Atlas of Pain Injection Techniques

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Atlas
of Pain
Injection
Techniques
SECOND EDITION

Therese C. O’Connor MB FFARCSI

Consultant Anesthetist, Pain Specialist
Sligo Regional Hospital
Ireland

Stephen E. Abram MD
Professor, Department of Anesthesiology
Medical College of Wisconsin
Milwaukee, WI, USA
an imprint of Elsevier Limited
© 2014, Elsevier Limited. All rights reserved.

First edition 2003

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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to
be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

ISBN: 9780702044717
Ebook ISBN: 9780702050343

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 vii

Dedication

For my Parents
Therese C. O’Connor
To my teachers, my colleagues, my patients and my family
Stephen Abram
 ix

ACKNOWLEDGMENT

I would like to acknowledge Florence Grehan, photographer, and the nursing staff of the Day Services Unit,
Sligo Regional Hospital.
Therese C. O’Connor

PREFACE TO THE FIRST EDITION
While the role of anesthesiologists in the management of
patients with severe or intractable pain has expanded
dramatically in the past few decades, it has traditionally
been anesthesiologists’ ability to use regional anesthetic
techniques both diagnostically and therapeutically that has
made their contributions to pain medicine unique. This
textbook emphasizes those regional anesthetic techniques
that have been included in the anesthesiologist’s
armamentarium for many years. In recent years, there have
been dramatic advances in the technology of pain
management interventions. These include implantable drug
delivery devices, radiofrequency and cryoanalgesia
neuroablation techniques, spinal cord and peripheral nerve
stimulators, percutaneous nucleoplasty, annuloplasty and
vertebroplasty devices. Despite these innovations, there is
still a substantial role in acute, chronic and cancer pain
management for many of the older, more conventional
regional anesthetic techniques.
Nerve blocks play a variety of roles in the management of
pain. For acute postoperative or post-traumatic pain, they
may be continued throughout the most painful interval,
serving as the sole analgesic technique or as adjunctive
measures, reducing the need for opioids and other systemic
analgesics. For patients with chronic or cancer pain, they
may provide long-term benefit by reducing nociceptive
inputs to sensitized regions of the spinal cord or brain.
They provide periods of antinociception that facilitate
physical therapy and reconditioning. Combined with
corticosteroids, they reduce neural inflammation and
xi
produce neuronal membrane stabilization. They provide
diagnostic information regarding sites and mechanisms of
pain. Joint and muscular injections also provide an
important contribution to the diagnosis and management
of chronic pain. In the cancer patient, neurolytic
procedures may provide extended periods of interruption
of the most active sources of nociception. Long-term
infusions of local anesthetics, often combined with opioids
and other analgesic agents, can provide weeks to months
of relief when systemic analgesics have failed.
Our aim in embarking on the preparation of this atlas was
to provide a description of many of the basic regional
anesthetic tools and the common joint and muscular
injections that may be of benefit to patients with persistent
or severe pain. It is unusual for these procedures to be
curative on their own. Their value lies in their rational use
in combination with other management techniques,
including, but by no means limited to, physical therapy,
exercise, psychotherapy, and systemic medication. All
chapters in the book have been written to a template
taking the reader through each block in a consistent and
easy-to-follow way. Step-by-step illustrations accompanied
by photographs are used to teach technique within the
context of the surrounding anatomical structures and we
have also highlighted where injections can go wrong and
offered advice on how to avoid problems. It is our hope
that this atlas will fulfill our aim of providing a strong
foundation of regional anesthetic techniques in the
treatment of pain.
 MECHANISMS OF PAIN
TRANSMISSION—AN
OVERVIEW OF ANATOMY
AND PHYSIOLOGY
The term pain is used to define sensations that hurt or are
unpleasant. There are, however, different types of pain.
Pain following injury can be considered to have a useful
protective function by rendering the injured area
hypersensitive to external stimuli. Specific groups of
primary sensory neurons carry stimuli defining the quality,
duration and intensity of noxious stimuli from injured
tissue. Their organized projections to the spinal chord or
trigeminal nucleus mean that the origin of the stimuli can
be precisely located. This somatic pain is often termed
“ouch” pain and is usually associated with acute, direct
injury to tissue. It arises from structures that are innervated
by somatic nerves, e.g. muscle, skin, synovium, and
periosteum. Thus the pain is usually easily localized to the
distribution of the nerve supplying the injured area, and is
often sharp and intense.
On the other hand, pain arising from visceral organs is
poorly localized. It may be appreciated as being deep in the
body, often arising from the midline, or may be referred to
distant structures. The reason for this is that visceral
sympathetic afferents converge on the same dorsal horn
neuron as do somatic nociceptive afferents, and both of
these stimuli travel to the brain via the spinothalamic
pathways. Thus, pain is appreciated in the cutaneous area
corresponding to the dorsal horn neuron upon which the
visceral afferents converge, accompanied by allodynia and
hyperalgesia in this dermatome. As a result, reflex somatic
motor activity may result in the spasm of muscles.
Consequently, cutaneous nociceptors may be stimulated,
which may be partly responsible for referred pain. In
addition, there is considerable branching of peripheral
visceral afferents with resulting overlap in the territory of
individual dorsal roots. Compared with somatic nociceptor
fibers, only a small number of visceral afferents converge
on dorsal horn neurons. This overlap, combined with
convergence of visceral afferents on the dorsal horn over a
wide number of segments, means that visceral pain is
usually dull, vague, and very often poorly localized.
While damage to cutaneous or deep tissue is usually
associated with inflammation of that tissue, neuropathic
1 
pain is significantly influenced by pathologic changes in
peripheral nerve function. Thus neuropathic pain can
persist long after the original injury has healed. Pathologic
peripheral nerve changes include generation of spontaneous
neural inputs, neuroma formation and regeneration of
nerves. An injured nerve may become mechanically
sensitive, and mild pressure or traction may produce bursts
of rapid firing followed by many minutes of after-
discharge, perceived as pain in the affected root. With
time, the dorsal horn pain projection cells (wide dynamic
range neurons) may attain lower thresholds and expanded
receptive fields, adding to the traffic from pain fibers.
The character of the pain varies and typically may be
throbbing, shooting, lancinating, burning or freezing.
Recently, it has become apparent that the receptive-field
properties of dorsal horn neurons are not fixed or hard-
wired, but can change. The reason for this is that sensory
input from primary sensory fibers and interneurons onto
spinal neurons is normally too low in amplitude to
generate an action-potential discharge in the postsynaptic
cell. A temporal or spatial summation of postsynaptic
action potentials is required to exceed the threshold of the
cell. The center of the receptive field usually constitutes the
firing zone, where an adequate stimulus will generate an
action-potential discharge in the cell. Surrounding this
firing zone is the subliminal zone; a peripheral stimulus
evokes a response that is subthreshold. Changes may occur
in the area because an increase in excitability of a neuron
can convert a previously subthreshold input into a
suprathreshold response, leading to receptive-field
plasticity, or central sensitization. Thus, afferent barrages
of high-frequency C fiber activity can generate changes
in sensory processing in the spinal cord, leading to a
hyperalgesic state.
Careful investigation of the likely neurologic basis of each
patient’s pain may help in its treatment; thus whenever
possible the following aspects should be determined: site(s),
character, radiation, temporal pattern, factors increasing or
decreasing pain, and associated factors. An attempt should
be made to determine if the pain is somatic, visceral or
 1 
CHAPTER
2
Mechanisms of pain transmission—an overview of anatomy and physiology
neuropathic in origin, so that a rationale for treatment may
be planned.
In addition, it should be remembered that there are other
factors that determine an individual’s level of pain
perception. Psychologic factors are as important as sensory
factors in determining pain perception and are more
important in their contribution to suffering. Various
responses to painful conditions exist, but depressive
features tend to predominate in patients with chronic pain.
Analysis of the patient from a psychologic perspective will
provide a more thorough understanding of the patient’s
pain complaint and the ramifications thereof. Being attuned
to psychologic issues will enable the physician to plan and
execute a more comprehensive treatment plan. The
relationship between depression, anxiety and pain is
circular or reciprocal, rather than linear. The existence of
pain often has detrimental effects on the patient’s mood,
increasing feelings of anxiety or depression. The
development of depression or anxiety can exacerbate the
experience of pain.
There have also been many reports about the perception
and communication of pain, and its treatment may be
influenced by sociodemographic factors. These include
ethnicity and cultural background, as well as gender, age,
education, and socioeconomic class.
It is therefore important to approach the management of
pain bearing foremost in the mind the varying influences
on perception of pain.
On the other hand, repeated blockade of sympathetic
activity with local anesthetic has been shown to reduce the
severity of sympathetically maintained pain. Visceral pain
may also be reduced by local anesthetic blockade of
visceral afferent fibers that accompany the sympathetic
efferents. However, the result is short-lived if pathology
remains that will cause continued stimulation; for example,
carcinoma of the head of the pancreas causes pain
mediated through the celiac plexus. In these cases it is
reasonable to consider neurolytic visceral afferent blockade
for pain relief.
It has been demonstrated that locally applied
corticosteroids prevent development of ectopic discharge
and suppress ongoing discharge of injured nerves. Thus in
the patient with chronic nerve pain, it is reasonable to
consider injection of corticosteroid at the site of injury to a
nerve, e.g. epidural or nerve root injection for nerve injury
due to intervertebral disc pathology.
Degeneration and inflammation of joints can produce pain
that is usually somatic in character, although this may
sometimes be difficult to distinguish from neuropathic
pain; for example, facet joint pain may be very similar to
radicular pain. Joint arthropathy as a cause of pain can be
confirmed by injection of local anesthetic into the joint.
Addition of corticosteroid to the local anesthetic has been
shown to decrease inflammation in the joint and thereby
reduce pain.
The myofascial syndrome is a very common cause of
somatic pain. It is associated with marked tenderness of
discrete points (trigger points) within affected muscles, and
with pain that is often referred to an area some distance
away. In addition, the affected areas may have the
appearance of tight, ropey bands of muscle with associated
autonomic changes such as vasoconstriction. Biopsies of
such trigger points can show degenerative changes
corresponding to the severity of pain (or can show little or
no change at all). The most important aspect of the
treatment of myofascial pain is to regain the length and
elasticity of affected muscles. This is best achieved by
physical maneuvers that stretch muscle. However, these
maneuvers are often painful and may worsen muscle
contraction. Therapy aimed at reducing pain and sensitivity
in muscles is best instituted prior to stretching exercises.
Trigger-point injections—injection of local anesthetic
directly into the trigger point—can confirm the diagnosis of
myofascial pain and a series of injections can markedly
reduce muscle sensitivity. These injections, combined with
stretching exercises, can produce significant analgesia for
myofascial pain.
 JOINT INJECTIONS
2 
2.1 LUMBAR FACET JOINT INJECTION

Anatomy
The zygopophyseal or facet joints (Fig. 2.1.1) are paired
articular surfaces between the posterior aspects of
adjacent vertebrae. In the cervical region, rotation and
flexion are possible as the joint surfaces lie midway
between the coronal and the axial planes. Rotation is
prevented in the lumbar region but flexion is possible as
Lumbar vertebra
Superior facet
the anterior portion of the lumbar facet joints lie in the
coronal plane and the posterior portions in the sagittal
plane. In the thoracic region, the joints’ inferior and
superior articular surfaces overlap each other in an almost
vertical incline.
The facet joints bear most of the shear forces when the
spine is flexed. In addition, when the intervertebral discs
are degenerated, the facet joints carry increased load and
weight, especially when the spine is extended. Innervation
of the facet joints is via the medial branches of the
dorsal rami of the spinal nerves. These nerves also
innervate the muscles and ligaments surrounding the joints.
Each medial branch divides into proximal and distal
branches (Fig. 2.1.2). The proximal branch innervates the

Articular surfaces
of facet joints
Superior Inferior oblique Lateral
Mb
A Inferior facet
Lb
Ppr

SvN
Sn

Gr
Medial branch Intervertebral disc

Fig. 2.1.2  Lumbar spine innervation. Innervation of the lumbar

spinal structures in the transverse view. Note the posterior primary
ramus (Ppr) leaving the spinal nerve (Sn) and splitting into a  
lateral branch (Lb) and a medial branch (Mb). The medial branch
Zygopophyseal passes under the mamillo-accessory ligament to innervate the  
joint facet joint and capsule, the spinous process and the multifidus
muscles. Sensory fibers traveling with the gray rami (Gr) form the
sinu-vertebral nerve (SvN) and provide sensory function to  
the disc annulus. (Reproduced with permission from  
B Cousins and Bridenbaugh’s Neural Blockade in Clinical
Anesthesia and Management of Pain, 4th edition,
Fig. 2.1.1  Wolters Kluwer/Lippincott Williams & Wilkins, 2009.)
 2 
CHAPTER
4
Joint injections
adjacent facet joint, and the distal branch innervates the
next facet joint below. The medial branch also innervates
the interspinous ligaments and the multifidus muscles and
the lateral branch innervates other adjacent muscles. Thus,
pain from irritation of a joint may cause generalized
sensitization of the dorsal rami with secondary
hyperactivity and spasm of the innervated muscles and may
be difficult to localize.
The facet joints contain vascular, highly innervated
intra-articular synovial inclusions, which may
become trapped and inflamed when the joint is injured,
causing pain.
Equipment
• 2 ml and 10 ml syringes
• 25 G needle
• 22 G spinal needle, end-opening
• Non-ionic radio-opaque contrast medium
• ECG, BP, and SpO2 monitors
• Resuscitation equipment (see Appendix 3)
• C-arm fluoroscopy or ultrasound
Drugs
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
25 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3)
Position of patient
• Prone.
• Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 2.1.3).
Fig. 2.1.3 
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The lumbar midline and an area 10 cm × 5 cm laterally
is cleaned with antiseptic solution.
• The spinous processes of the vertebrae are marked.
• The insertion point of the needle lies 2–3 cm lateral to
the cephalic end of the spinous process of the vertebra
(Fig. 2.1.4 a,b).
• C-arm fluoroscopy is positioned at an angle of about
30°, tilted towards the side of the joint to be injected.
The angle is adjusted until the joint is well visualized. A
radio-opaque object, e.g. the tip of a hemostat, is
positioned over the joint and the skin is marked.
• Thereby, with the aid of fluoroscopy, the insertion point
is identified.
• A skin wheal is raised and the area is infiltrated with
lidocaine (lignocaine) 1%.
• A spinal needle is introduced in a vertical direction to
the skin, until the needle is observed to enter the joint
space, preferably near the lowest aspect of the joint
(inferior recess). Confirmation of intra-articular
placement is made by observation of the needle tip
remaining on the joint line as the fluoroscope is rotated
laterally (Fig. 2.1.5).
• After negative aspiration, 0.5 ml of non-ionic radio-
opaque contrast medium (that is compatible with nerve
tissue) is injected.
• The correct placement is indicated by outlining the joint
with non-ionic radio-opaque contrast medium, visible
on anteroposterior and oblique views (Fig. 2.1.6 a,b).
 5
2.1  •  Lumbar facet joint injection

A B

Fig. 2.1.4 

Ultrasound may also be helpful in identifying the facet

joint (Fig. 2.1.7).
• When the correct placement of the needle is confirmed,
lidocaine (lignocaine) 1% 0.5 ml plus corticosteroid, e.g.
triamcinolone diacetate 25 mg, may be injected and the
needle removed while clearing with lidocaine
(lignocaine) 1% 1 ml.

Confirmation of a successful injection

• Relief of pain.

Tips
• Care must be taken to inject only a small amount of
volume as described above. A total volume of more than
1 ml may damage the joint. If the joint is disrupted
anteriorly, drug may spread to the epidural space.

Fig. 2.1.5 
 2 
CHAPTER
6
Joint injections

Potential problems Lumbar Facet Nerve Injection

• Solution may spread to the epidural space via the • Facet nerve injection may be carried out by placing a
anteromedial capsule. spinal needle at the point where the superior articular
• Nerve root injection. and transverse processes join as the median branch
passes over the cephalad edge of the transverse process
(Fig. 2.1.8).
• The direct posterior approach should be avoided as the
needle placement may be obstructed by the superior
portion of the facet joint.
• Approach to the target site from a lateral oblique angle
30° to skin is recommended.
• The needle is advanced towards the target site (the
posterior-superior edge of the transverse process) until
bone is encountered.
• It is recommended that the transverse process be
approached first, to determine depth.
• The needle is then repositioned medially until the lateral
edge of the facet joint is reached.
• The needle is then moved superiorly until it just “falls
A off” the superior edge of the transverse process (Fig.
2.1.9).
• The optimum position is obtained by repositioning the
needle to the postero-superior edge of the transverse
process.
• The patient may now report reproduction of back pain.
• Injection of lidocaine (lignocaine) 1% 0.5 ml plus
triamcinolone diacetate 25 mg may be carried out for
therapeutic effect. Diagnostic blockade may be
unreliable as anesthesia of a facet joint means that both
nerves supplying the joint should be blocked. However,
this means that the joint above and the joint below will
also be partially blocked and therefore diagnosis of pain
in a particular joint using nerve block is not feasible.

B
Potential problems
• The same potential problems may occur as described for
Fig. 2.1.6  lumbar facet joint injection (see above).
 7
2.1  •  Lumbar facet joint injection

A B

Fig. 2.1.7  A High-resolution sonogram (15-MHz linear transducer) of vertebral bone L3 immersed in water in the cross-axis view.
B Corresponding anatomic cross-sectional cadaver preparation. Circles indicate targets. ESM erector spinae muscle; N needle; PM
psoas muscle; SAP superior articular process; SC spinal channel; TP transverse process; VB vertebral body. (From Greher M, Scharbert
G, Kamolz LP, et al, Ultrasound-guided lumbar facet nerve block: a sonoanatomic study of a new methodologic approach.
Anesthesiology 2004; 100:1242–8 © 2004 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.)

Mb

Fig. 2.1.8  Fig. 2.1.9 

 2 
CHAPTER
8
Joint injections

2.2 CERVICAL FACET JOINT INJECTION

Anatomy
The anatomy relevant to injection of the cervical facet
joints is similar to that relevant to the lumbar facet joints.
The cervical facet joints below the C2–3 level are
innervated by the medial branches of the cervical posterior
primary rami. These divide into lateral and medial
branches after leaving the posterior spinal canal and the
splenius capitis muscles cover the medial branch
posteriorly. The medial branches lie in close proximity to
the vertebral artery and the epidural space is in close
proximity to the anterior joint capsule (Fig. 2.2.1). The
C2–3 facet joint is innervated by the medial branch of the
third occipital nerve, which travels beneath the tendonous Medial branch
origin of the splenius capitis muscle where it may be
accessed for local anesthetic blockade (Fig. 2.2.2).

Equipment
• 2 ml and 10 ml syringes
• 25 G needle
• 22 G spinal needle, end-opening
• Radio-opaque contrast medium
• ECG, BP, and SpO2 monitors Vertebral artery
• Resuscitation equipment (see Appendix 3)
Fig. 2.2.1 
• C-arm fluoroscopy or ultrasound

Drugs
• Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate Splenius capitus
25 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3) Vertebral
artery

Position of patient
• Prone.
• Neck slightly flexed (Fig. 2.2.3).
C2–3 joint
Needle puncture and technique
3rd
Caution: injection of 0.5–1 ml of lidocaine (lignocaine) occipital
1% into the vertebral artery may result in immediate nerve
convulsion and/or loss of consciousness with possible
cardiovascular system (CVS) collapse.
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The cervical midline and an area of 7 cm × 5 cm
laterally is cleaned with antiseptic solution.
• The spinous processes are marked. Fig. 2.2.2 

Fig. 2.2.3 
Fig. 2.2.4  Fig. 2.2.5
• The insertion point of the needle lies 2–3 cm lateral to
the cephalic end of the spinous process of the vertebra
(Fig. 2.2.4).
• C-arm fluoroscopy is positioned at an angle of about
30°, tilted towards the side of the joint to be injected.
The angle is adjusted until the joint is well visualized.
A radio-opaque object, e.g. the tip of a hemostat, is
positioned over the joint and the skin is marked.
• Thereby, with the aid of fluoroscopy, the insertion point
is identified.
• A skin wheal is raised and the area is infiltrated with
lidocaine (lignocaine) 1%.
• A spinal needle is introduced in a vertical direction to
the skin, until the needle is observed to enter the joint
space (Fig. 2.2.5). Confirmation of intra-articular
placement is made by observation of the needle tip
9
2.2  •  Cervical facet joint injection
 
remaining on the joint line as the fluoroscope is rotated
(Fig. 2.2.6) or on ultrasound.
• After negative aspiration, 0.5 ml of non-ionic radio-
opaque contrast medium (that is compatible with nerve
tissue) is injected.
• The correct placement is indicated by outlining the joint
with non-ionic radio-opaque contrast medium, visible
on anteroposterior and oblique views.
• When the correct placement of the needle is confirmed,
lidocaine (lignocaine) 1% 0.5 ml plus corticosteroid, e.g.
triamcinolone diacetate 25 mg, may be injected and the
needle removed while clearing with lidocaine
(lignocaine) 1% 1 ml.
Confirmation of a successful injection
• Relief of pain.
 2 
CHAPTER
10
Joint injections
Fig. 2.2.6  Fig. 2.2.7
Tips
• Care must be taken to inject only a small amount of
volume, as described above. A total volume of more
than 1 ml may damage the joint. If the joint is disrupted
anteriorly, a drug may spread to the epidural space.
Potential problems
• Solution may spread to the epidural space via the
anteromedial capsule.
• Nerve root injection.
• Intrathecal injection resulting in spinal anesthesia may
occur if local anesthetic is inadvertently injected into
the nerve root sleeve. Prompt recognition of this
complication is vital during cervical procedures, because
the patient’s breathing may be arrested and there may be
immediate convulsion and/or loss of consciousness with
CVS collapse requiring immediate resuscitation. In
addition, the patient’s head should be immediately
elevated after the injection to ensure that the lidocaine
(lignocaine) flows inferiorly. Some practitioners elevate
the head of the table during all cervical injections to
help prevent this complication. Intravenous injection
may be harmless, but it results in a suboptimal or
false-negative result.
• Intra-arterial injection may result in immediate
convulsion and/or loss of consciousness with possible
CVS collapse. Intrarterial injection can be dangerous if
the agent is injected into the vertebral artery or radicular
branches that enter the neural foramina at various levels
3rd occipital
branch
Medial branch
 
and, rarely, persisting paraplegia or paraparesis have
been reported after cervical facet joint injection or nerve
root block. These complications may be due to
embolism from intra-arterial injection of particulate
corticosteroid. However, even when contrast injection
prior to steroid infiltration confirms extravascular needle
placement, nerve damage may occur, which suggests an
alternative cause for the complication, such as
vasospasm or direct arterial injury from the needle-tip.
Regardless of the cause, contrast injection is
recommended to at least potentially reduce the risk of
intravascular injection. Ultrasound will have limitations
in this regard.
• Hematoma may occur (avoid performing block on
patients who have coagulopathy).
CERVICAL FACET NERVE INJECTION
• Facet nerve injection may be carried out by placing a
spinal needle at the point where the superior articular and
transverse processes join as the median branch passes over
the cephalad edge of the transverse process (Fig. 2.2.7).
• The direct posterior approach should be avoided as the
needle placement may be obstructed by the superior
portion of the facet joint.
• Approach to the target site from a lateral oblique angle
30° to the skin is recommended.
• The needle is advanced towards the target site (the
posterior–superior edge of the transverse process) until
bone is encountered.
• It is recommended that the transverse process be
approached first, to determine depth.

• The needle is then repositioned medially until the lateral
edge of the facet joint is reached.
• The needle is then moved superiorly until it just “falls
off” the superior edge of the transverse process.
• The optimum position is obtained by repositioning the
needle to the posterosuperior edge of the transverse
process.
• The patient may now report reproduction of back pain.
11
2.2  •  Cervical facet joint injection
• Injection of lidocaine (lignocaine) 1% 0.5 ml plus
triamcinolone diacetate 25 mg may be carried out for
therapeutic effect. Diagnostic blockade may be
unreliable as anesthesia of a facet joint means that both
nerves supplying the joint should be blocked. However,
this means that the joint above and the joint below will
also be partially blocked and therefore diagnosis of pain
in a particular joint using nerve block is not feasible.
 2 
CHAPTER
12
Joint injections

2.3 SACRO-ILIAC JOINT INJECTION

Anatomy • 22 G spinal needle, end-opening

The surfaces of the sacrum and ilium form a synovial joint,
the sacro-iliac joint. Ligaments and connective tissue
surround the joint, conferring stability and preventing
excessive movement of the joint (Figs 2.3.1, 2.3.2). The
joint is innervated by L4, L5, S1 (the superior gluteal
nerve), S2, and L3. Localization of the pain is therefore
difficult due to this wide nerve supply to the joint.
Equipment
• 2 ml and 10 ml syringes
• 25 G needle
• Radio-opaque contrast medium
• ECG, BP, and SpO2 monitors
• Resuscitation equipment (see Appendix 3)
• C-arm fluoroscopy or ultrasound
Drugs
• Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
25 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3)
Position of patient
• Prone.
• Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 2.3.3).

