Needle Entry Research Articles

Clinical Identification of the Vertebral Level at Which the Lumbar Sympathetic Ganglia Aggregate.

BackgroundThe location and the number of lumbar sympathetic ganglia (LSG) vary between individuals. The aim of this study was to determine the appropriate level for a lumbar sympathetic ganglion block (LSGB), corresponding to the level at which the LSG principally aggregate.MethodsSeventy-four consecutive subjects, including 31 women and 31 men, underwent LSGB either on the left (n = 31) or the right side (n = 43). The primary site of needle entry was randomly selected at the L3 or L4 vertebra. A total of less than 1 ml of radio opaque dye with 4% lidocaine was injected, taking caution not to traverse beyond the level of one vertebral body. The procedure was considered responsive when the skin temperature increased by more than 1℃ within 5 minutes.ResultsThe median responsive level was significantly different between the left (lower third of the L4 body) and right (lower margin of the L3 body) sides (P = 0.021). However, there was no significant difference in the values between men and women. The overall median responsive level was the upper third of the L4 body. The mean responsive level did not correlate with height or BMI. There were no complications on short-term follow-up.ConclusionsSelection of the primary target in the left lower third of the L4 vertebral body and the right lower margin of the L3 vertebral body may reduce the number of needle insertions and the volume of agents used in conventional or neurolytic LSGB and radiofrequency thermocoagulation.

Longitudinal parallel compression suture to control postopartum hemorrhage due to placenta previa and accrete

ObjectiveTo assess the efficacy and safety of longitudinal parallel compression suture to control heavy postpartum hemorrhage (PPH) in patients with placenta previa/accreta. Materials and MethodsFifteen women received a longitudinal parallel compression suture to stop life-threatening PPH due to placenta previa with or without accreta during cesarean section. The suture apposed the anterior and posterior walls of the lower uterine segment together using an absorbable thread A 70-mm round needle with a Number-1 absorbable thread was used. The point of needle entry was 1 cm above the upper margin of the cervix and 1 cm from the right lateral border of the lower segment of the anterior wall. The suture was threaded through the uterine cavity to the serosa of the posterior wall. Then, it was directed upward and threaded from the posterior to the anterior wall at ∼1–2 cm above the upper boundary of the lower uterine segment and 3-cm medial to the right margin of the uterus. Both ends of the suture were tied on the anterior aspect of uterus. The left side was sutured in the same way. ResultsThe success rate of the procedure was 86.7% (13/15). Two of 15 cases were concurrently administered gauze packing and achieved satisfactory hemostasis. All patients resumed a normal menstrual flow, and no postoperative anatomical or physiological abnormalities related to the suture were observed. Three women achieved further pregnancies after the procedure. ConclusionLongitudinal parallel compression suture is a safe, easy, effective, practical, and conservative surgical technique to stop intractable PPH from the lower uterine segment, particularly in women who have a cesarean scar and placenta previa/accreta.

Inadvertent Intradiscal Injection with TFESI Utilizing Kambin's Retrodiscal Approach in the Treatment of Acute Lumbar Radiculopathy.

There is very strong evidence for the efficacy of transforaminal epidural steroid injection (TFESI) in relieving lumbar radicular pain due to a herniated disk. However, case studies have documented paralysis as a potential complication from this approach as the artery of Adamkiewicz may traverse within the subpedicular "safe triangle." Kambin's retrodiscal approach has been postulated as a safe means to the transforaminal approach to avoid the artery of Adamkiewicz. A 51-year-old woman presented with right-sided lumbar radicular pain at the L3-L4 and L4-L5 level secondary to a herniated disk. As conservative therapies failed to improve her radicular back pain, the patient opted to proceed with an epidural steroid injection. She subsequently underwent a right L3-L4 and L4-L5 transforaminal epidural steroid injection via Kambin's retrodiscal approach. Although anteroposterior and lateral views revealed optimal needle placement, live and postcontrast fluoroscopy revealed an unavoidable and inadvertent intradiscal spread. Kambin's approach is at the level of the intervertebral disk and may increase the incidence of intradiscal needle entry and injection.

