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MD,
*Institute of Anatomy and Histology, Department of Neurology, and Department of Anaesthesiology and Critical Care
Medicine, Leopold-Franzens University of Innsbruck, Innsbruck, Austria; Anatomische Anstalt, Ludwig-Maximilian
University Munich, Munich, Germany; and Department of Anaesthesiology and Intensive Care Medicine, University of
Vienna, Vienna, Austria
Methods
All volunteers gave informed consent, and institutional approval was obtained. Spinal deformities and
Presented in part at the 19th annual meeting of the European
Society of Regional Anesthesia (ESRA), Rome, Italy, September,
2000. Published in part in the International Monitor (2000;12:197)
(Special Abstract Issue, 19th Annual ESRA Congress).
Accepted for publication April 16, 2001.
Address correspondence and reprint requests to Lukas Kirchmair, MB, Institute of Anatomy and Histology, University of Innsbruck, Muellerstrasse 59, A-6010 Innsbruck, Austria. Address e-mail
to lukas.kirchmair@tirol.com.
2001 by the International Anesthesia Research Society
0003-2999/01
477
478
ANESTH ANALG
2001;93:47781
ANESTH ANALG
2001;93:47781
TECHNICAL COMMUNICATION
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ULTRASOUND AND LUMBAR PLEXUS BLOCK
479
No.
Age (yr)
Height (cm)
Weight (kg)
BMI (kg/m2)
NW
OW
OB
13
5
3
24 (1943)
33 (2360)
33 (3152)
176 (164186)
184 (180192)
167 (165187)
71 (5081)
95 (89100)
107 (86130)
22.0 (17.723.9)
27.8 (27.128.7)
37.2 (30.839.3)
Results
Discussion
480
ANESTH ANALG
2001;93:47781
Table 2. Feasibility Rates of Posterior Paravertebral Sonography and Measured SPD Values
Group
No.
F-L2/L3
F-L3/L4
F-L4/L5
SPD (cm)
NW
OW
OB
78
30
18
26/26
8/10
4/6
26/26
8/10
4/6
26/26
7/10
3/6
5.2 0.6
7.3 0.6
8.8 0.9
Total
126
38/42
38/42
36/42
n total number of examined levels; F feasibility rates for each level (successfully examined levels/total number of levels); SPD skin-plexus distance;
NW normal weight; OW overweight; OB obese.
SPD values are median sd.
obese individuals. Occasionally, a reliable sonographic examination at L4-5 may be unfeasible in men
because of the obstructing iliac crests.
Usually, the lower poles of the kidneys reach the
level of L3, but during deep inspiration they may
descend to reach the level of L3-4, appearing as hypoechoic, oval-shaped structures in the posterior transverse sonograms of L3-4. Distinguishing between the
kidneys and the typical echotexture of the psoas muscle [hyperechoic striations on an echo-poor background (12)] was feasible in all successfully examined
volunteers. Aida et al. (9) reported two cases of renal
subcapsular hematoma caused by lumbar plexus
blockade at L3 and stated that a posterior approach to
the lumbar plexus must be performed at L4-5 to avoid
renal injury. The use of real-time US guidance for
approaches at L2-3 and L3-4 should help to avoid such
complications by visualizing the structures at risk.
This study revealed that it is necessary to apply
curved-array transducers operating at lower frequencies (4 5 MHz) because they provide appropriate tissue penetration and image size but less spatial resolution. Therefore, it was not possible to distinguish
between peripheral nerves (13,14) as parts of the lumbar plexus and tendon fibers (which appear as hyperechoic striations, similar to peripheral nerves) within
the psoas muscle (12). For a reliable and accurate
delineation of the latter, the application of linear array
transducers (7.5 MHz) is recommended (15). Nevertheless, Koyama et al. (16) reported the depiction of
parts of the lumbar plexus within the psoas muscle by
using a 3.5-MHz curved array transducer.
Consequently, skin-plexus distance-measurements
were made indirectly with the use of a reference point
(junction of the anterior two-thirds and the posterior
third of the psoas muscle in its anteroposterior diameter) that was estimated to be the approximate position of the lumbar plexus (10). The lumbar plexus is
situated within the posterior part of the psoas muscle
at all lumbar levels (Fig. 2) (8,10,1720). The median
skin-plexus distances measured with US are smaller
than those measured with CT at all examined levels.
The most likely explanation for this decrease is the
pressure of the transducer against the skin (compression of the subcutaneous tissue and paraspinal
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ANESTH ANALG
2001;93:47781
TECHNICAL COMMUNICATION
KIRCHMAIR ET AL.
ULTRASOUND AND LUMBAR PLEXUS BLOCK
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