Effect of arching spine on deformation of the ligamentum flavum during epidural needle insertion

2012 ◽  
Author(s):  
K. Naemura
Keyword(s):  
Ligamentum Flavum ◽  
Needle Insertion ◽  
Epidural Needle

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 Effect of young's modulus of porcine ligamentum flavum on the epidural needle insertion

2019 ◽  
Vol 2019 (14) ◽  
pp. 473-477
Author(s):  
Kiyoshi Naemura ◽  
Yoshikazu Matsumoto ◽  
Hideya Saito
Keyword(s):  
Young’S Modulus ◽  
Ligamentum Flavum ◽  
Young's Modulus ◽  
Needle Insertion ◽  
Epidural Needle

Cervical and High Thoracic Ligamentum Flavum Frequently Fails to Fuse in the Midline

2003 ◽  
Vol 99 (6) ◽  
pp. 1387-1390 ◽  
Author(s):  
Philipp Lirk ◽  
Christian Kolbitsch ◽  
Guenther Putz ◽  
Joshua Colvin ◽  
Hans Peter Colvin ◽  
...  
Keyword(s):  
Ligamentum Flavum ◽  
Epidural Needle ◽  
Complete Fusion ◽  
Thoracic Epidural ◽  
Loss Of Resistance ◽  
Ligamenta Flava ◽  
Mean Width ◽  
Human Cadavers ◽  
The Mean ◽  
High Thoracic Epidural

Background Cervical and high thoracic epidural anesthesia and analgesia have gained increasing importance in the treatment of painful conditions and as components of anesthetics for cardiac and breast surgery. In contrast to the hanging-drop technique, the loss-of-resistance technique is thought to rely on the penetration of the ligamentum flavum. However, the exact morphology of the ligamentum flavum at different vertebral levels remains controversial. Therefore, the aim of this study was to investigate the incidence and morphology of cervical and high thoracic ligamentum flavum mid-line gaps in embalmed cadavers. Methods Vertebral column specimens were obtained from 52 human cadavers. On each dissected level, ligamentum flavum mid-line gaps were recorded and evaluated with respect to shape and size. Results The following variations were encountered: complete fusion in the mid-line, mid-line fusion with a gap in the caudal part, mid-line gap, and mid-line gap with widened caudal end. The incidence of mid-line gaps at the following levels was: C3-C4: 66%, C4-C5: 58%, C5-C6: 74%, C6-C7: 64%, C7-T1: 51%, Th1-Th2: 21%, Th2-Th3: 11%, Th3-Th4: 4%, Th4-Th5: 2%, and Th5-Th6: 2%. The mean width of mid-line gaps was 1.0 +/- 0.3 mm. Conclusions In conclusion, the present study shows that gaps in the ligamenta flava are frequent at cervical and high thoracic levels but become rare at the T3/T4 level and below, such that one cannot always rely on the ligamentum flavum as a perceptible barrier to epidural needle placement at these levels.

Epidural needle insertion

2018 ◽  
Vol 67 (12) ◽  
pp. 922-930 ◽  
Author(s):  
H. Bomberg ◽  
N. Paquet ◽  
A. Huth ◽  
S. Wagenpfeil ◽  
P. Kessler ◽  
...  
Keyword(s):  
Needle Insertion ◽  
Epidural Needle

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 EMLA Cream Prior to Insertion of Elective Epidurals

1995 ◽  
Vol 23 (3) ◽  
pp. 339-341 ◽  
Author(s):  
J. A. Elson ◽  
M. J. Paech
Keyword(s):  
Elective Caesarean Section ◽  
Needle Insertion ◽  
Patient Comfort ◽  
Epidural Needle ◽  
Double Blind Study ◽  
Double Blind ◽  
Emla Cream ◽  
Skin Infiltration ◽  
Group A ◽  
Group B

A randomized double-blind study was conducted in 83 women scheduled for elective caesarean section to determine the efficacy of EMLA and lignocaine infiltration for epidural insertion. The patients were randomly allocated to one of three groups: Group A (EM/LIG) received EMLA and intradermal and subdermal 1% lignocaine infiltration, Group B (EM/SAL) EMLA and saline while Group C (PL/LIG) received placebo cream and 1% lignocaine. Assessments using a 100 mm pain score were performed on skin infiltration and after subsequent insertion of a 16 gauge Tuohy needle into the supraspinous ligament. Skin changes under the applied cream and nursing rating of patients’ response were also noted. Statistical analyses were performed using Kruskal-Wallis and Fisher's Exact Tests. Groups were comparable for age, weight, parity and EMLA application time (interquartile range 105-150 minutes) There were significantly higher pain scores for skin infiltration in Group C (PL/LIG) (P<0.01) and for epidural needle insertion in Group B (EM/SAL) (P<0.05). We concluded that in this patient population, the application of EMLA cream for at least 90 minutes plus 1% lignocaine infiltration optimized patient comfort for epidural insertion.

