Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd

6. Indications for Peripheral Nerve Blocks

Jeff Gadsden


During the past 20 years, increasing knowledge in functional regional anesthesia anatomy, coupled with new technologies for locating peripheral nerves, has resulted in expansion of regional anesthesia techniques. This phenomenon served to provide the clinician with a wide variety of techniques from which to choose. Nevertheless, many nerve block techniques are quite similar and result in a similar, if not exact, distribution of anesthesia. The proper choice of the nerve block for a particular surgical procedure and/or patient, however, is far more important than deliberation on the minutia of various technical techniques. In this chapter, a rational selection of the nerve block techniques is approached in three sections. In the first section, indications for common nerve blocks are listed with a short summary of the advantages and disadvantages of each technique selected. In the second section, specific protocols for intraoperative anesthesia and postoperative analgesia for the common surgical procedures are suggested as practiced by anesthesiologists affiliated with the St. Luke’s and Roosevelt Hospitals in New York. This cookbook approach was chosen to allow clinicians to duplicate the results that we have found, via trial and error, to work best in our own practice. The last section is a more comprehensive compendium of published medical literature on the indications for peripheral nerve blocks.

Section I: Advantages and Disadvantages of Specific Nerve Blocks

Upper Limb Blocks

With the advent of ultrasound guidance for nerve blocks, the choice of which brachial plexus block to perform has become less relevant because the block can be extended by needle repositioning into the desired area. For example, the interscalene approach was not recommended in the past for procedures on the hand or elbow because it was believed that local anesthetic would not sufficiently cover the inferior trunk of the brachial plexus. However, this barrier can be overcome with the use of a low-interscalene approach or by using sonographic guidance to target all three trunks. Multiple injections at different levels of the brachial plexus through a single-needle insertion site can make the interscalene brachial plexus applicable for most upper limb procedures. Regardless, the common approaches to brachial plexus block are sufficiently different in their anesthetic coverage to deserve knowledgeable consideration when making a decision about which block to use. In addition to the anesthetic coverage, the block selection should also take into consideration other factors, such as patient comfort, preexisting respiratory dysfunction, and practitioner experience. Table 6-1 lists common nerve block procedures and their indications.

TABLE 6-1 Common Upper Limb Blocks



Lower Limb Blocks

Achieving quality anesthesia or analgesia of the lower limb is more challenging than with an upper extremity. This is because its innervation stems from two major plexuses, the lumbar and the sacral. The lumbar plexus is formed by the roots of L1-L4 and gives rise to the femoral, obturator, and lateral femoral cutaneous nerves, among others. The sacral plexus originates from L4-S3, and its principal branch is the sciatic nerve. Most of the indications for lower limb blockade involve joint surgery on either the hip or the knee. Because both joints are supplied by elements of each plexus, complete anesthesia often requires at least two nerve blocks. Consequently, many clinicians choose to perform just one block for the purpose of analgesiaTable 6-2 lists some common lower limb blocks and their advantages and disadvantages.



TABLE 6-2 Common Lower Limb Blocks

Section II: Protocols

A variety of different methods are available to provide intraoperative and postoperative analgesia for surgery on the extremity. Any anesthetic or analgesic plan is based on patient and surgical factors as well as practical considerations such as the practitioner’s skill level, availability of a block room, availability of skilled assistants, and departmental and hospital policies. The protocols for most common major orthopedic procedures outlined in this section were refined through trial and error and are the actual methods used in our daily practice.

The choice of the block combination for postoperative pain is based on several factors. The orthopedic surgeons at St. Luke’s-Roosevelt Hospital prefer a regimen of twice-daily dosing of low molecular weight heparin (LMWH) for thromboprophylaxis, which makes the use of an indwelling epidural catheter for postoperative pain impractical or unsuitable. Similarly, although we recognize there is some controversy regarding the use of lumbar plexus catheters in the same setting, by and large, we treat them as neuraxial catheters and remove them before the first dose of LMWH. Other perineural catheters are routinely placed and maintained even in patients who are treated with anticoagulants.

