Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional
Anesthesia, second edition, is being published at an exciting time in
the development of regional anesthesia. Reflecting on the first edition of
the book,* we believe its success was due largely to the tried-and-true
nature of the material taught. It would not be an overstatement to say that
the first edition of this book influenced professional lives of many
colleagues and ultimately benefited patients worldwide. The success helped
garner the New York School of Regional Anesthesia (NYSORA) additional esteem
that it enjoys today. In line with the philosophy of the first edition, this
second edition minimizes presentation of theoretical considerations.
Instead, the featured techniques and teachings are gleaned directly from the
trenches of the clinical practice of regional anesthesia.
In recent years, the field of regional anesthesia, and in
particular peripheral nerve blockade, has entered an unprecedented
renaissance. This renaissance is due primarily to the widespread
introduction of ultrasound-guided regional anesthesia. The ability to
visualize the anatomy of interest, the needle–nerve relationship, and
the spread of the local anesthetic has resulted in significant growth of
interest in and use of peripheral nerve blocks. Regardless, many aspects of
ultrasound-guided regional anesthesia still require clarification and
standardization. Examples include dilemmas regarding the ideal placement of
the needle for successful and safe blockade, the number of injections
required for individual techniques, the volume of local anesthetic for
successful blockade, the integration of additional monitoring tools such as
nerve stimulation and injection pressure monitoring and many others. For
these reasons, we decided to defer publication of the second edition and
opted to wait for clarification from clinical trials or collective
experience to provide more solid recommendations. As a result, just as with
the first edition, the second book features only tried-and-true descriptions
of peripheral nerve block techniques with wide clinical applicability rather
than a plethora of techniques and modifications that have mere theoretical
considerations. Where the collective experience has not reached the
necessary level to recommend teaching a certain technique (e.g., neuraxial
blocks), we opted to feature anatomic considerations rather than vague or
inadequately developed technique recommendations, which may lead to
disappointments, or possibly complications, if they are adopted without
careful consideration.
The second edition is
organized as a collection of practical introductory chapters, followed by
detailed and unambiguous descriptions of common regional anesthesia block
procedures rather than an exhaustive theoretical compendium of the
literature. Although ultrasound guidance eventually may become the most
prevalent method of nerve blockade globally, most procedures world-wide are
still performed using the methods of peripheral nerve stimulation and/or
surface landmarks, particularly in the developing world. Because this book
has been one of the main teaching sources internationally, we decided to
retain the section on the traditional techniques of nerve blockade in
addition to the new section on ultrasound-guided regional anesthesia. Since
knowledge of surface anatomy is essential for practice of both traditional
and ultrasound regional anesthesia procedures, we decided to also add an
Atlas of Surface Anatomy (Section 8).
The book is
organized in eight sections that progress from the foundations of peripheral
nerve blocks and regional anesthesia to their applications in clinical
practice. Ultrasound-guided regional anesthesia is a field in evolution, and
many of its aspects still lack standardization and clear guidance. For this
reason, we decided to produce this new edition as an international
collaborative effort. This collaboration resulted in teaching that is based
not only on our experience at NYSORA but also is endorsed by a number of
opinion leaders in the field from around the globe. I would like to thank
them for the contributions, enthusiasm, and passion that they invested in
creating the second edition of
Peripheral Nerve Blocks. This book
also would not be what it is without the large extended family of educators
and trainees, who took part in the numerous NYSORA educational programs,
including our educational outreach program in developing countries in Asia.
I thank you immensely for your input, which inspired us to deliver this
updated edition, and for your multiple contributions through e-mails,
suggestions, and discussion on the
NYSORA.com
website.
There are no standards of care related to
peripheral nerve blocks, despite their widespread use. With this edition, we
have tried to standardize the techniques and the monitoring approach during
local anesthetic delivery, for both greater consistency and greater safety
of peripheral nerve blocks. Different institutions naturally may have
different approaches to techniques that they customize for their own needs.
The material we present in this volume however, comes from the trenches of
clinical practice, so to speak. Most procedures described are accompanied by
carefully developed flowcharts to facilitate decision making in clinical
practice that the authors themselves use on an everyday basis.
The successful practice of ultrasound-guided regional
anesthesia and pain medicine procedures depends greatly on the ability to
obtain accurate ultrasound images and the ability to recognize the relevant
structures. For these reasons, we decided to add an atlas of ultrasound
anatomy for regional anesthesia and pain medicine (Section 7) procedures to
this volume. The anatomy examples consist of a pictorial guide with images
of the transducer position needed to obtain the corresponding ultrasound
image and the cross-sectional gross anatomy of the area being imaged. Once
the practitioner absorbs this material, he or she can extrapolate the
knowledge of the practical techniques presented to practice virtually any
additional regional anesthesia technique. We have expended painstaking
efforts to provide cross-sectional anatomy examples where possible.
Perfecting the matching of ultrasound and anatomy sections is not always
possible because the sonograms and cross-sectional anatomy views are
obtained from volunteers and fresh cadavers, respectively. The reader should
keep in mind that the ultrasound images are obtained from videos during
dynamic scanning. For this reason, the labeled ultrasound images are
accurate to the best of our abilities and within the limitations of the
ultrasound equipment even when they do not perfectly match the available
paired cross-sectional anatomy.
Due to popular
demand, we decided to include a DVD containing videos of the most common
ultrasound-guided nerve block procedures. Assuming that videos are the most
beneficial method for novices and trainees, we decided to include videos of
well-established ultrasound-guided nerve blocks that should cover most
indications for peripheral nerve blocks. Once trainees have mastered these
techniques, they typically require only knowledge about the specific anatomy
of the block(s) to be performed to apply the principles learned in the
videos to any other nerve block procedure. This is another example of how
the atlas of ultrasound anatomy (Section 7) included in the book will be
useful. With the wealth of information presented in a systematic fashion, we
believe that the Atlas also will be of value to anyone interested in the
ultrasound anatomy of peripheral nerve and musculoskeletal systems,
including radiologists, sonographers, neurologists, and others.
With this edition of
Peripheral Nerve Blocks and
Anatomy for Ultrasound-Guided Regional Anesthesia, we have tried to
provide a wealth of practical information about the modern practice of
peripheral nerve blocks and the use of ultrasound in regional anesthesia and
to present multiple pathways to troubleshoot common clinical problems. We
hope this book will continue to serve as one of the standard teaching texts
in anesthesiology, and we thank the readership of previous edition their
support and encouragement.
Sincerely,
Admir
Hadzic, MD
*The first edition was titled
Peripheral
Nerve Blocks: Principles and Practice.