Anaesthesia - 2021 - McLeod - Novel Approaches To Needle Tracking and Visualisation PDF

Anaesthesia 2021, 76 (Suppl. 1), 160–170 doi:10.1111/anae.
15232
Review Article
Novel approaches to needle tracking and visualisation

G. A. McLeod1,2,3
1 Consultant, Ninewells Hospital, Dundee, UK

2 Honorary Professor, Institute of Academic Anaesthesia, University of Dundee, UK
3 Honorary Senior Lecturer, University of East Anglia, Norwich, UK
Summary
The accuracy and reliability of ultrasound are still insufficient to guarantee complete and safe nerve block for all
patients. Injection of local anaesthetic close to, but not touching, the nerve is key to outcomes, but the exact
relationship between the needle tip and nerve epineurium is difficult to evaluate, even with ultrasound.
Ultrasound has insufficient resolution, tissues are difficult to discern due to acoustic impedance and needles are
more difficult to see with increased angulation. The limitations of ultrasound have shifted the focus of innovation
towards bio-markers that help detect needle tip position by utilising the physical properties of tissues, (e.g.
pressure, electrical, optics, acoustic and elastic). Although most are at the laboratory stage and results are as yet
only available from phantom or cadaver studies, clinical trials are imminent. For example, fine optical fibres
placed within the lumen of block needles can measure needle tip pressure. Electrical impedance differentiates
between intraneural and perineural needle tip placement. A new tip tracker needle has a piezo element
embedded at its distal end that tracks the needle tip in-plane and out-of-plane as a blue/red or green circle
depending on its relative location within the beam. Micro-ultrasound at the tip of the needle is in development.
Early images using 40MHz in anaesthetised pigs reveal muscle striation, distinct epineurium and 30–40 fascicles
> 75 micron in diameter. The next few years will see a technological revolution in tip-tracking technology that
has the potential to improve patient safety and, in doing so, change practice.
.................................................................................................................................................................
Correspondence to: G. A. McLeod
Email: g.a.mcleod@dundee.ac.uk
Accepted: 17 June 2020
Keywords: needle; nerve block; simulation; technology; ultrasonography
Twitter: @gamcleod2
In this review, I discuss emerging and future needle-tracking Change is driven by real-world problems. The First
technologies that have the potential to improve the World War provided the impetus for development of
performance of regional anaesthesia, and the basic piezoceramics and application of the pulse-echo
scientific mechanisms that drive their development. principle in order to detect submarines. Obstetric
Solutions are emerging from the fusion of anaesthesia, ultrasound [1] was invented by Tom Brown, a research
physics, computing, engineering, psychological and engineer in Glasgow, who was testing welds in ship
biological science. In the future, attention will turn, as with construction. In the 2020s, one of the fundamental
other interventional specialities, to the pursuit of artificial challenges facing us is how to invent disruptive
intelligence, deep learning, augmented/virtual reality, 3D technology that enables a safe, effective, long-lasting,
printing, genomics, biotechnology and nanotechnology. opioid-free nerve block that changes the culture of
These will be discussed in another review within this anaesthesia, and in doing so alters patient expectations
supplement. of surgery.
160 © 2021 Association of Anaesthetists