Needle puncture and technique

Disaligned joint
with pressure • Intravenous access is inserted.
• Monitors are attached.
Posterior • Resuscitation equipment and drugs are checked and
sacro-iliac made ready for use.
ligament
• The sacral area is prepared antiseptically.
• An AP image is obtained, centered over the joint to be
injected.
• Two joint lines are observed. The posterior joint line is
located more medial in a direct AP view (Fig. 2.3.4a).
Sacrospinalis muscle The image intensifier (positioned above the patient) is
Fig. 2.3.1  rotated toward the opposite side until the two joint lines

Fig. 2.3.2  Fig. 2.3.3 


A Ilium
Fig. 2.3.4  Fig. 2.3.6
are superimposed (usually about 10–20°) (Fig. 2.3.4b).
The skin is marked and a skin wheal is raised. The area
is infiltrated with lidocaine (lignocaine) 1% over the
joint line 1 cm above the most caudal point of the joint.
• A 22 or 25 G 3½ in spinal needle is advanced no more
than 1 cm into the joint. Some resistance is usually felt
as the needle contacts the joint.
• A lateral view is then obtained. The needle should
traverse no more than half the distance across the
sacrum, and should never be advanced beyond the
anterior cortex.
• Contrast dye, 0.5 to 1 ml, may be injected to ensure
intra-articular spread. Intravascular injection is best
detected during “live” fluoroscopy injection. In the AP
view, dye should be seen within the joint space. Some
13
2.3  •  Sacro-iliac joint injection
Spine of
sacrum
Sacro-iliac Sacrum
joint
Fig. 2.3.5 
Needle
Sacro-iliac joint injection
 
extravasation outside the joint is common. If extensive,
the needle should be repositioned.
• 1–2 ml lidocaine 1% is injected alone for diagnostic
purposes. Reproduction of the patient’s pain during
needle positioning and injection as well as pain relief
following the block will help confirm the sacro-iliac
joint as the pain generator (avoid sedation with opioids
for diagnostic procedures).
• Corticosteroid, e.g. triamcinolone diacetate 25 mg, plus
1–2 ml 1% lidocaine may be injected for therapeutic
effect.
• Ultrasound may also be used to identify the joint
(Fig. 2.3.5).
• CT scan may also be used to identify the joint but is not
usually necessary (Fig. 2.3.6).
 2 
CHAPTER
14
Joint injections

Confirmation of a successful injection
• Reproduction of pain during injection and relief of pain
following injection confirms correct placement.
• Radiologic assessment of the X-ray image after injection
of contrast medium may demonstrate tears in the joint
capsule.
Tips
• While the joint may be easily entered, injection can be
difficult where the joint is heavily invested with
connective tissue and ligaments. This is especially true in
elderly patients, where the joint is rigid and the joint
space cannot expand to accommodate a volume of
liquid. In such cases it may be possible to inject only as
the needle is being removed from the joint.
• Sometimes, injection into the deep sacro-iliac ligaments
around the joint may be helpful for pain relief.
Introduction of a spinal needle just above the midline
of the upper sacrum and advanced at 45° to the
skin, under the rim of the ilium and in the direction
of the joint, will access these ligaments. Lidocaine
(lignocaine) 1% 4 ml plus triamcinolone diacetate
25 mg may then be injected.
Potential problems
• Discomfort on injection.
• Epidural injection.
• Sacral nerve root blockade.
• Subperiosteal injection (painful in the awake patient).
 EPIDURAL INJECTION
Intervertebral disc disease may produce inflammation of
spinal nerve roots, which may be the cause of radicular pain.
The L5 and S1 nerve roots are most commonly affected,
probably because they exit the bony canal through a narrow
lateral bony recess, therefore increasing the likelihood of
nerve compression and irritation. Lumbo-sacral
radiculopathy consists of low-back pain that radiates a
varying distance into the lower extremity, and which may be
associated with motor and sensory loss consistent with
damage to the affected nerve root. If bowel and bladder
symptoms of dysfunction are present, large midline disc
protrusion is suspected and prompt surgical intervention is
indicated. Otherwise, if severe pain exists after treatment
with immobilization and mild analgesics, epidural steroid
injection may be carried out. Similarly, pain of thoracic
3 
or cervical disc origin may respond to epidural steroid
injection.
Triamcinolone diacetate is the most commonly
administered preparation and injection should be carried
out as close to the affected nerve root as possible. Injection
of a small amount of local anesthetic with the steroid will
help to confirm drug placement and provide analgesia. In
patients with S1 pathology the drug may not spread to the
affected nerve root using the lumbar approach and the
caudal approach to the epidural space may be required.
Cervical epidural injection accesses the cervical spinal nerve
roots, while in the thoracic region a paramedian approach
is usually more successful.
 3
CHAPTER
16
Epidural injection

3.1 LUMBAR EPIDURAL BLOCK

Anatomy Drugs
Structures encountered when inserting an epidural needle • Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
include skin, subcutaneous tissue, supraspinous ligament, • Corticosteroid if indicated, e.g. triamcinolone diacetate
interspinous ligament, ligamentum flavum (5–6 mm thick 50 mg (or its equivalent)
in the midline of the lumbar region, 3–5 mm thick in • Saline (NaCl) 10 ml
the midline of the thoracic region), prior to reaching the • Resuscitation drugs (see Appendix 3)
epidural space itself (Fig. 3.1.1). Beyond this space lies
the dura mater, the arachnoid mater and intrathecal space
containing the cerebrospinal fluid. The spinal cord usually
ends at the L2 level (Fig. 3.1.2).
One should expect a distance of 3.5–6 cm from skin to the 1
1
epidural space using a midline approach. In the lumbar C1
2 2
region the spinous processes are generally perpendicular to 3 3
the vertebral bodies (Fig. 3.1.3). In the thoracic region the 4
4
5
spinous processes lie at an angle of 30–45° to the thoracic
6 5
vertebral body, thus making midline epidural injection a 7 6
little more difficult, and sometimes necessitating a 8
7
C7 1
paravertebral approach. Other relevant anatomy of the 1
2
vertebral bodies is illustrated in Fig. 3.1.4. T1
3
2
4
3
Equipment 5
4
• 2 ml and 10 ml syringes 6
5
• 18 G, 20 G, and 25 G needles 7
6
• ECG, BP, and SpO2 monitors
8 7
• 18 G epidural set (Fig. 3.1.5)
• Filter aspiration needle 9
8

• Resuscitation equipment (see Appendix 3) 10

9
• Fluoroscopy (optional) 10
11
• Ultrasound (optional)
12 11
1
Subcutaneous Epidural Ligamentum 12
5
tissues space flavum
1
1
5

L1 2

5
S1
1
2
3
4
Supraspinous Interspinous 5
Skin ligament ligament

Fig. 3.1.1  Fig. 3.1.2 

 17
3.1  •  Lumbar epidural block

Superior
articular process
(a) Cervical
Pedicle
Transverse process

Spine

Inferior articular
(b) Thoracic Facet process
Facet

Superior articular
process

Transverse process
(c) Lumbar
Inferior articular
process

Lamina
Inferior and superior
articular facets

Fig. 3.1.3 
Transverse
process

Position of patient Pedicle

• Lateral, usually lying on the side of the radiculopathy. Vertebral

• Shoulders and buttocks parallel to the edge of the bed, foramen
perpendicular to the floor, with spine flexed.
Fig. 3.1.4 
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The midline and an area 10 cm × 5 cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
• Lidocaine (lignocaine) 1% 2 ml is drawn up into three
2 ml syringes.
• Lidocaine (lignocaine) 1% 2 ml, plus corticosteroid, e.g.
triamcinolone diacetate 50 mg is drawn up into the
10 ml syringe.
• NaCl 10 ml is drawn up into the 10 ml loss-of-
resistance syringe.
Fig. 3.1.5 
• The iliac crest is palpated and the intercrestal line (this
corresponds with the inferior aspect of the spinous
process of L4 or may lie in the L4–5 interspace) is
MIDLINE APPROACH FOR
identified (Fig. 3.1.6). THE RIGHT-HANDED OPERATOR
• The spinous processes are palpated, and the level With the left hand
requiring injection is identified. • The fore- and middle fingers are placed each side of the
• This may be confirmed by fluoroscopy or ultrasound. interspace.
 3
CHAPTER
18
Epidural injection

Vertebra
prominens C7

Root of spine
of scapula T3

Inferior angle
of scapula T7

Rib margin 10cm

from midline L1

Superior aspect
of iliac crest L4 B

Fig. 3.1.7 
Posterior superior
iliac spine S2

• The needle is slowly and carefully advanced, while

Fig. 3.1.6  aiding the advance, while at the same time applying a
• These fingers are kept in place until the epidural needle
is gripped by the interspinous ligament.
With the right hand
• The interspinous ligament is infiltrated with lidocaine
(lignocaine) 1% 2 ml.
• The epidural needle is inserted, bevel facing the side of
the radiculopathy, between the fore- and middle fingers
of the left hand in a direction 60° cephalad,
perpendicular to the spine, parallel to the floor, until it
is gripped by the interspinous ligament (Fig. 3.1.7 a,b).
In the case of thoracic epidural injection (midline
approach), the point of entry of the needle should be as
close as possible to the caudal end of the interspinous
space and the needle directed 30–45° cephalad to enter
between the spinous processes.
• The hub of the needle is gripped with the fore- and
middle fingers of the left hand and this hand is steadied
by leaning the wrist against the patient’s back.
• The stylet is removed and the loss-of-resistance syringe
is applied.
constant pressure is applied to the plunger, the left hand
brake if required (Fig. 3.1.8 a,b).
• At the point at which the needle enters the ligamentum
flavum, absolute resistance to injection is experienced.
• At this point the needle is advanced very slowly until a
sudden loss of resistance to the pressure on the plunger
is experienced, the point at which the epidural space is
entered.
• After negative aspiration for blood or cerebrospinal fluid
(CSF), lidocaine (lignocaine) 1% 3 ml is injected.
• After 5 minutes the patient is questioned about any
changes in sensation or power, and any changes in heart
rate or blood pressure are noted.
• If the injection is for diagnostic purposes only, the
needle may be removed at this point.
• If therapeutic effect is required, lidocaine (lignocaine)
1% 2 ml, plus corticosteroid if indicated, e.g.
triamcinolone diacetate 50 mg (or its equivalent), may
be injected. Alternatively, a catheter may be inserted
through the needle if indicated.
• The needle is flushed with NaCl 1 ml and removed.
• The patient is allowed to lie in the lateral position, on
the side of the pain.
 19
3.1  •  Lumbar epidural block

Fig. 3.1.9 

Fig. 3.1.8 

• Monitors should be left attached and i.v. access left in

situ for at least 30 minutes.
• The patient is advised to contact the hospital should the
anesthesia remain after several hours.
FLUOROSCOPIC GUIDED LUMBAR
EPIDURAL INJECTION
• Position the patient prone with a pillow under the lower
abdomen to increase lumbar flexion.
• The interlaminar space for the desired segmental level is
Fig. 3.1.10 
identified fluoroscopically using a straight AP view.
Angling the fluoroscope slightly cephalad may open the
space if it appears very narrow.
• Prepare skin with antiseptic and sterile drape. ligamentum flavum using a loss of resistance technique
• Raise a local anesthetic skin wheal just below the with air or saline. Once loss of resistance is achieved,
interlaminar space, about 0.5 cm from the midline obtain a lateral view to ensure the needle is barely into
toward the symptomatic side. the bony spinal canal.
• Advance the Tuohy needle, angling slightly toward the • Attach a low volume extension set to the needle,
midline until resistance of the ligamentum flavum is aspirate to ensure there is no blood return, and inject
encountered, keeping the trajectory just lateral to the 0.5–1 ml of non-ionic contrast medium during live
midline to avoid contacting the spinous process. Repeat fluoroscopy. Dye should be seen spreading within the
imaging periodically to ensure that the needle is bony canal (see Fig. 3.1.10). Prior to injecting local
approaching the space, not the lamina or spinous anesthetic or steroid, obtain an AP view to reconfirm
process (see Fig. 3.1.9). Advance the needle through the epidural spread.
 3
CHAPTER
20
Epidural injection

• Aspirate again, then inject local anesthetic (1–2 ml) and

50 mg triamcinolone diacetate or equivalent.
• Loss of resistance is occasionally encountered with the
needle superficial to the epidural space. Dye will be seen
dorsal to the epidural space on the lateral view, and
spread lateral to the spinal canal will be seen on the AP
view. The needle can then be advanced through the
ligamentum flavum, again using loss of resistance,
followed by dye confirmation.

Confirmation of a successful block

• Relief of pain.
• Anesthesia in the distribution of the blocked nerves.
• For lumbar epidural steroid injection, improvement in
Fig. 3.1.11 
straight-leg raising may be evident.

• Injection of radio-opaque dye under direct fluoroscopy

Tips
• Air may be used instead of NaCl to determine loss of
resistance. If this technique is used it is advisable to
avoid constant pressure on the plunger, as the air is
compressible; instead it should be bounced intermittently
with the thumb to test for resistance and loss of
resistance.
• Advocates claim identification of CSF is easier with this
technique.
• Advocates of the use of NaCl point out that absolute
resistance to pressure identifies the ligamentum flavum,
and that by applying constant pressure to the plunger
one can identify loss of resistance earlier, thereby more
easily avoiding the possibility of dural tap.
• An epidural catheter may be inserted through the needle
and the needle removed, taking care not to withdraw
the catheter when removing the needle. However, a test
dose of lidocaine (lignocaine) 1% 4 ml with/without
epinephrine (adrenaline) 1 : 200 000 is given after
insertion, before any injection through the catheter is
carried out.
• Ultrasound may guide the insertion of the needle as
spinous proccesses are easily visible on ultrasound
(optional) (Fig. 3.1.11).
can confirm epidural placement.
• Insertion of a radio-opaque epidural catheter may be
carried out also under fluoroscopy.
Potential problems
IMMEDIATE
• Failure to locate epidural space (sitting position may be
successful).
• Intravascular injection (test dose important); addition of
epinephrine (adrenaline) to test dose may help
identification of intravascular injection.
• Intrathecal injection (test dose important).
• Hypotension due to sympathetic blockade (give i.v. fluid;
consider ephedrine).
• Headache (possible dural puncture).
• Allergic reaction.
LATER
• Infection (epidural abscess; bacterial meningitis).
• Aseptic meningitis; usually a result of intrathecal
injection (test dose important).
• Cushingoid symptoms; usually as a result of repeated
steroid injections.
 21
3.2  •  Thoracic epidural block

3.2 THORACIC EPIDURAL BLOCK

Anatomy Position of patient

In the thoracic region, the spinous processes lie at an angle
of 30–45° to the thoracic vertebral body (Fig. 3.2.1 a,b)
thus making midline epidural injection a little more
difficult, and sometimes necessitating a paramedian
approach (Fig. 3.2.2 a–d).
Equipment
• 2 ml and 10 ml syringes
• 18 G, 20 G, and 25 G needles
• ECG, BP, and SpO2 monitors
• 18 G epidural set
• Resuscitation equipment (see Appendix 3)
• Fluoroscopy or ultrasound (optional)
Drugs
• Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)
• Saline (NaCl) 10 ml
• Resuscitation drugs (see Appendix 3)
• Lateral, usually lying on the side of the radiculopathy.
• Shoulders and buttocks parallel to the edge of the bed,
perpendicular to the floor, with spine flexed.
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The midline and an area 10 cm × 5 cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
• Lidocaine (lignocaine) 1% 2 ml is drawn up into three
2 ml syringes.
• Lidocaine (lignocaine) 1% 2 ml, plus corticosteroid, e.g.
triamcinolone diacetate 50 mg, is drawn up into the
10 ml syringe.
• NaCl 10 ml is drawn up into the 10 ml loss-of-
resistance syringe.
• The spinous processes are palpated, and the level
requiring injection is identified.
• This may be confirmed by fluoroscopy or ultrasound.

T1–4 T5

T6
Lateral Oblique Posterior
C7
C7

T5–8

T10
T10

L3 L3
T9–12

B
A

Fig. 3.2.1 
 3
CHAPTER
22
Epidural injection

Lumbar epidural Thoracic epidural

(a) Midline (b) Paraspinous (a) Midline (b) Paraspinous

L3 1cm T3

T4

L4 T5
10 10 (a) 1cm
L5 25
(a)
(b) 35 (b) T7
45

45
A B 55

C D

Fig. 3.2.2 

Paramedian approach
FOR THE RIGHT-HANDED OPERATOR
With the left hand
• The fore- and middle fingers are placed each side of the
interspace.
• These fingers are kept in place until the epidural needle
is gripped by the interspinous ligament.
With the right hand
• The interspinous ligament is infiltrated with lidocaine
(lignocaine) 1% 2 ml.
• The insertion point of the epidural needle in the
paravertebral approach lies 1 cm lateral to the
midline, at the lower border of the spinous process
(Fig. 3.2.3 a,b). The epidural needle is inserted, bevel
facing the side of radiculopathy, between the fore- and
middle fingers of the left hand, perpendicular to the
spine, parallel to the floor, until it is gripped by the
interspinous ligament.
• The direction of the needle is 130° cephalad and 15°
medial to the midline. Care must be taken as the
ligamentum flavum is not as thick laterally, and may not
be identified as easily. Therefore, it is usually easiest to
first identify the lamina and walk the needle off the
lamina in a cephalad direction until the needle enters the
ligamentum flavum. At that point the loss-of-resistance
technique may be performed.
• The hub of the needle is gripped with the fore- and
middle fingers of the left hand and this hand is steadied
by leaning the wrist against the patient’s back.
• The stylet is removed and the loss-of-resistance syringe
is applied.
• The needle is slowly and carefully advanced until the
osseous endpoint of the lamina is encountered.
• It is then walked off the lamina in the cephalad
direction until it enters the ligamentum flavum.
• At the point at which the needle enters the ligamentum
flavum, absolute resistance to injection is experienced.
• It is then carefully advanced further while constant
pressure is applied to the plunger, the left hand aiding
the advance, while at the same time applying a brake if
required (Fig. 3.2.4, viewed from above).
• The needle is advanced very slowly until a sudden loss
of resistance to the pressure on the plunger is
experienced, the point at which the epidural space is
entered.
• After negative aspiration for blood or cerebrospinal
fluid, lidocaine (lignocaine) 1% 2 ml is injected.
 23
3.2  •  Thoracic epidural block

Transverse
process

Facet
Lamina
Spinous process

Paramedian
approach
(spinal or epidural) Fig. 3.2.4 
15

Midline approach • The patient is advised to contact the hospital should

(spinal or epidural)
A anesthesia remain after several hours.

Confirmation of a successful block

• Relief of pain.
L3
• Anesthesia in the distribution of blocked nerves.
• For lumbar epidural steroid injection, improvement in
straight-leg raising may be evident.

15
1cm
L4
L5
B resistance to pressure identifies the ligamentum flavum,
Fig. 3.2.3  and that by applying constant pressure to the plunger
• After 5 minutes the patient is questioned about changes
in sensation or power, and any changes in heart rate or
blood pressure are noted.
• If the injection is for diagnostic purposes only, the
needle may be removed at this point.
• If therapeutic effect is required, lidocaine (lignocaine)
1% 2 ml plus corticosteroid, e.g. triamcinolone diacetate
50 mg, may be injected.
• The patient is allowed to lie in the lateral position, on
the side of the pain.
• Monitors should be left attached and i.v. access should
remain in situ for at least 30 minutes.
Tips
• Air may be used instead of NaCl to determine loss of
resistance. If this technique is used it is advisable to
avoid constant pressure on the plunger, as the air is
compressible; instead the plunger should be bounced
intermittently with the thumb to test for resistance and
loss of resistance.
• Advocates claim identification of CSF is easier with this
technique.
• Advocates of the use of NaCl point out that absolute
one can identify loss of resistance more immediately,
thereby avoiding the possibility of dural tap more
easily.
• An epidural catheter may be inserted through the needle
and the needle removed, taking care not to withdraw
the catheter when removing the needle. However, a test
dose of lidocaine (lignocaine) 1% 4 ml with epinephrine
(adrenaline) 1 : 200 000 is given after insertion, before
any injection through the catheter is carried out.
• Identification of the insertion point may be aided by
ultrasound (Fig. 3.2.5).
• Injection of radio-opaque dye under direct fluoroscopy
can confirm epidural placement.
• Insertion of a radio-opaque epidural catheter may be
carried out also under fluoroscopy.
 3
CHAPTER
24
Epidural injection

• Intravascular injection (test dose important); addition of

epinephrine (adrenaline) to test dose may help
identification of intravascular injection.
• Intrathecal injection (test dose important).
• Hypotension due to sympathetic blockade (give i.v. fluid,
consider ephedrine).
• Headache (possible dural puncture).
• Allergic reaction.
• Spinal cord injury may occur if the epidural space is not
recognized. Deep sedation should be avoided during
needle insertion and drug injection.
LATER
• Infection (epidural abscess, bacterial meningitis).
Fig. 3.2.5  • Aseptic meningitis, usually the result of intrathecal
injection (test dose important).
• Cushingoid symptoms (usually as a result of repeated
injections).
Potential problems • Epidural hematoma. This complication should be
suspected when sensory or motor function loss occurs
IMMEDIATE minutes to hours after the procedure. Immediate
• Failure to locate epidural space (sitting position may be diagnostic imaging (CT or MRI) is essential. Prompt
successful). surgical decompression may be required.
 25
3.3  •  Cervical epidural block

3.3 CERVICAL EPIDURAL BLOCK

Anatomy Epidural space

Spinal cord
In the cervical region, the spinous processes are almost
perpendicular to the vertebral bodies, especially in the Dura matter
lower part. They also widen and become bifid. As a result,
insertion of the needle is often easy. However, it must be Ligament
remembered that the epidural space is relatively narrow in Subarachnoid space
this area (2–4 mm), and that the spinal cord lies very close
to it (Fig. 3.3.1 a,b). Most workers prefer to use the
“hanging drop” technique when accessing the cervical Ligamentum
epidural space, as there exists a significant negative flavum
pressure in the cervical region in the sitting position. Interspinous
ligament

Equipment Supraspinous
• 2 ml, 5 ml, and 10 ml syringes ligament

• 18 G, 20 G, and 25 G needles

• ECG, BP, and SpO2 monitors
• 18 G epidural set
• Resuscitation equipment (see Appendix 3)
• Fluoroscopy or ultrasound (optional)
A
Drugs
• Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
Atlas
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)
Axis
• Saline (NaCl) 10 ml
• Resuscitation drugs (see Appendix 3)
C3

Position of patient C4
• Sitting.
C5
• Head flexed forward.
C6
Needle puncture and technique C7
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The midline and an area 10 cm × 5 cm laterally is
cleaned with antiseptic solution and a fenestrated drape
B
is placed over the sterile area.
• Lidocaine (lignocaine) 1% 2 ml is drawn up into two Fig. 3.3.1 
2 ml syringes.
• Lidocaine (lignocaine) 1% 1 ml plus corticosteroid, e.g. root of the spine of the scapula, is identified and
triamcinolone diacetate 50 mg, is drawn up into a 5 ml marked. The prominent spinous process of C7 (vertebra
syringe. prominens) is identified (Fig. 3.3.2) and marked
• NaCl 10 ml is drawn up into a 10 ml syringe. (Fig. 3.3.3 a,b). Ultrasound can be used to guide needle
• The patient is allowed to sit up straight for a moment, placement (Fig. 3.3.3 c,d). The interspace to be used for
and the spinous process of T3, which lies opposite the epidural injection is also marked.
 3
CHAPTER
26
Epidural injection

1 1
C1
2 2
3 3
4
5
4
6 5
7 6
8
7
C7 1
2 1
T1
3
2
4
3
5
4
6
5
7
6

8 7
A
9
8

10
9

Fig. 3.3.2 

FOR THE RIGHT-HANDED OPERATOR

With the left hand
• The fore- and middle fingers are placed each side of the
interspace.
• These fingers are kept in place until the epidural needle
is gripped by the interspinous ligament.
With the right hand
• The interspinous ligament is infiltrated with lidocaine
(lignocaine) 1% 2 ml.
• The epidural needle is inserted, bevel facing caudad,
between the fore- and middle fingers of the left hand in
a direction 60° cephalad, until it is gripped firmly by the
interspinous ligament.
• The hub of the needle is gripped with the fore- and
middle fingers of the left hand and this hand is steadied
by leaning the wrist against the patient’s spine.
• The stylet is removed.
• The hub of the epidural needle is filled with saline
(Fig. 3.3.4) such that a “hanging drop” appears (Fig. 3.3.5).
With both hands
• The wings of the epidural needle are gripped with each
hand, steadying the hands by resting the wrists against
the posterior thoracic wall (Fig. 3.3.6). B
• The needle is slowly and carefully advanced with both
Fig. 3.3.3 
hands.
• It is prudent periodically to confirm high resistance of
the needle in the ligament by testing with an air-filled
syringe, then replace the stylet to make sure there is no
tissue blocking the needle before resuming the “hanging
drop” technique.
 27
3.3  •  Cervical epidural block

C D

Fig. 3.3.3, cont’d

• The “hanging drop” at the hub of the needle is watched

closely, and the patient is asked periodically about the
presence of paresthesia.
• At the point at which the epidural needle enters the
epidural space, the drop should appear to be sucked
into the needle (Figs 3.3.7, 3.3.8).
• After negative aspiration for blood or CSF, lidocaine
(lignocaine) 1% 2 ml is injected.
• After 1–2 minutes the patient is questioned about
Fig. 3.3.4 
changes in sensation or power, and any changes in heart
rate or blood pressure are noted.
• If the injection is for diagnostic purposes only, the
needle may be removed at this point.
• If therapeutic effect is required, lidocaine (lignocaine)
1% 1 ml plus corticosteroid, e.g. triamcinolone diacetate
50 mg, may be injected.
• The patient is allowed to lie in the lateral position, on
the side of the pain.
• Monitors should be left attached and i.v. access kept in
Fig. 3.3.5  situ for at least 30 minutes.
 3
CHAPTER
28
Epidural injection
Fig. 3.3.6  Fig. 3.3.8
Fig. 3.3.7  higher levels.
• Ultrasound may aid in identifying the interspinous space
as spinous processes are easily visible.
FLUOROSCOPIC GUIDED CERVICAL
EPIDURAL INJECTION
• Check MRI to ensure that the spinal cord is not
displaced posteriorly. If the posterior epidural space is
compromised or the spinal cord is shifted posteriorly,
it is safer to enter the upper thoracic epidural space
and advance a radio-opaque catheter to the low
cervical level.
• Position patient prone, with pillow under shoulders,
neck flexed, arms at sides, shoulders as far downward as
possible.
 
• Identify targeted interlaminar space (T1–2, C7–T1, or
C6–7) in direct AP fluoroscopic view. Adjust angle
upward or downward slightly to maximize view of
interlaminar space.
• Mark skin over lower border of T1–2, C7–T1
(preferred) or C6–7 interlaminar space just lateral to
the midline. Do not perform epidural injection above
C6–7 because of absence of midline epidural fat at
• Prepare skin with antiseptic and sterile drape.
• Provide only minimal sedation or no sedation. Instruct
patient to report any pain or paresthesia during the
procedure.
• Infiltrate skin and subcutaneous tissue with lidocaine
(lignocaine) 1%.
• Advance the Tuohy needle through the insertion point
into the interspinous ligament and check the fluoroscopy
image to ensure the needle tip is directed toward the
midline (Fig. 3.3.9).
• Begin to advance through the ligament using loss of
resistance with air or saline. Check lateral view if
possible (may be obscured by the shoulders). Proceed
with needle advancement. When loss of resistance
 29
3.3  •  Cervical epidural block

Fig. 3.3.9  Fig. 3.3.10 

occurs, recheck the lateral view. If unable to visualize the

spinal canal, obtain slightly oblique view (Fig. 3.3.10).
• Attach a low volume extension set to the needle and
inject a small volume (1 ml or less) of non-ionic contrast
medium under live fluoroscopy, preferably in lateral
view (AP or oblique view is used if this is not possible)
(Fig. 3.3.11), then observe the AP view to confirm
epidural dye spread.
• Aspirate to ensure there is no blood return, then inject
1–2 ml lidocaine (lignocaine) 1% followed by 25–50 mg
triamcinolone diacetate or equivalent.

Fig. 3.3.11 
Confirmation of a successful block
• Relief of pain.

