Spinal Sonography for Ultrasound-Guided Lumbar Neuraxial Anesthesia

Summary

The protocol described here provides the basics of spine sonoanatomy and a quick, straightforward method for performing ultrasound-guided neuraxial anesthesia. Additionally, two handheld devices that enhance portability are presented, one of which uses pattern recognition software to aid in epidural space localization.

Abstract

Neuraxial anesthesia is one of the few remaining forms of regional anesthesia that relies on palpation and tactile feedback techniques to facilitate catheterization into the epidural space. Over two decades ago, spine ultrasonography was demonstrated to provide reliable guidance for locating the epidural space. Compared to the palpation technique, preprocedural ultrasonography has been shown to result in fewer needle punctures and fewer traumatic procedures, particularly in patients with abnormal or distorted spine anatomy (e.g., scoliosis, obesity). Despite its utility, the ultrasound-guided neuraxial technique is still marginally used, even for patients with abnormal anatomy. Some experts attribute this to cost, a relatively high success rate without ultrasound, and a lack of technical expertise, which is often tied to formal education and regular practice. Several proponents of the ultrasound technique emphasize that proficiency requires practice on patients with normal spine anatomy, though this training may not be as challenging as once thought. This protocol was designed to help all providers learn the basics of lumbar spine anatomy and how to apply this knowledge clinically. Through a series of videos, we will provide step-by-step instructions for performing neuraxial ultrasonography and offer practical tips for troubleshooting in cases of difficult anatomy.

Introduction

Lumbar epidural analgesia provides the dual benefit of providing effective labor analgesia and the best way of avoiding the use of general anesthesia¹. The latter has been associated with anesthetic and surgical complications as well as an increased risk of postpartum depression^2,3. Hence, it is not surprising that anesthesiologists have evaluated many techniques over the years to decrease the incidence of epidural catheter failures. Several techniques (e.g., combined spinal and dural puncture epidural) evaluated over the years have been shown to reduce the incidence of epidural cathete....

Protocol

All procedures involving human participants in the study were conducted in accordance with the ethical standards of the institutional guidelines for research and the 1964 Declaration of Helsinki, including its later amendments or comparable ethical standards. The protocol was developed based on input from previously published articles in the academic literature^30,31,32. Imaging studies were conducted on the authors themselves fo.......

Discussion

The main findings of this research are that the use of US-guided neuraxial anesthesia results in an overall increased first-attempt success. That is, fewer needle attempts and passes are needed to identify the epidural space²⁹. The abovementioned findings are in agreement with those of several meta-analysis studies when comparing preprocedural US-guided neuraxial anesthesia to the landmark technique^7,8,9<.......

Materials

Name	Company	Catalog Number	Comments
ACCURO	Rivanna Medical	NA	Described throughout the manuscript as the automated device
Butterfly iQ+	Butterfly Network	iQ+	Described throughout the manuscript as the handheld device
Traditional ultrasound	SonoSite	SonositePX	Select a low-frequency (2-5 MHZ) curvilinear probe  if utilizing a traditional ultrasound device.