Localization of epidural space: A review of available technologies

Hesham Elsharkawy, Abraham Sonny, Ki Jinn Chin, Hesham Elsharkawy, Abraham Sonny, Ki Jinn Chin

Abstract

Although epidural analgesia is widely used for pain relief, it is associated with a significant failure rate. Loss of resistance technique, tactile feedback from the needle, and surface landmarks are traditionally used to guide the epidural needle tip into the epidural space (EDS). The aim of this narrative review is to critically appraise new and emerging technologies for identification of EDS and their potential role in the future. The PubMed, Cochrane Central Register of Controlled Clinical Studies, and Web of Science databases were searched using predecided search strategies, yielding 1048 results. After careful review of abstracts and full texts, 42 articles were selected to be included. Newer techniques for localization of EDS can be broadly classified into techniques that (1) guide the needle to the EDS, (2) identify needle entry into the EDS, and (3) confirm catheter location in EDS. An ideal method should be easy to learn and perform, easily reproducible with high sensitivity and specificity, identifies inadvertent intrathecal and intravascular catheter placements with ease, feasible in perioperative setting and have a cost-benefit advantage. Though none of them in their current stages of development qualify as an ideal method, many show tremendous potential. Some techniques are useful in patients with difficult spinal anatomy and infants, and thus are complementary to traditional methods. In addition to improving the existing technology, future research should aim at proving the superiority of these techniques over traditional methods, specifically regarding successful EDS localization, better safety profile, and a favorable cost-benefit ratio.

Keywords: Epidural localization; epidural space; loss of resistance; new technologies.

Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
(a) Generation of image using SonixGPS, (b) Real-time image acquisition using SonixGPS, (c) Preprocedure scanning with GPS needle(Source: www.analogicultrasound.com)
Figure 2
Figure 2
Ultrasound reconstruction of the spine with the camera on probe (reprinted with permission, source: Rafii-Tari H, Abolmaesumi P, Rohling R. Panorama Ultrasound for Guiding Epidural Anesthesia: A Feasibility Study. In: Taylor RH, Yang GZ, editors. Information Processing in Computer Assisted Interventions LNCS 6689, Berlin, Heidelberg: Springer science and business media; 2011. p. 179-89.
Figure 3
Figure 3
Ultrasound transducer and a standard 18-gauge Tuohy epidural needle
Figure 4
Figure 4
Intelligent recognition system (reprinted with permission, source)[76]
Figure 5
Figure 5
Typical epidural pressure waveform transduced through an epidural catheter shown along with other standard monitors (reprinted with permission, source)[94]

References

    1. Sicard JA, Forestier J. Radiographic method for exploration of the extradural space using lipiodol. Rev Neurol. 1921;28:1264–6.
    1. Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: Causes and management. Br J Anaesth. 2012;109:144–54.
    1. Ready LB. Acute pain: Lessons learned from 25,000 patients. Reg Anesth Pain Med. 1999;24:499–505.
    1. Kinsella SM. A prospective audit of regional anaesthesia failure in 5080 Caesarean sections. Anaesthesia. 2008;63:822–32.
    1. Collier CB. Why obstetric epidurals fail: A study of epidurograms. Int J Obstet Anesth. 1996;5:19–31.
    1. Sharrock NE. Recordings of, and an anatomical explanation for, false positive loss of resistance during lumbar extradural analgesia. Br J Anaesth. 1979;51:253–8.
    1. Hamilton CL, Riley ET, Cohen SE. Changes in the position of epidural catheters associated with patient movement. Anesthesiology. 1997;86:778–84.
    1. Motamed C, Farhat F, Rémérand F, Stéphanazzi J, Laplanche A, Jayr C. An analysis of postoperative epidural analgesia failure by computed tomography epidurography. Anesth Analg. 2006;103:1026–32.
    1. Agarwal D, Mohta M, Tyagi A, Sethi AK. Subdural block and the anaesthetist. Anaesth Intensive Care. 2010;38:20–6.
    1. Mhyre JM, Greenfield ML, Tsen LC, Polley LS. A systematic review of randomized controlled trials that evaluate strategies to avoid epidural vein cannulation during obstetric epidural catheter placement. Anesth Analg. 2009;108:1232–42.
    1. Gulur P, Tsui B, Pathak R, Koury KM, Lee H. Retrospective analysis of the incidence of epidural haematoma in patients with epidural catheters and abnormal coagulation parameters. Br J Anaesth. 2015;114:808–11.
