Preprocedural ultrasound versus landmark techniques for spinal anesthesia performed by novice residents in elderly: a randomized controlled trial

Marwan S Rizk,Waseem S Alfahel,Samia K Sayyid,Joanna N Bouez,Nathalie J Bteich,Sahar M Siddik-Sayyid,Carine A Zeeni

doi:10.1186/s12871-019-0882-8

Marwan S Rizk, Waseem S Alfahel + Show 5 more

Open Access

https://doi.org/10.1186/s12871-019-0882-8

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Abstract

BackgroundSpinal anesthesia using the midline approach might be technically difficult in geriatric population. We hypothesized that pre-procedural ultrasound (US)-guided paramedian technique and pre-procedural US-guided midline technique would result in a different spinal anesthesia success rate at first attempt when compared with the conventional landmark-guided midline technique in elderly patients.MethodsIn this prospective, randomized, controlled study, one hundred-eighty consenting patients scheduled for elective surgery were randomized into the conventional surface landmark-guided midline technique (group LM), the pre-procedural US-guided paramedian technique (group UP), or the pre-procedural US-guided midline technique (group UM) with 60 patients in each group. All spinal anesthesia were performed by a novice resident.ResultsThe successful dural puncture rate on first attempt (primary outcome) was higher in groups LM and UM (77 and 73% respectively) than in group UP (42%; P < 0.001). The median number of attempts was lower in groups LM and UM (1 [1] and 1 [1–1.75] respectively) than in group UP (2 [1, 2]; P < 0.001). The median number of passes was lower in groups LM and UM (2 [0.25–3] and 2 [0–4]; respectively) than in group UP (4 [2–7.75]; P < 0.001). The time taken to perform the spinal anesthesia was not different between groups LM and UM (87.24 ± 79.51 s and 116.32 ± 98.12 s, respectively) but shorter than in group UP (154.58 ± 91.51 s; P < 0.001).ConclusionsA pre-procedural US scan did not improve the ease of midline and paramedian spinal anesthesia as compared to the conventional landmark midline technique when performed by junior residents in elderly population.Trial registrationRetrospectively registered at Clinicaltrials.gov, registration number NCT02658058, date of registration: January 18, 2016.

Highlights

Spinal anesthesia using the midline approach might be technically difficult in geriatric population
We randomized 209 patients of whom twentynine did not receive the allocated intervention for the following reasons: the surgical procedure was canceled by the surgical team (4 patients), the attending anesthesiologist with the expertise in the US-guided technique was unavailable (11 patients), it was deemed that there was insufficient time to perform study assessments (3 patients), or there was a change in the anesthesia type (11 patients)
The successful dural puncture rate on first attempt was higher in groups Landmark-guided midline (LM) and Ultrasound guided midline technique (UM) (77 and 73% respectively) than in group Ultrasound guided paramedian (UP) (42%; P < 0.001)

Summary

Introduction

Spinal anesthesia using the midline approach might be technically difficult in geriatric population. The parasagittal oblique (PSO) view allows for a wider ultrasound window of the epidural space, providing an enhanced visibility of the neuraxis and surrounding structures compared to the TM view [8]. It is still not evident whether these superior PSO views lead to an easier paramedian needle insertion. There are no studies directly comparing the US-guided paramedian approach using the PSO view, the US-guided midline approach using the TM view, and the conventional landmark midline approach to perform spinal anesthesia by novice residents in elderly patients

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