Comparing a Mechanical Analogue With the Da Vinci User Interface: Suturing at Challenging Angles

The da Vinci Surgical System offers a natural user interface and wrist articulation, which enable suturing and other complex surgical actions in confined spaces. However, both the one-time cost of the system and the recurring cost of the limited-use instruments remain high. This has motivated the development of several hand-held alternatives-some partially motorized, some fully mechanical-in recent years. While a few of these have been commercialized, none have yet met with broad commercial success comparable to the da Vinci robot. In this letter, we suggest a user interface-based explanation for this, and describe a new mechanical instrument that provides wrist articulation with a novel user interface. We provide results of a single-user pilot study with an experienced laparoscopic surgeon to compare the new device with a traditional wristless laparoscopic tool, a prior commercial wristed mechanical tool (the RealHand), and the da Vinci robot, in the context of suturing at challenging angles. We observe better targeting of desired suture needle entry and exit points with the new device in comparison to prior wristed and wristless mechanical instruments, with the da Vinci only slightly outperforming the new tool.

Contrast Spread Technique: Evolution.

Dear Editor, The recognition of needle entry into an epidural space is a pivotal moment in cervical, thoracic, or lumbar epidural injections. Its significance cannot be overestimated. Regardless of how experienced you are, realizing that you are approaching an epidural space makes your heart beat faster. The safety of the procedure and its success rate depends upon proper and reliable identification of the needle entering into the epidural space. Recent advances in our understanding of fluoroscopic guidance allow pain practitioners to safely place the needle close to the ventral interlaminar line (VILL) [1–4]. However, recognition of the needle exiting the ligamentum flavum and entering into the epidural space was until now performed with the art of the loss of resistance technique (LORT). To rely upon LORT, a practitioner has to master his tactile sensation of change in resistance to the level of …

Use of Bronchoscopy in Percutaneous Dilational Tracheostomy

A modified percutaneous dilational tracheostomy (PDT) is a relatively new alternative method of performing PDTs in which tissues overlying the trachea are dissected, but needle entry is still performed blindly. Many centers use bronchoscopy-assisted PDT, but the necessity of bronchoscope assistance for modified PDTs has not been examined. Discontinuing bronchoscopy for this procedure could potentially decrease cost and increase efficiency with similar outcomes compared with bronchoscopy-assisted PDT. To evaluate the necessity of bronchoscopy in placement of PDT. A single-center, retrospective cohort study of 149 patients who underwent PDT, with or without bronchoscope assistance, was conducted between May 1, 2007, and February 1, 2015, in a tertiary care facility. Data analysis was performed from April 15, 2015, to May 1, 2015. Modified PDT with or without bronchoscopy. The primary outcomes of interest were postprocedural complications and length of stay during the hospitalization at which the tracheostomy was placed. Of the 149 patients who underwent modified PDT during the study period and met the inclusion criteria, 107 were in the no-bronchoscope cohort (66 [61.7%] were men; mean [SD] age, 56.0 [18.7] years) and 42 were in the bronchoscope-assisted cohort (26 [61.9%] were men; mean [SD] age, 58.0 [15.7] years). Complications with PDT were significantly associated with use of a bronchoscope (odds ratio, 6.7; 95% CI, 1.3-43.4; P = .04). The rate of complications was 1.9% in the no-bronchoscope cohort and 11.9% in the bronchoscope-assisted cohort (P = .05). The mean (SD) length of hospital stay was not significantly different between the 2 groups (51.4 [49.4] days in the no-bronchoscope cohort vs 46.9 [28.6] days in the bronchoscope-assisted cohort; P = .58). Percutaneous dilational tracheostomy can be performed with similarly low complication rates with or without the use of bronchoscopy. Discontinuing the use of bronchoscopy in these procedures appears to be a safe, cost-effective alternative with reassuring outcomes and low complication rates.

The arcTOA Technique for Out-of-Plane Ultrasound-Guided Injections

Out-of-plane (OOP) ultrasound-guided injections are often cited as being more difficult than in-plane ultrasound-guided injections, particularly for the novice ultrasonographer. In certain circumstances, the OOP approach is required as a result of the constraints of adjacent anatomic structures. To date, only the “walk-down” approach has been detailed in the literature as a means of improving accuracy with the OOP approach. However, this approach uses a set needle entry angle (angle of incidence) and distance for the injection. This article uses the trigonometric function, arctan = opposite/adjacent (arcTOA), to allow readers to easily estimate the needle angle of incidence (arcTOA technique), allowing more flexibility when planning and performing OOP injections.

