scholarly journals Epidural Needle Extension through the Ligamentum Flavum Using the Standard versus the CompuFlo®-Assisted Loss of Resistance to Saline Technique: A Simulation Study

2020 ◽  
Vol 2020 ◽  
pp. 1-4
Author(s):  
E. Capogna ◽  
A. Coccoluto ◽  
M. Velardo
Keyword(s):  
Epidural Space ◽  
Simulation Study ◽  
Ligamentum Flavum ◽  
Standard Technique ◽  
High Sensitivity ◽  
Tuohy Needle ◽  
Epidural Needle ◽  
Loss Of Resistance ◽  
The Mean ◽  
Extension Length

Background. The CompuFlo® epidural system has been recently introduced and validated as an objective and sensible tool to detect the epidural space. We aimed to verify whether the high sensitivity of the instrument may help the anesthesiologist to identify the epidural space very early, limiting the extension of the Tuohy needle into the epidural space. Methods. In this prospective, simulation study, we evaluated the Tuohy needle extension through a simulated ligamentum flavum during the epidural procedure performed by 52 expert anesthesiologists by using the CompuFlo® epidural instrument or their standard loss of resistance to saline technique (LORT). Results. The mean (SD) needle extension length was 3.90 (3.71) mm in the standard technique group and 0.68 (0.46) mm in the CompuFlo® group (P<000001). The extremely reduced variability of the data in the CompuFlo® group (F test 0.01) made the results obtained with this instrument highly predictable. Conclusions. Puncturing high-resistance material that simulated the ligamentum flavum, the use of CompuFlo® has determined the arrest of the needle more precociously when compared with the traditional LORT.

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.

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 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

In-Vivo Obstetric Pressure Measurements for Patient-Specific Epidural Simulator

2014 ◽  
Author(s):  
Neil Vaughan ◽  
Venketesh N. Dubey ◽  
Michael Y. K. Wee ◽  
Richard Isaacs
Keyword(s):  
Needle Insertion ◽  
Epidural Needle ◽  
Patient Specific ◽  
Pressure Measurements ◽  
Epidural Pressure ◽  
Loss Of Resistance ◽  
New Finding ◽  
The Mean ◽  
Thickness Measurements

The aim of this study was to measure changing pressures during Tuohy epidural needle insertions for obstetric parturients of various BMI. This has identified correlations between BMI and epidural pressure. Also we investigated links between BMI and the thicknesses and depths of ligaments and epidural space as measured from MRI and ultrasound scans. To date there have been no studies relating epidural pressure and ligament thickness changes with varying Body Mass Indices (BMI). Further goals following measurement of pressure differences between various BMI patients, were to allow a patient-specific epidural simulator to be developed, which has not been achieved before. The trial has also assessed the suitability of our in-house developed wireless pressure measurement device for use in-vivo. Previously we conducted needle insertion trial with porcine for validation of the measurement system. Results showed that for each group average pressures during insertion decrease as BMI increases. Pressure measurements obtained from the patients were matched to tissue thickness measurements from MRI and ultrasound scans. The mean Loss of Resistance (LOR) pressure in each group reduces as BMI increases. Variation in the shape of the pressure graphs was noticed between two epiduralists performing the procedure, suggesting each anaesthetist may have a signature graph shape. This is a new finding which offers potential use in epidural training and assessment. It can be seen that insertions performed by the first epiduralist have a higher pressure range than insertions performed by second epiduralist.

Anatomy of the lumbar interspinous ligament: findings relevant to epidural insertion using loss of resistance

2021 ◽  
pp. rapm-2021-103014
Author(s):  
Sue Lawrence ◽  
Stacey Llewellyn ◽  
Helen Hunt ◽  
Gary Cowin ◽  
David J Sturgess ◽  
...  
Keyword(s):  
Epidural Space ◽  
Predictive Value ◽  
Ligamentum Flavum ◽  
Anatomical Features ◽  
Interspinous Ligament ◽  
Anatomical Basis ◽  
Loss Of Resistance ◽  
Ligamenta Flava ◽  
Morphometric Characterization

Background and objectivesThe ‘loss of resistance’ technique is used to determine entry into the epidural space, often by a midline needle in the interspinous ligament before the ligamentum flavum. Anatomical explanations for loss of resistance without entry into the epidural space are lacking. This investigation aimed to improve morphometric characterization of the lumbar interspinous ligament by observation and measurement at dissection and from MRI.MethodsMeasurements were made on 14 embalmed donor lumbar spines (T12 to S1) imaged with MRI and then dissected along a tilted axial plane aligned with the lumbar interspace.ResultsIn 73 interspaces, median (IQR) lumbar interspinous plus supraspinous ligament length was 29.7 mm (25.5–33.4). Posterior width was 9.2 mm (7.7, 11.9), with narrowing in the middle (4.5 mm (3.0, 6.8)) and an anterior width of 7.3 mm (5.7, 9.8).Fat-filled gaps were present within 55 (75%). Of 51 anterior gaps, 49 (67%) were related to the ligamenta flava junction. Median (IQR) gap length and width were 3.5 mm (2.5, 5.1) and 1.1 mm (0.9, 1.7).Detection of gaps with MRI had 100% sensitivity (95% CI 93.5 to 100), 94.4% specificity (72.7, 99.9), 98.2% (90.4, 100) positive predictive value and 100% (80.5, 100) negative predictive value against dissection as the gold standard.ConclusionsThe lumbar interspinous ligament plus supraspinous ligament are biconcave axially. It commonly has fat-filled gaps, particularly anteriorly. These anatomical features may form the anatomical basis for false or equivocal loss of resistance.

