BJA Education, 16 (11): 374–380 (2016)
doi: 10.1093/bjaed/mkw026
Matrix reference
2G03, 3A09
Challenges, solutions, and advances in
ultrasound-guided regional anaesthesia
M Henderson MB ChB, FRCA1 and J Dolan BSc (Hons), MSc (Distn), PhD, MB ChB,
FFARCSI, EDRA2, *
1
Specialist Trainee, Department of Anaesthesia, Glasgow Royal Infirmary, Walton Building, 84 Castle Street,
Glasgow G4 0SF, UK, and 2Consultant Anaesthetist, Department of Anaesthesia, Glasgow Royal Infirmary,
Walton Building, 84 Castle Street, Glasgow G4 0SF, UK
*To whom correspondence should be addressed. E-mail: johndolan@nhs.net
Key points
• Challenges to successful ultrasound-guided region-
al anaesthesia include the acquisition of acceptable
ultrasound images of the nerve while avoiding
artifacts.
• The most common ultrasound artifacts are acoustic
or anatomic.
• Physiological and pathological factors attributable to
the patient affect image quality and interpretation.
• Needle artifacts may cause confusion and error
during ultrasound-guided nerve blocks.
• The combination of ultrasound guidance and
peripheral nerve stimulation, ‘dual guidance’, may
offer reassurance when the nerve or needle image
is suboptimal.
Ultrasonography offers significant advantages in the practice
of regional anaesthesia, including faster sensory onset and
improved success rates compared with landmark-based techni-
ques.1 Adequate visualization of neural and surrounding struc-
tures together with monitoring the spread of local anaesthetic
(LA) are absolute prerequisites for the safe and successful
practice of ultrasound-guided regional anaesthesia (USGRA).
The creation of an ultrasound (US) image is based on the physical
properties of the US beam formation, propagation of sound in
matter, interaction of sound with reflective interfaces, echo de-
tection, and machine processing. However, there are often a
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number of significant challenges to acquiring the optimal US
images necessary to achieve successful nerve blocks. Such chal-
lenges include the acquisition and interpretation of optimal US
images of the target structure and needle while avoiding tissue
and needle artifacts. Other difficulties may include physiological,
pathological, and anatomical factors attributable to the patient
and which may affect image quality and interpretation. This art-
icle will describe some of these problems, discuss strategies to
avoid them, and highlight current and future advances which
may assist the practice of USGRA.
Challenges presented by the ultrasound
machine
The spatial resolution of any imaging system is defined as its abil-
ity to distinguish two points as separate entities in space. Spatial
resolution is commonly subcategorized into axial and lateral reso-
lution.2 Axial resolution is defined as the US machine’s ability to
differentiate two objects located at different depths in the direction
parallel to the direction of the US beam. If the distance between
two objects is greater than half the length of the US pulse then
the two objects will be distinguished. Axial resolution can be
improved by increasing the US pulse frequency and reducing the
pulse length. High-frequency transducers having shorter pulse
lengths will therefore provide optimal axial resolution but is lim-
ited to superficial structures. When viewing deeper structures,
the operator should chose a transducer with the highest frequency
which permits adequate tissue penetration of the US beam.
Lateral resolution refers to the ability of the US machine to dif-
ferentiate two objects which are adjacent to each other, e.g. the
tibial and common peroneal nerves in the popliteal fossa. The
width of the US beam and depth of imaging both influence lateral
374
 Challenges, solutions, and advances in USGRA

resolution.2 All US beams typically diverge at greater depth, while Challenges presented by the ultrasound image
wider beams diverge further in the far field. Therefore, lateral
Artifacts are presentations on the display which are added or
resolution is best at shallow depths and worse with deeper im-
omitted, or are of improper location, brightness, shape, and
aging. Lateral resolution is improved by positioning the focal
size compared with the true anatomical features. Some artifacts
zone, the narrowest part of the US beam, at the level of the target
are useful in interpretation, while others may cause confusion
object.