    1. Angle P, Tang SL, Thompson D, Szalai JP. Expectant management of postdural puncture headache increases hospital length of stay and emergency room visits. Can J Anaesth. 2005;52:397–402.
    1. Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult thoracic and lumbar spine for central neuraxial blockade. Anesthesiology. 2011;114:1459–85.
    1. Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound imaging for identification of lumbar intervertebral level. Anaesthesia. 2002;57:277–80.
    1. Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for presumed difficult epidural puncture. Acta Anaesthesiol Scand. 2001;45:766–71.
    1. Arzola C, Davies S, Rofaeel A, Carvalho JC. Ultrasound using the transverse approach to the lumbar spine provides reliable landmarks for labor epidurals. Anesth Analg. 2007;104:1188–92.
    1. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Ultrasound imaging facilitates localization of the epidural space during combined spinal and epidural anesthesia. Reg Anesth Pain Med. 2001;26:64–7.
    1. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in obstetric epidural anesthesia. J Clin Anesth. 2002;14:169–75.
    1. McLeod A, Roche A, Fennelly M. Case series: Ultrasonography may assist epidural insertion in scoliosis patients. Can J Anaesth. 2005;52:717–20.
    1. Chin KJ, Macfarlane AJ, Chan V, Brull R. The use of ultrasound to facilitate spinal anesthesia in a patient with previous lumbar laminectomy and fusion: A case report. J Clin Ultrasound. 2009;37:482–5.
    1. Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of combined spinal-epidural anaesthesia. Eur J Anaesthesiol. 2004;21:25–31.
    1. Tran D, Kamani AA, Al-Attas E, Lessoway VA, Massey S, Rohling RN. Single-operator real-time ultrasound-guidance to aim and insert a lumbar epidural needle. Can J Anaesth. 2010;57:313–21.
    1. Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time ultrasound-guided paramedian epidural access: Evaluation of a novel in-plane technique. Br J Anaesth. 2009;102:845–54.
    1. Yaniv Z, Wilson E, Lindisch D, Cleary K. Electromagnetic tracking in the clinical environment. Med Phys. 2009;36:876–92.
    1. Banovac F, Tang J, Xu S, Lindisch D, Chung HY, Levy EB, et al. Precision targeting of liver lesions using a novel electromagnetic navigation device in physiologic phantom and swine. Med Phys. 2005;32:2698–705.
    1. Levy EB, Tang J, Lindisch D, Glossop N, Banovac F, Cleary K. Implementation of an electromagnetic tracking system for accurate intrahepatic puncture needle guidance: Accuracy results in an in vitro model. Acad Radiol. 2007;14:344–54.
    1. Eberhardt R, Anantham D, Herth F, Feller-Kopman D, Ernst A. Electromagnetic navigation diagnostic bronchoscopy in peripheral lung lesions. Chest. 2007;131:1800–5.
    1. Condino S, Ferrari V, Freschi C, Alberti A, Berchiolli R, Mosca F, et al. Electromagnetic navigation platform for endovascular surgery: How to develop sensorized catheters and guidewires. Int J Med Robot. 2012;8:300–10.
    1. Brinkmann S, Tang R, Sawka A, Vaghadia H. Single-operator real-time ultrasound-guided spinal injection using SonixGPS™: A case series. Can J Anaesth. 2013;60:896–901.
    1. Shi J, Schwaiger J, Lueth TC. Nerve block using a navigation system and ultrasound imaging for regional anesthesia. Conf Proc IEEE Eng Med Biol Soc. 2011;2011:1153–6.
    1. Wong SW, Niazi AU, Chin KJ, Chan VW. Real-time ultrasound-guided spinal anesthesia using the SonixGPS® needle tracking system: A case report. Can J Anaesth. 2013;60:50–3.
    1. Clendenen SR, Robards CB, Clendenen NJ, Freidenstein JE, Greengrass RA. Real-time 3-dimensional ultrasound-assisted infraclavicular brachial plexus catheter placement: Implications of a new technology. Anesthesiol Res Pract 2010. 2010:pii: 208025.
    1. Choquet O, Capdevila X. Case report: Three-dimensional high-resolution ultrasound-guided nerve blocks: A new panoramic vision of local anesthetic spread and perineural catheter tip location. Anesth Analg. 2013;116:1176–81.
    1. Belavy D, Ruitenberg MJ, Brijball RB. Feasibility study of real-time three-/four-dimensional ultrasound for epidural catheter insertion. Br J Anaesth. 2011;107:438–45.
