Nerve Blocks of The Scalp, Neck, and Trunk: Techniques

Nerve blocks of the scalp, neck, and trunk: Techniques - UpToDate 11/04/17 21(12
Official reprint from UpToDate

www.uptodate.com 2017 UpToDate
Nerve blocks of the scalp, neck, and trunk: Techniques
Authors: Meg A Rosenblatt, MD, Yan Lai, MD, MPH

Section Editor: Lisa Warren, MD
Deputy Editor: Marianna Crowley, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2017. | This topic last updated: Feb 21, 2017.
INTRODUCTION Nerve blocks of the scalp, neck, thorax, and abdomen are used for operative anesthesia
and/or postoperative analgesia for a variety of surgeries. This topic will discuss the innervation of these
anatomic areas, techniques and drugs used for these blocks, and complications specific to these blocks.
Indications, contraindications, comparison of techniques relevant to all peripheral nerve blocks, equipment,
and complications common to all nerve blocks are discussed separately. Nerve blocks for airway anesthesia
for awake intubation and infraorbital and mental nerve blocks are also discussed separately. (See "Overview
of peripheral nerve blocks" and "Flexible scope intubation for anesthesia", section on 'Airway anesthesia' and
"Assessment and management of facial lacerations", section on 'Facial nerve blocks'.)
SCALP BLOCK Individualized, targeted nerve blocks of the scalp have evolved to become sophisticated
and effective techniques compared with traditional local anesthetic (LA) infiltration [1-4]. Scalp nerve blocks
are useful for awake and routine craniotomies, deep brain stimulation, stereotactic procedures,
craniosynostosis repair in pediatric patients, and for chronic pain syndromes of the head and neck [1-3].
Scalp blocks are performed for craniotomy in order to blunt the hemodynamic response to skull pinning and
to reduce postoperative pain [4-6]. Preoperative scalp block can reduce intraoperative opioid requirement,
which can facilitate early postoperative neurologic assessment [5-7]. As an example, a 2013 meta-analysis of
seven trials with 320 patients found a reduction in pain scores up to 12 hours after craniotomy and a
reduction in cumulative opioid requirements over the first 24 postoperative hours with the use of scalp nerve
blocks [1]. (See "Anesthesia for craniotomy", section on 'Surgical steps'.)
Anatomy Four branches of the trigeminal nerve and two branches of the cervical nerve roots C2 and C3
provide innervation to the anterior and posterior scalp (figure 1) [2,3]. The supraorbital and supratrochlear
nerves are sensory nerves that innervate the forehead and upper eyelids. They are derived from the
ophthalmic division of the trigeminal nerve (V1). The zygomaticotemporal nerve comes from the maxillary
division (V2) and supplies a small area lateral to the outer canthus of the eye. The auriculotemporal nerve is a
branch of the mandibular division (V3) and provides sensation to the area in front of and above the ear. The
greater occipital nerve comes from the dorsal ramus of C2 and ascends through the posterior scalp medial to
the occipital artery. The lesser occipital nerve originates from the ventral rami of C2 and C3 and courses
upward from the posterior neck to innervate the scalp behind the ear (figure 2) [2,3].
Scalp block technique Six nerves are blocked on each side for complete scalp block. This block is
performed with long-acting LA (eg, bupivacaine 0.25 or 0.5%, or ropivacaine 0.2 or 0.5%) using a 1.5-inch,
25- or 27-gauge needle, using the following techniques (figure 3):
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Supraorbital and supratrochlear nerves With the patient in supine position, palpate the supraorbital
notch in the medial third of the supraorbital ridge. The notch is usually located directly above the
midpoint of the pupil (figure 4). Insert the needle 0.5 to 1 cm deep, perpendicular to the skin, until bone is
contacted. Withdraw the needle slightly, and after negative aspiration, inject 3 mL of LA to block the
supraorbital nerve. Redirect the needle medially under the skin, advance approximately 1 cm, and after
negative aspiration, inject 2 to 3 mL of LA to block the supratrochlear nerve. If paresthesia is elicited, the
needle should be repositioned prior to injection.
Auriculotemporal nerve The following technique minimizes the chance of anesthetizing the facial
nerve, which runs near the auriculotemporal artery at the level of the tragus [8].
Palpate the superior temporal artery 1 cm cephalad to the level of the tragus of the ear. Insert the needle
perpendicular to the skin, just behind the temporal artery. Loss of resistance or a click can usually be felt
when the needle passes through the temporalis fascia, at a depth of 1 to 2 cm. After negative aspiration,
inject 2 mL of LA below the fascia and another 1 mL superficial to the fascia as the needle is withdrawn.
Zygomaticotemporal nerve Palpate a groove along the zygomatic arch just lateral to the lateral
canthus of the eye. At that point, insert the needle perpendicular to the skin and advance until loss of
resistance or a click is felt as the needle passes through the temporalis fascia. After negative aspiration,
inject 1 to 2 mL of LA below the fascia.
Greater occipital nerve Palpate the occipital artery midway between the occipital protuberance and
the mastoid process. Insert the needle medial to the artery and, after negative aspiration, inject 5 mL of
LA.
Lesser occipital nerve Insert the needle 2.5 cm lateral to the injection point for the greater occipital
block and, after negative aspiration, inject 5 mL of LA.
Complications The auriculotemporal nerve block can cause transient facial nerve paralysis [8,9]. Facial
nerve block should be self-limited and should resolve as the scalp block wears off, but it may complicate
assessment of facial nerve trauma related to surgery. The incidence of facial nerve block may be reduced by
minimizing the volume of LA injected for auriculotemporal block and by performing the block as described
above [8].
CERVICAL PLEXUS BLOCKS Superficial and deep cervical plexus blocks are the peripheral nerve blocks
used for neck surgery. An intermediate cervical plexus block has also been described. These blocks can be
used as primary anesthetics for carotid endarterectomy, where neurologic monitoring of an awake patient
may identify cerebral thromboembolic or ischemic events. In this setting, coverage from a cervical plexus
block may be variable and may require supplemental local anesthetic (LA) infiltration by the surgeon. (See
"Anesthesia for carotid endarterectomy and carotid stenting", section on 'Local/regional anesthesia
technique'.)
Cervical plexus block can also be utilized for postoperative pain control after thyroid, parathyroid, trachea,
and medial clavicle surgeries; cervical spine procedures; and after other neck procedures [10,11].
Deep cervical plexus blocks, especially landmark-based techniques, are rarely performed, for the following
reasons:
The incidence of significant complications (eg, vertebral artery or subdural injection of LA) is higher with
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deep block compared with superficial block. (See 'Complications' below.)
Inadequate block is more common with deep cervical plexus block than with superficial block [12].
Superficial cervical plexus block supplemented with intraoperative neck infiltration is often sufficient to
provide postoperative analgesia.
Deep cervical plexus block is more difficult to perform than superficial block.
Anatomy The cervical plexus is composed of the ventral rami of the first four cervical spinal nerves (ie, C1
through C4). The anterior rami of C2 through C4 emerge from the posterior border of the sternocleidomastoid
muscle (SCM) (figure 5). There are four cutaneous branches of the cervical plexus, all of which are derived
from C2 to C4. They are the lesser occipital nerve, the greater auricular nerve, the transverse cervical nerve,
and the supraclavicular nerve. The cervical plexus supplies the skin of the anterolateral neck and
posterolateral scalp, the skin around the ear, and the muscles of the neck, including the scalenes and strap
muscles (figure 6). The cervical plexus also innervates the diaphragm via the phrenic nerve (C3, C4, C5)
[12,13].
Cervical plexus blocks are defined by injections relative to the two layers of the deep cervical fascia (ie, the
superficial, or investing, layer and the deep layer). A superficial cervical plexus block is injected superficial to
the investing layer, and the intermediate block is injected between these two layers, and the deep block is
injected below the deep layer [14].
Cervical plexus block techniques
Superficial cervical plexus block technique Superficial cervical plexus block is easy to master, is
associated with few complications, and does not usually require ultrasound guidance. Nevertheless, we
prefer ultrasound guidance because it can provide more precise deposition of LA in the posterior fascial
plane of the SCM with visualization of the needle through the SCM. Ultrasound also allows identification
of central vessels, allows navigation away from more superficial vessels (eg, external jugular vein), and
avoids LA spread into the interscalene nerve plexus.
The patient is positioned supine, with the head slightly away from the side to be blocked.
Ultrasound guidance Ultrasound guidance can be used, with the following technique:
- Place a small, linear ultrasound probe in transverse orientation at the posterior border of the
sternocleidomastoid muscle, midway between the mastoid process and the C6 transverse
process (figure 7 and picture 1). Visualize the posterior fascia of the SCM muscle. The cervical
plexus, when it can be seen, may be visualized as a collection of small hypoechoic (black)
ovals, immediately deep or lateral to the posterior border of the SCM.
- Insert the needle in plane to the transducer (picture 2) and advance until the tip is adjacent to
the nerves (image 1). After negative aspiration, inject 10 mL of LA in 5-mL increments, with
gentle aspiration between injections. If the plexus is not visualized, place the needle tip in the
plane between the posterior fascia of the SCM and the prevertebral fascia below. Inject 10 mL
of LA as the needle is advanced, with intermittent aspiration. LA should be visualized spreading
in the fascial plane.
Anatomic technique Draw a line from the mastoid process to the C6 transverse process (ie, the
Chassaignac tubercle) along the posterior border of the sternocleidomastoid muscle (figure 7).
Insert the needle at the midpoint of this line. After negative aspiration, inject 10 to 15 mL of LA in 5-
mL increments along the posterior border of the sternocleidomastoid muscle, fanning the injection 2
to 3 cm above and below the needle insertion site, with gentle aspiration between injections.
Injection deeper than 2 cm should be avoided to reduce injury to deep vessels and nerves.
Deep cervical plexus block technique The deep cervical plexus block is essentially a cervical
paravertebral block with anatomy and complications similar to paravertebral blocks in the thoracic and
abdominal regions. (See 'Thoracic paravertebral block' below and "Lower extremity nerve blocks:
Techniques", section on 'Lumbar plexus (psoas compartment) block'.)
The landmark-based deep cervical plexus block is performed at the level of C6, which is known as the
Chassaignac tubercle. When ultrasound guidance is used, LA can be deposited precisely in a more
cephalad location, in the paravertebral spaces at the transverse processes of C2 to C4, while avoiding
vascular and neuraxial complications.
The patient is positioned supine, with the head slightly away from the side to be blocked.
Ultrasound guidance We believe that deep cervical plexus block should be performed with
ultrasound guidance. The following technique is used [15]:
- Place a small, linear ultrasound probe in transverse orientation just below the mastoid process.
Scan caudally in a line between the mastoid process and the C6 transverse process. Visualize
the loop of the vertebral artery to avoid vascular puncture. The transverse process of C2 is
about 1 cm caudal to the loop or in the vicinity of the artery and should be identified by a
hyperechoic bony structure with a large, dark drop-off shadow deep to the bone.
- Insert the needle in plane (picture 2) to the transducer in an anterior-to-posterior orientation and
advance until the tip contacts the superficial tip of the transverse process of the C2 vertebra.
After negative aspiration, inject 5 mL of LA. LA should be visualized spreading adjacent to the
transverse process.
- Scan caudally to the transverse processes of C3 and C4, and repeat injections.
Anatomic technique Where ultrasound is unavailable, the following landmark-based approach

