Surface Anatomy and Sonoanatomy for the Occasional

Regional Anesthesiologist

@EMARIANOMD

Edward R. Mariano, M.D., M.A.S.Professor of Anesthesiology, Perioperative & Pain Medicine

Stanford University School of MedicineChief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System

Surface Anatomy and Sonoanatomy

Financial Disclosures

Halyard Health, B Braun – Unrestricted educational program funding paid to my institution

The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.

Surface Anatomy and Sonoanatomy

Learning Objectives

Define optimal ultrasound transducer position for cross-sectional imaging of nerves

Apply surface anatomic landmark identification in ultrasound transducer application

Identify sonoanatomy of common peripheral nerves and surrounding structures

Discuss tips and tricks to improve ultrasound images and block techniques

Surface Anatomy and Sonoanatomy

How Hard Can It Be?

NYSORA.COM -

Surface Anatomy and Sonoanatomy

Lesson #1

Surface Anatomy and Sonoanatomy

Lesson #2

Regional anesthesia is applied anatomy

Surface Anatomy and Sonoanatomy

History of Nerve Localization

Anatomic landmarks Fascial clicks or pops Electrical nerve

stimulation Sustained “twitch” at

< 0.5 mA current suggests appropriate needle position

Ultrasound

Surface Anatomy and Sonoanatomy

Overview

Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks

Surface Anatomy and Sonoanatomy

Overview

Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks

Surface Anatomy and Sonoanatomy

Basic Sonoanatomy

Blood vessels: hypo-echoic (dark)

Muscles: hypo- > hyper-echoic (striations)

Bone and fascia: hyper-echoic (white)

Nerves: hypo-echoic

Connective tissues are hyper-echoic (epineurium, perineurium)

Surface Anatomy and Sonoanatomy

A Closer Look at the Nerve

Short-Ax is View

Surface Anatomy and Sonoanatomy

The “A.R.T.” of Target Imaging

A lignment

R otation

T ilt

Surface Anatomy and Sonoanatomy

Alignment: Where Do We Look?

Surface Anatomy and Sonoanatomy

Optimal Rotation

Surface Anatomy and Sonoanatomy

Optimal Rotation

Surface Anatomy and Sonoanatomy

Optimal Tilt

Surface Anatomy and Sonoanatomy

Optimal Tilt

Surface Anatomy and Sonoanatomy

Overview

Introduction to ultrasound Surface anatomic landmarks Relevant gross anatomy Traditional nerve block techniques Sonoanatomy for nerve blocks

Surface Anatomy and Sonoanatomy

Interscalene Block: How We Did It

Needle inserted in IS groove at C6

Antero-lateral approach

Needle angle 30-45º Elicit motor response

(deltoid, biceps, triceps, pectoralis)

Borgeat A, et al. Anesth 2003:99:436

Surface Anatomy and Sonoanatomy

Interscalene Anatomy

Position: supine with head turned away

SCM clavicular head Interscalene groove

posterior to SCM at cricoid level (C6)

External jugular vein Subclavian artery

Subclavian Art

Cricoid

Surface Anatomy and Sonoanatomy

Interscalene Sonoanatomy

Transverse Short-Axis View

SCM

ASMMSM

CTP

BP

Mariano ER, et al. JUM 2010;29:329

Surface Anatomy and Sonoanatomy

Infraclavicular Block: How We Did It

Insertion 2 cm medial and 2 cm caudad to CP

Needle inserted plumb-bob

Avg depth 4.24±1.49 cm in men, 4.01±1.29 cm in womenWilson JL, et al. A&A 1998;87:870

Surface Anatomy and Sonoanatomy

Infraclavicular Anatomy

Position: supine with arm at side or abducted 90°

Palpate coracoid process below the clavicle

Plexus runs under coracoid process

Coracoid

Surface Anatomy and Sonoanatomy

Infraclavicular Sonoanatomy

Transverse Short-Axis View

PMa

PMi

AA AVNN

N

Mariano ER, et al. JUM 2009;28:1211

Surface Anatomy and Sonoanatomy

Femoral Nerve Block: How We Did It

Needle insertion: lateral to artery at 45° angle aiming cephalad

Feel 2 “pops” Proper motor

response = quad contraction

Ilfeld, BM, et al. Anesth 2008;108:703

Surface Anatomy and Sonoanatomy

Femoral Anatomy

Position: supine with roll under hip

Leg straight Inguinal crease Femoral artery Femoral nerve is

lateral to femoral artery

Surface Anatomy and Sonoanatomy

Femoral Sonoanatomy

Transverse Short-Axis View

FA

FL

FIIliacus

N

Mariano ER, et al. JUM 2009;28:1453

Surface Anatomy and Sonoanatomy

Adductor Canal Anatomy

Position: supine with thigh externally rotated and knee slightly flexed

Subsartorial tunnel begins distal to the apex of the femoral triangle

Saphenous nerve runs with superficial femoral artery

Horn JL, et al. RAPM 2009;34:486Manickam B, et al. RAPM 2009;34:578

Surface Anatomy and Sonoanatomy

Adductor Canal Ultrasound

Transducer placed along medial aspect of thigh distal to inguinal crease

Short-axis view Landmarks

Sartorius (S) muscle Saphenous (N) Femoral artery (A)

Mariano ER, et al. JUM 2014;33:1653

Sartorius

N A

Surface Anatomy and Sonoanatomy

Popliteal Fossa Block: How We Did It

Insertion site: 8-10 cm cephalad to popliteal crease or at intertendinous junction

4” needle angled 45° cephalad

Plantar flexion or inversion preferred

Hadzic A, et al. A&A 2002;94:1321

Surface Anatomy and Sonoanatomy

Popliteal Anatomy

Position: prone with knee slightly flexed

Popliteal crease Biceps femoris

laterally Semimembranosus

and semitendinosus medially

Intertendinous “junction”

Surface Anatomy and Sonoanatomy

Popliteal SonoanatomyTransverse Short-Axis View

F

BFN

Mariano ER, et al. RAPM 2009;34:480

Surface Anatomy and Sonoanatomy

Transversus Abdominis Plane Anatomy

Surface Anatomy and Sonoanatomy

TAP Sonoanatomy

Transverse Short-Axis View

EO

IO

TA

Surface Anatomy and Sonoanatomy

Summary

We defined optimal ultrasound transducer position for cross-sectional imaging of nerves

We applied surface anatomic landmark identification in ultrasound transducer application

We identified sonoanatomy of common peripheral nerves and surrounding structures

We discussed tips and tricks to improve ultrasound images and block techniques