Editorial Views  |   August 2003
Is Regional Anesthesia Simply an Exercise in Applied Sonoanatomy?: Aiming at Higher Frequencies of Ultrasonographic Imaging
Author Affiliations & Notes
  • Manfred Greher, M.D.
  • *University of Vienna, Vienna General Hospital, Vienna, Austria.
Article Information
Editorial Views
Editorial Views   |   August 2003
Is Regional Anesthesia Simply an Exercise in Applied Sonoanatomy?: Aiming at Higher Frequencies of Ultrasonographic Imaging
Anesthesiology 8 2003, Vol.99, 250-251. doi:
Anesthesiology 8 2003, Vol.99, 250-251. doi:
The key steps in any successful regional anesthetic involve identifying the exact position of the nerve, reaching it with a precisely placed needle (without damage to any adjacent structures), and, finally, carefully injecting local anesthetic. Although easy in principle, clinicians are confronted daily with the difficulty of converting this theory into practice. Knowledge of anatomy based on surface landmarks is an essential starting point but is hardly ever satisfactory alone. The introduction of the peripheral nerve stimulator into clinical practice was a major advance. Unfortunately, even with this tool, our performance is still far from perfect, resulting in unpredictable block failures, inadvertent puncture of adjacent structures leading to complications, or frustrating and time-consuming trial-and-error attempts.
Alon P. Winnie once predicted:“Sooner or later someone will make a sufficiently close examination of the anatomy involved, so that exact techniques will be developed.”1 Ultrasonography may represent just such a method for providing a “sufficiently close examination of the anatomy.” Studies comparing ultrasound guidance with nerve stimulator guidance have found significantly higher success rates, shorter onset times, 2 and a decrease in local anesthetic needs 3 and complications with the former method. In this issue of Anesthesiology, Perlas et al.  4 contribute further to our knowledge with a volunteer study, using the newest-technology high-frequency probes (12-MHz) to identify the brachial plexus in five typical locations and to guide a needle and verify its position with nerve stimulation. With figures of excellent quality and high educational value, this article once more demonstrates the technical feasibility of ultrasound-guided brachial plexus block.
Ultrasound-facilitated nerve blocks were first reported in 1978, 5 and interest has increased in the past 10 yr owing to progress in transducer technology and image processing. Although early studies were limited to vascular identification by Doppler ultrasound, recent studies have tried to directly visualize the nerves. 6 Normal peripheral nerves in transverse scans appear as multiple round or oval hypoechoic areas encircled by a relative hyperechoic background. As with tendons, the connective tissue within the nerves (perineurium and epineurium) displays an anisotropic behavior, depending on the angle of the emitted ultrasound wave relative to the long axis of the nerve. 7 
This Editorial View accompanies the following article: Perlas A, Chan VWS, Simons M: Brachial plexus examination and localization using ultrasound and electrical stimulation: A volunteer study. Anesthesiology 2003; 99:429–35.
Earlier, low-frequency methods were not ideal. However, the move toward higher frequencies, resulting in the 7- to 15-MHz linear transducers of today, has resulted in much higher image resolution. Moreover, ultrasound has become portable, providing increased flexibility and applicability. However, a fundamental rule of ultrasound physics shows that although higher frequency results in higher spatial resolution, the depth of tissue penetration is also reduced. Accordingly, the highest frequency is not automatically the best choice for all applications. Thus, it is not surprising that in Perlas’ study 4 the 12-MHz probe offered higher resolution compared to lower-frequency transducers in superficial plexus locations but failed to identify the nerves in 73% of the cases in the infraclavicular region, where they can easily be identified with 5–10 MHz in 3 cm distance. 8 Different frequency probes will probably be needed for different purposes. For example, we use 15-MHz probes in experimental laboratory settings 9 but 4- to 5-MHz probes for an ultrasound-guided posterior lumbar plexus block with a target deeper than 5 cm. 10 To visualize the brachial plexus in 1 cm depth at the interscalene, supraclavicular, or axillary level, the 12-MHz transducer is obviously an excellent choice. 4,11,12 
However, we reckon that inserting the needle on the outer end of the transducer and advancing it in a lateral to medial direction, as proposed here, contrary to the common practice of inserting it close to the middle of the transducer and guiding it perpendicularly to the ultrasound beam, makes more sense in deep blocks and is questionable for 1-cm deep targets. This may displace the insertion point unnecessarily far from the nerve and thus increase the length of tissue penetration.
