. Local and regional anesthesia : with chapters on spinal, epidural, paravertebral, and parasacral analgesia, and on other applications of local and regional anesthesia to the surgery of the eye, ear, nose and throat, and to dental practice. s magnus. The typical course of an intercostal nerve is seen in Fig. 132, and inFig. 67 is seen the area in which the supraclavicular anterior andposterior thoracic nerves intermingle in their distribution with branchesfrom the intercostal. 284 LOCAL ANESTHESIA In the scapula region behind the thoracic wall is overhung by thisbone and its attached muscles,
. Local and regional anesthesia : with chapters on spinal, epidural, paravertebral, and parasacral analgesia, and on other applications of local and regional anesthesia to the surgery of the eye, ear, nose and throat, and to dental practice. s magnus. The typical course of an intercostal nerve is seen in Fig. 132, and inFig. 67 is seen the area in which the supraclavicular anterior andposterior thoracic nerves intermingle in their distribution with branchesfrom the intercostal. 284 LOCAL ANESTHESIA In the scapula region behind the thoracic wall is overhung by thisbone and its attached muscles, which will have to be dealt with inany procedure which involves the chest wall at this point; however,this is not often the site of surgical intervention. It will be seen from the above and a study of Fig. 67, which repre-sents diagramatically the intermingling of the areas of distributionof these nerves, that any methods of regional anesthesia, when ap-plied to the anterior chest wall above or the lateral chest wall behind,must deal with nerves which enter the field from a variety of direc-tions. To block the intercostal nerves over a wide area of distribution isbest done behind near the angle of the ribs, where they approach close. Fig. 68.—Shows line of anesthesia and points for entering long needle for blocking inter-costal nerves at angle of ribs. to the posterior wall and before the lateral branches are given off,though this can be done at any point of their course. A vertical line of cutaneous anesthesia is carried down the the angle of the ribs, as seen in Fig. 68; the scapula is carried wellforward and the finger locates the rib; a long fine needle is now passeddown to the interval between the ribs; this is best done obliquelyfrom below; with a finger pressed firmly on the rib, the needle is madeto pass upward and inward, injecting as it is advanced until it strikesthe bone; it is then pushed upward and inward for about 1 cm. furtherinto the intercostal sp
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