All Lessons
The Block Buddy Pro App contains over 35 ultrasound-guided peripheral nerve block lessons and more than 80 videos – saving patients unnecessary pain and saving you time and worry. Explore what Block Buddy Pro offers in this overview:
Block Buddy Pro: Table of Contents
I. Blocks
A. Head/Neck
1. Intermediate Cervical Plexus
2. Sphenopalatine Ganglion (SPG) Block
B. Upper Extremity
1. Forearm Block
2. Interscalene Block
3. Supraclavicular Block
4. Infraclavicular Block
5. Axillary Block
6. Suprascapular and Axillary Nerve Blocks
C. Truncal
1. PECS Block
2. Serratus Plane Block
3. Paravertebral Block
4. Erector Spinae Block
5. External Oblique Intercostal Block
6. Subcostal TAP Block
7. Mid-Axillary TAP Block
8. Ilioinguinal-iliohypogastric Block
9. Transversalis Fascia Block
10. Quadratus Lumborum (QL2) Block
11. Quadratus Lumborum (QL3) Block
12. Rectus Sheath Block
D. Neuraxial Block
E. Lower Extremity
1. Genicular Nerve Block
2. Femoral Nerve Block
3. Pericapsular Nerve Group (PENG) Block
4. Fascia Iliaca Block
5. Lateral Femoral Cutaneous Nerve Block
6. Obturator Nerve Block
7. Adductor Canal Block
8. iPACK and LIA Blocks
9. Popliteal Plexus Block
10. Transgluteal Sciatic Nerve Block
11. Subgluteal Sciatic Nerve Block
12. Popliteal Sciatic Nerve Block
II. Basics of Ultrasound
III. Joint Innervation
A. Upper Extremity
1. Shoulder Joint
2. Elbow Joint
B. Lower Extremity
1. Hip Joint
2. Knee Joint
IV. Nerve Plexuses
A. Cervical Plexus
B. Brachial Plexus
C. Lumbosacral Plexus
V. Nociceptive Pathways
A. Upper Airway Ultrasound
B. Lung Ultrasound
C. Gastric Ultrasound
D. Diaphragm Ultrasound
VI. POCUS
A. Upper Airway Ultrasound
B. Lung Ultrasound
C. Gastric Ultrasound
D. Diaphragm Ultrasound
VII. Regional Anesthesia and Coagulation
VIII. Spine and Pelvis Anatomy
IX. Non-Surgical Pain Management
A. Cervical
1. Stellate Ganglion Block
B. Lumbar
1. Lumbar Interlaminar Epidural Steroid Injection
2. Lumbar Transforaminal Epidural Steroid Injection
3. Lumbar Medial Branch Block
4. Lumbar Intra-Articular Facet Injection
B. Sacral
1. Sacral Joint Injection
X. RX Guide
BLOCKS
Head/Neck
Intermediate Cervical Plexus
The intermediate cervical plexus block targets the superficial sensory branches of the cervical plexus: greater auricular, lesser occipital, transverse cervical, and supraclavicular nerves. Blocking these branches provides analgesia to the head and neck region.
Sphenopalatine Ganglion (SPG) Block
The Sphenopalatine Ganglion Block involves depositing local anesthetic to the sphenopalatine ganglion (SPG)—a group of nerve cells located at the pterygopalatine fossa, posterior to the middle turbinate—to relieve head and facial pain.
Upper Extremity
Forearm Block
The Forearm Block involves depositing a local anesthetic agent around the radial, median, and/or ulnar nerves in the forearm with the goal of achieving anesthesia of the hand.
The interscalene block is a regional anesthesia technique that effectively blocks sensations to the shoulder and upper arm. Generally, patients in need of shoulder surgery are typical candidates for this nerve block.
The supraclavicular block, also known as the spinal of the arm, is a regional anesthesia technique that targets the brachial plexus at the level of the divisions. This approach is commonly performed for a variety of surgical procedures involving the shoulder, arm, and hand.
