Does the Technique for Assessing Loss of Resistance Alter the Magnitude of Epidural Needle Tip Overshoot?

Abstract

Introduction Postdural puncture headache due to accidental dural puncture is a consequence of excessive needle tip overshoot distance after entering the epidural space via a loss of resistance (LOR) technique. We are not aware of any quantitative comparison of the magnitude of needle tip overshoot (distance traveled by the needle tip beyond the point where LOR can be discerned) for the various LOR assessment techniques that are taught. Such a comparison may provide insight into contributing factors of accidental dural puncture and associated postdural puncture headache. Methods A custom-built simulator was used to evaluate the following 3 LOR assessment techniques: incremental needle advancement, intermittent LOR assessment (II); continuous needle advancement, high-frequency intermittent LOR assessment (CI); and continuous needle advancement, continuous LOR assessment (CC). Results There were significant mean differences in maximum overshoot past a virtual LOR plane due to technique (F (2,124) = 79.31, P < 0.001) (Fig. 2). Specifically, maximum overshoot was greater with technique II [mean = 3.8 mm, 95% confidence interval (CI) = 3.4–4.3] versus either CC (mean = 1.9 mm, 95% CI = 1.5–1.8, P < 0.001) or CI (mean = 1.4 mm, 95% CI = 0.9–2.3, P < 0.001). Differences in maximum overshoot between CC and CI were not statistically different (P = 0.996). Maximum overshoot was greater at 4 cm (mean = 3.0 mm, 95% CI = 2.6–3.4) compared with 5 cm (mean = 2.3 mm, 95% CI = 2.0–2.5, P = 0.044), 6 cm (mean = 2.0 mm, 95% CI = 1.9–2.2, P = 0.054), 7 cm (mean = 1.9 mm, 95% CI = 1.7–2.1, P = 0.002), and 8 cm (mean = 1.8 mm, 95% CI = 1.6–2.1, P = 0.001). In addition, maximum overshoot at 5 cm was greater than that at 7 cm (P = 0.020) and 8 cm (P = 0.037). The other LOR depths were not statistically significantly different from each other. Depth did not have a significant interaction with technique (P = 0.517). Technique preference had neither a significant relationship to maximum overshoot (P = 0.588) nor a significant interaction with LOR assessment technique (P = 0.689). Discussion Technique II LOR assessment produced the greatest needle overshoot past the simulated LOR plane after obtaining LOR. This was consistent across all LOR depths. In this bench study, the II technique resulted in the deepest needle tip maximum overshoot. We are in the process of designing a clinical study to collect similar data in patients.

Smmarts

“…The SMMARTS SDK, available at https://github.com/UF-CSSALT/SMMARTS-SDK, was used to develop simulators within our internal development team and later externally to evaluate its utility and identify areas needing improvement. Internally, it has been used to develop simulators for ventriculostomy (aka external ventricular drain, EVD), loss-of-resistance and needle tip overshoot during epidural blocks, 15 instructor-less CVA training, pterygopalatine fossa block, chest tube insertion, lumbar block, and chronic pain blocks. Externally, it has been used by undergraduate biomedical engineering students to refine a transrectal US-guided transrectal (side-fire and end-fire) and transperineal prostate biopsy trainer and by undergraduate volunteers to start development on an IV access trainer.…”

Extended Reality for Neuraxial Anesthesia and Pain Procedures: A Scoping Review

“…On phantoms with simulated respiratory motion, AR combined with fluoroscopy reduced procedure time and radiation exposure. [38,39] Finally, an atypical use case for XR neuraxial simulators was presented by Cometa et al [40] They compared the epidural space overshoot associated with different loss-of-resistance techniques using measurements derived from an MR-based simulator. Intermittent needle advancement with intermittent plunger pressure resulted in the most significant overshoot.…”

“…Intermittent needle advancement with intermittent plunger pressure resulted in the most significant overshoot. [40]…”

Skill Assessment of an Epidural Anesthesia Using the PeriSIM Simulator

“…These are some of the metrics that may be used to assess mastery of a gesture in a 3D space. Concerning the specific lumbar epidural anesthesia procedure, one of the most commonly used metrics is what is called "overshoot" [23]in medical jargon. This overshoot corresponds to the distance crossed between the time the needle tip enters the epidural space and the time the gesture is stopped.…”

“…We looked for trends in the data-set to set apart novices and experts. In that regard, some variables have already been identified as crucial concerning the lumbar epidural anesthesia procedure, the most prevalent being the overshoot ( [30], [23]) . Some other remarkable variables are the proportion of syringe emptied, variances of the velocity, and acceleration as a representation of motion smoothness and mean insertion velocity which can be linked to TCT.…”