It appears that until a prospective study designed to address some of the controversial issues outlined is undertaken, we will remain ignorant about the need for surgery to release tongue-tie in children.
Purpose The SonixGPS TM is a novel needle tracking system that has recently been approved in Canada for ultrasound-guided needle interventions. It allows optimization of needle-beam alignment by providing a real-time display of current and predicted needle tip position. Currently, there is limited evidence on the effectiveness of this technique for performance of realtime spinal anesthesia. This case series reports performance of the SonixGPS system for real-time ultrasound-guided spinal anesthesia in elective patients scheduled for joint arthroplasty. Methods In this single-centre case series, 20 American Society of Anesthesiologists' class I-II patients scheduled for lower limb joint arthroplasty were recruited to undergo real-time ultrasound-guided spinal anesthesia with the SonixGPS after written informed consent. The primary outcome for this clinical cases series was the success rate of spinal anesthesia, and the main secondary outcome was time required to perform spinal anesthesia. Results Successful spinal anesthesia for joint arthroplasty was achieved in 18/20 patients, and 17 of these required only a single skin puncture. In 7/20 (35%) patients, dural puncture was achieved on the first needle pass, and in 11/20 (55%) patients, dural puncture was achieved with two or three needle redirections. Median (range) time taken to perform the block was 8 (5-14) min. The study procedure was aborted in two cases because our clinical protocol dictated using a standard approach if spinal anesthesia was unsuccessful after three ultrasound-guided insertion attempts. These two cases were classified as failures. No complications, including paresthesia, were observed during the procedure. All patients with successful spinal anesthesia found the technique acceptable and were willing to undergo a repeat procedure if deemed necessary. Conclusions This case series shows that real-time ultrasound-guided spinal anesthesia with the SonixGPS system is possible within an acceptable time frame. It proved effective with a low rate of failure and a low rate of complications. Our clinical experience suggests that a randomized trial is warranted to compare the SonixGPS with a standard block technique. Résumé Objectif Le SonixGPSTM est un système innovant de suivi de l'aiguille récemment approuvé au Canada pour les interventions échoguidées réalisées avec une aiguille. Cet appareil optimise l'alignement entre l'aiguille et le faisceau grâce à un affichage en temps réel du positionnement actuel et prévu de la pointe de l'aiguille. À l'heure actuelle, les données probantes concernant l'efficacité de cette technique pour réaliser une rachianesthésie en temps réel sont limitées. Cette série de cas porte sur la performance du système SonixGPS pour réaliser une rachianesthésie échoguidée en temps réel chez des patients devant subir une chirurgie non urgente d'arthroplastie.
To the Editor,With improvements in ultrasound (US) technology, there is significant momentum to develop and apply a clinically viable real-time ultrasound-guided neuraxial technique. 1,2 Previously described methods using in-plane approaches have been hindered by poor needle visibility due to the steep needle insertion angles required for neuraxial blockade, the acoustic shadows of the bony spinal structures, and the fine gauge of spinal needles. We recently used a cadaver model to develop a new technique involving single-operator real-time US-guided needlethrough-needle spinal injection.Two unembalmed cadavers, one female and one male, were obtained in accordance with the University of British Columbia Clinical Research Ethics Board. A SonixTablet TM ultrasound system (Ultrasonix, Richmond, BC, Canada) was used in an out-of-plane approach with either a 5-14 MHz SonixGPS TM enabled linear transducer or a 2-5 MHz convex transducer, depending on the depth to the neuraxial space.The SonixGPS TM system (Ultrasonix, Richmond, BC, Canada) uses sensors in the needle and ultrasound probe to track the needle position relative to the ultrasound image. Predicted trajectory and location of the needle tip are displayed digitally in real-time and overlaid on the ultrasound image.Two anesthesiologists with experience using the SonixGPS TM system for regional anesthesia used the technology for the first time for a neuraxial technique. With the cadavers in a prone position, the anesthesiologists performed 16 injections between T2/3 and