Epidural Needle Research Articles

Comparison of ultrasound‐guided transmuscular quadratus lumborum block catheter technique with surgical pre‐peritoneal catheter for postoperative analgesia in abdominal surgery: a randomised controlled trial

Following abdominal surgery, the provision of postoperative analgesia with local anaesthetic infusion through both transmuscular quadratus lumborum block and pre-peritoneal catheter have been described. This study compared these two methods of postoperative analgesia following laparotomy. Eighty-two patients 18-85years of age scheduled to undergo elective surgery were randomly allocated to receive either transmuscular quadratus lumborum block or pre-peritoneal catheter block. In the transmuscular quadratus lumborum group, an 18-gauge Tuohy needle was passed through the quadratus lumborum muscle under ultrasound guidance to reach its anterior aspect. A 20-ml bolus of ropivacaine 0.375% was administered and catheters placed bilaterally. In the pre-peritoneal catheter group, 20ml of ropivacaine 0.375% was infiltrated at each of three subcutaneous sub-fascial levels, and pre-peritoneal plane catheters were placed bilaterally. Both groups received an infusion of ropivacaine 0.2% at 5ml.h-1 , continued up to 48h along with a multimodal analgesic regime that included regular paracetamol and patient-controlled analgesia with fentanyl. The primary end-point was postoperative pain score on coughing, assessed using a numerical rating score (0-10). Secondary outcomes were pain score at rest, fentanyl usage until 48h post-operation, satisfaction scores and costs. There was no treatment difference between the two groups for pain score on coughing (p=0.24). In the transmuscular quadratus lumborum group, there was a reduction in numerical rating score at rest (p=0.036) and satisfaction scores on days 1 and 30 (p=0.004, p=0.006, respectively), but fentanyl usage was similar. In the transmuscular quadratus lumborum group, the highest and lowest blocks observed in the recovery area were T4 and L1, respectively. The transmuscular quadratus lumborum technique cost 574.64 Australian dollars more per patient than the pre-peritoneal catheter technique.

The benefits of radiological imaging for postoperative orthostatic headache: a case report

BackgroundTraditionally, the diagnosis of post-dural puncture headache (PDPH) relied upon the patient’s history regarding dural puncture and symptoms, such as orthostatic headache. However, such evidence may not always be reliable or specific. We report an unexpected diagnosis with spontaneous intracranial hypotension (SIH), which was confirmed upon examination of Magnetic Resonance (MR) images in a patient who was initially suspected to have PDPH because he had recently undergone a uncertain dural puncture.Case presentationA 45-year-old man had undergone a thoracic epidural catheter insertion for perioperative analgesia prior to general anesthesia induction. Due to intermittent dripping of fluid while the epidural needle was being advanced, a dural puncture was suspected. The patient complained of an orthostatic headache after recovery from surgery, therefore a PDPH was suspected. MR images revealed signs of SIH: dural sinus engorgement, contrast enhancement along the neural sleeves of the left C6–7, bilateral C7-T1, T1–2, T2–3, T3–4, T4–5, and T5–6. Computed tomography-guided epidural blood patching (EBP) was performed the following day, with the patient experiencing immediate relief of the headache.ConclusionThe benefits of radiological imaging in this case included confirming the correct diagnosis, guiding the accurate level and proper approach of EBP, distinguishing the epidural space from the intrathecal space, and ultimately increasing the likelihood of successful EBP.

Distributed fiber optics 3D shape sensing by means of high scattering NP-doped fibers simultaneous spatial multiplexing.

A novel approach for fiber optics 3D shape sensing, applicable to mini-invasive bio-medical devices, is presented. The approach exploits the optical backscatter reflectometry (OBR) and an innovative setup that permits the simultaneous spatial multiplexing of an optical fibers parallel. The result is achieved by means of a custom-made enhanced backscattering fiber whose core is doped with MgO-based nanoparticles (NP). This special NP-doped fiber presents a backscattering-level more than 40 dB higher with respect to a standard SMF-28. The fibers parallel is built to avoid overlap between NP-doped fibers belonging to different branches of the parallel, so that the OBR can distinguish the more intense backscattered signal coming from the NP-doped fiber. The system is tested by fixing, with epoxy glue, 4 NP-doped fibers along the length of an epidural needle. Each couple of opposite fibers senses the strain on a perpendicular direction. The needle is inserted in a custom-made phantom that simulates the spine anatomy. The 3D shape sensing is obtained by converting the measured strain in bending and shape deformation.