In performing ultrasonography-guided blocks, observing a homogeneous and complete local anesthetic spread around the nerve is the most reliable predictor of block success. This is not necessarily achieved with the needle tip in the closest proximity to the nerve. This signifies a fundamental difference from the blind, one-dimensional nerve-stimulator technique in which injections are typically performed after the needle is placed as close to the nerve as possible (as defined by a low stimulating current). Interestingly, in the present study, there was no clear correlation between ultrasonographically verified needle-to-nerve contact and nerve stimulated muscle contraction with currents of up to 1.5 mA. We may speculate about the reasons, 13 but, above all, this underlines the demand for precisely defined and calibrated nerve stimulators, at least in experimental settings. This is important, because we know, for example, that only with an impulse duration of 0.1 ms will the current correlate with the distance to the nerve. Nevertheless, commercially available devices have recently been identified as being highly variable in their accuracy of current output and preset electrical characteristics. 14 
Ultrasound has proved helpful for regional anesthesia in two ways: First, it allows the systematic, noninvasive, in vivo  assessment of topographic sonoanatomy and its variations. 11 Performing careful ultrasound measurements enhances our anatomic understanding, tests the accuracy of common block techniques, and can even result in suggestions to modify them, 8 as likewise demonstrated with magnetic resonance imaging. 15 We still have much to learn from in vivo  ultrasound, inasmuch as anatomy textbooks rely mainly on cadaver dissections. Second, and probably most important, ultrasound helps to individually guide the needle in real time. Advantages of ultrasound-guidance include the direct visualization of the nerves, the entire needle, or the needle tip; identification of adjacent structures to avoid; and, finally, monitoring of local anesthetic spread.
In conclusion, the use of ultrasound-guidance in regional anesthesia and interventional pain management is growing. The technique provides information about upper and lower extremity block anatomy, 12 facilitates neuraxial methods, 16 and is being used to guide the performance of a wide range of other blocks, including blocks of the stellate ganglion, 17 coeliac plexus, 18 or lumbar facet nerves. 9 Currently, many centers have performed thousands of ultrasound-guided procedures (e.g.  , n > 2,000, Vienna Study Group), and detailed descriptions of the methods are entering textbooks. 19 
Ultrasound imaging brings light into regional anesthesia, which has hitherto been the domain of extraordinarily experienced “needle-magicians.” The statement that nobody has an eye on the needle now can be revised: We have a dispassionate eye above the needle to control what we are doing and to give nerve blocks an objective basis. Ultrasound guidance offers anesthetists a unique chance to improve block success and decrease the rate of complications, even if they are less experienced in regional techniques. Devices have become user-friendly, more affordable, and can be shared with other specialties. Studies like the one in this issue of Anesthesiology 4 contribute largely to making regional anesthesia more of a science rather than an art. However, despite all the proven advantages of ultrasound-guidance, this method is incredibly underused in daily practice. Consequently, after achieving today's high transmitter frequencies, our next step should be to markedly increase application frequency.
