Real Time Ultrasound Guided Spinal Anesthesia in Elderly Patients

Real-Time Ultrasound-Guided Neuraxial Puncture in Elderly Patients: A Randomized Controlled Trial Comparing Between Paramedian Transverse and Parasagittal Oblique

In this prospective randomized observational study, investigators aim to compare the efficacy and procedural outcomes of real-time ultrasound guided parasagittal oblique (RTU-PO) and real-time ultrasound guided paramedian transverse (RTU-PT) approaches in elderly patients undergoing elective surgery under spinal anesthesia.

Study Overview

• Status: Completed
• Conditions: Realtime Ultrasound
• Intervention / Treatment: Device: Parasagittal oblique technique (Ultrasound); Device: Paramedian tranverse technique (Ultrasound)

Detailed Description

Background: Since its first introduction in 1898 by Bier, Spinal anesthesia has been performed using the anatomical landmark guided approach. Despite being useful, the landmark technique doesn't take into account anatomical variations, spine abnormalities or age-related changes in the lumbar spine as seen in elderly, obese or pregnant patients and thus can lead to incorrect identification of a certain interspace. Neuraxial ultrasonography has been introduced as a technique to allow the operator to preview spinal anatomy, identify the midline, determine the interspace and guide the needle insertion site and trajectory. It was found to be a feasible and promising technique that can result in successful cerebrospinal fluid acquisition where other methods have failed. While pre-procedural Ultrasound has been used by many studies to identify the right epidural or subarachnoid spaces and have an idea about the angle of needle insertion, it remains a blind technique. Real-time ultrasound guided technique was found to improve the limitations of the pre-puncture ultrasound guided techniques by direct, real-time visualization of the needle trajectory. In spinal anesthesia, a midline approach has been the most common technique used for needle insertion. However, this approach is often technically difficult in the geriatric population because of poorly palpable surface landmarks, lumbar scoliosis, marked thoracic kyphosis, degenerative changes and inability to flex the lumbar spine in the sitting position. While the parasagittal oblique approach tends to provide a better sonographic window into the vertebral canal than the midline approach, it is still not evident whether it will lead to an easier paramedian needle insertion. In the literature, there are no studies directly comparing the paramedian transverse and parasagittal oblique approaches in the performance of real time ultrasound guided spinal anesthesia.

Specific Aim: The aim of this study is to find out the optimal approach to perform spinal anesthesia under real time ultrasound guidance in the elderly population. Thus, investigators will compare real time ultrasound-guided paramedian approach using parasagittal oblique view with real time ultrasound guided paramedian approach using the paramedian transverse median view. The aim is thus to adopt a real time ultrasound guided technique that will result in an easier access to the subarachnoid space in patients with difficult anatomy and results in better patient satisfaction and less discomfort.

Methodology and analysis: In a prospective randomized observational study, 84 patients scheduled for surgery amenable to spinal anesthesia, aged more than 65 years, with American Society of Anesthesiologists physical status 1 to 3 will be assigned to receive spinal anesthesia to one of two treatment groups: real time ultrasound-guided parasagittal oblique technique (group RTU-PO) or Real time ultrasound-guided paramedian transverse technique (group RTU-T). Ultrasonography of the lumbar spine and Real time spinal blockade will be performed by the experienced anesthesiologist. Patients in both groups will have an ultrasound scan of the lumbar spine to measure the depth of the dura, to specify and guide the needle insertion site and trajectory. The primary outcome is the rate of successful dural puncture on the first needle insertion attempt under real time ultrasound guidance. Normally distributed data will be summarized as mean ± SD and nonnormally distributed data will be summarized as median [interquartile range].

Significance: Investigators believe that real time US-guided technique is a superior modality of performance of spinal anesthesia. However, investigators would like to evaluate which approach will be better for the acquisition of cerebrospinal fluid in elderly patients. Investigators think that this study would have an impact on current practice in term of introducing real time ultrasound guided technique into everyday practice and determining the best approach to perform a successful neuraxial block in a patient with a suspected difficult back.

