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 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.

Fiber-needle Swept-source Optical Coherence Tomography System for the Identification of the Epidural Space in Piglets

2015 ◽  
Vol 122 (3) ◽  
pp. 585-594 ◽  
Author(s):  
Wen-Chuan Kuo ◽  
Meng-Chun Kao ◽  
Kuang-Yi Chang ◽  
Wei-Nung Teng ◽  
Mei-Yung Tsou ◽  
...  
Keyword(s):  
Optical Coherence Tomography ◽  
Epidural Space ◽  
Ex Vivo ◽  
Optical Probe ◽  
Epidural Needle ◽  
Optical Coherence ◽  
Fiber Probe ◽  
Swept Source ◽  
Signal Intensities

Abstract Background: Epidural needle insertion is traditionally a blind technique whose success depends on the experience of the operator. The authors describe a novel method using a fiber-needle–based swept-source optical coherence tomography (SSOCT) to identify epidural space. Methods: An optical fiber probe was placed into a hollow 18-gauge Tuohy needle. It was then inserted by an experienced anesthesiologist to continuously construct a series of two-dimensional SSOCT images by mechanically rotating the optical probe. To quantify this observation, both the average SSOCT signal intensities and their diagnostic potentials were assessed. The insertions were performed three times into both the lumbar and thoracic regions of five pigs using a paramedian approach. Results: A side-looking SSOCT is constructed to create a visual image of the underlying structures. The image criteria for the identification of the epidural space from the outside region were generated by the analysis of a training set (n = 100) of ex vivo data. The SSOCT image criteria for in vivo epidural space identification are high sensitivity (0.867 to 0.965) and high specificity (0.838 to 0.935). The mean value of the average signal intensities exhibits statistically significant differences (P &lt; 0.01) and a high discriminatory capacity (area under curve = 0.88) between the epidural space and the outside tissues. Conclusions: This is the first study to introduce a SSOCT fiber probe embedded in a standard epidural needle. The authors anticipate that this technique will reduce the occurrence of failed epidural blocks and other complications such as dural punctures.

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 Double Assurance of Epidural Space Detection Using Fiberoptics-Based Needle Design and Autofluorescence Technologies for Epidural Blockade in Painless Labor

Sensors ◽  
2018 ◽  
Vol 18 (11) ◽  
pp. 3592
Author(s):  
Cihun-Siyong Gong ◽  
Huang-Chang Lee ◽  
Yin Chang ◽  
Chien-Kun Ting ◽  
Po-Hsun Tu
Keyword(s):  
Fluorescence Spectroscopy ◽  
Epidural Space ◽  
Ex Vivo ◽  
In Vivo Study ◽  
Epidural Needle ◽  
Needle Puncture ◽  
Double Peak ◽  
Interspinous Ligament ◽  
Auto Fluorescence

Purpose: Technology of reflectance spectroscopy incorporated with auto-fluorescence spectroscopy were employed to increase the safety of epidural placement in regional anesthesia which is generally used for surgery, epidural anesthesia, post-operative pain control and painless childbirth. Method: Ex vivo study of auto-fluorescence spectroscopy was performed for the para-vertebral tissues contained fat, interspinous ligament, supraspinous ligament and ligamentumflavum by multimode microplate reader at wavelength 405 nm for the purpose of tissue differentiation. A specially designed optic-fiber-embedded needle was employed to incorporate with both reflectance and autofluorescence spectroscopies in order to probe the epidural space as double assurance demands. In vivo study was carried out in a Chinese native swine weighted about 30 kg under intubated general anesthesia with ventilation support. The reflective (405 nm) and autofluorescence signals (λ and λ*) were recorded at 5 different sites by an oscilloscope during the needle puncture procedure from skin to epidural space in the back of the swine. Results: Study of either autofluorescence spectroscopy for tissue samples or ex vivo needle puncture in porcine trunk tissues indicates that ligmentumflavum has at least 10-fold higher fluorescence intensity than the other tissues. In the in vivo study, ligamentumflavum shows a double-peak character for both reflectance and autofluorescence signals. The epidural space is located right after the drop from the double-peak. Both peaks of reflectance and fluorescence are coincident which ensures that the epidural space is correctly detected. Conclusions: The fiber-optical technologies of double-assurance demands for tissue discrimination during epidural needle puncture can not only provide an objective visual information in a real-time fashion but also it can help the operator to achieve much higher success rate in this anesthesia procedure.

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.

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.

Habituation of stress in psychotherapists performing subsequent in vivo exposures—A case series.

2017 ◽  
Vol 27 (2) ◽  
pp. 218-224 ◽  
Author(s):  
Sarah Schumacher ◽  
Felix Betzler ◽  
Robert Miller ◽  
Clemens Kirschbaum ◽  
Andreas Ströhle
Keyword(s):  
Case Series

Herpetic Whitlow of the Hand in Infants

2020 ◽  
Author(s):  
Mohammad M. Al-Qattan ◽  
Nada G. AlQadri ◽  
Ghada AlHayaza
Keyword(s):  
Bacterial Infection ◽  
Case Reports ◽  
Case Series ◽  
Individual Case ◽  
Senior Author ◽  
Secondary Bacterial Infection ◽  
Clinical Appearance ◽  
History Of ◽  
Mode Of Transmission ◽  
Time Of Presentation

Abstract Introduction Herpetic whitlows in infants are rare. Previous authors only reported individual case reports. We present a case series of six infants. Materials and Methods This is a retrospective study of six cases of herpetic whitlows in infants seen by the senior author (MMA) over the past 23 years (1995–2017 inclusive). The following data were collected: age, sex, digit involved in the hand, mode of transmission, time of presentation to the author, clinical appearance, presence of secondary bacterial infection, presence of other lesions outside the hand, method of diagnosis, treatment, and outcome. Results All six infants initially presented with classic multiple vesicles of the digital pulp. In all cases, there was a history of active herpes labialis in the mother. Incision and drainage or deroofing of the vesicles (for diagnostic purposes) resulted in secondary bacterial infection. Conclusion The current report is the first series in the literature on herpetic whitlows in infants. We stress on the mode of transmission (from the mother) and establishing the diagnosis clinically. In these cases, no need for obtaining viral cultures or polymerase chain reaction; and no medications are required. Once the vesicles are disrupted, secondary bacterial infection is frequent and a combination of oral acyclovir and intravenous antibiotics will be required.