• Intravascular injection; addition of epinephrine

Tips
• Loss-of-resistance techniques may also be used to access
the cervical epidural space.
• The steroid may be given soon after the test dose, as
hypotension may be a problem if the patient remains in
the sitting position.
Potential problems
IMMEDIATE
• Failure to locate epidural space (lateral position with
loss of resistance technique may be successful).
• Pain on injection (caution: close proximity to
spinal cord).
• Intrathecal injection (test dose important).
• Hypotension ± bradycardia due to sympathetic blockade
(maximum 3 ml local anesthetic administered in this
technique).
• Vasovagal syncope is common in young adult patients.
(adrenaline) 1 : 200 000 to the test dose may aid
identification of intravascular injection.
• Headache (possible dural puncture).
• Allergic reaction.
• Spinal cord injury may occur if the epidural space is not
recognized. Deep sedation should be avoided during
needle insertion and drug injection.
LATER
• Infection (epidural abscess, bacterial meningitis).
• Aseptic meningitis, usually the result of intrathecal
injection (test dose important).
• Cushingoid symptoms (usually as a result of repeated
injections).
• Epidural hematoma. This complication should be
suspected when sensory or motor function loss occurs
minutes to hours after the procedure. Immediate
diagnostic imaging (CT or MRI) is essential. Prompt
surgical decompression may be required.
 3
CHAPTER
30
Epidural injection

3.4 CAUDAL EPIDURAL BLOCK

Anatomy • Saline (NaCl) 10 ml

Injection of anesthetic through the sacral hiatus allows
access to the sacral epidural space or caudal anesthesia.
The sacrum is roughly triangular in shape and is made up
of five fused sacral vertebrae (Fig. 3.4.1). Its dorsal aspect
is convex and there is a midline sacral canal that allows
passage of the sacral nerves through four pairs of foramen,
anteriorly and posteriorly. At the caudal end lies the
coccyx, and at the cephalad end lies the fifth lumbar
vertebra. The posterior wall of S5, and sometimes S4, is
unfused. The thick fibrous sacro-coccygeal membrane or
sacral hiatus covers the defect. This may be variable in size
as the posterior wall of other sacral vertebrae may also be
unfused. Penetration of this membrane allows access to the
sacral epidural space.
Equipment
• 2 ml, 5 ml, and 20 ml syringes
• 18 G, 20 G, and 25 G needles
• 22 G, 3–5 cm short-bevel needle, with stylet
• ECG, BP, and SpO2 monitors
• Resuscitation equipment (see Appendix 3)
• Fluoroscopy or ultrasound (optional)
• Resuscitation drugs (see Appendix 3)
Position of patient
• Prone.
• Pillow under abdomen and/or operating table broken to
allow flexion of the lumbo-sacral spine.
• Lower limbs abducted 15°, toes rotated to point
towards the opposite foot (Fig. 3.4.2).
Needle puncture and technique (adult)
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The midline and an area 10 cm × 5 cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.

Drugs
• Lidocaine (lignocaine) 1%, 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)

Sacral cornua
Sacro-coccygeal
ligament

Fig. 3.4.1  Fig. 3.4.2 

 31
3.4  •  Caudal epidural block

• Lidocaine (lignocaine) 1% 2 ml is drawn up into three • After 5 minutes the patient is questioned about changes
2 ml syringes. in sensation or power of the lower limbs, and any
• Lidocaine (lignocaine) 1% 15 ml plus corticosteroid, e.g. changes in heart rate or blood pressure are noted.
triamcinolone diacetate 50 mg, is drawn up into the • Then lidocaine (lignocaine) 1% 5–15 ml plus
20 ml syringe. corticosteroid, e.g. triamcinolone diacetate 50 mg, may
• NaCl 10 ml is drawn up into the 10 ml syringe. be injected in order to promote spread to upper sacral
and lower lumbar segments (a volume of at least 10 ml
FOR THE RIGHT-HANDED OPERATOR
should be used if the symptoms are at the level of S1
With the left hand nerve root or higher) (Fig. 3.4.6). The needle is then
• The posterior superior iliac spines are identified.
• The sacral cornua (the unfused spinous processes of S5)
are also identified and marked.
• Between the cornua lies the base of the sacral hiatus, a
roughly triangular fibroelastic structure.
• The index and middle fingers of the left hand are placed
on each of the sacral cornua (Fig. 3.4.3).
• The insertion point lies between these two fingers.
With the right hand
• The insertion point is infiltrated with lidocaine
(lignocaine) 1% 2 ml.
• The 22 G short-bevel needle with stylet is inserted at an
angle of 45° to the skin (Fig. 3.4.4. a,b). Ultrasound can
be used to guide needle placement (Fig. 3.4.4c).
A
• As the needle passes through the fibroelastic sacral
hiatus, a “pop” may be experienced, although this is not
always evident in adults, and bone may be contacted.
• After passing through the sacral hiatus, the needle is
withdrawn a little, and redirected to an angle to the skin
of 15–20° (Fig. 3.4.5). This should allow further
advancement of 1–2 cm, as the needle enters the long
axis of the caudal epidural space.
• After negative aspiration, lidocaine (lignocaine) 1% 2 ml
is injected.

Sacral cornua

Fig. 3.4.3  Fig. 3.4.4 

 3
CHAPTER
32
Epidural injection
Fig. 3.4.5 
Fig. 3.4.6  Fig. 3.4.7
removed while clearing it with lidocaine (lignocaine) 1%
2 ml.
• Monitors should be left attached and i.v. access kept in
situ for at least 30 minutes.
• It is prudent to warn the patient about possible loss of
sensation and or power of one or both lower limbs.
FLUOROSCOPIC GUIDED CAUDAL
EPIDURAL INJECTION
• This approach may be used for treating L5 or S1
radiculopathy. It is a reasonable alternative to the
interlaminar approach when surgery has disrupted the
posterior spinal anatomy.
• Position the patient prone.
• Locate the sacral hiatus using the sacral cornua as
landmarks.
• Prepare skin with antiseptic and sterile drape.
• Place the tip of a sterile blunt instrument over the sacral
hiatus and obtain a lateral fluoroscopic view of the
sacrum.
• Raise a skin wheal with 1% lidocaine (lignocaine) just
below the sacral hiatus and infiltrate with lidocaine
down to the sacral hiatus with a small gauge needle.
 
• Advance a Tuohy needle at a 45° angle to the skin
through the sacral hiatus, checking a lateral fluoroscopic
view to make sure the needle has entered the spinal
canal. Lower the needle angle and advance the needle
slightly. Recheck lateral fluoroscopy to ensure the needle
is in the spinal canal.
• Aspirate to rule out intravascular placement and
inject 0.5–1 ml contrast medium under live
fluoroscopy. Check a lateral and AP image to ensure
epidural spread.
• If no epidural catheter is used, inject a mixture of local
anesthetic and steroid. Inject 10 ml 0.5% lidocaine plus
50 mg triamcinolone diacetate. This volume should be
sufficient to reach the L5 or S1 nerve roots.
• Alternatively, a radio-opaque catheter can be inserted
through the needle and advanced to the desired level.
Check the catheter position in both AP and lateral
views (Fig. 3.4.7). Attach the injection hub to the
catheter and inject 0.5–1 ml contrast medium
under live fluoroscopy, rechecking dye spread in both
AP and lateral views (Fig. 3.4.8). Inject 1–2 ml 1%
lidocaine plus 50 mg triamcinolone diacetate or
equivalent.
 33
3.4  •  Caudal epidural block

Fig. 3.4.9 

Fig. 3.4.10 

Fig. 3.4.8 

Fig. 3.4.11 

Confirmation of a successful block Potential problems

• Relief of pain.
• Anesthesia or diminished sensation in distribution of
blocked nerves.
• Improvement in straight-leg raising (although for sacral
nerve root-related pain, this may not have been positive
prior to caudal blockade).
Tips
• After location of the caudal epidural space, the left hand
may be placed over the sacral hiatus while 10 ml saline
is rapidly injected (Fig. 3.4.6). Misplacement of the
needle in the subcutaneous tissue (Fig. 3.4.9) should be
evident if the injection is appreciated by the palpating
left hand.
• Subperiosteal injection in the awake patient will cause
pain (Fig. 3.4.10). The needle angle is important as the
tip may come to lie anterior to the sacrum (Fig. 3.4.11).
• Anatomic variations exist in many patients, making
access to the caudal epidural space difficult or impossible.
Fluoroscopy using lateral views is useful to confirm the
epidural needle position. Ultrasound may also be helpful
in identifying the sacro-coccygeal membrane.
IMMEDIATE
• Failure to locate epidural space.
• Intravascular injection (test dose important); addition of
epinephrine (adrenaline) to test dose may help
identification of intravascular injection.
• Intrathecal injection, rare but possible (test dose
important).
• Hypotension due to sympathetic blockade (give i.v. fluid,
consider ephedrine).
• Transient exacerbation of radiculopathic pain (caution
patient).
• Headache (possible dural puncture, rare).
• Allergic reaction.
LATER
• Infection (epidural abscess, bacterial meningitis).
• Aseptic meningitis, usually the result of intrathecal
injection (test dose important).
• Cushingoid symptoms (usually as a result of repeated
injections).
• Infection (epidural abscess).
• Epidural hematoma.
 3
CHAPTER
34
Epidural injection
3.5 LONG-TERM EPIDURAL CATHETER INSERTION
Anatomy
As described for lumbar epidural block in Section 3.1.
Equipment
• 2 ml and 10 ml syringes
• 18 G, 20 G, and 25 G needles
• ECG, BP, and SpO2 monitors
• 18 G epidural set
• Epidural catheter passer
• A surgical pack, including small scalpel and suture set
• Resuscitation equipment (see Appendix 3)
• Fluoroscopy or ultrasound (optional)
Drugs
• Lidocaine (lignocaine) 1% (preservative free) 20 ml (or
its equivalent)
• Lidocaine (lignocaine) 1% (preservative free) 4 ml plus
epinephrine (adrenaline) 1 : 200 000
• Saline (NaCl) 10 ml
Position of patient
• Lateral, lying on side of radiculopathy (Fig. 3.5.1).
• Shoulders and buttocks parallel to the edge of the bed,
perpendicular to the floor, with spine flexed.
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The midline and an area 10 cm × 5 cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
• Lidocaine (lignocaine) 1%, 2 ml is drawn up into three
2 ml syringes.
• Lidocaine (lignocaine) 1% 10 ml is drawn up into one
10 ml syringe.
Fig. 3.5.1  Fig. 3.5.2
• NaCl 10 ml is drawn up into the 10 ml loss-of-
resistance syringe.
• An epidural catheter is inserted through the needle as
previously described, 5–6 cm into epidural space (see
Section 3.1).
• The needle is withdrawn 1–1.5 cm, but is not removed.
• After negative aspiration, a test dose of lidocaine
(lignocaine) 1% 4 ml, with epinephrine (adrenaline)
1 : 200 000, is given. After 5 minutes the patient is
questioned about changes in sensation or power, and
any changes in heart rate or blood pressure are noted.
• After a negative reaction lidocaine (lignocaine) 1%
10 ml is injected slowly over 10 minutes. Assessment of
the level of blockade is carried out after a further
15 minutes.
• Subcutaneous infiltration around the epidural needle
with lidocaine (lignocaine) 1% is carried out. Note: a
small incision is made to include the epidural needle
(Fig. 3.5.2).
• A purse string suture is placed around the epidural
needle, but is not tied (Fig. 3.5.3).
• Another small incision in the lateral abdominal wall is
made after subcutaneous infiltration with lidocaine
(lignocaine) 1% (Fig. 3.5.4). A catheter passer is
tunneled through the subcutaneous tissue between the
two incision sites.
• A catheter is manually bent to a curve and tunneled
through the subcutaneous tissue between the two
incision sites in the direction from the abdominal site to
the epidural needle site (Fig. 3.5.5).
• The epidural needle is carefully removed (Figs 3.5.6,
3.5.7).
• The catheter is secured to subcutaneous tissue in the
midline by tightening the purse string suture (Fig. 3.5.8).
• The catheter is further secured using an angle piece and
then threaded in a lateral direction through the catheter
L2
L3
L4
 
 35
3.5  •  Long-term epidural catheter insertion

Fig. 3.5.3  Fig. 3.5.6 

7cm

2cm

Fig. 3.5.4 

Fig. 3.5.5  Fig. 3.5.7 

 3
CHAPTER
36
Epidural injection

Fig. 3.5.8  Fig. 3.5.9 

passer from the needle site to the abdominal wall site
and connections are secured (Fig. 3.5.9).
• A pump may be placed in the abdominal wall site and
the skin incisions closed.
Confirmation of a successful block
• Relief of pain.
• Anesthesia or diminished sensation in the distribution of
affected nerves.
Tips
• Injection of radio-opaque dye under direct fluoroscopy
can confirm epidural placement.
• Insertion of a radio-opaque epidural catheter may be
carried out also under fluoroscopy.
• Ultrasound may aid insertion
Potential problems
• As described for lumbar epidural block in Section 3.1.
• However, in view of the long-term nature of epidural
catheter implantation, any symptoms of infection should
be immediately investigated and treated.
• Epidural catheters should not be inserted or removed
during anticoagulation. Coagulation and platelet
function should be normalized before catheter removal.
 SOMATIC NERVE BLOCKADE
Mechanical nerve root compression was originally thought
to be the cause of pain in discogenic radiculopathy.
However, it has been found that many asymptomatic
patients demonstrate substantial disc protrusion on
magnetic resonance (MR) imaging, myelography and
subsequent autopsy examination. In addition, surgical
decompression does not result in uniform success in the
relief of such pain. Following a period of mechanical
nerve-root compression it is likely that an acute
inflammatory process ensues, resulting in intraneural
accumulation of serum proteins and fluid, raised
intraneural pressure, ischemia and axonal degeneration.
Degenerating glycoprotein material from the
nucleus pulposis may also contribute to the
inflammatory process.
4 
There are many situations in which injection of spinal
nerve roots with local anesthetic may be helpful in the
diagnosis of radicular pain. These include those where
investigations including electromyography, computer
tomography (CT) or MR imaging are not consistent with
the clinical findings, where there are multiple levels of
pathology, and after spinal surgery with subsequent
scarring in the area of the surgery. In addition, the
contribution of the somatic nerve root may be elucidated
in pain of uncertain origin, e.g. chest pain or abdominal
pain, by specific nerve root local anesthetic injection.
It may be used therefore to determine the level of surgery,
if indicated, and the addition of steroid may produce
longer-lasting pain relief.
 4
CHAPTER
38
Somatic nerve blockade

4.1 INTERCOSTAL NERVE BLOCK

Anatomy Equipment
The intercostal nerve is made up of several types of nerves: • 2 ml and 5 ml syringes
sympathetic white and grey rami communicantes, • 30 G needle
cutaneous and motor fibers supplied by dorsal rami, • 22 G 3–4 cm short-bevel needle
sensory fibers to the chest wall, anterior and posterior, via • Extension set (optional)
the lateral cutaneous branch, and further sensory fibers to
• ECG, BP, and SpO2 monitors
the anterior chest wall via the anterior cutaneous branch.
• Resuscitation equipment (see Appendix 3)
The lateral cutaneous branch exits just distal to the angle
of the rib. Just below the inferior edge of the rib, in the • Ultrasound (optional)
intercostal groove, lie the intercostal nerve, artery and vein,
the latter lying superior to the nerve. The optimal site to Drugs
block the intercostal nerve is the most posterior point at • Lidocaine (lignocaine) 1% 2 ml for skin
which the rib is palpable, usually the angle of the rib infiltration
(Fig. 4.1.1 a,b). • Lidocaine (lignocaine) 1% 5 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3)

Position of patient
• Prone (this allows best access, although a lateral or
supine position may also be used).
• Pillow under mid-abdomen to widen the intercostal
Inferior angle spaces.
of rib
• Arms hanging over sides of table to rotate the scapulae
laterally.

Needle puncture and technique

• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
Skin Rib Vein Nerve Intercostal • Sedation may be administered if multiple blocks are
Artery muscle being performed.
A
• The midline and an area 10 cm × 10 cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
• The midline is palpated and marked.
• The inferior edge of the rib is palpated and marked at
the most posterior point at which the rib is palpable;
this is the insertion point (Fig. 4.1.2). If multiple blocks
are planned these marks will form a line that becomes
more medial towards the cephalad end as the scapulae
are avoided laterally (Fig. 4.1.2).
FOR THE RIGHT-HANDED OPERATOR
With the left hand
B
• The inferior edge of the rib is palpated with the fore-
Fig. 4.1.1  and middle fingers (Fig. 4.1.3).
 39
4.1  •  Intercostal nerve block

Fig. 4.1.4 

• The skin is drawn up over the rib itself.

• The fingers of the left hand will grip the needle-hub for
controlled advancement of the needle once contact with
the rib is made during injection.
With the right hand
• The insertion point is infiltrated with lidocaine
(lignocaine) 1% using a 2 ml syringe and a 30 G needle.
• The 22 G short-bevel needle with syringe attached is
inserted between fore- and middle finger of the left hand
Fig. 4.1.2  in a direction 15–20° cephalad, until it makes contact
with the rib (Figs 4.1.4, 4.1.5).
• The needle-hub is gripped with the fingers of the left
hand and this hand is steadied by leaning the wrist
against the patient’s posterior chest wall.
• With the right and left hands acting as one unit, the
needle is walked off the edge of the rib until it enters
the intercostal space immediately below the rib (Fig
4.1.6). Alternatively, a catheter may be inserted between
the needle and syringe and injection may then be carried
out by a second operator, while the first maintains the
needle steady in the correct position (Fig. 4.1.7).
• It is then advanced 2 mm.
• After negative aspiration, 3–4 ml of local anesthetic, plus
corticosteroid if indicated, is injected and the needle is
withdrawn.
• Monitors are left attached and i.v. access left in situ for
at least 30 minutes.
Fig. 4.1.3  • Chest X-ray is performed if pneumothorax is suspected.
 4
CHAPTER
40
Somatic nerve blockade

Fig. 4.1.7 

Confirmation of a successful block

• Relief of pain.
• Anesthesia in the distribution of the blocked nerve.

Tips
• The approximate depth to the rib may be determined
with the left fore- and middle fingers before insertion of
the needle.
• Insertion of the needle > 2 mm deeper than the rib
when intercostal space is reached is avoided. This
will minimize the risk of pneumothorax, as the
Fig. 4.1.5  average distance from the rib to the pleura is
8 mm. If patient coughs on injection, pneumothorax
is suspected.
• Neurolytic intercostal nerve block, e.g. with alcohol
1 2
50% 3 ml (made up by combining equal parts of
alcohol 100% and lidocaine (lignocaine) 1% or its
equivalent), or phenol 6%, may be carried out after
local anesthetic block confirms accurate placement of
the needle as described above. However, it is important
to note that injection may result in subarachnoid spread
of a neurolytic agent with resultant possible permanent
spinal cord damage.
• Ultrasound may aid accurate placement of the needle
(Fig. 4.1.8). Injection of non-ionic radio-constrast
medium may also aid accurate placement of the needle
in neurolytic block (Fig. 4.1.9).
• Placement of a catheter into the intercostal space can be
achieved by threading 3 cm of catheter through an 18 G
epidural needle after the intercostal neurovascular
bundle has been identified as above.

Fig. 4.1.6 

Fig. 4.1.8 
Radiofrequency lesioning
• Radiofrequency lesioning of the intercostal nerve is
simple and has a low level of side effects. The lesioning
is carried out using the same method of placement of
the needle as described for intercostal nerve block with
local anesthetic.
• However, after placement of the needle and confirmation
of accuracy by fluoroscopy (as described above), a trial
of stimulation is carried out using 2 V at 50 Hz. If the
needle has been placed accurately the patient should
experience paresthesiae in the distribution of that
intercostal nerve. A pulsed radiofrequency lesion may
then be produced at 40–45 °C for 5 minutes or 49–60 °C
for 90 seconds.
41
4.1  •  Intercostal nerve block
Fig. 4.1.9 
Potential problems
• Injection within the nerve sheath can result in the spread
of anesthetic to the subarachnoid space.
• Intercostal block in patients with severe respiratory
problems should be avoided as there is risk of a
pneumothorax. Careful observation of a small
pneumothorax is usually all that is required but
failure to re-expand the lung may require chest tube
insertion.
• Because of the vascularity of the intercostal space, there
may be rapid absorption of local anesthetic and systemic
effects can occur quickly, especially with multiple
blocks. However, peak plasma concentration of local
anesthetic may occur 15–20 minutes after the block is
performed, when systemic toxicity effects may develop.
Addition of epinephrine (adrenaline) to the anesthetic
solution may decrease the peak plasma concentration of
local anesthetic.
• If aspiration of blood occurs, the needle should be
removed, keeping the left fore- and middle fingers in
place. The needle is cleared, reinserted to contact the rib
again, and the block is continued as above.
 4
CHAPTER
42
Somatic nerve blockade

• Care of the airway must be remembered if sedation is
administered to a patient in the prone position.
• Complications of neurolytic intercostal nerve block
include pneumothorax, infection (especially in the
immunocompromised patient) as well as post-lesioning
intercostal nerve neuritis. The frequency of the latter in
radiofrequency lesioning increases as higher temperatures
are used. Intercostal nerve neuritis usually responds to
local injection of lidocaine (lignocaine) 1% 3 ml plus
triamcinolone diacetate 20 mg to the lesion site.

4.2 INTERPLEURAL BLOCK
Anatomy
The parietal pleura lines the thoracic wall, the thoracic
surface of the diaphragm and the lateral mediastinum. The
visceral pleura completely covers the surface of the lung.
Both the pleural layers become contiguous at the root
of the lung. Between the two pleural layers lies the
interpleural space (Fig. 4.2.1). Injection of local anesthetic
into this space produces an interpleural block by topical
contact with free nerve endings within the pleura,
and by local diffusion to nerves in the vicinity of the
injection site. These include the intercostal nerves, the
sympathetic chain, and the inferior part of the brachial
plexus. Local anesthetic solution may also track
to the epidural and subarachnoid spaces producing
blockade.
Equipment
• 2 ml and 10 ml syringes
• 18 G, 20 G, and 25 G needles
• ECG, BP, and SpO2 monitors
• 18 G epidural set
• Well-lubricated 5 ml glass syringe
• Resuscitation equipment (see Appendix 3)
Drugs
• Lidocaine (lignocaine) 1% 10 ml
• Levobupivacaine 0.25%, 20 ml (or its equivalent)
• Saline (NaCl) 10 ml
• Resuscitation drugs (see Appendix 3)
Interpleural space
Fig. 4.2.1  Fig. 4.2.2
43
4.2  •  Interpleural block
Position of patient
• The technique described here relies on negative
interpleural pressure to identify the interpleural space.
Therefore the patient should be breathing spontaneously
for this technique.
• Semi-prone.
• Side to be blocked uppermost, supported by a pillow
(Fig. 4.2.2).
• The arm should be allowed to fall forwards in front of
the body to rotate the scapula anterolaterally.
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The midline and an area 15 cm × 12 cm laterally is
cleaned with antiseptic solution and a fenestrated drape
is placed over the sterile area.
• Lidocaine (lignocaine) 2%, 2 ml is drawn up.
• Levobupivacaine 0.25% 20 ml is drawn up.
• Air is drawn up into a well-lubricated 5 ml syringe.
• The seventh and eighth ribs are palpated and marked.
 
 4
CHAPTER
44
Somatic nerve blockade

Fig. 4.2.3 

• A point approximately 10 cm from the midline,

immediately superior to the eighth rib, is marked; this is
the insertion point (Fig. 4.2.3).
FOR THE RIGHT-HANDED OPERATOR
With the left hand
• The fore- and middle fingers are placed each side of the
insertion point, palpating the superior aspect of the
eighth rib.
• These fingers are kept in place until the epidural needle
passes through the subcutaneous tissue.
With the right hand Fig. 4.2.4 
• A skin wheal is raised at the insertion point.
• Taking care not to allow air entry into the interpleural
• The epidural needle is inserted between the fore- and
cavity, a catheter is inserted approximately 10 cm
middle fingers of the left hand, taking care that the
into the interpleural space (Fig. 4.2.6). Once the
point of entry of the needle is as close as possible to the
catheter is in position it is best to place the patient
superior aspect of the eighth rib. This helps to avoid
supine, tilted slightly, with the side to be blocked
damage to the neurovascular bundle, which lies
upwards (Fig. 4.2.7 a,b). (If blockade of the upper
immediately inferior to the seventh rib.
thoracic segments is required the patient is tilted
• After passage through the subcutaneous tissue, the hub
head-down).
of the needle is gripped with the fore- and middle fingers
• After negative aspiration and a test dose, 10–15 ml
of the left hand and this hand is steadied by leaning the
levobupivacaine 0.25% (or its equivalent) in divided
wrist against the patient’s posterior chest wall.
doses of 5 ml is injected.
• The stylet is removed and the well-lubricated glass
• Infusion of local anesthetic may be set up for continuous
syringe containing 3 ml air is applied (Fig. 4.2.4).
analgesia.
• The needle is slowly and carefully advanced, with no
• Monitors should be left attached and i.v. access left in
pressure applied to the plunger, the left hand aiding the
situ while the catheter is in place.
advance, while at the same time applying a brake if
required. • Chest radiograph may be performed to rule out
pneumothorax.
• Resistance from the tissues prevents the plunger from
advancing.
• At the point at which the needle enters the interpleural
Confirmation of a successful block
space a definite click is experienced, negative pressure • Relief of pain.
draws the air in and the barrel drops (Fig. 4.2.5). • Anesthesia in the distribution of the blocked nerves.
 45
4.2  •  Interpleural block

Pleural
reflection

8–10 cm
A Air

Parietal
pleura

B Visceral pleura C D
Fig. 4.2.5 

Epidural Intercostal
needle muscle Skin

Rib
Neurovascular bundle
Parietal pleura
Visceral pleura
Lung
Epidural catheter
Fig. 4.2.6 

Supine Pleural cavity Pericardial cavity

Lung Phrenic nerve

Local anesthetic Sympathetic Splanchnic Local anesthetic

A solution chain nerve B solution
Fig. 4.2.7 
 4
CHAPTER
46
Somatic nerve blockade

Tips Potential problems

• As an alternative technique, the barrel of the syringe
may be removed and the open syringe filled with NaCl
or local anesthetic and advanced until the fluid level
begins to fall as the solution is sucked into the
interpleural space (Fig. 4.2.8).
• Also, a bag containing NaCl 500 ml may be attached to
the epidural needle via a giving set, and drops observed
on entry to the interpleural space (Fig. 4.2.9).
• Ultrasound may aid placement of the needle (Fig. 4.2.10).
• Pneumothorax.
• Unpredictable analgesia. The mechanism of action of
interpleural block is still unproven and spread of the
local anesthetic solution may be unpredictable. The
duration of the block may be decreased when a
thoracotomy drainage tube is present.