Simulating a syringe behavior using a pneumatic cylinder haptic interface

Mastering medical gestures, such as epidural needle insertion, requires much practice. Haptic interfaces can be efficient training solutions. Nevertheless, they must provide users with an accurate experience for an effective training. This article introduces a control framework that turns a pneumatic cylinder into a haptic interface able to simulate a syringe and more specifically the loss of resistance phenomenon encountered during an epidural needle insertion. To achieve this, the framework switches between two control laws (position and force tracking) according to the system state. Experiments involving two anesthetists confirm the practicality of this system for hands-on training or rehearsal purposes.

A Review of Pneumatic Actuators Used for the Design of Medical Simulators and Medical Tools

Simulators have been traditionally used for centuries during medical gestures training. Nowadays, mechatronic technologies have opened the way to more evolved solutions enabling objective assessment and dedicated pedagogic scenarios. Trainees can now practice in virtual environments representing various kind of patient and body parts including physio-pathologies issues. Gestures, to be mastered, vary according to each medical specialty (e.g., ultrasound probe orientations, or forceps installation during assisted delivery). Hence, medical students need kinesthetic feedback in order to significantly improve their learning capabilities. Gesture simulators require haptic devices with variable stiffness actuators. Existing solutions do not always fit the requirements because of their significant size. Contrary to electric actuators, pneumatic technology is low-cost, available off-the-shelf and offers a better mass–power ratio. However, it presents two main drawbacks: nonlinear dynamics and need for a compressed air supply. During the last decade, we have developed several haptic solutions based on pneumatic actuation (e.g., birth simulator, epidural needle insertion simulator) and, recently, in a joint venture with Prisme laboratory, a pneumatic probe master device for remote ultrasonography. This paper recalls literature scientific approaches on pneumatic actuation developed in the medical context and illustrated with the aforementioned applications to highlight the benefits.

Lumbar Drain Tunneling: A Safe Two-Needle Technique

AbstractLumbar drain catheter insertion for prolonged periods of time is necessary in a myriad of neurosurgical patients which entails its tunneling. We describe a safe and simple technique of catheter insertion and tunneling using two Tuohy needles instead of one, which prevents unintentional catheter damage during the procedure.

Single-Site Laparoscopic Percutaneous Extraperitoneal Closure of the Internal Ring Using an Epidural Needle for Children with Inguinal Hernia.

BackgroudThis study evaluated the safety and effectiveness of single-site laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle for children with inguinal hernia.Material/MethodsWe retrospectively analyzed clinical data of 542 children with inguinal hernia who underwent single-site laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle at our hospital from June 2014 to June 2017.ResultsAll patients successfully underwent surgery and none were converted to conventional surgery. Abdominal vascular injury, vasectomy injury, testicular vascular injury, umbilical hernia, iatrogenic cryptorchidism, testicular atrophy, hydrocele, hernia recurrence, and scrotal edema were not reported during the perioperative period. A follow-up of these patients was performed for 12–24 months. During the follow-up period, umbilical hernia, iatrogenic cryptorchidism, testicular atrophy, and hydrocele were not noted, but 3 cases of hernia recurrence were found.ConclusionsThe single-site laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle for children with inguinal hernia is safe and effective, and this procedure has the advantages of minimal trauma, no scarring, and good cosmetic effect.

Failed dural puncture during needle-through-needle combined spinal-epidural anesthesia: a case series.