Real-time Ultrasound-Guided Lumbar Epidural with Transverse Interlaminar View: Evaluation of an In-Plane Technique

Pain Medicine ◽  
2019 ◽  
Vol 20 (9) ◽  
pp. 1750-1755 ◽  
Author(s):  
Hesham Elsharkawy ◽  
Wael Saasouh ◽  
Rovnat Babazade ◽  
Loran Mounir Soliman ◽  
Jean-Louis Horn ◽  
...  
Keyword(s):  
Success Rate ◽  
Real Time ◽  
Epidural Anesthesia ◽  
Needle Insertion ◽  
Adult Patients ◽  
Epidural Needle ◽  
Anatomical Landmarks ◽  
Care Hospital ◽  
Open Prostatectomy ◽  
Ultrasound Guided

Abstract Objective The anatomical landmarks method is currently the most widely used technique for epidural needle insertion and is faced with multiple difficulties in certain patient populations. Real-time ultrasound guidance has been recently used to aid in epidural needle insertion, with promising results. Our aim was to test the feasibility, success rate, and satisfaction associated with a novel real-time ultrasound-guided lumbar epidural needle insertion in the transverse interlaminar view. Design Prospective descriptive trial on a novel approach. Setting Operating room and preoperative holding area at a tertiary care hospital. Subjects Adult patients presenting for elective open prostatectomy and planned for surgical epidural anesthesia. Methods Consented adult patients aged 30–80 years scheduled for open prostatectomy under epidural anesthesia were enrolled. Exclusion criteria included allergy to local anesthetics, infection at the needle insertion site, coagulopathy, and patient refusal. A curvilinear low-frequency (2–5 MHz) ultrasound probe and echogenic 17-G Tuohy needles were used by one of three attending anesthesiologists. Feasibility of epidural insertion was defined as a 90% success rate within 10 minutes. Results Twenty-two patients were enrolled into the trial, 14 (63.6%) of whom found the process to be satisfactory or very satisfactory. The median time to perform the block was around 4.5 minutes, with an estimated success rate of 95%. No complications related to the epidural block were observed over the 48 hours after the procedure. Conclusions We demonstrate the feasibility of a novel real-time ultrasound-guided epidural with transverse interlaminar view.

Successful transforaminal epidural blood patch in a patient with multilevel spinal fusion

2020 ◽  
Vol 45 (9) ◽  
pp. 746-749
Author(s):  
Hanwool Ryan Choi ◽  
Benjamin Fuller ◽  
Michael Magdy Bottros
Keyword(s):  
Case Report ◽  
Spinal Fusion ◽  
Epidural Blood Patch ◽  
Autologous Blood ◽  
Anatomical Variations ◽  
Needle Insertion ◽  
Electrode Placement ◽  
Epidural Needle ◽  
First Case ◽  
Blood Patch

IntroductionEpidural blood patch (EBP) is a vital tool in treating postdural puncture headache (PDPH). Traditional interlaminar epidural needle insertion into the epidural space, however, may be challenging due to anatomical variations. As an alternative method, we successfully performed an EBP via transforaminal approach.Case reportA mid-50-year-old male patient with multilevel spinal fusion developed PDPH after a failed spinal cord stimulator electrode placement. A transforaminal EBP was carried out by injecting a total of 8 mL of autologous blood into the neuroforamen at the L1–L2 level bilaterally. Our patient’s positional headache resolved immediately after the procedure.DiscussionTo our knowledge, this is the first case reported of a transforaminal EBP in a patient with diffuse epidural adhesive fibrosis secondary to multilevel laminectomies and spinal fusion. This case report highlights potential risks and benefits of this novel technique and also discusses its therapeutic mechanism of action. We believe that a transforaminal EBP should be considered in patients who are poor candidates for the traditional interlaminar EBP.

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