Winnie AP, Buckheoj P, Hoakansson L: Plexus anesthesia: perivascular techniques of brachial plexus block, Revis Edition. Philadelphia, Saunders, 1994
Marhofer P, Schrogendorfer K, Koinig H, Kapral S, Weinstabl C, Mayer N: Ultrasonographic guidance improves sensory block and onset time of three-in-one blocks. Anesth Analg 1997; 85: 854–7Marhofer, P Schrogendorfer, K Koinig, H Kapral, S Weinstabl, C Mayer, N
Marhofer P, Schrogendorfer K, Wallner T, Koinig H, Mayer N, Kapral S: Ultrasonographic guidance reduces the amount of local anesthetic for 3-in-1 blocks. Reg Anesth Pain Med 1998; 23: 584–8Marhofer, P Schrogendorfer, K Wallner, T Koinig, H Mayer, N Kapral, S
Perlas A, Chan VWS, Simons M: Brachial plexus examination and localization using ultrasound and electrical stimulation: A volunteer study. A nesthesiology 2003; 99: 429–35Perlas, A Chan, VWS Simons, M
La Grange P, Foster PA, Pretorius LK: Application of the Doppler ultrasound bloodflow detector in supraclavicular brachial plexus block. Br J Anaesth 1978; 50: 965–7La Grange, P Foster, PA Pretorius, LK
Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C: Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg 1994; 78: 507–13Kapral, S Krafft, P Eibenberger, K Fitzgerald, R Gosch, M Weinstabl, C
Kapral S, Marhofer P, Grau T: Ultrasound in local anaesthesia. Part I: technical developments and background (in German). Anaesthesist 2002; 51: 931–7Kapral, S Marhofer, P Grau, T
Greher M, Retzl G, Niel P, Kamolz L, Marhofer P, Kapral S: Ultrasonographic assessment of topographic anatomy in volunteers suggests a modification of the infraclavicular vertical brachial plexus block. Br J Anaesth 2002; 88: 632–6Greher, M Retzl, G Niel, P Kamolz, L Marhofer, P Kapral, S
Greher M, Scharbert G, Kamolz L, Beck H, Gustorff B, Kapral S: Ultrasound guided lumbar facet nerve block: A feasibility study of a new methodological approach. Eur J Anaesthesiol 2003; 20( suppl): A709Greher, M Scharbert, G Kamolz, L Beck, H Gustorff, B Kapral, S
Kirchmair L, Entner T, Wissel J, Moriggl B, Kapral S, Mitterschiffthaler G: A study of the paravertebral anatomy for ultrasound-guided posterior lumbar plexus block. Anesth Analg 2001; 93: 477–81Kirchmair, L Entner, T Wissel, J Moriggl, B Kapral, S Mitterschiffthaler, G
Retzl G, Kapral S, Greher M, Mauritz W: Ultrasonographic findings of the axillary part of the brachial plexus. Anesth Analg 2001; 92: 1271–5Retzl, G Kapral, S Greher, M Mauritz, W
Kapral S, Marhofer P: Ultrasound in local anaesthesia. Part II: ultrasound-guided blockade of peripheral nerve channels (in German). Anaesthesist 2002; 51: 1006–14Kapral, S Marhofer, P
Ben-David B, Chelly JE: Current channeling: A theory of nerve stimulator failure. Anesth Analg 2003; 96: 1531–2Ben-David, B Chelly, JE
Hadzic A, Vloka J, Hadzic N, Thys DM, Santos AC: Nerve stimulators used for peripheral nerve blocks vary in their electrical characteristics. A nesthesiology 2003; 98: 969–74Hadzic, A Vloka, J Hadzic, N Thys, DM Santos, AC
Klaastad O, Lilleas FG, Rotnes JS, Breivik H, Fosse E: Magnetic resonance imaging demonstrates lack of precision in needle placement by the infraclavicular brachial plexus block described by Raj et al. Anesth Analg 1999; 88: 593–8Klaastad, O Lilleas, FG Rotnes, JS Breivik, H Fosse, E
Grau T, Leipold RW, Conradi R, Martin E: Ultrasound control for presumed difficult epidural puncture. Acta Anaesthesiol Scand 2001; 45: 766–71Grau, T Leipold, RW Conradi, R Martin, E
Kapral S, Krafft P, Gosch M, Fleischmann D, Weinstabl C: Ultrasound imaging for stellate ganglion block: Direct visualization of puncture site and local anesthetic spread—A pilot study. Reg Anesth 1995; 20: 323–8Kapral, S Krafft, P Gosch, M Fleischmann, D Weinstabl, C
Kirvela O, Svedstrom E, Lundbom N: Ultrasonic guidance of lumbar sympathetic and celiac plexus block. Reg Anesth 1992; 17: 43–6Kirvela, O Svedstrom, E Lundbom, N
Meier G, Büttner J: Allgemeine Aspekte peripherer Nervenblockaden der Extremitaeten, Lokalanaesthesie, Regionalanaesthesie, Regionale Schmerztherapie, 2nd edition. Edited by Niesel HG, Van Aken H. Stuttgart, New York, Georg Thieme Verlag, 2003, pp 235–65