    1. Rafii-Tari H, Abolmaesumi P, Rohling R. Panorama Ultrasound for Guiding Epidural Anesthesia: A Feasibility Study. In: Taylor RH, Yang GZ, editors. Information Processing in Computer Assisted Interventions LNCS 6689. Berlin, Heidelberg: Springer science and business media; 2011. pp. 179–89.
    1. Purnama KE, Wilkinson MH, Veldhuizen AG, van Ooijen PM, Lubbers J, Burgerhof JG, et al. A framework for human spine imaging using a freehand 3D ultrasound system. Technol Health Care. 2010;18:1–17.
    1. Lang A, Mousavi P, Gill S, Fichtinger G, Abolmaesumi P. Multi-modal registration of speckle-tracked freehand 3D ultrasound to CT in the lumbar spine. Med Image Anal. 2012;16:675–86.
    1. Chiang HK, Zhou Q, Mandell MS, Tsou MY, Lin SP, Shung KK, et al. Eyes in the needle: Novel epidural needle with embedded high-frequency ultrasound transducer – epidural access in porcine model. Anesthesiology. 2011;114:1320–4.
    1. Chen GS, Chang YC, Chang Y, Cheng JS. A prototype axial ultrasound needle guide to reduce epidural bone contact. Anaesthesia. 2014;69:746–51.
    1. Bigeleisen PE, Chien J. Identification of nerves on ultrasound scans using artificial intelligence and machine vision. In: Bigeleisen PE, editor. Ultrasound Guided Regional Anesthesia and Pain Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. pp. 263–71.
    1. Ashab HA, Lessoway VA, Khallaghi S, Cheng A, Rohling R, Abolmaesumi P. AREA: An augmented reality system for epidural anaesthesia. Conf Proc IEEE Eng Med Biol Soc. 2012;2012:2659–63.
    1. Kerby B, Rohling R, Nair V, Abolmaesumi P. Automatic identification of lumbar level with ultrasound. Conf Proc IEEE Eng Med Biol Soc. 2008;2008:2980–3.
    1. Yu S, Tan KK, Sng BL, Li S, Sia AT. Automatic identification of needle insertion site in epidural anesthesia with a cascading classifier. Ultrasound Med Biol. 2014;40:1980–90.
    1. Tran D, Rohling RN. Automatic detection of lumbar anatomy in ultrasound images of human subjects. IEEE Trans Biomed Eng. 2010;57:2248–56.
    1. Palmeri ML, Dahl JJ, MacLeod DB, Grant SA, Nightingale KR. On the feasibility of imaging peripheral nerves using acoustic radiation force impulse imaging. Ultrason Imaging. 2009;31:172–82.
    1. Rotemberg V, Palmeri M, Rosenzweig S, Grant S, Macleod D, Nightingale K. Acoustic Radiation Force Impulse (ARFI) imaging-based needle visualization. Ultrason Imaging. 2011;33:1–16.
    1. Nagaro T, Yorozuya T, Kamei M, Kii N, Arai T, Abe S. Fluoroscopically guided epidural block in the thoracic and lumbar regions. Reg Anesth Pain Med. 2006;31:409–16.
    1. Kim WJ, Kim TH, Shin HY, Kang H, Baek CW, Jung YH, et al. Fluoroscope guided epidural needle insertioin in midthoracic region: Clinical evaluation of Nagaro's method. Korean J Anesthesiol. 2012;62:441–7.
    1. Washburn K, Yeager M, Barr P, Bonham AK, Loftus R, Parra M. Fluoroscopic Guidance Decreases the Mechanical Failure Rate of Thoracic Epidural Catheters Used for Postoperative Pain Control; Abstract Presented at 38th Annual Regional Anesthesiology and Acute Pain Medicine Meeting; 2013.
    1. Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, et al. Epidural anaesthesia and analgesia and outcome of major surgery: A randomised trial. Lancet. 2002;359:1276–82.
    1. Eappen S, Blinn A, Segal S. Incidence of epidural catheter replacement in parturients: A retrospective chart review. Int J Obstet Anesth. 1998;7:220–5.
    1. Crawford JS. The second thousand epidural blocks in an obstetric hospital practice. Br J Anaesth. 1972;44:1277–87.
    1. Paech MJ, Godkin R, Webster S. Complications of obstetric epidural analgesia and anaesthesia: A prospective analysis of 10,995 cases. Int J Obstet Anesth. 1998;7:5–11.
    1. Wilson MJ. Epidural endeavour and the pressure principle. Anaesthesia. 2007;62:319–22.
    1. Lin BC, Chen KB, Chang CS, Wu KC, Liu YC, Chen CC, et al. A ‘membrane in syringe’ technique that allows identification of the epidural space with saline while avoids injection of air into the epidural space. Acta Anaesthesiol Sin. 2002;40:55–60.
