Hannes Gruber Alexander Loizides Bernhard Moriggl Editors Sonographic Peripheral Nerve Topography A Landmark-based Algorithm 123 Sonographic Peripheral Nerve Topography Hannes Gruber • Alexander Loizides Bernhard Moriggl Editors Sonographic Peripheral Nerve Topography A Landmark-based Algorithm Editors Hannes Gruber Alexander Loizides Department Radiologie Department Radiologie Medizinische Universität Innsbruck Medizinische Universität Innsbruck Innsbruck Innsbruck Austria Austria Bernhard Moriggl Clinical & Functional Anatomy Medical University of Innsbruck Innsbruck Austria Translation from the German language edition: Nervensonographie kompakt - Anatomie der peripheren Nerven mit Landmarks edited by Gruber, Loizides, Moriggl. Copyright © Springer-Verlag GmbH Deutschland 2018 Springer is part of Springer Nature All Rights Reserved. ISBN 978-3-030-11032-1 ISBN 978-3-030-11033-8 (eBook) https://doi.org/10.1007/978-3-030-11033-8 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword If we wish to be consistently successful in finding peripheral nerves, whether it is for regional anesthesia, pain management, or other clinical applications, we must have in-depth knowledge of clinically relevant anatomy. Recognizing vascular, muscular, bony, and other nearby non- neural structures helps us identify the target nerve we seek to find. For beginners of nerve sonography, learning to identify relevant sonoanatomy can be quite challenging at the outset and often time consuming if it is self-taught. It is akin to traveling in a foreign land for the first time without a map or navigation aid of any kind. It would be most helpful to be prepared before embarking on a new journey by gathering useful information and directions. This is especially true for ultrasound-guided regional anesthesia as well as many other interventional pain management or diagnostic procedures. This nerve sonography handbook authored by Professors Hannes Gruber, Alexander Loizides, and Bernhard Moriggl, all experts in nerve sonography, is precisely such a helpful aid. One may consider this handbook the Google Maps for nerve sonographers to navigate the world of peripheral nerve sonography. It is a simple, easy-to-follow, reference book with some very cool features – simplicity, landmark-based illustrations, practical tips on scanning, and standardized algorithm for nerve localization. In this handbook, a search of the nerve not only includes a basic nerve compass, it also highlights alternate routes to find the nerve realizing that variation is the rule of human anatomy as Professor Moriggl, the best anatomy and ultra- sound professor I have ever known, so often reminds us. This is a great feature to overcome navigational difficulties by showing sonographic views and screenshots of unfamiliar anatomi- cal terrains. I am confident you will find this one-of-a-kind handbook an invaluable asset to sonogra- phers of musculoskeletal and peripheral nerve anatomy. You will benefit from the authors’ wealth of knowledge, practical scanning advice, and step-by-step nerve localization algorithm. This handbook is easy to understand, concise, and enlightening. Studying this book is a great way to plan and get ready before embarking on a journey of peripheral nerve sonography. As the popular slogan says, “Don’t Leave Home Without It.” Vincent W. S. Chan, MD, FRCPC, FRCA Department of Anesthesia University of Toronto Toronto, ON, Canada v Preface “For whom, and why?” Our target audience and the purpose of this book. This atlas is meant to be a useful “vade mecum” for all colleagues interested and involved in nerve sonography in order to locate nerves as quickly and easily as possible in daily clinical practice. You could put it this way, too: “Never search again for a nerve” – for in this book, you have already found it. Thus, the “Why?” has already been nearly answered since nothing com- parable exists until now. With this book, you will save valuable time, time that most certainly can be better used for a subsequent diagnosis, intervention, and/or therapy. Quite deliberately, this atlas does not contain any information on these latter aspects! Due to the clear descriptions of visible and/or palpable “external” landmarks by illustra- tions and short (!) texts, the ultrasound probe can be placed optimally from the beginning: initial probe positioning. In the ultrasound images, a few but characteristic “internal” land- marks are shown, which help in finding the location and topographic allocation of the “target structure” nerve. As a valuable support for practical application, we, in particular, documented those areas where specific nerves can be delimited best: the respective “point of optimal visi- bility” (POV). Such a point does exist for (nearly) any peripheral nerve! Not without reason, the “POV” does take central position in the overview tables for each single nerve! We are convinced that, especially in cases of unfavorable sonographic conditions, the exact knowl- edge of these POVs can be of decisive help. All this shows that the authors paid very special attention to the practical aspects of nerve sonography. As a result, relevant variations were mentioned, and – if feasible and reasonable – alternative plans were addressed. Additionally, some comments (concerning, e.g., positioning or pitfalls) were enclosed. References to the innumerable studies concerning nerve sonogra- phy, however, were intentionally left out since including them would have conflicted with the intention of this compact manual. We do hope very much that you will be pleased by this atlas and that, above all, it will be used frequently! We should close our introduction with a “quotation” inspired by the famous German author Wilhelm Busch (1832–1908): “You’ll miss a nerve quite easily, if searched for it where it can’t be.” May our book help you to avoid that calamity! Innsbruck, Austria Bernhard Moriggl Alexander Loizides Hannes Gruber vii Contents 1 How to Use This Book Effectively: A User’s Guide! . . . . . . . . . . . . . . . . . . . . . . . . 1 Bernhard Moriggl, Alexander Loizides, and Hannes Gruber 2 Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Alexander Loizides, Sebastian Schuhmayer, and Bernhard Moriggl 3 Upper Arm, Forearm and Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Alexander Loizides, Sebastian Schuhmayer, and Bernhard Moriggl 4 Trunk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 Alexander Loizides, Hannes Gruber, Philipp Koch, Sebastian Schuhmayer, and Bernhard Moriggl 5 Gluteal Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 Hannes Gruber, Philipp Koch, and Bernhard Moriggl 6 Thigh, Lower Leg, and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157 Hannes Gruber, Philipp Koch, and Bernhard Moriggl Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .227 ix Contributors Hannes Gruber Department of Radiology, Medical University Innsbruck, Innsbruck, Austria Philipp Koch Department of Radiology, Medical University Innsbruck, Innsbruck, Austria Alexander Loizides Department of Radiology, Medical University Innsbruck, Innsbruck, Austria Bernhard  Moriggl Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria Sebastian Schuhmayer Department of Radiology, Medical University Innsbruck, Innsbruck, Austria xi Abbreviations A. Arteria Aa. Arteriae AP Alternative plan ELM External landmarks ILM Internal landmarks IPOS Initial positioning of the probe K Comments M. Musculus Mm. Musculi N. Nervus Nn. Nervi POV Point of optimal visibility R. Ramus Rr. Rami V. Vena VAR Variations Vv. Venae xiii How to Use This Book Effectively: 1 A User’s Guide! Bernhard Moriggl, Alexander Loizides, and Hannes Gruber Contents The simple structure 2 The example: Ramus palmaris of Nervus medianus 2 General remarks 5 B. Moriggl (*) Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected] A. Loizides · H. Gruber Department of Radiology, Medical University Innsbruck, Innsbruck, Austria e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2019 1 H. Gruber et al. (eds.), Sonographic Peripheral Nerve Topography, https://doi.org/10.1007/978-3-030-11033-8_1