Fig. 4.2.8 

Fig. 4.2.9  Fig. 4.2.10 


4.3 LUMBAR NERVE ROOT BLOCK
Anatomy
The lumbar nerves are made up of sensory and motor
fibers to the trunk and lower limbs, and sympathetic white
and grey rami communicantes. Each lumbar nerve exits via
the intervertebral foramen which lies just inferior to the
caudad edge of the transverse process of the respective
vertebral body, and passes anteriorly over the lateral aspect
of the transverse process of the vertebral body below
(Fig. 4.3.1). It then branches into posterior and anterior
branches. The posterior branch supplies the paravertebral
muscles and cutaneous fibers to the back. The anterior
branch passes through the substance of the psoas muscle
and branches further, communicating with the other
anterior branches to form the lumbar plexus. As a result
there is significant overlap of nerve supply. The fascial
layers of the psoas muscle prevent spread of local
anesthetic to the sympathetic lumbar chain. It may be
helpful to consider blockade of a lumbar nerve root to be
similar to intercostal nerve block except that the transverse
process is present instead of a rib and the insertion site is
therefore more medial.
Equipment
• 2 ml and 10 ml syringes
• 25 G needle
Fig. 4.3.1  that vertebra (Fig. 4.3.4 a,b).
47
4.3  •  Lumbar nerve root block
• 22 G spinal needle, end-opening
• Radio-opaque contrast medium
• ECG, BP, and SpO2 monitors
• Resuscitation equipment (see Appendix 3)
• Fluoroscopy or ultrasound
Drugs
• Lidocaine (lignocaine) 1% 10 ml (or its
equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
25 mg (or its equivalent)
• Resuscitation drugs
Position of patient
• Prone.
• Pillow under the anterior superior iliac spine to flatten
the normal lumbar lordosis (Fig. 4.3.2).
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The lumbar midline and an area 10 cm × 5 cm laterally
is cleaned with antiseptic solution and a fenestrated
drape is placed over the sterile area.
• The iliac crests are palpated and the intercrestal line is
identified. This corresponds with the inferior aspect of
the spinous process of L4 or may lie in the L4–5
interspace (Fig. 4.3.3 a).
• The spinous processes are counted until the level to
be blocked is identified and confirmed with
fluoroscopy.
• The spinous processes of the vertebrae are marked
(Fig. 4.3.3 b).
• The insertion point of the needle lies 2–3 cm lateral to
the cephalic end of the spinous process of the vertebra.
The nerve corresponding to each vertebra emerges just
below the transverse process of that vertebra at this site
(see Appendix 6).
• Therefore, with the aid of fluoroscopy, the insertion
point is identified.
• A skin wheal is raised and the area is infiltrated with
lidocaine (lignocaine) 1%.
• A spinal needle is introduced in a vertical direction to
the skin, until the needle contacts bone at an
approximate depth of 3–5 cm, the transverse process of
 4
CHAPTER
48
Somatic nerve blockade

Fig. 4.3.2 

L1
L2
L3

L4

A B

Fig. 4.3.3 

• The needle is then walked off the transverse process
in the caudad direction and advanced 1.5–2 cm, the site
of the emerging nerve root (Fig. 4.3.5).
• It is useful to confirm the needle tip over the
intervertebral foramen with fluoroscopy.
• Paresthesia in the distribution of the nerve may be
experienced.
• After aspiration, non-ionic radio-opaque contrast
medium 1 ml is injected.
• The correct placement is indicated by outlining the nerve
root with non-ionic radio-opaque contrast medium,
visible on anteroposterior and lateral fluoroscopic views
(Fig. 4.3.6).
• After further aspiration, lidocaine (lignocaine) 1%
0.5–1 ml is injected.
• After 5 minutes the patient is questioned about changes
in pain, sensation and power of the lower limb.
• For diagnostic nerve root blockade, the needle
may be removed when the level causing pain is
identified.
• Ultrasound may also aid placement of the needle
(Fig. 4.3.7).
 49
4.3  •  Lumbar nerve root block

A B

Fig. 4.3.4 

Confirmation of a successful block However, even small volumes of epidural spread may
confound the diagnostic value of the block.
• Relief of pain and anesthesia in distribution of the
• Sympathetic blockade is unlikely, but it may occur and
blocked nerve.
cause hemodynamic changes.
• Intravascular injection. Injection of particulate steroids
Tips into a radicular artery can cause spinal cord infarction.
• As in the case of thoracic nerve root block, it has also Particulate steroids should never be injected near the
been recommended that the needle is angled 20° foramen unless intravascular placement has been ruled
medially after entering the paravertebral space. However out using live fluoroscopy contrast dye injection,
care must be taken, with the aid of fluoroscopy, not to preferably with digital subtraction technique.
inject local anesthetic solution into the nerve sheath
allowing tracking of the solution centrally to produce
intrathecal blockade.

Potential problems
• Intrathecal injection.
• Epidural blockade usually occurs with this block, but
this is not a problem once low volumes are used.
 4
CHAPTER
50
Somatic nerve blockade

3cm

Sympathetic chain Lumbar nerve

Fig. 4.3.5 

Fig. 4.3.7 

Fig. 4.3.6 
 51
4.4  •  Thoracic nerve root block

4.4 THORACIC NERVE ROOT BLOCK

Anatomy • ECG, BP, and SpO2 monitors

The anatomy relevant to thoracic paravertebral nerve root
blockade is very similar to the anatomy relevant to lumbar
paravertebral nerve root block, except that:
• ribs are present instead of the rudimentary ribs of the
lumbar spine, the transverse processes;
• the lung and pleura are in close proximity to the injection
site, therefore the risk of pneumothorax is significant;
• unlike the lumbar region, where the needle passes
through the substance of the psoas muscle, the needle
passes through connective tissue only in the thoracic
region (Fig. 4.4.1 a,b);
• the fascial layers of the psoas muscle prevent spread to
the sympathetic lumbar chain. However, such layers do
not exist in the thoracic region, and paravertebral
injection usually results in sympathetic blockade.
Equipment
• 2 ml and 10 ml syringes
• 25 G needle
• 22 G spinal needle, end-opening
• Radio-opaque contrast medium
• Resuscitation equipment and drugs (see Appendix 3)
• Fluoroscopy or ultrasound
Drugs
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
25 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3)
Position of patient
• Prone (the block requires localization of the transverse
process and can be performed in a lateral, sitting or
prone position) (Fig. 4.4.2).
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The thoracic midline and an area 10 cm × 5 cm laterally
is cleaned with antiseptic solution.

Pleura

Sympathetic ganglion

Anterior Anterior
costotransverse costotransverse
ligament ligament

Nerve

Rib Lamina

B
A

Fig. 4.4.1 
 4
CHAPTER
52
Somatic nerve blockade

A
Fig. 4.4.2 

Anterior
• The inferior angle of the scapula is identified; this lies costotransverse
at the level of the spinous process of T7. ligament
• The root of the spine of the scapula is identified; this
lies at the level of the spinous process of T3.
• The spinous processes are counted until the level to be Posterior
costotransverse
blocked is identified, and confirmed with fluoroscopy. ligament
• The spinous processes of vertebrae are then marked.
• The insertion point of the needle lies 1.5–3 cm lateral to
the cephalic end of the spinous process of the vertebra,
Azygos vein
usually midway between the ribs (Fig. 4.4.3 a,b).
Lung
• The nerve corresponding to each vertebra emerges just Thoracic
duct
below the transverse process of that vertebra at this site.
• Therefore, with the aid of fluoroscopy, the insertion Esophagus
point is identified. Aorta

• A skin wheal is raised and the area is infiltrated with

Greater
lidocaine (lignocaine) 1%. splanchnic
• The transverse process is identified under fluoroscopy nerve
and the spinal needle is introduced in a direction
perpendicular to the skin until the needle contacts bone. Thoracic
• A slightly mesiad inclination avoids the pleura and sympathetic
chain
increases the chances of placing the needle tip near the
nerve root.
1.5cm
• Care must be taken to avoid the pleura by not
advancing the needle any further than is necessary to
locate the transverse process, approximately 3 cm. If the B Superior
costotransverse ligament
needle does not contact the transverse process by 3 cm,
it should be withdrawn and re-advanced in a more Fig. 4.4.3 
caudad, and subsequently more cephalic, direction,
again taking care not to advance beyond 3 cm.
• The needle is then walked off the caudad edge • After aspiration, radio-opaque contrast medium 1 ml, is
of the transverse process until it slips off the edge injected.
(Fig. 4.4.4 a,b). It is then advanced 1 cm, the site • The correct placement is indicated by outlining the nerve
of the emerging nerve root at that level. root with non-ionic radio-opaque contrast medium,
• It is useful to confirm the needle tip over the visible on anteroposterior and lateral views (as in
intervertebral foramen with fluoroscopy. the description of lumbar somatic nerve injection in
• Paresthesia in the distribution of the nerve may be Section 4.3).
experienced. • Ultrasound may aid placement of needle.

A B
Fig. 4.4.4 
• After further aspiration, lidocaine (lignocaine) 1%
0.1–1 ml is injected.
• After 5 minutes the patient is questioned about
changes in pain and sensation in the distribution of the
nerve root.
• For diagnostic nerve root blockade the needle may be
removed when the level causing pain is identified.
Confirmation of a successful block
• Relief of pain and anesthesia in distribution of the
blocked nerve.
Tips
• An alternative approach is to advance the needle in a
mesiad direction until the lamina is contacted. The
needle is inserted more medially, 1.5 cm lateral to the
cephalad edge of the spinous process and then walked
laterally off the edge of the lamina until it slips into the
costovertebral ligament and is advanced 1 cm.
53
4.4  •  Thoracic nerve root block
• Some workers advocate applying an air-filled loss-of-
resistance syringe to the needle after it has been walked
off the transverse process or lamina, and advancing the
needle while applying pressure to the plunger. Loss of
resistance has been described as the needle pops through
the costotransverse ligament to enter the thoracic
paravertebral space.
• A catheter may be passed into the paravertebral space
via an epidural needle, with the bevel medial, by using
this technique.
Potential problems
• Pneumothorax.
• While it has been recommended that the needle be
angled 20° medially after entering the paravertebral
space, care must be taken with the aid of fluoroscopy
that the local anesthetic solution is not injected into the
nerve sheath causing the solution to track centrally to
produce intrathecal blockade.
 4
CHAPTER
54
Somatic nerve blockade
• Epidural blockade usually occurs with this block, but
this is not a problem once low volumes are used.
However, even small volumes of epidural spread may
confound the diagnostic value of the block.
• Sympathetic blockade may cause hemodynamic changes.
• Neuritis may occur with catheter placement.
• Intravascular injection. Injection of particulate steroids
into a radicular artery can cause spinal cord infarction.
Particulate steroids should never be injected near the
foramen unless intravascular placement has been ruled
out using live fluoroscopy contrast dye injection,
preferably with digital subtraction technique.
 55
4.5  •  Sacral nerve root block

4.5 SACRAL NERVE ROOT BLOCK

Anatomy Equipment
Each of the five sacral nerves is accessible by passing a • 2 ml and 10 ml syringes
needle into the sacral foramen via the posterior opening at • 25 G needle
the level of the nerve. The sacral canal is the caudal • 22 G spinal needle, end-opening
extension of the epidural space and nerves of the cauda • ECG, BP, and SpO2 monitors
equina leave via the sacral foramina (Fig. 4.5.1). The distal
• Resuscitation equipment (see Appendix 3) and drugs
dural sac ends at S2, the level of the posterior superior iliac
• Fluoroscopy or ultrasound
spines. The epidural space ends at the sacral hiatus
(Fig. 4.5.2). While variability in the bony anatomy of the
sacrum is common, this occurs usually in the midline. Drugs
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3)

Conus medullaris
Position of patient
• Prone.
• Pillow under anterior superior iliac spine to flatten the
Dura matter normal lumbar lordosis (Fig. 4.5.3).

Spinous process Transverse

1 process Needle puncture and technique
Termination of the L1
• Intravenous access is inserted.
spinal cord at the 2
level of L1 • Monitors are attached.
L2 • Resuscitation equipment and drugs are checked and
made ready for use.
3
Cauda equina • The sacral midline and an area 10 cm × 5 cm laterally is
L3
cleaned with antiseptic solution and a fenestrated drape
4 is placed over the sterile area.

L4
Termination 5
of the Subarachnoid
subarachnoid space (CSF)
L5
space at S2
Sacral nerves
in the caudal
S1 epidural space

Posterior sacral
S2 foramen

S3
Sacral
S4 hiatus
Filum Cornu of sacrum
terminale First
S5 coccygeal Coccygeal cornu
vertebra
Coccygeal nerve

Fig. 4.5.1  Fig. 4.5.2 

 4
CHAPTER
56
Somatic nerve blockade

A
Fig. 4.5.3 

1cm

S1
S2 Posterior
S3 superior
iliac spine
S4
Sacral cornu

Fig. 4.5.4 

• Iliac crests are palpated and an intercrestal line is

identified.
• This corresponds with the inferior aspect of the spinous
process of L4 or may lie in the L4–5 interspace.
• For this block, it is almost essential that the posterior
opening of the sacral foramina is identified with
fluoroscopy. The X-ray beam is used to guide the needle
tip into the foramen. It is important to note that when
B
the anteroposterior X-ray view is used, it is usually the
anterior opening of the foramen that is the most Fig. 4.5.5 
prominent.
• The insertion point of the needle lies 2–3 cm lateral • A spinal needle is introduced in a vertical direction to
to the midline (variable) and approximately 1 cm medial the skin, and aimed slightly cephalad until bone is
to the posterior iliac spine (Figs 4.5.4, 4.5.5 a,b). contacted (Fig. 4.5.6).
• Therefore, with the aid of fluoroscopy, the insertion • The needle is then walked off the sacrum in a caudad
point is identified. direction until it slips into the foramen. After
• A skin wheal is raised and the area is infiltrated with confirmation with the aid of fluoroscopy it is then
lidocaine (lignocaine) 1%. advanced 1 cm.

Fig. 4.5.6  and posterior sacral foramina. Consequently, when the
• Paresthesia may be produced.
• After aspiration, non-ionic radio-opaque contrast
medium 0.5 ml is injected.
• The correct placement is indicated by a needle tip flush
with the anterior surface of the spinal canal in the
lateral fluoroscopic view.
• Injection of 0.5 ml non-ionic contrast should spread
diagonally along the S1 spinal nerve (Fig. 4.5.7).
• After further aspiration, lidocaine (lignocaine) 1%
0.5 ml is injected.
• After 5 minutes, the patient is questioned about changes
in pain, sensation and power of the lower limb.
• For diagnostic nerve root blockade the needle may be
removed when the level causing pain is identified.
• Ultrasound may also aid placement.
Confirmation of a successful block
• Relief of pain.
• Anesthesia in the distribution of the blocked nerve.
57
4.5  •  Sacral nerve root block
Fig. 4.5.7 
Tips
• Some workers advocate drawing a line from a point
2–3 cm medial to the posterior superior iliac spine to a
point 1–2 cm lateral to the sacral cornua. The sacral
foramina usually lie along this line.
• It is best to angle the X-ray beam caudally, thereby
perpendicular to the sacrum, superimposing the anterior
needle is introduced in a direction perpendicular
(Fig. 4.5.8) to the skin, fluoroscopic guidance is easier.
Optimally, the needle makes gentle contact with the
spinal nerve in the middle of the canal (Figs 4.5.9,
4.5.10) and produces paresthesia in the distribution of
the nerve.
• While all sacral nerve roots are accessible, using this
technique for blockade of S5 is achieved by walking the
needle caudally off the inferior edge of the bony plate of
the sacrum and advancing the needle 1 cm.
Potential problems
• Caudal epidural blockade may occur with this block,
but this is not a problem once low volumes are used.
However, even small volumes of epidural spread may
confound the diagnostic value of the block.
• Intravascular injection. Injection of particulate steroids
into a radicular artery can cause spinal cord infarction.
Particulate steroids should never be injected near the
foramen unless intravascular placement has been ruled
out using live fluoroscopy contrast dye injection,
preferably with digital subtraction technique.
 4
CHAPTER
58
Somatic nerve blockade

S4 S3
S5 S2

S1

Fig. 4.5.8  Fig. 4.5.9 

S4 S3
S5 S2

S1

Fig. 4.5.10 
 59
4.6  •  Occipital nerve block

4.6 OCCIPITAL NERVE BLOCK

Anatomy • ECG, BP, and SpO2 monitors

The greater occipital nerve arises from the dorsal rami of
the second cervical nerve. From here it passes through the
muscles of the neck and becomes subcutaneous at the
superior nuchal line, where it emerges with the occipital
artery (Fig. 4.6.1). The superior nuchal line extends from
the mastoid process to the greater occipital protuberance
bilaterally (Fig. 4.6.2).
• Resuscitation equipment (see Appendix 3)
Drugs
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent)
• Corticosteroid if indicated, e.g. triamcinolone diacetate
50 mg (or its equivalent)
• Resuscitation drugs (see Appendix 3)

Equipment Position of patient

• 10 ml syringe • Sitting.
• 25 G needle • Neck flexed.

Greater occipital Needle puncture and technique

protuberance • The superior nuchal line is cleaned with antiseptic
Mastoid process solution (no drape is required) (Fig. 4.6.3).

Greater
occipital nerve
Occipital artery

Lesser
occipital nerve

Greater
auricular nerve
posterior branch

Fig. 4.6.1 

Greater
occipital
nerve
Lesser
occipital
nerve
Superior
nuchal line
Mastoid
process
Greater
occipital
protuberance

Fig. 4.6.2  Fig. 4.6.3 

 4
CHAPTER
60
Somatic nerve blockade

• The occipital artery is palpated 2 cm lateral to the Tips

greater occipital protuberance on the superior nuchal
• Bone should be contacted at a depth no greater than
line (Fig. 4.6.4).
1–2 cm.
• A 25 G needle is inserted subcutaneously at this point.
• The lesser occipital nerve is blocked by redirecting the
• After negative aspiration, 3–5 ml of lidocaine
needle towards the mastoid process along the greater
(lignocaine) 1% or its equivalent, plus corticosteroid if
nuchal line and injecting a further 3 ml of solution.
indicated, is injected to surround the occipital artery.
• It is often difficult to feel an occipital artery pulse. If
this is the case, it is best to pick a point midway Potential problems
between the occipital protuberance and the mastoid • Injection into the cerebrospinal fluid (CSF) of the
bone and fan out the injection in both directions, cisterna magna is possible and will produce a total
medially and laterally from that site (Fig. 4.6.5). spinal block.

Confirmation of a successful block

• Relief of pain and anesthesia in distribution of nerve.

Fig. 4.6.4  Fig. 4.6.5 

 61
4.7  •  Trigeminal ganglion (Gasserian) block

4.7 TRIGEMINAL GANGLION (GASSERIAN) BLOCK

Anatomy two-thirds of the ganglion and contains cerebrospinal fluid

The trigeminal ganglion gives rise to the fifth cranial nerve
and divides into three branches, the ophthalmic, maxillary,
and mandibular nerves (Fig. 4.7.1). These provide the
sensory nerve supply to the ipsilateral face and the anterior
two-thirds of the head (Fig. 4.7.2). The mandibular nerve
also provides motor supply to the muscles of mastication.
The trigeminal ganglion is located at the apex of the
petrous temporal bone in a fold of dura mater, “Meckel’s
cave”. This dural invagination covers the posterior
Ophthalmic
(CSF). Posterior to Meckel’s cave lies the brainstem,
superior to it lies the temporal lobe, and medially lies the
cavernous sinus which contains the internal carotid artery
and cranial nerves III, IV, and VI. Accordingly, extreme
care must be taken when carrying out this block, especially
if neurolytic agents are used. Blockade of the ganglion is
carried out by passage of a needle through the foramen
ovale, which lies immediately below it (Fig. 4.7.3).
Equipment
• 2 ml and 10 ml syringes
• 25 G needle
• 22 G 8–10 cm needle
• Non-ionic radio-opaque contrast medium
• ECG, BP, and SpO2 monitors
• Resuscitation equipment (see Appendix 3)
• Fluoroscopy

Maxillary
Drugs
• Lidocaine (lignocaine) 2% 10 ml
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent)
Mandibular
• Neurolytic agent, e.g. phenol 6% plus glycerol (or its
equivalent)
• Sedative, e.g. midazolam, propofol
• Resuscitation drugs (see Appendix 3)
Fig. 4.7.1 
Position of patient
• Supine.
• Eyes directed straight ahead.

Ophthalmic

Meckel's cave
Maxillary
Gasserian
ganglion

C2 Mandibular Zygomatic arch

Foramen ovale
C3

C4

Posterior Anterior
primary rami primary rami

Fig. 4.7.2  Fig. 4.7.3 

 4
CHAPTER
62
Somatic nerve blockade

Needle puncture and technique the needle is reinserted to walk off the bone and
enter the foramen ovale (Fig. 4.7.7).
Caution: Injection of 0.25 ml of lidocaine (lignocaine) 1%
• Paresthesia in the distribution of the mandibular nerve
into the CSF may result in immediate convulsion and/or
(sometimes the other branches of the trigeminal nerve)
loss of consciousness with possible cardiovascular system
or contraction of the muscles of mastication may be
(CVS) collapse.
experienced at this point.
• The cheek on the side of the block is cleaned with • The needle is advanced a further 1 cm to bring the tip
antiseptic solution or saline. to lie in the trigeminal ganglion. The correct placement
• Mild sedation is induced. is indicated by a visible outline of Meckel’s cave on
• It is best to stand on the side of the block, just below injection of 0.25 ml non-ionic radio-opaque contrast
the shoulder. medium under fluoroscopy (Figs 4.7.8, 4.7.9).
• The insertion point lies 1–3 cm posterior to the lateral • The patient is allowed to awaken from sedation and is
margin of the mouth, at the medial edge of the masseter questioned about the presence and distribution of
muscle (located by asking the patient to clench the jaw) paresthesia and pain.
and is marked. • A stimulating device may aid placement in patients who
• In edentulous patients the insertion point should be are not able to locate the paresthesia with accuracy.
more caudad as sufficient angle towards the • If necessary, analgesia may be administered, although
infratemporal surface of the sphenoid bone may not be this may affect accurate assessment of the blockade.
achieved. • Adjustment of the needle may be required to place the
• One finger is placed inside the upper lip to avoid needle near the appropriate nerve division.
injection into the buccal cavity and possible bacterial
contamination, and a skin wheal is raised at this site.
• Viewed from above, a 22 G 8–10 cm needle is advanced
towards the ipsilateral pupil (Figs 4.7.4–4.7.6), or
viewed from the side the needle advances towards the
mid-point of the zygomatic arch (see Anatomy above)
until bone is contacted; the roof of the infratemporal
fossa. This lies just anterior to the foramen ovale and
lateral to the base of the pterygoid process. The location
of the needle tip is confirmed with fluoroscopy.
• A depth mark is set and the needle is withdrawn to
the subcutaneous tissue. With the aid of fluoroscopy

Fig. 4.7.4  Fig. 4.7.5 

 63
4.7  •  Trigeminal ganglion (Gasserian) block

Fig. 4.7.8 

Fig. 4.7.6 

Roof of
infratemporal
fossa

Zygomatic arch

Foramen ovale

2
1

Fig. 4.7.7  Fig. 4.7.9 

 4
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64
Somatic nerve blockade
• After careful negative aspiration for CSF or blood,
lidocaine (lignocaine) 1% 0.25 ml is injected (Caution:
injection into CSF may cause loss of consciousness.)
This is followed by further boluses of lidocaine
(lignocaine) 1% 0.25 ml until a total of 1 ml is given.
• After 5 minutes the patient is questioned about pain
relief and changes in sensation.
• When the desired analgesia has been achieved for
diagnostic blockade the needle may be removed.
Confirmation of a successful block
• Relief of pain and anesthesia in the distribution of the
trigeminal nerve or its desired branches.
Tips
• Intravenous anesthesia using a short-acting agent, e.g.
propofol, may be induced to allow placement of the
needle. The patient is then allowed to awaken and a
stimulating device may aid accurate placement of the
needle.
• The needle is advanced beyond the infratemporal bone
by 0.5 cm for location of the mandibular division,
1.0 cm for the maxillary division, and 1.5 cm for the
ophthalmic division.
• Gangliolysis using thermocoagulation may be employed
for trigeminal-nerve division destruction after location
of the ganglion using this technique. Further intravenous
anesthesia using a short-acting agent, e.g. propofol, may
be induced after placement of the insulated needle to
facilitate this painful procedure.
• Injection of glycerol alone may produce pain relief with
this injection technique. This involves placement of the
needle in the cul-de-sac of CSF, positioning the patient
face-down or supine, with the head extended to prevent
spill-over into the posterior cranial fossa. After entry
into the CSF, and positive aspiration of CSF, 0.1–0.3 ml
of glycerol may be injected.
Potential problems
• Injection of 0.25 ml of lidocaine (lignocaine) 1% into
the CSF may result in immediate convulsion and/or loss
of consciousness with possible CVS collapse.
• Spread of hyperbaric neurolytic solution may immediately
affect cranial nerves VI, VIII, IX, X, XI, and XII.
• Spread of hypobaric neurolytic solution may
immediately affect the oculomotor and trochlear nerves.
• Neurolytic blocks of the trigeminal ganglion commonly
produce corneal and hemifacial anesthesia.
 AUTONOMIC BLOCKADE
Autonomic blockade is useful in the diagnosis and
treatment of pain of autonomic origin. In cases of thoracic,
abdominal or pelvic pain, it is often difficult to distinguish
between that of visceral origin and that of somatic. Pain of
visceral origin, e.g. pancreatic cancer or pelvic cancer, may
cause pain that responds to celiac or hypogastric plexus
blockade, respectively. A prognostic block may be carried
out prior to neurolytic blockade for relief of cancer pain.
Pain of the upper abdominal viscera may also be relieved
by celiac plexus block, proceeding to neurolytic blockade
as appropriate for cancer-related pain. The retrocrural
approach to the celiac plexus also targets the splanchnic
nerves to produce a splanchnic nerve block if required.
Chest pain may be of somatic origin, e.g. intercostal
neuralgia and costochondritis, or visceral origin, e.g.
pulmonary or cardiac-related pain. Stellate ganglion
blockade may be helpful in the diagnosis and management
of the latter.
In addition, increased sympathetic activity is thought to
contribute to a large number of pain states. These are
5 
generally grouped under the term Complex Regional Pain
Syndrome Type I and II. In these cases, trophic changes
and alterations in blood flow are often obvious but the
pathophysiologic origin is not. Blockade of sympathetic
innervation may therefore help in diagnosis and
management of such pain. This may also indicate other
therapies that could be beneficial, e.g. sympathetically
active drugs or destructive therapies. Similarly, these
therapies would not be indicated if sympathetic blockade
failed to relieve the pain. If blockade did succeed in
relieving this type of pain, further blocks may effect lasting
relief.
There are a number of other conditions in which the
diagnosis is clear but there is a possible contribution of
sympathetic activity in the pathogenesis of the pain. These
conditions include central pain, post-herpetic neuralgia,
trigeminal neuralgia, peripheral vascular disease and
others. Blockade of sympathetic activity may help to clarify
the sympathetic contribution to the pain and therefore help
to indicate management options.
 5
CHAPTER
66
Autonomic blockade

5.1 STELLATE GANGLION Block—C6

(CLASSIC) APPROACH
Anatomy Position of patient
The cervical sympathetic trunk—the superior, middle, and • Supine.
stellate ganglia—supplies the sympathetic innervation of • Thin pillow under head.
the head, neck, and upper limbs. The stellate ganglion is • Roll under neck.
made up of a combination of the lower cervical and first • Eyes directed at ceiling.
thoracic ganglia. It lies on the prevertebral fascia of the
• Mouth slightly open.
seventh cervical and first thoracic vertebrae (Fig. 5.1.1).
However, as the sixth cervical anterior tubercle
(Chassaignac’s tubercle) is easy to palpate, injection of a Needle puncture and technique
large volume of local anesthetic is made at this level and Caution: Injection of 0.5–1 ml of lidocaine (lignocaine)
allowed to track caudally along the prevertebral fascia to 1% into the vertebral artery may result in immediate
block the stellate ganglion. The vertebral and carotid convulsion and/or loss of consciousness with possible
arteries, the pleura, and the brachial plexus are in close cardiovascular system (CVS) collapse.
proximity to the stellate ganglion.
• Intravenous access is inserted.
• Monitors are attached, each temperature probe is
Equipment attached to the palmar aspect of the middle finger of
• 10 ml syringe each hand (Fig. 5.1.2).
• 22 G short-bevel needle • Resuscitation equipment and drugs are checked and
• Extension set (optional) made ready for use.
• ECG, BP, SpO2 monitors • The side of the neck is cleaned with antiseptic solution.
• Skin temperature monitor • It is best to stand at the same side of the neck as the
• Resuscitation equipment (see Appendix 3) ganglion to be blocked.
• Ultrasound (optional) FOR THE RIGHT-HANDED OPERATOR
With the left hand
Drugs • The thyroid cartilage is located and marked.
• Lidocaine (lignocaine) 1%, 10 ml • The cricoid cartilage is identified and marked
• Resuscitation drugs (see Appendix 3) (Figs 5.1.3, 5.1.4).