Anatomic Evaluation of the Sacroiliac Joint: A Radiographic Study with Implications for Procedures

Background: Sacroiliac joint (SI) pain is increasingly being recognized as a source of low back pain. Injections and percutaneous type procedures are performed to treat symptomatic joints. However, there are limited studies available assessing the anatomy of the SI joint in vivo among patients with pain. Objectives: The purpose of this study was to provide more precise information on the dimensions and orientation of the SI joint using a new technique for the radiographic evaluation of this joint. Study Design: Observational study. Setting: Emergency department Methods: Three dimensional computed tomographic (CT) reconstructions of the pelvis were formatted from 100 SI joints in 50 patients who had clinically indicated abdominal/pelvic scans. These images were manipulated to evaluate the SI joint in multiple planes and measure its dimensions, area, and relationship to anatomic landmarks such as the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS). Results: Of the 50 patients, 23 were men and 27 women. Their mean age was 47.6 years (± 18.1). The SI joint consists of a superior limb which measures 39.7 mm (± 4.8) in length, and an inferior limb which measures 54.3 mm (± 5.1), oriented at an angle of 100.1° (± 8.1) to one another. The mean area of the joint was 1276.8 mm2 (± 189.8). The horizontal distance from the ASIS to the front of the superior SI joint is 75.4 mm (± 8.4). The horizontal distance from the PSIS to the back of the superior SI joint is 43.9 mm (± 5.6). The joint stretches 7.5 mm (± 5.9) cephalad and 38.1 mm (± 6.4) caudal to the PSIS, and 35.4 mm (± 8.8) cephalad and 10.2 mm (± 11.4) caudal to the ASIS. Limitations: CT scans were performed with patients lying supine, while most SI joint procedures are performed with a patient prone. However it is doubtful that the bony anatomic landmarks would change appreciable in this largely immobile joint. These patients were seen in the emergency department for a variety of conditions related to abdominal and pelvic pain, and not exclusively for SI joint pain. Conclusions: Treatment of the SI joint by surgeons and interventionalists is hampered by the limited number of anatomic studies in the literature. Our study presents the SI joint as a 2-limbed structure, sitting from slightly above the level of the PSIS rostrally to slightly below the level of the ASIS caudally. Palpation of these landmarks may assist in directing physicians to the joint. To begin an interventional pain procedure, with a patient lying prone, this data supports tilting the x-ray image intensifier 10 degrees caudal past the vertical anteroposterior (AP) view for optimal approach of the SI joint’s inferior limb. The needle entry should be about 44.1 mm (1.75 inches) caudal to the PSIS. The image intensifier should have a 12 degree left lateral oblique view for injection of the right SI joint, and a 12 degree right lateral oblique view for the left SI joint. Key words: Sacroiliac joint, arthriti, sacroiliac, anatomy, injections, intra-articular, tomography, x-ray computed, imaging, three-dimensional, pain management, back pain, radiology

Ultrasound‐Guided Proximal Suprascapular Nerve Block With Radiofrequency Lesioning for Patients With Malignancy‐Associated Recalcitrant Shoulder Pain

The classic suprascapular nerve block has limitations, such as postural requirements and lack of direct nerve visualization. This series investigated the analgesic effect of ultrasound-guided supraclavicular suprascapular nerve blocks in patients with malignancy-associated shoulder pain. Ablative radiofrequency lesioning of the suprascapular nerve in 6 patients provided substantial pain relief. The mean distance from the suprascapular nerve to the brachial plexus was 8.05 mm, and the mean angle of needle entry was 20.6°. This approach appears to be effective in relieving malignancy-associated shoulder pain and is tolerated by patients unable to sit or lie prone.