can be used:
- Draw a line from the cricoid cartilage to the posterior border of the SCM. Palpate the bony C6
transverse process (ie, the Chassaignac tubercle) at this point by applying digital pressure in a
posteromedial direction. Insert the needle in a posteromedial and inferior orientation until the
transverse process is contacted at 1 to 2 cm. After negative aspiration, inject 15 to 20 mL of LA
in 5-mL increments, with frequent aspiration. Avoid fanning and injection deeper than 2 cm
(figure 7).
Intermediate cervical plexus block technique The intermediate cervical plexus block consists of a
slightly more posterior superficial cervical block at C4. LA is deposited between the superficial and deep
cervical fascia in the posterior triangle of the neck [16]. This block is performed using ultrasound
guidance as follows:
Place a small, linear ultrasound probe in transverse orientation in the posterior triangle of the neck
at the level of the transverse process of C4. Insert the needle in plane to the transducer in an
anterior-to-posterior orientation through the SCM and past the prevertebral fascia. The posterior
cervical space is bounded by prevertebral fascia superficially, deep cervical paravertebral fascia
medially, middle scalene or levator scapulae muscles posteriorly, and longus capitis or anterior
scalene muscles anteriorly.
After negative aspiration, inject 15 mL of LA in 5-mL increments, with gentle aspiration between
injections. LA should be visualized spreading within the space described above.
Local anesthetic choice A longer-acting, relatively dilute LA is preferred for most neck procedures (eg,
0.2 to 0.5% ropivacaine or 0.25 to 0.5% bupivacaine). Higher concentrations are not required because there
is no need to block motor function (table 1) [13]. (See "Overview of peripheral nerve blocks", section on
'Drugs'.)
Complications Complications are rare but are more common with deep cervical plexus blocks than with
superficial blocks [11-13]. With deep block, potential complications include intravascular injection of LA,
respiratory compromise with diaphragmatic or vocal cord paralysis, and, very rarely, intrathecal injection of
LA. A systematic review of complications of superficial and deep cervical plexus blocks reported that
conversion to general anesthesia was more common with deep blocks (odds ratio [OR] 5.15) [12]. The most
common reasons for conversion to general anesthesia were block failure and patient anxiety or lack of
cooperation.
THORACIC BLOCKS Peripheral nerve blocks of the thoracic region include intercostal blocks, thoracic
paravertebral blocks, and the interfascial blocks of the pectoral region.
Intercostal nerve block Intercostal nerves can be blocked individually to provide anesthesia and/or
analgesia for thoracic surgical procedures (eg, thoracotomy, video-assisted thoracoscopy), chest tube
placement, breast surgery, rib fractures, and upper abdominal procedures [17,18]. Each intercostal block
achieves a band-like segment of anesthesia at the chosen level. This block is easy to perform, though
multiple blocks are often required.
When used to manage acute pain with multiple traumatic rib fractures, intercostal nerve blocks have been
shown to decrease opioid requirements and to improve pulmonary mechanics [18-20].
Anatomy The intercostal nerves arise from the ventral rami of the thoracic spinal nerves from T1 to T11
(figure 8) [17,21]. The corresponding nerve associated with T12 is the subcostal nerve. The first six
intercostal nerves are called the thoracic intercostal nerves. The remaining nerves (T7 to T11) supply the
thorax and abdomen and comprise the thoracoabdominal intercostal nerves [17,21].
The thoracic spinal nerve roots emerge from the intervertebral foramina and divide into ventral and dorsal
rami (figure 9). The ventral rami enter the groove on the underside of each rib, becoming the intercostal
nerves. The intercostal nerves run between the innermost intercostal muscles and the internal intercostal
muscles, in association with the intercostal vessels, at the lower margin of each rib [19]. The nerve is the
most inferior structure in the neurovascular bundle. The thoracic intercostal nerves supply the parietal pleura;
their lateral and anterior branches provide sensory innervation of the skin of the lateral and anterior thorax
(figure 10) [19].
Intercostal nerve block technique Intercostal block can be performed using anatomic landmarks or
with ultrasound guidance. We perform intercostal block with ultrasound guidance to minimize the chance of
intravascular injection and pneumothorax and to increase reliable dermatomal coverage. The injection can be
made closer to the vertebral column (and more proximal in the course of the nerve) with ultrasound guidance
because palpation of the rib is less important than with an anatomic landmark approach. Therefore, with
ultrasound, the injection more reliably blocks the nerve prior to its division into the lateral and anterior
branches, increasing the likelihood of full dermatomal anesthesia (figure 9).
The patient is placed in the lateral, prone, or sitting position.
Ultrasound guidance When possible, the patient is positioned prone, with the arms resting above the
head (to rotate the scapula) and a pillow under the abdomen (picture 3). If necessary for patient comfort,
sitting or lateral decubitus positioning can also be used.
Place the ultrasound transducer 4 cm from the spinous process in a sagittal plane (picture 3). The
rib is visualized as a dark shadow; the pleura and lung are visualized below the intercostal space,
deep to the rib. The rib can be confirmed by sliding the probe toward the midline to visualize the
transition of the rib into the transverse process of the spine (image 2).
Insert the needle either in plane or out of plane to the transducer (picture 2 and picture 4) and
advance to place the tip just below the inferior border of the rib.
After negative aspiration, inject 3 to 5 mL of LA; as the drug is injected, the pleura can be seen
moving away.
Anatomic approach Palpate the rib in the midposterior axillary line, usually 6 to 8 cm from the midline.
Insert a 22- to 25-gauge needle at the inferior border of the rib, oriented approximately 20 degrees
cephalad, and advance 0.5 cm underneath the rib. After negative aspiration, inject 3 to 5 mL of local
anesthetic (LA) (figure 9). If the needle comes into contact with bone, "walk" the needle off the bone
inferiorly. The block can be repeated at each of the levels appropriate for the surgical procedure.
Local anesthetic choice Rapid uptake of LA from the vascular intercostal space may reduce the
duration of anesthesia and analgesia and increase the risk of LA toxicity. The addition of epinephrine can
reduce uptake and allow the use of lower-concentration LA, and can achieve longer duration of block. We
typically use 0.2% ropivacaine or 0.25% bupivacaine with epinephrine (1:200,000 or 5 mcg/mL) to achieve
analgesia. Patients are also monitored in the post-anesthesia care unit (PACU) or intensive care unit (ICU) for
30 minutes to detect delayed absorption of LA. (See "Overview of peripheral nerve blocks", section on
'Drugs'.)
Complications Pneumothorax is a risk of intercostal block and may be less likely with ultrasound-
guided block. The incidences of asymptomatic and symptomatic pneumothorax are less than 0.5 percent and
0.1 percent, respectively [22]. Symptomatic pneumothorax can usually be treated with needle
decompression; the need for chest tubes is extremely rare. LA toxicity is possible, especially when multiple
blocks are performed. Rarely, case reports have described subarachnoid spread of LA occurring with
intercostal blocks if the needle tip enters a dural sleeve [23]. (See "Overview of peripheral nerve blocks",
section on 'Complications'.)
Thoracic paravertebral block Thoracic paravertebral block (TPVB) is a compartment block; success
relies on spread of injected LA within the paravertebral space. This block anesthetizes spinal nerves as they
emerge from intervertebral foramina and run through the paravertebral space. TPVB results in somatic and
sympathetic nerve block, similar to that which would be achieved with epidural blockade. Paravertebral block
is used most commonly to provide anesthesia and/or analgesia for mastectomy, cosmetic and other breast
surgeries, thoracic surgery, nephrectomy, and rib fractures.
Single-injection TPVB at T4 level is an alternative to general anesthesia for breast surgery [24,25] and has
been described as a sole method of anesthesia for video-assisted thoracoscopic surgery [26]. One
randomized trial found significantly shortened recovery times, improved postoperative pain scores, reduced
analgesic medication requirements, and decreased incidence of vomiting in women undergoing breast
surgery with a TPVB compared with those who underwent general anesthesia [24]. Preoperative TPVB may
also reduce the incidence of chronic pain following breast surgery [27,28]. Retrospective analyses have
suggested a decreased rate of metastasis among patients undergoing breast cancer surgery using TPVB
[29]. Data from prospective trials are needed to confirm this potential benefit [30].
Compared with epidural blockade, TPVB offers the possibility of unilateral block and is associated with a
lower incidence of hypotension, urinary retention, respiratory problems, and postoperative nausea and
vomiting (PONV) [31-33].
Anatomy The thoracic paravertebral space is a channel-like cavity on both sides of the thoracic spine,
filled with adipose tissue, the sympathetic trunk, and small vessels. The thoracic spinal nerves run through
the space as they emerge from the intervertebral foramina to become intercostal nerves (figure 11) [21].
The paravertebral space is bounded by the superior costotransverse ligament (SCTL) posteriorly, by the
parietal pleura anterolaterally, and medially by the vertebral bodies and disks. Laterally, the paravertebral
space is continuous with the intercostal space, and the SCTL continues as the internal intercostal membrane
(IIM) or ligament. Medially, the space communicates with the epidural space via the intervertebral foramina,
and with the contralateral paravertebral space through the prevertebral fascia. Cranially, the paravertebral
space is in close proximity to the adipose tissue associated with the brachial plexus, phrenic nerve, and
cervical sympathetic trunk. The caudal extent of the paravertebral space is debated. While one cadaver study
reported that the insertion of the psoas muscle sealed the lower space [34], others reported that thoracic
paravertebral injectate extended through diaphragmatic ligaments to the lumbar plexus [35,36].
TPVB technique TPVB can be performed using one or more injections, and can be performed using
anatomic landmarks or ultrasound guidance. We prefer to use ultrasound guidance to precisely localize the
injection, to improve success and reduce complications, and to avoid the pain of needle contact with bone,
which is required with a blind technique [21,37].
For either technique, the spinous processes from C7 to T7 are identified. The spinous process of C7 is
usually the most prominent in this region. The spine of the scapula corresponds to T3, and the lower border
of the scapula corresponds to T7. Injection points corresponding to the transverse process are marked 2.5
cm lateral to the midline at each desired level.
Single LA injection at the T3 or T4 level or multiple injections at alternate levels (T2/4/6 or T3/5/7) are
performed, depending on the required extent of the block. When TPVB is performed as the sole anesthetic for
a surgical procedure, multiple injections may be more effective and preferable [38], while a single injection
may be as effective and adequate when the block is used primarily for postoperative analgesia [39].
Ultrasound guidance The patient is positioned prone, with a pillow under the abdomen and the arm
hanging at the side of the stretcher (picture 5).
Place a high-frequency (5- to 19-MHz) linear transducer 2 cm lateral to the midline at the chosen
spinal level (picture 6 and picture 7). The probe can be placed either in a sagittal plane or transverse
plane, and both viewing planes should be explored during the scout scan to better identify
landmarks. The sagittal view may provide better visualization of the SCTL and the pleura, especially
if the ultrasound beam is directed medially by tilting the probe laterally and the probe is rotated in an
oblique orientation. However, an optimal acoustic window between bony structures may be difficult
to obtain in the sagittal view, and the required needle trajectory is relatively steep [21].
The transverse processes appear hyperechoic, with acoustic shadowing. The SCTL (or IIM) is a
bright white line spanning the adjacent transverse processes at an angle. The parietal pleura can
also be visualized as a bright white line deep to the transverse process and SCTL (image 3 and
image 4).
Insert the needle in-plane (picture 2) in a caudal-to-cranial trajectory. Because of the steep angle of
needle insertion, the tip can be difficult to visualize. A small amount of LA can be injected to assist
visualization of the needle tip. As the needle is advanced, indentation of the SCTL is often
visualized, a "pop" may be felt, and visible recoil of the ligament may be appreciated on ultrasound
once the needle has passed.
If multiple injections are planned, after negative aspiration, inject 3 to 5 mL of LA. The target for LA
injection is the space between the SCTL and the pleura; the injectate can be observed expanding
below the ligament, often pushing the pleura anteriorly (image 5 and image 6). The spread of LA to
adjacent levels can also be observed with ultrasound imaging [37].
Repeat the procedure at additional levels, as needed, to effect anesthesia and analgesia at multiple
dermatomes. Injections are commonly made at alternating thoracic levels, such as at T1/T3/T5 or at
T2/T4/T6, based on dermatomes required, but rarely exceeding three levels. A total of 15 to 20 mL
of LA is usually sufficient for unilateral blockade, depending on surgical procedure.
A single injection with a larger volume of LA can be performed at a level central to the required
sensory distribution and will usually cover four to five dermatomes [39]. In this setting, once the
paravertebral space is identified, after negative aspiration, inject 15 to 20 mL of LA in 5-mL
increments, with gentle aspiration between injections. The extent of LA spread should be visualized
cephalad and caudad to the injection site.
Anatomic approach The patient is seated or placed in the lateral decubitus position, with the spine
curved into a kyphotic position. Injection sites are determined and marked as described above.
For each injection, infiltrate the skin and subcutaneous tissues with LA using a 25-gauge needle. Insert a
22-gauge, 10-cm, short-bevel needle almost perpendicular to the skin, aiming slightly laterally, to avoid
pneumothorax and neuraxial injection. At a depth of 2 to 4 cm, contact should be made with the
transverse process; withdraw the needle slightly and redirect cranially or caudally to walk off the
transverse process. The needle should be inserted 1 cm past the transverse process; loss of resistance
may be felt but is subtle and not always reliable [40-42]. After negative aspiration, inject 5 mL of LA.
Repeat the procedure at multiple levels, as needed, to effect anesthesia at multiple dermatomes.
Continuous thoracic paravertebral block Indwelling catheters may be placed for prolonged
postoperative analgesia. The technique for placing catheters is the same as for single-shot injections, using
ultrasound guidance or anatomic landmarks.
Place a high-frequency (5 to 19 MHz) linear transducer 1 to 2 cm lateral to the midline at the chosen spinal
level in a sagittal or oblique orientation. A 17- or 18-gauge Touhy needle is placed in a caudal-to-cephalad
orientation. After injecting either LA or saline through the needle, a 20- or 19-gauge single-orifice or multi-
orifice epidural catheter is threaded far enough past the needle tip to ensure that the catheter orifices are
beyond the needle and, therefore, in the paravertebral space.
Alternatively, catheter-over-needle kits are available for catheter placement, using ultrasound guidance,
anatomic landmark technique, or both. The technique for placement is the same, but the catheter slides over
the end of the needle, similar to intravenous (IV) catheter placement. Leak around the catheter and patient
discomfort may be less with catheter-over-needle equipment since smaller-gauge needles are used.
However, we prefer Touhy needles for this application because the newer catheter-over-needle systems are
more costly, less proven, and in our experience may be technically difficult to use.
The catheter is secured to the skin with a sterile sealant such as Dermabond and a sterile dressing.
Continuous infusion of LA is administered at 5 to 12 mL/hour postoperatively. Our practice is as follows:
For ambulatory patients, a continuous infusion of 0.2% ropivacaine is used, and the patient receives a
comprehensive instruction sheet that includes the signs and symptoms of LA toxicity, pump maintenance
information, and the acute pain service phone number prior to discharge.
For inpatients, 0.1% bupivacaine is administered, with follow-up from acute pain management service.
Local anesthetic choice For unilateral blockade, we typically use 20 mL of 0.5% ropivacaine or 0.5%
bupivacaine. We reduce the concentration (eg, to 0.2% ropivacaine or 0.25% bupivacaine) and/or volume
(eg, to 10 to 15 mL per side) if we are performing bilateral block or if the block is a supplement to general
anesthesia, though others use up to a total of 40 mL of 0.5% bupivacaine with epinephrine 1:400,000 for
bilateral TPVB. (See "Overview of peripheral nerve blocks", section on 'Drugs'.)
Complications Complications of TPVB are infrequent, ranging from 2.6 to 5 percent when a blind,
anatomic approach is used [23,40,43]. Reported complications include Horner syndrome, pneumothorax,
vascular puncture, and epidural or intrathecal spread. The risk of pneumothorax increases with multiple levels
of injection [25], and has been reported to occur in 0.8 percent of cases using a landmark technique with
nerve stimulation [32]. Ultrasound guidance may reduce the incidence of accidental pleural puncture. This
was suggested by a retrospective review of over 1400 TPVBs using ultrasound to guide a single transverse,
in-plane injection, which reported no cases of pleural puncture or symptomatic pneumothorax [44].
Failed paravertebral block is reported in 6 to 19 percent of patients [32,45].
TPVB is a deep block, performed in a fixed, noncompressible space; if bleeding occurs, hemostasis depends
on the patient's ability to clot. We agree with the American Society of Regional Anesthesia and Pain Medicine
(ASRA) recommendation that anticoagulation guidelines for neuraxial blocks be followed when performing
deep blocks such as TPVB [46]. (See "Neuraxial (spinal, epidural) anesthesia in the patient receiving
anticoagulant or antiplatelet medication".)
For patients who are anticoagulated or who are coagulopathic for other reasons, a Pecs 1, Pecs 2, or
serratus plane block may be performed as an alternative to TPVB.
Interfascial plane blocks of the chest wall The pectoral nerve blocks (Pecs) types I and II and serratus
plane (SP) blocks are peripheral nerve blocks that rely on injection of LA between the muscles of the chest
wall to anesthetize nerves that run in the fascial planes. They can be used for surgical anesthesia and
postoperative analgesia for procedures of the pectoral region of the chest as alternatives to the more invasive
paravertebral and epidural blocks [47-49].
Their applications are as follows:
Pecs I block Pecs I blocks are used for superficial procedures of the pectoral region (eg, simple
mastectomy, placement of breast tissue expanders, pectoral muscle dissection, pacemaker placement,
and Port-A-Cath placement).
Pecs II block The Pecs II provides analgesia for the deeper structures in the anterolateral chest and
axilla. This block may be used for deep procedures of the chest (eg, mastectomy, tumor excision, and
axillary node dissection) [48,50]. The Pecs II block has also been used along with supraclavicular
brachial plexus block for upper arm arteriovenous fistula creation [51-53].
The Pecs II block may more effectively block the T2 to T4 dermatomes than Pecs I, and it is better suited
for reconstructive breast or anterior chest wall procedures [48].
SP block Like the Pecs II block, the SP block provides analgesia for deep structures in the
anterolateral chest and axilla. It spreads more posteriorly and covers more dermatomes than the Pecs II
block (ie, T2 to T9). This block is effective for analgesia after major reconstructive breast surgery,
anterior thoracotomy, chest tube placement, traumatic rib fractures, and chronic pain syndromes after
mastectomy and thoracotomy [47-49].
Anatomy The pectoral nerves (lateral and medial) arise from the cords of the brachial plexus and
innervate the pectoral major and minor muscles (figure 12). The lateral pectoral nerve (C5 to C7) courses
along the undersurface of the pectoralis major muscle, in the fascial plane between the pectoralis major and
minor muscles, and is consistently located lateral to the thoracoacromial artery. The medial pectoral nerve
(C8 to T1) also runs between the pectoralis major and minor muscles [48,54]. These are small nerves that
are not usually visualized using ultrasound.
The intercostobrachial nerve (thoracic nerve, T2), the lateral cutaneous branches of the thoracic intercostal
nerves (T2-9), the long thoracic nerve, and the thoracodorsal nerve run in variable anatomic courses, piercing
the fascial plane between the serratus anterior muscle, ribs, and pectoralis minor muscle. These nerves
innervate deep structures in the anterior, posterior, and lateral breast; the chest wall; axillary structures; and
the upper abdomen (figure 10) [49,54].
Pecs I block The Pecs I block is performed by injection of LA in the plane between the pectoralis major
and minor muscles to anesthetize the lateral and medial pectoral nerves. It is performed using ultrasound
guidance.
Place a linear, high-frequency ultrasound probe in the parasagittal plane below the clavicle, just medial to
the coracoid process. Identify the pectoralis major and pectoralis minor muscles (image 7). Rotate the
probe laterally using color-flow Doppler to identify the pectoral branch of the thoracoacromial artery
between the muscles, to avoid puncture, and to more precisely deposit LA near the nerves.
Insert the needle in plane (picture 2) and place the tip of the needle in the fascial plane between the two
https://www.uptodate.com/contents/nerve-blocks-of-the-scalp-nerce=search_result&search=bloqueio%20nervo&selectedTitle=4~150 Pgina 10 de 59
muscles.
injections.
Pecs II block The Pecs II block, also called the modified Pecs I block, aims to block the pectoral
nerves, intercostobrachial nerve, the intercostal nerves 3 through 6, and the long thoracic nerve. The Pecs I
block is performed first as above, and a second injection in the plane between the pectoralis minor muscle
and the serratus anterior muscle completes the Pecs II modification. This block is performed using ultrasound
guidance.
The Pecs I block is performed as above. In the same Pecs I view, slide the probe caudally to identify the
first rib deep to the axillary artery (image 7). Rib shadows are visualized as bright white hyperechoic
structures. After identifying the first rib, move the probe in a lateral and caudal direction while counting
the ribs. Slide the ultrasound probe toward the axilla until the third rib is visualized at the midaxillary line
on the lateral chest wall. Direct the ultrasound beam medially towards the lungs. At the level of the third
rib, the pectoralis major and minor muscles and the insertion of the serratus anterior muscle are
visualized. The hyperechoic (white) pleura should also be identified, with the lung sliding with respiration
beneath the pleura. If identification of the ribs proves difficult, aiming the probe medially may help.
Insert the needle in plane (picture 2), past the pectoralis and serratus anterior muscles, until the rib is
contacted. Withdraw the needle slightly until it is positioned deep to the serratus anterior, just on top of
the rib. If the serratus muscle is not well visualized, LA can be injected just deep to the pectoralis minor
muscle. The goal is to pierce the axillary sheath deep to the pectoralis minor muscle, in the axillary
compartment. Injection can be made above or below the serratus anterior muscle but must be deep to
the pectoralis minor muscle.
After negative aspiration, inject 20 mL of LA in 5-mL increments, aspirating gently between injections.
Serratus plane block The SP block is designed to anesthetize the thoracic intercostal nerves in order
to provide analgesia for the lateral chest wall. Intercostal nerves from T2 to T9 are usually blocked [49]. The
SP block is a more posterior and lateral modification of the Pecs II block; they are not performed together. It is
performed using ultrasound guidance.
Place a linear, high-frequency ultrasound probe in a sagittal plane under the mid-clavicle (image 7).
Move the probe inferolaterally, counting ribs until the fifth rib is identified in the midaxillary line. Identify
the latissimus dorsi superficially and posteriorly, the teres major muscle superiorly, and the serratus
muscle deep and inferiorly, overlying the fifth rib.
Insert the needle in plane to the probe (picture 2) from the medial side, and position the tip above the
serratus muscle.
After negative aspiration, inject 20 mL of LA in 5-mL increments, aspirating between injections.
Local anesthetic choice For each of the chest wall blocks, a long-acting LA is administered (eg,
0.25% bupivacaine or 0.2% ropivacaine). (See "Overview of peripheral nerve blocks", section on 'Drugs'.)
Complications To date, there are no published complications of Pecs I, Pecs II, or SP blocks.
Theoretical concerns include the possibility of pneumothorax, LA systemic toxicity, and injury to the long
thoracic nerve, which would result in a winged scapula.
ABDOMINAL BLOCKS A variety of peripheral nerve blocks can be performed to provide anesthesia
and/or analgesia for abdominal wall procedures. The lower thoracic intercostal blocks can be used for upper
abdominal procedures (eg, cholecystectomy, subcostal incisions). (See 'Intercostal nerve block' above.)
Other abdominal peripheral nerve blocks are performed by injection of local anesthetic (LA) into interfascial
planes through which peripheral nerves run. They include:
Transversus abdominis plane (TAP) block