and error. A good understanding of artifacts, why they arise
Temporal resolution refers to the US machine frame rate
and how to deal with them when they occur, is important in
which is the speed at which an imaging device produces
the practice of USGRA. Failure to recognize imaging artifacts
consecutive images and is important in real-time imaging during
may lead to complications, including incorrect needle placement
USGRA.3 The rate at which consecutive image frames are gener-
or deposition of LA in the wrong location or hazardous areas. Ar-
ated and viewed affects the visualization of moving structures. A
tifacts are commonly observed during ultrasound-guided nerve
low frame rate may obscure motion during a procedure including
blocks and may be related either to the tissues, the block needle,
probe movement, needle insertion, and the placement of LA dur-
or both (Table 1). The most common artifacts observed during
ing USGRA. Temporal resolution is influenced by the speed of
USGRA are either acoustic or anatomic.

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sound in tissue and may be improved by decreasing the imaging
depth to just below the target and minimizing tissue movement
by the slow injection of LA. Acoustic artifacts
Acoustic artifacts are usually the result of incorrect assumptions
during processing by the instrumentation. These assumptions
Table 1 Errors associated with ultrasound artifacts include sound travels in straight lines; the intensity of returning
echoes is directly related to scatter from the imaged object and
Artifact Error distance of structures on the image is directly proportional to
the time taken for the sound wave to return to the transducer.
Acoustic Presentation of ultrasound information
Some acoustic artifacts are also secondary to operator error, in-
Anatomic or pitfall Interpretation
Optical illusion Perception cluding improper transducer placement or scanning technique.
Other Electrical noise A common operator error is a suboptimal angle of insonation re-
sulting in a significant portion of the returning US beam being
transmitted away from the transducer producing a degraded
image (Fig. 1). As the incident angle of the US beam to the
nerve approaches 90°, the target image becomes optimal. This
artifact can be reduced by sweeping the transducer through an
arc to determine the position of the transducer which provides
the best available image of the target nerve. Classification of com-
mon acoustic artifacts together with their origins and imaging
errors are listed in Table 2.
Acoustic errors may also be subdivided into missing or falsely
perceived structures and are often due to errors in gain setting.
Gain refers to the degree of amplification applied to all US signals
returning to the transducer. Too high a gain will make the image
too bright and obscure structures, while too little gain will darken
the image and may make a structure appear absent. This artifact
is avoided by adjusting the gain setting to permit an optimal view
Fig 1 Angle of insonation. When the ultrasound beam is perpendicular to the
of the target nerve and surrounding tissues. Attenuation is the
reflector, the ultrasound beam is returned to the transducer. When the angle of progressive loss of acoustic energy and signal strength as the
insonation is reduced, the ultrasound beam is reflected away from the US wave passes through tissue. Attenuation can be reduced by in-
transducer and the view of the target is suboptimal. creasing the overall gain control and image brightness. Time gain

Table 2 Ultrasound artifacts and their origins

Acoustic artifact Origin Artifact

group

Attenuation Reduced amplitude of echoes by intervening structures with high attenuation Shadowing
Increased relative amplitude of echoes caused by an intervening structure of low attenuation Enhancement
Resolution Pulse frequency Axial resolution
Beam divergence Lateral resolution
Interference patterns from echoes generated by closely spaced reflectors Speckle
Propagation path Sound pulse reverberates back and forth between two strong parallel reflectors Reverberation
Change in direction of a sound pulse when it crosses a boundary and when a change of speed Refraction
of sound occurs
Reflection of the sound pulse from a highly reflective surface Mirror image
Side beams from the transducer cause objects to be viewed in a lateral location Side lobe
Miscellaneous Two closely spaced reflective surfaces and generated echoes with a conical shape Comet tail

BJA Education | Volume 16, Number 11, 2016 375

Challenges, solutions, and advances in USGRA
Fig 2 Reverberation artifact and acoustic shadowing. AS, acoustic shadowing; PL,
peritoneal layer; PRS, posterior layer of rectus sheath; RA, reverberation artifact;
SI, small intestine.
Fig 3 Acoustic enhancement. AA, axillary artery; AE, acoustic enhancement;
AV, axillary vein; MCN, musculocutaneous nerve; MN, median nerve; UN, ulnar
nerve.
compensation (TGC) is a setting applied in ultrasonography to ac-
count for tissue attenuation of the US beam. TGC independently
increases the gain of reflected signals with increasing time from
the transmitted pulse and is equivalent to increasing the gain of a
reflected US signal with increasing tissue depth.
