Anesthetizing part of the chest wall usually requires placement of local anesthetic around more than one intercostal nerve. The usual site to begin is in line with the inferior angle of the scapular over the posterolateral aspect of the chest; the inferior angle lies over the seventh rib and this can be palpated on either side of it. The neurovascular bundle runs along the subcostal groove and the proximity of the vessels again emphasises the need to withdraw the plunger of syringe before any injection. Palpate the rib and insert the needle onto its lower part, then ‘walk it’ down over the lower border (figure 42). The depth of the rib is established in this manoeuvre and once the lower border is passed, the needle is not advanced to any greater depth for the injection.

Anesthetizing the lumbar sympathetic chains is usually undertaken under image guidance. The surface marking is just below the tip of the twelfth rib, at the lateral border of the erector spinae muscle mass on each side. The needle is passed horizontally forwards at 45 degrees towards the vertebral column. It is then advanced to the anterior border of the vertebra, by ‘walking’ the needle along the vertebra until it is felt to disappear. Aspiration is again essential before injection of local anesthetic, as the lumbar vessels, and the aorta or inferior vena cava may be entered (figure 43).

Anesthetizing the lumbar sympathetic chains is usually undertaken under image guidance. The surface marking is just below the tip of the twelfth rib, at the lateral border of the erector spinae muscle mass on each side. The needle is passed horizontally forwards at 45 degrees towards the vertebral column. It is then advanced to the anterior border of the vertebra, by ‘walking’ the needle along the vertebra until it is felt to disappear. Aspiration is again essential before injection of local anesthetic, as the lumbar vessels, and the aorta or inferior vena cava may be entered (figure 43).