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430 Theresa Tak Lai LI
the scapula body into the suprascapular notch
(Fig. 26.19). A paraesthesia is often elicited as the
needle makes contact with the nerve [36]. e
needle should not be advanced more than 1 cm
further to prevent the risk of pneumothorax. An
anteroposterior fluoroscopic image provides direct
visualisation of the needle as it makes contact with
the scapular bone and traverses the suprascapular
notch. Further confirmation of the position of
the needle can be seen when the contrast solution
fills the suprascapular notch and runs towards the
glenoid cavity (Figs. 26.20 to 26.22). With the
needle in the optimal position, 5–10 ml of 0.5%
bupivacaine for diagnostic block or 3–5 ml 10%
phenol in Conray contrast medium is injected for
neurolytic block. When treating painful conditions
that are mediated via the suprascapular nerve,
40 mg depomedrol is often added to the local
anaesthetic.
Complications
e close proximity of the suprascapular vasculature
increases the risk of inadvertent intravascular injection
and possible local anaesthetic systemic toxicity. us
meticulous care should be taken in calculating the
total safe dose of agent to be given. Pneumothorax is
also a potential technical complication if the needle
is advanced too deep through the suprascapular
notch causing pleural puncture.
Figure 26.21 Radiograph of a needle at the
suprascapular notch
Figure 26.22 Radiograph of contrast spread along
the suprascapular nerve
Figure 26.19 Photo of a needle at the
suprascapular notch
Figure 26.20 Radiograph of a pointer at the
suprascapular notch
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Peripheral Nerve Blocks 431
Obturator Nerve Block
Indications
An important indication of obturator nerve block is
based on its anatomical relationship as it runs along
the neck of the bladder and the prostate. Due to
the proximity of this nerve to the prostate, is can be
electrically stimulated during transurethral resection
surgery. is leads to significant contraction of the
adductors which can interfere with the surgical
procedure, and serious complications such as
bladder wall perforation with secondary infection
and tumour dissemination have been reported [1].
is can occur despite adequate spinal anaesthesia
with complete blockade of nerve roots proximal
to the site of stimulation. Obturator nerve block
with local anaesthetic has been shown to effectively
abolish the adductor spasms during transurethral
prostatic surgery [17].
e addition of an obturator nerve block to femoral
and sciatic blockade is also performed to improve
postoperative analgesia following total knee
replacement [12, 15]. Adductor muscle spasticity
is problematic in patients with neurological
sequelae of stroke, head trauma, spinal cord injury,
cerebral palsy or any lesion of the motor neurone.
In rehabilitation medicine, obturator nerve block
has been extensively used in the management of
patients with adductor muscle spasticity to reduce
spasm and associated pain, and improve gait and
hygienic care [31, 32, 39]. Obturator nerve block
can be used as a diagnostic tool for complex pain
problems involving the hip and nearby area. Cases
of obturator nerve entrapment have been reported
in athletes and in patients after pelvic surgery and
a diagnostic obturator nerve block can provide
information to make a clinical diagnosis.
Anatomy
e obturator nerve is formed from the anterior
primary rami of L2 to L4 with contribution of
L3 predominant. e nerve passes through the
psoas muscle and leaves the muscle at the lateral
border. It then travels posterior to the iliac vessels
and reaches the undersurface of the superior pubic
ramus and emerges through the obturator foramen
along with the obturator artery (Fig. 26.23). At this
point the obturator nerve divides into the anterior
and the posterior branches. e obturator nerve
is predominantly a motor nerve with the anterior
branch innervating the anterior adductor muscles
and the posterior branch innervating the adductor
magnus muscles. Is has a variable cutaneous sensory
supply to the hip and knee joints, and an area along
the medial aspect of the thigh.
Procedure
e patient is placed in a supine position and the
legs slightly abducted. e procedure is performed
under sterile conditions after antiseptic skin
preparation. A 22G x 50 mm insulated block needle
is inserted almost perpendicularly to the skin, 1–2
cm caudally and 1–2 cm laterally to the pubic
tubercle. e needle is advanced until it contacts
the inferior border of the superior pubic ramus
bone and is then tilted almost 90° and redirected
posteriorly and slightly laterally to walk off the
inferior margin of the superior pubic ramus.
e needle trajectory can be more precisely seen
with fluoroscopic guidance, which also allows direct
visualisation of the pubic ramus and the obturator
foramen. First obtain an anteroposterior image of
the pelvis and then the fluoroscope is rotated in a
cephalocaudad projection to view the pubic ramus
and obturator foramen directly in line with the
fluoroscopy beam. e point of skin entry remains
the same but the needle is aimed along the axis of
the fluoroscopy beam towards the lateral end of the
superior pubic ramus and then passed underneath
the inferior edge to enter the obturator foramen
(Fig. 24.25). e needle should not be advanced
more than 3 cm from this point to prevent pelvic
organ damage.
