<p begin="00:00:07.889" end="00:00:09.349" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.349" end="00:00:12.631" style="s2">with a nerve exam type is used<br />to perform ultrasound guided</p>
<p begin="00:00:12.631" end="00:00:14.687" style="s2">popliteal nerve block.</p>
<p begin="00:00:14.687" end="00:00:17.850" style="s2">The target depth is<br />approximately 2 to 4 centimeters</p>
<p begin="00:00:17.850" end="00:00:20.373" style="s2">in an 80 kilogram adult.</p>
<p begin="00:00:20.373" end="00:00:23.568" style="s2">The patient is positioned in<br />a lateral decubitus position</p>
<p begin="00:00:23.568" end="00:00:26.091" style="s2">with the hip and knee slightly flexed.</p>
<p begin="00:00:26.091" end="00:00:28.135" style="s2">The transducer is placed transversely</p>
<p begin="00:00:28.135" end="00:00:31.135" style="s2">on the popliteal skin<br />crease with the orientation</p>
<p begin="00:00:31.135" end="00:00:33.388" style="s2">marker directed laterally.</p>
<p begin="00:00:33.388" end="00:00:36.393" style="s2">The transducer should be<br />moved medially and laterally</p>
<p begin="00:00:36.393" end="00:00:40.222" style="s2">to identify the dark round<br />pulsatile popliteal artery.</p>
<p begin="00:00:40.222" end="00:00:43.492" style="s2">The compressible poplital<br />vein can be seen superior</p>
<p begin="00:00:43.492" end="00:00:45.695" style="s2">to the popliteal artery.</p>
<p begin="00:00:45.695" end="00:00:49.145" style="s2">The tibial nerve lies<br />superficial to the popliteal vein</p>
<p begin="00:00:49.145" end="00:00:52.668" style="s2">and appears as a bright<br />hyperechoic oval structure.</p>
<p begin="00:00:52.668" end="00:00:55.331" style="s2">The transducer should be slowly translated</p>
<p begin="00:00:55.331" end="00:00:57.926" style="s2">up the posterior thigh<br />to identify the point</p>
<p begin="00:00:57.926" end="00:01:00.976" style="s2">where the peroneal and tibial nerves join.</p>
<p begin="00:01:00.976" end="00:01:04.783" style="s2">The ideal point for needle<br />insertion is at or just below</p>
<p begin="00:01:04.783" end="00:01:07.763" style="s2">the split of the tibial<br />and peroneal nerves.</p>
<p begin="00:01:07.763" end="00:01:11.138" style="s2">The needles is advanced<br />using an in-plane technique.</p>
<p begin="00:01:11.138" end="00:01:14.455" style="s2">The needle is positioned<br />1 to 2 centimeters lateral</p>
<p begin="00:01:14.455" end="00:01:18.534" style="s2">to the transducer and<br />advanced under the transducer.</p>
<p begin="00:01:18.534" end="00:01:20.831" style="s2">The initial end point for<br />the needle is immediately</p>
<p begin="00:01:20.831" end="00:01:22.906" style="s2">beside the tibial nerve.</p>
<p begin="00:01:22.906" end="00:01:25.326" style="s2">Local anesthetic should<br />be principally injected</p>
<p begin="00:01:25.326" end="00:01:27.880" style="s2">around the tibial nerve,<br />as it is responsible</p>
<p begin="00:01:27.880" end="00:01:31.963" style="s2">for the majority of the<br />innervation of the foot.</p>

<p begin="00:00:07.379" end="00:00:09.137" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.137" end="00:00:11.666" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.666" end="00:00:14.865" style="s2">a median and ulnar regional nerve block.</p>
<p begin="00:00:14.865" end="00:00:18.167" style="s2">The target depth is approximately<br />one to two centimeters</p>
<p begin="00:00:18.167" end="00:00:20.392" style="s2">in an 80-kilogram adult.</p>
<p begin="00:00:20.392" end="00:00:23.105" style="s2">The patient is placed supine with the arm</p>
<p begin="00:00:23.105" end="00:00:25.641" style="s2">externally rotated at the side.</p>
<p begin="00:00:25.641" end="00:00:28.475" style="s2">The transducer is placed<br />in a transverse plane</p>
<p begin="00:00:28.475" end="00:00:29.721" style="s2">at the wrist crease</p>
<p begin="00:00:29.721" end="00:00:31.120" style="s2">with the orientation marker</p>
<p begin="00:00:31.120" end="00:00:33.953" style="s2">directed towards the patient's right side.</p>