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McLeod | Needle tracking and visualisation Anaesthesia 2021, 76 (Suppl. 1), 160–170
This requires technology that enables anaesthetists to ultrasound [8]. The greater the distance between
accurately and reliably identify the needle tip relative to a transducer and target nerve and the higher the
target nerve, and it is worth first exploring the clinical and transducer frequency (MHz), the more acoustic energy is
technological reasons why this is still not the case. dispersed as heat at a rate of approximately 0.5 to
1 dB.cm−1.MHz−1 (sound measured in dB is on a
Clinical issues logarithmic scale). Low-frequency transducers, in contrast,
In the two decades, since the introduction of ultrasound to lose less energy for a given depth and allow visibility of
regional anaesthesia, patient characteristics have changed. deeper structures, but with less detail. In order to offset
Patients are now more obese, live longer and are more likely attenuation, time gain compensation should be
to have multiple chronic conditions treated with considered by applying higher gain to deeper echoes
polypharmacy. For example, the prevalence of chronic pain that take longer to reach the transducer.
in the UK varies between one-third and one-half of Interpretation of images may be difficult because
individuals [2]. adjacent tissues, such as nerve and adipose tissue, have
Demand for ultrasound-guided regional anaesthesia similar acoustic impedance. Acoustic impedance is a
has increased. When performed by subspecialists it is very measure of the response of tissue to an acoustic wave and is
reliable, and is now considered a pivotal intervention that analogous to impedance in an alternating current circuit.
changes the dependency and course of patient care. The acoustic impedance ðZÞ of tissue increases with both
Typical examples of the latter would be prolonged pain tissue density (ρ) and stiffness (k), but can also be expressed
relief and better rehabilitation after amputation using nerve as the product of density (ρÞ and the speed of sound ðcÞ
catheters or extended pain relief after ankle block for awake travelling through tissue [8]:
day-case mid and hind foot surgery.
pffiffiffiffiffiffiffi
Supply of regional anaesthesia, however, is poor. Z¼ ρ:k ¼ ρ:c
Insufficient numbers of anaesthetists can provide high-
quality nerve block, and the majority of patients are denied The difference in acoustic impedance at tissue borders
this intervention. Uptake of regional anaesthesia is determines the relative absorption and reflection from a
tempered by the fear of accidental nerve damage [3], surface. The density ðρÞ of adipose tissue is 916 kg.m−3 and
accidental intravascular injection, and open demonstration of muscle is 1060 kg.m−3, whereas wave speed (c) ranges
of poor performance. Intraneural injection is difficult to see from 1629 m.s−1 in adipose tissue to 1412 ms−1 in muscle.
with ultrasound, and needle-nerve contact difficult to detect For example, the femoral nerve is often difficult to visualise
using electrical nerve stimulation. False negative rates for below the fascia iliaca and becomes apparent only after
the former range between 16% and 35% [4, 5] and for the local anaesthetic is injected, heightening contrast between
latter is approximately 25% [6]. anechogenic fluid and nerve tissue and increasing acoustic
impedance.
The technical problem Thus, a need arises to provide technological solutions
In order to understand why anaesthetists have difficulty in order to encourage more anaesthetists to perform nerve
interpreting ultrasound images and diagnostic tools, it is blocks, improve accuracy and performance and provide the
important to understand the physical mechanisms that best outcomes for a changing population.
underpin the interaction of acoustic waves with tissue.
Important features include image resolution, acoustic Tracking technology to improve
impedance and non-linear propagation effects. accuracy and performance
As ultrasound waves pass through tissue, acoustic In order to improve accuracy and performance, technology
intensity diminishes as energy is attenuated within the should focus on the key procedures that anaesthetists find
tissue. Transducer frequencies between 5 MHz and most difficult and cause most harm. Recent educational
10 MHz transducer offer resolution from 600 micron to studies [9–11] used Rasch modelling to identify the biggest
300 micron respectively, but fine anatomical detail, such technical challenges [9]. These were: identification of
as the adventitia of the interscalene nerve roots, is difficult the needle tip before advancing the needle; seeing the
to see and may account for the higher incidence of needle tip at all times; adjustment of the needle tip;
subepineural injection during interscalene block [7]. identification of the needle tip before injection; and
Attenuation of ultrasound energy occurs through recognition of tissue contact, local anaesthetic spread and
absorption, scattering, reflection or refraction of intraneural injection.
© 2021 Association of Anaesthetists 161