Figure 26.23 Drawing of the anatomy of an
obturator nerve
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432 Theresa Tak Lai LI
e location of the obturator nerve is detected
with the aid of the nerve stimulator during needle
advancement by eliciting strong adductor muscle
contraction with a current of 0.5 mA at 2 V. A
small amount of non-ionic contrast medium is
injected to outline the nerve on fluoroscopy (Fig.
26.26). After optimal needle position is confirmed
and negative aspiration, 10 ml of local anaesthetic
(0.5% bupivacaine) or 5–10 ml of neurolytic agent
(10% phenol in contrast medium) is injected
incrementally.
Complications
Careful location of anatomical landmarks and the
use of fluoroscopy significantly reduce the incidence
of serious complications. e most commonly seen
complication is haematoma or ecchymosis in the
inguinal region post block. is is likely if the
obturator artery which travels with the obturator
nerve is inadvertently punctured. If the needle is
advanced too deep into the pelvis (more than 3
cm), the risk of damage to pelvic organs such as the
bladder is possible.
Maxillary Nerve Block
Indications
e maxillary nerve block can be performed for
analgesia during maxillofacial surgery involving the
upper jaw [25]. It may also be used as a diagnostic
tool in chronic facial pain syndrome. erapeutic
maxillary nerve block with a neurolytic agent
is used to treat painful tumours of the anterior
Figure 26.26 Radiograph of bilateral obturator
nerves outlined with contrast agent
Figure 26.24 Radiograph of needle at the inferior
border of the superior pubic ramus
Figure 26.25 Radiograph of needle at the inferior
border of the superior pubic ramus
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Peripheral Nerve Blocks 433
antrum [23]. Maxillary nerve block with local
anaesthetic or steroids is an excellent adjunct to the
pharmacological treatment in trigeminal neuralgia
and acute herpes zoster infection in the distribution
of second division of the trigeminal nerve.
Anatomy
e maxillary nerve constitutes the second division
of the trigeminal nerve. It is a pure sensory nerve
which travels anteroinferiorly and exits through the
foramen rotundum and enters the sphenopalatine
fossa (Fig. 26.27). e maxillary nerve gives off
branches to supply the upper jaw, teeth, gums,
hard and soft palate, and cheek. It also contains
some parasympathetic fibres. e maxillary nerve
then passes through the infraorbital foramen and
becomes the infraorbital nerve, which supplies the
sensation from the lower eyelid to the upper lip.
Procedure
e patient is placed supine with the head straight
and appropriate skin antiseptic preparation applied.
e coronoid notch is identified by asking the
patient to open and close the mouth or by direct
visualisation under a lateral fluoroscopic beam. A
22G x 7.5 cm spinal needle is directed perpendicular
to the skin through the coronoid notch below
the midpoint of the zygomatic arch. e needle
is advanced until it contacts the lateral pterygoid
plate. e needle is then withdrawn and redirected
anteriorly and superiorly at a 45° angle towards the
Figure 26.27 Drawing of the Gasserian ganglion in
the middle cranial fossa and the course of the three
divisions and distal branches
roof of the nose (Fig. 26.28). e needle should
not be advanced more than 1 cm past the pterygoid
plate. Once the needle is positioned and negative
aspiration for blood and cerebrospinal fluid (CSF)
confirmed, local anaesthetic (0.5% bupivacaine)
is injected slowly: 1–3 ml for diagnostic block, or
3–5 ml followed by 1 ml of neurolytic agent (10%
phenol) for therapeutic block.
Complications
Facial ecchymosis and haematoma associated with
the procedure are usually self-limiting. Precautions
should be taken to prevent the needle advancing too
deeply and in a cephalad direction to avoid entering
the infraorbital fissure and possibly damaging the
optic nerve. Drug deposited in this region can
also spread to the posterior aspect of the orbit and
the optic nerve producing blindness. Inadvertent
intravascular and subarachnoid injections are
potential lethal side effects.
Mandibular Nerve Block
Indications
e mandibular nerve block provides effective pain
relief for surgical reduction of fractured mandible.
It may be used as a diagnostic tool in chronic facial
pain syndrome. It is useful for palliation of pain
secondary to malignancy of the tongue, lower
jaw and floor of the mouth [24]. Mandibular
nerve block with local anaesthetic or steroids is an
Figure 26.28 Needle placement at the maxillary
nerve via the coronoid notch
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434 Theresa Tak Lai LI
excellent adjunct to the pharmacological treatment
in trigeminal neuralgia and acute herpes zoster
infection in the distribution of third division of the
trigeminal nerve V3.