Acoustic shadowing may also cause structures to appear less
echogenic and occurs when a target lies below a structure which
strongly absorbs or reflects US waves. Air and bone are common
causes of acoustic shadowing during USGRA and may be avoided
by changing the transducer position (Fig. 2).
Acoustic enhancement occurs when an area behind a weakly
attenuating structure produces stronger echoes than the sur-
rounding structures. This artifact commonly occurs behind
blood vessels and may lead to confusion with neural structures
lying posterior to arteries and veins. This is particularly import-
ant when scanning the axilla where the radial nerve lies behind
the axillary artery and may be confused with acoustic enhance-
ment artifact (Fig. 3). In such instances, the use of a nerve stimu-
lator may be helpful to confirm the presence or absence of the
radial nerve.
Image degradation is often the result of reverberation which
results from US waves reflecting off two strong reflectors, for ex-
ample, the pleura, peritoneum, or a fascial plane. The image
376 BJA Education | Volume 16, Number 11, 2016
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Fig 4 Mirror artifact. BP, brachial plexus; FR, first rib; PL, pleura; MI, mirror image;
SA, subclavian artery.
Fig 5 Tendons and nerves. MN, median nerve; T, tendon.
shows multiple linear and hyperechoic areas distal to the reflect-
ing surface (Fig. 2). The comet tail sign refers to the mergence of
multiple reverberation artifacts in a tapered band adjacent to the
object.4 Increasing the pressure of the probe on the skin may
eliminate the reverberation artifact. The ‘double-barrelled sub-
clavian artery’ is also an example of a reverberation artifact
(Fig. 4). This results from the US beam bouncing within the
lumen of the subclavian artery and creating a mirror image of
the subclavian artery deep to the first rib. It is important to recog-
nize that the image of the subclavian artery under the first rib is
an artifact and attempted needle insertion towards this point
may lead to a pneumothorax.
Anatomic or pitfall error
Anatomic artifacts are tissue structures which resemble the
target nerve. These errors are also referred to as ‘pitfall errors’.
Tendons and nerves may be difficult to distinguish by ultrason-
ography (Fig. 5). This is a particular problem in the wrist, but
tracking structures proximally often assist in differentiating the
two structures since tendons will integrate within their respect-
ive muscles. Blood vessels are not normally mistaken for nerves.
Arteries are anechoic and pulsatile, while veins are compressible.
Nerves are usually hyperechoic (echo bright) or hypoechoic (echo
dark) and non-compressible. However, the roots of the brachial
plexus may sometimes appear similar to a small diameter ves-
sels. Colour Doppler is useful in identifying vascular structures
but may be misleading if the transducer is placed perpendicular

Fig 6 Tissue oedema. AE, acoustic enhancement; FA, femoral artery; FI, fascia
iliaca; FN, femoral nerve; LN, lymph node; O, oedema.
to the blood vessels and detection of blood flow is suboptimal.
Flow detection is best when the transducer is aligned in the dir-
ection of blood flow.
Inflamed lymph nodes may also be mistaken for nerves, but
the former are often well circumscribed, non-compressible
anechoic structures with small, hypoechoic internal features
(Fig. 6). Additionally, a nerve stimulator will differentiate
between a lymph node and motor nerve.
Optical illusion
Illusions may be categorized as illusions of sensation, perception,
and image formation.5 They represent alterations in the appear-
ance of reality due to the process of image formation and may
result in misinterpretation.
Random noise
Noise degrades the quality of an US image and often appears
as low-amplitude echoes in echolucent areas. The origins of
random noise are extensive and often include excessive gain
and other changes in machine settings. A common source of
noise in the operating theatre is electrocautery. Ultrasound
machines are often fitted with filters to limit the amount of
electrical interference.
Challenges presented by the patient
Obesity
Obesity is a rapidly growing pandemic disease and regional an-
aesthesia offers many potential advantages to the obese patient.