Transjugular Intrahepatic Portosystemic Shunt Creation Using a Three-Dimensional Fluoroscopy Guidance System in Patients with the Budd-Chiari Syndrome

When performed for Budd-Chiari syndrome (BCS), transjugular intrahepatic portosystemic shunt (TIPS) creation can be technically difficult due to hepatic congestion and asymmetric hypertrophy. We present three female patients with decompensated BCS in whom TIPS were created using a three-dimensional fluoroscopy guidance system. On a dedicated workstation using three-dimensional volumes of computed tomography imaging, a virtual needle path was created by the operator extending from the needle entry point (hepatic vein stump or inferior vena cava) to the target portal vein. Subsequently, the virtual needle path was overlaid on the fluoroscopy image for guidance of portal venous cannulation. This technology can be used for TIPS procedures in patients with BCS and other complex TIPS cases, as it may help delimit the trajectory of the needle pass and optimally result in more efficient procedures with decreased radiation dose.

The study of needle tip aspirates and entry sites after intravitreal injections with different needle types

PurposeTo compare the entry site and study the cellular content of different needle tip aspirates after transscleral intravitreal injection (IVI) on rat eyes.MethodsThe intravitreal injections (IVI) were performed on 20 white outbred rat eyes (10 IVI with 30‐gauge subcutaneous needles (SCN), 10 with 27‐gauge Pencan needle (PCN) (B.Braun)). The 1.0 cc syringes were preloaded with 0.02 cc of balanced salt solution (BSS) and connected to the needles. The penetration was performed 1 mm posterior to the limbus, followed by aspiration of 0.01 cc vitreous body. Aspirated material was evacuated onto glass slides and stained by Azure‐2‐Eosin. Enucleation and histological analysis of the IVI entry site was performed at magnification 100 and 400 times.ResultsCellular content of the aspirated material was revealed in all cases. The aspirated cells represented conjunctival epithelial‐, ciliary body non‐pigmented epithelial‐, sclerocyte‐like cells and vitreous crystallised specimens. The amount of conjunctival epithelial cells prevailed in 27‐gauge PCN IVI cases. The stained granular proteins were less significant in the case of 27‐gauge PCN tips. The entry sites after 30‐gauge SCN injection showed concrete cut of all tissues, while partial reassembling of the sclerocyte bindings was seen after 27‐gauge PCN injections.ConclusionsThe use of 30‐gauge SCN and 27‐gauge PCN needles for transscleral IVI has resulted in trauma of all layers of the rats’ eye wall. Histological analysis of the needle tip aspirates showed less tissue damage by 27‐gauge PCN; moreover, the SCN tips created complete cuts due to their sharp edges, in contrast to the PCN tips.

The study of needle tip aspirates and entry sites after intravitreal injections with different needle types

PurposeTo compare the entry site and study the cellular content of different needle tip aspirates after transscleral intravitreal injection (IVI) on rat eyes.MethodsThe intravitreal injections (IVI) were performed on 20 white outbred rat eyes (10 IVI with 30‐gauge subcutaneous needles (SCN), 10 with 27‐gauge Pencan needle (PCN) (B. Braun)). The 1.0 cc syringes were preloaded with 0.02 cc of balanced salt solution (BSS) and connected to the needles. The penetration was performed 1 mm posterior to the limbus, followed by aspiration of 0.01 cc vitreous body. Aspirated material was evacuated onto glass slides and stained by Azure‐2‐Eosin. Enucleation and histological analysis of the IVI entry site was performed at magnification 100 and 400 times.ResultsCellular content of the aspirated material was revealed in all cases. The aspirated cells represented conjunctival epithelial‐, ciliary body non‐pigmented epithelial‐, sclerocyte‐like cells and vitreous crystallised specimens. The amount of conjunctival epithelial cells prevailed in 27‐gauge PCN IVI cases. The stained granular proteins were less significant in the case of 27‐gauge PCN tips. The entry sites after 30‐gauge SCN injection showed concrete cut of all tissues, while partial reassembling of the sclerocyte bindings was seen after 27‐gauge PCN injections.ConclusionsThe use of 30‐gauge SCN and 27‐gauge PCN needles for transscleral IVI has resulted in trauma of all layers of the rats’ eye wall. Histological analysis of the needle tip aspirates showed less tissue damage by 27‐gauge PCN; moreover, the SCN tips created complete cuts due to their sharp edges, in contrast to the PCN tips.

Comparison of Direct Trocar Entry and Veress Needle Entry in Laparoscopic Bariatric Surgery: Randomized Controlled Trial.