Ilioinguinal (II) and iliohypogastric (IH) blocks
Rectus sheath blocks
Transversalis fascia plane blocks
These regional techniques are used to supplement general anesthesia for procedures that involve a variety of
surgical incisions of the abdominal wall. Unilateral blocks are used for one-sided procedures such as
appendectomy, cholecystectomy, and renal transplant, while bilateral blocks are used for midline and
transverse abdominal incisions such as ventral or umbilical hernia, colostomy closures, cesarean section,
hysterectomy, or radical retropubic prostatectomy [55-65].
Anatomy The sensory supply of the skin, muscles, and parietal peritoneum of the anterolateral abdominal
wall is derived from ventral rami of the thoracoabdominal intercostal nerves (ie, T7 to T11), the subcostal
nerve, and the L1 spinal nerve. The II and IH nerves arise from the lumbar plexus (L1) and provide sensory
cutaneous innervation in the groin, upper hip, and thigh (figure 10 and figure 8). Cutaneous branches of all of
these nerves travel variably through the transversus abdominis (TA) and internal oblique (IO) muscles and
course within the TAP [56-58]. At the lateral edge of the rectus muscle near the linea semilunaris, the anterior
cutaneous branches gather posterior to the rectus muscle, pierce through the muscle, and terminate at the
umbilicus and anterior abdominal wall [66,67]. (See "Anatomy of the abdominal wall", section on 'Nerves'.)
The fascial layers in the abdomen are essential to the performance of the abdominal nerve blocks. The
planes between the TA and IO muscles, between the rectus muscle and its sheath, and between the
transversalis fascia and quadratus lumborum muscle are sites for deposition of LA for these blocks.
The peritoneum and bowel lie deep to the rectus sheath and the IO muscle and must be avoided during block
placement.
Transversus abdominis plane block The TAP block is used for analgesia for laparoscopic and open
abdominal procedures. This block relies on injection of LA in the neurovascular plane between the TA and IO
muscles. The term TAP block usually refers to a block performed in the flank, just above the level of the
umbilicus, targeting dermatomes from T8 to L1. The subcostal TAP block is performed at the costal margin to
achieve a block as high as T6. (See 'Subcostal transversus abdominis plane block' below.)
We perform TAP blocks as part of a multimodal approach to postoperative pain control.
The literature regarding the efficacy of intraoperative and postoperative analgesia with TAP blocks is
inconclusive. Meta-analyses have been limited by heterogeneity of studies; they include a variety of surgical
procedures, TAP block techniques, LA type and volume, and measured results [55,58,59,68]. As an example,
a 2012 meta-analysis of nine studies including 413 patients who underwent abdominal surgery reported a
reduction in cumulative morphine consumption in the first 48 hours after surgery and a reduction of
postoperative nausea and vomiting, without a reduction in visual analog pain scores, with the use of TAP
blocks [59]. Another systematic review of TAP block for abdominal surgery including 18 trials reported
analgesic benefit for colorectal surgery, open and laparoscopic appendectomy, and laparoscopic
cholecystectomy, with unclear efficacy for other abdominal procedures [58]. Heterogeneity and methodologic
flaws precluded meta-analysis.
Transversus abdominis plane block technique We perform TAP blocks with ultrasound guidance,
though others have used anatomic landmarks [57,58,69]. TAP blocks can also be placed under direct vision
by the surgeon during laparoscopy or laparotomy. TAP blocks are usually placed under general anesthesia,
either before incision or at the end of the procedure after skin closure. Ultrasound-guided block is described
here.
Ultrasound guidance The patient is positioned supine. The procedure continues as follows:
Place a high-frequency ultrasound probe in a transverse position, parallel to the iliac crest,
immediately posterior to the midaxillary line, at or above the level of the umbilicus (picture 8).
Visualize the external oblique, IO, and TA muscles, as well as the peritoneal cavity; fascial planes
appear hyperechoic relative to the adjacent hypoechoic muscle (image 8).
Insert the needle in an in-plane approach (picture 2) from medial to lateral. The needle tip is
visualized as it penetrates the fascial layer between the IO and TA muscles. Subtle needle clicks
can be appreciated with puncture of the muscle and fascial layers.
injections. Expansion of the interfascial layer should be visualized, with superficial displacement of
the IO muscle and downward displacement of the TA muscle. If necessary to achieve interfascial
spread, the tip of the needle should be repositioned.
Repeat the procedure on the other side as necessary.
Continuous transversus abdominis plane block Indwelling catheters may be placed for prolonged
postoperative analgesia. The technique for placing catheters is the same as for single-shot injections using
ultrasound guidance or anatomic landmarks. (See 'Continuous thoracic paravertebral block' above.)
Subcostal transversus abdominis plane block The subcostal TAP block involves injection of LA in the
potential space between the rectus abdominis and TA muscles. This block anesthetizes the T6 to T12
dermatomes and may spare the L1 dermatome [70]. This block is used for analgesia for upper abdominal and
lower thoracic surgery [71].
Technique The patient is positioned supine. The subcostal TAP is performed with ultrasound guidance
using the following technique:
Place a high-frequency (ie, 5- to 10-MHz) ultrasound probe in oblique orientation along the costal margin
starting with the medial edge of the probe at the xiphoid process. Move the probe along the costal
margin diagonally to visualize the rectus abdominis muscle and its posterior fascial sheath (picture 9). A
preliminary anatomical scan from a medial-to-lateral direction can be useful to identify the aponeuroses
of the rectus sheath, the entirety of the rectus muscle, and the transition into the various lateral muscle
layers, including the IO and TA muscles. At the medial location at the xiphoid process, the TA muscle is
usually not visualized. Move the probe laterally until the transversus muscle is clearly visualized to start
the block (image 9).
Insert a 100- to 150-mm block needle near the xiphoid process in an in-plane approach (picture 2) in a
medial-to-lateral direction. Position the tip behind the body of the rectus muscle 2 cm lateral to the
midline, along the lateral edge of the rectus muscle.
After negative aspiration, deposit 5 mL of LA while visualizing LA spread within the sheath.
Move the probe laterally, where the TA muscle is visualized behind the rectus abdominis sheath. Reinsert
the needle in plane to the transducer in a medial-to-lateral direction. Position the tip between the TA and
rectus muscles. After negative aspiration, inject 15 mL of LA in 5-mL increments, aspirating gently
between injections. Separation of the muscles should be visualized as the LA is injected.
Continuous subcostal transversus abdominis plane block Indwelling catheters may be placed for
prolonged postoperative analgesia. The technique for placing catheters is the same as for single-shot
injections, using ultrasound guidance. (See 'Continuous thoracic paravertebral block' above.)
Rectus sheath block The rectus sheath block involves injection of LA between the rectus abdominus
muscle and the posterior rectus muscle sheath. This block results in periumbilical anesthesia of the T9 to T11
dermatomes and is particularly useful for umbilical surgery for children and adults and for umbilical
laparoscopy port incisions [72,73] (figure 13 and figure 14).
Technique We perform rectus sheath blocks with ultrasound guidance. Ultrasound guidance may
increase the success rate of rectus sheath block compared with an anatomic approach and may reduce the
incidence of complications [74].
The following procedure is performed with the patient in a supine position:
Place a high-frequency (ie, 5- to 10-MHz) ultrasound probe in a transverse orientation, 2 to 5 cm above