Temperature probe

Stellate
ganglion

C6

C7

Fig. 5.1.1  Fig. 5.1.2 

 67
5.1  •  Stellate ganglion block—C6 (classic) approach

Fig. 5.1.3  Fig. 5.1.6 

Thyroid cartilage

Cricoid cartilage

C6 anterior
tubercle

Fig. 5.1.4  Fig. 5.1.7 

Muscles • Chassaignac’s tubercle is palpated with the middle finger,

just lateral to the cricoid cartilage (Fig. 5.1.5).
• The sternocleidomastoid (SCM) muscle is gently pulled
laterally and the carotid pulse is palpated (Fig. 5.1.6).
• Chassaignac’s tubercle is palpated again and positioned
between the fore- and middle fingers.
With the right hand
• The needle is inserted between the fore- and middle
fingers of the other hand, directly perpendicular
to the floor, aiming for Chassaignac’s tubercle
(Figs 5.1.7, 5.1.8).
• When contact with the tubercle is reached, the injecting
hand is steadied and the needle is withdrawn 2 mm.
• The hub of the needle is held in place with the
Fig. 5.1.5  other hand.
 5
CHAPTER
68
Autonomic blockade
Fig. 5.1.8  Fig. 5.1.9
• After negative aspiration, lidocaine (lignocaine) 1%,
0.5 ml, is injected.
• The patient is questioned about sensation and any
change in level of consciousness is noted.
• If negative, the same procedure is repeated as 0.5 ml
boluses are given until 10 ml is injected.
• The needle is withdrawn and the patient is immediately
put in the sitting position.
• Monitors should be left attached and i.v. access left in
situ for at least 30 minutes. The patient is requested not
to eat or drink for 2 hours, as the recurrent laryngeal
nerve may be blocked.
• Note: if aspiration of blood occurs during the block the
needle is removed and cleared, keeping left fore- and
middle fingers in place. It is then reinserted and the
block is continued as above.
• If hematoma occurs before the solution is injected
it may be worth performing the block at the
C7 level.
• If there is pain on injection and/or paresthesia, it is
likely that the brachial plexus may have been contacted,
the needle is withdrawn and the landmarks are
rechecked.
Confirmation of a successful block
• Skin temperature, measured over the palmar aspect
of the hand or fingers on the blocked side, should begin
to rise within 2–3 minutes. Extensive sympathetic
blockade is confirmed by a rise in skin temperature to
> 33 °C.
• Ptosis of eyelid.
• Miosis of pupil.
• Unilateral blockage of nose on side of block.
• Unilateral flushing of conjunctiva of eye on side of
block.
 
• Blockade of the upper sympathetic chain can occur in
the absence of sympathetic denervation of the upper
extremity, resulting in Horner’s syndrome without a rise
in skin temperature in the hand.
Tips
• The external jugular vein usually crosses the SCM
muscle at the level of C6.
• Skin infiltration prior to block should be avoided if
possible, as this will make landmarks more difficult to
locate.
• If palpation is painful or difficult it may be helpful to
try to bounce the middle finger off the tubercle during
identification.
• An extension set may be inserted between the needle
and syringe for better stability of needle (Fig. 5.1.9), but
an assistant is then required to continue the procedure
as described above.
• Consideration should be given to performance of the
block under fluoroscopy or CT control if the landmarks
are difficult to locate.
• Lidocaine (lignocaine) 1% 15 ml may be given if a
previous block failed to relieve sympathetically
maintained pain in the presence of correctly placed
solution. This may improve tracking of the solution
caudally to produce more effective blockade of the
stellate ganglion.
• Ultrasound may aid placement of needle
(Fig. 5.1.10 a,b).
Potential problems
• Intra-arterial injection or intrathecal injection may result
in immediate convulsion and/or loss of consciousness
with possible CVS collapse.
 69
5.1  •  Stellate ganglion block—C6 (classic) approach

Fig. 5.1.10  From Gupta Prashant K, Gupta Kumkum, Dwivedi Amit Nandan D, Jain Manish. Potential role of ultrasound in anesthesia
and intensive care, Anesthesia Essays and Research, 2011 Volume 5, Issue Number 1, Page: 11-19.

• Hematoma may occur (avoid performing block on
patients who have coagulopathy).
• Pneumothorax may occur.
• Recurrent laryngeal nerve block may occur and it is
prudent to advise the patient about possible hoarseness
post-blockade. Bilateral stellate ganglion blockade
should be avoided for the same reason.
• Phrenic nerve block may occur and it is prudent to
caution the patient about possible shortness of breath
post blockade of the stellate ganglion.
 5
CHAPTER
70
Autonomic blockade

5.2 STELLATE GANGLION BLOCK—C7 APPROACH

Anatomy • Resuscitation equipment (see Appendix 3)

• Ultrasound (optional)
As for stellate ganglion block (C6 approach) in Section 5.1
(Figs 5.2.1 a,b).
Drugs
Equipment • Lidocaine (lignocaine) 1%, 10 ml
• Resuscitation drugs (see Appendix 3)
• 10 ml syringe
• 22 G short-bevel needle
Position of patient
• Extension set (optional)
• Supine.
• ECG, BP, SpO2 monitors
• Thin pillow under head.
• Skin temperature monitor
• Roll under neck.
• Fluoroscopy or CT (optional)
• Eyes directed at ceiling.
• Mouth slightly open.

C5
Needle puncture and technique
Caution: injection of 0.5–1 ml of lidocaine (lignocaine)
1% into the vertebral artery may result in immediate
Middle
cervical convulsion and/or loss of consciousness with possible
C6 ganglion cardiovascular (CVS) collapse. The risk of pneumothorax
is greater with this approach.
Stellate • Intravenous access is inserted.
ganglion • Monitors are attached.
• Each temperature probe is attached to the palmar aspect
Vertebral of the middle finger of each hand. (Fig. 5.2.2).
T1 artery
• Resuscitation equipment and drugs are checked and
made ready for use.
Common
• The side of the neck is cleaned with antiseptic solution.
carotid
artery

A Right subclavian Lung

artery Temperature probe

Longus colli

C2
Superior stellate
ganglion C3 Anterior
C4 scalenus
C5
Middle ganglion C6 Medius
C7
scalenus
Stellate T1
ganglion
Subclavian
artery

Dome of pleura

1st rib

B Carotid artery
Fig. 5.2.1  Fig. 5.2.2 

• It is best to stand at the same side of the neck as the
ganglion to be blocked.
FOR THE RIGHT-HANDED OPERATOR
With the left hand
• The thyroid cartilage is located and marked.
• The cricoid cartilage is identified and marked
(Figs 5.2.3, 5.2.4).
• The sternoclavicular junction is palpated and marked
(Fig. 5.2.5).
• The SCM muscle is gently pulled laterally and the
carotid pulse is palpated (Fig. 5.2.6).
• The site of insertion of the needle lies 3 cm above the
sternoclavicular junction or one to two finger-breadths
below the level of the cricoid cartilage.
Fig. 5.2.3 
Thyroid cartilage
Cricoid cartilage
C6 anterior
tubercle
Fig. 5.2.4  Fig. 5.2.6
71
5.2  •  Stellate ganglion block—C7 approach
With the right hand
• The patient is requested to exhale deeply before needle
insertion to minimize the risk of pneumothorax.
• The needle is inserted between the fore- and middle
fingers of the other hand, directly perpendicular to the
floor.
• When contact with the transverse process of C7 is
reached, the injecting hand is steadied and the needle is
withdrawn 2 mm.
• The hub of the needle is held in place with the
other hand.
• After negative aspiration, lidocaine (lignocaine) 1%,
0.5 ml, is injected.
• The patient is questioned about sensation, and any
change in level of consciousness is noted.
• If negative, the same procedure is repeated and 0.5 ml
boluses are given until 5–8 ml is injected.
• The needle is withdrawn and the patient is immediately
put in the sitting position.
Muscles
Fig. 5.2.5 
 
 5
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72
Autonomic blockade
• Monitors should be left attached and i.v. access left in
situ for at least 30 minutes. Blockade of the recurrent
laryngeal nerve is less likely with the C7 approach but
it is wise to advise the patient not to eat or drink for
2 hours.
• Note: if aspiration of blood occurs during the block, the
needle is removed and cleared, keeping the left fore- and
middle fingers in place. It is then reinserted and the
block is continued as above.
• If there is pain on injection and/or paresthesia, it is
likely that the brachial plexus may have been contacted,
the needle is withdrawn and the landmarks are
rechecked.
• Ultrasound may aid placement of the needle.
Confirmation of a successful block
• Temperature increase >1° on the side of block. The
temperature should begin to rise in the finger of the
blocked side within 3 minutes of injection.
• Ptosis of eyelid.
• Miosis of pupil.
• Unilateral blockage of nose on side of block.
• Unilateral flushing of conjunctiva of eye on side
of block.
• Relief of sympathetically maintained pain.
Tips
• Some workers advocate targeting the ventrolateral
aspect of the C7 vertebral body instead of its transverse
process. The needle is directed 15–20° medially. With
the aid of fluoroscopy, ultrasound or CT, the vertebral
body is contacted just medial to the insertion of the
longus colli muscle. The needle is then withdrawn
2 mm, stabilized, and 1 ml of non-ionic contrast
medium is injected.
• The external jugular vein usually crosses the SCM
muscle at the level of C6.
• Skin infiltration prior to block should be avoided if
possible, as this will make landmarks more difficult
to locate.
• An extension set may be inserted between the needle
and syringe for better stability of needle, but an assistant
is then required to continue the procedure as described
above.
• Lidocaine (lignocaine) 1% 10 ml may be given if a
previous block failed to relieve sympathetically
maintained pain in the presence of correctly placed
solution. This may improve tracking of the solution
caudally to produce more effective blockade of the
stellate ganglion.
Potential problems
• Intra-arterial injection or intrathecal injection may result
in immediate convulsion and/or loss of consciousness
with possible CVS collapse.
• Hematoma may occur (avoid performing block on
patients who have coagulopathy).
• Pneumothorax may occur (more likely with C7
approach).
• Recurrent laryngeal nerve block may occur and it is
prudent to advise the patient about possible hoarseness
post blockade. Bilateral stellate ganglion blockade
should be avoided for the same reason.
• Phrenic nerve block may occur and it is prudent to
caution the patient about possible shortness of breath
following blockade of the stellate ganglion.

5.3 LUMBAR SYMPATHETIC BLOCK
Anatomy
The lumbar sympathetic chain is located in the prevertebral
fascia, which lies on the anterolateral aspects of the
vertebral bodies. The psoas muscle separates the lumbar
sympathetic chain from the lumbar somatic nerves. A
single injection of local anesthetic at the level of L2 will
usually provide a complete block of postganglionic
sympathetic efferents to the lower extremity because the
lowest preganglionic sympathetic outflow to the chain is at
the level of L2.
Equipment
• 2 ml, 5 ml, and 10 ml syringes
• 30 G needle
• Two 15 cm 22 G needles
• Extension set (optional)
• ECG, BP, SpO2 monitors
• Skin temperature monitor (two probes)
• Resuscitation equipment (see Appendix 3)
• Fluoroscopy
Drugs
• Lidocaine (lignocaine) 1%, 5 ml for skin infiltration
• Lidocaine (lignocaine) 1%, 15–20 ml (or its equivalent)
for block
• Phenol 6%
• Radio-opaque contrast medium
• Resuscitation drugs (see Appendix 3)
Fig. 5.3.1 
73
5.3  •  Lumbar sympathetic block
Position of patient
• Prone.
• Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.3.1).
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Each temperature probe is attached to the plantar aspect
of the big toe (Fig. 5.3.2).
• Resuscitation equipment and drugs are checked and
made ready for use.
• The thoracolumbar midline and an area 10 cm × 5 cm
laterally is cleaned with antiseptic solution and a
fenestrated drape is placed over the sterile area.
• The twelfth rib is identified and a line is drawn along its
inferior border (Fig. 5.3.3 a,b).
• The iliac crests are palpated and the intercrestal line is
identified (this corresponds with the inferior aspect of the
spinous process of L4 or may lie in the L4–5 interspace).
• The spinous processes are counted until L2 is identified
and confirmed with fluoroscopy.
• The insertion point lies 8 cm lateral to the L2 spinous
process and is also marked (Fig. 5.3.4).
• A skin wheal is raised at one of the marked sites and
the area is infiltrated with lidocaine (lignocaine) 1%.
• At a 30° angle to the frontal plane, a 22 G 15 cm
needle is advanced slightly cephalad towards the lower
 5
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74
Autonomic blockade

Temperature probe

Fig. 5.3.2 

portion of the L2 vertebral body (Fig. 5.3.5), until its

vertebral body is contacted at a depth of about 7–9 cm
and confirmed with fluoroscopy. If the needle contacts
bone at a more superficial level, it is probable that it has
come into contact with the transverse process and it will
need to be repositioned.
• The needle depth is noted.
• The needle is then withdrawn to the subcutaneous tissue
and, with the aid of fluoroscopy, it is re-advanced, this A
time at an angle 45° to the frontal plane, until the
previous depth (as noted) is reached. It should slip past
the vertebral body at a depth about 1–2 cm deeper than
the first depth mark (Fig. 5.3.6).
• After negative aspiration, the fluoroscopic image is
observed as a small amount of non-ionic radio-contrast
medium is injected. The correct placement of the needle L2
is indicated by the presence of a layer of contrast
medium in a thin line along the anterior border of the
vertebral column (Figs 5.3.7–5.3.9).
• After further negative aspirations, 5 ml of lidocaine
(lignocaine) 1% is injected. The patient is questioned
about pain relief and observations of skin temperature
are made. There should be little resistance to injection,
similar to resistance felt when injecting through an
epidural needle. If resistance is encountered, or if the
injection is painful, the needle should be repositioned. A
unilateral rise in skin temperature indicates a successful
block.
• After 10 minutes the patient is questioned about pain
relief and any symptoms of somatic nerve blockade. B
Sensory and motor functioning of the lower extremities
Fig. 5.3.3 
is checked. The procedure should be abandoned if there
is evidence of somatic blockade.
 75
5.3  •  Lumbar sympathetic block

8 cm 2 1

8cm

10cm

Kidney Sympathetic chain

Vena cava Aorta
Thoracic duct
Fig. 5.3.6 

Fig. 5.3.4  • Neurolysis may be achieved by leaving the needle in

place after block has been confirmed and injecting 5 ml
phenol 6%. To avoid leaving alcohol in the needle tract,
the needle is then cleared with air or local anesthetic
1 ml, and removed. However, because of the very high
incidence of genitofemoral neuralgia that can occur
post-neurolytic lumbar sympathetic block, the benefit
versus risk should be considered carefully.
• Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.

Confirmation of a successful block

• Increase in skin temperature on the plantar surface of
the foot to about 35 °C; temperature should begin to
rise in the foot on the side of the block within 3 minutes
of injection of local anesthetic.
• Relief of sympathetically maintained pain in the
lower limb.

Tips
• If fluoroscopy is not available ultrasound may aid
placement of the needle. A line 10 cm from the midline
is drawn parallel to the midline; the lowest rib is
identified and a line is drawn along its inferior border.
• The point of intersection of these lines should be lateral
to the L2 vertebral body.
• Consideration should be given to performance of the
block under CT control if the block is unsuccessful.
• Repeated blocks may bring about gradual improvement
in sympathetically maintained pain.
• Immediate physiotherapy after blockade may improve
Fig. 5.3.5  the outcome.
 5
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76
Autonomic blockade

Fig. 5.3.7 

Fig. 5.3.9 

Potential problems
• If the needle tip is placed too superficially, the tip may
come to lie in the intervertebral foramen and injection
may result in a subarachnoid block, an epidural block,
or a somatic nerve block. Confirmation of needle
position using lateral fluoroscopy is therefore
recommended.
• Genitofemoral neuralgia may occur in 5–10% of
patients post-neurolytic block causing pain in the groin.
• Perforation of the aorta or the inferior vena cava is
possible and retroperitoneal hematoma may occur.
Consequently the block should be avoided in patients
with coagulopathy.
• Intravascular injection may occur.
• Perforation of the kidney or ureter is usually of no
clinical significance unless neurolytic agents are used.
• Perforation of the intervertebral disc may occur. This
also is usually of no clinical significance but may produce
a septic discitis if bacterial contamination occurs.
• Postural hypotension, secondary to sympathetic
blockade, may occur.
• Injection of neurolytic solution into the psoas muscle
may cause rhabdomyolysis.
Fig. 5.3.8  • Patients in the prone position should be monitored
carefully when intravenous sedation is administered.
 77
5.4  •  Celiac plexus block—retrocrural approach

5.4 CELIAC PLEXUS BLOCK—RETROCRURAL APPROACH

Anatomy
The celiac plexus is flat and lies against the crus of the
diaphragm, surrounding the root of the celiac and
mesenteric arteries and anterior to three vertebral bodies
centered at L1. Posteriorly on the left side is the aorta, and
on the right is the inferior vena cava. The kidneys lie
lateral and the pancreas anterior to the celiac plexus
(Fig. 5.4.1 a,b).
The celiac plexus is made up of pre- and postganglionic
sympathetic and parasympathetic nerve fibers.
Postganglionic sympathetic fibers are supplied from the
paired celiac ganglia. Preganglionic sympathetic efferents
from the thoracic sympathetic chain are supplied via the
greater and lesser splanchnic nerves. The intra-abdominal
viscera are supplied by postganglionic sympathetic fibers
Celiac artery
Celiac plexus
Liver
that have synapsed in the celiac ganglia (Fig. 5.4.2). The
vagus nerve also supplies parasympathetic nerve fibers. Via
the celiac plexus dorsal root, ganglion cells innervate the
whole of the abdominal viscera, including the liver, spleen,
kidneys, suprarenal glands, and intestines, with the
exception of the pelvic organs, the rectum, and the left half
of the colon.
Pain originating from the viscera is often vague and poorly
localized as a result of convergence of neurons in the
dorsal horn and crossing over the midline of some of the
visceral afferents.
There are two main approaches to celiac plexus blockade.
One approach places the two needles posterior to the crura
of the diaphragm, the retrocrural approach. The
retrocrural approach to the celiac plexus also targets the
splanchnic nerves to produce a splanchnic nerve block if
required. The other approach places a needle anterior to
the crus of the diaphragm on the right, the anterocrural
approach (Fig. 5.4.3), as discussed in Section 5.5.
Sympathetic chain

Dorsal root
Inferior Thoracic
Aorta vena cava spinal cord

Splanchnic
nerve
Somatic nerve
Kidney Kidney

A L1 Diaphragmatic crus Grey

ramus

Aorta
Ventral root
Diaphragm White ramus Vagus nerve

Retrocrural spread
Splanchnic nerve
Celiac plexus

Celiac
ganglion
Anterocrural
spread Viscus

Splanchnic nerves
Diaphragmatic
crus
Superior
B B mesenteric ganglion
Fig. 5.4.1  Fig. 5.4.2 
 5
CHAPTER
78
Autonomic blockade

Equipment RETROCRURAL APPROACH

• A 15 cm 22 G spinal needle is selected. A slight curve at
• 2 ml, 5 ml, and 10 ml syringes
the needle tip, away from the bevel direction, may be
• 30 G needle created, which allows the needle to be redirected during
• Two 15 cm 22 G needles placement.
• Extension set (optional) • An AP view of the upper lumbar/low thoracic spine is
• ECG, BP, SpO2 monitors obtained and the C-arm is adjusted to superimpose the
• Resuscitation equipment (see Appendix 3) T12–L1 endplates.
• Fluoroscopy • A skin wheal is raised at the lower border of the
twelfth rib on the right just above the level of the L1
Drugs transverse process (Fig. 5.4.5 a). The needle is inserted
at this site and advanced at an angle 30° from
• Mild sedative
perpendicular inward until the L1 body is contacted
• Lidocaine (lignocaine) 1%, 5 ml for skin infiltration
just below the upper endplate (Fig. 5.4.5). The curve
• Lidocaine (lignocaine) 1%, 15–20 ml (or its equivalent) of the needle is turned laterally and the needle is
for block advanced along the upper portion of the body. Once the
• 6% aqueous phenol or 50–75% alcohol (ethanol). Our needle has slipped a few millimeters past the lateral
suggestion: mix 2 parts absolute alcohol with one part aspect of the L1 body, a lateral view is obtained.
1% lidocaine. This will help reduce the incidence and The curve of the needle is directed inward toward the
severity of pain following injection. In addition, precede body and advanced until the tip lies at the anterior
all alcohol injections with 3–4 ml 1% lidocaine border of the body, near the upper endplate, in a direct
• Non-ionic radio-opaque contrast medium lateral view.
• Resuscitation drugs (see Appendix 3) • Using “live” fluoroscopy, 1 ml non-ionic contrast
medium is injected. The dye should remain against the
Position of patient anterior aspect of the bodies in the lateral view
• Prone. (Fig. 5.4.6 a).
• Pillow under anterior superior iliac spine to flatten the • If dye is seen spreading dorsally toward the neural
normal lumbar lordosis (Fig. 5.4.4). foramina (see Fig. 5.4.6 b), the needle should be
withdrawn and repositioned at a higher level.
• An AP view is obtained, which should demonstrate dye
Needle puncture and technique spread against the lateral aspect of the bodies
• Intravenous access is inserted. (Fig. 5.4.6 c).
• Monitors are attached. • Spread more laterally indicates injection within the
• Resuscitation equipment and drugs are checked and psoas muscle, in which case the needle should be
made ready for use. repositioned more medially and anteriorly. 3 ml
• Mild sedation may be induced. 1% lidocaine is then injected. The dye shadow will

Greater splanchnic nerve Thoracic duct

Paravertebral T10 Azygos vein
sympathetic trunk Diaphragm

Lesser splanchnic T11 Celiac plexus

nerve

T12
Celiac axis

L1 Superior
mesenteric
artery
L2
Classic Aorta
celiac block

Prevascular celiac block

Fig. 5.4.3  Fig. 5.4.4 
 79
5.4  •  Celiac plexus block—retrocrural approach

R L
L1

12th Rib 12th Rib

L3 L2 L1

Kidney Aortic Kidney Liver

artery

Pancreas Inferior
A B vena cava

C Fig. 5.4.5 

A B

Fig. 5.4.6 
 5
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80
Autonomic blockade

C D

E
Fig. 5.4.6, cont’d

be seen to expand superiorly, spreading to the
thoracic levels to contact the splanchnic nerves
(see Fig. 5.4.6 d).
• After confirming negative aspiration for blood,
15–20 ml alcohol or phenol is injected. The needle is
cleared with 1 ml lidocaine prior to removal.
• Alternatively, the needle can be advanced more
cephalad to a position at the anterior border of T12
preferably near either the lower or upper endplate
(Fig. 5.4.6 e).
• Injection near the mid-point of the body is more likely
to result in dorsal spread of the drug toward the neural
foramen. More cephalad placement is a bit more
difficult technically, but places the needle closer to the
splanchnic nerves.
• The procedure is repeated in an identical manner on the
left side.
Confirmation of a successful block
• Relief of upper abdominal pain.

Tips
• After injection of non-ionic radio-contrast medium, a
blush will indicate injection into muscle. If visible
contrast medium disappears immediately it is likely that
intravascular injection has occurred.
• Consideration should be given to performance of
the block under CT control if the block is
unsuccessful.
• Placement of the needle anterior to the diaphragmatic
crus can also be achieved via insertion through the
abdominal wall.
Potential problems
• The position of each needle tip should always be
confirmed with fluoroscopy before injection of neurolytic
agent as it may lie in the peritoneal cavity, within a
viscus or intravascularly. If a needle tip is placed too
superficially, the tip may come to lie in the intervertebral
foramen and injection may result in an epidural block or
a somatic nerve block. Injection of neurolytic solution
into the psoas muscle may cause rhabdomyolysis.
• Perforation of the aorta or the inferior vena cava is
possible and consequently the block should be avoided
in patients with coagulopathy. Dissection of the aorta
81
5.4  •  Celiac plexus block—retrocrural approach
may occur as a result of direct damage during the block.
Retroperitoneal hematoma may occur and for this
reason also the block should be avoided in patients with
coagulopathy.
• Orthostatic hypotension may occur as a result of
sympathetic blockade for up to 3 days after a neurolytic
block. Diarrhea may occur also and hydration of the
patient should be monitored.
• Pneumothorax may occur.
• Transient motor paralysis and paraplegia may occur
after the block, probably as a result of spasm of the
segmental arteries.
• Perforation of the intervertebral disc may occur, but this
also is usually of no clinical significance.
• Perforation of the kidney or ureter is usually of
no clinical significance unless neurolytic agent is
injected.
• The thoracic duct may be damaged (possibly causing
chylothorax, or lymphedema).
• Abdominal and chest discomfort may be experienced for
30 minutes after injection of alcohol.
• There may be a detectable odor from the breath after
alcohol injection.
• Patients in the prone position should be monitored
carefully when intravenous sedation is administered.
 5
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82
Autonomic blockade

5.5 CELIAC PLEXUS BLOCK—ANTEROCRURAL APPROACH

Anatomy • Lidocaine (lignocaine) 1%, 15–20 ml (or its equivalent)

The anterocrural approach places a needle anterior to each
crus of the diaphragm. The needles are inserted more
medially and directed at a larger angle towards the midline
until they come to lie in the retroperitoneal compartment
between the aorta, and the inferior vena cava dorsally, and
the pancreas ventrally (Fig. 5.5.1). Fluoroscopic imaging is
necessary for accurate placement of the anterocrural needles
using this approach.
Equipment
• 2 ml, 5 ml, and 10 ml syringes
• 30 G needle
• 15 cm 22 G needle (penetration of the diaphragmatic
crus is easier with a large gauge needle)
• Extension set (optional)
• ECG, BP, SpO2 monitors
• Resuscitation equipment (see Appendix 3)
• Fluoroscopy
Drugs
• Mild sedative
• Lidocaine (lignocaine) 1%, 5 ml for skin infiltration
for block
• 6% aqueous phenol or 50–75% alcohol (ethanol).
Our suggestion: mix 2 parts absolute alcohol with
one part 1% lidocaine. This will help reduce the
incidence and severity of pain following injection. In
addition, precede all alcohol injections with 3–4 ml 1%
lidocaine
• Non-ionic radio-opaque contrast medium
• Resuscitation drugs (see Appendix 3)
Position of patient
• Prone.
• Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.5.2).
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• Mild sedation may be induced.

