Needle Insertion Technique Research Articles

Minimized Endothelial Cell Loss in DSAEK (Descemet’s Stripping Automated Endothelial Keratoplasty) Using A 30-G Needle Insertion Technique

International Ophthalmology Clinics: Winter 2013 - Volume 53 - Issue 1 - p 15-26 doi: 10.1097/IIO.0b013e3182713487

Ultrasound‐guided infragluteal sciatic nerve block: a comparison between four different techniques

Ultrasound guided sciatic block can be performed by different techniques. We compared namely short or long axis views of the sciatic nerve with in-plane or out-of-plane needle insertion techniques for the infragluteal sciatic nerve block (ISNB). One hundred twenty patients with American Society of Anesthesiologists physical status I-III, scheduled for foot surgery were assigned into four groups. Group SI: patients received ultrasound-guided SNB using short axis (S) view of the SN and in-plane (I) insertion of needle. Group LI: patients received SNB using long axis (L) view of SN and (I) insertion of the needle. Group SO: patients received SNB using (S) view of SN and out-of-plane (O) insertion of the needle. Group LO: patients received SNB using (L) view of SN and (O) insertion of the needle. Primary outcomes included the time to perform the block (recognition and performance time) and the level of patient discomfort during block placement. The recognition time and performance time were shortest in LI group (51 ± 16.4 and 87.7 ± 14.8 s), while they were longest in LO group (138.7 ± 21.4 and 160.3 ± 17.5 s). There were no significant differences between the groups as regards the number of attempts and needle redirections to elicit sciatic motor response. The level of patient discomfort was significantly less in the LI group in comparison with the SI and LO groups. The LI approach required less time to complete the infragluteal sciatic nerve block procedure and it was more comfortable for the patients in comparison to the SO, SI and LO approaches.

Seed migration after transperineal interstitial prostate brachytherapy with I-125 free seeds: analysis of its incidence and risk factors

The purpose of this study was to evaluate the incidence and predictors of seed migration after transperineal interstitial prostate brachytherapy. From March 2007 to March 2011, 121 patients with stage T1-T2 prostate cancer underwent transperineal interstitial prostate brachytherapy. Pre-planning was performed 3 weeks prior to implantation, and the implants were inserted using the standard parallel needle insertion technique. All patients underwent a series of radiographs [chest radiography, kidney-ureter-bladder (KUB) radiography, and a CT scan] to assess whether seed migration had occurred on postoperative days 1 and 30, and 12 months. Seed migration occurred in 31 (25.6 %) of 121 patients. A total of 51 of 7,883 (0.65 %) implanted seeds migrated. Migration was detected on postoperative day 1 in 16 patients, day 30 in 13 patients and at 12 months in 4 patients (migration occurred at different times in 2 patients). The migrated seeds were found in the lungs, pelvis, heart, mediastinum, kidney, inguinal canal, liver and sacrum. The number of needles was a statistically significant factor in seed migration. The seeds migrated to many organs. No decrease in the dose administered to the prostate or adverse effects associated with seed migration were noted.

Ultrasound-guided bilateral brachial plexus blockade with propofol-ketamine sedation

We report the use of ultrasound-guided bilateral brachial plexus block in a patient with bilateral radius fractures. An axillary block was performed on the patient's right and a supraclavicular block on her left using an in-plane (long-axis) needle insertion technique. Into each side was injected 20 ml 0.5% ropivacaine, giving a total volume (dose) of 40 ml (200 mg). Provisions were made for rescue analgesia or unplanned conversion to general anesthesia during the operation, but these were not needed; furthermore, no perioperative complications were observed. General anesthesia has traditionally been used for simultaneous surgery involving the bilateral upper extremities because of concerns relating to local anesthetic toxicity, phrenic nerve blockade, and pneumothorax. The ultrasound-guided technique facilitates a reduction in the minimal effective volume of local anesthetic and can prevent potentially critical complications. Moreover, the technique can be performed within the recommended safe dose limits of the anesthetic, rendering it an important option for bilateral upper extremity surgery.