the umbilicus on the lateral edge of the rectus muscle. Visualize the rectus muscle, along with the
posterior rectus sheath, and the peritoneum deep to the sheath. To confirm the anatomy, the probe can
be slid laterally to visualize the medial convergence of the external oblique, IO, and TA muscles as their
aponeuroses form the rectus sheath. Epigastric arteries can occasionally be identified in this view and
should be avoided; color-flow Doppler can help identify these vessels (image 10) [66].
With the rectus muscle, sheath, and peritoneum in view, insert a 22-gauge, short-bevel, 50- to 100-mm
needle in plane (picture 2 and figure 13) and in a medial-to-lateral direction through the muscle. Place
the tip between the muscle body and the posterior sheath (image 10). Subtle clicks can be felt with entry
into the muscle and posterior sheath.
Make sure that the needle tip is well visualized during advancement into the rectus muscle. As the
needle tip approaches the posterior body of the muscle, inject small volumes of LA to confirm the needle
tip on ultrasound. This technique helps to avoid penetrating the peritoneum, which is usually in close
proximity to the posterior fascia of the rectus muscle.
After negative aspiration, inject 20 mL of LA in 5-mL increments, aspirating gently between injections.
Separation of the sheath from the muscle body should be visualized as LA is injected. The muscle is
displaced superiorly and the peritoneum downward (image 10). LA extends in cephalad and caudad
directions within the sheath. This LA spreading pattern can usually be confirmed by sliding the probe in a
head-to-foot direction.
Repeat the block on the other side as necessary [75].
Continuous rectus sheath block Catheters may be placed for continuous postoperative rectus sheath
block. Bilateral catheters are required, and they must be placed postoperatively to avoid intraoperative
catheter damage or displacement [75]. The technique for placing catheters is the same as for single-shot
injections. (See 'Continuous thoracic paravertebral block' above.)
Ilioinguinal and iliohypogastric nerve block The ilioinguinal (II) and iliohypogastric (IH) nerves are
blocked together with a targeted injection of LA within the TAP. This block is useful for postoperative
analgesia after inguinal hernia repair for children and adults (figure 8) [65,76,77].
Ilioinguinal and iliohypogastric block technique The patient is positioned supine. The block is
performed with ultrasound guidance using the following technique:
Place a linear ultrasound transducer (6- to 18-MHz) cephalad and medial to the anterior superior iliac
spine, oriented along a line between the anterior superior iliac spine (ASIS) and the umbilicus (figure 15).
Visualize the external oblique, IO, and TA muscles (image 11). The II and IH nerves may appear as
echogenic (ie, they appear white) structures within the fascial plane between the IO and TA muscles. The
deep circumflex iliac artery, or a branch of it, may be seen with the nerves. The II and IH nerves are
usually visualized as one or two structures. However, depending on the position of the probe and the
patient's anatomy, the nerves may not be visible at all, in which case block success requires spread of
the LA in the TAP.
Insert a 50- to 100-mm, 22-gauge needle in plane (picture 2) in a medial-to-lateral direction. Place the
needle tip near the II and IH nerves. A pop may be felt as the needle pierces the posterior internal
oblique fascia.
After negative aspiration, inject 10 mL of LA in 5-mL increments, with gentle aspiration between [67,78].
Transversalis fascia plane block The transversalis fascia plane block is a posterior version of the II and
IH block; ultrasound is used to identify the posterior tail of the TA muscle, aiming for the origins of the II and
IH nerves. This block targets branches of T12 and L1 in the plane between the TA muscle and the deeper
transversalis fascia [79]. It is useful for analgesia for anterior iliac crest bone graft harvest.
Technique The patient is positioned supine. This block is performed with ultrasound guidance, as
follows:
Place a linear ultrasound transducer (6- to 18-MHz) cephalad and medial to the anterior superior iliac
spine, oriented along a line between the ASIS and the umbilicus, as for the II and IH block (figure 15 and
image 11). Identify the external oblique, IO, and TA muscles, and trace them laterally until a tail is seen
where the TA merges with the IO, becoming the transversalis fascia (image 12). The quadratus
lumborum muscle is identified deep to the transversalis fascia [79,80].
Insert a 22-gauge, 100- to 150-mm needle in plane (picture 2) in a medial-to-lateral direction. Place the
needle tip deep to the transversalis fascia, anterior to the quadratus lumborum muscle.
After negative aspiration, inject 10 to 20 mL of LA in 5-mL increments, with gentle aspiration between
injections. Expansion of the space should be visualized as LA is injected [79,80].
Local anesthetic choice Abdominal nerve blocks are usually performed for postoperative pain control.
Thus, long-acting LAs such as ropivacaine (0.2 or 0.5%) or bupivacaine (0.25 or 0.5%) are usually
administered for these blocks. (See "Overview of peripheral nerve blocks", section on 'Drugs'.)
Complications A number of complications have been reported with abdominal nerve blocks, including
bowel perforation and hematoma, liver laceration, retroperitoneal hematoma, and transient femoral nerve
palsy [81-88]. Since relatively large volumes of LA are injected for interfascial plane blocks, LA toxicity is
always a concern.
We prefer ultrasound guidance rather than anatomic landmark techniques for abdominal blocks to increase
the success rate and decrease the incidence of vascular, peritoneal, and organ puncture.
PERINEUM Local nerve blocks of the perineum (eg, pudendal, paracervical) are typically administered by
the patient's surgeon (gynecologist, obstetrician, urologist, colorectal surgeon), rather than by an
anesthesiologist. These blocks are discussed separately. (See "Pudendal and paracervical block" and
"Vasectomy and other vasal occlusion techniques for male contraception", section on 'Anesthesia'.)
SUMMARY AND RECOMMENDATIONS
Scalp nerve blocks can provide intraoperative and postoperative analgesia for craniotomy and for other
procedures on the scalp and skull. A total of 12 nerves (six on each side) are blocked to achieve a
complete scalp block. (See 'Scalp block' above.)
Cervical plexus blocks anesthetize the anterior and lateral neck and scalp. They can provide
intraoperative anesthesia and postoperative analgesia for surgery in the neck and are particularly useful
for carotid endarterectomy. (See 'Cervical plexus blocks' above.)
Thoracic and thoracoabdominal intercostal nerves can be blocked individually to provide anesthesia
and/or analgesia for thoracic and upper abdominal surgical procedures (eg, thoracotomy, video-assisted
thoracoscopy, chest tube placement, breast surgery, rib fractures, and upper abdominal procedures).
Each intercostal block achieves a band-like segment of anesthesia at the chosen level. This block is
easy to perform, though multiple blocks are often required. (See 'Intercostal nerve block' above.)
Thoracic paravertebral block (TPVB) is a compartment block used most commonly to provide anesthesia
and/or analgesia for mastectomy and cosmetic breast surgery, thoracic surgery, nephrectomy, and rib
fractures. Compared with epidural blockade, TPVB offers the possibility of unilateral block. (See
'Thoracic paravertebral block' above.)
The thoracic interfascial plane blocks include the Pecs I, Pecs II, and serratus plane (SP) blocks. These
blocks can be used in combination and with other blocks for superficial and deep surgery in the pectoral
and axillary regions (eg, mastectomy, cosmetic breast surgery, chest tube placement, multiple rib
fractures). (See 'Pecs I block' above and 'Pecs II block' above and 'Serratus plane block' above.)
Transverse abdominis plane (TAP) block, subcostal TAP block, and ilioinguinal (II) and iliohypogastric
(IH) nerve blocks are abdominal blocks performed by injection of local anesthetic (LA) into the TAP to
anesthetize nerves as they traverse the space. They are used for analgesia for open and laparoscopic
abdominal surgery. (See 'Transversus abdominis plane block' above and 'Subcostal transversus
abdominis plane block' above and 'Ilioinguinal and iliohypogastric nerve block' above.)
The rectus sheath block is performed by injection of LA between the body of the rectus muscle and its
posterior sheath. It is used for midline, periumbilical surgery. (See 'Rectus sheath block' above.)
The transversalis fascia plane block is performed by injection of LA between the transversalis fascia and
the quadratus lumborum muscle. It is particularly useful for analgesia after iliac crest bone graft harvest.
(See 'Transversalis fascia plane block' above.)
We use ultrasound guidance for cervical plexus block, thoracic blocks, and abdominal blocks to increase
the success rate and reduce complications.
Perineural catheters may be placed for continuous infusion of LA for postoperative pain for TPVBs, TAP
blocks, and rectus sheath blocks. (See 'Continuous thoracic paravertebral block' above and 'Continuous
transversus abdominis plane block' above and 'Continuous subcostal transversus abdominis plane block'
above and 'Continuous rectus sheath block' above.)
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REFERENCES
1. Guilfoyle MR, Helmy A, Duane D, Hutchinson PJ. Regional scalp block for postcraniotomy analgesia: a
systematic review and meta-analysis. Anesth Analg 2013; 116:1093.
2. Pinosky ML, Fishman RL, Reeves ST, et al. The effect of bupivacaine skull block on the hemodynamic
response to craniotomy. Anesth Analg 1996; 83:1256.
3. Osborn I, Sebeo J. "Scalp block" during craniotomy: a classic technique revisited. J Neurosurg
Anesthesiol 2010; 22:187.
4. Nguyen A, Girard F, Boudreault D, et al. Scalp nerve blocks decrease the severity of pain after
craniotomy. Anesth Analg 2001; 93:1272.
5. Geze S, Yilmaz AA, Tuzuner F. The effect of scalp block and local infiltration on the haemodynamic and
stress response to skull-pin placement for craniotomy. Eur J Anaesthesiol 2009; 26:298.
6. Bala I, Gupta B, Bhardwaj N, et al. Effect of scalp block on postoperative pain relief in craniotomy
patients. Anaesth Intensive Care 2006; 34:224.
7. Ayoub C, Girard F, Boudreault D, et al. A comparison between scalp nerve block and morphine for
transitional analgesia after remifentanil-based anesthesia in neurosurgery. Anesth Analg 2006;
103:1237.
8. Bebawy JF, Bilotta F, Koht A. A modified technique for auriculotemporal nerve blockade when
performing selective scalp nerve block for craniotomy. J Neurosurg Anesthesiol 2014; 26:271.
9. McNicholas E, Bilotta F, Titi L, et al. Transient facial nerve palsy after auriculotemporal nerve block in
awake craniotomy patients. A A Case Rep 2014; 2:40.
10. Suh YJ, Kim YS, In JH, et al. Comparison of analgesic efficacy between bilateral superficial and
combined (superficial and deep) cervical plexus block administered before thyroid surgery. Eur J
Anaesthesiol 2009; 26:1043.
11. Guay J. Regional anesthesia for carotid surgery. Curr Opin Anaesthesiol 2008; 21:638.
12. Pandit JJ, Satya-Krishna R, Gration P. Superficial or deep cervical plexus block for carotid
endarterectomy: a systematic review of complications. Br J Anaesth 2007; 99:159.
13. Masters RD, Castresana EJ, Castresana MR. Superficial and deep cervical plexus block: technical
considerations. AANA J 1995; 63:235.
14. Sait Kavakl A, Kavrut ztrk N, Umut Ayolu R, et al. Comparison of Combined (Deep and Superficial)
and Intermediate Cervical Plexus Block by Use of Ultrasound Guidance for Carotid Endarterectomy. J
Cardiothorac Vasc Anesth 2016; 30:317.
15. Sandeman DJ, Griffiths MJ, Lennox AF. Ultrasound guided deep cervical plexus block. Anaesth
Intensive Care 2006; 34:240.
16. Usui Y, Kobayashi T, Kakinuma H, et al. An anatomical basis for blocking of the deep cervical plexus
and cervical sympathetic tract using an ultrasound-guided technique. Anesth Analg 2010; 110:964.
17. Thavaneswaran P, Rudkin GE, Cooter RD, et al. Brief reports: paravertebral block for anesthesia: a
systematic review. Anesth Analg 2010; 110:1740.
18. Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma 2003;
54:615.
19. Kopacz DJ, Thompson GE. Intercostal blocks for thoracic and abdominal surgery. Tech Reg Anesth
Pain Manage 1998; 2:25.
20. Nunn JF, Slavin G. Posterior intercostal nerve block for pain relief after cholecystectomy. Anatomical
basis and efficacy. Br J Anaesth 1980; 52:253.
21. Krediet AC, Moayeri N, van Geffen GJ, et al. Different Approaches to Ultrasound-guided Thoracic
Paravertebral Block: An Illustrated Review. Anesthesiology 2015; 123:459.
22. Brown DL. Intercostal block. In: Atlas of Regional Anesthesia, 4th ed, Brown DL. (Ed), Elsevier,
Philadelphia 2010. p.221.
23. Chaudhri BB, Macfie A, Kirk AJ. Inadvertent total spinal anesthesia after intercostal nerve block
placement during lung resection. Ann Thorac Surg 2009; 88:283.
24. Pusch F, Freitag H, Weinstabl C, et al. Single-injection paravertebral block compared to general
anaesthesia in breast surgery. Acta Anaesthesiol Scand 1999; 43:770.
25. Cooter RD, Rudkin GE, Gardiner SE. Day case breast augmentation under paravertebral blockade: a
prospective study of 100 consecutive patients. Aesthetic Plast Surg 2007; 31:666.
26. Piccioni F, Langer M, Fumagalli L, et al. Thoracic paravertebral anaesthesia for awake video-assisted
thoracoscopic surgery daily. Anaesthesia 2010; 65:1221.
27. Iohom G, Abdalla H, O'Brien J, et al. The associations between severity of early postoperative pain,
chronic postsurgical pain and plasma concentration of stable nitric oxide products after breast surgery.
Anesth Analg 2006; 103:995.
28. Kairaluoma PM, Bachmann MS, Rosenberg PH, Pere PJ. Preincisional paravertebral block reduces the
prevalence of chronic pain after breast surgery. Anesth Analg 2006; 103:703.
29. Exadaktylos AK, Buggy DJ, Moriarty DC, et al. Can anesthetic technique for primary breast cancer
surgery affect recurrence or metastasis? Anesthesiology 2006; 105:660.
30. Vila H Jr, Liu J, Kavasmaneck D. Paravertebral block: new benefits from an old procedure. Curr Opin
Anaesthesiol 2007; 20:316.
31. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of
paravertebral vs epidural blockade for thoracotomy--a systematic review and meta-analysis of
randomized trials. Br J Anaesth 2006; 96:418.
32. Naja Z, Lnnqvist PA. Somatic paravertebral nerve blockade. Incidence of failed block and
complications. Anaesthesia 2001; 56:1184.

