Landmark-guided versus modified ultrasound-assisted Paramedian techniques in combined spinal-epidural anesthesia for elderly patients with hip fractures: a randomized controlled trial

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

BACKGROUND

Data 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.

METHODS

We 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.

RESULTS

Analysis 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.

CONCLUSIONS

Ultrasound-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.

Comparative efficacy of ultrasound guidance or conventional anatomical landmarks for neuraxial puncture in adult patients: a systematic review and network meta-analysis

BACKGROUND

Preprocedural, real-time, and computer-aided three-dimensional ultrasound has been widely used for neuraxial puncture; however, the optimal guidance is unclear. We examined the comparative efficacy of three ultrasound guidance and anatomical landmarks for neuraxial puncture in adults.

METHODS

We searched for randomised controlled studies comparing the efficacy of ultrasound guidance and anatomical landmarks for neuraxial puncture in adults using electronic databases and unpublished studies. The primary outcomes were first-pass success and patient satisfaction. A random-effects network meta-analysis (NMA) was used.

RESULTS

We identified 74 eligible studies (7090 patients). Preprocedural ultrasound and real-time ultrasound-guided neuraxial puncture improved first-pass success compared with anatomical landmarks (risk ratio [RR] 1.6; 95% credible interval [CrI] 1.3-1.9; RR 1.9; 95% CrI 1.3-2.9, respectively, moderate confidence). Computer-aided ultrasound-guided neuraxial puncture also increased first-pass success (RR 1.8; 95% CrI 0.97-3.3, low confidence), although estimates were imprecise. However, real-time ultrasound-guided neuraxial puncture resulted in minimal difference in first-pass success compared with preprocedural ultrasound (RR 1.2; 95% CrI 0.8-1.8, moderate confidence). Preprocedural ultrasound improved patient satisfaction slightly compared with anatomical landmark use (standardised mean differences 0.28; 95% CrI 0.092-0.47, low confidence).

CONCLUSIONS

This NMA provides evidence supporting ultrasound-guided neuraxial puncture compared with use of anatomical landmarks, including indirect comparisons. Among the three ultrasound guidance methods, preprocedural ultrasound appears to be a better adjunctive option.

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

Background

There are different types of real-time ultrasound (US)-guided combined spinal epidural (CSE) anesthesia techniques. We aimed to investigate the effect of real-time US-guided paramedian sagittal oblique (PSO), transverse interlaminar (TI) approach method, and landmark-guided (LG) CSE anesthesia.

Methods

Ninety patients who underwent CSE block were included in the study. Patients were randomized into LG (n = 30), PSO (n = 30), and TI (n = 30) groups. The primary outcome was number of needle manipulations. The secondary outcomes are the number of attempts, needle visibility, procedure time, procedure success rate, catheter placement difficulty, posterior complex distance, and complications.

Results

The number of needle manipulations was statistically significantly lower in the LG technique group (P < 0.000). When the number of attempts, the difficulty of catheter placement, and the procedure's success rate were compared between the three groups, we did not find a statistically significant difference (P > 0.05). In addition, when the procedure times were compared, the time measured for the LG group was statistically significantly lower than in the PSO and TI groups (P < 0.000).

Conclusion

In the results of this study, the real-time US-guided CSE anesthesia application had a similar success and complication level with LG technique. The LG method had a shorter processing time and fewer needle manipulations.

Administration of combined spinal epidural anesthesia with ultrasound-assisted positioning in obese patients undergoing open hysterectomy: A randomized controlled trial

BACKGROUND

Administration of combined spinal epidural anesthesia (CSEA) with traditional landmark-guided positioning can be challenging in patients with high body mass index (BMI). The popularization of ultrasound technology may effectively solve these problems. However, reports on the administration of CSEA ultrasound-assisted positioning in obese populations are relatively limited and have made inconsistent conclusions. We aimed to investigate the ability of ultrasound-assisted positioning to improve the success rate of CSEA in obese patients.

METHODS

Overall, 118 adult women with a BMI ≥ 30 kg/m2 who scheduled to undergo open hysterectomy and received CSEA were recruited. Finally, 108 patients were enrolled and randomly assigned to 2 groups: the ultrasound-assisted positioning group (group A) and traditional landmark-guided positioning group (group B). Ultrasound-assisted or landmark-guided positioning was employed to locate the puncture interspace before anesthesia. The primary outcomes were the success rate of first attempt and number of attempts. The secondary outcomes were the patient positioning accuracy, positioning time, CSEA operation time, patient-satisfaction scores, anesthesia characteristics, and complications of CSEA.

