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Intraneural or Extraneural: Diagnostic Accuracy of Ultrasound Assessment for Localizing Low-Volume Injection
  1. Annelot C. Krediet, MD*,
  2. Nizar Moayeri, MD, PhD,
  3. Ronald L. A. W. Bleys, MD, PhD and
  4. Gerbrand J. Groen, MD, PhD§
  1. *Department of Anesthesiology, University Medical Center Utrecht, Utrecht
  2. Department of Neurosurgery, University Medical Center Utrecht, Utrecht
  3. Department of Anatomy, University Medical Center Utrecht, Utrecht
  4. §Pain Center, Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
  1. Address correspondence to: Gerbrand J. Groen, MD, PhD, Pain Center, Department of Anesthesiology, University Medical Center Groningen, Mailstop EB 31, Postbus 30001, 9700RB, Groningen, the Netherlands (e-mail: g.j.groen{at}


Background and Objectives When one is performing ultrasound-guided peripheral nerve blocks, it is common to inject a small amount of fluid to confirm correct placement of the needle tip. If an intraneural needle tip position is detected, the needle can then be repositioned to prevent injection of a large amount of local anesthetic into the nerve. However, it is unknown if anesthesiologists can accurately discriminate intraneural and extraneural injection of small volumes. Therefore, this study was conducted to determine the diagnostic accuracy of ultrasound assessment using a criterion standard and to compare experts and novices in ultrasound-guided regional anesthesia.

Methods A total of 32 ultrasound-guided infragluteal sciatic nerve blocks were performed on 21 cadaver legs. The injections were targeted to be intraneural (n = 18) or extraneural (n = 14), and 0.5 mL of methylene blue 1% was injected. Cryosections of the nerve and surrounding tissue were assessed by a blinded investigator as “extraneural” or “intraneural.” Ultrasound video clips of the injections were reviewed by 10 blinded observers (5 experts, 5 novices) independently who scored each injection as either “intraneural,” “extraneural,” or “undetermined.”

Results The mean sensitivity of experts and novices was measured to be 0.84 (0.80–0.88) and 0.65 (0.60–0.71), respectively (P = 0.006), whereas mean specificity was 0.97 (0.94–0.98) and 0.98 (0.96–0.99) (P = 0.53).

Conclusions Discrimination of intraneural or extraneural needle tip position based on an injection of 0.5mL is possible, but even experts missed 1 of 6 intraneural injections. In novices, the sensitivity of assessment was significantly lower, highlighting the need for focused education.

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  • This work should be attributed to the Department of Anesthesiology, University Medical Center Utrecht, and the Pain Center, Department of Anesthesiology, University Medical Center Groningen.

    This work was supported by the Netherlands Organization for Scientific Research (Nederlandse Organisatie voor Wetenschappelijke onderzoek [NWO], the Hague, the Netherlands), grant 017.005.12, and by departmental funds. Esaote BV, Maastricht, the Netherlands, provided a MyLab ultrasound platform for data collection.

    A preliminary account of the results was given at the 2013 Annual Meeting of the American Society of Anesthesiologists on October 15, 2013 (Abstract A4301). The results were also presented at the Annual Science Day of the Dutch Society of Anesthesiology on September 20, 2013.

    The authors declare no conflict of interest.

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