33. Powell ES, Cook D, Pearce AC, et al. A prospective, multicentre, observational cohort study of
analgesia and outcome after pneumonectomy. Br J Anaesth 2011; 106:364.
34. Lnnqvist PA, Hildingsson U. The caudal boundary of the thoracic paravertebral space. A study in
human cadavers. Anaesthesia 1992; 47:1051.
35. Saito T, Tanuma K, Den S, et al. Pathways of anesthetic from the thoracic paravertebral region to the
celiac ganglion. Clin Anat 2002; 15:340.
36. Saito T, Den S, Tanuma K, et al. Anatomical bases for paravertebral anesthetic block: fluid
communication between the thoracic and lumbar paravertebral regions. Surg Radiol Anat 1999; 21:359.
37. Ben-Ari A, Moreno M, Chelly JE, Bigeleisen PE. Ultrasound-guided paravertebral block using an
intercostal approach. Anesth Analg 2009; 109:1691.
38. Naja ZM, El-Rajab M, Al-Tannir MA, et al. Thoracic paravertebral block: influence of the number of
injections. Reg Anesth Pain Med 2006; 31:196.
39. Kaya FN, Turker G, Mogol EB, Bayraktar S. Thoracic paravertebral block for video-assisted
thoracoscopic surgery: single injection versus multiple injections. J Cardiothorac Vasc Anesth 2012;
26:90.
40. Richardson J, Lnnqvist PA. Thoracic paravertebral block. Br J Anaesth 1998; 81:230.
41. Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95:771.
42. Eid H. Paravertebral block: An overview. Curr Anaesth Crit Care 2009; 20:65.
43. Coveney E, Weltz CR, Greengrass R, et al. Use of paravertebral block anesthesia in the surgical
management of breast cancer: experience in 156 cases. Ann Surg 1998; 227:496.
44. Pace MM, Sharma B, Anderson-Dam J, et al. Ultrasound-Guided Thoracic Paravertebral Blockade: A
Retrospective Study of the Incidence of Complications. Anesth Analg 2016; 122:1186.
45. Cotter JT, Nielsen KC, Guller U, et al. Increased body mass index and ASA physical status IV are risk
factors for block failure in ambulatory surgery - an analysis of 9,342 blocks. Can J Anaesth 2004;
51:810.
46. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving
antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine
Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64.
47. Blanco R. The 'pecs block': a novel technique for providing analgesia after breast surgery. Anaesthesia
2011; 66:847.
48. Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel
approach to breast surgery. Rev Esp Anestesiol Reanim 2012; 59:470.
49. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided
thoracic wall nerve block. Anaesthesia 2013; 68:1107.
50. Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast cancer
surgery: a randomized clinical trial. Reg Anesth Pain Med 2015; 40:68.
51. Purcell N, Wu D. Novel use of the PECS II block for upper limb fistula surgery. Anaesthesia 2014;
69:1294.
52. Tan YR, Quek KH. Tackling the axillary blind spot with PECS II. Anaesthesia 2015; 70:230.
53. Murata H, Ichinomiya T, Hara T. Pecs block for anesthesia in breast surgery of the elderly. J Anesth
2015; 29:644.
54. Hoffman GW, Elliott LF. The anatomy of the pectoral nerves and its significance to the general and
plastic surgeon. Ann Surg 1987; 205:504.
55. Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (TAP) blocks
for analgesia after abdominal surgery. Cochrane Database Syst Rev 2010; :CD007705.
56. Finnerty O, Carney J, McDonnell JG. Trunk blocks for abdominal surgery. Anaesthesia 2010; 65 Suppl
1:76.
57. Jankovic ZB, du Feu FM, McConnell P. An anatomical study of the transversus abdominis plane block:
location of the lumbar triangle of Petit and adjacent nerves. Anesth Analg 2009; 109:981.
58. Abdallah FW, Chan VW, Brull R. Transversus abdominis plane block: a systematic review. Reg Anesth
Pain Med 2012; 37:193.
59. Johns N, O'Neill S, Ventham NT, et al. Clinical effectiveness of transversus abdominis plane (TAP) block
in abdominal surgery: a systematic review and meta-analysis. Colorectal Dis 2012; 14:e635.
60. De Oliveira GS Jr, Castro-Alves LJ, Nader A, et al. Transversus abdominis plane block to ameliorate
postoperative pain outcomes after laparoscopic surgery: a meta-analysis of randomized controlled
trials. Anesth Analg 2014; 118:454.
61. Zhao X, Tong Y, Ren H, et al. Transversus abdominis plane block for postoperative analgesia after
laparoscopic surgery: a systematic review and meta-analysis. Int J Clin Exp Med 2014; 7:2966.
62. McDonnell JG, O'Donnell B, Curley G, et al. The analgesic efficacy of transversus abdominis plane
block after abdominal surgery: a prospective randomized controlled trial. Anesth Analg 2007; 104:193.
63. McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block
after cesarean delivery: a randomized controlled trial. Anesth Analg 2008; 106:186.
64. Carney J, McDonnell JG, Ochana A, et al. The transversus abdominis plane block provides effective
postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg 2008;
107:2056.
65. Aveline C, Le Hetet H, Le Roux A, et al. Comparison between ultrasound-guided transversus abdominis
plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair.
Br J Anaesth 2011; 106:380.
66. Willschke H, Bsenberg A, Marhofer P, et al. Ultrasonography-guided rectus sheath block in paediatric
anaesthesia--a new approach to an old technique. Br J Anaesth 2006; 97:244.
67. Eichenberger U, Greher M, Kirchmair L, et al. Ultrasound-guided blocks of the ilioinguinal and
iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection. Br J
Anaesth 2006; 97:238.
68. Brogi E, Kazan R, Cyr S, et al. Transversus abdominal plane block for postoperative analgesia: a
systematic review and meta-analysis of randomized-controlled trials. Can J Anaesth 2016; 63:1184.
69. Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anaesthesia 2001; 56:1024.
70. Niraj G, Kelkar A, Powell R. Ultrasound-guided subcostal transversus abdominis plane block.
International Journal of Ultrasound and Applied Technologies in Perioperative Care 2010; 1:9.
71. Hebbard P. Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg
2008; 106:674.
72. Ferguson S, Thomas V, Lewis I. The rectus sheath block in paediatric anaesthesia: new indications for
an old technique? Paediatr Anaesth 1996; 6:463.
73. Smith BE, Suchak M, Siggins D, Challands J. Rectus sheath block for diagnostic laparoscopy.
Anaesthesia 1988; 43:947.
74. Abrahams MS, Horn JL, Noles LM, Aziz MF. Evidence-based medicine: ultrasound guidance for truncal
blocks. Reg Anesth Pain Med 2010; 35:S36.
75. Shido A, Imamachi N, Doi K, et al. Continuous local anesthetic infusion through ultrasound-guided
rectus sheath catheters. Can J Anaesth 2010; 57:1046.
76. Willschke H, Bsenberg A, Marhofer P, et al. Ultrasonographic-guided ilioinguinal/iliohypogastric nerve
block in pediatric anesthesia: what is the optimal volume? Anesth Analg 2006; 102:1680.
77. Willschke H, Marhofer P, Bsenberg A, et al. Ultrasonography for ilioinguinal/iliohypogastric nerve
blocks in children. Br J Anaesth 2005; 95:226.
78. Gofeld M, Christakis M. Sonographically guided ilioinguinal nerve block. J Ultrasound Med 2006;
25:1571.
79. Hebbard PD. Transversalis fascia plane block, a novel ultrasound-guided abdominal wall nerve block.
Can J Anaesth 2009; 56:618.
80. Chin KJ, Chan V, Hebbard P, et al. Ultrasound-guided transversalis fascia plane block provides
analgesia for anterior iliac crest bone graft harvesting. Can J Anaesth 2012; 59:122.
81. Farooq M, Carey M. A case of liver trauma with a blunt regional anesthesia needle while performing
transversus abdominis plane block. Reg Anesth Pain Med 2008; 33:274.
82. Frigon C, Mai R, Valois-Gomez T, Desparmet J. Bowel hematoma following an iliohypogastric-
ilioinguinal nerve block. Paediatr Anaesth 2006; 16:993.
83. Jankovic Z, Ahmad N, Ravishankar N, Archer F. Transversus abdominis plane block: how safe is it?
Anesth Analg 2008; 107:1758.
84. Yuen PM, Ng PS. Retroperitoneal hematoma after a rectus sheath block. J Am Assoc Gynecol
Laparosc 2004; 11:448.
85. Rosario DJ, Jacob S, Luntley J, et al. Mechanism of femoral nerve palsy complicating percutaneous
ilioinguinal field block. Br J Anaesth 1997; 78:314.
86. Manatakis DK, Stamos N, Agalianos C, et al. Transient femoral nerve palsy complicating "blind"
transversus abdominis plane block. Case Rep Anesthesiol 2013; 2013:874215.
87. Weintraud M, Marhofer P, Bsenberg A, et al. Ilioinguinal/iliohypogastric blocks in children: where do we
administer the local anesthetic without direct visualization? Anesth Analg 2008; 106:89.
88. Orebaugh SL, Kentor ML, Williams BA. Adverse outcomes associated with nerve stimulator-guided and
ultrasound-guided peripheral nerve blocks by supervised trainees: update of a single-site database.
Reg Anesth Pain Med 2012; 37:577.
Topic 100071 Version 18.0
GRAPHICS
Sensory distribution scalp block
The purple-shaded areas show the extent of sensory anesthesia after scalp block.
Graphic 106221 Version 1.0
Cutaneous innervation of the head and neck
The sensory distribution of the trigeminal nerve (cranial nerve V) and its three
divisions (V1, V2, V3) is shown along with branches of the cervical spinal nerves that
innervate cutaneous regions of the head and neck.
Scalp block insertion sites
The numbered dots in this graphic show the needle insertion sites for injection of local
anesthetic for the six nerve blocks that comprise the scalp block, as follows:
(1) Supraorbital and supratrochlear nerve blocks
(2) Zygomaticotemporal nerve block
(3) Auriculotemporal nerve block
(4) Lesser occipital nerve
(5) Greater occipital nerve
For details of block technique, refer to UpToDate topic on nerve blocks of the scalp, neck,
and trunk, section on scalp block.
n.: nerve.
Modified from: Guilfoyle MR, Helmy A, Duane D, et al. Regional scalp block for postcraniotomy
analgesia: A systematic review and meta-analysis. Anesth Analg 2013; 116:1093.
Supraorbital and supratrochlear nerve block
This block anesthetizes the forehead and anterior third of the scalp. To
perform, locate the supraorbital nerve foramen in the medial aspect of the
supraorbital ridge as shown in A. After cleansing, insert a small needle (25 or
27 gauge) to a depth of 0.5 to 1 cm just medial and directed towards the
foramen as shown in B. Inject 1 to 3 mL of local anesthetic. In older children,
adolescents, and adults who report paresthesias, withdraw the needle until
paresthesias resolve prior to injection of anesthetic. Allow 5 to 10 minutes
for complete anesthesia to occur.
Reproduced with permission from: Cimpello LB, Deutsch RJ, Dixon C, et al.
Illustrated techniques of pediatric emergency procedures. In: Textbook of Pediatric
Emergency Medicine, 6th edition, Fleisher GR, Ludwig S (Eds), Lippincott Williams &
Wilkins, Philadelphia 2010. Copyright 2010 Lippincott Williams & Wilkins.
www.lww.com.
Cervical plexus 2
The cervical plexus is composed of the ventral rami of the first four cervical spinal
nerves (ie, C1 through C4). The anterior rami of C2 through C4 emerge from the
posterior border of the sternocleidomastoid muscle.
Sensory distribution cervical plexus block
The purple-shaded area shows the extent of sensory anesthesia after cervical plexus
block.
Superficial cervical plexus block
For the superficial cervical plexus block using anatomic landmarks, a line is drawn from the
mastoid process to the C6 transverse process (ie, Chassaignac tubercle) along the posterior
border of the sternocleidomastoid muscle (line shown in blue). The midpoint of this line is
marked (red dot) as the injection site. After negative aspiration, 10 to 15 mL of local
anesthetic is injected in 5-mL increments along the posterior border of the
sternocleidomastoid muscle, fanning the injection 2 to 3 cm above and below the needle
insertion site, with gentle aspiration between injections. Injection deeper than 2 cm should
be avoided. See topic text for block details.
Superficial cervical plexus block ultrasound probe placement
For ultrasound-guided superficial cervical plexus block, the ultrasound probe is placed in a
transverse orientation at the posterior border of the sternocleidomastoid muscle, midway
between the mastoid process and the C6 transverse process. For further details on this
block, refer to the UpToDate topic on nerve blocks of the scalp, neck, and trunk.
In-plane needle placement
Courtesy of Christina L Jeng, MD
Superficial cervical plexus block ultrasound
The cervical plexus can sometimes be visualized as a collection of hypoechoic ovals, posterior to the posterior fascia
the sternocleidomastoid muscle. The arrow indicates needle insertion. For further details, refer to the UpToDate top
nerve blocks of the scalp, neck, and trunk.
Local anesthetics for peripheral nerve block
Maximal dose*
Duration of Duration of
Onset (mg)
Anesthetic anesthesia analgesia
(minutes) without/with
(hours) (hours)
epi
1.5% mepivacaine 10 to 20 2 to 5 3 to 8 350/500
2% lidocaine 10 to 20 2 to 5 3 to 8 350/500
0.2% ropivacaine 15 to 30 n/a 5 to 12 200/250
0.5% ropivacaine 15 to 30 4 to 8 5 to 12 200/250
0.75% ropivacaine 10 to 15 5 to 10 6 to 24 200/250
0.25% bupivacaine 15 to 30 n/a 5 to 12 175/225
0.5% bupivacaine 15 to 30 5 to 15 6 to 30 175/225