In recent years, we have made an effort to minimize the use of parenteral opioids for postoperative pain if possible. In particular, patients admitted to the ward with a perineural catheter and intravenous patient-controlled opioid analgesia can find it confusing to have two buttons to press, and therefore they do not use the catheter effectively, leading to inadequate analgesia. For this reason, we strive to make use of a multimodal regimen instead, consisting of acetaminophen, a nonsteroidal anti-inflammatory drug, and an oral opioid.

For lower limb surgery, such as total knee replacement, clinicians often debate whether the sciatic nerve and/or obturator blocks should be routinely used in addition to the femoral (or lumbar plexus) block. We do not routinely do this but rather assess the patient after the femoral/lumbar plexus blockade is performed. In our practice, in the majority of patients, postoperative pain is adequately managed (visual analog scale [VAS] ≤3) by continuous femoral nerve block alone. A small proportion of patients (about 20%) may require a sciatic nerve block for adequate pain control. Although often debated and taught in various regional courses, the usefulness of the obturator block in our practice is questionable at best. Consequently, we do not use obturator blocks in patients having knee arthroplasty.

The timing of block placement is institution dependent, and it relies on the presence of various factors, such as availability of the designated block personnel, operating room flow, ancillary staff, and a separate block area. Single-injection nerve blocks for surgery are performed either in the holding area or operating room immediately prior to the surgical procedure. Catheters for upper limb surgery are usually placed in a similar manner if the technique is used for surgical anesthesia as well. In contrast, most of our lower limb nerve blocks or catheters are placed in the postanesthesia care unit before the resolution of the neuraxial block. Although the practice of performing blocks in anesthetized patients (in this case in the presence of spinal anesthesia), we believe that when modern monitoring is used (combination of ultrasound, nerve stimulation, and injection pressure monitoring), it is irrelevant whether the blocks are performed in anesthetized or nonanesthetized patients.

Finally, we do not routinely combine general anesthesia with regional anesthesia, although this is a widely used practice elsewhere. Our regional anesthetics are often used as the primary anesthesia modality, rather then solely for the purpose of postoperative analgesia. Instead of general anesthesia, we typically use sedation with propofol and/or intravenous midazolam titrated to light sleep and spontaneous breathing with supplemental oxygen via a facemask. Table 6-3 lists some common surgical procedures, peripheral nerve blocks that are suitable for anesthesia and analgesia, as well as other common analgesic options.

TABLE 6-3 Common Surgical Procedures and Analgesic Options





Section III: Compendium of the Literature

The previous two sections described some of the most common indications for peripheral nerve blocks in our practice. However, the usefulness of peripheral nerve blocks is much greater than the few common ones discussed here. For the sake of completeness, the compendium of indications for peripheral nerve blocks reported in medical literature is listed in the accompanying chart. Readers should use their own discretion when determining whether any indications would fit the realm of their own clinical practice.










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2. Goldberg ME, Schwartzman RJ, Domsky R, Sabia M, Torjman MC. Deep cervical plexus block for the treatment of cervicogenic headache. Pain Physician. 2008;11:849-854.

3. Stoneham MD, Knighton JD. Regional anaesthesia for carotid endarterectomy. Br J Anaesth. 1999;82:910-919.

4. Naja ZM, Al-Tannir MA, Zeidan A, et al. Bilateral guided cervical block for Zenker diverticulum excision in a patient with ankylosing spondylitis. J Anesth. 2009;23:143-146.

5. Ling KU, Hasan MS, Ha KO, Wang CY. Superficial cervical plexus block combined with auriculotemporal nerve block for drainage of dental abscess in adults with difficult airways. Anaesth Intensive Care. 2009;37:124-126.

6. Shteif M, Lesmes D, Hartman G, Ruffino S, Laster Z. The use of the superficial cervical plexus block in the drainage of submandibular and submental abscesses—an alternative for general anesthesia. J Oral Maxillofac Surg. 2008;66:2642-2645.

