This document contains slides related to regional anesthesia techniques. It discusses various regional blocks including thoracic epidural, lumbar epidural, spinal, paravertebral, TAP and rectus sheath blocks. The slides provide information on identifying vertebral levels, choosing insertion sites based on the indication, and practical tips for performing epidural placements. Key information includes how to identify the C7 and T7 vertebrae, dermatomal coverage of different epidural levels, and technical advice for skin localization, needle angulation, and patient communication.
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Regional Anesthesia Techniques and Landmark Identification
1. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Neuraxial and Truncal Regional
Anesthesia
Brian Allen
07/2014
2. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Scalp* (U,P){2}
Interscalene (S,L){2}
Transgluteal Sciatic (L,P){4,6}
Paravertebral (U,L){4,6}
Thoracic Epidural (U,L){4,6}
Lumbar Plexus† (L){4,6}
TAP (S){4}
Superficial Cervical Plexus* (S){2}
Axillary* (S,A){2}
Infraclavicular (S,A){4}
Supraclavicular (S){2}
Lumbar Epidural (U,L){4,6}
Infragluteal Sciatic (S,L,P){4,6}
Ankle* (S){2}
Lat Fem Cut* (S){2,4}
Popliteal Sciatic (S,U,L){4}
Femoral (S){2,4}
Obturator* (S){4}
Saphenous (S,P){4}
HEENT*{2}
Wrist* (S){2}
Legend:
* = Only Single Shot
Bold = May Place Catheter
Underline = uncommonly done
† = Nerve Stimulator always used
Positioning ( ):
S = Supine
U = Sitting Up
P = Prone
L = Lateral Decubitus or Simms
A = Arm Over Head
Needle Length { in inches }
Common Regional
and Neuraxial
Blocks
Suprascapular* (U){2,4}
Spinal (U,L){3.5,6}
3. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Thoracic Epidural
Lumbar Epidural
Spinal
Paravertebral
TAP and Rectus Sheath
4. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Spine Anatomy and Site Selection for
Neuraxial Anesthesia
Brian Allen
06/2015
13. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Identifying Vertebral Level
T7
C7
Counting Vertebrae is more
accurate from C7 than T7
14. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Identifying Vertebral Level
T7
C7
Your estimate of level is
frequently off by 1 level with
either method, BUT
More likely to be off by 2+
levels if using scapula to
determine entry site
15. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Identifying Vertebral Level
T7
C7
Iliac Crest
16. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Identifying Vertebral Level
T7
C7
Intercristal
Line
17. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Identifying Vertebral Level
T7
C7
Radiographically
L4-5
18. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Identifying Vertebral Level
T7
C7
By Palpation
L3-4
Especially in Females
and High BMI
19. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Identifying Vertebral Level
T7
C7
L3-4
20. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
T7
C7
L3-4
Dermatomes
T4
T10
T4
T12
Indication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Labor
Lower Extremity
Ortho or Vascular
Surgery
Insertion Site
T6
21. BFSA
Slide by Brian F S Allen
BFSA
BFSA
T4-T10
(depending on
fractures)
Anesthetic
Coverage RequiredInsertion Site Indication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
Choosing Epidural Insertion Level
T2-T12
(depending on
fractures)
22. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
Insertion Site
Anesthetic Coverage
RequiredIndication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
T5-T7
T3-T8
23. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
Insertion Site
Anesthetic Coverage
RequiredIndication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
T7-T9
T4-T12
(depending on
surgical extent)
24. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
Insertion Site
Anesthetic Coverage
RequiredIndication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
T6-T12 (surgical)
T8-T12 (post-op)
T8-T11
25. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
T9-T12
but
CSE may be useful
Insertion Site
Anesthetic Coverage
RequiredIndication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
T6-Sacral (surgical)
T8-T12 (post-op)
26. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
Insertion Site
Anesthetic Coverage
RequiredIndication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
L2-L5
T10-Sacral
27. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
Insertion Site
Anesthetic Coverage
RequiredIndication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
T4-Sacral
L2-L5
28. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
L2-L5
Insertion Site
Anesthetic Coverage
RequiredIndication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
T12-S3
29. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
T4-T10
T5-T7
T7-T9
T8-T11
L2-L5 T9-T12
L2-L5
Insertion Site
T2-T12
Anesthetic Coverage
Required
T4-T12
T3-T8
Indication:
Rib Fractures
Thoracic Surgery
Sub-Xiphoid Ex Lap
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
T8-T12 (post-op)
T6-T12 (surgical)
T6-Sacral (surgical)
T10-Sacral
T4-Sacral
T8-T12 (post-op)
L2-L5
T12-S3
30. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Epidural Insertion Level
High Thoracic
Epidurals:
Block Cardiac
Accelerator Fibers
Hypotension Likely
Very Low Thoracic
or Lumbar
Epidurals:
Block Lumbar Roots
Leg Weakness,
Urinary Retention
Likely
31. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Spinal Insertion Level
All Spinal
Placements
L2-S1
Preferably L3 or below
Insertion Site
Anesthetic Coverage
RequiredIndication:
Rib Fractures not used
Thoracic Surgery not used
Sub-Xiphoid Ex Lap rare
Sub-Umbilical Ex Lap
Pelvic Surgery
Labor
Caesarian Section
Lower Extremity
Ortho or Vascular
Surgery
T6-Sacral
T6-Sacral
T10-Sacral
T4-Sacral
T12-Sacral
T4-Sacral
32. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Spinous Process
Lamina
Transverse
Process
41. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep Superficial
Comes in from the
side, bypasses some
ligament
42. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• Lumbar Epidurals generally done midline
• Thoracic epidurals generally done paramedian
• Spinals generally done midline
Practical Guide to Neuraxial Placement
43. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• General tips:
– Positioning is crucial
– Use time wisely
– Communicate with the patient
• Use lay terms
• Avoid troubling words/phrases
– Blood = “Heme”
– Bone = “Os”
– “Oops” & Uh-oh” are 4 letter words
– Provide appropriate sedation
– Work in one plane at a time
– Technical skills improve faster than sterile technique
– Protect yourself!
• Needle tips pointing down on the tray
• No sharps on patient bed
Practical Guide to Epidural Placement
44. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• Time saving performance sequence:
– Arrive & Communicate with patient
– Position patient & Palpate landmarks
– Time Out & Prep skin
• Chlorhexidine X 2 for CPS
• Povidone Iodine (in the kit) for OB
– Allow prep to dry then apply drape
– Draw & Give skin local (25g needle)
– Finally, set up remaining kit
– Place epidural
– Put sharps in small tray as you go
Practical Guide to Epidural Placement
45. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
Come in parallel to
the back in all planes
Lumbar Epidural
Thoracic Epidural
46. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
Inject JUST under the
skin, raising a broad,
flat weal
Lumbar Epidural
Thoracic Epidural
47. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
If the injection is too
deep, weal will be
more raised,
distorting landmark
palpation
Lumbar Epidural
Thoracic Epidural
48. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
After skin weal,
advance needle,
injecting somewhat
AS YOU GO Note any increase in
injection pressure,
c/w ligament
Lumbar Epidural
Thoracic Epidural
49. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
If Os (bone) contacted,
infiltrate well
Lumbar Epidural
Thoracic Epidural
50. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
If landmarks are clear, only
administer local in midline,
dorsal-ventral plane
If landmarks unclear, use
local needle as finder for Os
or ligament
Lumbar Epidural
51. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
Do not go too deep in
low BMI patients
Lumbar Epidural
52. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
For Paramedian approach,
walk medial along lamina,
injecting as you go
53. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
For Paramedian approach,
walk medial along lamina,
injecting as you go
54. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
Do not go too deep in
low BMI patients
55. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Skin Localization
Skin
Save enough medication in
syringe for localization of an
additional skin site
Lumbar Epidural
56. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Thoracic Epidural
Lumbar Epidural
Spinal
Paravertebral
TAP and Rectus Sheath
57. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Palpate:
Vertebra
Prominens
Practical Guide to Thoracic Epidural Placement
Skin
58. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Count:
From C7
down to
desired
level
T1
T2
T3
T4
T5
T6
T7
Practical Guide to Thoracic Epidural Placement
Skin
59. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Confirm
Midline by
Palpation
T6
Practical Guide to Thoracic Epidural Placement
Skin
60. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Judge 1 cm lateral
& 0.5 cm caudal to
tip of Spinous
Process
1 cm
0.5 cm
1 cm
1 cm
0.5 cm
Practical Guide to Thoracic Epidural Placement
Skin
61. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Mark:
Needle Insertion
Skin
Practical Guide to Thoracic Epidural Placement
Skin
62. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Thoracic Epidural Placement
Insert needle
in dorsal to ventral
plane, perpendicular to
skin in all planes
Skin
Plane 1:
Dorsal to Ventral
63. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Advance needle to
lamina
Mark needle depth
Practical Guide to Thoracic Epidural Placement
Skin
Lamina
Depth
Plane 1:
Dorsal to Ventral
64. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Withdraw needle, angle
5-10 degrees medial,
advance to bone
Plane 2:
Lateral to Medial
Stop if no bone
found before
lamina depth + 0.5 cm
Skin
Practical Guide to Thoracic Epidural Placement
65. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Repeat needle
withdrawal, medial
angulation and
advancement
Skin
Repeat process until
bone found at
shallower depth
Practical Guide to Thoracic Epidural Placement
Plane 2:
Lateral to Medial
66. BFSA
Slide by Brian F S Allen
BFSA
BFSA
When shallower depth
to bone found, stop
medial angulations.