<p begin="00:00:33.953" end="00:00:38.214" style="s2">The hypoechoic pulsatile<br />ulnar artery is identified.</p>
<p begin="00:00:38.214" end="00:00:40.485" style="s2">It may be helpful to use color Doppler</p>
<p begin="00:00:40.485" end="00:00:42.265" style="s2">if the artery is small.</p>
<p begin="00:00:42.265" end="00:00:45.357" style="s2">The ulnar nerve is an oval, or triangular,</p>
<p begin="00:00:45.357" end="00:00:47.294" style="s2">bright, hyperechoic structure</p>
<p begin="00:00:47.294" end="00:00:50.318" style="s2">that lies immediately<br />medial to the artery.</p>
<p begin="00:00:50.318" end="00:00:52.141" style="s2">Trace the nerve up the forearm</p>
<p begin="00:00:52.141" end="00:00:54.392" style="s2">following the course of the artery.</p>
<p begin="00:00:54.392" end="00:00:57.527" style="s2">The ulnar nerve will start<br />to separate from the artery</p>
<p begin="00:00:57.527" end="00:01:00.689" style="s2">approximately 2/3 of<br />the way up the forearm.</p>
<p begin="00:01:00.689" end="00:01:03.902" style="s2">The separation allows safe<br />placement of local anesthetic</p>
<p begin="00:01:03.902" end="00:01:05.269" style="s2">around the nerve.</p>
<p begin="00:01:05.269" end="00:01:07.372" style="s2">Follow the fascial plane medially</p>
<p begin="00:01:07.372" end="00:01:10.376" style="s2">to the superficial and deep flexor muscles</p>
<p begin="00:01:10.376" end="00:01:14.030" style="s2">to identify the bright,<br />hyperechoic median nerve.</p>
<p begin="00:01:14.030" end="00:01:17.358" style="s2">The median nerve appears<br />as an oval, or triangular,</p>
<p begin="00:01:17.358" end="00:01:20.735" style="s2">bright, hyperechoic structure<br />between the muscles.</p>
<p begin="00:01:20.735" end="00:01:22.051" style="s2">The needle can be advanced</p>
<p begin="00:01:22.051" end="00:01:25.372" style="s2">using an in-plane or<br />out-of-plane technique.</p>
<p begin="00:01:25.372" end="00:01:28.332" style="s2">For an in-plane approach,<br />the needle is positioned</p>
<p begin="00:01:28.332" end="00:01:31.655" style="s2">one to two centimeters<br />lateral to the transducer</p>
<p begin="00:01:31.655" end="00:01:34.231" style="s2">and advanced under the transducer.</p>
<p begin="00:01:34.231" end="00:01:37.655" style="s2">The initial path for the needle<br />is toward the ulnar nerve</p>
<p begin="00:01:37.655" end="00:01:38.812" style="s2">to allow the needle tip</p>
<p begin="00:01:38.812" end="00:01:41.893" style="s2">to lie immediately beside the ulnar nerve.</p>
<p begin="00:01:41.893" end="00:01:45.441" style="s2">Inject three to five<br />cc of local anesthetic</p>
<p begin="00:01:45.441" end="00:01:48.604" style="s2">around the ulnar nerve<br />to perform the block.</p>
<p begin="00:01:48.604" end="00:01:52.681" style="s2">The needle is then redirected<br />laterally to the median nerve.</p>
<p begin="00:01:52.681" end="00:01:56.245" style="s2">Injection of three to five<br />cc of local anesthetic</p>
<p begin="00:01:56.245" end="00:01:57.726" style="s2">around the median nerve</p>
<p begin="00:01:57.726" end="00:02:00.809" style="s2">will complete the median nerve block.</p>

<p begin="00:00:07.382" end="00:00:09.372" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.372" end="00:00:11.583" style="s2">with a nerve exam type is used to perform</p>
<p begin="00:00:11.583" end="00:00:14.256" style="s2">an ultrasound-guided<br />saphenous nerve block.</p>
<p begin="00:00:14.256" end="00:00:16.488" style="s2">The target depth is approximately</p>
<p begin="00:00:16.488" end="00:00:19.895" style="s2">one to three centimeters<br />in an 80 kilogram adult.</p>
<p begin="00:00:19.895" end="00:00:22.767" style="s2">The patient is positioned<br />in a supine position</p>
<p begin="00:00:22.767" end="00:00:26.181" style="s2">with the leg slightly abducted<br />and externally rotated.</p>
<p begin="00:00:26.181" end="00:00:29.113" style="s2">The transducer is placed<br />in the middle of the thigh</p>
<p begin="00:00:29.113" end="00:00:32.156" style="s2">in a transverse plane,<br />with the orientation marker</p>