L4/5. For each simulated spinal block, they obtained an optimal sonographic view of the laminae and neuraxial structures in a paramedian oblique sagittal plane. A SonixGPS TM enabled 8-cm 19G introducer needle was inserted out-of-plane and directed with the needle guidance technology towards the ligamentum flavum. Once the tip was positioned near the ligamentum, the inner stylet containing the needle sensor was removed, and a 12-cm 22G spinal needle was inserted through the introducer in a needle-through-needle technique. The spinal needle was then advanced to the neuraxial space and coloured acrylic dye was injected through the needle (see Figure). The spinal needles were left in situ to guide subsequent dissection by a blinded anatomist.All 16 spinal needles and injections were found to be at the target upon dissection. The anatomist confirmed presence of dye in the neuraxial space in 100% of attempts, and there was no dye found in the tissues outside the neuraxial space. There was excellent visualization of spinal sonoanatomy in 63% of attempts and good visualization in the remainder. The SonixGPS TM system allowed prediction of the appropriate needle direction to target the neuraxial space in 100% of attempts. Mean (standard deviation) depth to the neuraxial space on US was 3.21 (0.71) cm and 4.74 (0.59) cm for the female and male cadavers, respectively. Importantly, all 16 attempts required only a single skin puncture with minimal requirement for redirection.SonixGPS TM needle guidance techno...
To the Editor,We read with interest the recent case report 1 on ultrasound-guided spinal anesthesia with the Ultrasonix GPS needle tracking system. Based on our recent experience with this technique, we suggest that this report merits further discussion on certain methodological considerations. 2 We recently described our preliminary experience with this system on spinal anesthesia in two cadavers in the prone position, 2 and we have subsequently used the technique in several patients in the sitting position. In our cadaver study, a 2-5 MHz convex transducer was used in a parasagittal oblique plane. A 19G SonixGPS TM needle was inserted out-of-plane using the needle guidance technology and coloured dye was injected. The spinal needles were left in situ, and 16 injections between T2/3 and L4/5 were completed. All 16 attempts required only a single skin puncture. An anatomist carried out a post-procedural dissection, revealing successful needle and dye placement in the neuraxial space in 100% of attempts. 2In the case report by Wong et al., it is unclear which needle trajectory was employed relative to the ultrasound plane. Based on their Fig. 2, it appears that they utilized an in-plane approach directed cephalad. The position of the needle relative to the probe is indicated at the bottom right of the screen shot. For our cadaver study, 2 we used both in-plane and out-of-plane approaches with the SonixGPS system. We found that the in-plane approach was technically difficult because of the size of the transducer head, the acute angle required, and the narrow interlaminar space. This approach also increased the skin-to-target distance travelled by the needle. The approach facilitating easiest access to the neuraxial space without encountering the lamina was the medially angled paramedian view with the needle entering out-of-plane at the medial aspect of the transducer (Figure).Needle tracking using the SonixGPS system with an in-plane approach helps to align the needle with the transducer and to identify the position of the needle shaft and tip. Nevertheless, the needle entry point is confined to the midline on either the caudal or cephalad edge of the transducer. Due to the length of the curvilinear probe, an in-plane approach greatly increases the required needle length to reach the subarachnoid space. An out-of-plane approach, however, maximizes the benefit of a needle tracking system. The system extrapolates where the needle tip will intersect the ultrasound plane based on the needle trajectory. This allows for unlimited needle entry starting points along the long edge of the transducer with a shorter distance to the dura and, in the case of neuraxial blocks, helps avoid laminae. The needle trajectory does not need to line up with the plane of the ultrasound beam and, therefore, this constraint is eliminated.Based on our experience with real-time ultrasoundguided neuraxial techniques using the SonixGPS in the prone 2 and sitting positions, we also consider the sitting position to be more familiar and more ergon...
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