Skin
Practical Guide to Thoracic Epidural Placement
Plane 2:
Lateral to Medial
67. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Return to angle where
bone found deepest
Mark deepest depth in
lateral to medial plane
Skin
Practical Guide to Thoracic Epidural Placement
Plane 2:
Lateral to Medial
68. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Withdraw needle, angle
5-10 degrees cephalad,
advance to bone
Plane 3:
Caudal to Cranial
Stop if no bone
found before previous
bone depth + 0.5 cm
Skin
Practical Guide to Thoracic Epidural Placement
69. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Repeat needle
withdrawal, cephalad
angulation and
advancement
Repeat until bone
“walked off” and/or
engaged in ligament
Skin
Practical Guide to Thoracic Epidural Placement
Plane 3:
Caudal to Cranial
70. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Repeat needle
withdrawal, cephalad
angulation and
advancement
Repeat until bone
“walked off” and/or
engaged in ligament
Skin
Practical Guide to Thoracic Epidural Placement
Plane 3:
Caudal to Cranial
71. BFSA
Slide by Brian F S Allen
BFSA
BFSA
When engaged in
ligament, remove
stylet, connect LOR
syringe
With LOR syringe,
check for LOR initially
and every 2mm
advancement
Skin
Practical Guide to Thoracic Epidural Placement
Plane 3:
Caudal to Cranial
72. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Disconnect syringe,
pass catheter
Skin
Practical Guide to Thoracic Epidural Placement
Plane 3:
Caudal to Cranial
When LOR noted, stop
advancement, inject
LOR fluid (or air)
73. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Thoracic Epidural
Lumbar Epidural
Spinal
Paravertebral
TAP and Rectus Sheath
74. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
Palpate:
Iliac Crests
Skin
75. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Count: From
L3-L4 to
desired level
Practical Guide to Lumbar Epidural Placement
Choose:
the best
Interspace
Skin
76. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
0.5
cm
0.5 cm
0.5 cm
0.5 cm
Judge a slight
distance ~ 0.5 cm
caudal to tip of
Spinous Process
Skin
77. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
Mark:
Needle
Insertion
Skin
78. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
Insert needle
in dorsal to ventral
plane, perpendicular
to skin in all planes
Skin
79. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• Before you advance needle, come up with 3
numbers in your mind:
– #1: Expected depth to epidural space (ED)
– #2: Shortest possible depth to epidural space (SD)
– #3: Longest reasonable depth to epidural space (LD)
Practical Guide to Lumbar Epidural Placement
80. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
Advance needle until
engaged in ligament
Stop if engaged in ligament or
you reach shortest possible
epidural depth (SD)
Skin
81. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
When engaged in
ligament or at
SD, remove
stylet, connect
LOR syringe
With LOR syringe,
check for LOR initially and
every 2mm advancement
Skin
82. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
When engaged in
ligament or at
SD, remove
stylet, connect
LOR syringe
With LOR syringe,
check for LOR initially and
