OpenAnesthesia Regional Expert of the Month: July 2015


Adam Niesen, MD

Current Institution:

Mayo Clinic, Rochester, MN

Current Position:

Assistant Professor of Anesthesiology; North Division of Anesthesia Education Director

Regional Fellowship (where and when):

Mayo Clinic, 2008-2009

Who would you consider your greatest mentor?

It is difficult to choose just one. There have been a number of folks that have provided excellent guidance during my training and beyond. There are four in particular that come to mind: Sandy Kopp, Jim Hebl, Terre Horlocker, Hugh Smith, and Adam Jacob. I am very fortunate to call all of these wonderful people colleagues and friends.

Specific interest in regional anesthesia/acute pain:

Truncal blocks

Least favorite block and why?

Interscalene block. Initially I had great difficulty visualizing the anatomy as a resident. Even now, it is the most likely block to make me seasick due to the frequent movement of the probe.

Favorite journal Article in the last 2 years:

Desmet M. et al. I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study. British Journal of Anaesthesia 2013; 111(3):445-452.

Favorite journal article of all time:

Capdevila X, Bringuier S, Borgeat A. Infectious risk of continuous peripheral nerve blocks. Anesthesiology 2009; 110:182-8.

Favorite (featured) block:

Thoracic paravertebral block

Why is it your favorite block?

This block requires a detailed understanding of the associated anatomy, and can be assisted greatly with the use of ultrasound. Despite multiple potential approaches to imaging the paravertebral space, each one has distinct advantages and disadvantages. Overall, the target tends to be small, thus practice, with recognition of relevant anatomy, development of needle/probe skills, and use of surrogate markers for needle imaging are key to success.

3-5 articles about the block?

  1. Hara K, et al. Ultrasound guided thoracic paravertebral block in breast surgery. Anaesthesia 2009; 64:223-225.
  2. Karmakar MK, et al. Volumetric Three-Dimensional Ultrasound Imaging of the Anatomy Relevant for Thoracic Paravertebral Block. Anesthesia and Analgesia 2012; 115:1246-50.
  3. Naja ZM, et al. Guided paravertebral blocks with versus without clonidine for women undergoing breast surgery: a prospective double-blinded randomized study. Anesthesia and Analgesia 2013; 117(1):252-8.
  4. Paraskeuopoulos T et al. Thoracic paravertebral spread using two different ultrasound-guided intercostal injection techniques in human cadavers. Clinical Anatomy 2010; 23:840-7.

2-5 ultrasound images/videos of block:

Slide1 Slide2 Slide3 Slide4

Pearls, tips, and tricks for success:

  1. It is important to take into account the steep angulation of the spinous processes in the thoracic spine when performing a paravertebral block with any technique. The transverse process that is directly lateral from a particular spinous process originates from the vertebral body one level below that of the spinous process. For example, the transverse process seen directly lateral to the T4 spinous process would be the T5 transverse process, thus placing the needle inferior to the T5 transverse process would target the T5 spinal nerve.
  2. The transverse processes are deepest at the upper thoracic levels, becoming more superficial in the mid-thoracic region. This would seem to create an unfavorable angle for needle entry between transverse processes using a caudal to rostral needle approach; however, this has not been an issue in my experience. In addition, the ergonomics and hand mechanics of a caudal to rostral needle approach are significantly better than attempting a rostral to caudal technique.
  3. As the probe and needle insertion site are moved more laterally, the paravertebral space becomes narrower in the anterior to posterior dimension, with the pleura more closely approaching the transverse process or rib. This results in a smaller target area for the needle tip.

A few more things about you:


Travel, playing with my children, spending time with my wife, gardening, cooking.

Person you most look up to:

My parents. Hard working dairy farmers who made sure my sisters and I pursued our own interests in life.

Favorite iPad app:

Yelp. It helps me find a good place to stay and new places to eat.

Favorite thing about OpenAnesthesia:

Accessibility, easy to read information all in one place.