RESULTS

The success rate of patient first puncture attempt in group A was significantly higher than that in group B (78.4% vs 52.9%, P = .007). The total number of punctures was lower in group A than that in groups B (average rank 44.54 vs 58.46, P = .005). Using ultrasound positioning as the gold standard, the accuracy of landmark-guided location was only 67%. Positioning time in croup A was longer in group A than that in group B (P = .004), while CSEA operation time spent in Group A was less than that in Group B (P < .001). Patient satisfaction score in group A was significantly higher than that in group B (P = .002). The successful puncture interspace in group A were more likely at L3-4 than that in group B (P = .02).

CONCLUSION

The success rate of first puncture attempt and positioning accuracy in CSEA with ultrasound-assisted is significantly higher than those based on landmark-guided location in obese patients.

Impact of Ultrasound-Assisted Method on Success Rate of Spinal Anesthesia Performed by Novice Trainees: A Retrospective Comparative Study

In current practice, single-shot spinal anesthesia has traditionally been performed using the conventional surface-anatomic-Landmark-Guided technique. This "blind" technique has significant critical issues such as a high risk of complications due to the numerous attempts at spinal needle placement and the negative impact on the learning curve of the trainees. Ultrasound-Assisted spinal anesthesia could reduce these critical issues and allow trainees to perform the procedure more easily and with fewer complications for the patient. We performed a before-and-after monocentric retrospective comparative study at the University of Naples "Federico II" (Naples, Italy). Inclusion criteria were as follows: patients aged 18 years or older; ASA physical status between I and IV; and elective orthopedic surgery under single-shot spinal anesthesia performed by supervised trainees between January 2022 and December 2022. In the selected cohort, 88 patients were included in group A (Landmark-Guided spinal anesthesia) and 91 in group B (Ultrasound-Assisted spinal anesthesia). The number of attempts by trainees (p-value < 0.005), procedure performing time (<0.001), and patient discomfort (<0.001) were significantly lower in group B than in group A. Ultrasound-Assisted single-shot spinal anesthesia performed by novice trainees reduces the number of attempts, complication rate, periprocedural pain, and patient discomfort.

Comparative Study Between Conventional Landmark Versus Ultrasound-Guided Paravertebral Block in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Study

INTRODUCTION

Thoracic paravertebral block (TPVB) has emerged as an effective and safe regional technique for providing postoperative analgesia. We aimed to compare the ease and efficacy of conventional landmark and ultrasound-guided (USG) paravertebral blocks for postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

METHODS

This was a randomized controlled study. Seventy-six patients of either sex, age 18-40 years, body mass index (BMI) 18-29 kg/m², American Society of Anesthesiologists physical status classifications I and II posted for elective laparoscopic cholecystectomy under general anesthesia were randomly allocated into two groups of 38 each. Patients in group A were administered a paravertebral block using the anatomical landmark technique (ALT), and group B using an ultrasound-guided paravertebral block in the sitting position. In both groups, 20 ml of 0.5% bupivacaine injection was administered at the T7 vertebral level on the right side. The primary outcome was the first-pass success rate. Secondary outcomes were the number of passes and attempts, duration of analgesia, visual analog scale (VAS) score for pain during 24 h postoperatively and complications if any, were recorded.

RESULTS

No patients were excluded in the study. Demographic characteristics were comparable in both groups. The number of passes was less in group B (1.45±0.5) compared to group A (2.42±0.95) and was reported to be statistically significant (p = 0.001). The number of attempts was less in group B (1.00±0) as compared to group A (1.29±0.46) and was statistically significant (p = 0.001). The duration of analgesia was longer in group B (530.00±326.33 minutes) compared to group A (345.60±252.95 minutes) and was observed to be statistically significant (p<0.05). The VAS score was significantly lower in group B (1.87±0.78, 2.24 ±0.82) compared to group A (2.42±0.72, 3.13±1.07) at the second and fourth hours, respectively (p = 0.001).  Conclusion: We concluded that paravertebral block using an ultrasound-guided technique is more efficacious than the conventional landmark technique for postoperative analgesia in patients undergoing laparoscopic cholecystectomy.

Usage of augmented reality for interventional neuraxial procedures: A phantom-based study

BACKGROUND

Neuraxial access is necessary for an array of procedures in anaesthesia, interventional pain medicine and neurosurgery. The commonly used anatomical landmark technique is challenging and requires practical experience.

OBJECTIVE

We aimed to evaluate the technical feasibility of an augmented reality-guided approach for neuraxial access and tested the hypothesis that its use would improve success as the primary outcome. As secondary outcomes, we measured accuracy and the procedural duration compared with the classical landmark approach.