every 2mm advancement
Skin
83. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
Skin
When engaged in
ligament or at
SD, remove
stylet, connect
LOR syringe
With LOR syringe,
check for LOR initially and
every 2mm advancement
84. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Lumbar Epidural Placement
Skin
Disconnect
syringe, pass
catheter
When LOR noted, stop
advancement, inject
LOR fluid (or air)
85. BFSA
Slide by Brian F S Allen
BFSA
BFSA
If Bone encountered Mark Depth
Withdraw, Redirect
Cephalad, Pass Needle
Deeper
Bone encountered
Pass Successful
Same DepthMore Shallow
Location: Walking up
Inferior Spinous Process
Location: On Lamina
Reassess Landmarks
Location: Walking down
Superior Spinous Process
Practical Guide to Lumbar Epidural Placement
86. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• Test dose – to rule out IV or IT
– 2 to 3 mL 1.5% Lidocaine with 1:200,000 Epinephrine
• Lidocaine 45 mg
• Epinephrine 15 mcg
• Each component has different effect depending on catheter location
• 4 main possibilities
– Intrathecal
– Intravascular
– Epidural
– Intramuscular or within other tissue
– Rarely subdural
Practical Guide to Any Epidural Placement
87. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Test dose effect based on catheter location
Epinephrine Effect
Intravascular Intrathecal Epidural Intramuscular
• Heart Rate Elevation
HR rises 20 sec after
dose
HR up 20 BPM
Lasts 20 sec
HR drops 20 BPM
HR tracing like
square wave
May be non-diagnostic in:
• Labor if contraction
occurs
• Patients on Beta
Blockers
• Heart transplant
• No Acute Effect • No Acute Effect • No Effect
H
R
Time
“Rule”
of 20s
88. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Test dose effect based on catheter location
Lidocaine Effect
Intravascular Intrathecal Epidural Intramuscular
• Effect within 20 sec
• Tinnitus
• Roaring in ears
• Perioral numbness
• No effect
No sensory or motor
changes found
• Effect within 3-8 min
• If LEC: leg motor block
• If TEC: broad chest
numbness, possible
leg or arm weakness
or numbness
Thoracic
Intrathecal
Lumbar
Intrathecal
• Effect within 5-10 min
• Band of numbness
• 2-4 dermatomes
• Depends on vertebral
level catheter placed
Thoracic
Epidural
Lumbar
Epidural
89. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Epidural Catheter Testing
• All epidural catheters should be evaluated after
placement
• 3 mL test dose should take effect rapidly
– 5-10 minutes to development of discernable level
– Small bilateral sensory level to ice or pinprick
– Approximately 2 dermatomes wide
• No patient should go to surgery without block eval
– Takes little time
– Presence of a level confirms correct placement
– Absence of level reveals need for
troubleshooting/replacement
– Testing preop limits need for epidural function confirmation
postop
– Unilateral blocks can be addressed immediately
• Failure to evaluate block = poor patient care
90. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Thoracic Epidural
Lumbar Epidural
Spinal
Paravertebral
TAP and Rectus Sheath
91. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Spinal Placement
Similar to Lumbar Epidural
Locate best lumbar interspace
Skin
Lower interspaces preferable.