Feasibility study of real-time three-/four-dimensional ultrasound for epidural catheter insertion

Real-time two-dimensional (2D) ultrasound can be used to facilitate neuraxial anaesthesia. Four-dimensional (4D) ultrasound allows the use of multiple imaging planes and three-dimensional reconstruction of ultrasound data. We assessed how 4D ultrasound could be used to perform epidural catheter insertion in a cadaver model. We then also compared 4D ultrasound and a previously described 2D technique in real-time epidural catheterization. Epidural catheter insertion was attempted on four embalmed cadavers using a variety of 4D techniques. A feasible, 4D ultrasound-guided in-plane needle insertion technique was then compared qualitatively with the 2D technique in a further six cadavers. A feasible technique of real-time 4D ultrasound-guided epidural insertion used two perpendicular imaging planes to improve the orientation of the operator. It resulted in changes in the needle direction in half of the approaches. Using 4D ultrasound, the Tuohy needle could only be seen reliably in the primary imaging plane. In-plane needle visibility using 4D imaging was inferior to 2D imaging. Successful epidural catheterization was also aided by an acoustic window being present, which allowed visualization of the vertebral body. The study demonstrates that 4D ultrasound can be used for real-time epidural catheter insertion and has both advantages and limitations compared with the 2D technique. Four-dimensional ultrasound has the potential to improve operator orientation on the vertebral column. However, this comes at the price of decreased resolution, frame rate, and needle visibility. Prospective evaluation of the importance of an acoustic window in neuraxial anaesthesia is required.

Detection of IDH1 Mutations and the Status of MGMT Promoter on Intraoperative Fresh Tissue Section from Frameless Neuronavigation Needle Biopsy. Analysis on 17 Patients with Brain Glial Tumor Ineligible for Craniotomy and Tumor Resection

It is well known that primary and secondary glioblastomas are histologically largely indistinguishable. Therefore, the detection of IDH1 mutations or the status of the MGMT promoter on a simple bioptic sample could be one of major diagnostic and prognostic importance for glial patients that complements clinical criteria for distinguishing secondary from primary glioblastomas and to predict a more favourable prognosis. Currently, biopsy is the method of choice to obtain tissue from intracranial lesions with uncertain neurodiagnostic findings or in deep locations, with a minimal invasive approach. The needle biopsy with frameless neuronavigation could provide a sampling with elevated diagnostic yield and high concentration of DNA, due to the "image-guided" computer assisted technique of needle insertion through the most neurodiagnostic representative tumor area. The freezing of fresh tumor tissue at biopsy could greatly improve the success of DNA extraction. The concentration of the DNA samples can also improved from a withdrawal in an area with high probability of neoplastic cells. The present study reports the results of 17 patients who had undergone frameless image-guided intracranial needle biopsy from April 2008 until July 2010 at Neurosurgery Unit of the "Arcispedale Santa Maria Nuova" of Reggio Emilia. For these patients the molecular determination of MGMT promoter was assessed with the Nested-Methylation Specific-Polymerase Chain Reaction and the screening of mutations in IDH1 e IDH2 genes was performer by polymerase chain reaction (PCR) and direct sequencing on fresh or cryopreserved needle bioptic tissue.

Chinese Acupuncture Expert System (CAES)—A Useful Tool to Practice and Learn Medical Acupuncture

This paper describes the development of a Chinese Acupuncture Expert System (CAES) that will assist the learning and practice of medical acupuncture. This was the development of a Chinese Acupuncture Expert System which incorporated eight functional modules. These modules were 1) Add Patient Record subsystem; 2) Diagnosis subsystem ; 3) Acupuncture Prescription subsystem ; 4) Needle Insertion Position Animation subsystem ; 5) Acupuncture Points Usage Statistic subsystem ; 6) History Query subsystem; 7) Acupuncture Points Query subsystem and 8) Diagnosis Remarks and Diagnosis Record Save subsystem. Two databases were built-Patient Record database and Diagnosis (Acupuncture) Knowledge database. All the Traditional Chinese Medicine (TCM) knowledge and acupuncture treatment prescriptions were extracted from officially used TCM textbooks and received guidance and expert advice from two acupuncturists working in this project. A Chinese Acupuncture Expert System (CAES) was built, which after the input from users of any Chinese disease symptoms and signs, it can provide a list of related TCM syndrome diagnoses based on the patients' disease symptoms and signs, and at the same time it can offer advice of the appropriate Chinese acupuncture treatment to the users. CAES also provided text descriptions and acupuncture animations showing the acupoint locations and the direction and depth of the needle insertion technique. Therefore users can easily learn acupuncture and practice it. This new acupuncture expert system will hopefully provide an easy way for users to learn and practice Chinese Acupuncture and establish its usefulness after it was fully evaluated.

