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TECHNICAL COMMUNICATION

A Study of the Paravertebral Anatomy for Ultrasound-Guided


Posterior Lumbar Plexus Block
Lukas Kirchmair, MB*, Tanja Entner, MD, Jorg Wissel, MD, Bernhard Moriggl,
Stephan Kapral, MD, and Gottfried Mitterschiffthaler, MD

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

The benefits of applying real-time ultrasound (US)


guidance to achieve successful and safe peripheral
nerve blocks have been demonstrated (1 4). The exact
delineation of injection sites and the monitoring of
needle insertion and spread of local anesthetics established US as an useful adjunct during the performance
of supraclavicular (1), femoral (2,3), and stellate ganglion blocks (4). The use of US for posterior lumbar
plexus blocks has not been studied. Several approaches to the psoas compartment block have been
described (57). The advantages of an approach at
L2-3 were mentioned (8), but cases of renal hematoma
(9) made them precarious. Several different techniques
to locate the lumbar plexus, including loss of resistance (5), elicitation of paresthesias (6), and nerve
stimulation (7) have been described. None of these
techniques provides information on the exact relationship between the needle and the plexus.
To overcome these disadvantages, we investigated
the feasibility of posterior paravertebral sonography
as a basis for a US-guided posterior approach to the
lumbar plexus. This study was conducted in two stages: a pilot study to establish the detailed US anatomy
of this region and a volunteer study to examine the
feasibility of posterior paravertebral sonography in
individuals of varying body types.

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

pregnancy were criteria for exclusion. A standard US


device (Sonoline VersaPlus; Siemens, Vienna, Austria)
was used. Four different US transducers (two curved
array transducers, 4 and 5 MHz; two linear array
transducers, 7.5 and 5 MHz; Siemens) were evaluated,
and the best imaging was achieved by the curved
array transducers.
The normal sonographic appearance of the relevant
paravertebral structures (psoas muscle, quadratus
lumborum muscle, and erector spinae) was investigated at L2-3, L3-4, and L4-5 by means of two corresponding posterior sonograms (longitudinal and
transverse; Fig. 1). The normal cross-sectional anatomy of L2-5 levels was also demonstrated by means of
cross-sectional preparations derived from an embalmed cadaver (Fig. 2). The transverse sonograms
were compared with these preparations to establish
the sonographic anatomy of the paravertebral region.
For longitudinal sonograms, the transducer was
placed approximately 3 cm parallel to the lumbar
spinous processes to localize the corresponding transverse processes (Fig. 1). The latter were used as landmarks, as was the cephalad portion of the sacrum, by
caudad movement of the transducer. Those bony
structures produced bright reflections followed by
distal sound extinction (Fig. 3). To ensure that the
echoes did not result from the articular processes, the
transducer was moved further laterally to depict just
the tips of the processes. Exact localization of levels
L2-3, L3-4, and L4-5 was achieved by counting the
transverse process echoes from the sacrum upward.
At each level, half the distance between two adjacent
transverse processes was set in the center of the longitudinal sonogram (Fig. 3), and the transducer was
rotated approximately 90 degrees into a transverse
plane (Fig. 1). It was here that the number of bony
components disturbing the spread of the US beam is
least; this is necessary to gain optimal sonograms. The
lateral aspect of the vertebral arch and the articular
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Figure 1. Transducer-alignment for longitudinal (A) and transverse


(B) sonograms. Differences of the iliac crests in males (IC-M) and
females (IC-F) are shown. *Psoas muscle.

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Figure 3. Longitudinal sonogram. PM psoas muscle; ES erector


spinae; TP L3/L4/L5 bright reflections produced by the posterior
surfaces of the transverse processes at the corresponding lumbar
levels. Distal sound extinction.

Figure 4. Transverse sonogram at the level of L3-4. PM psoas


muscle; QL quadratus lumborum muscle; ES erector spinae; AP
articular process; VB/D vertebral body or intervertebral disk
(depending on the level of examination). *Ultrasound reflection
caused by bowel gas.

Figure 2. Cross-sectional preparation at L3-4 corresponding to the


transverse sonograms at this level. A branch of the lumbar plexus (*)
is shown within the posterior part of the psoas muscle (PM). QL
quadratus lumborum muscle; ES erector spinae; K kidney; D
duodenum; SP spinous process; AP articular process.

process occurred as landmarks at the medial border of


the sonogram (Fig. 4).
Twenty healthy volunteers were seated prone with
a cushion placed under the abdomen to minimize
lumbar lordosis. A curved array transducer (3,5C40;
Siemens; operated with 4 MHz) was applied, and
sonograms were obtained as described. The psoas

muscle was traced in the transverse sonograms of L3-4


and L4-5 levels on both sides, and measurements of its
cross-sectional areas were computed and compared
between examiners.
Twenty-one healthy volunteers were examined at
L2-3, L3-4, and L4-5. The volunteers were allocated to
three groups (Table 1): normal weight (n 13; body
mass index [BMI] 18.524.9 kg/m2), overweight (n
5; BMI 25.0 29.9 kg/m2), and obese (n 3; BMI
30.0 kg/m2). Posterior paravertebral sonography
was considered feasible when the psoas muscle, the
quadratus lumborum muscle, and the erector spinae
could be clearly delineated in transverse sonograms at
each level. Skin-plexus distance measurements were
performed by one of the examiners at L2-3, L3-4, and
L4-5. Skin-plexus distances were measured between
the junction of the posterior third and the anterior
two-thirds of the psoas muscle and the skin surface
(estimated position of the lumbar plexus) (10). The
measurements were computed in the center of the
transverse sonograms parallel to the axis of the US
beam to minimize measurement errors (11).
Finally, skin-plexus distance measurements were
performed equally by means of computed tomography (CT) in 10 embalmed cadavers to obtain reference

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479

Table 1. Volunteer Data


Group

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)

Values are median (range).