Spinal cord ends at L1-L2 in adults
Can be lower in high proportion
92. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Spinal Placement
Skin
Place needle
introducer
in dorsal to ventral
plane, perpendicular
to skin in all planes
93. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Spinal Placement
Skin
Advance needle until
engaged in ligament
94. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Spinal Placement
Skin
Place spinal needle thru
introducer, paying
attention to feel during
needle advancement
95. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Spinal Placement
Skin
When subtle “pop” felt,
remove stylet, check for
CSF flow
If CSF flow,
Connect syringe,
aspirate, inject
spinal med
96. BFSA
Slide by Brian F S Allen
BFSA
BFSA
If Bone encountered Mark Depth
Withdraw, Redirect
Cephalad, Pass Needle
Deeper
Bone encountered
Pass Successful
Same DepthMore Shallow
Location: Walking up
Inferior Spinous Process
Location: On Lamina
Reassess Landmarks
Location: Walking down
Superior Spinous Process
Practical Guide to Spinal Placement
97. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Thoracic Epidural
Lumbar Epidural
Spinal
Paravertebral
TAP and Rectus Sheath
98. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Pleura
Catheter
Sympathetic
Ganglion
Touhy
Needle
Spinous
Process
Transverse
Process
Rib
Lamina
Dorsal
Root
Ventral Root
Gray and White
Rami Communicantes
Vertebral Body
Ventral Ramus
Dorsal Ramus
99. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
• Paravertebral space
– Triangular space lateral to
neural foramen
– Medial Boundary: Vertebra
– Posterior Boundary:
Costotransverse ligament
– Anterior and Lateral
Boundary: Pleura
– Holds emerging spinal roots
– Communicates vertically
100. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
• Paravertebral space
– Triangular space lateral to
neural foramen
– Medial Boundary: Vertebra
– Posterior Boundary:
Costotransverse ligament
– Anterior and Lateral
Boundary: Pleura
– Holds emerging spinal roots
– Communicates vertically
101. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
• Paravertebral space
– Triangular space lateral to
neural foramen
– Medial Boundary: Vertebra
– Posterior Boundary:
Costotransverse ligament
– Anterior and Lateral
Boundary: Pleura
– Holds emerging spinal roots
– Communicates vertically
102. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
• Paravertebral space
– Triangular space lateral to
neural foramen
– Medial Boundary: Vertebra
– Posterior Boundary:
Costotransverse ligament
– Anterior and Lateral
Boundary: Pleura
– Holds emerging spinal roots
– Communicates vertically
103. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
• Paravertebral space
– Triangular space lateral to
neural foramen
– Medial Boundary: Vertebra
– Posterior Boundary:
Costotransverse ligament
– Anterior and Lateral
Boundary: Pleura
– Holds emerging spinal roots
– Communicates vertically
104. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Image: Chelly 2012
105. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Image: Chelly 2012
• Paravertebral space
– Medial Boundary:
Vertebra
– Posterior Boundary:
Costotransverse
ligament
– Lateral Boundary:
Pleura
– Communicates
vertically
106. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Image: Chelly 2012
• Paravertebral space
– Medial Boundary:
Vertebra
– Posterior Boundary:
Costotransverse
ligament
– Lateral Boundary:
Pleura
– Communicates
vertically
107. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Epidural
Unilateral
Uncommon
No
No
No
Very Rare
Features
Laterality
Hypotension
Pruritis
PONV
Urinary
Retention
Spinal Injury
Risk
Bilateral
Common
Common
Common
Common
Rare
Comparing Paravertebral and Epidural Characteristics
Paravertebral
Chart: Chelly 2012
108. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Palpate:
Vertebra
Prominens
Practical Guide to Paravertebral Placement
Skin
109. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Count:
From C7
down to
desired
level
T1
T2
T3
T4
T5
T6
T7
Practical Guide to Paravertebral Placement
Skin
110. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Confirm
Midline by
Palpation
T4
Practical Guide to Paravertebral Placement
Skin
111. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Measure 2.5 cm
lateral to tip of
Spinous Process
2.5 cm
2.5 cm
2.5 cm
Practical Guide to Paravertebral Placement
Skin
112. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Mark:
Needle Insertion
Practical Guide to Paravertebral Placement
Skin
113. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Skin
Plane 1:
Dorsal to Ventral
Insert needle
in dorsal to ventral
plane, perpendicular to
skin in all planes
114. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Skin