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.

scholarly journals Differentiating False Loss of Resistance from True Loss of Resistance While Performing the Epidural Block with the CompuFlo® Epidural Instrument

2019 ◽  
Vol 2019 ◽  
pp. 1-4 ◽  
Author(s):  
Pasquale Vaira ◽  
Michela Camorcia ◽  
Tiziana Palladino ◽  
Matteo Velardo ◽  
Giorgio Capogna
Keyword(s):  
Epidural Space ◽  
Epidural Block ◽  
Epidural Needle ◽  
Predictive Values ◽  
Specificity And Sensitivity ◽  
Loss Of Resistance ◽  
Accidental Dural Puncture ◽  
Sudden Decrease ◽  
Sensitivity Specificity ◽  
Labor Epidural

Background. The occurrence of false losses of resistance may be one of the reasons for inadequate or failed epidural block. A CompuFlo® epidural instrument has been introduced to measure the pressure of human tissues in real time at the orifice of a needle and has been used as a tool to identify the epidural space. The aim of this study was to investigate the sensitivity and the specificity of the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance encountered during the epidural space identification procedure. Method. We performed epidural block with the CompuFlo® epidural instrument in 120 healthy women who requested labor epidural analgesia. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase in the pitch of the audible tone) was followed by a sudden and sustained drop in pressure for more than 5 seconds accompanied by a sudden decrease in the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau. We evaluate the sensitivity, specificity, and positive and negative predictive values of the ability of CompuFlo® recordings to correctly identify the true LOR from the false LOR. Results. The drop in pressure associated with the epidural space identification was significantly greater than that recorded after the false loss of resistance (73% vs 33%) (P=0.000001). The sensitivity was 0.83, and the AUC was 0.82. Discussion. We have confirmed the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance and established its specificity and sensitivity. Conclusion. An easier identification of dubious losses of resistance during the epidural procedure is essential to reduce the number of epidural attempts and/or needle reinsertions with the potential of a reduced risk of accidental dural puncture especially in difficult cases or when the procedure is performed by trainees.

scholarly journals Intraoperative use of cone-beam computed tomography for the safe epidural blood patch: Technical case report

2019 ◽  
Vol 10 ◽  
pp. 110
Author(s):  
Takashi Kawahara ◽  
Ryuji Awa ◽  
Masamichi Atsuchi ◽  
Kazunori Arita
Keyword(s):  
Computed Tomography ◽  
Epidural Space ◽  
Cone Beam Computed Tomography ◽  
Epidural Blood Patch ◽  
Cone Beam ◽  
Epidural Needle ◽  
Cerebrospinal Fluid Leakage ◽  
Loss Of Resistance ◽  
Blood Patch ◽  
Outer Needle

Background: Epidural blood patch (EBP) is a common method utilized to treat intracranial hypotension, and secondarily, to treat unintentional dural puncture. The authors propose an effective technique for correct epidural needle positioning during EBP using cone-beam computed tomography (CB-CT) images. Case Description: A 31-year-old female underwent an EBP. Following confirmation of the spinal level of the cerebrospinal fluid leakage, the ideal trajectory for the proposed EBP was assessed from the entry point on the skin to the spinolaminar line under CB-CT imaging. The epidural needle was then gently advanced along the appropriate trajectory. At the 10 mm mark, behind the spinolaminar line, the inner needle was removed. This allowed for slow advancement of the outer needle until its tip reached the epidural space, and its location was confirmed by the “loss of resistance to the saline technique.” Using biplane epidurography, the spread of dye within the epidural space for appropriate localization was confirmed. In this case study, the patient’s postural headache immediately improved. Conclusion: Using the CB-CT technique described, a patient successfully underwent EBP without complications.

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 A New Technique to Assist Epidural Needle Placement

2010 ◽  
Vol 112 (5) ◽  
pp. 1128-1135 ◽  
Author(s):  
Chien-Kun Ting ◽  
Mei-Yung Tsou ◽  
Pin-Tarng Chen ◽  
Kuang-Yi Chang ◽  
M. Susan Mandell ◽  
...  
Keyword(s):  
Real Time ◽  
Optical Fibers ◽  
Epidural Space ◽  
Optical Method ◽  
Porcine Model ◽  
Ligamentum Flavum ◽  
Ex Vivo ◽  
Epidural Needle ◽  
Time Data ◽  
532 Nm

Background Up to 10% of epidurals fail due to incorrect catheter placement. We describe a novel optical method to assist epidural catheter insertion in a porcine model. Methods Optical emissions were tested on ex vivo tissues from porcine paravertebral tissues to identify optical reflective spectra. The wavelengths of 650 and 532 nm differentiated epidural space from the ligamentum flavum. We then used a hollow stylet that contained optical fibers to place epidural needles in anesthetized pigs. Real-time data were displayed on an oscilloscope and stored for analysis. A total of 50 punctures were done in four laboratory pigs. Data were expressed as mean +/- SD. Results Paired t test shows significant optical differences between the epidural space and the ligamentum flavum at both 650 nm (P &lt; 0.001) and 532 nm (P = 0.014). Mean magnitudes for 650 nm, 532 nm, and their ratio were 3.565 +/- 0.194, 2.542 +/- 0.145, and 0.958 +/- 0.172 at epidural space and 3.842 +/- 0.191, 2.563 +/- 0.131, and 1.228 +/- 0.244 at ligamentum flavum, respectively. There were no differences in the optical characteristics of the ligamentum flavum and epidural space at different levels in the lumbar and thoracic region (two-way ANOVA P &gt; 0.05). Conclusions This is the first study to introduce a new optical method to localize epidural space in a porcine model. Epidural space could be identified by the changes in the reflective pattern of light emitted at 650 nm, which were specific for the ligamentum flavum and dural tissue. Real-time optical information successfully guided a modified Tuohy needle into the epidural space.

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