Infraclavicular Block
The infraclavicular brachial plexus block provides anesthesia to the arm and hand. Unlike the axillary approach, it can be performed without abducting the arm, making it useful for patients with limited shoulder mobility.
Axillary Block
The axillary block targets the terminal branches of the brachial plexus which include the median, ulnar, radial and musculocutaneous nerves. The musculocutaneous nerve divides away from the brachial plexus in a more proximal location from where the axillary block is performed and should be blocked separately.
Suprascapular and Axillary Nerve Blocks
The Suprascapular and Axillary Nerve Blocks target 2 of the 5 nerves that innervate the shoulder joint. This block technique minimizes or avoids the risk of phrenic nerve blockade that may occur with other approaches to blocking the brachial plexus.
Truncal
PECS Block
The PECS block provides analgesia to the anterolateral chest wall and axilla and can be used for many procedures ranging from port placement to radical mastectomies.
Serratus Plane Block
The Serratus Plane Block provides analgesia to the anterolateral chest wall and axilla by targeting the thoracodorsal nerve, long thoracic nerve, and intercostal nerves.
Paravertebral Block
The Paravertebral Block is a regional technique where local anesthetic is injected into the space adjacent to the vertebrae to block the spinal nerves as they emerge from the intervertebral foramina. At this location, the spinal nerves are devoid of covering fascia making them sensitive to the action of local anesthetics.
Erector Spinae Block
The Erector Spinae Block is an alternative approach to the paravertebral block that targets the dorsal rami, ventral rami, and rami communicantes. This block can be performed in the cervical, thoracic, lumbar, and sacral regions for a variety of surgical procedures.
External Oblique Intercostal Block
The External Oblique Intercostal Block provides reliable coverage of the upper anterolateral abdominal wall by targeting the lateral and anterior cutaneous branches of intercostal nerves T7-T10. The block is performed around the level of the 7th rib near the anterior axillary line.
Subcostal TAP Block
The Subcostal TAP Block targets the ventral rami of spinal nerves T7-T10 traveling within the transversus abdominis plane (TAP) and provides somatic pain relief to the anterolateral abdominal wall.
Mid-axillary TAP Block
The Mid-axillary TAP Block targets the ventral rami of spinal nerves T10-L1 traveling within the transversus abdominis plane (TAP) and provides somatic pain relief to the anterolateral abdominal wall.
Ilioinguinal-iliohypogastric Block
The Ilioinguinal-Iliohypogastric Block targets the ilioinguinal and ilihypogastric nerves traveling within the transversus abdominis plane (TAP) and provides somatic pain relief at L1. This technique can be useful for inguinal hernia repair or incisions involving the suprapubic region.
Transversalis Fascia Block
The transversalis fascia plane block is a truncal block that targets the ventral ramus of L1 deep to the transversus abdominis muscle before it divides into the ilioinguinal and iliohypogastric nerves. These nerves will eventually pierce the transversus abdominis muscle to enter the transversus abdominis plane (TAP) between the internal oblique and transversus abdominis muscles.
Quadratus Lumborum (QL2) Block
The Quadratus Lumborum (QL2) Block, also known as the posterior QL block, involves depositing local anesthetic within the middle thoracolumbar fascia along the posterior surface of the quadratus lumborum muscle. The proposed mechanism of action involves the spread of local anesthetic within the paravertebral space to target the dorsal rami, ventral rami, and sympathetic trunk. Local anesthetic may also block mechanoreceptors and nociceptors within the thoracolumbar fascia.
The quadratus lumborum (QL3) block, also known as a transmuscular or anterior QL block, is a fascial plane block that is performed anterior to the quadratus lumborum muscle. The proposed mechanism of action involves the spread of local anesthetic into the thoracic paravertebral space to target the dorsal rami, ventral rami, and sympathetic trunk.