Plane 1:
Dorsal to Ventral
Advance needle to
transverse process
Mark needle depth
115. BFSA
Slide by Brian F S Allen
BFSA
BFSA
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
Practical Guide to Paravertebral Placement
Skin
Above T7
Walk off
Caudal or
Cranial to TP
T7 or below
Walk off
Caudal to TP
For this example,
we will adjust
caudal
116. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Skin
Plane 2:
Cranial to Caudal
Withdraw needle, angle
5-10 degrees caudal,
advance
If bone contacted
remove needle and
repeat caudal
angulation
117. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Skin
Plane 2:
Cranial to CaudalRepeat needle
withdrawal, caudad
angulation and
advancement
Maintain needle in
strict AP plane
118. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Skin
Plane 2:
Cranial to Caudal
When bone walked off,
advance cautiously
Advance NO MORE
than 1 cm to 1.25 cm
past transverse
process
119. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Skin
Subtle LOR can be
felt, but is
nonspecific
Feels different
from epidural LOR
When 1 to 1.25 cm past
TP, remove stylet,
connect LOR syringe
120. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Practical Guide to Paravertebral Placement
Skin
Catheter can be
difficult to thread
Dilate paravertebral
space then pass catheter
121. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• Test dosing with epinephrine-containing
solution recommended
• Ultrasound can be used
– Preprocedure OR Intraprocedure
– Intraprocedure can challenging for catheters
• Single Injection Paravertebrals
– May block multiple levels
– Unilateral or Bilateral
– LOR technique not used
– Closed system limits pneumothorax risk
Practical Guide to Paravertebral Placement
122. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Paravertebral Insertion Level
T1-T5
Insertion Site
Indication:
Breast Surgery
Esophagectomy
Thoracic Surgery
Liver Resection
Abdominal Surgery
Pelvic Surgery
123. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Paravertebral Insertion Level
T2-T3
Bilateral
Insertion Site
Indication:
Breast Surgery
Esophagectomy
Thoracic Surgery
Liver Resection
Abdominal Surgery
Pelvic Surgery
124. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Paravertebral Insertion Level
T4-T5
Insertion Site
Indication:
Breast Surgery
Esophagectomy
Thoracic Surgery
Liver Resection
Abdominal Surgery
Pelvic Surgery
125. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Paravertebral Insertion Level
T6-T7
Bilateral
Insertion Site
Indication:
Breast Surgery
Esophagectomy
Thoracic Surgery
Liver Resection
Abdominal Surgery
Pelvic Surgery
126. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Paravertebral Insertion Level
T8-T9
Bilateral
Insertion Site
Indication:
Breast Surgery
Esophagectomy
Thoracic Surgery
Liver Resection
Abdominal Surgery
Pelvic Surgery
127. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Paravertebral Insertion Level
T10-L1
Bilateral
Insertion Site
Indication:
Breast Surgery
Esophagectomy
Thoracic Surgery
Liver Resection
Abdominal Surgery
Pelvic Surgery
128. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Choosing Paravertebral Insertion Level
T2-T6
T4-T5
T2-T3
T6-T7
T8-T9
T10-L1
Insertion Site
Indication:
Breast Surgery
Esophagectomy
Thoracic Surgery
Liver Resection
Abdominal Surgery
Pelvic Surgery
129. BFSA
Slide by Brian F S Allen
BFSA
BFSA
T1
T2
T3
T4
T5
T6
Practical Guide to Paravertebral Placement
Skin
2.5 cm
For Single
Injection PVBs:
Mark All Needle
Insertion Sites
Usually every
level or every
other level
Limit volume and
concentration injected
to prevent toxicity
2.5 cm
130. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Thoracic Epidural
Lumbar Epidural
Spinal
Paravertebral
TAP and Rectus Sheath
132. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• TAP Block = Transversus
Abdominus Plane Block
– Injection into fascial plane
between 2 muscle layers
• Internal Oblique
• Transversus Abdominus
• Rectus Sheath Block
– Injection into fascial plane deep
to Rectus Abdominus muscle
• Between Rectus and Peritoneum
Practical Guide to
Trunk Block Placement
Postero-Lateral
Antero-Medial
Deep
Superficial
133. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• Numbs body wall, muscles,
fascia
• No effect on visceral pain
• Performed under Ultrasound
– Landmark based blocks inaccurate
Practical Guide to
Trunk Block Placement
Postero-Lateral
Antero-Medial
Deep
Superficial
134. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• Muscles of Abdominal Wall
– External Oblique
– Internal Oblique
– Transversus Abdominus
– Rectus Abdominus
• Landmarks
– Costal Margin
– Iliac Crest
Practical Guide to
Trunk Block Placement
Postero-Lateral
