Real-time ultrasound-guided spinal anaesthesia: a prospective observational study of a new approach

P H Conroy, C Luyet, C J McCartney, P G McHardy, P H Conroy, C Luyet, C J McCartney, P G McHardy

Abstract

Identification of the subarachnoid space has traditionally been achieved by either a blind landmark-guided approach or using prepuncture ultrasound assistance. To assess the feasibility of performing spinal anaesthesia under real-time ultrasound guidance in routine clinical practice we conducted a single center prospective observational study among patients undergoing lower limb orthopaedic surgery. A spinal needle was inserted unassisted within the ultrasound transducer imaging plane using a paramedian approach (i.e., the operator held the transducer in one hand and the spinal needle in the other). The primary outcome measure was the success rate of CSF acquisition under real-time ultrasound guidance with CSF being located in 97 out of 100 consecutive patients within median three needle passes (IQR 1-6). CSF was not acquired in three patients. Subsequent attempts combining landmark palpation and pre-puncture ultrasound scanning resulted in successful spinal anaesthesia in two of these patients with the third patient requiring general anaesthesia. Median time from spinal needle insertion until intrathecal injection completion was 1.2 minutes (IQR 0.83-4.1) demonstrating the feasibility of this technique in routine clinical practice.

Figures

Figure 1
Figure 1
Typical positioning of the operator, ultrasound transducer and the patient during, real-time ultrasound-guided spinal anaesthesia.
Figure 2
Figure 2
Spine model showing the paramedian oblique transducer orientation (rotated by 45 degrees) used during real-time scanning with a typical ultrasound image.
Figure 3
Figure 3
Ultrasound image showing the paramedian spinal needle insertion path compared with a schematic overlay of the transducer orientation on a spinal model.

References

    1. Bier A. Versuche über cocainisirung des rückenmarkes. Deutsch Zeitschrift für Chirurgie. 1899;51(3):352–358.
    1. Broadbent CR, Maxwell WB, Ferrie R, Wilson DJ, Gawne-Cain M, Russell R. Ability of anaesthetists to identify a marked lumbar interspace. Anaesthesia. 2000;55(11):1122–1126.
    1. Wulf H. Epidural anaesthesia and spinal haematoma. Canadian Journal of Anaesthesia. 1996;43(12):1260–1271.
    1. Flaatten H, Felthaus J, Larsen R, Bernhardsen S, Klausen H. Postural post-dural puncture headache after spinal and epidural anaesthesia. A randomised, double-blind study. Acta Anaesthesiologica Scandinavica. 1998;42(7):759–764.
    1. Harrison DA, Langham BT. Spinal anaesthesia for urological surgery. A survey of failure rate, postdural puncture headache and patient satisfaction. Anaesthesia. 1992;47(10):902–903.
    1. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: Results of a prospective survey in France. Anesthesiology. 1997;87(3):479–486.
    1. Puolakka R, Haasio J, Pitkänen MT, Kallio M, Rosenberg PH. Technical aspects and postoperative sequelae of spinal and epidural anesthesia: a prospective study of 3,230 orthopedic patients. Regional Anesthesia and Pain Medicine. 2000;25(5):488–497.
    1. Horlocker TT, McGregor DG, Matsushige DK, Schroeder DR, Besse JA. A retrospective review of 4767 consecutive spinal anesthetics: central nervous system complications. Anesthesia and Analgesia. 1997;84(3):578–584.
    1. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav V. Ultrasound imaging facilitates spinal anesthesia in adults with difficult surface anatomic landmarks. Anesthesiology. 2011;115(1):94–101.
    1. Chin KJ, Chan VWS, Ramlogan R, Perlas A. Real-time ultrasound-guided spinal anesthesia in patients with a challenging spinal anatomy: two case reports. Acta Anaesthesiologica Scandinavica. 2010;54(2):252–255.
    1. Lee PJ, Tang R, Sawka A, Krebs C, Vaghadia H. Real-time ultrasound-guided spinal anesthesia using taylor’s approach. Anesthesia and Analgesia. 2011;112(5):1236–1238.
    1. Grau T, Leipold RUW, Horter J, Conradi R, Martin EO, Motsch J. Paramedian access to the epidural space: the optimum window for ultrasound imaging. Journal of Clinical Anesthesia. 2001;13(3):213–217.
    1. Atallah MM, Demian AD, Shorrab AA. Development of a difficulty score for spinal anaesthesia. British Journal of Anaesthesia. 2004;92(3):354–360.
    1. Sprung J, Bourke DL, Grass J, et al. Predicting the difficult neuraxial block: a prospective study. Anesthesia and Analgesia. 1999;89(2):384–389.
    1. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. British Medical Journal. 2000;321(7275):1493–1497.
    1. Weed J, Finkel K, Beach ML, Granger CB, Gallagher JD, Sites BD. Spinal anesthesia for orthopedic surgery: a detailed video assessment of quality. Regional Anesthesia and Pain Medicine. 2011;36:51–55.
    1. Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of combined spinal-epidural anaesthesia. European Journal of Anaesthesiology. 2004;21(1):25–31.
    1. De Oliveira Filho GR, Gomes HP, Da Fonseca MHZ, Hoffman JC, Pederneiras SG, Garcia JHS. Predictors of successful neuraxial block: a prospective study. European Journal of Anaesthesiology. 2002;19(6):447–451.
    1. Tessler MJ, Kardash K, Wahba RM, Kleiman SJ, Trihas ST, Rossignol M. The performance of spinal anesthesia is marginally more difficult in the elderly. Regional Anesthesia and Pain Medicine. 1999;24(2):126–130.
    1. Carney A, Hunt V. The use of neuraxial scanning can facilitate spinal anaesthesia for lower limb joint arthroplasty. Proceedings of the 15th Annual Scientific congress of the British Society of Orthopaedic Anaesthetists; Novemeber 2010; Nottingham, UK. pp. 407–408.
    1. Fettes PDW, Jansson JR, Wildsmith JAW. Failed spinal anaesthesia: mechanisms, management, and prevention. British Journal of Anaesthesia. 2009;102(6):739–748.
    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. Canadian Journal of Anesthesia. 2010;57(4):313–321.
    1. Karmakar MK, Li X, Ho AMH, Kwok WH, Chui PT. Real-time ultrasound-guided paramedian epidural access: evaluation of a novel in-plane technique. British Journal of Anaesthesia. 2009;102(6):845–854.
    1. Cook TM. Combined spinal-epidural techniques. Anaesthesia. 2000;55(1):42–64.
    1. Body Composition of Canadian Adults 2007 to 2009. Canadian Health Measures Survey, 2007 to 2009. National Health and Nutrition Examination Survey, 2007-2008.
    1. Weed JT, Taenzer AH, Finkel KJ, Sites BD. Evaluation of pre-procedure ultrasound examination as a screening tool for difficult spinal anaesthesia. Anaesthesia. 2011;66:925–930.
    1. Medd C, Chandrashekar R, Simon G. Needle-through-Quincke needle technique for establishing spinal anaesthesia in the obese patient. Anaesthesia. 2011;66(5):400–401.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa