The long thoracic nerve origins from the spinal nerve roots C5, C6 and C7

The upper two roots typically pierce the middle scalene muscle and the lower passes anterior to the muscle

The components of the nerve enter the axilla behind the brachial plexus and descend approximately in the midaxillary line; it runs on the superficial surface of the serratus anterior muscle which it innervates.

Identify the long thoracic nerve and the dorsal scapular nerve inside the middle scalene muscle with electrical nerve stimulation during ultrasound-guided interscalene brachial plexus block to avoid nerve injury

Selective diagnostic blockade of the long thoracic nerve in patients with suspected pain from serratus anterior muscle spasms

You have now completed the e-course about the advanced ultrasound guided peripheral nerve blocks

You have fulfilled the following learning objectives:

– Understanding the anatomy and sonoanatomy of the advanced nerve blocks

– Knowing how to perform each of the advanced nerve blocks

– Knowing about the pitfalls

Now you are ready to join the hands-on training

The sural nerve can be blocked as part of the ankle block with ultrasound guidance posterior to the lateral malleolus adjacent to the short saphenous vein

For an ankle block, the tibial nerve can be blocked with ultrasound guidance posterior to the medial malleolus, where the target nerve descends together with the posterior tibial artery and vein

The saphenous nerve is usually not visible sonographically at the level of the ankle

It can be blocked by infiltrating the subcutaneous tissue around the long saphenous vein anterior to the medial malleolus

Fredrickson MJ: Ultrasound-guided ankle block. Anaesthesia and Intensive Care 37(1): 143-44 (2009)

Lopez AM, Sala-Blanch X, Magaldi M, Poggio D, Asuncion J, Franco CD: Ultrasound-guided ankle block for forefoot surgery: The contribution of the saphenous nerve. Reg Anesth Pain Med 37(5): 554-57 (2012)

Coe A, Ram S: Ultrasound-guided ankle block for forefoot surgery: Is sural nerve block necessary? Reg Anesth Pain Med 38(3): 251 (2013)

All five nerves innervating the ankle are blocked in the ankle block. Place the patient supine.

Use a high-frequency linear probe and scan all five nerves in short-axis view:
– The deep peroneal nerve is blocked anterior to the ankle joint where it is adjacent to the dorsal pedis artery
– The superficial peroneal nerve is blocked approx. 10 cm proximal to the lateral malleolus where it emerges between the lateral and anterior compartments
– The tibial nerve is blocked posterior to the medial malleolus where it is adjacent to the posterior tibial artery
-The sural nerve is blocked posterior to the lateral malleolus where it is adjacent to the short saphenous vein
-The saphenous nerve is blocked anterior to the medial malleolus by infiltrating the subcutaneous tissue around the long saphenous vein

The target nerve and proxy arteries are visualized (see next pages). The needle is inserted with in-plane technique. Approx. 3-4 mL are injected perineurally around each target nerve

In front of the ankle joint the deep peroneal nerve runs adjacent to the dorsal pedis artery and vein

The deep peroneal nerve can be blocked with ultrasound guidance 5-10 cm proximal to the ankel, where the target runs adjacent to the anterior tibial artery sandwiched between the muscles of the anterior compartment and the interosseous membrane