Antero-Medial
Deep
Superficial
135. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Costal
Margin
Iliac
Crest
Practical Guide to
Trunk Block Placement
• Muscles of Abdominal Wall
– External Oblique
– Internal Oblique
– Transversus Abdominus
– Rectus Abdominus
• Landmarks
– Costal Margin
– Iliac Crest
Postero-Lateral
Antero-Medial
Deep
Superficial
136. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Costal
Margin
Iliac
Crest
• Muscles of Abdominal Wall
– External Oblique
– Internal Oblique
– Transversus Abdominus (TA)
– Rectus Abdominus
• Landmarks
– Costal Margin
– Iliac Crest
TA
Practical Guide to
Trunk Block Placement
Postero-Lateral
Antero-Medial
Deep
Superficial
137. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Costal
Margin
Iliac
Crest
• Muscles of Abdominal Wall
– External Oblique
– Internal Oblique (IO)
– Transversus Abdominus (TA)
– Rectus Abdominus
• Landmarks
– Costal Margin
– Iliac Crest
IO
TA
Practical Guide to
Trunk Block Placement
Postero-Lateral
Antero-Medial
Deep
Superficial
IO
TA
138. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Costal
Margin
Iliac
Crest
• Muscles of Abdominal Wall
– External Oblique (EO)
– Internal Oblique (IO)
– Transversus Abdominus (TA)
– Rectus Abdominus
• Landmarks
– Costal Margin
– Iliac Crest
EO
IO
TA
Practical Guide to
Trunk Block Placement
Postero-Lateral
Antero-Medial
Deep
Superficial
IO
TA
EO
139. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Costal
Margin
Iliac
Crest
• Muscles of Abdominal Wall
– External Oblique (EO)
– Internal Oblique (IO)
– Transversus Abdominus (TA)
– Rectus Abdominus (RA)
• Landmarks
– Costal Margin
– Iliac Crest
EO
IO
TA
RA
Practical Guide to
Trunk Block Placement
Postero-Lateral
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
140. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Costal
Margin
Iliac
Crest
• Muscles of Abdominal Wall
– External Oblique (EO)
– Internal Oblique (IO)
– Transversus Abdominus (TA)
– Rectus Abdominus (RA)
• Landmarks
– Costal Margin
– Iliac Crest
EO
IO
TA
RA
Practical Guide to
Trunk Block Placement
Postero-Lateral
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
142. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Ultrasound Guidance
for
TAP Block Placement
Ultrasound
Probe
Place probe lateral
and posterior on
body wall
Postero-Lateral Antero-Medial
Deep
Superficial
Antero-Medial
Deep
Superficial
143. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Find Peritoneum
Postero-Lateral Antero-Medial
Deep
Superficial
It is the deepest
bright line.
Its contents
peristalse
Ultrasound Guidance
for
TAP Block Placement
Intraperitoneal
144. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Count muscular
layers from
deepest to
superficial
Postero-Lateral Antero-Medial
Deep
Superficial
Transversus
Abdominus
below
Internal Oblique
below
External Oblique
Ultrasound Guidance
for
TAP Block Placement
Intraperitoneal
TA
145. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Postero-Lateral Antero-Medial
Deep
Superficial
Ultrasound Guidance
for
TAP Block Placement
Intraperitoneal
TA
Count muscular
layers from
deepest to
superficial
IO
Transversus
Abdominus
below
Internal Oblique
below
External Oblique
146. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Postero-Lateral Antero-Medial
Deep
Superficial
Ultrasound Guidance
for
TAP Block Placement
Intraperitoneal
TA
IO
Count muscular
layers from
deepest to
superficial
EO
Transversus
Abdominus
below
Internal Oblique
below
External Oblique
147. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Deep
Superficial
Ultrasound Guidance
for
TAP Block Placement
Intraperitoneal
TA
IO
Above External
Oblique is skin, SQ
tissue, fascia
Superficial
tissue often
easy to confuse
with muscle
EO
Skin, SQ, Fascia
Muscle
148. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
IO
TA
EO
RA
Postero-Lateral Antero-Medial
Deep
Superficial
Ultrasound Guidance
for
TAP Block Placement
TA
IO
Target is plane
between Internal
Oblique and
Transversus
Abdominus
EO
Mark: Needle
Insertion
Antero-Medial to
Probe
149. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
IO
TA
EO
RA
Postero-Lateral Antero-Medial
Deep
Superficial
Ultrasound Guidance
for
TAP Block Placement
TA
IO
In Plane with
ultrasound probe
EO
Advance needle
steeply from Antero-
Medial to Postero-
Lateral
150. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
IO
TA
EO
RA
Postero-Lateral Antero-Medial
Deep
Superficial
Ultrasound Guidance
for
TAP Block Placement
TA
IO
Look for ideal
hypoechoic spead
of injectate
between IO & TA
EO
Use 4” Stimuplex
needle and stand on
Ipsilateral side as the
block
151. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
RA
Antero-Medial Postero-Lateral
Deep
Superficial
Ultrasound Guidance