BMI body mass index; NW normal weight (BMI 18.524.9 kg/m2); OW overweight (BMI 25.0 29.9 kg/m2); OB obese (BMI 30.0 kg/m2).

values. The cadavers were also seated in the prone


position to avoid a decrease of the skin-plexus distances caused by body-weight pressure.
Interobserver reliability in the pilot study was determined by using Kendalls coefficient of concordance, W, to compare the psoas muscle cross-sectional
areas measured by the two examiners. The KruskalWallis test was used to reveal significant skin-plexus
distance differences among the L2-3, L3-4, and L4-5
levels, as well as skin-plexus differences among the
three BMI groups. The Mann-Whitney U-test was performed in case of significant skin-plexus distance differences between the analyzed levels as well as BMI
groups (revealed by the Kruskal-Wallis test). To analyze correlations between the measured skin-plexus
distances and BMIs, Spearmans coefficient of correlation was applied. P values 0.05 were considered
statistically significant. Skin-plexus distances are presented as median sd.

among the Normal Weight, Overweight, and Obese


groups (Table 2) were significant (P 0.001). Further,
Spearmans coefficient of correlation showed a significant positive correlation of 0.9 (P 0.01) between the
skin-plexus distances and the BMIs.
In 10 embalmed cadavers (3 male, 7 female) skinplexus distance measurements were computed at 56
lumbar levels (L2-3, n 18; L3-4, n 20; L4-5, n 18)
by means of CT. Their median age at death was 81 yr
(range, 51 88 yr) and height, 164 cm (range, 148 178
cm). Seven of 10 cadavers had normal body habitus,
and 3 of 10 were obese. Skin-plexus distances increased from L2-3 to L4-5, similar to the skin-plexus
distances obtained by sonography, but they showed
higher median values: 7.0 1.6 cm at L2-3, 7.3 1.5
cm at L3-4, and 7.9 1.3 cm at L4-5. The KruskalWallis test showed no significant skin-plexus distance
differences among the three levels (P 0.1).

Results

Discussion

In all 20 volunteers (10 men, 10 women), median age


24 yr (range, 19 43 yr), height 177 cm (range, 164 192
cm), weight 71 kg (range, 50 100 kg), and BMI
22 kg/m2 (range, 18 27kg/m2), posterior paravertebral sonography was performed successfully. The
psoas muscle, the quadratus lumborum muscle, and
the erector spinae could be traced reproducibly at all
examined levels (n 80). Kendalls W was 0.9 (P
0.001).
Twenty-one volunteers (13 men, 8 women), divided
into three groups (Table 1), had 126 lumbar levels
(L2-3, L3-4, and L4-5, right and left side) examined.
Posterior paravertebral sonography was feasible at
112 of 126 lumbar levels (Table 2). In the Overweight
and Obese groups, sonography was impossible in one
volunteer at all levels (left and right side) and in
another at the level of L4-5 on one side (Table 2). For
both examiners, sonography was unfeasible in the
same volunteers at equal levels.
Although there was an increase of the skin-plexus
distances from L2-3 to L4-5, the Kruskal-Wallis test
revealed no significant differences among L2-3, L3-4,
and L4-5 (P 0.42). The skin-plexus distances were
5.5 1.4 cm at L2-3, 5.5 1.4 cm at L3-4, and 5.8 1.3
cm at L4-5. However, skin-plexus distance differences

This investigation is the first dealing with a detailed


and reliable description of the sonographic appearance of the lumbar paravertebral region. Posterior
paravertebral sonography is reliable and accurate, as
shown by the results of the interobserver reliability
test.
The main study revealed that in 19 of 21 examined
volunteers, posterior paravertebral sonography was
feasible for both examiners. In 2 of 21 volunteers,
posterior paravertebral sonography failed at all examined levels because of obesity. The quality of the obtained sonograms did not allow a sharp delineation of
the psoas muscle and the adjacent structures. There
are two reasons that sonography may fail in obese
subjects: first, the applied transducer provides too low
tissue penetration, and second, thick subcutaneous fat
tissue causes heavy reflections because of US dispersion in dense tissues. Further, the spread of US may be
disturbed in men at L4-5 by tall iliac crests, which are
an anthropometric feature of male pelvises (Fig. 1). For
that reason, both examiners were unable to perform
sonography at L4-5 in 2 of 13 male volunteers, each on
one side. These results indicate that posterior paravertebral sonography can be reliably performed in normal weight and in the majority of overweight and

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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

muscles) that is mandatory for obtaining optimal


sonograms. We estimated this reduction to be approximately 12 cm (depending on the dimension of subcutaneous tissue). Although the obtained skin-plexus
distances did not exactly represent the real values for
that reason, we considered them as guidelines for
further applications of posterior paravertebral sonography. The increase of the skin-plexus distances from
L2-3 to L4-5 (not significant) revealed by both CT and
US measurements can be explained with the topographical position of the psoas muscle (as the muscle
courses caudad, it moves anteriorly) (21). Nevertheless, skin-plexus distances showed significant differences among the Normal Weight, Overweight, and
Obese groups (see Table 1 for median values); this
could be confirmed by the significant positive correlation between the BMIs and skin-plexus distances.
In conclusion, we demonstrated detailed and reliable visualization of the lumbar paravertebral region
by means of posterior paravertebral sonography. Nevertheless, we were unable to delineate the lumbar
plexus. With the use of US, particularly approaches at
L2-3 and L3-4 should be feasible without any complications that occur because of blind approaches.

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