scholarly journals Eyes in the Needle

2011 ◽  
Vol 114 (6) ◽  
pp. 1320-1324 ◽  
Author(s):  
Huihua K. Chiang ◽  
Qifa Zhou ◽  
M. Susan Mandell ◽  
Mei-Yung Tsou ◽  
Shih-Pin Lin ◽  
...  
Keyword(s):  
Epidural Catheter ◽  
Dura Mater ◽  
Epidural Space ◽  
Dural Puncture ◽  
Ligamentum Flavum ◽  
Needle Insertion ◽  
Epidural Needle ◽  
Average Weight ◽  
Ultrasound Probe ◽  
Epidural Catheters

Background Epidural needle insertion is usually a blind technique where the rate of adverse events depends on the experience of the operator. A novel ultrasound method to guide epidural catheter insertion is described. Methods An ultrasound transducer (40 MHz, a -6 dB fractional bandwidth of 50%) was placed into the hollow chamber of an 18-gauge Tuohy needle. The single crystal was polished to a thickness of 50 μm, with a width of 0.5 mm. Tissue planes were identified from the reflected signals in an A-mode display. The device was inserted three times into both the lumbar and thoracic regions of five pigs (average weight, 20 kg) using a paramedian approach at an angle of 35-40°. The epidural space was identified using signals from the ligamentum flavum and dura mater. Epidural catheters were placed with each attempt and placement confirmed by contrast injection. Results The ligamentum flavum was identified in 83.3% of insertions and the dura mater in all insertions. The dura mater signal was stronger than that of the ligamentum flavum and served as a landmark in all epidural catheter insertions. Contrast studies confirmed correct placement of the catheter in the epidural space of all study animals. Conclusions This is the first study to introduce a new ultrasound probe embedded in a standard epidural needle. It is anticipated that this technique could reduce failed epidural blocks and complications caused by dural puncture.

scholarly journals “Don't Turn the Needle!”

1993 ◽  
Vol 21 (3) ◽  
pp. 328-330 ◽  
Author(s):  
B. L. Duffy
Keyword(s):  
Epidural Catheter ◽  
Epidural Space ◽  
Epidural Anaesthesia ◽  
Dural Puncture ◽  
Epidural Needle ◽  
Accidental Dural Puncture ◽  
Spinal Ligaments

Accidental dural puncture is a well-recognised complication of epidural anaesthesia. The technique of inserting the epidural needle with the bevel parallel to the spinal ligaments is still taught in some centres. Evidence is presented that the subsequent turning of the needle to allow passage of the epidural catheter may increase the likelihood of dural puncture. There would also appear to be a greater chance of subdural catheterisation. The epidural needle should be introduced with the bevel in the direction in which the catheter is to go and not moved once the epidural space is located.

scholarly journals Comparison of the effects of sagittal versus transvers 25-gauge quincke needle insertion on post-dural puncture headache development

2020 ◽  
Vol 7 (7) ◽  
pp. 554-559
Author(s):  
Mehmet Tercan ◽  
Tuğba Bingöl Tanrıverdi ◽  
Gülçin Patmano ◽  
Ahmet Atlas ◽  
Ahmet Kaya ◽  
...  
Keyword(s):  
Cesarean Section ◽  
Spinal Anesthesia ◽  
Dura Mater ◽  
Dural Puncture ◽  
Multivariate Logistic Regression Analysis ◽  
Needle Insertion ◽  
Spinal Needle ◽  
Post Dural Puncture Headache ◽  
Spinal Puncture ◽  
American Society