ObjectiveCombined spinal–epidural (CSE) anesthesia is a widely used neuraxial anesthetic technique. In clinical practice, failed dural puncture during needle-through-needle technique occasionally occurs, with incidence of 5%–29%. We radiologically evaluated four cases of failed dural puncture during needle-through-needle CSE anesthesia.Case seriesFour patients received CSE anesthesia for elective orthopedic surgery. CSE procedures were performed in the same manner using a CSE device for needle-through-needle technique. An epidural needle was inserted in midline at L4/5 interspaces using loss of resistance to air whilst patients lay in the lateral decubitus position. The spinal needle was then inserted through the epidural needle for subarachnoid block, however, negative cerebrospinal flow was identified. Subsequently, radiographic imaging using C-arm fluoroscopy was performed to evaluate the status of needles. We found that epidural needles were considerably deviated from the midline, while spinal needles exited epidural needles, not through back holes, but through the Tuohy curve in three patients. In one patient, when the spinal needle was inserted to 12 mm, the anesthesiologist felt the needle touching the bony structure. The spinal needle was in contact with the superior articular process of the fifth lumbar vertebra, which was confirmed by C-arm radiography.ConclusionExcessive paramedian deviation of the epidural needle may affect dural puncture during needle-through-needle CSE technique. Moreover, wrong passage of the spinal needle through Tuohy curve instead of the back hole, may contribute to failure of dural puncture.

Fluoroscopic evaluation of the influence of needle gauge on epidural spread in caudal block

Caudal block has limited injectate distribution to the desired lumbar level due to the relatively long distance from the injection site and reduction in the volume of injectate due to leakage into the sacral foramen. The objective of this study was to investigate the influence of needle gauge on fluoroscopic epidural spread and to assess the correlation between the spread level and analgesic efficacy in patients undergoing caudal block. We retrospectively analyzed data from 80 patients who received caudal block for lower back and radicular pain. We categorized patients based on the epidural needle gauge used into group A (23 gauge), group B (20 gauge), and group C (17 gauge). Fluoroscopic image of the final level of contrast injected through the caudal needle and pain scores before the block and 30 minutes after the block recorded using a numerical rating scale, were evaluated. Of the 80 patients assessed for eligibility, 7 were excluded. Thus, a total of 73 patients were finally analyzed. Age, sex, body mass index, diagnosis, lesion level, lesion severity, and duration of pain did not differ among the 3 groups. All patients showed cephalic spread of contrast. Contrast spread beyond L5 was seen in 26.9% of patients in group A, 41.7% in group B, 39.1% in group C, and 35.6% overall; there was no significant difference among the groups (P = .517). Analgesic efficacy was not significantly different among the groups (P = .336). The needle gauge did not influence the level of epidural spread or analgesic efficacy in caudal block.

Laparoscopic Percutaneous Extraperitoneal Internal Ring Closure for Pediatric Inguinal Hernia: 1,142 Cases.

Purpose: The purpose of this study was to summarize the clinical experience of the laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle for the treatment of inguinal hernias. Methods: There were 1,142 children with an isolated inguinal hernia who participated in this study from January 2013 to May 2018. An epidural needle was used to treat the indirect inguinal hernia with laparoscopic assistance. Symptoms and signs were followed up at 1 week, 3 months, and every 1-2 years after the operation. Results: All 1,142 children underwent laparoscopic surgery successfully. All patients were discharged 1-2 days after the operation. During the hospitalization and follow-up, there were 21 patients with complications, including 6 cases of hernia recurrence, 7 cases of poor healing of the umbilical incision, 5 cases of suture granuloma and 3 cases of groin traction pain discomfort. None of the following complications occurred: abdominal wall vascular injury, deferent duct injury, umbilical hernia, iatrogenic cryptorchidism, testicular atrophy, hydrocele, or scrotal oedema. Conclusion: Laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle is a safe and feasible method for the treatment of inguinal hernias in children. This method has the advantages of less trauma, no scarring and a good cosmetic effect.

Use of transversus abdominis plane block in chinchillas (Chinchilla lanigera)

ABSTRACT The association of regional anesthetic techniques in a balanced anesthesia aims to reduce the use of injectable and inhalation anesthetics for a smoother recovery and better postoperative recovery of the patient. The transversus abdominis plane block (TAP block) is already an option besides epidural block in humans, dogs, and cats. An ultrasound-guided approach was used with a 22-gauge Tuohy needle to deliver the local anesthetics between the internal abdominal oblique and the transversus abdominis muscles in chinchillas. This is the first report of the use of this regional anesthetic technique in rodents.

