Lesson Progress
0% Complete
Transducer position
- Select the target transverse process for the block.
- Place the transducer in a paramedian sagittal orientation, approximately 2 cm away from the midline (spinous processes).
Essential fact: |
---|
At higher thoracic levels, e.g., above T5; trapezius, rhomboid major and erector spinal muscles can be identified as three layers superficial to the transverse processes. In the lower and mid-thoracic levels, only trapezius and erector spinae muscles can be seen. |

Scanning
- Visualize the transverse process.
Common problems and solutions: |
If the transducer is placed too medial, the thoracic laminae will be visualized as flat hyperechoic lines (A). To fix: Slowly slide the transducer laterally (B). |
When the transducer is placed too lateral, ribs will be visualized as rounded acoustic shadows with an intermediate hyperechoic pleural line (C). To fix: Slowly slide the transducer medially (B). |

Tips |
At higher thoracic levels, e.g., above T5; trapezius, rhomboid major, and erector spinae muscles can be identified as three layers superficial to the transverse processes. |
In the lower and mid-thoracic levels, only trapezius and erector spinae muscles can be seen. |
Typically the rib-transverse process complex can be identified as a flat squared hyperechoic line with an acoustic shadow behind. |
Also, note that the pleura should not be visualized at the level where the block is performed. |
Needle insertion
- Insert the needle in-plane from a cranial to caudad direction until the needle tip contacts the transverse process.
Inject 1-3 mL of local anesthetic to confirm proper injection plane by visualization of a spread deep to the erector spinae muscles and superficial to the transverse process.
Complete the block with 20-30 mL of local anesthetic.
Let’s review the block:

