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Popliteal Nerve Bifurcation

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Clinical Specialties

Anesthesiology (Regional)

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3D How To: Popliteal Sciatic Nerve Block

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3D animation demonstrating an ultrasound guided Popliteal nerve block.

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How To Videos

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- [Voiceover] A linear array transducer
with a nerve exam type is used to perform ultrasound guided
popliteal nerve block.
The target depth is approximately 2 to 4 centimeters
in an 80 kilogram adult.
The patient is positioned in a lateral decubitus position
with the hip and knee slightly flexed.
The transducer is placed transversely
on the popliteal skin crease with the orientation
marker directed laterally.
The transducer should be moved medially and laterally
to identify the dark round pulsatile popliteal artery.
The compressible poplital vein can be seen superior
to the popliteal artery.
The tibial nerve lies superficial to the popliteal vein
and appears as a bright hyperechoic oval structure.
The transducer should be slowly translated
up the posterior thigh to identify the point
where the peroneal and tibial nerves join.
The ideal point for needle insertion is at or just below
the split of the tibial and peroneal nerves.
The needles is advanced using an in-plane technique.
The needle is positioned 1 to 2 centimeters lateral
to the transducer and advanced under the transducer.
The initial end point for the needle is immediately
beside the tibial nerve.
Local anesthetic should be principally injected
around the tibial nerve, as it is responsible
for the majority of the innervation of the foot.

Brightcove ID

5764118112001

https://youtube.com/watch?v=9c1A-87maFE

Body

3D animation demonstrating an ultrasound guided Popliteal nerve block.

3D How To: Median and Ulnar Nerve Block

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3D animation demonstrating an ultrasound guided median and ulnar nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Media Library Tag

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
a median and ulnar regional nerve block.
The target depth is approximately one to two centimeters
in an 80-kilogram adult.
The patient is placed supine with the arm
externally rotated at the side.
The transducer is placed in a transverse plane
at the wrist crease
with the orientation marker
directed towards the patient's right side.
The hypoechoic pulsatile ulnar artery is identified.
It may be helpful to use color Doppler
if the artery is small.
The ulnar nerve is an oval, or triangular,
bright, hyperechoic structure
that lies immediately medial to the artery.
Trace the nerve up the forearm
following the course of the artery.
The ulnar nerve will start to separate from the artery
approximately 2/3 of the way up the forearm.
The separation allows safe placement of local anesthetic
around the nerve.
Follow the fascial plane medially
to the superficial and deep flexor muscles
to identify the bright, hyperechoic median nerve.
The median nerve appears as an oval, or triangular,
bright, hyperechoic structure between the muscles.
The needle can be advanced
using an in-plane or out-of-plane technique.
For an in-plane approach, the needle is positioned
one to two centimeters lateral to the transducer
and advanced under the transducer.
The initial path for the needle is toward the ulnar nerve
to allow the needle tip
to lie immediately beside the ulnar nerve.
Inject three to five cc of local anesthetic
around the ulnar nerve to perform the block.
The needle is then redirected laterally to the median nerve.
Injection of three to five cc of local anesthetic
around the median nerve
will complete the median nerve block.

Brightcove ID

5508114149001

https://youtube.com/watch?v=6NKkzs9FA5I

3D How To: Gluteal Sciatic Nerve Block

Read more about 3D How To: Gluteal Sciatic Nerve Block

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3D animation demonstrating an ultrasound guided Gluteal Sciatic nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A curved array transducer
with a nerve exam type is used to perform
a ultrasound guided sciatic nerve block.
The target depth is approximately four to six centimeters
in an 80 kilogram adult.
The patient is positioned in a lateral decubitus position
with the hip and knee flexed.
The transducer is placed between the greater trochanter
and the ischial tuberosity in a transverse position
just proximal to the gluteal fold
with the orientation marker directed laterally.
The bony landmarks will appear
as bright hyperechoic crescents with posterior shadowing.
There are several layers of tissue
between the bony landmarks, which should be identified
from superficial to deep, including adipose tissue,
the gluteus maximus muscle and quadratus femoris muscle.
The sciatic nerve lies deep to the gluteus maximus
and superficial to the quadratus femoris muscle.
It appears as a bright hyperechoic oval
or triangular shaped density.
The transducer should be moved slightly cranially
or caudally from the initial position
by slightly rocking the transducer
so the beam is perpendicular to the nerve
for the best echo reflection if it is difficult to identify.
When the transducer is moved distally in the thigh,
the sciatic nerve becomes more oval in shape
and is found more superficially between the biceps femoris
and abductor magnus muscles.
The needle is advanced using an in plane technique.
The needle is positioned one to two centimeters lateral
to the transducer and advanced slowly under the transducer.
The initial end point for the needle
is just lateral and deep to the nerve.
The local anesthetic is injected incrementally
close to the nerve.
For a successful block, a spread of locals
should be observed around the medial side
or tibial component of the nerve.

Brightcove ID

5508134308001

https://youtube.com/watch?v=xvAY_bu_S7A

3D How To: Saphenous Nerve Block

Read more about 3D How To: Saphenous Nerve Block

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3D animation demonstrating an ultrasound guided saphenous nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Media Library Tag

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided saphenous nerve block.
The target depth is approximately
one to three centimeters in an 80 kilogram adult.
The patient is positioned in a supine position
with the leg slightly abducted and externally rotated.
The transducer is placed in the middle of the thigh
in a transverse plane, with the orientation marker
directed to the patient's right.
The leg is scanned medially to laterally
to identify the superficial femoral artery,
which lies underneath the sartorius muscle.
The saphenous nerve can lie either
anterior or posterior to the artery.
The saphenous nerve may not be visible.
If it is, it will appear as a bright,
hyperechoic oval or triangular structure.
The needle is positioned one to two centimeters lateral
to the transducer, and advanced under the transducer.
Local anesthetic is injected incrementally,
superficial and deep to the artery
to complete the saphenous nerve block.

Brightcove ID

5508114714001

https://youtube.com/watch?v=54VG2GhJ3w4

Body

3D animation demonstrating an ultrasound guided saphenous nerve block.

How To: Sacroiliac Injection

Read more about How To: Sacroiliac Injection

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This video discusses some of the scanning techniques when performing a sacroiliac injection under ultrasound guidance.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Media Library Tag

S.I

Sacraliliac Joint Injection

Anesthetic Nerve Block

Subtitles

- Today I'm gonna demonstrate the sacroiliac joint injection
as facilitated by ultrasonography.
The anatomic considerations are the posterior superior
iliac spine, the sacrum, and the insertion formed
of the sacroiliac joint.
The C60 probe is placed in the transverse orientation.
After anesthetizing the skin the needle enters
out of plane into the joint, thusly performing the block.
The sacroiliac joint injection is useful specifically
to diagnose issues within the sacroiliac joint that might
be causing hip pain to the patient.
Typically on physical examination, there might be a positive
FABER or flexion abduction external rotation test,
also known as Patrick's sign,
or a positive Gaenslen's maneuver.
This can also occur when the patient has a pelvic tilt
or a leg-length discrepancy.
The injection is useful both diagnostically
and therapeutically.
Traditionally, fluoroscopy is utilized to place the needle
within the sacroiliac joint space.
The sacroiliac joint is a very complicated joint in that
it is a fibrous insertion superiorly and a traditional
articulating joint in the lower portion of it.
On fluoroscopy, issues arise such as parallax
and it is well-documented that sometimes the injection
is not placed within the joint but rather periarticularly
and, therefore, not providing the coverage
or the response that is expected.
To perform this particular block,
the following equipment is necessary.
Chlorhexidine for sterile technique.
Local anesthetic syringe containing 1% buffered lidocaine.
And then a syringe containing 5cc of bupivacaine,
one-half percent mixed with 5cc of one percent lidocaine.
And then 40-80 milligrams of triamcinolone kenalog
which is a particulate steroid.
A 3 1/2 inch, 25 gauge spinal needle will also be utilized
for the procedure.
There will be sterile 4 x 4s necessary to clean the area
at the conclusion.
And a simple band-aid will suffice to cover the wound.
The patient is placed in the traditional prone position.
There is a bolster within and under the abdomen
to facilitate opening of the sacroiliac joints.
And then I utilize the C60 probe with its curvy linear
structure to better visualize the interface between
the sacrum and the iliac crest.
The depth is usually set to 7 - 9 centimeters,
depending on the patient's habitus.
Additionally, I utilize the muscoloskeletal, or the MSK,
setting because it provides enhancement of the bony
structures and the enhancement of the joint space.
The probe is placed on the patient in the transverse
orientation approximately a centimeter or two above
the beginnings of the gluteal folds.
And I've found the anatomic midline by identifying
the spinous process of the sacral plate.
As I roll the probe laterally, the posterior superior
iliac spine comes into view very clearly at the top
of the screen, up here.
The space between the posterior superior iliac spine
and the shadow cast by the iliac crest and the sacrum
as it dives down represents the sacroiliac joint.
And you can see that in the center of the screen.
It's important to remember that the iliac crest and ilium
folds and cantilevers towards the sacrum.
Therefore, the needle angle needs to track from medial
to lateral into the space identified
in the center of the screen.
Local anesthetic is placed.
And as a finder needle, this injectate using hydrodissection
demonstrates the needle tip at all times.
The needle is going in the short axis, therefore,
it won't be completely visualized on the screen.
However, hydrodissection can help notice where
the tip is at all times.
Then I'll utilize the 3 1/2 inch spinal needle, 25 gauge,
and enter that track that I have placed
local anesthetic with it.
The needle tip will then be placed within that joint
identified in the center of the screen, right here.
At this point, I attach my syringe containing the local
anesthetic steroid and saline mix.
And then I could utilize color flow Doppler to actually
visualize perturbations of the liquid
as it enters the joint.
- [Voiceover] The view is in the short axis, therefore,
the needle is not visible.
The iliac crest is visible as the large hyperechoic
structure on the right of the screen.
The lateral crest of the sacrum is visible below.
The target is the void between the lateral crest
of the sacrum and the iliac crest.
This helps solidify understanding of the three-dimensional
structure of the sacroiliac joint.
- At this point the probe is removed.
I utilize the 4 x 4s to clean the area.
And a band-aid is placed over the wound.
This successfully completes the ultrasonographic
facilitation of a sacroiliac joint injection.

Brightcove ID

5734039824001

https://youtube.com/watch?v=7G56DN38mz8

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Popliteal Nerve Bifurcation

Popliteal Nerve Bifurcation

3D How To: Popliteal Sciatic Nerve Block

3D How To: Popliteal Sciatic Nerve Block

3D How To: Median and Ulnar Nerve Block

3D How To: Median and Ulnar Nerve Block

3D How To: Gluteal Sciatic Nerve Block

3D How To: Gluteal Sciatic Nerve Block

3D How To: Saphenous Nerve Block

3D How To: Saphenous Nerve Block

How To: Sacroiliac Injection

How To: Sacroiliac Injection

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