Airway manipulation and cardiopulmonary depression are
avoided, while postoperative pain control is improved. However,
peripheral and centroneuroaxis nerve block may be technically
difficult in the obese patient. While US guidance has revolutio-
nized the practice of regional anaesthesia, it has several limita-
tions, particularly in the obese patient. Neural structures are
more deeply situated in obese patients and the US beam is highly
attenuated as it travels a greater distance through the tissue
layers. Sound attenuation in adipose tissue is defined as the
product of the attenuation coefficient (decibels per centimetre
at 1 MHz), the transducer frequency (MHz), and thickness of the
Challenges, solutions, and advances in USGRA
adipose tissue (cm).6 Adipose tissue is also associated with
phased aberration of the US beam due to the uneven speed of
sound within the irregularly shaped layers of adipose tissue.7
Whenever an US beam crosses a tissue boundary, a portion of
the sound energy is reflected back to the transducer creating
more echoes and further artifacts including speckling and clutter
which are particular problems in the obese patient. Speckling
artifact refers to interference patterns from echoes generated
by closely spaced reflectors and which are too small to resolve.8
The resulting US image appears to have a granular structure
which obscures the underlying anatomy. Clutter artifact appears
as a diffuse haze in hypoechoic areas overlying areas of interest
and degrading image quality.9 Sources of acoustic clutter include
sound reverberation in tissue layers, US beam distortion, and
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random acoustic noise. Consequently, the acquired US image in
obese patients is often suboptimal.
US imaging in obese patients may be improved by using a
lower frequency transducer, while the US machine should be
set to ‘penetrate’ to enable greater depth penetration of the US
beam at the lower frequency. Signal attenuation is reduced and
more of the primary beam penetrates the subcutaneous adipose
tissue. The needle should be aligned as parallel as possible to the
probe by carefully choosing the entry site and by tilting the far
end of the probe down (‘heel in’ manoeuvre). Harmonic imaging
is a technique in ultrasonography which provides images of bet-
ter quality by exploiting non-linear propagation of US through
body tissues.10 Distortion of the US beam leads to the generation
of harmonics, multiples of the transmitted US frequency. These
harmonic waves which are generated within the tissue increase
with increasing depth. Near field clutter is reduced and reso-
lution increased, thus improving image quality. Spatial com-
pound imaging which combines overlapping image frames
from different US beam angles to form a single real-time image
may also assist in reducing artifacts.8 Other processing filters
including speckle reduction may also improve image quality.
Oedema
Tissue oedema offers a number of challenges during ultrasound-
guided nerve blocks. Diffuse oedema may amplify sound absorp-
tion and decrease the echo contrast that normally exists between
nerves and the surrounding tissues (Fig. 6). Oedema may also
compress or displace neural structures changing its anatomic
position or shape.
Tissue oedema is a particular problem in the ankle and may
obscure the anatomy and make identification of neural struc-
tures and the observation of LA spread particularly difficult. In
extreme cases, it is often necessary to choose a more proximal
area where tissue oedema is less prevalent to permit effective
and safe execution of the ultrasound-guided nerve block.
Air
Air forms an impenetrable barrier to sound and casts a shadow-
ing artifact (Fig. 2). Image quality is degraded and underlying
structures obscured. Air may be present secondary to a patho-
logical process including subcutaneous emphysema but may
also be due to air injection during the ultrasound-guided proced-
ure. The presence of microbubbles in an injectate may degrade an
image by reflecting the US beam, thus obscuring the target and
surrounding structures (Fig. 7; Online video 1). Care should be
taken to remove air bubbles before undertaking the procedure
and to minimize the number of syringe changes. Additionally,
pre-warmed LA may assist in reducing microbubble formation.
BJA Education | Volume 16, Number 11, 2016 377
Challenges, solutions, and advances in USGRA
Fig 7 Degradation of the ultrasound image by injected air. Air within reflects the
ultrasound beam and degrades the view of the median nerve and needle tip. FDP,
flexor digitorum profundus; FDS, flexor digitorum superficialis; MN, median
nerve. The small unlabelled arrows indicate the block needle.
Video 1 If reading the pdf online, click on the image to view the video.