7. Pintaric TS, Hocevar M, Jereb S, Casati A, Jankovic VN. A prospective, randomized comparison between combined (deep and superficial) and superficial cervical plexus block with levobupivacaine for minimally invasive parathyroidectomy. Anesth Analg. 2007;105:1160-1163; table of contents.

8. Jones HG, Stoneham MD. Continuous cervical plexus block for carotid body tumour excision in a patient with Eisenmenger’s syndrome. Anaesthesia. 2006;61:1214-1218.

9. Choi DS, Atchabahian A, Brown AR. Cervical plexus block provides postoperative analgesia after clavicle surgery. Anesth Analg. 2005;100:1542-1543.

10. Aunac S, Carlier M, Singelyn F, De Kock M. The analgesic efficacy of bilateral combined superficial and deep cervical plexus block administered before thyroid surgery under general anesthesia. Anesth Analg. 2002;95:746-750.

11. Nadig M, Ekatodramis G, Borgeat A. Continuous brachial plexus block at the cervical level using a posterior approach in the management of neuropathic cancer pain. Reg Anesth Pain Med. 2002;27:446; author reply 446-447.

12. Christiansen TG, Nielsen R. Reduction of shoulder dislocations under interscalene brachial blockade. Arch Orthop Trauma Surg. 1988;107:176-177.

13. Roubal PJ, Dobritt D, Placzek JD. Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis. J Orthop Sports Phys Ther. 1996;24:66-77.

14. Barak M, Iaroshevski D, Poppa E, Ben-Nun A, Katz Y. Low-volume interscalene brachial plexus block for post-thoracotomy shoulder pain. J Cardiothorac Vasc Anesth. 2007;21:554-557.

15. Casati A, Borghi B, Fanelli G, et al. Interscalene brachial plexus anesthesia and analgesia for open shoulder surgery: a randomized, double-blinded comparison between levobupivacaine and ropivacaine. Anesth Analg.2003;96:253-259.

16. Faryniarz D, Morelli C, Coleman S, et al. Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery. J Shoulder Elbow Surg. 2006;15:686-690.

17. Hingorani AP, Ascher E, Gupta P, et al. Regional anesthesia: preferred technique for venodilatation in the creation of upper extremity arteriovenous fistulae. Vascular. 2006;14:23-26.

18. Hadzic A, Williams BA, Karaca PE, et al. For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery over general anesthesia. Anesthesiology. 2005;102:1001-1007.

19. Stone MB, Price DD, Wang R. Ultrasound-guided supraclavicular block for the treatment of upper extremity fractures, dislocations, and abscesses in the ED. Am J Emerg Med. 2007;25:472-475.

20. Harmon D, Frizelle HP. Supraclavicular block for day-case anaesthesia at altitude. Anaesthesia. 2001;56:197.

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23. Thompson AM, Newman RJ, Semple JC. Brachial plexus anaesthesia for upper limb surgery: a review of eight years’ experience. J Hand Surg Br. 1988;13:195-198.

24. Dhir S, Ganapathy S. Comparative evaluation of ultrasound-guided continuous infraclavicular brachial plexus block with stimulating catheter and traditional technique: a prospective-randomized trial. Acta Anaesthesiol Scand. 2008;52:1158-1166.

25. Morimoto M, Popovic J, Kim JT, Kiamzon H, Rosenberg AD. Case series: Septa can influence local anesthetic spread during infraclavicular brachial plexus blocks. Can J Anaesth. 2007;54:1006-1010.

26. Gurkan Y, Hosten T, Solak M, Toker K. Lateral sagittal infraclavicular block: clinical experience in 380 patients. Acta Anaesthesiol Scand. 2008;52:262-266.

27. Dingemans E, Williams SR, Arcand G, et al. Neurostimulation in ultrasound-guided infraclavicular block: a prospective randomized trial. Anesth Analg. 2007;104:1275-1280.

28. Hadžić A, Arliss J, Kerimoglu B, et al. A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist day-case surgeries. Anesthesiology. 2004;101:127-132.