Anaesthesia 2021, 76 (Suppl. 1), 160–170 McLeod | Needle tracking and visualisation
Beforehand, however, it is worth emphasising that few seconds to a peak, known commonly as the opening
current ultrasound machines have many features not used pressure [14]. During this phase there is theoretically an
by anaesthetists. One example is beam steering [12]. uninterrupted column of fluid between the syringe and
Several beams are fired in multiple directions in a phased epineurium, and pressure at all sites should ideally be
fashion so that structures are insonated more than once. equivalent (Pascal’s law) [19]. Once opening pressure is
This technology compensates for the well-recognised fall in overcome, infusion pressure is influenced by needle size,
needle visibility with increased angulation. With spatial injection rate and tissue viscosity (Bernoulli’s principle). In
compounding some beams invariably strike needles at fact, local anaesthetic invariably flows at the beginning of
angles close to 90° and improve shaft visibility. the process and the term opening pressure should be
The other commonly available feature is harmonics. replaced by the term peak pressure [20].
One characteristic of acoustic waves is that the high- An ingenious new device measures pressure at the tip
pressure parts of waves (peaks and troughs) travel faster of the needle. It consists of a Fabry–Plerot optical cavity
than the lower pressure parts. The consequence is that the bonded to the tip of an optical fibre that is embedded within
greater the wave speed, the greater the tendency for the the shaft of a standard nerve block needle [21, 22]. The
sine wave to distort and resemble a saw-tooth pattern, underlying mechanism of action is based on interferometry.
increasing the likelihood of harmonics developing as a The optical cavity is air-filled and bound by two glass
function of the fundamental frequency f0 [8]. The frequency diaphragms (Fig. 1). Light is reflected from the proximal and
2f0, known as the second harmonic, can improve lateral distal diaphragms, leading to interference. Axial force
resolution and reduce artefacts. reduces the optical cavity length and changes the total
The limitations of ultrasound have shifted the focus of intensity (amplitude) of interfered light according to the sum
innovation towards bio-markers that detect needle tip of the light intensities of the two reflected light beams, and
position by utilising the physical properties of tissues, such their phase difference (the relative distance between light
as pressure, electrical, optic, acoustic and elastic. waves expressed in radians) [23, 24]. The change in optical
path difference is dependent on force and temperature
Pressure [23].
Animal experiments have consistently demonstrated that Optical fibres have inherent advantages. They are light,
subepineural pressure ≥ 25 psi (172 kPa) is associated with flexible, dielectric (a non-conductor of direct electric
nerve damage, and that such pressures should be avoided current) and provide a continuous graphical output. Their
during nerve blocks [13, 14]. Anaesthetists rely on small size also allows the sensors to be placed directly in the
subjective feedback from the needle tip during ultrasound- region of interest. Moreover, they are biocompatible and
guided regional anaesthesia but perception of high have the potential to be kept in situ over several days.
injection pressure shows high inter-rater variability [15]. Three laboratory experiments have been conducted in
Two pressure devices are available to regional regional anaesthesia. The first, in ex-vivo leg of pork,
anaesthetists. A disposable in-line pressure manometer demonstrated marked differences between in-line pressure
(BSmartTM, B.Braun Medical, Sheffield, UK) provides a and pressure at the needle tip in perineural tissue [22]. The
colour-coded marker of in-line injection pressure. second, showed clear discrimination between perineural
Alternatively, an injection pressure limiter is available that and subepineural injection pressures [21] and the third
fits between the syringe and injection tubing (NerveGuard, confirmed that pressures were independent of injection
PAJUNK®, Gelsingen, Germany). rate, unlike in-line pressure measurement [25]. This is a
In-line pressure measurement [16, 17] in patients promising technology and clinical trials are awaited that
demonstrated high sensitivity for detection of needle nerve investigate the accuracy of discrimination between
contact, using a diagnostic threshold of 15 psi (103kPa) but perineural, epineural and subepineural sites.
questions still remain over the validity of this technique.
Animal experiments have observed low pressures (< 11 psi; Electrical
76 kPa) in 42% [14] to 60% [18] of subepineural injections; Impedance
and the pressure response is slow. The electrical impedance of tissues may be used to
Two physical principals underlie in-line pressure differentiate between intraneural and extraneural
monitoring. Initial pressure on the plunger takes up the placement. Ohm’s law describes the relationship in a direct
slack in the infusion system, and pressure increases over a current between the driving voltage (V), and flow of current

Figure 1 Example of
Fabry–Plerot optical cavity
bonded to the tip of an optical
fibre and embedded within the
shaft of standard nerve block
needle. The optical cavity is air
filled and bound by two glass
diaphragms. Light is reflected
from each back to the optical
fibre, leading to interference.
Axial force reduces the optical
cavity length and changes the
total intensity (amplitude) of
interfered light according to the
sum of the light intensities of the
two reflected light beams, and
their phase difference.
(I) across a resistance (R) circuit according to the following As the voltage frequency is increased, impedance reduces.
equation, V = I × R For alternating current circuits, the Early studies [26, 27], using a square-wave nerve stimulator,
magnitude or modulus of resistance to current is termed showed that impedance increased on intraneural needle
impedance (Ζ). It is a complex number measured in Ohms insertion. However, absolute measurements showed large
(Ω) and phase shift. The phase shift of the complex variations in intra-subject and inter-subject impedance.
impedance is the angle (θ) by which the current lags the Accuracy, calculated from the area under the curve (AUC) of
voltage, Technically, impedance (Ζ) is theqsummation
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi of a ROC curve was poor at 0.67 [26].
resistance (R) and reactance (X) where Ζ = ðR2 þ X2 Þ and Norwegian investigators took a more comprehensive
reactance is the portion of impedance attributed to engineering approach by taking account of the reduction in
capacitance and inductance. The phase angle, θ, = arctan XR. impedance with increased voltage frequency [28].
Unlike a direct current, the reactance, capacitance and Impedance modulus and phase shift were measured at 25
inductance are dependent on the frequency of the voltage. logarithmically distributed frequencies from 1.26 to
Figure 2 Impedance modulus