<p begin="00:00:32.156" end="00:00:34.315" style="s2">directed to the patient's right.</p>
<p begin="00:00:34.315" end="00:00:36.942" style="s2">The leg is scanned medially to laterally</p>
<p begin="00:00:36.942" end="00:00:39.876" style="s2">to identify the<br />superficial femoral artery,</p>
<p begin="00:00:39.876" end="00:00:42.604" style="s2">which lies underneath<br />the sartorius muscle.</p>
<p begin="00:00:42.604" end="00:00:44.704" style="s2">The saphenous nerve can lie either</p>
<p begin="00:00:44.704" end="00:00:47.489" style="s2">anterior or posterior to the artery.</p>
<p begin="00:00:47.489" end="00:00:50.222" style="s2">The saphenous nerve may not be visible.</p>
<p begin="00:00:50.222" end="00:00:52.648" style="s2">If it is, it will appear as a bright,</p>
<p begin="00:00:52.648" end="00:00:55.461" style="s2">hyperechoic oval or triangular structure.</p>
<p begin="00:00:55.461" end="00:00:58.688" style="s2">The needle is positioned one<br />to two centimeters lateral</p>
<p begin="00:00:58.688" end="00:01:02.121" style="s2">to the transducer, and<br />advanced under the transducer.</p>
<p begin="00:01:02.121" end="00:01:04.989" style="s2">Local anesthetic is<br />injected incrementally,</p>
<p begin="00:01:04.989" end="00:01:07.315" style="s2">superficial and deep to the artery</p>
<p begin="00:01:07.315" end="00:01:10.482" style="s2">to complete the saphenous nerve block.</p>

<p begin="00:00:09.277" end="00:00:12.473" style="s2">- Today I will perform<br />an anatomic demonstration</p>
<p begin="00:00:12.473" end="00:00:14.176" style="s2">of the cervical spine utilizing</p>
<p begin="00:00:14.176" end="00:00:16.894" style="s2">the M-Turbo Ultrasound System,</p>
<p begin="00:00:16.894" end="00:00:20.272" style="s2">utilizing the C60 curvilinear probe.</p>
<p begin="00:00:20.272" end="00:00:22.765" style="s2">The point of this<br />exercise is to demonstrate</p>
<p begin="00:00:22.765" end="00:00:25.246" style="s2">the anatomic considerations<br />when performing</p>
<p begin="00:00:25.246" end="00:00:28.005" style="s2">cervical epidural steroid injections</p>
<p begin="00:00:28.005" end="00:00:29.905" style="s2">and cervical facet injections.</p>
<p begin="00:00:29.905" end="00:00:32.402" style="s2">Typical patients may have have<br />a variance in their anatomy</p>
<p begin="00:00:32.402" end="00:00:35.125" style="s2">and the traditional approaches utilizing</p>
<p begin="00:00:35.125" end="00:00:36.739" style="s2">loss of resistance techniques for</p>
<p begin="00:00:36.739" end="00:00:40.204" style="s2">cervical epidural steroids<br />can present come challenges.</p>
<p begin="00:00:40.204" end="00:00:43.271" style="s2">The purpose of utilizing<br />the ultrasound system</p>
<p begin="00:00:43.271" end="00:00:46.105" style="s2">for an anatomic survey<br />is that the patient,</p>
<p begin="00:00:46.105" end="00:00:49.308" style="s2">who normally has a cervical<br />epidural steroid injection</p>
<p begin="00:00:49.308" end="00:00:51.419" style="s2">performed under fluoroscopic technique</p>
<p begin="00:00:51.419" end="00:00:54.799" style="s2">may occasionally encounter<br />false losses of resistance.</p>
<p begin="00:00:54.799" end="00:00:57.909" style="s2">Utilizing this particular<br />tool as a sounding device</p>
<p begin="00:00:57.909" end="00:01:01.742" style="s2">may perhaps improve the<br />accuracy of injection.</p>
<p begin="00:01:02.726" end="00:01:06.584" style="s2">The way this is performed is<br />utilizing again the C60 probe,</p>
<p begin="00:01:06.584" end="00:01:11.234" style="s2">setting the depth to<br />approximately 9.2 centimeters,</p>
<p begin="00:01:11.234" end="00:01:14.283" style="s2">remembering that the average<br />depth to the epidural space</p>
<p begin="00:01:14.283" end="00:01:16.584" style="s2">is appx six centimeters.</p>
<p begin="00:01:16.584" end="00:01:19.283" style="s2">The nerve setting will also be used</p>
<p begin="00:01:19.283" end="00:01:22.646" style="s2">to highlight any neural structures<br />that may be of interest.</p>
<p begin="00:01:22.646" end="00:01:25.938" style="s2">On the patient, initially, I like to mark</p>
