Korean J Pain.  2013 Apr;26(2):111-124. 10.3344/kjp.2013.26.2.111.

Ultrasound-Guided Pain Interventions: A Review of Techniques for Peripheral Nerves

• Soneji N
• Peng PW

• KMID: 1978654
• DOI: http://doi.org/10.3344/kjp.2013.26.2.111

Abstract

Ultrasound has emerged to become a commonly used modality in the performance of chronic pain interventions. It allows direct visualization of tissue structure while allowing real time guidance of needle placement and medication administration. Ultrasound is a relatively affordable imaging tool and does not subject the practitioner or patient to radiation exposure. This review focuses on the anatomy and sonoanatomy of peripheral non-axial structures commonly involved in chronic pain conditions including the stellate ganglion, suprascapular, ilioinguinal, iliohypogastric, genitofemoral and lateral femoral cutaneous nerves. Additionally, the review discusses ultrasound guided intervention techniques applicable to these structures.

Keyword

genitofemoral nerve; ilioinguinal nerve; lateral femoral cutaneous nerve; stellate ganglion; suprascapular nerve; ultrasound

MeSH Terms

Chronic Pain
Humans
Needles
Peripheral Nerves
Stellate Ganglion

Figure

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  Fig. 1 Prevertebral region of the neck. The target site for needle insertion in classical approach is marked as *. The breadth of the transverse process is marked as A. Reproduced with permission from USRA (www.usra.ca).

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  Fig. 2 (A) Cross section of the neck at the sixth cervical vertebral level correlating with the ultrasonographic image. (B) Ultrasonographic image of neck at C6. C: carotid artery, *: internal jugular vein (compressed), SCM: sternocleidomastoid muscle, LC: longus colli muscle, LCa: longus capitis muscle, T: airway, AT: anterior tubercle. The prevertebral fascia is marked by small solid arrows. The needle paths of anterior and lateral approach are marked by long solid and dotted arrow respectively. Reproduced with permission from USRA (www.usra.ca).

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  Fig. 3 Suprascapular nerve and its branches of the left shoulder. Superior articular branch (Br. SA) supplies the coracohumeral ligament, subacromial bursa and posterior aspect of the acromioclavicular joint capsule; Inferior articular branch (Br. IA) supplies the posterior joint capsule; Br. SS: branch to the supraspinatus muscle, Br. IS: branch to the infraspinatus muscle. Reproduced with permission from USRA (www.usra.ca).

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  Fig. 4 Superior view of the left shoulder. The course of the suprascapular nerve enters the suprascapular fossa through the suprascapular notch (SSNo) and then enters the infrascapular fossa through the spinoglenoid notch (SGNo). Reproduced with permission from USRA (www.usra.ca).

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  Fig. 5 (A) Lateral view of the scapula. The scapula spine forms an angle (39.5° ± 5.8°) to the axis of the scapula blade. The content of the suprascapular fossa cannot be revealed when scanning from the ultrasound probe (a), which is behind the dorsal border of the scapular spine, because of the obstruction of view from the scapular spine. By moving the ultrasound probe position to (b), the content of the suprascapular fossa cannot be revealed either. The optimal ultrasound probe position is at (c) when the probe is almost at the coronal plane with a slight anterior tilt. (B) Ultrasonographic image of the suprascapular nerve on the floor of the scapular spine between suprascapular notch and spinoglenoid notch. Both suprascapular nerve and artery run underneath the fascia of supraspinatus muscle. Reproduced with permission from USRA (www.usra.ca).

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  Fig. 6 Schematic diagram showing the pathway of ilioinguinal, iliohypogastric and genitofemoral nerve. GFN: genitofemoral nerve. Reproduced with permission from USRA (www.usra.ca).

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  Fig. 7 (A) Schematic diagram to show the position of the ultrasound probe. The probe (a) is placed above and 3 finger breadth lateral to the anterior superior iliac spine and is in the short axis of the course of ilioinguinal nerve (i.e. at right angle to the iliac crest). The probe (b) is placed in the inguinal line in long axis of femoral and external iliac artery. (B) Figure showing the three layers of muscles and the fasica split (white line arrows) with the ilioinguinal and iliohypogastric nerves inside. Solid triangles outline the iliac crest. (C) Similar to figure 7b with Doppler showing the deep circumflex iliac artery. EO: external oblique muscle, IO: internal oblique muscle, TA: transverse abdominus muscle, IL: iliacus, F: adipose tissue, Lat: lateral. Reproduced with permission from USRA (www.usra.ca).

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  Fig. 8 (A) Long axis view of the femoral and external iliac artery showing the cross section of spermatic cord (outlined by solid arrows) in a male patient. The red dashed line outlines the deep abdominal fascia. (B) Similar view as 8a with color Doppler showing the vessels inside the spermatic cord. (C) Following injection, the inguinal canal can be well visualized (outlined by solid arrows) filled with local anesthetic (LA). The spermatic cord is indicated by *. Reproduced the with permission from USRA (www.usra.ca).

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  Fig. 9 Schematic diagram showing the pathway of a typical course of lateral femoral cutaneous nerve. Note that the nerve course beneath the inguinal ligament and runs superficially to the sartorius muscle and then in between this muscle and tensor fascia lata muscle. Reproduced with permission from USRA (www.usra.ca).

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  Fig. 10 Nerves at the inguinal area. Reproduced with permission from USRA (www.usra.ca).

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  Fig. 11 (A) Ultrasonographic picture showing the lateral femoral cutaneous nerve (LFCN). The LFCN is indicated by line arrows. The fascia is indicated by bold arrows (FL: Fascia Lata, FI: Fascia Iliaca); the ilium is indicated by solid arrows; Sar: Sartorius muscle, ASIS: Anterior Superior Iliac Spine. (B) Post-injection ultrasonographic picture; the needle is indicated by line arrows, LA: local anesthetic, *LFCN. (C) The LFCN has already branched into smaller nerves and appears as hypoechoic structures (solid line arrows). Reproduced with permission from USRA (www.usra.ca).

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