle, 70f
meningitis, aseptic see aseptic meningitis
menstrual cycle irregularity, 113
mesenteric artery, 77
methylprednisolone, 113
midazolam, 117
middle cervical ganglion, 70f
miosis of pupil, 68, 72
MRI (magnetic resonance imaging), 37
multifidus muscle, 104, 104f
muscle contraction, involuntary, 101
muscle injections, 101110
muscles
erector spinae, 104
external oblique, 104f
gemelli, 106
gluteus, 104
iliocostalis, 104
infraspinatus, 103f
intercostal, 38f, 45f
internal oblique, 104f
interspinalis, 104f
latissimus dorsi, 102
levator scapulae, 102
longissimus, 104
longus colli, 72
masseter, 62
mastication, 6162
medius scalenus, 70f
multifidus, 104, 104f
paravertebral, 47
piriformis, 106, 108
psoas, 47, 51, 73, 7880, 104f
quadratus femoris, 106
quadratus lumborum, 104f
rhomboid, 102
rotatores, 104
sacrospinalis, 12f
semispinalis, 104
spinalis, 104
splenius capitis, 102
sternocleidomastoid, 67, 71
supraspinatus, 103f
teres major, 103f
teres minor, 103f
transversospinal, 104
trapezius, 102, 103f
muscle spasm, 1
muscle wasting, 113

Index
myelography, 37
myofascial pain syndrome, 2, 101, 108
myopathy, 113
myotomes, 123

N
nasopharyngeal airway, 117
neck, 112
nerve fibers
parasympathetic, 77, 86
pre- and postganglionic, 77
sympathetic, 77, 86
nerve roots, mechanical compression, 37
nerve(s)
injured, 1
regeneration, 1
nerve sheath, 4142, 49, 53
neural foramina, 78
neuritis in thoracic nerve root block, 54
neurolysis, 75
neurolytic agents
in autonomic blockade, 76, 81, 8485,
8890, 93
in somatic nerve blockade, 40, 61, 64
suggested, 115
neurolytic blocks, 40, 6465, 76, 81, 84, 90
neuroma formation, 1
neuropraxia, 96, 99
neurotransmitters, 94, 97
neurovascular bundle, 4041, 44, 45f
norepinephrine, 68, 94, 97, 99
nose blockage, unilateral, 68, 72
nucleus pulposis, 37

O
occipital artery, 60
occipital nerve, 59
occipital nerve block, 5960
anatomy, 59, 59f
confirmation of success, 60
drugs, 59
equipment, 59
needle puncture and technique, 5960,
59f60f
position of patient, 59
potential problems, 60
tips, 60
oculomotor nerve, 64
ophthalmic nerve, 61
oropharyngeal airway, 117
orthostatic hypotension, 81, 84, 90
osteoporosis, 113
oxygen bag and masks, 117
oxygen source, 117

P
pacemaker, cardiac, 112
pain
cervical epidural block, 29
communication of, 2
definition, 1
joint, 2
management of, 2
mechanisms, 12
myofascial, 2
neuropathic, 12
perception, 2
psychologic factors, 2
radicular, 2, 15, 33

referred, 1
somatic, 12
visceral, 12, 77
pancreas
anatomy, 77
cancer, 2, 65
paralysis, transient motor see transient
motor paralysis
paraparesis, 10
paraplegia, 10
post-celiac plexus block, 81, 85
post-hypogastric plexus block, 90
parasympathetic nerve fibers, 77, 86
paravertebral injection, 51
paravertebral muscles, 47
paravertebral space, 53
paravertebral sympathetic trunk, 78f, 84f
paresthesia
in lumbar nerve root block, 48
in sacral nerve root block, 57
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68
in thoracic nerve root block, 52
in trigeminal ganglion (Gasserian) block,
62
parietal pleura, 43
pelvic cancer, 65
pelvic organs, 77
pericardial cavity, 45f
perineum, 91
periosteal injection, 93
peripheral nerve changes, 1
peripheral sympathetic blockade, 94f
peripheral vascular disease, 65
peripheral visceral afferents, 1
petrous temporal bone, 61
phenol, 115
celiac plexus block
anterocrural approach, 83
retrocrural approach, 80
ganglion impar block, 93
hypogastric plexus block, 87
phrenic nerve block, post-stellate ganglion
block
C7 approach, 72
C6 (classic) approach, 69
physiotherapy
post-intravenous regional sympathetic
block, 96, 98
and trigger point injections, 103, 105
pia mater, 125f
piriformis injection, 108110
anatomy, 108, 108f
confirmation of success, 108
drugs, 108
equipment, 108
needle puncture and technique, 108,
109f110f
position of patient, 108, 108f
potential problems, 110
tips, 108110
piriformis muscle, 106, 108
pleura, 43, 51, 66
avoidance in thoracic nerve root block, 52
pleural cavity, 45f
pneumothorax
in celiac plexus block, 81, 85
in intercostal nerve block, 3941
in interpleural block, 44, 46
in stellate ganglion block
C7 approach, 7072
C6 (classic) approach, 69

in thoracic nerve root block, 51, 5354


in trigger point injections, 103, 105
posterior sacral foramen, 55f, 57
posterior sacro-iliac ligament, 12f
posterior superior iliac spines, 31, 55
gluteus medius injection, 106
piriformis injection, 108
post-herpetic neuralgia, 65
postural hypotension, 76
preganglionic sympathetic efferents, 77
prevertebral fascia, 73
propofol, 64
prostate, 86
psoas muscle, 47, 51, 73, 7880, 104f
psychologic upset, 113
pterygoid process, 62
ptosis of eyelid, 68, 72