DESIGN

A randomised phantom-based study.

SETTING

The three-dimensional image of a thoracolumbar phantom spine model with the surrounding soft tissue was created with a neurosurgical planning workstation and ideal trajectories to the epidural space on the levels T10-L1 were planned using a paramedian approach. Both the three-dimensional holographic image of the spine and the trajectories were transferred to an augmented reality-headset. Four probands (two anaesthesiologists, one neuroradiologist and one stereotactic neurosurgeon) performed 20 attempts, 10 each of either conventional landmark or augmented reality-guided epidural punctures, where anatomical level, side and sequence of modality were all randomised.

OUTCOME MEASURES

Accuracy was assessed by measuring Euclidean distance and lateral deviation from the predefined target point. Success of epidural puncture on the first attempt was compared between the conventional and the augmented reality-guided approaches.

RESULTS

Success was achieved in 82.5% of the attempts using augmented reality technique, compared with 40% with the conventional approach [ P  = 0.0002, odds ratio (OR) for success: 7.07]. Euclidean distance (6.1 vs. 12 mm, P  < 0.0001) and lateral deviation (3.7 vs. 9.2 mm, P  < 0.0001) were significantly smaller using augmented reality. Augmented reality-guided puncture was significantly faster than with the conventional landmark approach (52.5 vs. 67.5 s, P  = 0.0015).

CONCLUSION

Augmented reality guidance significantly improved the accuracy and success in an experimental phantom model of epidural puncture. With further technical development, augmented reality guidance might prove helpful in anatomically challenging neuraxial procedures.

Dual- vs. Single-Plane Ultrasonic Scan-Assisted Positioning during Lumbar Spinal Puncture in Elderly Patients: A Randomized Controlled Trial

The purpose of this study was to investigate the ability of single- versus dual-plane ultrasound scan-assisted spinal anesthesia techniques to improve the success rate and efficacy of spinal anesthesia in elderly patients undergoing lower extremity surgery. A total of 120 elderly patients undergoing lower extremity surgery were randomly assigned to either receive single-plane (Group A) or dual-plane ultrasonic scan-assisted spinal anesthesia (Group B). The primary outcome analyzed by this study was first-attempt success rate. Secondary outcomes analyzed included number of needle insertion attempts, needle redirections, locating time, procedural time, total time, puncture depth, quality of ultrasound images, level of block, adverse reactions, and complications. The first-attempt success rate was significantly higher in Group B compared to Group A (88.3% vs. 68.3%, p = 0.008). In comparison with Group A, the number of needle insertion attempts (1 (1−2) vs. 1 (1−1), p = 0.005) and needle redirections (2 (1−3) vs. 1 (0−2), p < 0.001) were both significantly lower in Group B; Group B also had a shorter procedural time (249.2 ± 30.1 vs. 380.4 ± 39.4 s, p < 0.001) but a longer locating time (250.1 ± 26.2 vs. 137.8 ± 13.5 s, p < 0.001). The dual-plane ultrasonic scan-assisted spinal anesthesia technique warrants consideration for application in elderly patients.

Comparative evaluation of three techniques for paramedian subarachnoid block: Point-of-care preprocedural ultrasound assisted, real-time ultrasound guided and landmark based

Background and Aims

Preprocedural ultrasound (US) assisted and real-time US-guided subarachnoid block (SAB) are useful adjuncts for successful SAB. This study compared the feasibility and efficacy of real-time US-guided SAB with preprocedural US-assisted and landmark-based SAB using paramedian approach.

Methods

The study enroled 150 American Society of Anesthesiologists I and II patients, aged 20-65 years, scheduled for lower limb orthopaedic surgery under SAB. In group L (n = 50), the patients underwent landmark-guided SAB utilising paramedian approach. In group P (n = 50), preprocedural US-assisted SAB was instituted and in group M (n = 50) real-time US-guided SAB was administered. The number of needle attempts for a successful SAB was the primary outcome. The secondary outcomes included successful SAB in first attempt, time taken to perform SAB and patients' satisfaction.

Results

The number of attempts for SAB were (mean ± standard deviation = 1.05 ± 0.35, 1.00 ± 0.28, 1.03 ± 0.26) in groups L, P and M, respectively (P = 0.436). The SAB was successful in the first attempt in 82%, 82% and 80% in groups L, P and M, respectively (P = 0.207). The time taken for the successful SAB was more in group M as compared to groups L and P (groups L and M, P = 0.045 and groups P and M, P = 0.004). The patients' satisfaction score was comparable.