Objective: Post-dural puncture headache (PDPH) is one of the most important complications after spinal anesthesia. This study aimed to investigate the effect of the sagittal or transverse application of 25-gauge Quincke spinal needle on PDPH development in patients undergoing cesarean section. Material and Methods: A total of 295 patients with a planned cesarean section between the ages of 18-40 years with an American Society of Anesthesiologists score of 1 or 2 were included in the study. For the spinal intervention, 25-gauge Quincke spinal needle was used in all patients. Patients were included in one of two groups according to the spinal needle cutting direction of the dura mater fibers as sagittal (parallel to dura mater fibers, Group S; n=145) or transverse group (perpendicular to dura mater fibers, Group T; n=150). Results: PDPH developed in 27 (9.2%) patients. Patients in Group T had significant higher ratio of PDPH compared to patients in Group S (16% vs. 2.1%, p<0.001). Additionally, patients with PDPH had a significantly higher frequency of ≥2 spinal puncture attempts compared to patients without PDPH (22.2% vs. 4.5%, p=0.003). Multivariate logistic regression analysis demonstrated that transverse needle direction (OR: 11.40, 95% CI: 2.73-34.71; p<0.001) and ≥2 spinal puncture attempts (OR: 9.73, 95% CI: 3.13-41.55; p<0.001) and were independent predictors for PDPH development. Conclusion: Transverse insertion of the 25-gauge Quincke needle into spinal cord fibers and repeated interventions are independently associated with the development of PDPH in cesarean section patients undergoing spinal anesthesia

scholarly journals Reliability and Safety of Contra-Lateral Oblique View for Interlaminar Epidural Needle Placement

2018 ◽  
Vol 1 (21;1) ◽  
pp. E65-E73
Author(s):  
Richard Derby
Keyword(s):  
Epidural Space ◽  
Ligamentum Flavum ◽  
Case Series ◽  
Senior Author ◽  
Epidural Block ◽  
Observer Agreement ◽  
Epidural Needle ◽  
Oblique View ◽  
Fluoroscopic Imaging

Cord trauma is a risk with a cervical and thoracic interlaminar epidural approach to the epidural space. Intermittent lateral fluoroscopic imaging to detect needle depth is often cumbersome and may be difficult to interpret. In comparison, the contra-lateral oblique (CLO) fluoroscopic view is efficient and easy to interpret. However, the in vivo reliability and safety of this technique has not been formally investigated. The senior author collected fluoroscopic images on 278 consecutive patients undergoing an interlaminar epidural block at the T1-T2 level performed using a 17 gauge Tuohy needle. Before catheter placement, anterior-posterior (AP) and CLO fluoroscopic images were saved with the needle at the ligamentum flavum and the needle just through the ligamentum flavum. We randomly selected the images of 40 cases that included the paired CLO images (total 80 images) documenting the views at and through the ligamentum flavum. Three interventionalists were asked to review, in a blinded fashion, the randomly selected, paired CLO images and to score each image, recording whether the 17 gauge needle was in or out of the epidural space to determine the accuracy and reliability of this technique. There was a 97.5%, 95%, and 93.8% agreement between each reviewing physician and the senior author resulting in a correlation using the Kappa statistic value of 0.950, 0.875, and 0.874, respectively (P < 0.001). The 3 reviewing physicians disagreed with the senior author’s correct answer in 2.5%, 5%, and 6.2%, respectively, however, the disagreement occurred primarily because of poor image quality. Agreement between the 3 reviewing physicians was 93.8%, 96.3%, and 90%, with a Kappa value of 0.875, 0.924, and 0.799, respectively (P < 0.001). There was 100% technical success in the 278 case series without “wet taps,” provocation of pain during entry, or any other immediate post procedural complication. We conclude the CLO view provides an efficient and reliable method to visualize needle tip depth in relation to the epidural space. The close inter-observer agreement was possible with minimal physician instruction. Key words: Cervical interlaminar, cervical epidural, contra-lateral oblique, fluoroscopic imaging

scholarly journals Concordance between the loss of resistance technique and ultrasound in measuring the distance from the skin to the epidural space in pediatric patients: Observational study

2020 ◽  
Vol 48 (4) ◽  
Author(s):  
Piedad Cecilia Echeverry-Marín ◽  
Andrea Carolina Pérez-Pradilla ◽  
Bernardo Reyes-Escobar ◽  
Rocío del Pilar Pereira-Ospina ◽  
Manuela Quiroga-Carrillo
Keyword(s):  
Observational Study ◽  
Latin American ◽  
Dura Mater ◽  
Epidural Space ◽  
Pediatric Patients ◽  
Ligamentum Flavum ◽  
Standard Technique ◽  
Conventional Technique ◽  
Ultrasound Measurement ◽  
Loss Of Resistance