for
TAP Block Placement
TA
IO
Repeat on
Contralateral side
EO
Inject on EACH side:
20-30 mL local anesthetic
+/- Dexamethasone
152. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Before injection After properly placed injection
Ultrasound Guidance for TAP Block Placement
153. BFSA
Slide by Brian F S Allen
BFSA
BFSA
• Counting muscles
– If you can find peritoneum, count up from TA
– If unclear, verify by counting down EO to IO to TA
– SQ tissues can be mistaken for muscle
• If target, TA, & IO still unclear:
– Place probe over RA, scan lateral until muscle
layers apparent
Practical Guide to TAP Block Placement
IO
TA
EO
RA
154. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
IO
TA
EO
RA
Postero-Lateral Antero-Medial
Deep
Superficial
TA
IO
EO
Distribution of
Analgesia for
TAP Block
Distribution may
be influenced by
insertion site
155. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
IO
TA
EO
RA
Postero-Lateral Antero-Medial
Deep
Superficial
TA
IO
EO
Distribution of
Analgesia for
TAP Block
Distribution may
be influenced by
insertion site
157. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Ultrasound
Probe
(placement depends
on desired block
distribution)
Place probe in
midline at
desired
location on
abdomen
Superficial
Deep
Superficial
Antero-Medial
Deep
Superficial
Midline
158. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Deep
Superficial
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Superficial
Deep
Midline
Intraperitoneal
Find Peritoneum
It is the deepest
bright line.
Its contents
peristalse
159. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Deep
Superficial
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Superficial
Deep
Midline
Intraperitoneal
Find Peritoneum
It is the deepest
bright line.
Its contents
peristalse
Pre-peritoneal Fat
160. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Deep
Superficial
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Superficial
Deep
Midline
Intraperitoneal
Find paired
Rectus Muscles RA
RA
161. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Superficial
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Superficial
Deep
Midline
Intraperitoneal
Slide the probe
to one side
162. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Superficial
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Superficial
Deep
Intraperitoneal
RA
Slide the probe
to one side
163. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Superficial
Deep
Intraperitoneal
RA
Antero-Medial
Deep
Superficial
IO
TA
EO
RA
Above Rectus
Abdominus is skin,
SQ tissue, fascia
Superficial
tissue can be
confused with
muscle
Skin, SQ, Fascia
Muscle
Ultrasound Guidance
for
Rectus Sheath Block
Placement
164. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
IO
TA
EO
RA
Deep
Superficial
Mark: Needle
Insertion
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Superficial
Deep
RA
Can be Medial or
Lateral to the
probe
165. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
IO
TA
EO
RA
Deep
Superficial
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Superficial
Deep
RA
If high subcostal or
subxiphoid injection
desired, probe can be
rotated
Many different
injection sites can be
chosen
166. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Superficial
Deep
RA
Deep
IO
TA
EO
RA
Target is plane
between Rectus
Abdominus and
Peritoneum
Ultrasound Guidance
for
Rectus Sheath Block
Placement
167. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
RA
Deep
IO
TA
EO
RA
Ultrasound Guidance
for
Rectus Sheath Block
Placement
In Plane with
ultrasound probe
Advance needle from
Medial to Lateral
(Lateral to Medial is OK too)
168. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
RA
Deep
IO
TA
EO
RA
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Look for ideal
hypoechoic spead
of injectate
between RA &
Peritoneum
Use 4” Stimuplex
needle
169. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
RA
Deep
IO
TA
EO
RA
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Slide the probe
to opposite side
SuperficialMidline
170. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
RA
Deep
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Use the same skin
insertion site
Superficial
Block the
contralateral side
171. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
RA
Deep
Ultrasound Guidance
for
Rectus Sheath Block
Placement
Superficial
Inject on EACH side:
10-15 mL local anesthetic
+/- Dexamethasone
Block the
contralateral side
172. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
RA
Deep
IO
TA
EO
RA
Distribution of
Analgesia for
Rectus Sheath Block
173. BFSA
Slide by Brian F S Allen
BFSA
BFSA
Deep
RA
Deep
IO
TA
EO
RA
Distribution of
Analgesia for
Rectus Sheath Block