    1. Macintosh RR. New inventions. Anaesthesia. 1950;5:97–9.
    1. Fyneface-Ogan S, Mato CN. A clinical experience with epidural balloon in the localisation of the epidural space in labouring parturients. Nig Q J Hosp Med. 2008;18:166–9.
    1. Sawada A, Kii N, Yoshikawa Y, Yamakage M. Epidrum(®): A new device to identify the epidural space with an epidural Tuohy needle. J Anesth. 2012;26:292–5.
    1. Kim SW, Kim YM, Kim SH, Chung MH, Choi YR, Choi EM. Comparison of loss of resistance technique between Epidrum® and conventional method for identifying the epidural space. Korean J Anesthesiol. 2012;62:322–6.
    1. Habib AS, George RB, Allen TK, Olufolabi AJ. A pilot study to compare the Episure Autodetect syringe with the glass syringe for identification of the epidural space in parturients. Anesth Analg. 2008;106:541–3.
    1. Carabuena JM, Mitani AM, Liu X, Kodali BS, Tsen LC. The learning curve associated with the epidural technique using the Episure™ AutoDetect™ versus conventional glass syringe: An open-label, randomized, controlled, crossover trial of experienced anesthesiologists in obstetric patients. Anesth Analg. 2013;116:145–54.
    1. Lechner TJ, van Wijk MG, Maas AJ. Clinical results with a new acoustic device to identify the epidural space. Anaesthesia. 2002;57:768–72.
    1. Lechner TJ, van Wijk MG, Maas AJ, van Dorsten FR, Drost RA, Langenberg CJ, et al. Clinical results with the acoustic puncture assist device, a new acoustic device to identify the epidural space. Anesth Analg. 2003;96:1183–7.
    1. Lechner TJ, van Wijk MG, Maas AJ, van Dorsten FR. Thoracic epidural puncture guided by an acoustic signal: Clinical results. Eur J Anaesthesiol. 2004;21:694–9.
    1. Ghelber O, Gebhard RE, Vora S, Hagberg CA, Szmuk P. Identification of the epidural space using pressure measurement with the compuflo injection pump – A pilot study. Reg Anesth Pain Med. 2008;33:346–52.
    1. Samhan YM, El-Sabae HH, Khafagy HF, Maher MA. A pilot study to compare epidural identification and catheterization using a saline-filled syringe versus a continuous hydrostatic pressure system. J Anesth. 2013;27:607–10.
    1. Schier R, Guerra D, Aguilar J, Pratt GF, Hernandez M, Boddu K, et al. Epidural space identification: A meta-analysis of complications after air versus liquid as the medium for loss of resistance. Anesth Analg. 2009;109:2012–21.
    1. Segal S, Arendt KW. A retrospective effectiveness study of loss of resistance to air or saline for identification of the epidural space. Anesth Analg. 2010;110:558–63.
    1. Antibas PL, do Nascimento Junior P, Braz LG, Vitor Pereira Doles J, Módolo NS, El Dib R. Air versus saline in the loss of resistance technique for identification of the epidural space. Cochrane Database Syst Rev. 2014;7:CD008938.
    1. Kalvøy H, Frich L, Grimnes S, Martinsen OG, Hol PK, Stubhaug A. Impedance-based tissue discrimination for needle guidance. Physiol Meas. 2009;30:129–40.
    1. Kalvoy H, Martinsen OG, Grimnes S. Determination of tissue type surrounding a needle tip by electrical bioimpedance. Conf Proc IEEE Eng Med Biol Soc. 2008;2008:2285–6.
    1. Ting CK, Chang Y. Technique of fiber optics used to localize epidural space in piglets. Opt Express. 2010;18:11138–47.
    1. Ting CK, Tsou MY, Chen PT, Chang KY, Mandell MS, Chan KH, et al. A new technique to assist epidural needle placement: Fiberoptic-guided insertion using two wavelengths. Anesthesiology. 2010;112:1128–35.
    1. Desjardins AE, Hendriks BH, van der Voort M, Nachabé R, Bierhoff W, Braun G, et al. Epidural needle with embedded optical fibers for spectroscopic differentiation of tissue: ex vivo feasibility study. Biomed Opt Express. 2011;2:1452–61.
    1. Rathmell JP, Desjardins AE, van der Voort M, Hendriks BH, Nachabe R, Roggeveen S, et al. Identification of the epidural space with optical spectroscopy: An in vivo swine study. Anesthesiology. 2010;113:1406–18.