Unilateral Epidural Blockade for Lower Limb Fracture Surgery: Parasagittal Epidural Versus Midline Epidural Anesthesia.

Objective:To compare the efficacy of parasagittal interlaminar (PIL) and midline interlaminar (MIL) approaches for epidural block in patients with lower limb orthopedic surgery. Methods:This double-blind randomized clinical trial was performed on 40 patients undergoing tibial shaft fracture surgery. In PIL group, an 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L2-3 or L3-4 intervertebral spaces and pushed forward in a posteroanterior (PA) direction vertical to the body surface. After determining the most lateral place for needle arrival in an anteroposterior (AP) view, needle was pushed forward into the epidural space. For the MIL group, needle was pushed forward from the midline interspinous space with the same method. After confirmation of needle position, 1 mL of contrast was injected to confirm the epidural space distribution and then 15 ml lidocaine 2% was injected. The sensory and motor block level, onset, duration, heart rate (HR), mean arterial pressure (MAP), and arterial oxygen saturation (SPO2), and success rate were recorded. Results:Mean patients’ baseline characteristics showed no statistically significant difference between the two groups.p>0.05). Outcome measures were statistically different and significantly higher in PIL group (p-values for sensory block level <0.001, motor block level <0.001, duration of sensory block: <0.001 and duration of motor block <0.001 and success rate: <0.001). Hemodynamic variables didn’t show statistically significant difference between the two groups (p-values for Systolic pressure: 0.997, diastolic pressure:0.579, MAP:0.585, HR:0.710).Conclusion:Epidural anesthesia with parasagittal interlaminar approach provide deep motor block, high sensory level block, and hemodynamic stability.Clinical trial registry: IRCT2017041615515N2

Effects of Epidural Needle Rotation on Evolution of Unilateral Epidural Block and Patients' Hemodynamics beside Recovery Profile in Patients Undergoing Arthroscopic Knee Surgeries; A Randomized Clinical Trial.

Objective:To evaluate the evolution pattern of epidural block after rotating the needle tip 45° to the operative side and evaluate its effects on patients’ hemodynamics and recovery profile in those undergoing arthroscopic knee surgery.Methods:Forty participants were randomly subdivided into control and rotation group (n=20). An 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L4-5 and pushed forward into the epidural space through parasagittal approach, in control group, the needle was pushed forward to the epidural space in cephaldad 90 degrees. For the rotation group, the needle was pushed forward to the epidural space and the tip was rotated 45 degrees to the surgical side.15 mL of bupivacaine 0.5% was injected and evolution of sensory and motor blocks until 2-segment regression of the sensory level below to T10 as well as total duration of motor block and surgery were recorded. Hemodynamic parameters (HR, MAP, and SPO2), hypotension, fluid intake, vasopressors, first ambulation and spontaneous urination were recorded. Statistical analysis was performed using SPSS and P≤0.5 considered significant.Results: Sensory block up to T10 level, Complete motor block and time for 2-segment regression of sensory level were earlier in the 45°-rotation than in the control group (p<0.001). Total duration of motor block in control group was lower than rotation group (p<0.001).Hypotension, N&V, vasopressors and fluid intake showed no statistically difference between the two groups (p=0.219). First spontaneous urination and ambulation were significantly lower in rotation group (p<0.001).Conclusion:45 degrees’ needle rotation to the surgical side provides a faster block evolution and hastened recovery profile with no significant difference in hemodynamic fluctuations.Clinical trial registry: IRCT20130518013364N7

An evaluation of contrast dispersal pattern on preganglionic epidural injection through trans-lateral recess approach in patients with lumbosacral radiculopathy.