29. De Jose Maria B, Banus E, Navarro Egea M, Serrano S, Perello M, Mabrok M. Ultrasound-guided supraclavicular vs infraclavicular brachial plexus blocks in children. Paediatr Anaesth. 2008;18:838-844.

30. Ponde VC. Continuous infraclavicular brachial plexus block: a modified technique to better secure catheter position in infants and children. Anesth Analg. 2008;106:94-96; table of contents.

31. Niemi TT, Salmela L, Aromaa U, Poyhia R, Rosenberg PH. Single-injection brachial plexus anesthesia for arteriovenous fistula surgery of the forearm: a comparison of infraclavicular coracoid and axillary approach. Reg Anesth Pain Med. 2007;32:55-59.

32. Day M, Pasupuleti R, Jacobs S. Infraclavicular brachial plexus block and infusion for treatment of long-standing complex regional syndrome type 1: a case report. Pain Physician. 2004;7:265-268.

33. Rettig HC, Gielen MJ, Boersma E, Klein J. A comparison of the vertical infraclavicular and axillary approaches for brachial plexus anaesthesia. Acta Anaesthesiol Scand. 2005;49:1501-1508.

34. Sauter AR, Dodgson MS, Stubhaug A, Halstensen AM, Klaastad O. Electrical nerve stimulation or ultrasound guidance for lateral sagittal infraclavicular blocks: a randomized, controlled, observer-blinded, comparative study. Anesth Analg. 2008;106:1910-1915.

35. Minville V, Fourcade O, Bourdet B, et al. The optimal motor response for infraclavicular brachial plexus block. Anesth Analg. 2007;104:448-451.

36. Rodriguez J, Taboada M, Oliveira J, Ulloa B, Bascuas B, Alvarez J. Radial plus musculocutaneous nerve stimulation for axillary block is inferior to triple nerve stimulation with 2% mepivacaine. J Clin Anesth. 2008;20:253-256.

37. Kang SB, Rumball KM, Ettinger RS. Continuous axillary brachial plexus analgesia in a patient with severe hemophilia. J Clin Anesth. 2003;15:38-40.

38. Brown AR. Anaesthesia for procedures of the hand and elbow. Best Pract Res Clin Anaesthesiol. 2002;16:227-246.

39. Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, Abbas S. Ultrasound guidance improves success rate of axillary brachial plexus block. Can J Anaesth. 2007;54:176-182.

40. Andersson A, Akeson J, Dahlin LB. Efficacy and safety of axillary brachial plexus block for operations on the hand. Scand J Plast Reconstr Surg Hand Surg. 2006;40:225-229.

41. Freitag M, Zbieranek K, Gottschalk A, et al. Comparative study of different concentrations of prilocaine and ropivacaine for intraoperative axillary brachial plexus block. Eur J Anaesthesiol. 2006;23:481-486.

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44. Fuzier R, Fourcade O, Pianezza A, Gilbert ML, Bounes V, Olivier M. A comparison between double-injection axillary brachial plexus block and midhumeral block for emergency upper limb surgery. Anesth Analg. 2006;102:1856-1858.

45. Theroux MC, Dixit D, Brislin R, Como-Fluero S, Sacks K. Axillary catheter for brachial plexus analgesia in children for postoperative pain control and rigorous physiotherapy—a simple and effective procedure. Paediatr Anaesth. 2007;17:302-303.

46. Kjelstrup T. Transarterial block as an addition to a conventional catheter technique improves the axillary block. Acta Anaesthesiol Scand. 2006;50:112-116.

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50. Gradl G, Beyer A, Azad S, Schurmann M. Evaluation of sympathicolysis after continuous brachial plexus analgesia using laser Doppler flowmetry in patients suffering from CRPS I [in German]. Anasthesiol Intensivmed Notfallmed Schmerzther. 2005;40:345-349.

51. Liu HT, Yu YS, Liu CK, et al. Delayed recovery of radial nerve function after axillary block in a patient receiving ipsilateral ulnar nerve transposition surgery. Acta Anaesthesiol Taiwan. 2005;43:49-53.