Q
quadratus femoris muscle, 106
quadratus lumborum muscle, 104f

R
radiculopathy
discogenic, 37
lumbar, 32
lumbo-sacral, 15
sacral, 32
radiofrequency lesioning of the intercostal
nerve, 41
radiograph, chest
intercostal nerve block, 39
interpleural block, 44
rami
cervical posterior primary, 8
dorsal, medial branches, 34
grey, 38, 47
posterior primary, cervical, 8
white, 38, 47
rectum, 77
distal, 91
perforation, 93
recurrent laryngeal nerve block, stellate
ganglion block
C7 approach, 72
C6 (classic) approach, 69
resuscitation, recommended drugs and
equipment, 117
retrocrural spread, 77f, 82f
retrograde cannulation, intravenous regional
sympathetic block
lower limb, 98
upper limb, 95
retroperitoneal compartment, 82
retroperitoneal space, 86, 92f
retroperitoneum, 93
rhabdomyolysis, 76, 8890
rhomboid muscles, 102
ribs
anatomy, 51
palpation, 3839, 4344
twelfth, 73, 83
rotatores muscle, 104

S
sacral canal, 55
sacral cornua, 3132

131

132

Index
sacral epidural space, 30
sacral foramen, 5557
sacral hiatus, 3032, 55
sacral nerve root block, 5557
anatomy, 55, 55f
confirmation of success, 57
drugs, 55
equipment, 55
needle puncture and technique, 5557,
56f58f
position of patient, 55, 56f
potential problems, 57
tips, 57
sacral nerve roots, 15
sacral nerves, 55
sacral promontory, 86
sacral radiculopathy, 32
sacrococcygeal junction, 92
sacrococcygeal ligament, 30f
sacrococcygeal membrane, 3032, 55
sacrococcygeal vertebral column, 93
sacro-iliac joint injection, 1214
anatomy, 12, 12f
confirmation of success, 14
drugs, 12
equipment, 12
needle puncture and technique, 1213,
12f13f
position of patient, 12, 12f
potential problems, 14
tips, 14
sacroiliac ligaments injection, 14
sacrospinalis muscle, 12f
sacrum, 30, 55, 125f
saline
in caudal epidural block, 31
in cervical epidural block, 2526
in interpleural block, 46
in intravenous regional sympathetic block
lower limb, 97
upper limb, 95
in long-term epidural catheter insertion,
34
in lumbar epidural block, 1718, 20
in thoracic epidural block, 23
scapula
inferior angle of, 52
root of the spine of, 52
sciatic nerve, 108
sciatic nerve block, 107
sciatic notch, 107
sedation
in autonomic blockade, 76, 78, 8182,
85, 93
in epidural injections, 24, 2829
in joint injections, 13
in somatic nerve blockade, 38, 42, 62
segmental arteries spasm, 81, 85, 90
seizures, 96
semispinalis muscle, 104
sensory neurons, 1
septic discitis, 76
sickle cell anemia, 96, 99
sixth cervical anterior tubercle, 6668
skin
depigmentation, 113
flushing, 113
temperature, 68, 72, 75
somatic nerve blockade, 3764
in celiac plexus block, 81, 8485
in ganglion impar block, 93
in hypogastric plexus block, 8790
in lumbar sympathetic block, 76

somatic nerves, 1
lumbar, 73
somatic nociceptive afferents, 1
somatic nociceptor fibers, 1
sphenoid bone, 62
spinal anaesthesia, 10
spinal block, total, 60
spinal cord, 16, 125f
injury
cervical epidural block, 29
thoracic epidural block, 24
segmental myotomes, 123
spinalis muscle, 104
spinal nerve roots inflammation, 15
spinal nerves, 34, 3f
spinothalamic pathways, 1
spinous processes
cervical, 25
lumbar, 1617, 47, 56, 73, 87
thoracic, 2122, 25, 52
splanchnic nerves, 77, 86
spleen, 77
splenius capitis muscle, 102
spontaneous neural inputs, 1
stellate ganglion, 66, 70f
stellate ganglion block
bilateral, 69
C7 approach, 7072
anatomy, 70, 70f
confirmation of success, 72
drugs, 70
equipment, 70
needle puncture and technique, 7072,
70f71f
position of patient, 70
potential problems, 72
tips, 72
C6 (classic) approach, 6669
anatomy, 66, 66f
confirmation of success, 68
drugs, 66
equipment, 66, 66f
needle puncture and technique, 6668
right-handed operator, 6668,
67f68f
position of patient, 66
potential problems, 6869
tips, 68, 69f70f
sternoclavicular junction, 71
sternocleidomastoid muscle, 67, 71
subarachnoid block, 76
subarachnoid space, 1920, 25f, 32f
subclavian artery, 70f
subcutaneous tissue atrophy, 113
subperiosteal injection, 33, 33f
succinylcholine, 117
superior articular process, 17f
superior gluteal nerve, 12
superior hypogastric plexus, 86, 86f, 90f
superior mesenteric artery, 77f78f, 84f
superior mesenteric ganglion, 77f
superior nuchal line, 5960
superior stellate ganglion, 70f
suprarenal glands, 77
supraspinatus muscle, 103f
supraspinous ligament, 16
sympathetic afferents, 1, 91
sympathetic blockade, 51
with lumbar nerve root block, 49
in thoracic nerve root block, 54
sympathetic chain, 43
sympathetic ganglia, 51f, 91
sympathetic lumbar chain, 47, 51

