Ease of lumbar epidural catheter insertion with prepuncture ultrasound as guidance compared with conventional palpatory technique when performed by anesthesiology residents: 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.

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.