Regional Anesthesia Techniques for Common Surgeries

1. Neuraxial Anesthesia (Spinal and Epidural)

2. Upper Extremity - Brachial Plexus Blocks

Interscalene Block (ISB)

• Surgery: Shoulder surgery (rotator cuff repair, shoulder arthroplasty, acromioplasty) - the preferred technique for shoulder.
• Target: Superior and middle trunks (C5, C6, C7) at the level between the anterior and middle scalene muscles.
• Technique: Patient supine, head turned away. High-frequency probe traces the plexus up the neck until trunks appear as hypoechoic structures between scalene muscles ("stoplight" sign). Needle in-plane or out-of-plane. Volume: 10-15 mL (as low as 5 mL with US guidance).
• Limitations: Not ideal for forearm/hand surgery - C8/T1 (inferior trunk) often spared. Not recommended in patients with significant pulmonary disease.
• Key complication: Ipsilateral phrenic nerve block is virtually universal (causes hemidiaphragm paralysis). Phrenic-sparing "lung-sparing" techniques targeting terminal shoulder nerves are an emerging alternative. - Miller's Anesthesia, p. 6236-6237

Supraclavicular Block

• Surgery: Elbow, forearm, and hand surgery.
• Target: Distal trunk / proximal division level - the plexus is most compact here, enabling reliable, rapid blockade with small volumes.
• Technique: Patient supine, head turned away, arm adducted. High-frequency linear transducer in supraclavicular fossa. Brachial plexus clusters vertically over the first rib, lateral to the subclavian artery. Needle advanced in-plane, lateral to medial. Volume: 15-30 mL (caution - high volumes risk ischemic compression).
• Key complication: Pneumothorax 0.5%-6% (reduced but not eliminated by US). Phrenic nerve block in 40%-60%. Horner syndrome. - Miller's Anesthesia, p. 6244

Infraclavicular Block

• Surgery: Complete brachial plexus anesthesia for elbow, forearm, and hand; also preferred when a continuous catheter is needed.
• Target: Cords of the brachial plexus (medial, lateral, posterior) surrounding the axillary artery deep to the pectoralis minor muscle.
• Technique: Lateral sagittal (paracoracoid) approach, shoulder abducted 90 degrees. Axillary artery visualized in short axis deep to pectoralis muscles. Desired sonographic signs of success: "U-shaped" local anesthetic distribution under the artery, separation of cords from artery ("free walls" sign). Volume: ~20-30 mL.
• Advantage: Stable catheter location, no arm manipulation needed. Deep location limits needle tip visibility. - Miller's Anesthesia, p. 6245-6249

Axillary Block

• Surgery: Distal upper arm, elbow, forearm, and hand surgery.
• Target: Terminal nerves (median, ulnar, radial, musculocutaneous) at the axilla.
• Technique: Ultrasound identifies the four nerves individually around the axillary artery in the axilla. Each nerve is directly targeted with small increments of local anesthetic. The musculocutaneous nerve moves from adjacent to the artery (round) into the coracobrachialis (flat) then out (triangular).
• Advantage: Relatively safe (no pleura, no phrenic nerve). With US, tourniquet-related pain can be addressed by targeting intercostobrachial and medial brachial cutaneous nerves.
• Miller's Anesthesia, p. 6248

3. Trunk Blocks

Paravertebral Block (PVB)

• Surgery: Thoracic surgery (thoracotomy, VATS), breast surgery, rib fractures, unilateral abdominal surgery.
• Mechanism: Local anesthetic in the paravertebral space blocks ipsilateral somatic and sympathetic nerves at each injected level.
• Complications: Risk of pneumothorax (0.5%-6%), dural puncture, intravascular injection, rare infraforaminal cord injury. Block failure 6%-10%. Respiratory decompensation with bilateral blockade in patients with severe pulmonary disease.

Erector Spinae Plane (ESP) Block

• Surgery: Thoracic procedures (lung, breast operations), chest trauma, rib fractures. A popular alternative to PVB.
• Technique: Patient seated or lateral decubitus. Parasagittal approach. Ultrasound identifies erector spinae muscles and transverse processes. Needle advanced in-plane craniocaudally; local anesthetic deposited deep to the erector spinae muscle over the transverse process periosteum. Volume: 15-30 mL (lower with bilateral blocks).
• Mechanism: Likely blocks dorsal and ventral rami + sympathetic nerves within targeted levels. Exact mechanism still debated.
• Advantage: More superficial than PVB, further from pleura. - Miller's Anesthesia, p. 6257-6258

Transversus Abdominis Plane (TAP) Block

• Surgery: Lower abdominal surgery (appendectomy, colostomy, cesarean, inguinal hernia, laparoscopic abdominal procedures). Provides somatic wall analgesia only - no visceral coverage.
• Target nerves: T6-T12 thoracoabdominal peripheral nerves (subcostal, ilioinguinal, iliohypogastric, genitofemoral) in the fascial plane between transversus abdominis and internal oblique muscles.
• Technique: Patient supine. Transducer placed between iliac crest and costal margin in the midaxillary line. Three lateral abdominal muscle layers clearly visualized. Needle injection into the fascia separating the internal oblique from the transversus abdominis. Volume: 15-20 mL dilute local anesthetic per side.
• Approaches: Subcostal (better superior/anterior coverage) vs. midaxillary (better lateral/inferior wall analgesia). - Miller's Anesthesia, p. 6258

4. Lower Extremity Blocks

Femoral Nerve Block

• Surgery: Hip fracture (analgesia), anterior thigh procedures, knee surgery.
• Target: Femoral nerve lateral to the femoral artery in the groove between iliacus and psoas muscles at the inguinal crease.
• Technique: High-frequency linear transducer at the inguinal crease. Femoral nerve identified as a slight indentation on the iliacus/psoas surface lateral to the femoral artery. In-plane (lateral to medial) or out-of-plane (distal to proximal) approach. If the profunda femoris artery is visible, the transducer is too distal. Local anesthetic layers under or around the nerve. - Miller's Anesthesia, p. 6263

Adductor Canal Block (ACB)

• Surgery: Total knee arthroplasty (TKA), knee arthroscopy - preserves motor function better than femoral nerve block.
• Target: Saphenous nerve (terminal sensory branch of femoral nerve) and nerve to vastus medialis, within the adductor canal in the mid-thigh.
• Technique: Patient supine, thigh in slight external rotation. High-frequency transducer transverse on anteromedial thigh at junction of middle and distal thirds. Vastoductor membrane defines the roof of the canal (borders: vastus medialis laterally, sartorius anteriorly, femoral artery medially). In-plane needle; 10-15 mL injected lateral to artery, deep to sartorius.
• Key advantage: Significantly less quadriceps weakness vs. femoral nerve block - enables earlier ambulation after TKA.
• Caution: Injection too distal misses the nerve to vastus medialis. Intramuscular spread causes severe myonecrosis. - Miller's Anesthesia, p. 6270-6271

Sciatic Nerve Block

• Surgery: Foot and ankle surgery, below-knee amputation, combined with femoral block for complete lower limb anesthesia.
• Target: Sciatic nerve (tibial + common peroneal components) can be blocked at the gluteal, subgluteal, mid-thigh, or popliteal level.
• Popliteal approach: Most common for foot/ankle; the tibial and common peroneal nerves separate at or above the popliteal fossa and are targeted individually or as one nerve proximal to the bifurcation.

5. Summary Table: Block by Surgery

6. Local Anesthetic Systemic Toxicity (LAST)