The Orientation of Gastric Biopsy Samples Improves the Interobserver Agreement of the OLGA Staging System

2017 ◽  
Vol 26 (4) ◽  
pp. 351-356 ◽  
Author(s):  
Bogdan Cotruta ◽  
Cristian Gheorghe ◽  
Razvan Iacob ◽  
Mona Dumbrava ◽  
Cristina Radu ◽  
...  
Keyword(s):  
Intestinal Metaplasia ◽  
Lamina Propria ◽  
Case Series ◽  
Gastric Biopsy ◽  
Gastric Atrophy ◽  
Observer Agreement ◽  
Gastric Body ◽  
Kappa Index ◽  
Gastric Biopsies

Background & Aims: Evaluation of severity and extension of gastric atrophy and intestinal metaplasia is recommended to identify subjects with a high risk for gastric cancer. The inter-observer agreement for the assessment of gastric atrophy is reported to be low. The aim of the study was to evaluate the inter-observer agreement for the assessment of severity and extension of gastric atrophy using oriented and unoriented gastric biopsy samples. Furthermore, the quality of biopsy specimens in oriented and unoriented samples was analyzed.Methods: A total of 35 subjects with dyspeptic symptoms addressed for gastrointestinal endoscopy that agreed to enter the study were prospectively enrolled. The OLGA/OLGIM gastric biopsies protocol was used. From each subject two sets of biopsies were obtained (four from the antrum, two oriented and two unoriented, two from the gastric incisure, one oriented and one unoriented, four from the gastric body, two oriented and two unoriented). The orientation of the biopsy samples was completed using nitrocellulose filters (Endokit®, BioOptica, Milan, Italy). The samples were blindly examined by two experienced pathologists. Inter-observer agreement was evaluated using kappa statistic for inter-rater agreement. The quality of histopathology specimens taking into account the identification of lamina propria was analyzed in oriented vs. unoriented samples. The samples with detectable lamina propria mucosae were defined as good quality specimens. Categorical data was analyzed using chi-square test and a two-sided p value <0.05 was considered statistically significant.Results: A total of 350 biopsy samples were analyzed (175 oriented / 175 unoriented). The kappa index values for oriented/unoriented OLGA 0/I/II/III and IV stages have been 0.62/0.13, 0.70/0.20, 0.61/0.06, 0.62/0.46, and 0.77/0.50, respectively. For OLGIM 0/I/II/III stages the kappa index values for oriented/unoriented samples were 0.83/0.83, 0.88/0.89, 0.70/0.88 and 0.83/1, respectively. No case of OLGIM IV stage was found in the present case series. Good quality histopathology specimens were described in 95.43% of the oriented biopsy samples, and in 89.14% of the unoriented biopsy samples, respectively (p=0.0275).Conclusion: The orientation of gastric biopsies specimens improves the inter-observer agreement for the assessment of gastric atrophy.Key words:  –  –  – .Abbreviations: H. pylori: Helicobacter pylori; OLGA: operative link for gastritis assessment; OLGIM: operative link on intestinal metaplasia assessment.

scholarly journals Effect of postoperative corticosteroids on surgical outcome and aqueous autotaxin following combined cataract and microhook ab interno trabeculotomy

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Megumi Honjo ◽  
Reiko Yamagishi ◽  
Nozomi Igarashi ◽  
Chui Yong Ku ◽  
Makoto Kurano ◽  
...  
Keyword(s):  
Surgical Outcome ◽  
Primary Open Angle Glaucoma ◽  
Open Angle Glaucoma ◽  
Case Series ◽  
Iop Elevation ◽  
Immunoenzymatic Assay ◽  
Postoperative Fibrosis ◽  
Ab Interno

AbstractTo evaluate the effect of postoperative corticosteroids on surgical outcome and autotaxin (ATX) levels after microhook ab interno trabeculotomy combined with cataract surgery (μLOT-CS), prospective, consecutive non-randomized case series comparing outcomes of 30 eyes with primary open angle glaucoma was performed. The aqueous ATX, intraocular pressure (IOP) and glaucoma medications were monitored for 3 months postoperatively. An in-vivo mouse μLOT model was generated. In vitro, ATX and fibrotic changes induced by dexamethasone (Dex) treatment following scratch (S) in cultured human trabecular meshwork (hTM) cells were assessed by immunofluorescence, immunoenzymatic assay, and RT-qPCR. Postoperative ATX at 1 week and the number of antiglaucoma medications at 3 months were significantly lower in non-steroid group, and steroid use was the only variable significantly associated with postoperative medications at 3 months in multiregression analyses. In vitro, ATX activity was significantly upregulated in the Dex + S group, and αSMA was significantly upregulated in the Dex and Dex + S groups. Fibronectin and COL1A1 were significantly upregulated in the S group. μLOT-CS decreased IOP and medications in the overall cohort, and non-use of postoperative steroids resulted in a smaller number of postoperative medications. Limiting postoperative steroids in μLOT may minimize IOP elevation and postoperative fibrosis.

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