We aimed to compare the direct trocar insertion (DTI) and Veress needle insertion (VNI) techniques in laparoscopic bariatric surgery. Eighty-one patients scheduled for bariatric surgery at Inonu University, Malatya, Turkey, were included in this study. In 39 patients, a bladed retractable nonoptical trocar was used for DTI, and VNI was performed in 42 patients. Intraoperative access-related parameters were compared. Data were analyzed with Student's t and chi-squared tests. A P value of <.05 was considered significant. Both groups had comparable demographic profiles. Laparoscopic entry time was shorter in the DTI group (79.6 ± 94.6 versus 217.6 ± 111.0 seconds; P < .0001). Successful entry rates in the first attempt, CO2 consumptions, failed attempt rates, and overall intraoperative complication rates were similar. However, in the DTI group, 2 patients had mesenteric injuries, and 1 of them required conversion to open surgery due to the mesenteric hemorrhage. DTI in obese patients significantly shortens the entry time, but there can be severe complications with DTI when a nonoptical bladed trocar is used blindly. Actually, neither method can be recommended for entry into the abdomen in this population based on our results. If the surgeon has to choose a nonoptical trocar in bariatric surgery, preference for the VNI technique instead of the DTI technique is safer.

294 A Comparison of Ultrasound-Guided and Palpation-Guided Identification of Lumbar Puncture Needle Entry Site in Patients as Body Mass Index Increases

294 A Comparison of Ultrasound-Guided and Palpation-Guided Identification of Lumbar Puncture Needle Entry Site in Patients as Body Mass Index Increases

Laparoscopic entry techniques.

Laparoscopic entry techniques.

Intentional Right Atrial Exit and Carbon Dioxide Insufflation to Facilitate Subxiphoid Needle Entry Into the Empty Pericardial Space: First Human Experience

ObjectivesThe purpose of this study was to test whether a microcatheter can safely be advanced across the right atrial appendage to access the pericardium and then withdrawn despite subsequent high-intensity anticoagulation. We also tested whether transatrial pericardial insufflation of carbon dioxide (CO2) would enhance the safety of subxiphoid needle access to the empty pericardium by separating the heart from the anterior pericardium. BackgroundSubxiphoid needle access to the empty pericardium, required for left atrial suture ligation and epicardial ablation for rhythm disorders, risks myocardial or coronary laceration. MethodsA catheter from the femoral vein engaged the right atrial appendage for angiographic confirmation of position. Through that catheter, the back end of a 0.014- or 0.018-inch guidewire crossed the right atrial wall to enter the pericardium and delivered a 2.4-F microcatheter. CO2 1 to 2 ml/kg was insufflated into the pericardium immediately before subxiphoid needle access under lateral projection fluoroscopy. Thirteen patients undergoing subxiphoid suture ligation of the left atrial appendage consented to participate in this research protocol. ResultsRight atrial exit succeeded in 11 subjects (85%) and failed uneventfully in 2 subjects. CO2 insufflation of 96 ± 22 ml achieved 12 ± 4 mm separation of the anterior pericardium from the myocardial wall, allowed rapid and successful subxiphoid anterior needle and guidewire entry in all 11 subjects, and did not have any evident hemodynamic effects. The immediate pericardial aspirate was serous in all but 1 subject. ConclusionsWe report the first human intentional transatrial exit procedure. Transatrial microcatheter access to the pericardium can be achieved safely. Pericardial insufflation with CO2 makes subxiphoid access to the empty pericardium rapid and safe. Although our clinical experience to date remains small, with further experience, this approach may prevent the life-threatening complications of “dry” subxiphoid pericardial access.