Aorta

Diaphragm

Retrocrural spread

Celiac plexus

Anterocrural
spread

Splanchnic nerves

Diaphragmatic
crus

Fig. 5.5.1 

Fig. 5.5.2 
• The thoracolumbar midline and area 10 cm × 5 cm
laterally is cleaned with antiseptic solution and a
fenestrated drape is placed over the sterile area.
• The twelfth rib and L1 are identified and confirmed
with fluoroscopy.
ANTEROCRURAL APPROACH
Right side
• A 15 cm 22 G spinal needle is selected. A slight curve at
the needle tip, away from the bevel direction, may be
created which allows the needle to be redirected during
placement.
• An AP view of the upper lumbar/low thoracic spine is
obtained and the C-arm is adjusted to superimpose the
T12–L1 endplates.
• A skin wheal is raised at the lower border of the twelfth
rib on the right just above the level of the L1 transverse
process. The needle is inserted at this site and advanced
at an angle 30° from perpendicular inward until the L1
body is contacted just below the upper endplate.
• The curve of the needle is turned laterally and the needle
is advanced along the upper portion of the body.
• Once the needle has slipped a few millimeters past
the lateral aspect of the L1 body, a lateral view is
obtained.
• The needle is advanced until the tip is 1.5–2 cm anterior
to the anterior border of the L1 body. The needle is
aspirated and if negative, 1 ml non-ionic contrast is
injected. Dye spread should be in an amorphous pattern
(Fig. 5.5.3).
• If aspiration is negative, 3 ml 1% lidocaine (lignocaine)
is injected. If no nerve block is noted after 10 minutes,
this is followed by 15–20 ml alcohol. If phenol is used,
the lidocaine is not needed.
83
5.5  •  Celiac plexus block—anterocrural approach
• 1 ml 1% lidocaine is injected before removing the needle
to clear it.
Left side
• The same procedure is repeated on the left.
• The needle is positioned 1.5–2 cm anterior to the
anterior border of the L1 body. It is then usually
within the aorta, and aspiration is positive for arterial
blood.
• The needle is advanced forward until aspiration is
negative for blood (Fig. 5.5.3 b).
• 1 ml contrast is injected. The pattern is generally
amorphous anteriorly, but a straight border of dye along
the anterior surface of the aorta may be seen (Fig. 5.4.4).
• Aspiration is repeated and, if negative, 3 ml 1%
lidocaine (lignocaine) is injected. If no nerve block is
noted after 10 minutes, this is followed by 15–20 ml
alcohol. If phenol is used, the lidocaine is not needed.
• 1 ml 1% lidocaine is injected before removing the needle
to clear it.
• Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.
Confirmation of a successful block
• Relief of upper abdominal pain.
Tips
• After injection of non-ionic radio-contrast medium, a
blush will indicate injection into muscle. If visible
contrast medium disappears immediately it is likely that
intravascular injection has occurred.
• Consideration should be given to performance of the
block under CT control if the block is unsuccessful.
 5
CHAPTER
84
Autonomic blockade

R L
L1

12th Rib 12th Rib

L3 L2 L1

Kidney Aortic Kidney Liver

artery

Pancreas Inferior
A B vena cava

Greater splanchnic nerve Thoracic duct

Paravertebral T10 Azygos vein

sympathetic trunk
Diaphragm

Lesser splanchnic T11 Celiac plexus

nerve

T12
Celiac axis

L1 Superior
mesenteric
artery

L2
Classic
Aorta
celiac block

C Prevascular celiac block

Fig. 5.5.3 

• Perforation of the aorta or the inferior vena cava is

Potential problems
• The position of each needle tip should always be
confirmed with fluoroscopy prior to injection of
neurolytic agent as it may lie in the peritoneal cavity,
within a viscus or intravascularly. If a needle tip is
placed too superficially, the tip may come to lie in the
intervertebral foramen and injection may result in
epidural block or a somatic nerve block. Injection of
neurolytic solution into the psoas muscle may cause
rhabdomyolysis.
possible and consequently the block should be avoided
in patients with coagulopathy. Dissection of the aorta
may occur as a result of direct damage during the block.
Retroperitoneal hematoma may occur and for this
reason also the block should be avoided in patients with
coagulopathy.
• Orthostatic hypotension may occur as a result of
sympathetic blockade for up to three days after a
neurolytic block. Diarrhea may occur also and hydration
of the patient should be monitored.

• Pneumothorax may occur.
• Transient motor paralysis and paraplegia may occur
after the block, probably as a result of spasm of
segmental arteries.
• Perforation of the intervertebral disc may occur, but this
also is usually of no clinical significance.
• Perforation of the kidney or ureter is usually of no
clinical significance unless neurolytic agents are injected.
85
5.5  •  Celiac plexus block—anterocrural approach
• The thoracic duct may be damaged (possibly causing
chylothorax, or lymphedema).
• Abdominal and chest discomfort may be experienced for
30 minutes after injection of alcohol.
• There may be a detectable odor from the breath after
alcohol injection.
• Patients in the prone position should be monitored
carefully when intravenous sedation is administered.
 5
CHAPTER
86
Autonomic blockade

5.6 HYPOGASTRIC PLEXUS BLOCK

Anatomy Equipment
The superior hypogastric plexus is formed from pelvic • 2 ml, 5 ml, and 10 ml syringes
sympathetic fibers of the aortic plexus and L2 and L3 • 30 G needle
splanchnic nerves. These afferent and efferent fibers • Two 15 cm 22 G needles
innervate the pelvic viscera, including the uterus, bladder, • Extension set (optional)
vagina, and prostate. The plexus is located between the
• ECG, BP, and SpO2 monitors
upper third of the first sacral vertebral body and the lower
• Resuscitation equipment (see Appendix 3)
third of the fifth lumbar vertebral body, at the sacral
promontory, in the retroperitoneal space (Fig. 5.6.1 a,b). • Fluoroscopy
Parasympathetic nerve fibers from S2–S4 pass through the
inferior hypogastric plexus.

Inferior vena cava

Aorta

Superior
hypogastric plexus

Psoas major
muscle
Superior
rectal artery

Internal iliac
artery and vein

External iliac
artery and vein

Fig. 5.6.1 

Drugs
• Lidocaine (lignocaine) 1%, 5 ml for skin infiltration
• Lidocaine (lignocaine) 1%, 15–20 ml (or its equivalent)
for block
• Phenol 6%
• Non-ionic radio-opaque contrast medium
• Resuscitation drugs (see Appendix 3)
Position of patient
• Prone.
• Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.6.2).
Needle puncture and technique
• Intravenous access is inserted.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The lumbosacral midline and area 10 cm × 5 cm
laterally is cleaned with antiseptic solution and a
fenestrated drape is placed over the sterile area.
• The iliac crests are palpated and the intercrestal line is
identified (this corresponds with the inferior aspect of
the spinous process of L4 or may lie in the L4–5
interspace).
• The spinous processes are counted until the L5–S1
interspace is identified and confirmed with fluoroscopy.
• The insertion points lie 2 cm lateral and 2 cm cephalad
to the space between the L5 transverse process and the
sacrum (Fig. 5.6.3 a,b).
• A skin wheal is raised at one of the marked sites and
the area is infiltrated with lidocaine (lignocaine) 1%.
• At a 30° angle to the frontal plane, a 22 G 15 cm
needle is advanced, aimed slightly caudad towards the
L5–S1 interspace (Fig. 5.6.3 c), until the lower part of
Fig. 5.6.2  injection has occurred.
87
5.6  •  Hypogastric plexus block
the L5 vertebral body is contacted at a depth of about
7–9 cm and confirmed with fluoroscopy. If the needle
contacts bone at a more superficial level, it is probable
that it has come into contact with the L5 transverse
process or the sacrum and needs to be repositioned.
• The needle depth is noted.
• The needle is then withdrawn to the subcutaneous tissue
and, with the aid of fluoroscopy, it is re-advanced, this
time at an angle 45° to the frontal plane (or with slight
concavity of the needle) until the previous depth (as
noted) is reached. It should slip past the vertebral body
at a depth about 1–2 cm deeper than the first depth
mark, to lie just anterior to the upper portion of the
sacrum (Fig. 5.6.4).
• After negative aspiration, the fluoroscopic image is
observed as a small amount of non-ionic radio-contrast
medium is injected (Fig. 5.6.5). The correct placement of
the needle is indicated by the presence of a collection of
contrast medium just anterior to the upper portion of
the sacrum or the L5–S1 interspace (Fig. 5.6.6). The
contrast medium usually spreads in all directions, not
usually along the sacrum.
• The procedure is repeated on the other side in a
mirrored fashion (Figs 5.6.7, 5.6.8).
• After further negative aspirations, 5 ml of lidocaine
(lignocaine) 1% is injected bilaterally and the patient is
questioned about pain relief. There should be little
resistance to injection, similar to that felt when injecting
through an epidural needle. If resistance is encountered,
or if the injection is painful, the needle should be
repositioned.
• After 10 minutes the patient is questioned about pain
relief and any symptoms of somatic nerve blockade.
Sensory and motor functioning of the lower extremities
is checked. The procedure should be abandoned if there
is evidence of somatic blockade.
• After confirmation of pain relief and lack of somatic
block, 6 ml phenol 6% is injected through each needle
using glass syringes. The needles are then cleared with
air or local anesthetic 1 ml, and removed.
• Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.
• Ultrasound may help placement of the needle
(Figs 5.6.9–5.6.10).
Confirmation of a successful block
• Relief of lower abdominal pain.
Tips
• After injection of non-ionic radio-contrast medium, a
blush will indicate injection into muscle. If this
disappears immediately it is likely that intravascular
 5
CHAPTER
88
Autonomic blockade

B C

Fig. 5.6.3 

• Consideration should be given to performance of the
block under CT control if the block is unsuccessful
(Fig. 5.6.10).
• Perforation of the aorta or the inferior vena cava is
Potential problems
• The position of each needle tip should always be
confirmed with fluoroscopy prior to injection of
neurolytic agents as it may lie in the peritoneal cavity,
within a viscus or intravascularly. If a needle tip is
placed too superficially, the tip may come to lie in the
intervertebral foramen and injection may result in an
epidural block or a somatic nerve block. Injection of
neurolytic solution into the psoas muscle may cause
rhabdomyolysis.
possible and consequently the block should be avoided
in patients with coagulopathy. Dissection of the aorta
may occur as a result of direct damage during the block.
Retroperitoneal hematoma may occur and for this
reason also the block should be avoided in patients with
coagulopathy.
 89
5.6  •  Hypogastric plexus block

Fig. 5.6.4  Fig. 5.6.6 

Fig. 5.6.5  Fig. 5.6.7 

 5
CHAPTER
90
Autonomic blockade

• Orthostatic hypotension may occur as a result of

sympathetic blockade for up to three days after a
neurolytic block. Diarrhea may occur also and hydration
of the patient should be monitored.
• Transient motor paralysis and paraplegia may occur
after the block, probably as a result of spasm of
segmental arteries.
• Perforation of the intervertebral disc may occur, but this
is usually of no clinical significance.

Superior
hypogastric
plexus

Bifurcation of Psoas
iliac vessels major muscle
Fig. 5.6.8 

Fig. 5.6.9  Fig. 5.6.10 

 91
5.7  •  Ganglion impar block

5.7 GANGLION IMPAR BLOCK

Anatomy Equipment
The ganglion impar is a retroperitoneal sympathetic • 2ml, 5 ml, and 10 ml syringes
ganglion located at the level of the sacrococcygeal junction • 30 G needle
(Fig. 5.7.1). Above the level of this ganglion the • 22 G spinal needle
sympathetic chains are paired. Sympathetic afferents from • Extension set (optional)
the perineum, distal rectum and anus, distal urethra, vulva
• ECG, BP, and SpO2 monitors
and the distal third of the vagina converge in the ganglion
• Resuscitation equipment (see Appendix 3)
impar.

Drugs
• Lidocaine (lignocaine) 1%, 5 ml for skin infiltration
• Lidocaine (lignocaine) 1%, 15–20 ml (or its equivalent)
for block
L5 • Phenol 6%
• Non-ionic radio-opaque contrast medium
• Resuscitation drugs (see Appendix 3)
S1
Position of patient
S2
• Prone.
S3 • Pillow under anterior superior iliac spine to flatten the
normal lumbar lordosis (Fig. 5.7.2).
S4

S5
Needle puncture and technique
Sacrococcygeal • Intravenous access is inserted.
Coccyx junction • Monitors are attached.
Ganglion impar • Resuscitation equipment and drugs are checked and
Anococcygeal
ligament Marks entrance made ready for use.
point of needle • The midline along the intergluteal groove and an area
Fig. 5.7.1  10 cm × 5 cm laterally is cleaned with antiseptic

Fig. 5.7.2 
 5
CHAPTER
92
Autonomic blockade

solution and a fenestrated drape is placed over the • After negative aspiration, the fluoroscopic image is
sterile area. observed as a small amount of non-ionic radio-contrast
• A skin wheal is raised at the superior aspect of the medium is injected. The correct placement of the needle
intergluteal groove, just above the anus, over the is indicated by the presence a small round blob of
anococcygeal ligament (Fig. 5.7.3). contrast medium at the anterior border of the vertebral
• The stylet from the 22 G spinal needle is removed, and column (Fig. 5.7.5 a,b).
the needle is bent with the fingers to form a 30° angle, • Lidocaine (lignocaine) 1% 5 ml is injected for ganglion
approximately 2 cm from the hub. blockade.
• The needle is inserted through the skin wheal, with the
concave curvature facing posteriorly.
• With the aid of fluoroscopy, the needle is advanced deep
into the coccyx, closely approximating its anterior
surface, until the tip reaches the level of the
sacrococcygeal junction (Fig. 5.7.4).

Iliac crest

Posterior suprior
iliac spine
Sacral cornua

Sacral hiatus

Coccyx

Anococcygeal
ligament A
Anus

Fig. 5.7.3 

Sacrococcygeal junction

Ganglion impar

Retroperitoneal Anococcygeal
space ligament
Sacrum

Anus
B
Rectum
Fig. 5.7.4  Fig. 5.7.5 

• After 10 minutes the patient is questioned about pain
relief and any somatic blockade. Sensory and motor
functioning of the lower extremities is checked. The
procedure should be abandoned if there is evidence of
somatic blockade.
• After confirmation of pain relief and lack of somatic
block, 5 ml of phenol 6% is injected using a glass
syringe. To avoid leaving alcohol in the needle tract the
needle is then cleared with air or local anesthetic 1 ml,
and removed.
• Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.
Confirmation of a successful block
• Relief of perineal pain.
Tips
• To aid access to the anococcygeal ligament an assistant
may be asked to retract the skin of the buttock; after
penetration of the skin, this is no longer required.
• Exaggerated anterior curvature of the sacrococcygeal
vertebral column may inhibit access and it may be
necessary to bend the needle to a more acute angle.
93
5.7  •  Ganglion impar block
Potential problems
• The position of each needle tip should always be
confirmed with fluoroscopy prior to injection of
neurolytic agent as it may lie in the peritoneal cavity,
within a viscus or intravascularly. Caudal epidural
placement of the needle is possible, therefore it is
essential that spread of contrast material is observed
to be restricted to the retroperitoneum, and that
a test dose produces no somatic nerve blockade.
Perforation of the rectum or periosteal injection is
also possible.
• Local tumor invasion may inhibit spread
of solution.
• Retroperitoneal hematoma may occur and the block
should be avoided in patients with coagulopathy.
Diarrhea may occur also and hydration of the patient
should be monitored.
• There may be a detectable odor from the breath after
alcohol injection.
• Patients in the prone position should be
monitored carefully when intravenous sedation is
administered.
 5
CHAPTER
94
Autonomic blockade

5.8 INTRAVENOUS REGIONAL SYMPATHETIC  

BLOCK—UPPER LIMB
Anatomy Drugs
Peripheral sympathetic blockade is achieved by limiting the • Lidocaine (lignocaine) 0.5% without epinephrine/
effect of the sympatholytic agent to the tissues of the adrenaline, or its equivalent
affected limb using a tourniquet. Intravenous injection of • Bretylium 1.5 mg/kg (or its equivalent, e.g. guanethedine
an agent that releases endogenous norepinephrine 0.25 mg/kg)
(noradrenaline) from sympathetic nerve endings causes • Saline (NaCl) 20 ml
depletion of this neurotransmitter, and thereby chemical • Resuscitation drugs (see Appendix 3)
sympathetic blockade.
Position of patient
Equipment • Supine.
• 20 ml syringe
• Two i.v. cannulae Technique
• Pneumatic tourniquet • Intravenous access is inserted in the contralateral limb.
• ECG, BP, and SpO2 monitors • Peripheral i.v. access is inserted in the limb to be
• Skin temperature monitor blocked (Fig. 5.8.1 a).
• Resuscitation equipment (see Appendix 3) • Monitors are attached.

A B

Fig. 5.8.1 

Fig. 5.8.2  temperature increase. However, the sympatholytic effect
• Resuscitation equipment and drugs are checked and
made ready for use.
• The limb is raised above the level of the heart for 2
minutes (Fig. 5.8.1 b).
• With the limb raised, it is exsanguinated by applying a
tight wrap, e.g. Esmarch bandage.
• A thin layer of padding is applied, e.g. Velband, under
the tourniquet site.
• The tourniquet is applied and the cuff is inflated to a
pressure 100 mmHg higher than the systolic blood
pressure (Fig. 5.8.2).
• The limb is then lowered. A mixture of lidocaine
(lignocaine) 0.5% 15 ml (without epinephrine/
adrenaline), bretylium 1.5 mg/kg (or guanethidine
0.25 mg/kg), and NaCl to make a total volume of 40 ml
(a final lidocaine (lignocaine) solution of 0.25%), is
injected through the i.v. cannula in the affected limb.
• The tourniquet is allowed to remain inflated for at least
30 minutes.
95
5.8  •  Intravenous regional sympathetic block—upper limb
Temperature probe
Fig. 5.8.3 
• It is then deflated in one step, but left in place.
Re-inflation may be required if there is a precipitous
change in blood pressure.
• Monitors should be left attached and i.v. access left in
situ for at least 30 minutes.
Confirmation of a successful block
• Relief of sympathetically maintained pain.
• Measurements of skin temperature of the affected limb
before and after the block should demonstrate
of the drug may not be immediate (Fig. 5.8.3).
Tips
• If i.v. access to the affected limb is difficult due to
vasoconstriction, a smear of glycerol trinitrate cream on
the dorsum of the hand will usually aid i.v. insertion.
• A single or double cuff may be employed for this block
but a double tourniquet may make the block more
comfortable. The proximal cuff is inflated first. A few
minutes after injection the distal cuff is inflated and
when inflation is complete the proximal cuff is released.
• Retrograde cannulation, i.e. towards the periphery
(Figs 5.8.4, 5.8.5) rather than proximally (Figs 5.8.6,
5.8.7), may help direct the spread of bretylium to the
periphery.
• Active or passive movements of the limb may hasten
the distribution of bretylium to the periphery.
• If the tourniquet inflation is painful, inhalation of
nitrous oxide–oxygen mixture may improve comfort.
• Repeated blocks may bring about gradual improvement
in sympathetically maintained pain.
 5
CHAPTER
96
Autonomic blockade

Fig. 5.8.4  Fig. 5.8.6 

Fig. 5.8.5  Fig. 5.8.7 

• Immediate physiotherapy after block may improve
outcome.
Potential problems
• Accidental deflation of the tourniquet early in the
procedure may cause a precipitous rise in blood pressure
due to the general release of endogenous norepinephrine/
noradrenaline when unfixed bretylium enters the
circulation. Systemic toxicity of lidocaine (lignocaine) may
also occur, possibly causing seizures. Blood pressure may
decrease after deflation of the cuff later in the procedure.
• The tourniquet inflation may be painful.
• A sensation of burning may occur after injection due to
release of endogenous norepinephrine.
• Neuropraxia may occur (rarely) with a very tight
tourniquet.
• Avoid in sickle cell anemia.
 97
5.9  •  Intravenous regional sympathetic block—lower limb

5.9 INTRAVENOUS REGIONAL SYMPATHETIC  

BLOCK—LOWER LIMB
Anatomy thrombosis. Inflation of this second cuff may aid
limitation of spread of sympatholytic agent to the
As in the case of the upper limb, peripheral sympathetic
periphery (Fig. 5.9.3).
blockade is achieved by limiting the effect of the
• The limb is then lowered and a mixture of lidocaine
sympatholytic agent to the tissues of the affected limb
(lignocaine) 0.5% 25 ml (without epinephrine),
using a tourniquet. Intravenous injection of an agent
bretylium 1.5 mg/kg (or its equivalent) and NaCl to
releases endogenous norepinephrine (noradrenaline) from
make a total volume of 40 ml (a final lidocaine/
sympathetic nerve endings, which causes depletion of this
lignocaine solution of 0.25%) is injected through the i.v.
neurotransmitter, and may bring about a chemical
cannula in the affected limb.
sympathetic block.
• The tourniquet is allowed to remain inflated for at least
30 minutes.
Equipment • It is then deflated in one step, but left in place.
• 50 ml syringe Re-inflation may be required if there is a precipitous
• Two i.v. cannulae change in blood pressure.
• Pneumatic tourniquet
• ECG, BP, and SpO2 monitors
• Skin temperature monitor
• Resuscitation equipment (see Appendix 3)

Drugs
• Lidocaine (lignocaine) 0.5% without epinephrine
(adrenaline), or its equivalent
• Bretylium 1.5 mg/kg (or its equivalent, e.g. guanethedine
0.5 mg/kg)
• Saline (NaCl) 30 ml
• Resuscitation drugs (see Appendix 3)

Position of patient
• Supine.

Technique
• Intravenous access is inserted in the contralateral limb.
• Peripheral i.v. access is inserted in the limb to be
blocked.
• Monitors are attached.
• Resuscitation equipment and drugs are checked and
made ready for use.
• The limb is raised above the level of the heart for 2
minutes (Fig. 5.9.1).
• With the limb raised, it is exsanguinated by applying a
tight wrap (Fig. 5.9.2).
• A thin layer of padding is applied, e.g. Velband, under
the tourniquet site.
• The tourniquet is applied and inflated to a pressure
100 mmHg higher than the systolic blood pressure. A
second tourniquet may be applied to the calf of patients
with no known predispositions to deep venous Fig. 5.9.1 
 5
CHAPTER
98
Autonomic blockade

• Monitors should be left attached and i.v. access left in

situ for at least 30 minutes.

Confirmation of a successful block

• Relief of sympathetically maintained pain.
• Measurements of skin temperature of the affected limb
before and after the block should demonstrate
temperature increase (Fig. 5.9.4).

Tips
• If i.v. access to the affected limb is difficult due to
vasoconstriction, a smear of glycerol trinitrate cream on
the dorsum of the foot will usually aid i.v. insertion.
• A single or double cuff may be employed for this block
but a double tourniquet may make the block more
comfortable. The proximal cuff is inflated first. A few
minutes after injection the distal cuff is inflated and
when inflation is complete the proximal cuff is released.
• Retrograde cannulation, i.e. towards the periphery
(Fig. 5.9.5) rather than proximally (see Fig. 5.9.3), may
help direct the spread of bretylium to the periphery.
• Active or passive movements of the limb may hasten the
distribution of bretylium to the periphery.
• If the tourniquet inflation is painful, inhalation of
nitrous oxide–oxygen mixture may improve comfort.
• Repeated blocks may bring about gradual improvement
in sympathetically maintained pain.
• Immediate physiotherapy after block may improve
outcome.

Fig. 5.9.2 

Temperature probe

Single cuff

Fig. 5.9.3  Fig. 5.9.4 

 99
5.9  •  Intravenous regional sympathetic block—lower limb

Potential problems
• Accidental deflation of the tourniquet early in the
procedure may cause a precipitous rise in blood pressure
due to the general release of endogenous norepinephrine
or epinephrine when unfixed bretylium enters the
circulation. Systemic toxicity of lidocaine (lignocaine)
may also occur in high doses possibly causing seizures.
Blood pressure may decrease after deflation of the cuff
later in the procedure.
• The tourniquet inflation may be painful.
• A sensation of burning may occur after injection due to
release of endogenous norepinephrine.
• Neuropraxia may occur (rarely) with a very tight
tourniquet.
• Avoid in sickle cell anemia.
Fig. 5.9.5 
 MUSCLE INJECTIONS
Myofascial pain occurs commonly in the muscles of
the upper and lower back. It is characterized by pain
associated with movement of the affected muscles that
develop areas of extreme tenderness, termed trigger points.
Palpation of these points is usually perceived as a tight
band or firm nodule in the muscle and reproduces pain
that may be referred some distance from the site of
palpation. Involuntary muscular contraction can occur on
palpation, and snapping palpation can result in a local
twitch response. Electromyography (EMG) is not reliable
in diagnosing myofascial pain syndrome and it is worth
remembering that this syndrome may occur in association
with underlying painful disorders of the spine.
Injection of trigger points with local anesthetic, especially
if repeated several times and combined with stretching
exercises, may have a beneficial therapeutic effect on the
pain of myofascial pain syndrome. Pain reproduction
during injection, followed by relief of pain after injection,
that lasts at least as long as the expected local anesthetic
effect, indicates that these painful points contribute to
myofascial pain syndrome.
6 
Fibromyalgia is a pain syndrome characterized by
widespread, diffuse and usually symmetrical tender areas of
muscles. Bony structures, such as costochondral junctions
and lateral epicondyles, produce local pain, but not
referred, on palpation of tender points. Injection of these
tender areas typically does not improve the pain of
fibromyalgia.
Usually a dilute solution of local anesthetic suffices for
beneficial effect. Bupivacaine produces more muscle
degeneration than any other local anesthetic when injected
into a muscle, and consequently it is usually avoided,
lidocaine (lignocaine) being the usual local anesthetic of
choice.
The optimum number of trigger-point injections required
to produce pain relief is variable. The injection sites may
themselves be painful after the local anesthetic wears off.
This may exacerbate muscle spasm if too many trigger-
point injections are performed. Consideration should be
given to the severity of the muscle spasm, the number of
trigger points, and to the sensitivity of the patient to pain
when deciding on the number of injections.
 6
CHAPTER
102
Muscle injections

6.1 TRIGGER-POINT INJECTIONS—NECK AND THORAX

Anatomy Equipment
The muscles most often involved in myofascial pain • 10 ml syringe
syndrome of the neck include the trapezius, rhomboid • 25 G needle
minor and major, latissimus dorsi, levator scapulae and
splenius capitis (Fig. 6.1.1; see also Fig. 2.1.2).
Drugs
• Lidocaine (lignocaine) 1% 10 ml

Position of patient
• Prone.
• Pillow under chest to allow the neck to flex.
Trapezius
• The sitting position is also used, but vasovagal response
Levator
scapula
may follow trigger-point injections especially in young
adults, and it is probably more prudent to use the prone
Rhomboid position.
minor
Rhomboid
major
Needle puncture and technique
• The neck, shoulders, and upper posterior thorax are
cleaned with antiseptic solution.
• Trigger points in the muscles are palpated (Fig. 6.1.2)
and marked (Fig. 6.1.3).
Latissimus • A 25 G needle with syringe attached is inserted into a
dorsi
trigger point (Fig. 6.1.4).
• After negative aspiration, 2–3 ml of lidocaine
(lignocaine) 1% is injected into the trigger point while
Fig. 6.1.1  moving the needle back and forth through the muscle.
• After injection, the next trigger point is injected in the
Relaxed muscle
same manner (Fig. 6.1.5 a,b).
fibers
Trigger point Confirmation of a successful injection
• Pain reproduction when the needle enters the muscle
confirms correct placement.