sympathetic nerve endings, 94, 97


sympathetic nerve fibers, 77, 86
sympatholytic agents, 94, 97

T
temperature, skin, 68, 72, 75
temporal lobe, 61
tender points, 101
tendon, rupture of injected, 113
TENS see transcutaneous electrical
stimulation (TENS)
teres major muscle, 103f
teres minor muscle, 103f
thermocoagulation, 64
thiopental (thiopentone), 117
thoracic disc pain, 15
thoracic duct damage, 81, 85
thoracic epidural block, 2124
anatomy, 21, 21f
confirmation of success, 23
drugs, 21
equipment, 21
needle puncture and technique, 21,
21f22f
paramedian approach, right-handed
operator, 2223, 23f
position of patient, 21
potential problems, 24
tips, 23, 24f
thoracic ganglia, 66
thoracic nerve root block, 5154
anatomy, 51, 51f
confirmation of success, 53
drugs, 51
equipment, 51
needle puncture and technique, 5153,
52f53f
position of patient, 51, 52f
potential problems, 5354
tips, 53
thoracic sympathetic chain, 52f, 77
thoracostomy drainage tubes, 46
thyroid cartilage, 6667, 71
total spinal block, 60
tourniquet, 68, 95, 9799
transcutaneous electrical stimulation
(TENS), 111112
burst stimulation, 112
continuous stimulation, 111
contraindications, 112
control settings, 111112, 111f112f
low-frequency high-intensity stimulation,
112
modulated settings, 112
trial period, 111
transient motor paralysis
post-celiac plexus block, 81, 85
post-hypogastric plexus block, 90
transverse processes, 17f, 52
transversospinal muscles, 104
trapezius muscle, 102, 103f
triamcinolone, 113
in caudal epidural block, 3132
in cervical epidural block, 27, 29
in cervical facet joint injection, 9
in epidural injection, 15
in lumbar epidural block, 18, 20
in lumbar facet joint injection, 5
in sacro-iliac joint injection, 13
in thoracic epidural block, 21, 23
trigeminal ganglion, 61

Index
trigeminal ganglion (Gasserian) block,
6164
anatomy, 61, 61f
confirmation of success, 64
drugs, 61
equipment, 61
needle puncture and technique, 6264,
62f63f
position of patient, 61
potential problems, 64
tips, 64
trigeminal nerve, 62, 64
trigeminal neuralgia, 65
trigeminal nucleus, 1
trigger point injections, 2, 101
back, 104105
anatomy, 104, 104f
confirmation of success, 105
drugs, 104
equipment, 104
needle puncture and technique, 105,
105f
position of patient, 104, 104f
potential problems, 105
tips, 105
neck and thorax, 102103
anatomy, 102, 102f
confirmation of success, 102
drugs, 102
equipment, 102
needle puncture and technique, 102,
102f103f
position of patient, 102

potential problems, 103


tips, 103
number of, 101
trigger points, 2, 101
palpation, 101
trochlear nerve, 64
twitch, local, 102f

U
ultrasonography
in caudal epidural block, 31
in cervical epidural block, 25, 28
in hypogastric plexus block, 87
in intercostal nerve block, 40
in interpleural block, 46
in long-term epidural catheter insertion,
36
in lumbar epidural block, 20, 20f
in lumbar facet joint injection, 45, 5f
in lumbar nerve root block, 48
in piriformis injection, 108
in sacral nerve root block, 57
in sacro-iliac joint injection, 13
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68
in thoracic epidural block, 23, 24f
in thoracic nerve root block, 52
ureters, perforation, 76, 81, 85
urethra, distal, 91
uterus, 86

V
vagina, 86, 91
vagus nerve, 77
vasovagal response, 103, 105
vasovagal syncope, 29
veins
azygos, 52f
external iliac, 86f
intercostal, 38f
internal iliac, 86f
jugular, 68, 72
Velband, 95, 97
vertebral arteries, 66, 7071, 70f
vertebra prominens, 18f, 25
visceral afferents, 1
visceral organs, 1
visceral pleura, 43
vulva, 91

W
white rami, 38, 47
wide dynamic range neurons, 1

Z
zygapophyseal joints see facet joints
zygomatic arch, 62

133