<p begin="00:01:25.938" end="00:01:29.605" style="s2">utilizing a Sharpie,<br />the C7 spinous process.</p>
<p begin="00:01:32.137" end="00:01:35.181" style="s2">This is the most easily<br />palpable spinous process,</p>
<p begin="00:01:35.181" end="00:01:37.149" style="s2">and this is facilitated with the patient</p>
<p begin="00:01:37.149" end="00:01:40.496" style="s2">in the prone position, a<br />bolster under the thorax,</p>
<p begin="00:01:40.496" end="00:01:42.913" style="s2">and the head slightly flexed.</p>
<p begin="00:01:43.954" end="00:01:45.925" style="s2">I place a copious amount of gel</p>
<p begin="00:01:45.925" end="00:01:49.821" style="s2">across the patient's C7 spinous process,</p>
<p begin="00:01:49.821" end="00:01:53.738" style="s2">and then utilizing the<br />probe in the transverse,</p>
<p begin="00:01:54.573" end="00:01:56.570" style="s2">that is the left-to-right positioning,</p>
<p begin="00:01:56.570" end="00:02:00.366" style="s2">I place contact on the<br />skin, and clearly visible</p>
<p begin="00:02:00.366" end="00:02:03.366" style="s2">is the patient's C7 spinous process.</p>
<p begin="00:02:04.461" end="00:02:07.097" style="s2">In this particular view you<br />can also see the lamina,</p>
<p begin="00:02:07.097" end="00:02:10.930" style="s2">and the transverse<br />processes of T1 just below.</p>
<p begin="00:02:12.973" end="00:02:14.856" style="s2">And in the center of the screen,</p>
<p begin="00:02:14.856" end="00:02:18.064" style="s2">under the shadow of the spinous<br />process is a white line.</p>
<p begin="00:02:18.064" end="00:02:21.897" style="s2">This white line, and I<br />will highlight it here,</p>
<p begin="00:02:24.556" end="00:02:29.129" style="s2">demonstrates the actual<br />location of the epidural space.</p>
<p begin="00:02:29.129" end="00:02:32.904" style="s2">So looking off to the right of the screen,</p>
<p begin="00:02:32.904" end="00:02:35.199" style="s2">we can see that the depth is approximately</p>
<p begin="00:02:35.199" end="00:02:38.866" style="s2">five centimeters in<br />this particular patient.</p>
<p begin="00:02:40.790" end="00:02:43.256" style="s2">Other potential views include</p>
<p begin="00:02:43.256" end="00:02:48.086" style="s2">the cranial carotid<br />orientation, or sagittal plane</p>
<p begin="00:02:48.086" end="00:02:51.910" style="s2">of the probe, and placed along the neck,</p>
<p begin="00:02:51.910" end="00:02:53.993" style="s2">and slightly off midline,</p>
<p begin="00:02:54.938" end="00:02:57.649" style="s2">again now can be seen newer structures.</p>
<p begin="00:02:57.649" end="00:03:01.164" style="s2">In this particular case<br />the facet joint line</p>
<p begin="00:03:01.164" end="00:03:05.238" style="s2">is very clearly indicated<br />at these locations.</p>
<p begin="00:03:05.238" end="00:03:08.513" style="s2">The actual location for<br />a medial branch block</p>
<p begin="00:03:08.513" end="00:03:11.513" style="s2">would be on these superior surfaces.</p>
<p begin="00:03:12.556" end="00:03:14.499" style="s2">On the lateral mass.</p>
<p begin="00:03:14.499" end="00:03:18.690" style="s2">If the probe is then rotated further out,</p>
<p begin="00:03:18.690" end="00:03:21.440" style="s2">and a more oblique view obtained,</p>
<p begin="00:03:22.365" end="00:03:25.371" style="s2">the actual foramen of the nerve roots</p>
<p begin="00:03:25.371" end="00:03:27.451" style="s2">can thus be discerned.</p>
<p begin="00:03:27.451" end="00:03:30.118" style="s2">And as we move further cephalad,</p>
<p begin="00:03:33.346" end="00:03:37.513" style="s2">it is possible to view the<br />vertebral artery pulsations.</p>
<p begin="00:03:43.765" end="00:03:44.930" style="s2">And this obviously is a structure</p>
<p begin="00:03:44.930" end="00:03:48.905" style="s2">that would want to be<br />avoided at all costs.</p>
<p begin="00:03:48.905" end="00:03:51.318" style="s2">This concludes the<br />successful anatomical survey</p>
<p begin="00:03:51.318" end="00:03:55.401" style="s2">utilizing ultrasonography<br />of the cervical spine.</p>