Conclusion

Real-time US guidance for spinal anaesthesia resulted in needle attempts comparable to landmark and preprocedural US-assisted SAB in patients with a normal spine. The time required for the completion of the block was more in real-time US-guided SAB.

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

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.

Real-Time Ultrasound-Guided Versus Ultrasound-Assisted Spinal Anesthesia in Elderly Patients With Hip Fractures: A Randomized Controlled Trial

BACKGROUND

Traditional landmark-guided spinal anesthesia can be challenging in elderly patients with hip fractures. Ultrasound assistance (USAS) and real-time ultrasound guidance (USRTG) techniques can facilitate lumbar neuraxial blocks. However, it remains undetermined which method is optimal for use in elderly patients. This study aimed to evaluate which technique was associated with a higher success rate of spinal anesthesia in elderly patients with hip fractures: USAS or USRTG technique.

METHODS

A total of 114 elderly patients (≥70 years of age) with hip fractures were randomly assigned to receive spinal anesthesia using either the USAS or USRTG technique. The primary outcome was the first-attempt success rate, analyzed using the χ2 test. Secondary outcomes included first-pass success rate, the number of needle attempts and passes, locating time, procedure time, total time, adverse reactions and complications, patient satisfaction, and procedural difficulty score.

RESULTS

The first-attempt success rate (80.7% vs 52.6%; 95% confidence interval [CI], for the difference, 11.6-44.6) and first-pass success rate (63.2% vs 31.6%; 95% CI for the difference, 14.2-49) were both significantly higher in the USAS compared with the USRTG group (both P = .001). The number of attempts (1 [1-1] vs 1 [1-3]; P = .001) and median passes (1 vs 3; P < .001) were both significantly lower in the USAS group than in the USRTG group. The USRTG group had a shorter locating time (175 seconds [129-234 seconds] vs 315 seconds [250-390 seconds]; P < .001) but a longer procedure time (488 seconds [260-972 seconds] vs 200 seconds [127-328 seconds]; P < .001) and total time (694 seconds [421-1133 seconds] vs 540 seconds [432-641 seconds]; P = .036). There were no significant differences between the 2 groups with regard to the adverse reactions and complications. More patients in the USAS group had a high satisfaction score of 3 to 5 (P = .008). Overall, anesthesiologists rated the USRTG group procedure as "more difficult" (P = .008).

CONCLUSIONS

In elderly patients with hip fractures, spinal anesthesia with the USRTG technique is not superior to the USAS technique since it has a lower success rate, longer procedure time, lower satisfaction score, and is more difficult to perform. So USAS technique may be more suitable for elderly patients.

Conventional landmark palpation versus preprocedural ultrasound for neuraxial procedures in nonobstetric patients: A systematic review with meta-analysis and trial sequential analysis of randomised controlled trials

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, I2 = 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; I2 = 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; I2 = 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; I2 = 29%) and the number of needle redirections (mean difference -1.24; 95% CI, -2.32 to -0.17; P = 0.020; I2 = 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; I2 = 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.

Using Lumbar X-Ray to Facilitate Modified Taylor's Approach of Spinal Anesthesia in an Elderly Patient With Scoliosis

In geriatric patients scheduled for hip or knee surgery, neuraxial anesthesia is a safe and effective anesthesia method and may be a better option than general anesthesia. Unfortunately, establishing neuraxial anesthesia is not always easy in this group of patients. Anatomical abnormalities, such as spinal stenosis, scoliosis, and narrowed interspaces, contribute to the difficulties that anesthesiologists face while performing these procedures. The classic Taylor’s approach targets the widest interspace, L5-S1, as the needle insertion site and accordingly has an increased success rate in difficult neuraxial anesthesia. As this technique historically relies solely on palpation, it might be difficult in patients with less prominent or distorted anatomic landmarks. Ultrasonography or fluoroscopy guidance may help to better target the epidural or subarachnoid space, but both have limitations due to equipment availability or provider expertise. The modified Taylor’s approach we propose in this case report is based on preoperative lumbar x-ray interpretation when point-of-care image guidance cannot be performed. By measuring on the patient’s preoperative lumbar x-ray, we successfully performed a modified Taylor's approach of spinal anesthesia on an elderly patient with severe scoliosis. She underwent open reduction and internal fixation (ORIF) of the left femur with satisfactory pain control and no complications.

Correction to: Landmark-guided versus modified ultrasound-assisted Paramedian techniques in combined spinal-epidural anesthesia for elderly patients with hip fractures: a randomized controlled trial

An amendment to this paper has been published and can be accessed via the original article.