Rectus Sheath Block
The rectus sheath block provides analgesia to the anterior abdominal wall by depositing local anesthetic between the rectus abdominis muscle and posterior rectus sheath. This technique blocks the anterior cutaneous branches of the intercostal nerves and is well suited for postoperative analgesia for midline abdominal incisions.
Neuraxial Block
Neuraxial Block
Using ultrasound for neuraxial blocks can be beneficial in locating the correct intervertebral space in patients with difficult surface anatomy (i.e. obesity, pregnancy, spinal deformity), previous spine surgery and narrowed intervertebral spaces. This technique can also assist with determining the correct needle insertion angle and identifying the correct depth to reach the ligamentum flavum/dura.
Lower Extremity
Genicular Nerve Block
The genicular nerve block can be used to provide analgesia to the anterior knee capsule by targeting the superomedial, superolateral, and inferomedial genicular nerves. This procedure can be beneficial in patients with chronic osteoarthritis or patients undergoing knee arthroplasty.
The femoral nerve block is a regional anesthesia technique that is performed at the level of the femoral crease. It can be beneficial for a variety of surgical procedures involving the anterior thigh and knee.
Pericapsular Nerve Group (PENG) Block
The Pericapsular Nerve Group (PENG) Block targets the articular branches to the anterior hip arising from the femoral, obturator and accessory obturator nerves.
The fascia iliaca block provides anesthesia to the hip, anterolateral thigh, anterior knee, and medial aspect of the lower leg, ankle, and foot. This block is commonly performed for hip fractures and hip arthroplasty.
Lateral Femoral Cutaneous Nerve Block
The lateral femoral cutaneous nerve (LFCN) block targets the LFCN in the proximal thigh after it passes under the inguinal ligament and enters a fat filled tunnel formed by the fascia lata. This tunnel can be located between the sartorius and tensor fascia lata muscles. The LFCN provides sensory innervation to the lateral thigh.
Obturator Nerve Block
The obturator nerve block is used to treat anterior hip joint pain and is also used in the relief of adductor muscle spasm associated with hemiplegia or paraplegia.
The adductor canal block is a regional anesthesia technique that is performed for surgical procedures involving the knee and the medial aspect of the lower leg and ankle. This approach can be paired with other blocks (i.e. popliteal sciatic, genicular, iPACK, or popliteal plexus) to provide more complete coverage of the knee, lower leg, and/or ankle. The adductor canal block primarily targets the saphenous nerve and preserves motor function of the quadriceps muscles.
iPACK Block and LIA Block
The iPACK block provides analgesia to the posterior knee capsule by targeting the articular branches from the tibial and the posterior branch of the obturator nerves as they pass through the interspace between the popliteal artery and capsule of the knee.
The ultrasound guided local infiltration analgesia (LIA) block provides analgesia to the anterior knee capsule by targeting the nerves to the vastus lateralis, vastus intermedius, and vastus medialis. Performing the iPACK and LIA blocks together helps provide greater coverage of the knee joint.
Popliteal Plexus Block
The Popliteal Plexus Block is performed in the distal adductor canal and involves the spread of local anesthetic into the popliteal fossa to target the popliteal plexus. Articular branches from the tibial nerve and posterior branch of the obturator nerve form the popliteal plexus. Blockade of these nerves provides analgesia to the posterior knee capsule.
Transgluteal Sciatic Nerve Block
The Transgluteal Sciatic Nerve Block targets the sciatic nerve in a proximal location between the gluteus maximus and quadratus femoris muscles. This approach provides anesthesia to the posterior thigh, posterolateral knee, and the entire lower leg (except for the medial aspect, which is innervated by the saphenous nerve). This block technique can be performed with other approaches (i.e. femoral or adductor canal) to provide more complete coverage of the lower extremity.
Subgluteal Sciatic Nerve Block
The Subgluteal Sciatic Nerve Block Targets the sciatic nerve in the subgluteal region between the long and short head of the biceps femoris muscle. The posterior femoral cutaneous nerve, which travels medial to the sciatic nerve and innervates the skin over the posterior thigh/knee, may not be reliably blocked with this approach.