Muscle atrophy
Muscle atrophy due to chronic myositis and muscle degeneration
in the elderly is commonly observed during USGRA. The atro-
phied muscles reflect the US beam and are shown as hyperechoic
structures. Failure of the US beam to adequately penetrate atro-
phied muscle obscures deeper structures. In such circumstances,
it is often unsafe to proceed and an alternative location for the
ultrasound-guided nerve block should be chosen.
Anatomical abnormalities
The observation of anatomical anomalies is not uncommon dur-
ing USGRA and is important to recognize. The musculocutaneous
nerve is absent in 1.4–6% of the population in whom branches
originate either from a common trunk arising from the median
nerve or directly from the median nerve itself (Fig. 8; Online
video 2).11 However, the majority of anatomical abnormalities
in the upper limb are related to vascular anomalies which may
impact on the practice of USGRA as blood vessels are often
used as landmarks for peripheral nerve blocks. Anatomical vari-
ation of the brachial artery may be observed in up to 25% of the
population and includes high proximal division into the terminal
branches.12 The brachial artery is often used as a landmark
for the median nerve block at the elbow, but this advantage is
378 BJA Education | Volume 16, Number 11, 2016
Fig 8 Fusion of the median and musculocutaneous nerves. The median and
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musculocutaneous nerves are fused proximally in the axilla and separate
distally in the arm. AA, axillary artery; MCN, musculocutaneous nerve; MN,
median nerve; UN, ulnar nerve.
Video 2 If reading the pdf online, click on the image to view the video.
lost if the brachial artery has already divided. Other anatomic
variants include the persistent median artery and veins which
accompany the median nerve in the forearm in ∼19% and 6% of
patients, respectively.13 These vessels normally evolute and are
not often noted in the adult population. When present, the nee-
dle should approach the nerve on its non-vascular aspect to avoid
inadvertent vessel puncture. Another common anatomical
anomaly is the superficial ulnar artery (SUA) and may be ob-
served in up to 10% of individuals.14 While the ulnar artery usu-
ally accompanies the ulnar nerve (UN) in the distal forearm, the
SUA lies superficial to the flexor muscles throughout its course
and is an unreliable landmark for identification of the UN
which may be difficult to distinguish from surrounding tendons.
In this instance, the use of a peripheral nerve stimulator is
advantageous before the deposition of LA.
Challenges presented by the block needle
Real-time assessment of needle position is vital during USGRA.
However, observation of the regional block needle and needle
tip can also pose challenges during the practice of USGRA.
Needles are strong reflectors of the US beam and are subject to
reverberation artifacts evident as multiple linear densities be-
hind the needle and which occur due to US waves bouncing
back and forth within the lumen of the needle (Fig. 9). It is

Fig 9 Needle artifacts: bayonet and reverberation. FDP, flexor digitorum
profundus; FDS, flexor digitorum superficialis; MN, median nerve; RA, radial
artery.
important to note that the true needle image is the one nearest
the transducer. Such artifacts most commonly occur when the
needle is completely perpendicular to the US beam and can
therefore be reduced by decreasing the angle of the US beam to
<90°. In addition, a reduction in far gain will darken the distal
artifacts.
A mirror artifact is a type of reverberation artifact and is pro-
duced when an object is located in front of a strong US reflector,
e.g. needles and bone. A second representation of the needle is
observed in an incorrect location behind the strong reflector
and may cause confusion. It is important to note that the true
needle image is the one nearest the transducer.
Another common needle artifact is the bayonet artifact in
which the needle appears broken or bent (Fig. 9). This artifact oc-
curs because of differences in the speed of sound in different
tissues which are adjacent to the needle. The speed of sound is
reduced in adipose tissue compared with muscle and takes long-
er to return to the transducer. Therefore, a needle placed in
adipose tissue will appear to be deeper than that part of the
needle which is in muscle.
The side lobe artifact is often seen during USGRA and may
cause confusion in image interpretation.15 Several low-intensity
beams, side lobes, are often located peripheral to the main axis of
an US beam. Although they are of a much lower intensity than
the main beam, these peripheral beams are sufficiently high to
create significant artifacts when they interact with highly reflect-
ive acoustic surfaces, including a metallic needle path. In con-
trast, other US artifacts, the side lobe artifact is visible anterior
to the true needle path. The artifact is divergent and diffuse
while the needle tip projected beyond the true needle pathway.