Anatomy
e mandibular nerve is the third division of the
trigeminal nerve. It consists of a large sensory root
and a small motor root. It travels inferolaterally
and exits through the foramen ovale where it
immediately divides into two branches, the anterior
and posterior branches (Fig. 26.27). e anterior
branch supplies motor fibres to the muscles of
mastication and only supplies sensation to the
lateral face and underlying mucosa by the buccal
nerve. e larger posterior branch is mostly sensory
and further divides into the auriculotemporal nerve,
the inferior dental nerve and the lingual nerve.
e auriculotemporal nerve emerges from behind
the temporomandibular joint to supply sensation
to the external auditory meatus and temple. e
inferior dental nerve enters the ramus of the
mandible to run through the bone and emerge
at the mental foramen as the mental nerve. e
lingual nerve runs in an inferolateral direction to
reach the medial side of the ramus of the mandible
and supply the anterior two thirds of the tongue
and inferior jaw.
Procedure
e patient is placed in a supine position with
appropriate skin antiseptic preparation. e
coronoid notch is identified by asking the patient to
open and close the mouth or by direct visualisation
under lateral fluoroscopic beam. A 22G x 7.5 cm
spinal needle is directed perpendicular to the skin
through the coronoid notch below the midpoint of
the zygomatic arch. e needle is advanced until it
contacts the lateral pterygoid plate. At this point,
the needle is walked backwards off the pterygoid
plate with the same depth maintained (Fig. 26.29).
A paraesthesia of the lower lip, lower jaw or tongue
is elicited preferably. Once the needle is positioned
and negative aspiration for blood and cerebrospinal
fluid (CSF) confirmed, local anaesthetic (0.5%
bupivacaine) is injected slowly: 1–3 ml for
diagnostic block, or 3–5 ml followed by 1 ml of
neurolytic agent (10% phenol) for therapeutic
block.
Complications
Facial ecchymosis and haematoma associated with
the procedure are usually self-limiting. Inadvertent
intravascular and subarachnoid injections are
potential lethal complications. e needle can
enter the pharynx if it is advanced too deep with
the possibility of puncturing the middle meningeal
artery, which enters the cranium through the
spinous foramen.
Sciatic Nerve Block
Labat first described the posterior approach to the
sciatic nerve in 1923 [23]. Various other methods of
sciatic nerve block have since then been introduced,
for example ,the anterior approach proposed by
Raj and associates in 1975 [23]. In recent times,
ultrasound-guided location of the nerve with
electrical stimulation confirmation has been widely
used in clinical anaesthesia.
Anatomy
e sciatic nerve is formed from the nerve roots of
L4 to L5 and S1 to S3 in the lumbosacral plexus.
It leaves the pelvis and enters the gluteal region
through the greater sciatic foramen and passes
through a tunnel between the greater trochanter
and the ischial tuberosity (Fig. 26.30). In the
buttocks, it runs underneath the piriformis muscle,
Figure 26.29 Needle placement at the mandibular
nerve via the coronoid notch
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Peripheral Nerve Blocks 435
posterior to the gemelli and obturator muscles, and
anterior to the gluteus maximus muscle. e sciatic
nerve courses down the posterior thigh and divides
into the tibial and common peroneal nerves in the
popliteal fossa.
Indications
e sciatic nerve is commonly blocked for surgery
and analgesia involving the foot and ankle.
Technique
Posterior approach
Classically the posterior approach is performed with
the patient placed in the semi-prone position with
the side to be blocked uppermost and the hip and
knee flexed. e gluteal region is then sterilised and
draped. e prominence of the greater trochanter
and posterior superior iliac spine is located and a
line joining these two points drawn (Fig. 26.31).
At the midpoint, a 4 cm perpendicular line is then
drawn caudally. A skin wheal is raised and a 22G
needle is inserted perpendicular to the skin and the
sciatic nerve is usually contacted at 4 to 6 cm from
skin. A peripheral nerve stimulator can be used to
achieve more accurate location of the sciatic nerve.
A 21G x 10 cm insulated block needle is inserted
in a similar manner and the electrical stimulation
set a current of 0.5m A at 1–2 Hz. Dorsiflexion
or plantar flexion of the foot should be observed
for needle confirmation. A 20-ml volume of local
anaesthetic agent can be injected in divided doses
after negative aspiration for blood.