Popliteal Sciatic Nerve Block
The Popliteal Sciatic Nerve Block targets the sciatic nerve within the popliteal fossa before it divides into the tibial and common peroneal nerves. Blockade of the sciatic nerve at this location provides analgesia to the entire lower leg, ankle, and foot (except for the medial aspect, which is innervated by the saphenous nerve).
BASICS OF ULTRASOUND
Basics of Ultrasound
- Ultrasound provides real-time, cross-sectional images of anatomical structures.
- The use of ultrasound also allows users to view needle placement and spread of local anesthetic.
- Sound waves emitted from the transducer (incident waves) are transmitted through body tissue.
- Some of these waves will encounter an interface between body tissues and reflect back as echoes.
- Other sound waves will pass deeper into the body (transmitted waves) until they reach another interface and reflect back as echoes.
- Echoes reflected back to the transducer will be processed by the ultrasound machine to generate an image.
JOINT INNERVATION
Upper Extremity
Shoulder Joint
The shoulder joint is innervated by 5 nerves that arise from the brachial plexus: suprascapular, axillary, musculocutaneous, lateral pectoral, and upper subscapular nerves. Of these 5 nerves, the suprascapular nerve innervates approximately 70% of the shoulder.
Elbow Joint
Nerve supply to the elbow joint includes branches of all major nerves of the brachial plexus that cross the joint: musculocutaneous, radial, median, ulnar, and medial cutaneous nerve of the arm.
Lower Extremity
Hip Joint
The anterior hip capsule is innervated by articular branches that originate from the femoral, obturator, and accessory obturator nerves. The posterior hip capsule is innervated by articular branches that arise from the superior gluteal nerve, nerve to quadratus femoris, and sciatic nerve.
Knee Joint
Innervation of the anterior and posterior knee joint is obtained from 13 branches arising from the femoral, obturator, and sciatic nerves. These branches can be blocked by using a variety of motor sparing techniques: adductor canal, ultrasound guided LIA, genicular, iPACK, or popliteal plexus.
NERVE PLEXUSES
Cervical Plexus
The cervical plexus is formed by ventral rami of nerve roots C1-C4. The rami divide into superficial sensory and deep muscular branches that innervate several structures of the head and neck.
Brachial Plexus
The brachial plexus is a network of nerves that are formed by the ventral rami of nerve roots C5-T1. As the plexus descends through the neck and upper extremity, it will divide into 5 parts: roots, trunks, divisions, cords, and terminal branches. The nerves arising from the brachial plexus will innervate the muscles, bone and skin of the shoulder, arm, and hand.
Lumbosacral Plexus
The lumbar plexus is derived from the anterior rami of nerve roots L1 through L4, along with contribution from T12. The rami pass downward through the psoas major muscle before giving rise to the ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, obturator, and femoral nerves.
The sacral plexus is formed by the lumbosacral trunk and the anterior rami of nerve roots S1-S4. The sacral plexus will divide into anterior and posterior branches to provide motor and sensory innervation to the pelvis, posterior thigh, lower leg, and foot.
NOCICEPTIVE PATHWAYS
Nociceptive Pathways
Nociception refers to the processing of noxious stimuli (tissue injury and temperature extremes) through the peripheral and central nervous systems. Stimuli are converted to electrical signals and transmitted to the spinal cord and brain where pain is perceived. There are four phases in the nociceptive pathways: transduction, transmission, perception, and modulation.
POCUS
Upper Airway Ultrasound
Upper Airway Ultrasound is a quick, non-invasive assessment tool that allows for the identification of upper airway structures: hyoid bone, thyrohyoid membrane, epiglottis, thyroid cartilage, vocal cords, cricoid cartilage, cricothyroid membrane, thyroid, trachea/tracheal rings, and esophagus. Additionally, providers can evaluate soft tissue masses, locate the cricothyroid membrane, select correct endotracheal tube size, confirm endotracheal tube placement, and predict postextubation stridor.