Local twitch

Fig. 6.1.2  Fig. 6.1.3 

 103
6.1  •  Trigger-point injections—neck and thorax

Tips
• For best results, injection is carried out in a fan-like
manner by repeatedly withdrawing the needle slightly
and redirecting it.
• Stretching of the involved muscles by physiotherapy
within the duration of the local anesthesia improves
results.
• Some workers advocate massage of the area immediately
after injection.

Potential problems
• Pain on injection.
• Vasovagal response (especially in young adults in the
Fig. 6.1.4  sitting position).
• Pneumothorax (especially in thin patients).

Skin

Subcutaneous
tissue

Muscle

Trapezius

Supraspinatus
(under trapezius)

Infraspinatus
Teres minor
Teres major

A B

Fig. 6.1.5 
 6
CHAPTER
104
Muscle injections

6.2 TRIGGER-POINT INJECTIONS—BACK

Anatomy
The muscles most often involved in myofascial pain
syndrome of the back include the erector spinae (the
longissimus, iliocostalis, and spinalis columns) and the
deep transversospinal (semispinalis, multifidus, and
rotatores) muscles (Fig. 6.2.1 a,b). In the buttocks,
spasm of the gluteus medius muscle may also cause
significant pain.
Equipment
• 10 ml syringe
• 25 G needle
Drugs
• Lidocaine (lignocaine) 1% 10 ml
Position of patient
• Prone.
• Pillow under abdomen to straighten the normal lumbar
lordosis (Fig. 6.2.2 a).
• The sitting position is also used, but vasovagal response
may follow trigger-point injections, and it is probably
more prudent to use the prone position.
• Alternatively, the semiprone position will also allow
access to affected muscles (Fig. 6.2.2 b).

Psoas major

Quadratus
External oblique lumborum Quadratus
Latissimus dorsi Internal oblique lumborum
Longissimus
and iliocostalis
Interspinalis
Multifidus

A B Iliocostalis Longissimus

Fig. 6.2.1 

B
Fig. 6.2.2 
 105
6.2  •  Trigger-point injections—back

Needle puncture and technique
• The midline and the surrounding area are cleaned with
antiseptic solution.
• Trigger points in the muscles are identified by palpation
and marked (Fig. 6.2.3).
• A 25 G needle with syringe attached is inserted into a
trigger point (Fig. 6.2.4).
• After negative aspiration, 2–3 ml of lidocaine
(lignocaine) 1% is injected into the trigger point while
moving the needle back and forth through the muscle
(Fig. 6.2.5).
• After injection, the next trigger point is injected in the
same manner.
Confimation of a successful injection
• Pain reproduction when the needle enters the muscle
confirms correct placement.
Tips
• For best results, injection is carried out in a fan-like
manner by repeatedly withdrawing the needle slightly
and redirecting it.
• Stretching of the involved muscles by physiotherapy within
the duration of the local anesthetic improves results.
• Some workers advocate massage of the area immediately
after injection.

Potential problems
• Pain on injection.
• Vasovagal response (especially young adults in the
sitting position).
• Pneumothorax (especially in thin patients) is also a
possibility when injecting the upper back.

Fig. 6.2.3 
Skin

Subcutaneous
tissue

Muscle

Fig. 6.2.4  Fig. 6.2.5 

 6
CHAPTER
106
Muscle injections

6.3 GLUTEUS MEDIUS INJECTION

Anatomy • The greater trochanter is palpated.

• The insertion point of the needle lies approximately
When the buttock muscles are relaxed the quadratus
2 cm medial and superior to the greater trochanter
femoris, gemelli and gluteus medius muscles can be
(Figs 6.3.3, 6.3.4).
palpated. Spasm of the gluteus medius muscle (Fig. 6.3.1)
may be the source of buttock pain and may respond to • A 22 G needle is introduced in a direction vertical to the
trigger-point injection. Unlike pirformis muscle spasm, this skin and advanced until it is felt to be gripped by the
does not produce symptoms of sciatic nerve irritation but tense muscle (Fig. 6.3.5).
causes localized pain, often referred to the posterior thigh
and calf.

Equipment
• 10 ml syringe
• 22 G needle

Drugs Fig. 6.3.2 

• Lidocaine (lignocaine) 1% 10 ml

Gluteus minimus
Position of patient
• Prone.
• Pillow under abdomen to flatten the normal lumbar
lordosis (Fig. 6.3.2).

Needle puncture and technique

• The surface of the buttock and hip is cleaned with
antiseptic solution.
• The posterior superior iliac spine is palpated and marked.

Gluteus medius

Gluteus maximus
Fig. 6.3.3 
Gluteus medius

Gluteus maximus

Fig. 6.3.1  Fig. 6.3.4 

 107
6.3  •  Gluteus medius injection

Skin

Subcutaneous
tissue

Muscle

Gluteus medius

Fig. 6.3.5  Fig. 6.3.6 

• After negative aspiration, lidocaine (lignocaine) 1% Tips

3 ml is injected in the substance of the muscle while
moving the needle back and forth in the muscle
(Fig. 6.3.6).
• The procedure is repeated if other trigger points are
present in the muscle.
Confirmation of a successful injection
• Pain reproduction when the needle enters the muscle
confirms correct placement of the needle.
• Relief of pain on abduction of the hip.
• For best results injection is carried out in a fan-like
manner by repeatedly withdrawing the needle slightly
and redirecting it (see inset in Fig. 6.3.6).
Potential problems
• Sciatic nerve block: although this is unusual because the
injection site is not very close to the sciatic notch, it is
prudent to warn the patient of the possibility.
• Infection or abscess formation.
 6
CHAPTER
108
Muscle injections

6.4 PIRIFORMIS INJECTION

Anatomy Needle puncture and technique

The piriformis muscle inserts into the pelvic surface of the
sacrum from the second to the fourth segments, lateral to
the anterior sacral foramina, and passes out of the pelvis
through the greater sciatic foramen to insert into the
superior aspect of the greater trochanter (Fig. 6.4.1). It
overlies the sciatic nerve in the greater sciatic foramen.
Contraction contributes to abduction of the lower limb.
Spasm of the muscle in myofascial pain syndrome often
causes pain referred to the posterior thigh and calf.
Equipment
• 2 ml syringe and two 5 ml syringes
• 25 G needle
• 22 G spinal needle, end-opening
Drugs
• Lidocaine (lignocaine) 1% 10 ml (or its equivalent)
Position of patient
• Prone.
• Pillow under abdomen to flatten the normal lumbar
lordosis (Fig. 6.4.2).
• The surface of the buttock and hip is cleaned with
antiseptic solution and a fenestrated drape is placed over
the sterile area.
• The posterior superior iliac spine is palpated and
marked.
• The greater trochanter is palpated and marked.
• The insertion points of the needle lie at the points
one-third and two-thirds along, and 1–3 cm below the
line connecting these two marks (Figs 6.4.3 a,b,c).
• The first insertion point, the medial one, is infiltrated
with lidocaine (lignocaine) 1% 2 ml.
• A 22 G spinal needle is introduced in a direction vertical
to the skin and advanced until it is felt to be gripped by
the tense piriformis muscle, or until bone is contacted
(Figs 6.4.4, 6.4.5).
• The end-point is a fascial click at a depth of about
4–5 cm, depending on the thickness of adipose tissue.
• The patient is questioned about the presence of pain,
paresthesia, and changes in sensation in the distribution
of the sciatic nerve, while the needle is being advanced.
• If these symptoms arise, the needle may be in contact
with the sciatic nerve and should be repositioned. It is
also possible that spasm of the muscle on needle
insertion may produce these symptoms and often
reproduction of pain occurs with entry into the
muscle.
• After negative aspiration, lidocaine (lignocaine) 1% 5 ml
is injected.
• Ultrasound may aid placement of the needle
(Fig. 6.4.6 a,b)

Confirmation of a successful injection

• Relief of pain on abduction of the lower limb against
pressure on the lateral knee in the sitting position.

Tips
• If injection is not successful in relieving the pain, it may
be repeated at the lateral insertion point. This lies at a
Piriformis
muscle

Sciatic nerve

Fig. 6.4.1  Fig. 6.4.2 

 109
6.4  •  Piriformis injection

Sacral cornua Sciatic nerve Sacral cornu Sciatic nerve

Posterior superior Posterior superior

iliac spine iliac spine

Piriformis Piriformis
muscle muscle

Gluteus Greater Greater

A minimus trochanter B trochanter

Fig. 6.4.3 
 6
CHAPTER
110
Muscle injections

Fig. 6.4.4 

Piriformis
muscle
Fig. 6.4.5 

point two-thirds along and 1–3 cm below the line

joining the posterior superior iliac spine and the greater
trochanter.

Potential problems
B
• Sciatic nerve block.
• Infection or abscess may occur (rarely). Fig. 6.4.6 
 TRANSCUTANEOUS
ELECTRICAL NERVE
STIMULATION (TENS)
7 
Transcutaneous electrical nerve stimulation is thought to Control settings (Figs 7.1.1, 7.1.2)
modify pain appreciation by stimulation of large fibers
thereby blocking (or “closing the gate” to) smaller C-fibers CONTINUOUS STIMULATION
carrying nociceptive impulses. There is also evidence that • Amplitude set to zero.
high-frequency stimulation of the skin increases latency • Pulse width set to midrange.
and decreases maximum firing rates in small afferent fibers. • Switch to continuous mode.
This can produce conduction blockade in C-fibers as the • Increase pulse amplitude level gradually to the
current is increased, probably via potassium efflux from maximum level for comfort (sensation should be strong
the axon. It is thought that a combination of these actions but not painful).
is responsible for the analgesia derived from the use of
• Adjust pulse frequency to maximum level for comfort
TENS. This is probably not related to opiate-mediated
(amplitude may be reduced as pulse width is increased).
mechanisms when conventional parameters are used.
• Adjust pulse width to maximum level for comfort.
Not all pain responds to TENS. If the usual parameters do • Maintain for 45–60 minutes.
not produce pain relief, low frequency, high intensity
stimulation may be tried. This means that the current
amplitude is increased to a level that produces mild
discomfort and muscle stimulation. Analgesia from this
type of stimulation may be due to opiate-mediated
mechanisms. Burst stimulation means short bursts of high
frequency stimulation delivered at 1–2 Hz and may also
relieve pain that is not responsive to conventional TENS.
A TENS trial may be carried out prior to giving the unit to
the patient to use at home. This allows the patient to
become familiar with the use of TENS, and to ensure that
the pain is not aggravated by its use. A minimum of one
Rectangular Triangular
hour is recommended as the trial period. This will indicate
whether the patient is likely to respond to TENS. However,
failure to respond within this time period does not
necessarily mean that there will be no response if used for
longer periods, or with different settings. It is important to
allow the patient to use the TENS at home for a period of
Sine wave Exponential
at least 14 days.
The TENS stimulator is a battery-operated pulse generator
which has several controls. These include an on/off switch
plus amplitude control, frequency control, mode selector,
and width control. In addition, multichannel units have
amplitude controls for each channel. The pulse generator
connects to leads that then connect to electrodes, which are
Biphasic Asymmetric
applied to the skin. Electrodes are applied in pairs, and are
positioned so that they lie along the direction of the nerves
in the area being treated, e.g. longitudinally in the limbs,
but dermatomally in the trunk. Fig. 7.1.1 
 7
CHAPTER
112
Transcutaneous electrical nerve stimulation (TENS)

All the types of stimulation should be tried for each pain,

and the effects on the pain should be compared. The
optimum parameters must be found by trial and error.
The patient is usually advised to begin by using TENS
High frequency for at least one hour three times a day. Once the effect
of TENS on the pain is known it is recommended that
stimulation should be discontinued after 30 minutes if the
patient experiences one or more hours of analgesia from
Low frequency a single application. If pain relief is achieved only during
stimulation, the unit can be kept on constantly. However,
electrode sites should be changed every 24 hours.
Occasionally, skin rash under the electrodes may occur
Trains of impulses and this problem may be minimized by frequent rotation
of the electrode sites and with topical steroids. However,
very few side effects are associated with the use of TENS.
Fig. 7.1.2  Electrical skin burns may occur if TENS is applied to
skin with poor innervation and it is necessary to ensure
that there is normal sensation prior to applying the
Modulated settings electrodes. Allergic reaction to the electrodes or the
adhesive tape has also been described, but is not
BURST STIMULATION common.
• All controls set to zero.
Use of TENS is contraindicated on areas over the
• Switch to pulsed mode.
anterior neck (stimulation of carotid sinus, larynx), over
• Frequency set to 1–2 Hz. the pregnant uterus or in the presence of a cardiac
• Increase amplitude and pulse width as with continuous pacemaker.
mode described above.
Note: Description of the insertion technique of a
• Maintain for 45–60 minutes. spinal cord stimulator or peripheral nerve stimulator is
LOW-FREQUENCY HIGH-INTENSITY STIMULATION outside the scope of this text as the techniques are specific
• All controls set to zero. to the different types of stimulator.
• Increase amplitude to level where the muscle underlying
the electrodes twitches visibly but not painfully.
• Increase frequency to 2–4 Hz.
• Maintain for short period (5–15 minutes).
 APPENDIX
1
SUGGESTED
CORTICOSTEROIDS

Equivalent dosage Anti-inflammatory Mineralocorticoid

Drug name Duration of action (mg) potency (relative) potency (relative)
Triamcinolonea 12–36 h 4 5 0
Methylprednisolone 12–36 h 4 5 0.5
Dexamethasone 48 h 0.75 25 0
Hydrocortisone 12 h 20 1 2
a
Triamcinolone diacetate recommended for central neuroaxial injections.

Corticosteroid injection side effects SYSTEMIC SIDE EFFECTS (HIGHER INCIDENCE

WITH LARGER DOSES)
LOCAL SIDE EFFECTS
• Skin flushing
• Atrophy of subcutaneous tissue
• Irregularity of the menstrual cycle
• Rupture of injected tendon
• Impaired glucose tolerance
• Depigmentation of skin
• Osteoporosis
• Infection
• Muscle wasting and myopathy
• Arthropathy
• Suppression of adrenal function
• Psychologic upset
 APPENDIX
2
SUGGESTED NEUROLYTIC
AGENTS

• Aqueous phenol 6%.

• Alcohol 100% may be diluted to 50% (pain on injection
may be experienced and it is recommended that the
nerve is blocked with local anesthetic prior to injection).
 APPENDIX
3
RECOMMENDED RESUSCITATION
DRUGS AND EQUIPMENT

SUGGESTED RESUSCITATION DRUGS

Drug Suggested dosage (70 kg adult) Indication

Atropine 0.2–0.4 mg i.v. increments Bradycardia from vagal dominance
Ephedrine 5–10 mg i.v. increments Hypotension from sympathetic block
Lidocaine (lignocaine) 50–100 mg i.v. bolus Ventricular arrhythmias
Midazolam 1–3 mg i.v. increments Local anesthetic; seizure activity
Diazepam 2.5–5 mg i.v. increments Local anesthetic; seizure activity
Thiopental (thiopentone) 50–100 mg i.v. increments Local anesthetic; seizure activity
Succinylcholine 50–100 mg i.v. bolus Muscle relaxation; airway control
It is also recommended that the full range of drugs required for advanced cardiac life support (ACLS), including pre-filled
syringes, be available in the operating room.

Suggested resuscitation equipment

• Oxygen source
• Bag and masks (full range)
• Breathing system for positive pressure ventilation
• Oro- and nasopharangeal airways (full range)
• Laryngoscopes and blades (full range)
• Endotracheal tube stylets and forceps, e.g. Magill’s
forceps
 APPENDIX
4
DERMATOMES

C2

C2
C3 C3
T1
C3
C4 C4
T2
C4
3
T2
C5 C5 4
3
C5 5 C5
4 6
T2 5 7
6 T2 8 T2
7 T2 9
T1 8 10
T1 11 T1
9
C6 T1 12
10
C6 L1 S1
11
C7 C6 L3 C6
C8 12
S5
L1 C7 Coc C7
S3 C7 S3
C8 L2 S4 L2 C8
C8
S3
S4
L2

L2 S2 S2
S2
L3

L3 L3

S2
L5
S1
L4 L5 L4 L5
L4
S1
L4
L5
L5

L5 S1

S1 S1 S1

Fig. A.4.1  Fig. A.4.2 

120
Appendix 4

L3 L3

L5 L5

S2 S2
L4 L4
L2 L2

S4
L2 L2
S3 S3
S1 S1
L5 Coc L5
S1 S1
S5

Fig. A.4.3 

C2

C3

C4
C6 C5 T2 C5 C6
T1 3 T1
4
C7 5 C7
C8 C8
6
7
8
9
10
11
12
L1
L2 L3 L2
L5 L5
S2 S3 S4 S2
S1 S1
L4 L3 S5 L3 L4

Coc

C2

C3
C4 C4
C6 C5 C5 C6
T1 T2 T2 T2 T1
C7 3 C7
C8 4 C8
5
6
7
8
9
10
11
12
L2 L1 L2
S1 L3 L3 S1
L5 L4 S3 S3 L4 L5

Fig. A.4.4 
 121
Appendix 4

C2
C3
C4 C4
T2
C5 3 C5
4
T2 5 T2
6
L3
7
8
T1 9 T1
C3 C4 T2 3 4 5 6 7 8 9 10 11 12 L1 C6 C6
10
11
S3
C2 12
C7 L1 C7
C5

C8 S3 C8
L2 S4

L2 L2

T1
C6
L3 L3
L3 S2

C7 L4
C8
L4 L4

L5
L5 L5

S1 S1
S1

Fig. A.4.5  Fig. A.4.6 

 APPENDIX
5
SPINAL CORD SEGMENTAL
MYOTOMES

Each muscle in the body is supplied by a particular level or • T1–T12 supplies the chest wall and abdominal muscles.
segment of the spinal cord and by its corresponding spinal • L2 bends the hip.
nerve. • L3 straightens the knee.
• C5 also supplies the shoulder muscles and the muscle • L4 pulls the foot up.
that we use to bend our elbow. • L5 wiggles the toes.
• C6 is for bending the wrist back. • S1 pulls the foot down.
• C7 is for straightening the elbow. • S3, S4 and S5 supply the bladder, bowel and sex organs,
• C8 bends the fingers. and the anal and other pelvic muscles.
• T1 spreads the fingers.

C5 C6,7,8
C5 C6,7,8

L5,S1

L1,2,3
L2,3 L4,5

L5,S1
L1,2,3
L5, S1
C6
L3,4

L4,5 C7,8

S1,2
Fig. A.5.1 
 APPENDIX
6
LUMBO-SACRAL SPINE
ANATOMY

Spinal cord

Pia mater

Arachnoid

Dura mater

L1
Conus
medullaris
L1
L2

L2
Cauda equina
L3
Ligamentum
flavum (L3–4) L3

L4
Epidural space

L4
Internal filum
terminale L5

L5

Sacrum
Sacrum
Distal dural sac

S1
External filum
terminale S2

S3

S4

S5
Coccyx

Fig. A.6.1 
 127

INDEX

Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.

A carotid, 66, 70f C

celiac, 77f
abdominal discomfort, 81, 85 calf, 97, 106, 108
external iliac, 86f
abdominal viscera, 77 cancer
intercostal, 38f
abscess pain, 65
internal iliac, 86f
epidural, 33 pancreatic, 2, 65
mesenteric, 77
post-gluteus medius injection, 107 pelvic, 65
occipital, 60
ACLS (advanced cardiac life support), cannulation, retrograde see retrograde
segmental, 81, 85, 90
117 cannulation
subclavian, 70f
action potentials, 1 carcinoma of the head of the pancreas, 2
superior mesenteric, 78f, 84f
adipose tissue, 108 cardiac pacemaker, 112
vertebral, 66, 70–71, 70f
adrenal function suppression, 113 cardiovascular system (CVS) collapse,
arthropathy, 113
adrenaline see epinephrine stellate ganglion block
aseptic meningitis
advanced cardiac life support (ACLS), C7 approach, 70–72
after caudal epidural block, 33
117 C6 (classic) approach, 66, 68–69
after cervical epidural block, 29
air carotid arteries, 66, 70f
after lumbar epidural block, 20
in interpleural block, 43 carotid pulse, 67, 71
after thoracic epidural block, 24
in lumbar epidural block, 20 carotid sinus, 112
atlas, 25f
in thoracic epidural block, 23 catheter
atropine, 117
in thoracic nerve root block, 53 epidural see epidural catheter, long-term
autonomic blockade, 65–99
alcohol, 115 intercostal, 40–41
autopsy, 37
in celiac plexus block interpleural, 44
axis, 25f
anterocrural approach, 83, 85 passer, 34–36
axon, potassium efflux from, 111
retrocrural approach, 80–81 thoracic nerve root block, 53
axonal degeneration, 111
in ganglion impar block, 93 cauda equina, 55, 125f
azygos vein, 52f
allergic reaction caudal anesthesia, 30
caudal epidural block, 33 caudal epidural block, 30–33
cervical epidural block, 29 anatomy, 30, 30f
lumbar epidural block, 20 B confirmation of success, 33
thoracic epidural block, 24 drugs, 30
allodynia, 1 bacterial contamination, 62, 76 equipment, 30
analgesia bilateral stellate ganglion block, 69 needle puncture and technique, 31f
opiate-mediated mechanisms and, 111 bladder, 15, 86 adult, 30–32
unpredictable, 46 blood aspiration fluoroscopic-guided, 32, 32f–33f
analgesics, mild, 15 intercostal nerve block, 41–42 right-handed operator, 31–32, 31f–32f
anemia, sickle cell, 96, 99 stellate ganglion block position of patient, 30, 30f
anesthetics, local see local anaesthetics C7 approach, 72 potential problems, 33
anococcygeal ligament, 93 C6 (classic) approach, 68 with sacral nerve root block, 57
anterior costotransverse ligament, blood pressure changes, 18, 22–23, 27, 31, tips, 33, 33f
51f–52f 34 caudal epidural space, 31, 33
anterior scalenus, 70f fall, 96, 99 cavernous sinus, 61
anterior superior iliac spine rise, 68, 96, 99 celiac artery, 77f
in autonomic blockade, 73, 78, 82, 87, systolic, 95, 97 celiac axis, 78f, 84f
91 bowel dysfunction, 15 celiac block
in joint injections, 4, 12 brachial plexus, 43, 66, 68, 72 classical, 78f, 84f
in somatic nerve blockade, 47, 55 bradycardia, 29, 117 prevascular, 78f, 84f
anterocrural spread, 77f, 82f brainstem, 61 celiac ganglia, 77
anteromedial capsule, 6, 10 breath celiac plexus, 77
anus, 91–92, 92f after alcohol injections, 81, 85, 93 celiac plexus block
anxiety, 2 shortness of, 69, 72 anterocrural approach, 82–85
aorta breathing systems, 117 anatomy, 82, 82f
anatomy, 77 bretylium in intravenous regional confirmation of success, 83
dissection, 84, 88 sympathetic block drugs, 82
perforation, 76, 81, 84, 88 lower limb, 97–98 equipment, 82
aortic artery, 79f, 84f upper limb, 68, 95 needle puncture and technique, 82–83,
aortic plexus, 86 buccal cavity, 62 84f
arachnoid mater, 16 bupivacaine, 44, 101 position of patient, 82, 83f
arteries burning sensation, 96, 99 potential problems, 84–85
aortic, 79f, 84f buttock pain, 106 tips, 83
128
Index
retrocrural approach, 77–81
anatomy, 77, 77f–78f
confirmation of success, 80
drugs, 78
equipment, 78
needle puncture and technique, 78–80,
79f–80f
position of patient, 78, 78f
potential problems, 81
tips, 81
cerebrospinal fluid (CSF), 16, 60, 64
cervical anterior tubercle, sixth, 66–68
cervical disc pain, 15
cervical epidural block, 25–29
anatomy, 25, 25f
confirmation of success, 29
drugs, 25
equipment, 25
needle puncture and technique, 25–29,
26f–28f
fluoroscopic guided, 28–29, 29f
position of patient, 25
potential problems, 29
tips, 29
cervical epidural injection, 15
cervical epidural space, 25, 29
cervical facet joint injection, 8–11
anatomy, 8, 8f
confirmation of success, 9
drugs, 8
equipment, 8
needle puncture and technique, 8–9,
9f–10f
position of patient, 8, 9f
potential problems, 10
tips, 10
cervical ganglia, 66
cervical nerve, dorsal rami of second,
59
cervical nerve roots, 15
cervical sympathetic trunk, 66
C-fibers, 111
Chassaignac’s tubercle, 66–68
chest discomfort, 81, 85
chest X-ray
intercostal nerve block, 39
interpleural block, 44
chylothorax, 85
cisterna magna, 60
coagulopathy
and celiac plexus block, 81
and facet joint injections, 10
and hypogastric plexus block, 88
and lumbar sympathetic block, 76
coccygeal cornu, 55f
coccygeal nerve, 55f
coccygeal vertebra, 55f
coccyx, 92, 125f
colon, 77
Complex Regional Pain Syndrome Type 1
and II, 65
computed tomography (CT) scan, 37
in celiac plexus block, 83
in hypogastric plexus block, 88
in sacro-iliac joint injection, 13, 13f
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68
conjunctiva, unilateral flushing, 68, 72
consciousness, loss of in stellate ganglion
block
C7 approach, 70–72
C6 (classic) approach, 68–69
contrast medium, non-ionic radio-opaque dorsal nerve roots, 1
in celiac plexus block dural puncture, 20, 24, 29, 33
anterocrural approach, 83 dural sac, 55, 125f
retrocrural approach, 78, 81 distal, 55, 125f
in cervical epidural block, 29 dural tap, 20, 23
in cervical facet joint injection, 9 dura mater, 16, 125f
in ganglion impar block, 92
in hypogastric plexus block, 87–88
in intercostal nerve block, 40, 41f
in long-term epidural catheter insertion, 36
E
in lumbar epidural block, 19 electromyography (EMG), 37, 101
in lumbar facet joint injection, 4–5 endotracheal tubes, 117
in lumbar nerve root block, 48 ephedrine, 117
in lumbar sympathetic block, 74 epidural abscess, 33
in sacral nerve root block, 57 epidural block
in sacro-iliac joint injection, 13 in celiac plexus block, 81, 84–85
in thoracic epidural block, 23 in hypogastric plexus block, 88–90
in thoracic nerve root block, 52 lumbar, 16–20
in trigeminal ganglion (Gasserian) block, with lumbar nerve root block, 49
62 in lumbar sympathetic block, 76
conus medullaris, 55f, 125f in thoracic nerve root block, 54
convulsion, 64, 66 epidural catheter insertion, 20, 23
corneal anesthesia, 64 long-term, 34–36
corticosteroids, 2 anatomy, 34
in caudal epidural block, 31–32 confirmation of success, 36
in cervical epidural block, 27, 29 drugs, 34
in cervical facet joint injection, 9 equipment, 34
in lumbar epidural block, 18 needle puncture and technique, 34–36,
in lumbar facet joint injection, 5 34f–36f
in sacro-iliac joint injection, 13 position of patient, 34, 34f
side effects, 113 potential problems, 36
suggested, 113 tips, 36
in thoracic epidural block, 21, 23 epidural injection, 15–36
costochondral junctions, 101 caudal, 32
costotransverse ligament, 51f–52f, 53 cervical, 15, 25
coughing on injection, 40 lumbar, 19–20, 19f
cranial fossa, 64 epidural needle
cranial nerves, 61, 64 in autonomic blockade, 74, 87
cricoid cartilage, 66–67, 71 in epidural block, 16, 18, 22, 26–28,
CSF (cerebrospinal fluid), 16, 60, 64 33–34
CT see computed tomography (CT) scan in somatic nerve block, 40–41, 44, 46, 53
Cushingoid symptoms epidural space, 16, 24–25, 29, 33, 55, 125f
post-caudal epidural block, 33 epidural spread, 19, 32, 49, 54, 57
post-cervical epidural block, 29 epidural steroid injection, 15, 20, 23
post-lumbar epidural block, 20 epinephrine
post-thoracic epidural block, 24 in intercostal nerve block, 41
cutaneous fibers, 47 in intravenous regional sympathetic
cutaneous nociceptors, 1 block, 99
CVS collapse see cardiovascular system in long-term epidural catheter insertion,
(CVS) collapse 34
in lumbar epidural block, 20
in thoracic epidural block, 23
D erector spinae muscles, 104
Esmarch bandage, 95
decompression, 37 exsanguination, 95
depression, 2 external filum terminale, 125f
dermatomes, 119 external iliac artery, 86f
dexamethasone, 113 external iliac vein, 86f
diagnostic blockade, 11, 48, 53, 57, 64 external oblique muscles, 104f
diaphragm, 43, 77, 77f, 82, 82f, 84f
diaphragmatic crus, 77f, 82, 82f
diarrhea
post-celiac plexus block, 81, 84
F
post-ganglion impar block, 93 facet joints
post-hypogastric plexus block, 90 cervical, 8–11
diazepam, 117 lumbar, 3–6
discogenic radiculopathy, 37 pain, 2
discomfort facet nerve injection, 10–11
abdominal, 81, 85 fibromyalgia, 101
chest, 81 filum terminale, 125f
distal dural sac, 55, 125f fluoroscopy
dorsal horn neurons, 1 C-arm, 4, 9
dorsal horn pain projection cells, 1 in caudal epidural block, 32, 32f–33f