(+epi)
epi: epinephrine.
* Maximal doses are general guidelines for tissue infiltration. Systemic toxicity may occur with doses within the
recommended range, particularly with intravascular injection. Doses in excess of the recommended maximums have
been administered without toxicity. These recommendations do not account for the site of injection or the presence
of risk factors for systemic toxicity (eg, renal or hepatic dysfunction, cardiac failure, pregnancy, extremes of age).
Adapted from: Gadsen J. Local Anesthetics: Clinical Pharmacology and Rational Selection. The New York School of
Regional Anesthesia website, October 2013. Available at: http://www.nysora.com/regional-anesthesia/foundations-
of-ra/3492-local-anesthetics-clinical-pharmacology-and-rational-selection.html (Accessed January 9, 2014).
Nerves of the anterior chest and abdomen
The chest and abdominal walls are supplied by the thoracic and thoracoabdominal
intercostal nerves, as well as nerves from the lumbar plexus. The intercostal nerves arise
from the ventral rami of the thoracic spinal nerves from T1 to T11. The corresponding nerve
associated with T12 is the subcostal nerve.
n.: nerve; ns.: nerves.
Intercostal nerve block
Intercostal nerve block may be performed using an anatomic approach (at site B) by
palpating the rib. Alternatively, ultrasound guidance may be used to inject local
anesthetic more proximal in the course of the nerve (at site A), since palpation of the rib
is less important. With either approach, the needle is inserted at the inferior border of the
rib, and after negative aspiration, 3 to 5 mL of LA (0.2% ropivacaine or 0.25%
bupivacaine with epinephrine 1:200,000) is injected. For details of intercostal nerve
block, see topic text.
Dermatomes of the trunk
The thoracic intercostal nerves supply the parietal pleura; lateral and anterior branches
are sensory to the skin of the lateral and anterior thorax.
The thoracoabdominal intercostal and subcostal nerves supply the peritoneum; lateral
and anterior sensory cutaneous branches supply the skin.
The subcostal nerve provides cutaneous branches to the superior gluteal region.
Other cutaneous nerves of the lower abdomen include the lateral femoral cutaneous,
genitofemoral, ilioinguinal, and iliohypogastric nerves. The ilioinguinal and iliohypogastric
nerves arise from the the lumbar plexus (L1) and provide cutaneous sensory innervation in
the groin and upper hip and thigh regions.
Positioning and ultrasound probe placement for