Lung Ultrasound
Lung Ultrasound is a quick and efficient tool that can be used at the bedside to detect pulmonary changes such as pneumothorax, pulmonary edema, consolidation, and pleural effusion.
Diaphragm Ultrasound
Assesses diaphragmatic dysfunction or paralysis related to: phrenic nerve injury, brachial plexus blockade, neuromuscular disease, mechanical ventilation, or upper abdominal mass.
Gastric Ultrasound
Gastric Ultrasound is a simple, fast, and non-invasive bedside exam that allows for qualitative and quantitative evaluation of gastric contents to determine aspiration risk. This can be beneficial for emergency surgery, questionable fasting time, or in patients with comorbidities associated with delayed gastric emptying.
REGIONAL ANESTHESIA AND COAGULATION
Regional Anesthesia and Coagulation
The incidence of spinal epidural hematoma (SEH) has been reported to occur in approximately 1:150,000 epidural and 1:220,000 spinal anesthetics. SEH is a major complication of neuraxial blockade due to bleeding into a non-compressible space. This can lead to compression of the spinal cord, resulting in neurological injury and deficits.
The incidence of bleeding complications related to peripheral nerve blockade in patients receiving antiplatelet or anticoagulant medications is very low (0.82%). The degree of risk may vary depending if the peripheral nerve block is superficial or deep. Performing a ‘deep’ block may not allow for efficient compression at the block site or for early detection of hematoma formation. The use of ultrasound guidance may help mitigate the risk of vascular puncture.
SPINE AND PELVIS ANATOMY
Spine and Pelvis Anatomy
The vertebral column is comprised of 33 vertebrae that help protect the spinal cord, nerve roots, and internal organs. The vertebral column also functions to provide structural support for the body, allow for movement and flexibility, and serves as an attachment site for muscles and ligament.
NON-SURGICAL PAIN MANAGEMENT
Cervical
Stellate Ganglion Block
The Stellate Ganglion Block involves the blocking of postganglionic sympathetic nerve fibers that innervate the head, neck, upper chest, upper extremity, and myocardium. This block is beneficial for treating sympathetically mediated pain, vascular insufficiency, PTSD, hyperhidrosis, hot flashes, refractory ventricular arrhythmias, and long COVID symptoms
Lumbar
Lumbar Interlaminar Epidural Steroid Injection
Lumbar epidural steroid injections are used for both diagnostic and therapeutic indications including lumbar intervertebral disc disorder, lumbar radicular pain that is non-lateralizing, lumbar radiculopathy, chronic low back pain, and central canal stenosis.
Lumbar Transforaminal Epidural Steroid Injection
Lumbar epidural steroid injections are used for both diagnostic and therapeutic indications including lumbar intervertebral disc disorder, lumbar radicular pain that is often lateralized, lumbar radiculopathy, chronic low back pain, central canal stenosis, and lumbar neuroforaminal stenosis.
Lumbar Medial Branch Block
Lumbar medial branch block injections are used for diagnostic indications including lumbar spondylosis without myelopathy or radiculopathy, lumbar spondylolysis, lumbar spondylolisthesis, and lumbar facet syndrome.
Lumbar Intra-Articular Facet Injection
Lumbar intra-articular facet injections are used for both diagnostic and therapeutic indications including lumbar spondylosis without myelopathy or radiculopathy, lumbar spondylolysis, lumbar spondylolisthesis, lumbar facet syndrome, and facet synovial cyst.
Sacral
Sacroiliac Joint Injection
Sacroiliac Joint injections are used for both diagnostic and therapeutic purposes including sacral pain, sacroiliitis, degenerative changes, trauma, and previous spine surgery.
RX GUIDE
Anticoagulants and Antiplatelets
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