Pneumothorax as a Complication of the Ultrasound-Guided Supraclavicular Approach for Brachial Plexus Block

In this case report, we are the first to describe the occurrence of a pneumothorax after ultrasound-guided supraclavicular block. The block was performed using a medial-to-lateral in-plane needle insertion technique. The predisposing operator, technical, and patient factors as well as strategies for preventing this uncommon yet potentially severe complication are discussed.

Effect of Needle Size and Type, Reuse of Needles, Insertion Speed, and Removal of Hair on Contamination of Joints with Tissue Debris and Hair after Arthrocentesis

To assess joint contamination with tissue and hair after arthrocentesis of equine fetlock joints. Experimental. Limb specimens from 8 equine cadavers. Soft tissues including the joint capsule were harvested from the dorsal aspect of the fetlock joints and mounted on a wooden frame. Needles inserted through the joint tissue preparation were flushed into tissue culture plates that were examined for tissue and hair debris. Variables evaluated were gauge and type of needle (16, 18, 20, and 22 G sharp disposable needles and 20 G disposable spinal needles with stylet), number of times each needle was used (1, 2, 3, 4), length of hair (unclipped, clipped, shaved with razor), and needle insertion speed (fast, slow). Descriptive and statistical evaluations were performed. Tissue contamination was identified in 1145 of 1260 wells and hair contamination was identified in 384 of 1260 wells. Twenty gauge needles inserted through unclipped hair resulted in the least amount of hair contamination. Compared with 20 G needles with fast insertion 1 time through unclipped hair the odds ratios for contamination with hair were significantly greater for 16 G sharp disposable needles, 20 G spinal needles, clipped hair, shaved hair, and reuse of the needles. Spinal needles inserted through unclipped hair transferred many long hairs into the joint space. Reuse of needles for arthrocentesis should be avoided. Removal of hair is not indicated for arthrocentesis with sharp injection needles but is recommended when using spinal needles with stylets. Joint contamination with hair and tissue debris will be decreased by specific needle insertion techniques. Decreased contamination of joints may reduce the frequency of joint infections after arthrocentesis.

Technique of ultrasound-guided hook needle insertion before reoperation for recurrent papillary thyroid cancer

GIRIS Papiller tiroid kanseri en sik tiroid kanseri olup sagkalim orani diger kanserlere gore daha iyidir. Nuks hastalik genellikle servikal lenf nodulunde veya operasyon lojunda izlenir (1). Operasyona bagli fibrozis nedeni ile lenf nodullerinin palpasyonu zorlasmakta olup onemli vaskuler ve noral yapilar iceren kompartmanlarin operasyonda ayrimi zorlasir (2). Bu nedenlerle lenf nodulu metastazi tarzinda nuks eden nonpalpabl lezyonlarda reeksplorasyonun etkinligi dusuk olup komplikasyon orani nisbeten fazladir.

Simple technique for graft insertion in Descemet-stripping (automated) endothelial keratoplasty using a 30-gauge needle

We describe a needle insertion technique for graft insertion in Descemet-stripping (automated) endothelial keratoplasty (DSEK/DSAEK). A folded donor posterior corneal disk is inserted through a 5.0 mm scleral tunnel incision over a plastic glide using a 30-gauge needle. The technique enables safe and easy graft insertion without vertical or horizontal compression of the donor tissue, causing minimal trauma to the donor endothelium and/or host structures.

A New Technique for Subscapularis Muscle Needle Insertion

To investigate a new technique for needle insertion into the subscapularis muscle for botulinum toxin injection, nerve block with phenol, and electromyography. A new technique, which we have termed the inferior approach, was delineated by cadaver study. In the first step of the study, the thickest part of the subscapularis muscle and the route for the accurate course of the needle were determined by an anatomist on eight cadavers (16 sides). In the second step, using this technique, a physician attempted to inject India ink into the thickest part of the muscle on a separate 12 cadavers (24 sides). The anatomist then examined the accumulated ink by careful dissection of the involved muscle. The thickest part was determined to be at the lateral half of the muscle. With the exception of two muscles, all the cadavers were successfully injected using the defined route. If the route and injection sites are correct, there is no risk of injecting any muscle in that anatomic region other than the subscapularis. Furthermore, there were no neurovascular structures identified at risk in the area using the inferior approach. This new technique, termed the inferior approach, is both easy and anatomically safe: it did not involve any risk of damage to any major artery, vein, or nerve.