intercostal block
The photo shows patient positioning and the probe placement for ultrasound-
guided intercostal block. For details of block technique, refer to the UpToDate
topic on nerve blocks of the scalp, neck, and trunk.
From: Ben-Ari A, Moreno M, Chelly JE, et al. Ultrasound-guided paravertebral block

using an intercostal approach. Anesth Analg 2009; 109:1691. DOI:
10.1213/ANE.0b013e3181b72d50. Reproduced with permission from Lippincott
Williams & Wilkins. Copyright 2009 International Anesthesia Research Society.
Unauthorized reproduction of this material is prohibited.
Intercostal nerve block ultrasound
For ultrasound-guided intercostal nerve block, the tip of the needle is placed
between the internal intercostal muscle and the innermost intercostal muscle, as
shown by the tip of the arrow in this image. LA should be visualized spreading
the two muscles apart.
R: rib; EX: external intercostal muscle; IN: internal intercostal muscle; INM: innermost
intercostal muscle; PL: pleura; LA: local anesthetic.
Copyright 2012 Jens Brglum and Kenneth Jensen. Originally published in Abdominal
Surgery, Derbel F (Ed), InTech 2012, under CC BY 3.0 license. Available from: DOI:
10.5772/3020 (Accessed on November 4, 2015).
Out-of-plane needle placement
Courtesy of Christina L. Jeng, MD
Paravertebral space anatomy
The paravertebral space (shaded green) and the related anatomic structures are shown in
this graphic. For details of anatomy and technique for thoracic paravertebral block, refer to
the UpToDate topic on nerve blocks of the scalp, neck, and trunk.
m.: muscle; n.: nerve.
Transverse intercostal paravertebral block (photo of probe in place)
For thoracic paravertebral block, the transducer can be placed in either a sagittal plane or
transverse plane. Transverse placement is shown in this photo, with the needle oriented in
plane to the transducer. For further details, refer to the UpToDate topic on nerve blocks of the
scalp, neck, and trunk.
PVB: paravertebral block.
Paravertebral block ultrasound probe placement
For thoracic paravertebral block, the patient may be positioned prone, with one arm hanging over the side of the be
The probe is placed approximately 2 cm lateral to the midline at the chosen spinal level, and is rotated to achieve th
optimal ultrasound image.
Paramedian sagittal TPVB approach
For the paramedian, sagittal approach to thoracic paravertebral block, the

