The optimal angle of needle insertion for caudal block in children: ultrasound imaging

Abstract Background Caudal block is widely used in paediatric anaesthetic practice. Many angles for needle insertion were compared to find a optimal angle during caudal block with high successful caudal injection and minimal risk of complications. The aim of this study is to evaluate the safety and effectivity of a new method of needle insertion at an angel of 90°to the apex of the sacral hiatus for caudal block in newborns. Methods Sixty patients were included in our study, aged 0 to 28 days, posted for inguinal hernia surgery, randomly divided into two groups: a conventional method (CM) group and a new method (NM) group. In both groups, 1 ml∙kg-1 0.5% lignocaine at a rate of approximately 0.5 ml∙s-1 was given for caudal blocks after anaesthesia, and ultrasonographic observation of local anesthetic in the epidural space. Failure rate at the first attempt, puncture frequency, complications, and durations of block were recorded. Results The failure rate at the first attempt of caudal block were 16.7% in the conventional method group and 3.3% in the new method group (p<0.05). The mean time required (standard deviation) to perform needle insertion in the conventional method group was 2.6±0.5 minutes and in new method group 1.6±0.5 minutes (p<0.05). There were three cases aspirating the needle to find blood and one case to find cerebrospinal fluid in the conventional method group. The majority level which the local anesthetic reached are L1 by ultrasound imaging, 86.7% in the conventional method group and 83.3% in the new method group. Conclusion The study found that using the new method, the chance of performing a successful caudal injection can be increased, the time and the risk can be minimized compared to conventional technique. It is a safe and effective method.

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Optimal angle of needle insertion for spinal anesthesia in patients with spondylolisthesis: an ultrasonographic study

BMC Anesthesiology ◽

10.1186/s12871-021-01444-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Youngwon Kim ◽

Seokha Yoo ◽

Sun-Kyung Park ◽

Hansu Bae ◽

Young-Jin Lim ◽

...

Keyword(s):

Spinal Anesthesia ◽

Ultrasound Image ◽

Image Data ◽

Needle Insertion ◽

Oblique View ◽

Optimal Angle ◽

Link Type ◽

Upper Level ◽

Positive Angle ◽

Lumbar Spondylolisthesis

Abstract Background Spondylolisthesis is a common degenerative spinal deformity. At the level of spondylolisthesis, the anatomy of the interlaminar space may differ from normal spine, in which case optimal angle of the needle insertion for spinal anesthesia may change. This study compared the optimal angle of needle insertion during spinal anesthesia in patients with and without lumbar spondylolisthesis using ultrasound. Methods We recruited 40 patients, 20 with and 20 without lumbar spondylolisthesis (group S and N, respectively). Ultrasonography was performed in the transverse midline and parasagittal oblique views at the spondylolisthesis level and the adjacent upper level. We measured the probe application angle with the longest interlaminar height of the ligamentum flavum-dura mater complex (LFD), depth from the skin to the LFD, depth from the skin to the anterior complex, and intrathecal space width. A positive angle represented a cephalad angulation. Results The optimal needle insertion angle in the transverse midline view at the spondylolisthesis level was (-) 2.7 ± 3.4° in group S and 0.8 ± 2.5° in group N (P$$<$$ < 0.001). In the parasagittal oblique view, it was (-) 2.7 ± 4.5° in group S and 1.0 ± 3.2° in group N (P = 0.004). There were no between-group differences in the angles at the upper level, with all cephalad angles in both views. Other ultrasound image data were comparable between groups. Conclusion In patients with spondylolisthesis, caudad angulation of the spinal needle can aid successful spinal puncture at spondylolisthesis level, both in the midline and paramedian approaches. Trial registration www.ClinicalTrials.gov (NCT04426916); registered 11 June 2020.

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Description of Optimal Angle of Needle Insertion For L5 Transforaminal Epidural Injection Leads to Complications

January 2018 - Pain Physician ◽

10.36076/ppj.2015/18/e937 ◽

2015 ◽

Vol 5;18 (5;9) ◽

pp. E937-E938

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Epidural Injection ◽

Needle Insertion ◽

Optimal Angle ◽

Transforaminal Epidural Injection

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Anatomical Evaluation of the Sacral Hiatus Using Ultrasound Imaging: Factors That Inhibit Needle Insertion During Caudal Epidural Block Procedures

Pain Practice ◽

10.1111/papr.12826 ◽

2019 ◽

Vol 20 (1) ◽

pp. 55-61

Author(s):

Masahiro Nakahashi ◽

Hiroshi Uei ◽

Masahiro Hoshino ◽

Keita Omori ◽

Hidetoshi Igarashi ◽

...