measured on 25 occasions
between 1.26 and 398 kHz.
The y-axis gives the modulus
(Ohms) and the x-axis is log
frequency (Hz). Needle (a)
subepineural, (b) (epi)paraneural,
(c) muscle, (d) subcutaneous fat.
Each colour represents repeated
measurements from one test
animal. For modulus shown, best
discrimination 126 kHz and ROC
78%

398 kHz and plotted for subepineural, perineural, muscle which generates an electrical signal (Fig. 3). The signal is
and adipose tissue needle tip location (Fig. 2). Principal processed and represented on the ultrasound screen as a
components analysis showed best tissue discrimination at green circle surrounding the needle tip with the piezo
126 kHz for the modulus (Fig. 2), at 40 kHz for the Phase element at its centre. The radius of the green circle is greater
angle and between 126 and 158 kHz for delta phase angle than the distance between the tip and the centre of the
(the difference in measured phase angles between two piezo element, thus offering a margin of safety during
consecutive measurement frequencies). On an ROC curve, needle advancement. Studies so far have shown a reduction
the AUC progressively increased for modulus (78%), phase in procedure time when inserted out-of-plane on a pork
angle (86%) and delta (94%). A compound score, derived simulator [29], and a reduction in hand movements when
from these three variables, showed excellent accuracy and conducting out-of-plane lumbar plexus blocks on
discrimination between tissues, AUC 0.97. This needle volunteers [30]. Two studies investigating the effect of the
shows good potential and awaits clinical trials. tracker needle on learning curves showed better
performance using checklists of steps and errors validated
Piezo tracker for training assessment on the soft embalmed Thiel cadaver.
A new tip-tracking needle has been developed (OnvisionTM, The pilot study of eight anaesthetists demonstrated
B. Braun, Melsungen AG, Hessen, Germany and Koninklijke improved performance in one-third of the steps during
Philips N.V., Eindhoven, The Netherlands). The device repeated sciatic blocks [31]. The subsequent study, using
consists of a piezo element embedded onto the needle the same model, of 40 volunteers with a wide range of
shaft, near its tip. Acoustic mechanical waves emitted from experience, from absolute novice to expert, showed an
the ultrasound transducer compress the piezo element improvement in 14 out of 30 checklist items, divided equally
(a)
Piezo
Transducer
(b)
(c) (d)
Figure 3 Needle tip-tracking system. Acoustic mechanical waves emitted from the ultrasound transducer compress the piezo
element near the needle tip and generate an electrical signal (a). The intensity of the signal varies according to the position of the
piezo within the ultrasound beam. Alignment with the centre of the beam is indicated by the presence of a green circle
surrounding the needle tip with the piezo element at its centre. Movement laterally but within the beam manifests as two circles;
an inner red and an outer blue circle (b). The more lateral the piezo, the larger the blue circle and the greater the distance
between circles. Image 3c shows a needle (N) approaching the sciatic (SN) nerve in the plane of the transducer beam. F is the
femur. On activation of the tracker system (3d), the needle tip is identified and lying within the green circle