The side lobe artifact is a particular problem with but not unique
to linear transducers and can be observed with both static
and real-time equipment. The artifact is minimized by careful
repositioning of the US transducer.
Improving needle visibility
Maintaining optimal needle visibility during the ultrasound-guided
nerve block remains a significant challenge even to experienced
practitioners. Needle-beam alignment may be improved by the
use of a mechanical guide attached to the transducer, but needle
realignment may be restricted and the freehand technique is
often preferred. Needle visibility may be improved by using needle
with a larger diameter but at the expense of increased tissue
damage and patient discomfort. Needle tip and shaft visibility is
improved by keeping the needle shaft at more than 55° to the US
Challenges, solutions, and advances in USGRA
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Fig 10 An echogenic needle. The arrow indicates cornerstone technology. Image
reproduced with permission from Pajunk GmbH Medizintechnologie.
beam while keeping the needle tip at 0 or 180° to the US beam.
Priming the needle with air or fluid does not improve needle
echogenicity.
Combined neurostimulation and ultrasound guidance
The parallel contribution of US guidance and peripheral nerve
stimulation (PNS) or ‘dual guidance’ may offer versatility and re-
assurance when localizing nerves. Although ultrasonography
has the advantages of real-time imaging of nerves and monitor-
ing the spread of LA, it also encourages multiple injections and
needle realignments during ultrasound-guided nerve block.
However, PNS also has some disadvantages including a reliance
on eliciting a motor response which may be affected by numer-
ous factors, including disease processes. Failed nerve block in
the presence of an adequate motor response is not uncommon
and may be due to the presence of fascial planes inhibiting the
spread of LA and delivery of asymmetric current from the needle
tip. PNS combined with ultrasonography is useful for identifying
neural structures when there is doubt about the sonoanatomy
and as a warning system when there is uncertainty about the
position of the needle tip. Dual guidance may also be useful as
an aid when learning USGRA. However, it is sometimes difficult
to distinguish between intra- and extra-fascicular injection by
current resolution. Triple monitoring (US, PNS, and measure-
ment of injection pressure) has been proposed as the standard
to minimize nerve injury.16
New technology and future directions
US technology continues to advance. Recent advances have in-
cluded additions to both needle and machine technology. Ad-
vances in needle technology to improve the reflective signal
have included dimpling, roughing, scoring, and the application
of a polymeric coating to the needle with the aim of increasing
the return of the US signal to the transducer (Fig. 10).17 These nee-
dles may improve needle tip visibility when the insonation angle
is steep but are of limited value in superficial ultrasound-guided
blocks. Needles with piezoelectric polymer sensors at the tip
BJA Education | Volume 16, Number 11, 2016 379
Challenges, solutions, and advances in USGRA
have also been designed. Other approaches to improving needle
visibility include beam steering technology and the use of propri-
etary software algorithms within the US machine software to ad-
just the needle-beam angle to 90°. Ultrasound characterization of
tissue elasticity or elastography offers the ability to distinguish
key anatomical features and differentiate between neural and ex-
traneural tissue.18
In recent years, technology has improved enormously in
areas such as transducer sensitivity, beam formation, image
processing, and final data display. Three-dimensional US offers
several advantages over two-dimensional views. Multiple planes
of view can be visualized providing information about the spatial
relationship between structures and tracking of LA spread. How-
ever, the technology is currently limited by a slower frame rate
and reduced image quality while needle visibility is not en-
hanced. Other recent advances include the use of metamaterials
which permit US to pass through tissues with a high acoustic
index including bone.19 Machine recognition and automated
nerve block systems may also prove useful for enhancing the
accuracy of identification of peripheral nerves.
Online videos
The videos associated with this article can all be viewed from the
article in BJA Education online.
Declaration of interest
None declared
MCQs
The associated MCQs (to support CME/CPD activity) can be
accessed at https://access.oxfordjournals.org by subscribers to
BJA Education.
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