At the conclusion of this activity, learners will be able to: define optimal ultrasound transducer position for cross-sectional imaging of nerves; apply surface anatomic landmark identification in ultrasound transducer application; identify sonoanatomy of common peripheral nerves and surrounding structure; and discuss tips and tricks to improve ultrasound images and ultrasound-guided nerve block techniques.

1. Surface Anatomy and
Sonoanatomy for the Occasional
Regional Anesthesiologist
@EMARIANOMD@EMARIANOMD
Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain MedicineProfessor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of MedicineStanford University School of Medicine
Chief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System

2. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Financial Disclosures
 Halyard Health, B Braun – Unrestricted
educational program funding paid to my
institution
The contents of the following presentation are
solely the responsibility of the speaker
without input from any of the above
companies.

3. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Disclaimer
 This presentation is intended for educational
purposes only and is not meant to be
reproduced or redistributed for commercial
purposes

4. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Learning Objectives
 Define optimal ultrasound transducer position
for cross-sectional imaging of nerves
 Apply surface anatomic landmark
identification in ultrasound transducer
application
 Identify sonoanatomy of common peripheral
nerves and surrounding structures
 Discuss tips and tricks to improve ultrasound
images and block techniques

5. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
How Hard Can It Be?
NYSORA.COM
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6. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Lesson #1

7. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Lesson #2
Regional anesthesia isRegional anesthesia is
applied anatomyapplied anatomy

8. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
History of Nerve Localization
 Anatomic landmarks
 Fascial clicks or pops
 Electrical nerve
stimulation
 Sustained “twitch” at <
0.5 mA current
suggests appropriate
needle position
 Ultrasound

9. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Overview
 Introduction to ultrasound
 Surface anatomic landmarks
 Relevant gross anatomy
 Traditional nerve block techniques
 Sonoanatomy for nerve blocks

10. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Overview
 Introduction to ultrasound
 Surface anatomic landmarks
 Relevant gross anatomy
 Traditional nerve block techniques
 Sonoanatomy for nerve blocks

11. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Basic Sonoanatomy
 Blood vessels:
hypo-echoic (dark)
 Muscles: hypo- >
hyper-echoic
(striations)
 Bone and fascia:
hyper-echoic
(white)
 Nerves: hypo-
echoic
Connective tissues are hyper-Connective tissues are hyper-
echoic (epineurium, perineurium)echoic (epineurium, perineurium)

12. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
A Closer Look at the Nerve
Short-Axis ViewShort-Axis View

13. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
The “A.R.T.” of Target Imaging
A lignment
Rotation
Tilt

14. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Alignment: Where Do We Look?

15. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Optimal Rotation

16. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Optimal Rotation

17. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Optimal Tilt

18. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Optimal Tilt

19. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Overview
 Introduction to ultrasound
 Surface anatomic landmarks
 Relevant gross anatomy
 Traditional nerve block techniques
 Sonoanatomy for nerve blocks

20. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Interscalene Block: How We Did It
 Needle inserted in IS
groove at C6
 Antero-lateral approach
 Needle angle 30-45º
 Elicit motor response
(deltoid, biceps, triceps,
pectoralis)
Borgeat A, et al. Anesth 2003:99:436Borgeat A, et al. Anesth 2003:99:436

21. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Interscalene Anatomy
 Position: supine with
head turned away
 SCM clavicular head
 Interscalene groove
posterior to SCM at
cricoid level (C6)
 External jugular vein
 Subclavian artery
SCMSCM
Subclavian ArtSubclavian Art
CricoidCricoid

22. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Interscalene Sonoanatomy
Transverse Short-Axis ViewTransverse Short-Axis View
SC
M
AS
M MS
M
CTP
BP
Mariano ER, et al. JUM 2010;29:329Mariano ER, et al. JUM 2010;29:329

23. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Infraclavicular Block: How We Did It
 Insertion 2 cm
medial and 2 cm
caudad to CP
 Needle inserted
plumb-bob
 Avg depth
4.24±1.49 cm in
men, 4.01±1.29 cm
in women
Wilson JL, et al. A&A 1998;87:870Wilson JL, et al. A&A 1998;87:870

24. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Infraclavicular Anatomy
 Position: supine with
arm at side or
abducted 90°
 Palpate coracoid
process below the
clavicle
 Plexus runs under
coracoid process
CoracoidCoracoid
Clavicle
Clavicle

25. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Infraclavicular Sonoanatomy
Transverse Short-Axis ViewTransverse Short-Axis View
PMa
PMi
AA AVN
N
N
Mariano ER, et al. JUM 2009;28:1211Mariano ER, et al. JUM 2009;28:1211

26. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Femoral Nerve Block: How We Did It
 Needle insertion:
lateral to artery at
45° angle aiming
cephalad
 Feel 2 “pops”
 Proper motor
response = quad
contraction
Ilfeld, BM, et al. Anesth 2008;108:703Ilfeld, BM, et al. Anesth 2008;108:703

27. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Femoral Anatomy
 Position: supine with
roll under hip
 Leg straight
 Inguinal crease
 Femoral artery
 Femoral nerve is
lateral to femoral
artery
Inguinal C
rease
Inguinal C
rease

28. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Femoral Sonoanatomy
Transverse Short-Axis ViewTransverse Short-Axis View
FA
FL
FIIliacus
N
Mariano ER, et al. JUM 2009;28:1453Mariano ER, et al. JUM 2009;28:1453

29. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Adductor Canal Anatomy
 Position: supine with
thigh externally rotated
and knee slightly flexed
 Subsartorial tunnel
begins distal to the apex
of the femoral triangle
 Saphenous nerve runs
with superficial femoral
artery
Horn JL, et al. RAPM 2009;34:486Horn JL, et al. RAPM 2009;34:486
Manickam B, et al. RAPM 2009;34:578Manickam B, et al. RAPM 2009;34:578

30. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Adductor Canal Ultrasound
 Transducer placed
along medial aspect
of thigh distal to
inguinal crease
 Short-axis view
 Landmarks
 Sartorius muscle
 Saphenous (N)
 Femoral artery (A) Mariano ER, et al. JUM 2014;33:1653Mariano ER, et al. JUM 2014;33:1653
Sartorius
N A

31. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Popliteal Fossa Block: How We Did It
 Insertion site: 8-10
cm cephalad to
popliteal crease or
at intertendinous
junction
 4” needle angled
45° cephalad
 Plantar flexion or
inversion preferred
Hadzic A, et al. A&A 2002;94:1321Hadzic A, et al. A&A 2002;94:1321

32. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Popliteal Anatomy
 Position: prone with
knee slightly flexed
 Popliteal crease
 Biceps femoris
laterally
 Semimembranosus
and semitendinosus
medially
 Intertendinous
“junction”
BicepsFemoris
BicepsFemoris
Semi-M/TSemi-M/T

33. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Popliteal Sonoanatomy
Transverse Short-Axis ViewTransverse Short-Axis View
F
BF
N
Mariano ER, et al. RAPMMariano ER, et al. RAPM

34. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Transversus Abdominis Plane Anatomy

35. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
TAP Sonoanatomy
Transverse Short-Axis ViewTransverse Short-Axis View
EO
IO
TA

36. Surface Anatomy and SonoanatomySurface Anatomy and Sonoanatomy
Summary
 We defined optimal ultrasound transducer
position for cross-sectional imaging of nerves
 We applied surface anatomic landmark
identification in ultrasound transducer
application
 We identified sonoanatomy of common
peripheral nerves and surrounding structures
 We discussed tips and tricks to improve
ultrasound images and block techniques