A technique for simultaneous needle insertion in prostate seed implantation

The purpose was to develop a fast needle insertion system to shorten the implantation time and to restrain prostate swelling during the implantation, thus reducing the seed setup error. The basic idea is to insert all the needles simultaneously using ultrasound guidance. The developed system consists of two similar templates that are connected. All the needles are set and locked to a moveable rear template according to the dose plan. The needle pack is then pushed into position, the lock released and seeds implanted needle by needle. A test and training phantom was also built.

Anatomical and experimental studies of brachial plexus, sciatic, and femoral nerve-location using peripheral nerve stimulation in the dog

ObjectiveTo investigate the anatomy of the brachial plexus, sciatic, and femoral nerves for the use of a peripheral nerve-stimulator to perform nerve blocks in dogs. Study designProspective experimental trial. AnimalsFour canine cadavers and four healthy adult dogs weighing 23 ± 2.5 kg. MethodsPhase I: in four canine cadavers, an anatomical study was conducted to evaluate accurate needle-insertion techniques. Phase II: the utility of these techniques, and the value of electrostimulation, were evaluated in four anesthetized dogs in lateral recumbency (medetomidine, 5 μg kg−1/ketamine 5 mg kg−1) using an electrical stimulator and shielded needles. ResultsFor the brachial plexus, the needle was inserted cranial to the acromion, medial to the subscapularis muscle, at an angle of approximately 20–30° in relation to a plane vertical to the surface on which the animal was lying, oriented parallel to the long axis of the animal, in a ventro-caudal direction. For the sciatic nerve, the needle was inserted just cranial to the sacrotuberous ligament, through the gluteus superficialis muscle, at an angle of approximately 60° in relation to the horizontal plane, in a ventro-cranial direction, and up to the level of the ischium. For the femoral nerve, the needle was inserted perpendicular to the skin, just cranial to the femoral artery, and directed a little caudally. Using a peripheral nerve-stimulator, all nerves were located, and muscle contractions were elicited at a current of 0.2–0.4 mA. No complications were observed during the procedures. ConclusionElectrostimulation of peripheral nerves is useful in locating the branches of the brachial plexus as well as the sciatic and femoral nerves in dogs. Clinical relevancePeripheral nerve stimulation increases the reliability of a nerve block when compared with blind needle-insertion.

Feasibility of adequate dose coverage in permanent prostate brachytherapy using divergent needle insertion methods

Background and purpose The purpose of this study is to investigate the feasibility of adequate dose coverage in permanent prostate brachytherapy using divergent needle insertion methods. These methods can be useful in magnetic resonance imaging (MRI) guided needle insertion techniques to avoid pubic arch interference. Methods and materials MRI data were collected from 10 patients with T1–T2 prostate cancer. An inverse planning algorithm based on simulated annealing was used to optimize the dose distribution for three needle insertion methods: divergent needles with a single rotation point, divergent needles with a double rotation point, and current parallel needle insertion method. The dose constraints were based on our clinical criteria and the recent ESTRO/EAU/EORTC recommendations. Results If the planning target volume (PTV) surrounded the prostate and only intraprostatic seeds were allowed, the mean PTV volume that received 100% of the prescribed dose ( V 100) was 99% for all needle insertion methods. If the PTV was increased to the prostate with a 3 mm margin, the mean PTV V 100 equalled 94%, 95%, and 94% for the single rotation point, double rotation point and current parallel needle insertion method, respectively. If in the latter case the tips of the seeds were placed 3 mm outside the apex and base of the prostate, the mean PTV V 100 was 96% for all needle insertion methods. Conclusion This planning study shows that it is feasible to generate an adequate dose coverage using divergent needle insertion methods.

Modified CSEA With Single Spinal Needle: A New Approach

Modified Combined Spinal Epidural Analgesia (CSEA) with a 25 G Quincke spinal needle was tried in 200 adult patients subjected for lower abdominal or lower extremity surgery. Needle insertion technique advocated by Ali and Samson was used while identifying epidural space with a thin bore spinal needle. Patient's weight related dose of epidural buprenorphine (4 8 g kg-1 body weight) was tried . Modified CSEA could be successfully performed in 90% cases. Weight related dose of epidural buprenorphine (0.15-0.30 mg) in this study, offered almost 20 24 h post of pain relief in 58.5% cases without any incidence of respiratory depression, pruritus and post dural puncture headache. Modified CSEA advocated in the text is a cost effective and less complication prone alternative technique. Single shot, weight related dose of epidural buprenorphine provides considerably long duration of analgesia therefore need of epidural catheter might be obviated.

TH‐B‐224C‐02: Performance Evaluation and Optimization of a Novel Brachytherapy Robot

Purpose: To evaluate and optimize the performance of a prototype robotic manipulator designed for prostate seed implantations in a gel phantom. Methods and Materials: The prototype design is a custom‐built six degree‐of‐ freedom robot engineered for highly accurate prostate seed implantations. The robot allows for a fully automatic insertion or a manually assisted implantation using the device as a guide. The accuracy was determined using a gel phantom with a holed‐template placed at 10 cm depth. Insertion speed and rotation were varied, and the distance from the target hole was measured. The effect on the gel due to needle rotation was observed for increased damage. The experiment included both manual and automatic insertions using 30 cm, 17‐gauge, beveled‐tip prostate brachytherapy needles. Results: The optimal techniques were automatic insertions with a rotation speed of 10 rev/s or 1 rev/s. This provided a “hit” of the target 67% of the insertions with maximum displacement in the “non‐hit” insertions of 2.1 mm. The least accurate technique utilized a non‐rotated needle, which deflects towards its beveled‐tip as inserted. The total displacement from the target with this technique reached distances of greater than 8 mm for a 10 cm depth insertion with an average of 6.9 ± 0.8 mm. Conclusion: Preliminary results yielded an optimization of insertion parameters which increased the accuracy from near 1 cm to sub‐millimeter displacements. The robot was determined to have a high accuracy in tip placement within the gel. Rotation of the needle can dramatically increase the accuracy of the tip's final position. Rotating the needle at 1 rev/s yielded an accurate implant with minimal increase in gel damage. The robot used in conjunction with an optimized needle insertion technique benefits the patient with increased accuracy, leading to a more successful outcome and reduced complications.

Cervical Transforaminal Injection and the Radicular Artery: Variation in Anatomical Location Within the Cervical Intervertebral Foramina

Recent articles have detailed the adverse events associated with transforaminal steroid injections into the radicular arteries. Guidelines on strict transforaminal epidural techniques have been described to limit complications. There remains limited information regarding the cervical level of entry, location within the intervertebral foramina, and prevalence of the radicular arteries within the population. With the aid of premortem angiography and postmortem latex-injected vasculature, a single detailed cadaveric dissection was performed to elucidate the specific anatomic location of the radicular arteries within the intervertebral foramina and the anastomoses of the arteries to the anterior spinal artery. Five radicular arteries (C5, C6, two at C7, C8) were traced entering the foramina either anteriorly or posteriorly to supply the anterior and posterior spinal arteries. Radicular arteries received blood supply from either the deep cervical (C8) or vertebral arteries. The C8 radicular artery entered the lateral aspect of the foramen and penetrated the dural sleeve within the inferior portion of the foramen, directly inferior to the exiting spinal nerve, to supply the anterior spinal artery. This artery was of a large enough caliber to be entered by a 22-gauge needle. A larger population is necessary to characterize the range of anatomic variations in arterial supply within the foramina. Available studies support the current technique of fluoroscopic needle insertion. Yet, there is wide anatomic variation in the origin and location of these vessels, and even with strict adherence to technique, it is feasible that a properly placed needle could penetrate a radicular artery.

Bedside ultrasound for difficult lumbar puncture

Lumbar puncture is a common procedure performed in the emergency department for evaluation of several life-threatening conditions, including meningitis and subarachnoid hemorrhage. We describe the use of bedside ultrasound to assist in performance of the lumbar puncture in situations where the standard “blind” technique of needle insertion using palpable spinal landmarks is likely to be difficult or to fail. Use of ultrasound to guide lumbar puncture needle placement was originally reported 30 years ago in the Russian literature. More recently, ultrasound has been used for guiding needle placement for epidural and spinal anesthesia by anesthesiologists and for diagnostic lumbar puncture on infants by radiologists.

Acupuncture treatment of 32 cases of lumbar intervertebral disc protrusion

Yaoyangguan (GV 3), Shiqizhui (Ex-B 8) and Yanglingquan (GB 34) were selected as main points and a three-part needle insertion technique was used to treat 32 cases of lumbar intervertebral disc protrusion. The curative rate was 96.9%. Deep puncture is the key to the treatment.