between steps and errors. Two-thirds of these items were thoracic regions of five pigs [38]. An anaesthetist rotated the
concerned with the needle tip. Overall 25% of volunteers transducer manually and built up a series of images.
improved their performance, and efficiency, a key Identification of the epidural space had high sensitivity and
performance index derived from item analysis, improved specificity. Although this technology promises ultra-high
even when weighted for block difficulty and importance. resolution, it is expensive and requires incorporation into a
The psychological mechanisms accounting for improved needle guidance system.
performance come from eye-tracking data collected during
the study. Although activation of the tracker was associated Acoustics
with an increase in the duration of the block, eye fixations, Given the limitations of B-Mode ultrasound, the most
time on the monitor and fixations to the monitor all rational engineering approach is to take ultrasound
increased, indicating an increased focus and concentration elements as close to the target as possible and image
on the salient coloured tracker. needle-nerve interaction with micro-ultrasound, defined as
ultrasound using a frequency > 30 MHz. The development
Optics of micro-ultrasound was stimulated by the need to
Spectroscopy is the measurement of the absorption and characterise the anatomy of small animals in developmental
scattering of electromagnetic radiation from biological biology, genomics and cancer, but at a much cheaper cost
tissue. Tissues exhibit characteristic waveforms in response than cumbersome CT and MRI scanning [39]. Laboratory
to transmission of visible and near-infrared light, and this systems are available with ultrasound frequencies between
property can be used to detect the position of the needle 30 and 75 MHz that offer maximum resolution of 100 to
tip. For example, oxyhaemoglobin absorbs light in the 40 μm. Mechanical single element transducers have
visible spectrum, whereas lipid and water absorb light in the traditionally been used but are slow to build-up images, and
near-infrared spectrum. are now being replaced by linear transducer arrays with
In studies conducted in pigs and patients, spectroscopy greater functionality (Fig. 4).
identified the ligamentum flavum and epidural space [32, 33]
and reliably identified movement of the needle from
subcutaneous fat to muscle and from muscle to nerve.
However, transition from adipose tissue to nerve was difficult
to detect. Proximity to peripheral nerves was associated with
higher lipid and lower haemoglobin values in pigs [34] and
patients [35]. The technology was explored by industry but
was abandoned for several reasons. Adipose tissue varies
between patients and with age, sex and BMI; spectral change
from muscle to nerve is more acute than adipose tissue to
nerve; and false positive results may arise from blood
accumulation at the needle tip due to repeated injections.
Nevertheless, this technology has the potential to provide
real-time detection of intravascular catheter placement.
Figure 4 Schematic diagram explaining rational for
Optical coherence tomography is a laser-based microultrasound. Grey lines represent the transducer and
imaging technology already used to image retinal disease. acoustic beam, and yellow band represents perineural
Incorporation of optical coherence tomography into an tissue. Using standard ultrasound (US) nerves are visible
epidural needle [36–38] has the potential to image anatomy (green), but resolution is poor and limited to a maximum of
300 micron using a 10MHz transducer. Large, indistinct
in deep spaces with very high resolution between 5 and
anechoic areas represent the merging of fascicular bundles.
15 μm and reconstruct images in 3D. Such resolution is
High frequency ultrasound (HFUS)> 15 MHz has poor
similar to that obtained with histology. Unlike ultrasound, penetration of tissue because energy is attenuated within
imaging may be performed in air without direct contact with tissues. Therefore, nerve can be seen but only poorly and
tissue. The disadvantage of optical coherence tomography fascicle bundles not visible. On the other hand, micro-
is that backscatter and absorption of light limits imaging to ultrasound (MUS) using 30–45 MHz frequencies at the end
of a needle is able to visualise nerves with resolution
the first 2–3mm of tissue. An optical fibre has been recently
between 100 and 40 micron respectively. Fascicles greater
incorporated into the side of an 18 g Tuohy needle and than these diameters are visible, along with clear
paramedian epidural block conducted in the lumbar and delineation of epineurium, fascia and muscle