Keyword(s):

Ultrasound Imaging ◽

Needle Insertion ◽

Epidural Block ◽

Caudal Epidural Block ◽

Sacral Hiatus ◽

Caudal Epidural

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Ultrasound Imaging Facilitates Spinal Anesthesia in Adults with Difficult Surface Anatomic Landmarks

Anesthesiology ◽

10.1097/aln.0b013e31821a8ad4 ◽

2011 ◽

Vol 115 (1) ◽

pp. 94-101 ◽

Cited By ~ 117

Author(s):

Ki Jinn Chin ◽

Anahi Perlas ◽

Vincent Chan ◽

Danielle Brown-Shreves ◽

Arkadiy Koshkin ◽

...

Keyword(s):

Body Mass Index ◽

Spinal Anesthesia ◽

Body Mass ◽

Ultrasound Imaging ◽

Technical Difficulty ◽

Needle Insertion ◽

Lumbar Spine Surgery ◽

Distributed Data ◽

Anatomic Landmarks ◽

Neuraxial Blockade

Background Poor surface anatomic landmarks are highly predictive of technical difficulty in neuraxial blockade. The authors examined the use of ultrasound imaging to reduce this difficulty. Methods The authors recruited 120 orthopedic patients with one of the following: body mass index more than 35 kg/m² and poorly palpable spinous processes; moderate to severe lumbar scoliosis; or previous lumbar spine surgery. Patients were randomized to receive spinal anesthetic by the conventional surface landmark-guided technique (group LM) or by an ultrasound-guided technique (group US). Patients in group US had a preprocedural ultrasound scan to locate and mark a suitable needle insertion point. The primary outcome was the rate of successful dural puncture on the first needle insertion attempt. Normally distributed data were summarized as mean ± SD and nonnormally distributed data were summarized as median [interquartile range]. Results The first-attempt success rate was twice as high in group US than in group LM (65% vs. 32%; P < 0.001). There was a twofold difference between groups in the number of needle insertion attempts (group US, 1 [1-2] vs. group LM, 2 [1-4]; P < 0.001) and number of needle passes (group US, 6 [1-10] vs. group LM, 13 [5-21]; P = 0.003). More time was required to establish landmarks in group US (6.7 ± 3.1; group LM, 0.6 ± 0.5 min; P < 0.001), but this was partially offset by a shorter spinal anesthesia performance time (group US, 5.0 ± 4.9 vs. group LM, 7.3 ± 7.6 min; P = 0.038). Similar results were seen in subgroup analyses of patients with body mass index more than 35 kg/m and patients with poorly palpable landmarks. Conclusion Preprocedural ultrasound imaging facilitates the performance of spinal anesthesia in the nonobstetric patient population with difficult anatomic landmarks.

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Optimal Angle of Needle Insertion for Fluoroscopy-Guided Transforaminal Epidural Injection of L5

Pain Practice ◽

10.1111/papr.12187 ◽

2014 ◽

Vol 15 (5) ◽

pp. 393-399 ◽

Cited By ~ 2

Author(s):

In-Hoo Ra ◽

Woo-Kie Min

Keyword(s):

Epidural Injection ◽

Needle Insertion ◽

Optimal Angle ◽

Transforaminal Epidural Injection

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Confirmation of Caudal Needle Placement Using Nerve Stimulation

Anesthesiology ◽

10.1097/00000542-199908000-00010 ◽

1999 ◽

Vol 91 (2) ◽

pp. 374-378 ◽

Cited By ~ 78

Author(s):

Ban C. H. Tsui ◽

Pekka Tarkkila ◽

Sunil Gupta ◽

Ramona Kearney

Keyword(s):

Local Anesthetic ◽

Nerve Stimulation ◽

Pediatric Patients ◽

Needle Insertion ◽

Stimulation Test ◽

Needle Placement ◽

Caudal Block ◽

Stimulation Tests ◽

Local Anesthetic Injection ◽

To Receive

Background The study was designed to examine a new method of confirming proper caudal needle placement using nerve stimulation. Methods Thirty-two pediatric patients were studied. A 22-gauge insulated needle was inserted into the caudal canal via the sacral notch until a "pop" was felt. The needle placement was classified as correct or incorrect depending upon the presence or absence of anal sphincter contraction (S2-S4) to electrical simulation (1 to 10 mA). Results Three patients were excluded, two because they inadvertently received neuromuscular blockers and one because the patient's anatomy precluded any attempt at a caudal block. The sensitivity and specificity of the test were both 100% in predicting clinical outcomes of the caudal block. Six patients had a negative stimulation test after the first attempt to place the needle. Four of these went on to receive a second attempt of needle insertion after a subcutaneous bulge or resistance to local anesthetic injection were observed. Following needle reinsertion, positive stimulation tests were elicited. These patients received the local anesthetic injection with ease and had good analgesia postoperatively. No attempt was made to reinsert the needle in the remaining two patients with a negative stimulation test, as they did not show subcutaneous bulge or resistance upon injection. These patients had poor analgesia postoperatively. The positive predictive value of the test was greater than the presence of a "pop" alone (P < 0.05) but not significantly different (P = 0.492) over the presence of "pop" and easy injection. Conclusion This test may be used as a teaching and adjuvant tool in performing caudal block.

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