To evaluate the accessibility of the preganglionic epidural space in patients with lumbosacral radiculopathy treated with epidural steroid injection (ESI) through trans-lateral recess (TLR) approach. From September 2016 to December 2016, we enrolled 50 consecutive preganglionic ESI through TLR approach for 38 patients with lumbosacral radiculopathy at or below L4 territory. Fifteen of patients were diagnosed with lumbar disc herniation and 23 with lumbar spinal stenosis. TLR epidural injection was performed with 20-G Tuohy needles. To achieve proper final needle placement (i.e., in the axillary portion between the exiting and transversing nerve roots), the needle direction was set laterally from the center of the infra-adjacent spinous process to the medial wall of the corresponding pedicle and superiorly from the distal tip of infra-adjacent spinous process to the corresponding vertebral foramen. Finally, 1mL of contrast was injected to assess the epidurographic pattern. All patients achieved filling of the dorsal and ventral epidural space. Rostral spreading along the exiting nerve root to the foramen of target segment was present in 48/50 (96%) patients and caudal spreading along the transversing nerve root to the foramen of lower segment in 45/50 (90%) patients. No intravascular injection or dural puncture-related neural complications were observed. When delivered using the TLR approach, epidural injections result in excellent drug spread within the preganglionic area (i.e., ventral epidural contrast filling and periradicular infiltration of exiting and transversing nerve roots). As noted previously that higher rates of pre-ganglionic epidural infiltration might be led to improvements in clinical pain and disability, epidural injections delivered using the TLR approach are expected to complement existing epidural modalities. These slides can be retrieved under Electronic Supplementary Material.

Real-time Ultrasound-Guided Lumbar Epidural with Transverse Interlaminar View: Evaluation of an In-Plane Technique.

The anatomical landmarks method is currently the most widely used technique for epidural needle insertion and is faced with multiple difficulties in certain patient populations. Real-time ultrasound guidance has been recently used to aid in epidural needle insertion, with promising results. Our aim was to test the feasibility, success rate, and satisfaction associated with a novel real-time ultrasound-guided lumbar epidural needle insertion in the transverse interlaminar view. Prospective descriptive trial on a novel approach. Operating room and preoperative holding area at a tertiary care hospital. Adult patients presenting for elective open prostatectomy and planned for surgical epidural anesthesia. Consented adult patients aged 30-80 years scheduled for open prostatectomy under epidural anesthesia were enrolled. Exclusion criteria included allergy to local anesthetics, infection at the needle insertion site, coagulopathy, and patient refusal. A curvilinear low-frequency (2-5 MHz) ultrasound probe and echogenic 17-G Tuohy needles were used by one of three attending anesthesiologists. Feasibility of epidural insertion was defined as a 90% success rate within 10 minutes. Twenty-two patients were enrolled into the trial, 14 (63.6%) of whom found the process to be satisfactory or very satisfactory. The median time to perform the block was around 4.5 minutes, with an estimated success rate of 95%. No complications related to the epidural block were observed over the 48 hours after the procedure. We demonstrate the feasibility of a novel real-time ultrasound-guided epidural with transverse interlaminar view.

Face and construct validity of TU-Delft epidural simulator and the value of real-time visualization

Background and objectivesLearning epidural anesthesia traditionally involves bedside teaching. Visualization aids or a simulator can help in acquiring motor skills, increasing patient safety and steepening the learning curve. We evaluated...

Optically Guided Epidural Needle Placement Using 405-nm Wavelength for Accurate Puncture

Several approaches of locating the epidural space have been proposed. However, loss of Resistance method (LOR) remains the most common method for epidural anesthesia. Different optical signals were received from the ligamentum flavum and the epidural space allows operator to pinpoint position of the needle and determine whether the needle tip has entered the epidural space. Optical signals throughout the penetration process was recorded and position of needle tip was confirmed with a C-arm fluoroscopy. 60 lumbar punctures were performed in 20 vivo porcine models, and success rate of locating the epidural space with the optical auxiliary is calculated statistically. The data are expressed in mean ± SD. During all the lumber puncture processes, the strength of optical signals received decreased significantly while the needle tip penetrates the ligamentum flavum and entered the epidural space. The strength of optical signal received when needle tip was in the ligamentum flavum was 1.38 ± 0.57. The signal strength at epidural space was 0.46 ± 0.35. Strength of signal decreased by 67% when entered epidural space, and there is no significant differences in decrease of strength from data obtained from thevertebrae (lumbar segments)L2-L3, L3-L4, and L4-L5. Finally, we calculated with assistance of the proposed optical auxiliary, the success rate for guiding the needle tip to the epidural space using was as high as 87%. It is evidently believed that the optical auxiliary equipped is visualized to assist operators inserting needle accurately and efficiently into epidural space during epidural anesthesia operation.