Introduction: The use of ultrasound in regional anesthesia has become a standard technique to improve nerve block accuracy and reduce associated complications. The literature reports a good correlation between the distance from the skin to the dura mater or the ligamentum flavum measured on ultrasound and the conventional technique of “loss of resistance”. Latin American populations have not been included in the studies conducted so far but, because of differences in physical build, it is important to determine whether this correlation is maintained in the various populations. This paper offers new information about the role of ultrasound in determining the distance to the ligamentum flavum and recognizing the proximity of the dura mater to avoid accidental puncture of this structure in Latin American populations. Objective: To determine correlation and concordance in estimating the distance from the skin to the epidural space between the loss of resistance technique and ultrasound measurement. Methodology: Observational study conducted in 52 pediatric patients who received general anesthesia plus peridural analgesia for acute perioperative pain management between July 2014 and November 2015 to assess correlation and concordance between loss of resistance and ultrasound measurement of distance to the epidural space. Results: There is a correlation between distances measured using the two techniques, which appears to be higher as patient age increases. As for concordance, the study found that 0.43 cm should be added to the ultrasound measurement to achieve agreement with the distance obtained using the loss of resistance technique; however, the interval between the two measurements is 1.15 cm. Conclusions: A correlation was found between the measurement taken from the skin to the peridural space using ultrasound and the measurement obtained with the traditional needle puncture and loss of resistance technique. Although concordance was not as expected and the distance measured with ultrasound may be smaller than the real measurement with the needle, ultrasound offers good guidance regarding proximity to the peridural space.

scholarly journals Using Computed Tomography Scans and Patient Demographic Data to Estimate Thoracic Epidural Space Depth

2015 ◽  
Vol 2015 ◽  
pp. 1-6 ◽  
Author(s):  
Alyssa Kosturakis ◽  
Jose Soliz ◽  
Jackson Su ◽  
Juan P. Cata ◽  
Lei Feng ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Epidural Catheter ◽  
Epidural Space ◽  
Depth Measurement ◽  
Thoracic Epidural ◽  
Patient Demographics ◽  
Loss Of Resistance ◽  
Computed Tomography Scans ◽  
The Mean ◽  
Epidural Catheters

Background and Objectives. Previous studies have used varying methods to estimate the depth of the epidural space prior to placement of an epidural catheter. We aim to use computed tomography scans, patient demographics, and vertebral level to estimate the depth of the loss of resistance for placement of thoracic epidural catheters. Methods. The records of consecutive patients who received a thoracic epidural catheter were reviewed. Patient demographics, epidural placement site, and technique were collected. Preoperative computed tomography scans were reviewed to measure the skin to epidural space distance. Linear regression was used for a multivariate analysis. Results. The records of 218 patients were reviewed. The mean loss of resistance measurement was significantly larger than the mean computed tomography epidural space depth measurement by 0.79 cm (p<0.001). Our final multivariate model, adjusted for demographic and epidural technique, showed a positive correlation between the loss of resistance and the computed tomography epidural space depth measurement (R2=0.5692, p<0.0001). Conclusions. The measured loss of resistance is positively correlated with the computed tomography epidural space depth measurement and patient demographics. For patients undergoing thoracic or abdominal surgery, estimating the loss of resistance can be a valuable tool.

A Coaxial Dual-element Focused Ultrasound Probe for Guidance of Epidural Catheterization: An Experimental Study

2017 ◽  
Vol 39 (5) ◽  
pp. 283-294 ◽  
Author(s):  
Guo-Chung Dong ◽  
Li-Chen Chiu ◽  
Chien-Kun Ting ◽  
Jia-Ruei Hsu ◽  
Chih-Chung Huang ◽  
...  
Keyword(s):  
Focused Ultrasound ◽  
Needle Insertion ◽  
Epidural Block ◽  
Epidural Needle ◽  
Lumbar Region ◽  
Ultrasound Probe ◽  
Bone Contact ◽  
Ultrasonic Probe ◽  
Needle Pass ◽  
Epidural Catheterization

