Paramedian Spinal Anesthesia: Landmark vs. Ultrasound-guided Approaches

Kampitak, Wirinaree; Werawatganon, Thewarug; Uerpairojkit, Ketchada; Songthamwat, Banchobporn

doi:10.4172/2155-6148.1000837

Cited by 4 publications

(11 citation statements)

References 22 publications

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“…The sample size was determined based on the ability to perform successful paramedian CSE in the first attempt. Based on a previous study in which 70 elderly patients were randomly assigned to receive either the conventional surface-landmark guided paramedian ( n =35) or pre-procedural ultrasound-guided paramedian ( n =35) spinal anaesthesia for total knee or hip arthroplasty,[ 9 ] it was calculated that 45 patients in each group would provide 80% power to the study with an alpha error of 0.05. We assumed that a 20% baseline ratio of first pass needle success rate for CSE between the two groups would provide a clinically meaningful effect.…”

Section: Methodsmentioning

confidence: 99%

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

et al. 2022

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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.

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Section: Methodsmentioning

confidence: 99%

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

et al. 2022

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“…Of the initial 4978 unique article citations we identified, 18 randomised controlled trials met the inclusion criteria. [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] Cohen's kappa was 0.61, demonstrating substantial agreement between the two authors conducting the screening. Details of the screening process are depicted in Figure 1 and the results of the risk of bias assessment are illustrated in Figure 2.…”

Section: Study Selection and Risk Of Bias Within Studiesmentioning

confidence: 99%

“…The included trials comprised a total of 1800 patients, of which conventional landmark palpation was conducted in 880 and preprocedural ultrasound was performed in 920 (Table 1). In one trial, the indication for the neuraxial procedure was steroid injection, 14 in 11 trials it was for surgery, 12,13,[16][17][18]20,23,24,[26][27][28] and in five trials it was lumbar puncture. 15,19,21,22,25 The nature of the neuraxial technique was spinal in most trials, 11,13,15,16,[19][20][21][22][23][24][25][26][27][28] and lumbar epidural, 14 thoracic epidural 12,17 or combined spinalepidural 18 in one, two and one trials, respectively.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…In one trial, the indication for the neuraxial procedure was steroid injection, 14 in 11 trials it was for surgery, 12,13,[16][17][18]20,23,24,[26][27][28] and in five trials it was lumbar puncture. 15,19,21,22,25 The nature of the neuraxial technique was spinal in most trials, 11,13,15,16,[19][20][21][22][23][24][25][26][27][28] and lumbar epidural, 14 thoracic epidural 12,17 or combined spinalepidural 18 in one, two and one trials, respectively. In four, six and eight trials, the ultrasonographer and interventionalist were the same, 17,21-23 different 12,14,18,24,26,28 or not specified, 11,13,15,16,19,20,25,27 respectively.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…15,19,21,22,25 The nature of the neuraxial technique was spinal in most trials, 11,13,15,16,[19][20][21][22][23][24][25][26][27][28] and lumbar epidural, 14 thoracic epidural 12,17 or combined spinalepidural 18 in one, two and one trials, respectively. In four, six and eight trials, the ultrasonographer and interventionalist were the same, 17,21-23 different 12,14,18,24,26,28 or not specified, 11,13,15,16,19,20,25,27 respectively. In all of the trials, the ultrasonographer was experienced and in none of the trials was the difficulty of the neuraxial technique predicted to be easy.…”

Section: Study Characteristicsmentioning

confidence: 99%

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Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients

Onwochei

Nair

Young

et al. 2021

European Journal of Anaesthesiology

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BACKGROUND Central neuraxial modalities can occasionally be challenging to perform, particularly if the underlying anatomy is altered or obscured. OBJECTIVES To compare the efficacy, efficiency and the safety of preprocedural ultrasound to landmark palpation in the nonobstetric adult population. DESIGN Systematic review of randomised controlled trials with meta-analysis and trial sequential analysis. DATA SOURCES Systematic search of Central, CINAHL, Embase, Global Health, MEDLINE, Scopus and Web of Science to 13th February 2020. ELIGIBILITY CRITERIA Randomised controlled trials of nonobstetric adult patients having diagnostic and/or therapeutic neuraxial procedures using standard preprocedural ultrasound interpreted by the operator as the intervention and conventional landmark palpation as the comparator. KEY DEFINITIONS A skin puncture was defined as the insertion or reinsertion of the needle through the skin; needle redirection was the backward followed by the forward movement of the needle without its removal from the skin; first skin puncture referred to a single skin puncture with or without needle redirections; and first pass was a single skin puncture with no needle redirection. RESULTS In all, 18 randomised controlled trials with 1800 patients were included. The first pass success rate was not different between landmark and ultrasound methods [risk ratio 1.46; 95% confidence interval (CI), 0.99 to 2.16; P = 0.06, I 2 = 76%; moderate quality of evidence] and the trial sequential analysis demonstrated the futility of further randomisation of patients in modifying this finding. Preprocedural ultrasound increased the total time taken (mean difference 110.8 s; 95% CI, 31.01 to 190.65; P = 0.006; I 2 = 96%; moderate quality of evidence). Subgroup analyses revealed no influence of the predicted difficulty of the neuraxial procedure on outcomes. Compared with the landmark method, ultrasound increased the first skin puncture success rate (risk ratio 1.36; 95% CI, 1.18 to 1.57; P < 0.001; I 2 = 70%), and decreased the need for three or more skin punctures (risk ratio 0.46; 95% CI, 0.33 to 0.64; P < 0.001; I 2 = 29%) and the number of needle redirections (mean difference -1.24; 95% CI, -2.32 to -0.17; P = 0.020; I 2 = 83). The incidence of bloody tap was reduced with the use of ultrasound (risk ratio 0.61; 95% CI, 0.40 to 0.93; P = 0.020; I 2 = 42%). CONCLUSIONS The use of preprocedural ultrasound for neuraxial procedures in the nonobstetric adult population did not enhance the first pass success rate and increased the total time taken to a clinically insignificant extent. Improvement in secondary outcomes, including other markers of efficacy, should be interpreted with caution.

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Efficacy and safety of ultrasound-guided versus landmark-guided neuraxial puncture: a systematic review, network meta-analysis and trial sequential analysis of randomized clinical trials

de Carvalho,

Porto Genuino,

Vieira Morais

et al. 2024

Reg Anesth Pain Med

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BackgroundData suggest that preprocedural ultrasound may improve the efficacy of central neuraxial puncture. However, it remains uncertain whether these findings can be extended to various clinical scenarios, including diverse patient populations and the application of real-time ultrasound guidance. Additionally, it is unclear whether ultrasound-guided techniques improve safety and patient-centered outcomes.MethodsWe searched six databases for randomized trials of adult patients undergoing neuraxial puncture, comparing real-time ultrasound, preprocedural ultrasound, and landmark palpation for efficacy, safety and patient-centered outcomes. Our primary outcome was a failed first-attempt neuraxial puncture. After two-person screening and data extraction, meta-analyses were conducted and the Grading of Recommendations Assessment, Development and Evaluation approach was applied to assess the certainty of evidence.ResultsAnalysis of 71 studies involving 7153 patients, both real-time ultrasound (OR 0.30; 95% credible interval (CrI) 0.15 to 0.58; low certainty) and preprocedural ultrasound (OR 0.33; 95% CrI 0.24 to 0.44; moderate certainty) showed a significant reduction in the risk of a failed first neuraxial puncture. Real-time ultrasound had the best performance for preventing first-attempt failures (low certainty evidence). Although real-time ultrasound was also the leading method for reducing the risk of complete neuraxial puncture failure, the results did not show a statistically significant difference when compared with landmark palpation. Preprocedural ultrasound, however, significantly reduced the odds of complete puncture failure (OR 0.29; 95% CrI 0.11 to 0.61). These ultrasound-guided approaches also contributed to a reduction in certain complications and increased patient satisfaction without any other significant differences in additional outcomes. Trial sequential analysis confirmed that sufficient information was achieved for our primary outcome.ConclusionsUltrasound-guided neuraxial puncture improves efficacy, reduces puncture attempts and needle redirections, reduces complication risks, and increases patient satisfaction, with low to moderate certainty of evidence. Despite real-time ultrasound’s high ranking, a clear superiority over preprocedural ultrasound is not established. These results could prompt anesthesiologists and other clinicians to reassess their neuraxial puncture techniques.

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Paramedian Spinal Anesthesia: Landmark vs. Ultrasound-guided Approaches

Cited by 4 publications

References 22 publications

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

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

Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients

Efficacy and safety of ultrasound-guided versus landmark-guided neuraxial puncture: a systematic review, network meta-analysis and trial sequential analysis of randomized clinical trials

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