Differentiating False Loss of Resistance from True Loss of Resistance While Performing the Epidural Block with the CompuFlo® Epidural Instrument.

Background The occurrence of false losses of resistance may be one of the reasons for inadequate or failed epidural block. A CompuFlo® epidural instrument has been introduced to measure the pressure of human tissues in real time at the orifice of a needle and has been used as a tool to identify the epidural space. The aim of this study was to investigate the sensitivity and the specificity of the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance encountered during the epidural space identification procedure. Method We performed epidural block with the CompuFlo® epidural instrument in 120 healthy women who requested labor epidural analgesia. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase in the pitch of the audible tone) was followed by a sudden and sustained drop in pressure for more than 5 seconds accompanied by a sudden decrease in the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau. We evaluate the sensitivity, specificity, and positive and negative predictive values of the ability of CompuFlo® recordings to correctly identify the true LOR from the false LOR. Results The drop in pressure associated with the epidural space identification was significantly greater than that recorded after the false loss of resistance (73% vs 33%) (P=0.000001). The sensitivity was 0.83, and the AUC was 0.82. Discussion We have confirmed the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance and established its specificity and sensitivity. Conclusion An easier identification of dubious losses of resistance during the epidural procedure is essential to reduce the number of epidural attempts and/or needle reinsertions with the potential of a reduced risk of accidental dural puncture especially in difficult cases or when the procedure is performed by trainees.

Effect of young's modulus of porcine ligamentum flavum on the epidural needle insertion

In order to predict how much the human ligamentum flavum will be deformed and tented during insertion of an epidural needle, experiments with the porcine spines were done to check the effect of Young's modulus of the porcine ligamentum flavum. Porcine ligamentum flavums were harvested with vertebral bones and trimmed in rectangle shape. The epidural needle was inserted at 0.8 mm/s with a linear actuator from perpendicular to stretch direction of the specimens. Reaction force as insertion resistance with a load cell and side view of the specimen and the needle as deformation of the ligamentum flavum with a CCD camera were recorded synchronously. As results, width of vertebral bones related the maximum deformation, while no relation was observed between width of vertebral bones and the maximum insertion force. Young's modulus affected the maximum insertion force. Human ligamentum flavum has longer width of vertebral bones and larger Young's modulus. Thus, larger maximum deformation and higher maximum insertion force for the human ligamentum flavum were predicted.

A minimally-invasive serial cerebrospinal fluid sampling model in conscious Göttingen minipigs.

Drug concentrations in cerebrospinal fluid (CSF) are typically used as a as a surrogate measure of their availability in the CNS, and CSF penetration in animal studies are used for assessment of CNS drug delivery in early preclinical drug development. The minipig is a valid alternative to dogs and non-human primates as non-rodent species in preclinical research, but this species presents anatomical peculiarities that make the serial collection of CSF technically challenging. A minimally-invasive serial cerebrospinal fluid collection model via catheterization of the subarachnoid space in conscious minipigs was developed allowing assessment of longitudinal drug pharmacokinetics in the central nervous system in preclinical research. Shortly, the subarachnoid space was accessed in the anesthetized minipig by puncture with a Tuohy needle; when CSF was flowing through the needle a catheter was advanced and thereafter tunneled and fixed on the back. The PK of peptide A administered subcutaneously was performed and CSF could be sampled in the conscious animals for up to 48 h. When compared to the plasma kinetic data, there was a clear difference in the elimination phase of Pept. A from CSF, with an apparent longer average terminal half-life in CSF. The 3Rs are addressed by reducing the number of animals needed for a pharmacokinetic profile in central nervous system and by improving the validity of the model avoiding biases due to anesthesia, blood contamination, and inter-individual variability.