Three studies have used micro-ultrasound to image bridge. Striking high resolution micro-ultrasound images of
nerves and the epidural space. In two studies using fresh nerves were obtained with clear distinction between
cadaver nerves [40] and pig back [41], radiofrequency perineurium, inner epineurium and outer epineurium
waves were collected from single element micro-ultrasound (Fig. 5). In each image, between 20 and 40 anechoic
transducers. Processed images identified fascicular structures were seen that matched fascicles > 100 micron
bundles, needle insertion and subepineural tissue trauma. diameter on histology. Videos demonstrated nerve and
In pig back, tissue boundaries such as ligamentum flavum fascicle rotation on needle contact, and, in most instances,
and dura were readily identified. subepineural morphology returned to normal after
Real-time imaging was conducted in a third study on injection.
anaesthetised pigs in order to gain insight into the potential For deep blocks, the author envisages a combination of
strengths and weaknesses of micro-ultrasound [42]. The an active needle with a traditional ultrasound transducer
axillae of four anaesthetised pigs were dissected and a and two images. The needle would be guided, for example,
40 MHz micro-ultrasound transducer (Vevo 2100, to within 1–1.5 cm of the target nerve, then the micro-image
VisualSonics, Toronto, Canada) placed over a muscle activated, nerve and connective tissue identified and the
(a) (b)
Figure 5 Micro-ultrasound
images obtained from
anaesthetised pig. Axillae
dissected and 40MHz transducer
placed over muscle bridge.
Nerve < 1 cm from transducer.
Image (a) shows > 30 fascicles in
the median nerve embedded
within inner epineurium and clear
distinction between outer
(c) (d) epineurium and muscle. The
striations of muscle are clearly
seen. The needle tip is
located < 0.1 mm from the nerve
and upon advancement, within
the centre of the nerve (b).
Injection of 0.5-ml saline appears
as a hypoechoic region within the
middle of the nerve. In-plane
needle (N) insertion towards right
(e) (f) median nerve (c) and
subepineural injection (d). Out-
of-plane injection into left radial
nerve (images e and f).
Considerable axial tenting before
epineural penetration.
Subepineural (SE) Injectate
spread between fascicles. P,
perineural fluid; A, axillary artery.
Image (g) shows an ultrasound of
(g) rat sciatic nerve with overlay of
vasculature obtained with
photoacoustic system

needle tip guided precisely to its destination. In doing so, Strain elastography is offered on many ultrasound
micro-ultrasound holds out the promise of both improved machines. Raw radiofrequency data (otherwise termed
efficacy and reduced nerve damage for ultrasound-guided ultrasound A-lines), are collected before and after
regional anaesthesia but will be more complicated to use transducer compression, and compared using cross-
for many anaesthetists. correlation methods. Maximum correlation between two
sampling zones of the radiofrequency signal equates to
Photo-acoustics displacement and displayed as a colour elastogram.
Photo-acoustics uses a pulsed laser light emitted from The principal advantage of strain elastography is that
an attachment on the ultrasound transducer. Light is local anaesthetic flow is seen in colour or as a ghostly
absorbed by chromophores such as haemoglobin white shadow that superimposes on the B-Mode image.
causing heat and tissue expansion. In response, Using the latter, anaesthetic trainees were better able to
acoustic waves are generated that are detected by the diagnose accidental intraneural injection compared with
ultrasound transducer, processed and presented as a B-Mode ultrasound However, the application of strain
real-time map of blood flow superimposed on the elastography to ultrasound-guided regional anaesthesia
micro-ultrasound B-Mode image. Because oxy- and has several potential limitations. Interpretation is
deoxyhaemoglobin absorb light differently at different qualitative because strain is a unitless entity and subject to
wavelengths, photoacoustic imaging can be used to operator variability; the size and shape of the strain pattern
generate a high-resolution map of the blood flow and does not equate to the size and shape of the hydrospace
oxygen saturation non-invasively. This allows for the area because both fluid and tissue are displaced
real-time monitoring of functional processes in 3D. according to their intrinsic stiffness and structures beyond
Accrual of images is straightforward. All that is required 4 cm become increasingly difficult to compress (Fig 6).
is that a jacket, appropriate for the depth and Shear wave elastography (Aixplorer(R), Supersonic
sensitivity of photoacoustic imaging is clipped onto the Imagine, Aix-en-Provence, France) is a technology that uses
ultrasound transducer. Figure 5g shows a photo- differences in the density and stiffness of tissues in order to
acoustic image of a rat sciatic nerve using early accurately detect prostate [44] and breast cancer [45].
technology. The red areas indicate the presence of Supersonic speed insonification of tissues at different levels
haemoglobin. generates transverse (shear) waves that ripple outwards,
similar to throwing a stone into a pond. Shear wave speeds
vary between 1 and 10 m.s−1, and are considerably slower
Elasticity than mean ultrasound (1540 m.s−1). Wave speed is
Needle insertion and local anaesthetic injection displace detected by sensors in the ultrasound transducer and shear
visco-elastic tissue. Elastography, invented in 1991 by Ophir modulus (transverse elasticity) and Young’s modulus
et al. [43], is the umbrella term used to describe several (longitudinal elasticity) calculated using the formula:
technologies that image elasticity and, in essence, is a
digital form of palpation. E ¼ 3:ρ:c2s
Elasticity is defined as the resistance of tissue to
deformation and described mathematically as the where E ¼ Elasticity, C2s = shear wave speed and ρ = tissue
application of force over a specified area (stress) with density and 3 is the standard conversion factor from K (shear
displacement of tissue (strain). Stress (σ) is defined as Force wave modulus) to E.
per unit area with the units kPa or Nm−2 whereas strain (ε) is Studies in human volunteers [46] and soft embalmed
represented as: ε = (Lf - L0)/L0 where Lf is the length after and cadavers [47, 48] showed a three-fold difference between
L0 is the length before tissue displacement. neural and extraneural elasticity (stiffness). The advantages
The mechanics of soft tissues are very complex and of shear wave elastography are that no manual
assumptions are made when measuring elastic properties. compression is required, data are repeatable and
Tissues are regarded as homogeneous, isotropic, reproducible, it can be continuously recorded, is
incompressible solids that obey Hooke’s law (i.e. low values presented as a colour map and can be applied in both 2D
of strain are directly proportional to stress), have a density ρ and 3D formats. However, application of the transducer
of 1000 kg.m−3 and waveform velocity equivalent to the requires a light touch as any pressure will show as a
speed of sound, 1540 m.s−1. surface tissue strain. One interesting advantage is that,

