Case Report

Real-Time Three-Dimensional Ultrasound for

Continuous Popliteal Blockade: A Case Report
and Image Description
Neil G. Feinglass, MD*
Steven R. Clendenen, MD*
Klaus D. Torp, MD*

Two-dimensional ultrasound guidance has been used as an adjunct for neural

blockade. With the development of newer ultrasound technology, three-dimensional
ultrasound imaging is now available and may offer improved visualization of anatomic
structures and relationships. We describe the successful blockade of the popliteal nerve
with three-dimensional ultrasound guidance and image description.
(Anesth Analg 2007;105:2724)

R. Doris Wang, MD*

Ramon Castello, MD
Roy A. Greengrass, MD*

wo-dimensional (2D) ultrasound is commonly used

for guiding access to vascular structures, in transesophageal echocardiography, and most recently to guide
peripheral nerve blocks (1 4). Several studies have
shown the utility of 2D ultrasound to define the anatomy
and to guide needle insertion (5). Peripheral nerves,
being encased in fat, have ideal acoustic properties.
Neighboring vascular structures often allow Doppler
imaging (color, pulsed-wave, and continuous-wave) to
provide additional structural detail and avoid vascular
puncture and damage.
Nevertheless, 2D ultrasound has limited ability to
visualize spatial relationships (3,5). This results
from the nonlinear courses taken by vascular and
neural structures as they traverse tissue planes (5).
The 80-degree, cross-sectional, ultrasound beam can
identify cross-sections of these structures only as
they traverse the beam. However, visualizing the
end of a structure, such as the needle tip, is often
difficult.

This article has supplementary material on the Web site:

www.anesthesia-analgesia.org.
From the Departments of *Anesthesiology, and Cardiovascular
Disease, Mayo Clinic, Jacksonville, Florida.
Address correspondence and reprint requests to Neil G.
Feinglass, MD, Mayo Clinic, Jacksonville, FL. Address e-mail to
ngf06@bellsouth.net.
Copyright 2007 International Anesthesia Research Society
DOI: 10.1213/01.ane.0000265439.02497.a7

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Three-dimensional (3D) ultrasound can image the

entire anatomical region, nerve thickness, and 3D
relationships. Anesthetic distribution can be visualized in all 360-degree planes. This is generated from
simultaneous reconstruction of two standard orthogonal 2D planes (X and Y axes), with the additional
dimension of elevation (Z axis). The image may be
digitally rotated 360 degrees for better visualization of
the anatomic structures at the time of study, or at a
later date for postblock analysis.
This report describes the first real-time application of
3D ultrasound reconstruction for guidance of the insertion of a popliteal nerve catheter for ankle surgery. This
ultrasound technology is commercially available and is
currently used in cardiac ultrasonography.

CASE REPORT
The criteria for publication and patient care were met by
the Mayo Investigational Review Board. The patient was a
73-year-old woman scheduled for major reconstructive foot
surgery. Informed consent was obtained from the patient for
a continuous popliteal nerve catheter. The nerve block was
performed in the preoperative patient holding area. After
application of standard ASA monitors and administration of
nasal oxygen, the patient was sedated with 1 mg midazolam
and 50 g of fentanyl IV. The block was performed with the
patient in the prone position. A pillow was placed under the
leg to allow for slight knee flexion. 3D ultrasound (3D
Ultrasound System IE-33 with 3-1 Matrix Array Probe,
Philips Medical Systems; Andover, MA) was used during
the procedure for needle guidance, confirmation of the
catheter placement, and imaging of local anesthetic
distribution.
The knee flexor crease was identified and marked. The
borders of the biceps femoris and semitendinosus muscles
Vol. 105, No. 1, July 2007

Figure 1. a, Popliteal fossa imaged with 3D ultrasound from the posterior to anterior approach. Arrows identify the popliteal
catheter (after needle removal) in long axis coursing towards the sciatic nerve seen in short axis. Figures 1b and 1c are
developed upon rotating the image using the electronic processor-derived rotation of the image in real time. b, Popliteal fossa
imaged with 3D ultrasound from the posterior aspect of the knee as in Figure 1a. This image has now been electronically
rotated to allow for visualization of the sciatic nerve in long axis. The nerve is seen in its entire thickness. The peripheral nerve
catheter is seen partially transected as it courses to the popliteal nerve. The catheter has been injected with 10 mL of local
anesthetic. c, Transducer location has remained as in Figures 1a and 1b. The image is rotated again to a new vantage point
electronically with 3D reconstruction. In this orientation, the catheter is seen fully in short axis with anesthetic deposition seen
surrounding the catheter. Below the catheter, the popliteal nerve bundle is also seen in short axis with further deposition of
anesthetic seen below the nerve. Twenty mL of local anesthetic has been deposited.

were marked 8 cm above the knee crease. A line was drawn

between the two muscles. The midline point of this line was the
point of needle insertion. 3D ultrasound scanning confirmed
the presence of the popliteal nerve at a depth of 3 cm from the
skin at the surface mark. The 17-gauge, 50-mm Arrow continuous peripheral block needle was directed cephalad toward
the nerve at an 80 degree angle to the skin under continuous
ultrasound guidance of the needle. As the needle approached
the nerve, 2 Hz electrical stimulation was initiated at 1.5 mA.
Ultrasound was used to guide the needle to the popliteal sciatic
nerve. After obtaining toe flexion at 0.5 mA, a 19-gauge
stimulating catheter (Stimucath, Arrow International, Reading, PA) with an embedded wire to enhance echogenicity was
inserted 5 cm past the tip of the needle with electrical stimulation guidance. The 3D ultrasound demonstrated the catheter
to be in close proximity to the nerve (Fig. 1a).
Under 3D ultrasound visualization, the initial injection of
local anesthetic (3 mL followed by 7 mL of 0.5% ropivacaine)
was observed to lie posterior to the nerve (Fig. 1b). Continuous injection of local anesthetic revealed complete encircleVol. 105, No. 1, July 2007
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ment of the nerve (Fig. 1c). Subsequent clinical examination

revealed anesthesia in the sciatic distribution of the leg. A
saphenous nerve block at the knee was added to complete
the leg anesthesia. The patient was taken to the operating
room and underwent uneventful surgery.

DISCUSSION
3D ultrasound images are a significant advance in
digital ultrasound image processing. This technology
has allowed the cardiac sonographers to better define
valvular pathology as well as the size and function of
cardiac chambers with improved definition of detail (6).
3D image reconstruction that required 20 min in the past
can now be completed in real-time as demonstrated in
this case report.
The 3D ultrasound transducer used for our patient
was the first generation device that was designed for
2007 International Anesthesia Research Society

273

deep penetration of tissues and 3D cardiac reconstruction using frequencies of 13 MHz range. Second
generation 3D transducers use frequencies of 27
MHz, which are better suited for common neural
structures. Commercial vendors are customizing these
systems for regional anesthesia blockade. The ease of
use of these systems and improved image quality will
follow rapidly. It should also be appreciated that
while imaging in 3D, the clinician can at any time
rapidly revert to standard 2D images. Although the
application of 2D ultrasound to peripheral neural
blockade is well established, we believe 3D application will further enhance the use of ultrasound in
conjunction with regional anesthetic techniques.

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Case Report

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