Ultrasound guidance for epidural block has improved clinical blind-trial problems but the design of present ultrasonic probes poses operating difficulty of ultrasound-guided catheterization, increasing the failure rate. The purpose of this study was to develop a novel ultrasonic probe to avoid needle contact with vertebral bone during epidural catheterization. The probe has a central circular passage for needle insertion. Two focused annular transducers are deployed around the passage for on-axis guidance. A 17-gauge insulated Tuohy needle containing the self-developed fiber-optic–modified stylet was inserted into the back of the anesthetized pig, in the lumbar region under the guidance of our ultrasonic probe. The inner transducer of the probe detected the shallow echo signals of the peak-peak amplitude of 2.8 V over L3 at the depth of 2.4 cm, and the amplitude was decreased to 0.8 V directly over the L3 to L4 interspace. The outer transducer could detect the echoes from the deeper bone at the depth of 4.5 cm, which did not appear for the inner transducer. The operator tilted the probe slightly in left-right and cranial-caudal directions until the echoes at the depth of 4.5 cm disappeared, and the epidural needle was inserted through the central passage of the probe. The needle was advanced and stopped when the epidural space was identified by optical technique. The needle passed without bone contact. Designs of the hollow probe for needle pass and dual transducers with different focal lengths for detection of shallow and deep vertebrae may benefit operation, bone/nonbone identification, and cost.

scholarly journals Do the Gaps in the Ligamentum Flavum in the Cervical Spine Translate into Dural Punctures? An Analysis of 4,396 Fluoroscopic Interlaminar Epidural Injections

2015 ◽  
Vol 3;18 (3;5) ◽  
pp. 259-266
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Contrast Medium ◽  
Upper Extremity ◽  
Epidural Space ◽  
Dural Puncture ◽  
Ligamentum Flavum ◽  
The United States ◽  
Neurologic Complications ◽  
Epidural Injections ◽  
Number Of Patients ◽  
Significant Difference

Background: Cervical interlaminar epidural injections are performed frequently in managing chronic neck and upper extremity pain, although less commonly than lumbar interlaminar epidural injections. Recently, the US Food and Drug Administration warnings and safeguards to prevent neurologic complications. These were developed by the Multi-Society Pain Workgroup have taken center stage for all types of epidural injections, including cervical interlaminar epidural injections. The recommendations of safeguards to prevent neurologic complications after epidural steroid injections include that cervical interlaminar epidural injections must be performed utilizing fluoroscopy with anteroposterior, lateral, or oblique views with injection of contrast medium and that entry be limited to the C7-T1 epidural space or occasionally the C6-C7 with requirements for magnetic resonance imaging assessment of the epidural space. Objectives: To assess the incidence of dural puncture associated with fluoroscopically directed cervical interlaminar epidural injections. Study Design: A retrospective assessment of patients undergoing cervical interlaminar epidural injections from January 2012 through February 2015. Setting: A private interventional pain management practice; a specialty referral center in the United States. Methods: The data were collected for 4,396 consecutive cervical interlaminar epidural injections performed from January 2012 through February 2015. The procedures were all performed under fluoroscopic visualization under posteroanterior view with contrast medium injection with lateral view confirmation when indicated. The procedures were performed by one of 2 physicians; the dural puncture and subsequent postoperative complications with level of epidural entry were determined. Outcomes Assessment: The outcome was assessment of dural puncture. Results: A review of multiple manuscripts showed that defects in the ligamentum flavum may extend to as much as 100% of the population. However, it also has been shown that among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. Among the 4,396 epidural injections performed at C7-T1, C6-C7, and C5-C6, 1,227 were performed at C7-T1; 1,835 were performed at C6-C7; and 1,334 were performed at C5-C6. Dural punctures were observed in 1.8% (24 procedures) at the C5-C6 level entry; 0.87% (16 procedures) at the C6-C7 level entry; and 1.71% (21 procedures) at the C7-T1 level. There was no significant difference among the entry levels. No complications or spinal cord damage or postdural puncture headache were observed. Limitations: The limitations of this report include that it is an assessment by only 2 well experienced physicians, even though it included a relatively large number of patients Conclusion: This study illustrates that dural puncture is equally prevalent, though very rare, irrespective of the needle entry level into the epidural space, with an overall dural puncture rate of 1.4%, with 1.8% at the C5-C6 level, 0.87% at the C6-C7 level, and 1.71% at the C7-T1 level. Based on the present literature, it appears that performing the procedure by inserting the needle into the cephalic portion of the intervertebral space rather than the caudal portion may be safer. Key words: Cervical interlaminar epidural injection, dural puncture, steroids, neck pain, upper extremity pain.

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