(a) (b)
(c) (d)
(e) (f)
Figure 6 Elastography. The B-mode image (a) shows spread of local anaesthetic during a femoral block below the fascia iliaca.
The corresponding strain elastogram (b) highlights the needle (not seen on the B-Mode image), a demarcation between blue
and green indicating the fascia iliaca and a yellow/green circumferential spread around three branches of the femoral nerves.
Image (c) shows the infraclavicular anatomy on B-mode imaging and adjacent acoustic radiation force imaging image (d). The
yellow boxes are used to measure tissue elasticity (kPa). Box 3 overlies the posterior cord, box 2 lies close to, but not overlapping
the posterior cord, and box 3 overlies muscle. Note that higher stiffness is indicated by a brighter reflection and low stiffness by a
darker reflection. Images (e) and (f) are taken from a patient undergoing femoral nerve block under B-Mode imaging and shear
wave elastography. The coloured upper ridge in image (f) is the stiff fascia iliaca and the coloured lower area is the femoral
nerve. Although shear wave elastography recognises the nerve in colour, its epineurium remains indistinct
because shear waves do not pass through fluid, enables calculation of tissue stiffness. Images of elastic
hydrolocation can be seen as an anechoic area that modulus are presented on a grayscale. Acoustic radiation
accurately defines fluid spread and nerve anatomy (Fig. 6). force imaging, compared with strain elastography, has
The technology has some drawbacks; although nerves are better resolution and less inter-observer variability [49, 50].
identified in colour and have similar size to those identified However, it is restricted by only being able to create static
using B-Mode images, the relatively slow video frame rate images.
means that the colour mapping tends to be out of phase The role of elastography in regional anaesthesia is yet
and images do not overlap nerves exactly. to be established. Nevertheless, the technology is
A similar technology, acoustic radiation force imaging, interesting because differences in elasticity between
generates a high ‘acoustic push’ in order to move cells at the epineurium, subepineurium and perineural outweigh
cellular level. Movement generates a transverse wave that differences using greyscale.

Conclusion soft embalmed Thiel cadaver model. British Journal of

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Figure 2 is distributed under the terms of the Creative
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non-commercial use, distribution and reproduction in any
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Anaesthesia 2021, 76 (Suppl. 1), 160–170 doi:10.1111/anae.

Novel approaches to needle tracking and visualisation

1 Consultant, Ninewells Hospital, Dundee, UK

160 © 2021 Association of Anaesthetists

© 2021 Association of Anaesthetists 161

162 © 2021 Association of Anaesthetists

Figure 2 Impedance modulus

© 2021 Association of Anaesthetists 163

164 © 2021 Association of Anaesthetists

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166 © 2021 Association of Anaesthetists

© 2021 Association of Anaesthetists 167

168 © 2021 Association of Anaesthetists

Conclusion soft embalmed Thiel cadaver model. British Journal of

© 2021 Association of Anaesthetists 169

170 © 2021 Association of Anaesthetists

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