in celiac plexus block
anterocrural approach, 82
needle puncture and technique, 78
in cervical epidural injection, 28–29, 29f
in ganglion impar block, 92–93
in hypogastric plexus block, 87
in lumbar epidural injection, 19–20, 19f
in lumbar sympathetic block, 73–74
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68
foramen ovale, 61
forceps, 117
G equipment, 86
gangliolysis, 64
ganglion blockade see stellate ganglion
block
ganglion impar, 91
ganglion impar block, 91–93
anatomy, 91, 91f
confirmation of success, 93
drugs, 91
equipment, 91
needle puncture and technique, 91–93, 92f
position of patient, 91, 91f
potential problems, 93
tips, 93
Gasserian block see trigeminal ganglion
(Gasserian) block
Gasserian ganglion, 61f
gemelli muscles, 106
genitofemoral neuralgia, 76
glucose tolerance, impaired, 113
gluteus medius injection, 106–107
anatomy, 106
confirmation of success, 107
drugs, 106
equipment, 106
needle puncture and technique, 106–107,
106f–107f
position of patient, 106, 106f
potential problems, 107
tips, 107
gluteus muscles, 104
glycerol injection, 64
glycerol trinitrate cream, 98
greater auricular nerve, 59f
greater occipital nerve, 59
greater occipital protuberance, 59–60, 59f
greater sciatic foramen, 108
greater trochanter
gluteus medius injection, 106
piriformis injection, 108
grey rami, 38, 47
guanethedine, 94–95, 97
H lumbar facet joint, 3–6
hanging drop technique, 25–27, 27f
headache
post-caudal epidural block, 33
post-cervical epidural block, 29
post-lumbar epidural block, 20
post-thoracic epidural block, 24
heart rate changes, 18, 22–23, 27, 31, 34
hematoma
post-caudal epidural block, 33
post-cervical epidural block, 29
post-cervical facet joint injection, 10
post-stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68–69
post-thoracic epidural block, 24
retroperitoneal, 76, 81, 84, 88, 93
hemifacial anesthesia, 64
hoarseness, 69
hydrocortisone, 113
hyperalgesia, 1
hyperbaric neurolytic solution, 64
hypogastric plexus, 86
hypogastric plexus block, 86–90
anatomy, 86, 86f
confirmation of success, 87
drugs, 87
needle puncture and technique, 87,
88f–90f
position of patient, 87, 87f
potential problems, 88–90
tips, 87–88
hypotension
orthostatic, 81, 84, 90
post-caudal epidural block, 33
post-cervical epidural block, 29
post-lumbar epidural block, 20
post-thoracic epidural block, 24
I potential problems, 46
iliac crest, 73
hypogastric plexus block, 87
lumbar epidural block, 17
lumbar nerve root block, 47
sacral nerve root block, 56
iliac vessels, bifurcation of, 90f
iliocostalis muscle, 104
ilium, 12, 13f, 14
infection
post-caudal epidural block, 33
post-cervical epidural block, 29
post-corticosteroid injection, 113
post-gluteus medius injection, 107
post-long-term epidural catheter insertion,
36
post-lumbar epidural block, 20
post-thoracic epidural block, 24
inferior articular process, 17f
inferior hypogastric plexus, 86
inferior vena cava
anatomy, 77
perforation, 76, 81, 84, 88
infraspinatus muscle, 103f
infratemporal bone, 64
infratemporal fossa, 62
injections
cervical facet joint, 8–11
epidural, 15–36
joint, 3–14
sacro-iliac joint, 12–14
sacroiliac ligaments, 14
trigger point, 2
intercostal artery, 38f
intercostal muscle, 38f, 45f
intercostal nerve block, 38–42
anatomy, 38, 38f
confirmation of success, 40
drugs, 38
equipment, 38
needle puncture and technique, 38–39, 39f
right-handed operator, 38–39, 39f–40f
129
Index
neurolytic, 40, 41f, 42
position of patient, 38
potential problems, 41
radiofrequency lesioning, 41
tips, 40–41, 41f
intercostal nerves, 43
intercostal neuralgia, 65
intercostal space, 39–41
intercostal vein, 38f
intercrestal line, 73
hypogastric plexus block, 87
lumbar epidural block, 17
lumbar nerve root block, 47
sacral nerve root block, 56
intergluteal groove, 91–92
internal carotid artery, 61
internal filum terminale, 125f
internal iliac artery, 86f
internal iliac vein, 86f
internal oblique muscles, 104f
interpleural block, 43–46
anatomy, 43, 43f
confirmation of success, 44
drugs, 43
equipment, 43
needle puncture and technique, 43–44,
44f
right-handed operator, 44, 44f–45f
position of patient, 43, 43f
tips, 46, 46f
interpleural space, 43
interspinalis muscle, 104f
interspinous ligament, 16
in cervical epidural block, 26, 28–29
in lumbar epidural block, 18–19
in thoracic epidural block, 22–23
intervertebral disc
disease, 15
pain, 15
perforation, 76, 81, 85, 90
intervertebral foramen, 47, 76
intestines, 77
intra-arterial injection, 10, 68–69, 72
intraneural pressure, raised, 111
intrathecal blockade, 49
intrathecal injection, 10
in caudal epidural block, 33
in cervical epidural block, 29
in lumbar epidural block, 20
in lumbar nerve root block, 49
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68–69
in thoracic epidural block, 24
intrathecal space, 16
intravascular injection
in caudal epidural block, 33
in cervical epidural block, 29
in lumbar epidural block, 20
in lumbar nerve root block, 49
in lumbar sympathetic block, 76
in sacral nerve root block, 57
in thoracic epidural block, 24
in thoracic nerve root block, 54
intravenous injection, 10
intravenous regional sympathetic block
lower limb, 97–99
anatomy, 97
confirmation of success, 98
drugs, 97
equipment, 97
position of patient, 97
130
Index
potential problems, 99
technique, 97–98, 97f–99f
tips, 98
upper limb, 94–96
anatomy, 94
confirmation of success, 95
drugs, 94
equipment, 94
position of patient, 94
potential problems, 96
technique, 94–95, 94f–96f
tips, 95–96
ipsilateral face, 61
ipsilateral pupil, 62
ischemia, 111
J ligamentum flavum, 16, 125f
joint(s)
arthropathy, 2
degeneration, 2
information, 2
injections, 3–14
pain, 2
jugular vein, 68, 72
K loss-of-resistance technique, 22, 29
kidneys, 77
anatomy, 77
perforation, 76, 81, 85
L fluoroscopic guided lumbar epidural
lamina, 22
laryngeal nerve block, recurrent, 69,
72
laryngoscope, 117
lateral epicondyles, 101
latissimus dorsi muscle, 102
lesser occipital nerve, 59f, 60
levator scapulae muscle, 102
levobupivacaine, 43
lidocaine
caudal epidural block, 31–32
celiac plexus block
anterocrural approach, 83
retrocrural approach, 78–80
cervical epidural block, 25–29
cervical facet joint injection, 8–10
facet nerve injection, 11
ganglion impar block, 92
gluteus medius injection, 107
hypogastric plexus block, 87
intercostal nerve block, 39–40
interpleural block, 43
intravenous regional sympathetic block
lower limb, 97, 99
upper limb, 68, 95
long-term epidural catheter insertion,
34
lumbar epidural block, 17–19
lumbar facet joint injection, 4–5
lumbar nerve root block, 47–48
lumbar sympathetic block, 74
occipital nerve block, 60
piriformis injection, 108
for resuscitation, 117
sacral nerve root block, 56–57
sacro-iliac joint injection, 12–13
stellate ganglion block
C7 approach, 70–72
C6 (classic) approach, 66, 68
thoracic epidural block, 21–23
thoracic nerve root block, 52–53
toxicity, 68, 99
trigeminal ganglion (Gasserian) block,
62–64
trigger point injections, 101–102, 105
ligaments
anococcygeal, 93
anterior costotransverse, 51f–52f
costotransverse, 51f–52f, 53
posterior sacro-iliac, 12f
sacro-coccygeal, 30f
sacroiliac, 14
supraspinous, 16
lumbar epidural block, 18–19
thoracic epidural block, 22–23
lignocaine see lidocaine
liver, 77
local anaesthetics, 2
in lumbar epidural block, 20
rapid absorption in intercostal nerve
block, 41
longissimus muscle, 104
longus colli muscle, 72
lumbar epidural block, 16–20
anatomy, 16, 16f–17f
confirmation of success, 20
drugs, 16
equipment, 16, 17f
needle puncture and technique, 17–20
injection, 19–20, 19f
midline approach, right-handed
operator, 17–19, 18f–19f
position of patient, 17
potential problems, 20
tips, 20, 20f
lumbar epidural steroid injection, 23
lumbar facet joint injections, 3–6
anatomy, 3–4, 3f
confirmation of success, 5
drugs, 4
equipment, 4
needle puncture and technique, 4–5,
5f–7f
position of patient, 4, 4f
potential problems, 6
tips, 5
lumbar nerve root block, 47–49
anatomy, 47, 47f
confirmation of success, 49
drugs, 47
equipment, 47
needle puncture and technique, 47–48,
48f–50f
position of patient, 47, 48f
potential problems, 49
tips, 49
lumbar nerve roots, 15
lumbar nerves, 47
lumbar plexus, 47
lumbar radiculopathy, 32
lumbar somatic nerves, 73
lumbar spine innervation, 3f
lumbar sympathetic block, 73–76
anatomy, 73
confirmation of success, 75
drugs, 73
equipment, 73
needle puncture and technique, 73–75,
73f–76f
position of patient, 73, 73f
potential problems, 76
tips, 75
lumbar sympathetic chain, 73
lumbo-sacral radiculopathy, 15
lumbo-sacral spine anatomy, 125
lungs, 51
lymphedema, 85
M
Magill’s forceps, 117
magnetic resonance imaging (MRI), 37
mandibular nerve, 61–62
masseter muscle, 62
mastication muscles, 61–62
mastoid process, 59–60, 59f
maxillary nerve, 61
mechanical nerve root compression, 37
Meckel’s cave, 61
medius scalenus muscle, 70f
meningitis, aseptic see aseptic meningitis
menstrual cycle irregularity, 113
mesenteric artery, 77
methylprednisolone, 113
midazolam, 117
middle cervical ganglion, 70f
miosis of pupil, 68, 72
MRI (magnetic resonance imaging), 37
multifidus muscle, 104, 104f
muscle contraction, involuntary, 101
muscle injections, 101–110
muscles
erector spinae, 104
external oblique, 104f
gemelli, 106
gluteus, 104
iliocostalis, 104
infraspinatus, 103f
intercostal, 38f, 45f
internal oblique, 104f
interspinalis, 104f
latissimus dorsi, 102
levator scapulae, 102
longissimus, 104
longus colli, 72
masseter, 62
mastication, 61–62
medius scalenus, 70f
multifidus, 104, 104f
paravertebral, 47
piriformis, 106, 108
psoas, 47, 51, 73, 78–80, 104f
quadratus femoris, 106
quadratus lumborum, 104f
rhomboid, 102
rotatores, 104
sacrospinalis, 12f
semispinalis, 104
spinalis, 104
splenius capitis, 102
sternocleidomastoid, 67, 71
supraspinatus, 103f
teres major, 103f
teres minor, 103f
transversospinal, 104
trapezius, 102, 103f
muscle spasm, 1
muscle wasting, 113
 131
Index

myelography, 37 referred, 1 in thoracic nerve root block, 51, 53–54

myofascial pain syndrome, 2, 101, 108 somatic, 1–2 in trigger point injections, 103, 105
myopathy, 113 visceral, 1–2, 77 posterior sacral foramen, 55f, 57
myotomes, 123 pancreas posterior sacro-iliac ligament, 12f
anatomy, 77 posterior superior iliac spines, 31, 55
cancer, 2, 65 gluteus medius injection, 106
N paralysis, transient motor see transient piriformis injection, 108
nasopharyngeal airway, 117 motor paralysis post-herpetic neuralgia, 65
neck, 112 paraparesis, 10 postural hypotension, 76
nerve fibers paraplegia, 10 preganglionic sympathetic efferents, 77
parasympathetic, 77, 86 post-celiac plexus block, 81, 85 prevertebral fascia, 73
pre- and postganglionic, 77 post-hypogastric plexus block, 90 propofol, 64
sympathetic, 77, 86 parasympathetic nerve fibers, 77, 86 prostate, 86
nerve roots, mechanical compression, 37 paravertebral injection, 51 psoas muscle, 47, 51, 73, 78–80, 104f
nerve(s) paravertebral muscles, 47 psychologic upset, 113
injured, 1 paravertebral space, 53 pterygoid process, 62
regeneration, 1 paravertebral sympathetic trunk, 78f, 84f ptosis of eyelid, 68, 72
nerve sheath, 41–42, 49, 53 paresthesia
neural foramina, 78 in lumbar nerve root block, 48
neuritis in thoracic nerve root block, 54 in sacral nerve root block, 57
in stellate ganglion block
Q
neurolysis, 75
neurolytic agents C7 approach, 72 quadratus femoris muscle, 106
in autonomic blockade, 76, 81, 84–85, C6 (classic) approach, 68 quadratus lumborum muscle, 104f
88–90, 93 in thoracic nerve root block, 52
in somatic nerve blockade, 40, 61, 64 in trigeminal ganglion (Gasserian) block,
suggested, 115 62
parietal pleura, 43
R
neurolytic blocks, 40, 64–65, 76, 81, 84, 90
neuroma formation, 1 pelvic cancer, 65 radiculopathy
neuropraxia, 96, 99 pelvic organs, 77 discogenic, 37
neurotransmitters, 94, 97 pericardial cavity, 45f lumbar, 32
neurovascular bundle, 40–41, 44, 45f perineum, 91 lumbo-sacral, 15
norepinephrine, 68, 94, 97, 99 periosteal injection, 93 sacral, 32
nose blockage, unilateral, 68, 72 peripheral nerve changes, 1 radiofrequency lesioning of the intercostal
nucleus pulposis, 37 peripheral sympathetic blockade, 94f nerve, 41
peripheral vascular disease, 65 radiograph, chest
peripheral visceral afferents, 1 intercostal nerve block, 39
O petrous temporal bone, 61 interpleural block, 44
phenol, 115 rami
occipital artery, 60 celiac plexus block cervical posterior primary, 8
occipital nerve, 59 anterocrural approach, 83 dorsal, medial branches, 3–4
occipital nerve block, 59–60 retrocrural approach, 80 grey, 38, 47
anatomy, 59, 59f ganglion impar block, 93 posterior primary, cervical, 8
confirmation of success, 60 hypogastric plexus block, 87 white, 38, 47
drugs, 59 phrenic nerve block, post-stellate ganglion rectum, 77
equipment, 59 block distal, 91
needle puncture and technique, 59–60, C7 approach, 72 perforation, 93
59f–60f C6 (classic) approach, 69 recurrent laryngeal nerve block, stellate
position of patient, 59 physiotherapy ganglion block
potential problems, 60 post-intravenous regional sympathetic C7 approach, 72
tips, 60 block, 96, 98 C6 (classic) approach, 69
oculomotor nerve, 64 and trigger point injections, 103, 105 resuscitation, recommended drugs and
ophthalmic nerve, 61 pia mater, 125f equipment, 117
oropharyngeal airway, 117 piriformis injection, 108–110 retrocrural spread, 77f, 82f
orthostatic hypotension, 81, 84, 90 anatomy, 108, 108f retrograde cannulation, intravenous regional
osteoporosis, 113 confirmation of success, 108 sympathetic block
oxygen bag and masks, 117 drugs, 108 lower limb, 98
oxygen source, 117 equipment, 108 upper limb, 95
needle puncture and technique, 108, retroperitoneal compartment, 82
P 109f–110f
position of patient, 108, 108f
retroperitoneal space, 86, 92f
retroperitoneum, 93
pacemaker, cardiac, 112 potential problems, 110 rhabdomyolysis, 76, 88–90
pain tips, 108–110 rhomboid muscles, 102
cervical epidural block, 29 piriformis muscle, 106, 108 ribs
communication of, 2 pleura, 43, 51, 66 anatomy, 51
definition, 1 avoidance in thoracic nerve root block, 52 palpation, 38–39, 43–44
joint, 2 pleural cavity, 45f twelfth, 73, 83
management of, 2 pneumothorax rotatores muscle, 104
mechanisms, 1–2 in celiac plexus block, 81, 85
myofascial, 2 in intercostal nerve block, 39–41
neuropathic, 1–2
perception, 2
in interpleural block, 44, 46
in stellate ganglion block
S
psychologic factors, 2 C7 approach, 70–72 sacral canal, 55
radicular, 2, 15, 33 C6 (classic) approach, 69 sacral cornua, 31–32
132
Index
sacral epidural space, 30
sacral foramen, 55–57
sacral hiatus, 30–32, 55
sacral nerve root block, 55–57
anatomy, 55, 55f
confirmation of success, 57
drugs, 55
equipment, 55
needle puncture and technique, 55–57,
56f–58f
position of patient, 55, 56f
potential problems, 57
tips, 57
sacral nerve roots, 15
sacral nerves, 55
sacral promontory, 86
sacral radiculopathy, 32
sacrococcygeal junction, 92
sacrococcygeal ligament, 30f
sacrococcygeal membrane, 30–32, 55
sacrococcygeal vertebral column, 93
sacro-iliac joint injection, 12–14
anatomy, 12, 12f
confirmation of success, 14
drugs, 12
equipment, 12
needle puncture and technique, 12–13,
12f–13f
position of patient, 12, 12f
potential problems, 14
tips, 14
sacroiliac ligaments injection, 14
sacrospinalis muscle, 12f
sacrum, 30, 55, 125f
saline
in caudal epidural block, 31
in cervical epidural block, 25–26
in interpleural block, 46
in intravenous regional sympathetic block
lower limb, 97
upper limb, 95
in long-term epidural catheter insertion,
34
in lumbar epidural block, 17–18, 20
in thoracic epidural block, 23
scapula
inferior angle of, 52
root of the spine of, 52
sciatic nerve, 108
sciatic nerve block, 107
sciatic notch, 107
sedation
in autonomic blockade, 76, 78, 81–82,
85, 93
in epidural injections, 24, 28–29
in joint injections, 13
in somatic nerve blockade, 38, 42, 62
segmental arteries spasm, 81, 85, 90
seizures, 96
semispinalis muscle, 104
sensory neurons, 1
septic discitis, 76
sickle cell anemia, 96, 99
sixth cervical anterior tubercle, 66–68
skin
depigmentation, 113
flushing, 113
temperature, 68, 72, 75
somatic nerve blockade, 37–64
in celiac plexus block, 81, 84–85
in ganglion impar block, 93
in hypogastric plexus block, 87–90
in lumbar sympathetic block, 76
somatic nerves, 1
lumbar, 73
somatic nociceptive afferents, 1
somatic nociceptor fibers, 1
sphenoid bone, 62
spinal anaesthesia, 10
spinal block, total, 60
spinal cord, 16, 125f
injury
cervical epidural block, 29
thoracic epidural block, 24
segmental myotomes, 123
spinalis muscle, 104
spinal nerve roots inflammation, 15
spinal nerves, 3–4, 3f
spinothalamic pathways, 1
spinous processes
cervical, 25
lumbar, 16–17, 47, 56, 73, 87
thoracic, 21–22, 25, 52
splanchnic nerves, 77, 86
spleen, 77
splenius capitis muscle, 102
spontaneous neural inputs, 1
stellate ganglion, 66, 70f
stellate ganglion block
bilateral, 69
C7 approach, 70–72
anatomy, 70, 70f
confirmation of success, 72
drugs, 70
equipment, 70
needle puncture and technique, 70–72,
70f–71f
position of patient, 70
potential problems, 72
tips, 72
C6 (classic) approach, 66–69
anatomy, 66, 66f
confirmation of success, 68
drugs, 66
equipment, 66, 66f
needle puncture and technique, 66–68
right-handed operator, 66–68,
67f–68f
position of patient, 66
potential problems, 68–69
tips, 68, 69f–70f
sternoclavicular junction, 71
sternocleidomastoid muscle, 67, 71
subarachnoid block, 76
subarachnoid space, 19–20, 25f, 32f
subclavian artery, 70f
subcutaneous tissue atrophy, 113
subperiosteal injection, 33, 33f
succinylcholine, 117
superior articular process, 17f
superior gluteal nerve, 12
superior hypogastric plexus, 86, 86f, 90f
superior mesenteric artery, 77f–78f, 84f
superior mesenteric ganglion, 77f
superior nuchal line, 59–60
superior stellate ganglion, 70f
suprarenal glands, 77
supraspinatus muscle, 103f
supraspinous ligament, 16
sympathetic afferents, 1, 91
sympathetic blockade, 51
with lumbar nerve root block, 49
in thoracic nerve root block, 54
sympathetic chain, 43
sympathetic ganglia, 51f, 91
sympathetic lumbar chain, 47, 51
sympathetic nerve endings, 94, 97
sympathetic nerve fibers, 77, 86
sympatholytic agents, 94, 97
T
temperature, skin, 68, 72, 75
temporal lobe, 61
tender points, 101
tendon, rupture of injected, 113
TENS see transcutaneous electrical
stimulation (TENS)
teres major muscle, 103f
teres minor muscle, 103f
thermocoagulation, 64
thiopental (thiopentone), 117
thoracic disc pain, 15
thoracic duct damage, 81, 85
thoracic epidural block, 21–24
anatomy, 21, 21f
confirmation of success, 23
drugs, 21
equipment, 21
needle puncture and technique, 21,
21f–22f
paramedian approach, right-handed
operator, 22–23, 23f
position of patient, 21
potential problems, 24
tips, 23, 24f
thoracic ganglia, 66
thoracic nerve root block, 51–54
anatomy, 51, 51f
confirmation of success, 53
drugs, 51
equipment, 51
needle puncture and technique, 51–53,
52f–53f
position of patient, 51, 52f
potential problems, 53–54
tips, 53
thoracic sympathetic chain, 52f, 77
thoracostomy drainage tubes, 46
thyroid cartilage, 66–67, 71
total spinal block, 60
tourniquet, 68, 95, 97–99
transcutaneous electrical stimulation
(TENS), 111–112
burst stimulation, 112
continuous stimulation, 111
contraindications, 112
control settings, 111–112, 111f–112f
low-frequency high-intensity stimulation,
112
modulated settings, 112
trial period, 111
transient motor paralysis
post-celiac plexus block, 81, 85
post-hypogastric plexus block, 90
transverse processes, 17f, 52
transversospinal muscles, 104
trapezius muscle, 102, 103f
triamcinolone, 113
in caudal epidural block, 31–32
in cervical epidural block, 27, 29
in cervical facet joint injection, 9
in epidural injection, 15
in lumbar epidural block, 18, 20
in lumbar facet joint injection, 5
in sacro-iliac joint injection, 13
in thoracic epidural block, 21, 23
trigeminal ganglion, 61

trigeminal ganglion (Gasserian) block,
61–64
anatomy, 61, 61f
confirmation of success, 64
drugs, 61
equipment, 61
needle puncture and technique, 62–64,
62f–63f
position of patient, 61
potential problems, 64
tips, 64
trigeminal nerve, 62, 64
trigeminal neuralgia, 65
trigeminal nucleus, 1
trigger point injections, 2, 101
back, 104–105
anatomy, 104, 104f
confirmation of success, 105
drugs, 104
equipment, 104
needle puncture and technique, 105,
105f
position of patient, 104, 104f
potential problems, 105
tips, 105
neck and thorax, 102–103
anatomy, 102, 102f
confirmation of success, 102
drugs, 102
equipment, 102
needle puncture and technique, 102,
102f–103f
position of patient, 102
133
Index
potential problems, 103
tips, 103
V
number of, 101 vagina, 86, 91
trigger points, 2, 101 vagus nerve, 77
palpation, 101 vasovagal response, 103, 105
trochlear nerve, 64 vasovagal syncope, 29
twitch, local, 102f veins
azygos, 52f
external iliac, 86f
U intercostal, 38f
internal iliac, 86f
ultrasonography jugular, 68, 72
in caudal epidural block, 31 Velband, 95, 97
in cervical epidural block, 25, 28 vertebral arteries, 66, 70–71, 70f
in hypogastric plexus block, 87 vertebra prominens, 18f, 25
in intercostal nerve block, 40 visceral afferents, 1
in interpleural block, 46 visceral organs, 1
in long-term epidural catheter insertion, visceral pleura, 43
36 vulva, 91
in lumbar epidural block, 20, 20f
in lumbar facet joint injection, 4–5, 5f
in lumbar nerve root block, 48
in piriformis injection, 108
W
in sacral nerve root block, 57 white rami, 38, 47
in sacro-iliac joint injection, 13 wide dynamic range neurons, 1
in stellate ganglion block
C7 approach, 72
C6 (classic) approach, 68
in thoracic epidural block, 23, 24f
Z
in thoracic nerve root block, 52 zygapophyseal joints see facet joints
ureters, perforation, 76, 81, 85 zygomatic arch, 62
urethra, distal, 91
uterus, 86