52. Breschan C, Kraschl R, Jost R, Marhofer P, Likar R. Axillary brachial plexus block for treatment of severe forearm ischemia after arterial cannulation in an extremely low birth-weight infant. Paediatr Anaesth. 2004;14:681-684.

53. Hebl JR, Horlocker TT, Sorenson EJ, Schroeder DR. Regional anesthesia does not increase the risk of postoperative neuropathy in patients undergoing ulnar nerve transposition. Anesth Analg. 2001;93:1606-1611.

54. van den Berg B, Berger A, van den Berg E, Zenz M, Brehmeier G, Tizian C. Continuous plexus anesthesia to improve circulation in peripheral microvascular interventions [in German]. Handchir Mikrochir Plast Chir. 1983;15:101-104.

55. Bekler H, Beyzadeoglu T, Mercan A. Groin flap immobilization by axillary brachial plexus block anesthesia. Tech Hand Up Extrem Surg. 2008;12:68-70.

56. Kriwanek KL, Wan J, Beaty JH, Pershad J. Axillary block for analgesia during manipulation of forearm fractures in the pediatric emergency department: a prospective randomized comparative trial. J Pediatr Orthop.2006;26:737-740.

57. Jablecki J, Syrko M. The application of nerve block in early post-operative rehabilitation after tenolysis of the flexor tendon. Ortop Traumatol Rehabil. 2005;7:646-650.

58. Broekhuysen CL, Fechner MR, Kerkkamp HE. The use of a selective peripheral median nerve block for pain-free early active motion after hand surgery. J Hand Surg Am. 2006;31:857-859.

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60. Gebhard RE, Al-Samsam T, Greger J, Khan A, Chelly JE. Distal nerve blocks at the wrist for outpatient carpal tunnel surgery offer intraoperative cardiovascular stability and reduce discharge time. Anesth Analg. 2002;95:351-355.

61. Delaunay L, Chelly JE. Blocks at the wrist provide effective anesthesia for carpal tunnel release. Can J Anaesth. 2001;48:656-660.

62. Derkash RS, Weaver JK, Berkeley ME, Dawson D. Office carpal tunnel release with wrist block and wrist tourniquet. Orthopedics. 1996;19:589-590.

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70. Phelps DB, Rutherford RB, Boswick JA Jr. Control of vasospasm following trauma and microvascular surgery. J Hand Surg Am. 1979;4:109-117.

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77. Kirchhoff R, Jensen PB, Nielsen NS, Boeckstyns ME. Repeated digital nerve block for pain control after tenolysis. Scand J Plast Reconstr Surg Hand Surg. 2000;34:257-258.

78. Daly DJ, Myles PS. Update on the role of paravertebral blocks for thoracic surgery: are they worth it? Curr Opin Anaesthesiol. 2009;22:38-43.

79. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth. 2006;96:418-426.

80. Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. 2008;107:1026-1040.

81. Boezaart AP, Raw RM. Continuous thoracic paravertebral block for major breast surgery. Reg Anesth Pain Med. 2006;31:470-476.

82. Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. Single-injection paravertebral block compared to general anaesthesia in breast surgery. Acta Anaesthesiol Scand. 1999;43:770-774.

83. Coveney E, Weltz CR, Greengrass R, et al. Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases. Ann Surg. 1998;227:496-501.

84. Tsai T, Rodriguez-Diaz C, Deschner B, Thomas K, Wasnick JD. Thoracic paravertebral block for implantable cardioverter-defibrillator and laser lead extraction. J Clin Anesth. 2008;20:379-382.

85. Moussa AA. Opioid saving strategy: bilateral single-site thoracic paravertebral block in right lobe donor hepatectomy. Middle East J Anesthesiol. 2008;19:789-801.

86. Mehta Y, Arora D, Sharma KK, Mishra Y, Wasir H, Trehan N. Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery. Ann Card Anaesth. 2008;11:91-96.