The thyrohyoid membrane as a target for ultrasonography-guided block of the internal branch of the superior laryngeal nerve

Study objectiveThe objective was to present a proof of concept for a simple and consistently successful ultrasonograpy (US)-guided technique to block the internal branch of the superior laryngeal nerve (iSLN). DesignThis was a volunteer and cadaver anatomy study. SettingThe setting was an anesthesiology department and an anatomy laboratory at a medical school MeasurementsH13-6 MHz US scans were performed in 40 healthy volunteers positioned supine and with extended necks. The goals were to identify the thyrohyoid membrane, measure its depth (in centimeters) using the shortest vertical distance from the skin, and record the scanning time (in seconds) needed to obtain the optimal image.Anatomical dissection was performed with an operating microscope bilaterally on 5 adult cadaver heads, fixed in formalin, to expose the point of iSLN penetration through the thyrohyoid membrane. The distance between the greater horn of the hyoid bone and the nerve entry point into the thyrohyoid membrane was measured. Ultrasonography-guided in-plane injections were performed unilaterally with 22-gauge 50-mm nerve block needles in 3 fresh cadavers with 2-mL lidocaine/methylene blue mixture deposited under direct vision just superficial to the thyrohyoid membrane to evaluate technical feasibility and injectate spread. Main resultsAnatomically, the iSLN was identified in all formalin-preserved cadavers, with hyoid bone greater horn to nerve-membrane interface distances measuring 1.0-2.4 cm (mean, 2.0 cm; SD, 0.5).Sonographically, the iSLN was not visualized, whereas the hyoid bone and the thyrohyoid membrane were visualized in all volunteers. The mean distance from skin to thyrohyoid membrane was 1.69 cm (SD, 0.38). The mean time needed to scan was 15 seconds (SD, 2.3). After US-guided injection, the dye deposition was observed around the iSLN in all cadaver specimens. ConclusionsA simpler and consistently reproducible US-guided iSLN block is feasible using the thyrohyoid membrane as target plane for local anesthetic injection. Clinical trials are needed to determine its effectiveness and safety, needle entry point, trajectory, and local anesthetic volume.

Master device for teleoperated needle insertion-type interventional robotic system.

This paper proposes a new master device for teleoperated needle insertion-type interventional robotic system. The 5-DOF master device is optimally designed based on the newly defined interventional procedures and the physicians' requirements. It comprises a 2-DOF rotational mechanism for adjustment of needle orientation, a 2-DOF translational mechanism for fine-tuning of needle entry point, and a handle assembly. The handle assembly includes a 1-DOF translational mechanism for needle insertion and buttons for operation mode selection. The passive actuation modules of the rotational mechanism and the active actuation modules of the translational mechanism are controlled appropriately for the selected mode according to the procedure phase. The needle insertion mechanism also warns the user by vibrating the shaft when the needle reaches the dangerous region.

Lumbar Ultrasound Image Feature Extraction and Classification with Support Vector Machine

Needle entry site localization remains a challenge for procedures that involve lumbar puncture, for example, epidural anesthesia. To solve the problem, we have developed an image classification algorithm that can automatically identify the bone/interspinous region for ultrasound images obtained from lumbar spine of pregnant patients in the transverse plane. The proposed algorithm consists of feature extraction, feature selection and machine learning procedures. A set of features, including matching values, positions and the appearance of black pixels within pre-defined windows along the midline, were extracted from the ultrasound images using template matching and midline detection methods. A support vector machine was then used to classify the bone images and interspinous images. The support vector machine model was trained with 1,040 images from 26 pregnant subjects and tested on 800 images from a separate set of 20 pregnant patients. A success rate of 95.0% on training set and 93.2% on test set was achieved with the proposed method. The trained support vector machine model was further tested on 46 off-line collected videos, and successfully identified the proper needle insertion site (interspinous region) in 45 of the cases. Therefore, the proposed method is able to process the ultrasound images of lumbar spine in an automatic manner, so as to facilitate the anesthetists' work of identifying the needle entry site.

Integrated design of micro force sensor oriented to cell micro-operation

During the process of cell micro operation, the contact force between the entry needle and the cell membrane is usually a very small area to be tested. These two features have been utilized to design a high precision micro force sensor to provide a force feedback in the process of cell micro operation. However, PVDF (Polyvinylidene Fluoride) has continued to display both a wide range of frequency response and a highly sensitive transform between force and electricity. In this paper a charge signal is obtained. In order to transform the charge signal into a voltage signal, a signal processing circuit was designed. The data acquisition card PCI-6221 (National Instruments) was used. It was employed to collect the voltage signal. The resultant micro force sensor was calibrated by using a rating test. The experimental test results demonstrated that the sensitivity and linearity of the designed micro force sensor were higher than the sensitivity and linearity of a traditional piezoelectric sensor.