A comparative study of ultrasound assisted versus landmark technique for combined spinal-epidural anaesthesia in patients undergoing lower limb orthopaedic surgery

Abstract

Background and Aims: Spinal anatomy is better visualised in the para sagittal oblique view with the aid of ultrasonography. The present study was undertaken to investigate whether preprocedural ultrasonography can facilitate the ease of establishing combined spinal epidural (CSE) via paramedian approach versus landmark approach in patients undergoing lower limb orthopaedic surgery. Methods: This prospective randomised study was conducted in 100 American Society of Anesthesiologists (ASA) grade I-II patients, aged 18-60 years requiring CSE and randomly divided into two groups: Ultrasound-assisted (USG) group (n = 50) and Surface landmark (SLG) group (n = 50). The primary outcome was to compare the first pass needle success rate to establish CSE and the secondary outcomes were to compare the number of needle puncture attempts, time to establish landmarks (t1), time to accomplish CSE (t2) and complications. Results: First pass needle success rate in USG group was 43 (86.0%) versus 36 (60.0%) in SLG group ( P = 0.001). Number of attempts taken to establish CSE was lower in USG group as compared to SLG group ( P = 0.023). t1 was greater in USG group (1.45 ± 0.47) minutes as compared to (0.79 ± 0.34) minutes in SLG group ( P = 0.003). t2 was reduced in USG group (1.47 ± 0.55) minutes versus (2.73 ± 1.36) minutes in SLG group ( P = 0.005). Conclusion: Preprocedural USG for CSE via paramedian approach increases first pass needle success rate and reduces needle puncture attempts in patients undergoing lower limb orthopaedic surgery.

Comparison of ultrasound-guided and traditional localisation in intraspinal anesthesia: a systematic review and network meta-analysis

“…Nineteen two-arm studies and one three-arm study documented first-pass success rates and were pooled for analysis 2 3 11–17 19–27 29 30. Across all studies, traditional positioning was the most frequently cited (online supplemental figure 1A).…”

“…The network diagrams and forest diagrams of each study are shown in online supplemental figure 3A,B. The results2 3 11 12 17–19 21–23 26 27 30 show that the traditional positioning method has the shortest positioning time (online supplemental figure 3D), but the ultrasound-assisted and real-time guided puncture positioning time does not show significant differences (online supplemental figure 3C). The funnel plot is shown in figure 3SE.…”

“…All experiments were two or three arms. Among them, 13 studies compared ultrasound-assisted localisation with conventional localisation, [11][12][13][14][15][16][17][18][19][20][21][22][23] 5 studies compared ultrasound-assisted localisation with conventional localisation [24][25][26][27][28] and 3 studies compared ultrasoundassisted localisation with real-time guidance in the spinal anaesthesia. 2 3 19 One study compared the use of three methods in spinal anaesthesia.…”

Landmark-guided versus Real-time Ultrasound-guided Combined Spinal-epidural Anesthesia Techniques: Paramedian Sagittal Oblique and Transverse Interlaminar Approach

“…[ 17 ] In another study, which used preprocedural US to determine the intervention site, it was found that the paramedian approach for the CSE technique increased the chance of first-pass success and reduced the number of multiple interventions. [ 18 ] In another study, CSE anesthesia used a paramedian longitudinal approach accompanied by real-time US. Compared to other groups using LG technique and preprocedural US, the out-of-plane method in paramedian longitudinal imaging was found to reduce puncture entries and the number of manipulations.…”

“…[ 10 ] This factor may change the study results. [ 9 12 13 17 18 19 20 21 ] Adaptation to performing LG neuraxial block procedures with US, which regional anesthesiologists have been practicing for many years and have experience with, may take time. Technical problems during the process (probe sterilization, difficulties in the application by a single person, sterility of US gel, etc.)…”