    1. Lin SP, Mandell MS, Chang Y, Chen PT, Tsou MY, Chan KH, et al. Discriminant analysis for anaesthetic decision-making: An intelligent recognition system for epidural needle insertion. Br J Anaesth. 2012;108:302–7.
    1. Zysk AM, Nguyen FT, Oldenburg AL, Marks DL, Boppart SA. Optical coherence tomography: A review of clinical development from bench to bedside. J Biomed Opt. 2007;12:051403.
    1. Iftimia N, Bouma B, de Boer J, Park B, Cense B, Tearney G. Adaptive ranging for optical coherence tomography. Opt Express. 2004;12:4025–34.
    1. Raphael DT, Yang C, Tresser N, Wu J, Zhang Y, Rever L. Images of spinal nerves and adjacent structures with optical coherence tomography: Preliminary animal studies. J Pain. 2007;8:767–73.
    1. Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: A retrospective analysis of 19,259 deliveries. Int J Obstet Anesth. 2004;13:227–33.
    1. Tsui BC, Gupta S, Finucane B. Confirmation of epidural catheter placement using nerve stimulation. Can J Anaesth. 1998;45:640–4.
    1. Goobie SM, Montgomery CJ, Basu R, McFadzean J, O'Connor GJ, Poskitt K, et al. Confirmation of direct epidural catheter placement using nerve stimulation in pediatric anesthesia. Anesth Analg. 2003;97:984–8.
    1. Tsui BC, Gupta S, Finucane B. Determination of epidural catheter placement using nerve stimulation in obstetric patients. Reg Anesth Pain Med. 1999;24:17–23.
    1. Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation of caudal needle placement using nerve stimulation. Anesthesiology. 1999;91:374–8.
    1. de Medicis E, Tetrault JP, Martin R, Robichaud R, Laroche L. A prospective comparative study of two indirect methods for confirming the localization of an epidural catheter for postoperative analgesia. Anesth Analg. 2005;101:1830–3.
    1. Tsui BC, Gupta S, Finucane B. Detection of subarachnoid and intravascular epidural catheter placement. Can J Anaesth. 1999;46:675–8.
    1. Tsui BC, Gupta S, Emery D, Finucane B. Detection of subdural placement of epidural catheter using nerve stimulation. Can J Anaesth. 2000;47:471–3.
    1. Tsui BC, Wagner A, Cave D, Kearney R. Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: A review of 289 patients. Anesthesiology. 2004;100:683–9.
    1. Tsui BC, Bury J, Bouliane M, Ganapathy S. Cervical epidural analgesia via a thoracic approach using nerve-stimulation guidance in adult patients undergoing total shoulder replacement surgery. Acta Anaesthesiol Scand. 2007;51:255–60.
    1. Förster JG, Niemi TT, Salmenperä MT, Ikonen S, Rosenberg PH. An evaluation of the epidural catheter position by epidural nerve stimulation in conjunction with continuous epidural analgesia in adult surgical patients. Anesth Analg. 2009;108:351–8.
    1. Tsui BC, Seal R, Koller J. Thoracic epidural catheter placement via the caudal approach in infants by using electrocardiographic guidance. Anesth Analg. 2002;95:326–30.
    1. Uchino T, Hagiwara S, Iwasaka H, Kudo K, Takatani J, Mizutani A, et al. Use of imaging agent to determine postoperative indwelling epidural catheter position. Korean J Pain. 2010;23:247–53.
    1. Ghia J, Arora Sk, Castillo M, Mukherji Sk. Confirmation of location of epidural catheters by epidural pressure waveform and computed tomography cathetergram. Reg Anesth Pain Med. 2001;26:337–41.
    1. Lennox PH, Umedaly HS, Grant RP, White SA, Fitzmaurice BG, Evans KG. A pulsatile pressure waveform is a sensitive marker for confirming the location of the thoracic epidural space. J Cardiothorac Vasc Anesth. 2006;20:659–63.
    1. Chiu SC, Bristow SJ, Gofeld M. Near-infrared tracking system for epidural catheter placement: A feasibility study. Reg Anesth Pain Med. 2012;37:354–6.
    1. Willschke H, Marhofer P, Bösenberg A, Johnston S, Wanzel O, Sitzwohl C, et al. Epidural catheter placement in children: Comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique. Br J Anaesth. 2006;97:200–7.
    1. Ueda K, Shields BE, Brennan TJ. Transesophageal echocardiography: A novel technique for guidance and placement of an epidural catheter in infants. Anesthesiology. 2013;118:219–22.

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