• Study Type: Interventional
• Enrollment (Actual): 77
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Lebanon
  • Beirut, Lebanon
    • American University of Beirut Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 65 years and older (Older Adult)
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Patients aging above 65 years
• American Society of Anesthesiologists physical status 1 to 3
• Can give informed consent
• Scheduled for elective surgery

Exclusion Criteria:

• Inability to sit or to give consent
• Patients with severe cardiopulmonary diseases
• Previous back surgery or spinal congenital abnormalities
• Bleeding diathesis
• Anticoagulants or antiplatelets except aspirin
• Local anesthesia allergy

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Real time ultrasound-guided Parasagittal oblique technique (RTU-PO); In the RTU-PO group, the probe will be placed in a parasagittal plane to identify the articular processes then the sacrum will be identified. The probe will be moved cephalad in the parasagittal axis until the identification of the target lumbar interspaces L2-L3, L3-L4 or L4-L5. Once the appropriate lumbar interspace is identified, the probe will be tilted 45 degree towards the midline into a parasagittal oblique view. This provides a view of the paramedian interlaminar space. The ligamentum flavum and the dura form the posterior complex that can be often visualized as a single hyperechoic structure beneath which lies the hypoechoic intrathecal space. The needle will be inserted in plane from the caudal end of the ultrasound transducer with its tip directed towards the interlaminar space under real-time in-plane US guidance.	Device: Parasagittal oblique technique (Ultrasound); the probe will be placed in a parasagittal plane to identify the articular processes then the sacrum will be identified. The probe will be moved cephalad in the parasagittal axis until the identification of the target lumbar interspaces L2-L3, L3-L4 or L4-L5. Once the appropriate lumbar interspace is identified, the probe will be tilted 45 degree towards the midline into a parasagittal oblique view. The needle will be inserted in plane from the caudal end of the ultrasound transducer with its tip directed towards the interlaminar space under real-time in-plane US guidance.
Experimental: Real time ultrasound-guided paramedian tranverse technique (RTU-T); In the RTU-T group, similar to the RTU-PO group, the transducer will be applied in the parasagittal plane, and after identification of the intervertebral level, the probe will be rotated 90 degrees into a transverse orientation and centered on the neuraxial midline in a way to align the beam with the interspinous and interlaminar space and thus to get a paramedian transverse interlaminar view. The needle will be inserted in plane from the lateral end of the ultrasound transducer with its tip directed towards the medial border of the articular process.	Device: Paramedian tranverse technique (Ultrasound); the transducer will be applied in the parasagittal plane, and after identification of the intervertebral level, the probe will be rotated 90 degrees into a transverse orientation and centered on the neuraxial midline in a way to align the beam with the interspinous and interlaminar space and thus to get a paramedian transverse interlaminar view. The needle will be inserted in plane from the lateral end of the ultrasound transducer with its tip directed towards the medial border of the articular process.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of successful Dural puncture on the first needle insertion attempt	Successful needle insertion on the first attempt (Yes/No)	At the begining of the procedure (during the needle insertion)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of success of spinal anesthesia	Success of spinal anesthesia (Yes/No)	During the procedure
Time to identify posterior complex on ultrasound	Time to identify posterior complex on ultrasound (measured in seconds)	During the procedure
Time to perform spinal anesthesia	Time to perform spinal anesthesia (measured in seconds)	During the procedure
Procedural time	Procedural time (measured in minutes)	During the procedure
Depth of the posterior complex	Depth of the posterior complex (measured in cm)	During the procedure
Number of redirections	Number of redirections	During the procedure
Number of needle passes	Number of needle passes	During the procedure
Number of separate skin punctures	Number of separate skin punctures	During the procedure
Number of spinal levels attempted	Number of spinal levels attempted	During the procedure
Rate of satisfaction	Patient satisfaction (scale from 1 to 3: very satisfied, satisfied, dissatisfied)	After the procedure
Rate of complications	Complications (Yes/No)	During the procedure
Rate of complications, if present	Complications if present (Vascular puncture, Paresthesia, Conversion to GA 30 minutes after block, and Others)	During the procedure

Collaborators and Investigators

• Sponsor: American University of Beirut Medical Center
• Investigators: Principal Investigator: Marwan Rizk, MD, American University of Beirut Medical Center

Study record dates

Study Major Dates

• Study Start (Actual): January 30, 2020
• Primary Completion (Actual): July 4, 2024
• Study Completion (Actual): July 4, 2024

Study Registration Dates

• First Submitted: December 28, 2019
• First Submitted That Met QC Criteria: December 28, 2019
• First Posted (Actual): January 2, 2020

Study Record Updates

• Last Update Posted (Actual): July 25, 2024
• Last Update Submitted That Met QC Criteria: July 23, 2024
• Last Verified: July 1, 2024

More Information

Terms related to this study

• Other Study ID Numbers: BIO-2018-0589

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No