ultrasound probe is placed lateral to the midline at the chosen spinal level.
The needle can be inserted in plane or out of plane
OOP: out of plane
Paramedian sagittal PVB pre-injectate
The paravertebral space (blue oval) lies between the superior costotransverse ligament and the
pleura. For further details, refer to UpToDate content on ultrasound-guided thoracic paravertebral
nerve block.
SCTL: Superior costotransverse ligament
Transverse intercostal PVB with needle
The block needle is visualized with the tip in the paravertebral space, between the IIM and the pleura. For
further details, refer to UpToDate content on ultrasound-guided thoracic paravertebral block.
IIM: internal intercostal membrane.
Paramedian sagittal PVB post-injectate
After injection of LA for thoracic paravertebral block, the LA expands the space between the internal
intercostal membrane and the pleura. For further details, refer to UpToDate content on ultrasound-guided
thoracic paravertebral block.
LA: local anesthetic. IIM: internal intercostal membrane
Transverse intercostal PVB post-injectate
After injection, the local anesthetic expands below the IIM, and often pushes the pleura anteriorly. For
further details, refer to UpToDate content on ultrasound-guided thoracic paravertebral block.
IIM: internal intercostal membrane.
Pectoral chest region anatomy
The lateral and medial pectoral nerves arise from the cords of the brachial plexus and
innervate the pectoral major and minor muscles. The lateral pectoral nerve courses along
the undersurface of the pectoralis major muscle, in the fascial plane between the pectoralis
major and minor muscles. The medial pectoral nerve also runs between the pectoralis major
and minor muscles.
The intercostobrachial nerve, the lateral cutaneous branches of the thoracic intercostal
nerves, the long thoracic nerve, and the thoracodorsal nerve run in variable anatomic
courses, piercing the fascial plane between the serratus anterior muscle, ribs, and pectoralis
minor muscle. These nerves innervate deep structures in the anterior, posterior, and lateral
breast; the chest wall; axillary structures; and the upper abdomen.
m.: muscle; a.: artery; n.: nerve.
Modified from: Hoffman GW, Elliot LF. The anatomy of the pectoral nerves and its significance to the
general and plastic surgeon. Ann Surg 1987; 205:504.
Pecs I, Pecs II and Serratus plane blocks
This graphic shows the ultrasound probe position and ultrasound images for the thoracic interfascial plane
blocks, the Pecs I block (A), Pecs II block (B), and serratus plane block (C), and the relevant dermatomes
of the chest wall. For details of the thoracic interfascial plane blocks, refer to the UpToDate topic on nerve
blocks of the scalp, neck, and trunk.
PMm: pectoralis major muscle; Pmm: pectoralis minor muscle; Sm: serratus muscle; R4: fourth rib; TMm: teres
major muscle; LDm: latissimus dorsi muscle; R5: fifth rib.
From: Blanco R, Parras T, McDonnell JG, et al. Serratus plane block: A novel ultrasound-guided thoracic wall nerve
block. Anaesthesia 2013; 68:1107. http://onlinelibrary.wiley.com/doi/10.1111/anae.12344/abstract. Copyright
2013 The Association of Anaesthetists of Great Britain and Ireland. Reproduced with permission of John Wiley &
Sons, Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be
downloaded to PowerPoint, printed, shared, or emailed. Please contact Wiley's Permissions Department either via
email: permissions@wiley.com or use the RightsLink service by clicking on the Request Permission link
accompanying this article on Wiley Online Library (www.onlinelibrary.wiley.com).
Transversus abdominis plane (TAP) block ultrasound probe placement
For ultrasound-guided transversus abdominis plane (TAP) block, the ultrasound probe is placed in a transverse posi
parallel to the iliac crest, immediately posterior to the midaxillary line, at or above the level of the umbilicus. For de
of the TAP block technique, refer to the UpToDate topic on nerve blocks of the scalp, neck, and trunk.
Transversus abdominis plane (TAP) block ultrasound
For ultrasound-guided TAP block, the external oblique, internal oblique, transversalis
muscle, and peritoneal cavity are visualized. Fascial planes appear hyperechoic
relative to the adjacent hypoechoic muscle. The needle tip is visualized as it
penetrates the fascial layer between the internal oblique and transversus abdominis,
where a long-acting local anesthetic is injected. For further details, refer to
the UpToDate topic on nerve blocks of the neck, scalp, and trunk.
Subcostal transversus abdominis plane (TAP) block ultrasound probe position
For the subcostal transversus abdominis plane block, the probe is initially placed along the costal margin with the m
edge at the xiphoid process. The probe is then moved laterally along the costal margin, as shown in this photo, unt
tranversus muscle is clearly visualized on ultrasound. For further details, refer to UpToDate topic on nerve blocks of
scalp, neck, and trunk.
Subcostal transversus abdominis plane block ultrasound
For the subcostal TAP block, local anesthetic is injected between the rectus muscle and the transversus abdominis
muscle, in the transversus abdominis plane. For further details, refer to the UpToDate topic on nerve blocks of the n
scalp, and trunk.
TAP: transversus abdominis plane.
Rectus sheath block anatomy
m.: muscle; a.: artery.
Rectus sheath coverage and ultrasound probe placement
For rectus sheath block, the ultrasound probe is placed above the umbilicus,
at the edge of the rectus abdominus muscle, as shown by the rectangle in
this graphic. The sensory block includes an oval periumbilical area when the
block is performed bilaterally.
Rectus sheath ultrasound
The first ultrasound image shows a needle with the needle-tip positioned below the rectus muscle. The second ultra
is one second later as LA is injected to lift the rectus muscle off the posterior rectus sheath.
R: rectus muscle; I: injectate (local anesthetic); PRS: posterior rectus sheath (twin "tram"-lines); LA: local anesthetic.
Reproduced with permission from: Webster K. Ultrasound Guided rectus sheath block analgesia for abdominal surgery. Upda
Anaesthesia 2010; 26:12, available at: www.wfsahq.org/resources/update-in-anaesthesia. Copyright 2010 Update in Anaes
rights reserved.
Ilioinguinal iliohypogastric nerve block
The ultrasound transducer is placed superior and medial to the iliac spine on a line
(shown in blue) marked from the anterior superior iliac spine to the umbilicus. A
needle is inserted in the skin (red dot) and, with ultrasound guidance, directed
toward the ilioinguinal and iliohypogastic nerves, until a "pop" is felt as the needle
pierces the external oblique fascia. Local anesthetic (0.25 to 0.5 percent
bupivacaine or 0.5 to 0.75% ropivacaine) is administered.
II and IH block ultrasound probe placement and ultrasound image
For the ilioinguinal and iliohypogastric nerve block, the ultrasound probe is placed just cephalad and medial to the A
between the ASIS and the umbilicus. The internal oblique and transverse abdominis muscles are visualized, as in th
inserted in-plane to the transducer, and the tip is placed in the plane between these two muscles, as shown by the
negative aspiration, 10 mL of LA is injected in 5-mL increments, with gentle aspiration between injections. LA may
plane, as shown in the yellow ovals.
II: ilioinguinal; IH: iliohypogastric; EO: external oblique muscle; IO: internal oblique muscle; TA: transverse abdominis muscl
spine; LA: local anesthetic.
Copyright 2012 Jens Brglum and Kenneth Jensen. Originally published in Abdominal Surgery, Derbel F (Ed), InTech 2012,
Available from: DOI: 10.5772/3020 (Accessed on January 7, 2016).
Transversalis fascia plane block ultrasound
(A) Composite ultrasound image of the IO and TA tapering off posteriorly into their common aponeurosis adjacent t
QL.
(B) The needle tip is positioned just under the aponeurosis of the TA. Injection in this location should result in visibl
spread in the TFP, as shown.
EO: external oblique; IO: internal oblique; TA: transversus abdominis; QL: quadratus lumborum; LA: local anesthetic; TFP:
transversalis fascia plane.
Reproduced with permission. All rights reserved. Copyright 2008 Ultrasound for Regional Anesthesia, Toronto Western Hosp
Contributor Disclosures
Meg A Rosenblatt, MD Nothing to disclose Yan Lai, MD, MPH Nothing to disclose Lisa Warren,
MD Nothing to disclose Marianna Crowley, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Nerve Blocks of The Scalp, Neck, and Trunk: Techniques - UpToDate

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Nerve Blocks of The Scalp, Neck, and Trunk: Techniques - UpToDate

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Nerve blocks of the scalp, neck, and trunk: Techniques - UpToDate 11/04/17 21(12

Official reprint from UpToDate

Authors: Meg A Rosenblatt, MD, Yan Lai, MD, MPH

deep block compared with superficial block. (See 'Complications' below.)

Cervical plexus block techniques

Anatomic technique Where ultrasound is unavailable, the following landmark-based approach

The patient is placed in the lateral, prone, or sitting position.

ultrasound guidance or anatomic landmarks.

Continuous infusion of LA is administered at 5 to 12 mL/hour postoperatively. Our practice is as follows:

Failed paravertebral block is reported in 6 to 19 percent of patients [32,45].

Their applications are as follows:

After negative aspiration, inject 20 mL of LA in 5-mL increments, aspirating between injections.

thoracic nerve, which would result in a winged scapula.

Transversus abdominis plane (TAP) block

We perform TAP blocks as part of a multimodal approach to postoperative pain control.

Repeat the procedure on the other side as necessary.

the block (image 9).

The following procedure is performed with the patient in a supine position:

Place a high-frequency (ie, 5- to 10-MHz) ultrasound probe in a transverse orientation, 2 to 5 cm above

Repeat the block on the other side as necessary [75].

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

complications. Anaesthesia 2001; 56:1184.

Topic 100071 Version 18.0

Sensory distribution scalp block

Graphic 106221 Version 1.0

Cutaneous innervation of the head and neck

Graphic 70877 Version 4.0

Scalp block insertion sites

Graphic 105117 Version 2.0

Supraorbital and supratrochlear nerve block

Graphic 66299 Version 9.0

Graphic 106135 Version 1.0

Sensory distribution cervical plexus block

Graphic 106222 Version 1.0

Superficial cervical plexus block

Graphic 53917 Version 3.0

Superficial cervical plexus block ultrasound probe placement

Graphic 106516 Version 2.0

In-plane needle placement

Courtesy of Christina L Jeng, MD

Graphic 97801 Version 4.0

Superficial cervical plexus block ultrasound

Graphic 107807 Version 1.0

Local anesthetics for peripheral nerve block

1.5% mepivacaine 10 to 20 2 to 5 3 to 8 350/500

0.2% ropivacaine 15 to 30 n/a 5 to 12 200/250

0.5% ropivacaine 15 to 30 4 to 8 5 to 12 200/250

0.75% ropivacaine 10 to 15 5 to 10 6 to 24 200/250

0.25% bupivacaine 15 to 30 n/a 5 to 12 175/225

0.5% bupivacaine 15 to 30 5 to 15 6 to 30 175/225

Graphic 93203 Version 6.0

Nerves of the anterior chest and abdomen

n.: nerve; ns.: nerves.

Graphic 79068 Version 3.0

Intercostal nerve block

Graphic 81512 Version 5.0

Dermatomes of the trunk

Graphic 81709 Version 4.0

Positioning and ultrasound probe placement for

From: Ben-Ari A, Moreno M, Chelly JE, et al. Ultrasound-guided paravertebral block

Graphic 105087 Version 1.0