87. Serpetinis I, Bassiakou E, Xanthos T, Baltatzi L, Kouta A. Paravertebral block for open cholecystectomy in patients with cardiopulmonary pathology. Acta Anaesthesiol Scand. 2008;52:872-873.

88. Rudkin GE, Gardiner SE, Cooter RD. Bilateral thoracic paravertebral block for abdominoplasty. J Clin Anesth. 2008;20:54-56.

89. Cooter RD, Rudkin GE, Gardiner SE. Day case breast augmentation under paravertebral blockade: a prospective study of 100 consecutive patients. Aesthetic Plast Surg. 2007;31:666-673.

90. Culp WC, Payne MN, Montgomery ML. Thoracic paravertebral block for analgesia following liver mass radiofrequency ablation. Br J Radiol. 2008;81:e23-e25.

91. Berta E, Spanhel J, Smakal O, Smolka V, Gabrhelik T, Lonnqvist PA. Single injection paravertebral block for renal surgery in children. Paediatr Anaesth. 2008;18:593-597.

92. Lonnqvist PA, Olsson GL. Paravertebral vs epidural block in children. Effects on postoperative morphine requirement after renal surgery. Acta Anaesthesiol Scand. 1994;38:346-349.

93. Lopez-Berlanga JL, Garutti I, Martinez-Campos E, Pineiro P, Salvatierra D. Bilateral paravertebral block anesthesia for thymectomy by video-assisted thoracoscopy in patients with myasthenia gravis [in Spanish]. Rev Esp Anestesiol Reanim. 2006;53:571-574.

94. Kaya FN, Turker G, Basagan-Mogol E, Goren S, Bayram S, Gebitekin C. Preoperative multiple-injection thoracic paravertebral blocks reduce postoperative pain and analgesic requirements after video-assisted thoracic surgery. J Cardiothorac Vasc Anesth. 2006;20:639-643.

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97. Canto M, Sanchez MJ, Casas MA, Bataller ML. Bilateral paravertebral blockade for conventional cardiac surgery. Anaesthesia. 2003;58:365-e70.

98. Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. 2003;54:615-625.

99. Karmakar MK, Critchley LA, Ho AM, Gin T, Lee TW, Yim AP. Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs. Chest. 2003;123:424-431.

100. Dhole S, Mehta Y, Saxena H, Juneja R, Trehan N. Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth. 2001;15:288-292.

101. Paniagua P, Catala E, Villar Landeira JM. Successful management of pleuritic pain with thoracic paravertebral block. Reg Anesth Pain Med. 2000;25:651-653.

102. Sabanathan S, Shah R, Tsiamis A, Richardson J. Oesophagogastrectomy in the elderly high risk patients: role of effective regional analgesia and early mobilisation. J Cardiovasc Surg (Torino). 1999;40:153-156.

103. Jamieson BD, Mariano ER. Thoracic and lumbar paravertebral blocks for outpatient lithotripsy. J Clin Anesth. 2007;19:149-151.

104. Weltz CR, Klein SM, Arbo JE, Greengrass RA. Paravertebral block anesthesia for inguinal hernia repair. World J Surg. 2003;27:425-429.

105. Naja Z, Ziade MF, Lonnqvist PA. Bilateral paravertebral somatic nerve block for ventral hernia repair. Eur J Anaesthesiol. 2002;19:197-202.

106. Lee EM, Murphy KP, Ben-David B. Postoperative analgesia for hip arthroscopy: combined L1 and L2 paravertebral blocks. J Clin Anesth. 2008;20:462-465.

107. Basagan-Mogol E, Turker G, Yilmaz M, Goren S. Combination of a psoas compartment, sciatic nerve, and T12-L1 paravertebral blocks for femoropopliteal bypass surgery in a high-risk patient. J Cardiothorac Vasc Anesth. 2008;22:337-339.

108. Nair V, Henry R. Bilateral paravertebral block: a satisfactory alternative for labour analgesia. Can J Anaesth. 2001;48:179-184.

109. Suelto MD, Shaw DB. Labor analgesia with paravertebral lumbar sympathetic block. Reg Anesth Pain Med. 1999;24:179-181.

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