Figure 26.30 Drawing of the anatomy of the sciatic
nerve
Figure 26.31 Patient position for posterior
approach to sciatic nerve block. IT= Ischial
tuberosity; GT = greater tuberosity
Ultrasound scanning guided
technique
A subgluteal approach is used with the patient
placed in a semi-prone position with the block limb
Figure 26.32 An ultrasound probe placed along
a line joining the ischial tuberosity and the greater
trochanter
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436 Theresa Tak Lai LI
uppermost. e bony prominence of the greater
trochanter laterally and the ischial tuberosity
medially are marked and a line drawn between
these two points. e midpoint along this line
marks the approximate sciatic nerve location. After
skin preparation, a 10–15 MHz ultrasound probe
in placed over the subgluteal region in a transverse
plane (Fig. 26.32). e sciatic nerve is seen as
hyperechoic on ultrasonography along a plane
between the ischial tuberosity medially and the
greater trochanter laterally (Fig. 26.33). A 21G x 10
cm insulated block needle is inserted perpendicular
to the ultrasound probe (Fig. 26.34). When the
needle in is close proximity and contacts the nerve,
tissue or nerve movement can be seen. e position
of the needle is confirmed by electrical stimulation
to the sciatic nerve as described previously. When
the needle position is satisfied by nerve stimulation
and motor response, 20 ml of local anaesthetic is
injected under ultrasound visualization. is should
appear as circumferential spread of hypoechoic
local anaesthetic agent around the hyperechoic
nerve bundles. e sciatic nerve can be scanned
proximally and distally to observe longitudinal
spread of drug.
Complications
Potential complications include bleeding,
intravascular injection, intraneural injection and
possible residual dysaesthesiae.
Figure 26.33 The sciatic nerve appears as a
hyperechoic oval shape in a plane between the
ischial tuberosity medially and greated trochanter
laterally
Figure 26.34 Needle insertion under the guidance
of ultrasonography
References
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of an unsuccessful obturator nerve block. Acta Anaesthesiol Scand 1999;43(7):784–8.
2. Bradshaw C, McCrory P. Obturator nerve entrapment. Clin J Sport Med 1997;7(3):217–9.
3. Chan VWS, Perlas A, Rawson R, et al. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg
2003;97:1514–7.
4. Chan VWS. Applying ultrasound imaging to interscalene brachial plexus block. Reg Anesth Pain Med 2003;28(4):340–
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6. Dabu A, Chan VWS. A Practical Guide to Ultrasound Imaging for Peripheral Nerve Blocks. Toronto: University of
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Acta Urol Belg 1995;63(3):51–4.
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10. Jones DS, Chattopadhyay C. Suprascapular nerve block for the treatment of frozen shoulder in primary care: A
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19. Porter JM, McCarney CJL, Chan VWS. Needle placement and injection posterior to the axillary artery may predict
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Introduction
From its first description by Gaskell and Langley in 1889,
few structures in the body have received as much enthusiastic
but inappropriate attention as the sympathetic chain. Only
in recent times, with improved trial data, has a clearer view
appeared. is is especially so in the field of pain medicine,
where sympathetic blockade is often placed among the first
lines of treatment [51] despite little evidence to support this
practice. e theory of “sympathetic efferent hyperactivity” has
never been substantiated and blockade of the chain is perhaps
based on a false premise [15, 107]. In many instances, the
placebo arm of randomised controlled trials of sympathetic
blockade in the treatment of pain states has been as equally
effective as the active treatment. Some even consider blockade
of the sympathetic chain to be a futile procedure [96].
But should we consider sympathetic blockade to be totally
without merit? e answer probably lies somewhere between
the opposing views. Few could argue that the pain of upper
gastrointestinal cancer would not be greatly improved with
splanchnic and coeliac plexus blockade [24, 69]. Vascular
ulcers in the elderly can often be induced to heal with lumbar
sympathectomy [21]. Socially devastating hyperhidrosis,
especially in young women, can be significantly reduced but
perhaps with unacceptable sequelae [121]. Even sympathetic
blockade for complex regional pain syndrome (CRPS) may
have a place with careful patient selection [28].
is chapter will examine the role of sympathetic blockade
in the treatment of a number of conditions. It will span the
more traditional use of sympathectomy for peripheral vascular
disease and visceral pain in gastrointestinal cancer to the more
contentious indications such as the treatment of hyperhidrosis
and neuropathic pain states. It will also examine the evidence
in support of such practices. But, first let us examine the
27
Philip FINCH
The Sympathetic Chain:
Ecacy of Sympathetic Blockade and
Sympathectomy
INTRODUCTION
HISTORY
ANATOMICAL BASIS OF
SYMPATHETIC BLOCKS
SYMPATHOLYSIS AND
SYMPATHETIC BLOCKADE IN
PERIPHERAL VASCULAR DISEASE
SYMPATHOLYSIS IN THE
TREATMENT OF ABDOMINAL
VISCERAL PAIN
Anatomy of coeliac plexus
Anatomy of splanchnic nerves
Coeliac plexus blockade
Splanchnic nerve neurolysis
HYPOGASTRIC PLEXUS
AND GANGLION OF IMPAR
NEUROLYSIS
Neurolysis of the superior
hypogastric plexus
Ganglion of impar neurolysis
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