Utility of prepuncture ultrasound for localization of the thoracic epidural space.

BACKGROUND: Ultrasound has been shown to facilitate accurate identification of the intervertebral level and to predict skin-to-epidural depth in the lumbar epidural space with reliable precision. We hypothesized that we could accurately predict the skin-to-epidural depth and the intervertebral level in the thoracic spine with the use of ultrasound. METHODS: Twenty patients presenting for thoracic surgery were included in a feasibility study. The skin-to-epidural depth was measured using prepuncture ultrasound in the paramedian window, and the predicted depth was compared with the actual needle depth and the depth as measured by computed tomography. In addition, the intervertebral levels were identified by ultrasound using the "counting up" method, and the results were compared with the levels identified by anesthesiologists. RESULTS: The ultrasound-based depth measurements displayed a bias of 3.21 mm with 95% limits of agreement from -7.47 to 13.9 mm compared with the clinically determined needle depth. The intervertebral levels identified by the anesthesiologists and the sonographer matched in only 40% of cases. CONCLUSION: Ultrasound-based measurements of skin-to-epidural depth show acceptable agreement with the actual depth observed during epidural catheterization; however, the limits of agreement are wide, which restricts the predictive value of ultrasound-based measurements. Further study is required to delineate the role of ultrasound in thoracic epidural catheterizations.

Automatic detection of lumbar anatomy in ultrasound images of human subjects.

Ultrasound has been proposed for aiding epidural needle insertion, but challenges remain in differentiating spinal structures due to noise, artifacts, and inexperience by anesthesiologists in ultrasound interpretation. Moreover, the anesthesiologist needs to measure relevant distances while preserving sterile conditions; therefore, interaction with the ultrasound controls must be minimal. Automated measurement is needed. Beam-steered ultrasound images are captured and spatial compounding is used to improve image quality. Phase symmetry is used to enhance bone (lamina) and ligamentum flavum (LF) ridges. A lamina template is matched to this ridge map using Pearson's cross-correlation, and the most likely lamina positions are found. Then, the lamina is traversed using a LF template with the Pearson's cross-correlation, and the location of the LF is obtained. Tests are performed on 39 sets of compounded ultrasound images in the L2-3 and L3-4 levels of the spine in the paramedian plane. The proposed algorithm can detect the laminas in 38 of the 39 images, and the LF in 34 of the 39 images. In successful detections, the automatic detections versus manual segmentation has an rms error of 0.64 mm and average error 0.04 mm, versus independent sonographer-measured depth has a root-mean-squared error of 3.7 mm and average error 2.5 mm, and versus the actual needle insertion depth has a root-mean-squared of 5.1 mm and average error -2.8 mm. The computational time is 4.3 s on a typical personal computer. The accuracy, reliability, and speed suggest this method may be valuable for helping guide epidurals in conjunction with the traditional loss-of-resistance method.

Single-operator real-time ultrasound-guidance to aim and insert a lumbar epidural needle.

PURPOSE: In conventional practice of epidural needle placement, determining the interspinous level and choosing the puncture site are based on palpation of anatomical landmarks, which can be difficult with some subjects. Thereafter, the correct passage of the needle towards the epidural space is a blind "feel as you go" method. An aim-and-insert single-operator ultrasound-guided epidural needle placement is described and demonstrated. METHOD: Nineteen subjects undergoing elective Cesarean delivery consented to undergo both a pre-puncture ultrasound scan and real-time paramedian ultrasound-guidance for needle insertion. Following were the study objectives: to measure the success of a combined spinal-epidural needle insertion under real-time guidance, to compare the locations of the chosen interspinous levels as determined by both ultrasound and palpation, to measure the change in depth of the epidural space from the skin surface as pressure is applied to the ultrasound transducer, and to investigate the geometric limitations of using a fixed needle guide. RESULTS: One subject did not participate in the study because pre-puncture ultrasound examination showed unrecognizable bony landmarks. In 18 of 19 subjects, the epidural needle entered the epidural space successfully, as defined by a loss-of-resistance. In two subjects, entry into the epidural space was not achieved despite ultrasound guidance.Eighteen of the 19 interspinous spaces that were identified using palpation were consistent with those determined by ultrasound. The transducer pressure changed the depth of the epidural space by 2.8 mm. The measurements of the insertion lengths corresponded with the geometrical model of the needle guide, but the needle required a larger insertion angle than would be needed without the guide. CONCLUSION: This small study demonstrates the feasibility of the ultrasound-guidance technique. Areas for further development are identified for both ultrasound software and physical design.

Preinsertion paramedian ultrasound guidance for epidural anesthesia.

BACKGROUND: Ultrasound is receiving growing interest for improving the guidance of needle insertion in epidural anesthesia. Defining a paramedian ultrasound scanning technique would be helpful for correctly identifying the vertebral level. Finding surrogate measures of the depth of the epidural space may also improve the ease of scanning. METHODS: We examined 20 parturients with pre-epidural ultrasound in the paramedian plane, and the predicted depth was compared with the actual midline depth. The actual depth was also compared with subject biometrics, depth of transverse process, and thickness of lumbar fat. RESULTS: The scanning technique allowed the depth of the epidural space to be measured in all subjects. The depth measured in ultrasound was strongly correlated to the actual depth (R(2) = 0.8 and 95% limits of agreement of -14.8 to 5.2 mm), unlike patient biometrics (R(2) < 0.25), the depth of the neighboring transverse processes (R(2) = 0.35 and 95% limits of agreement of -13.8 to 19.1 mm), or the thickness of overlying fat (R(2) = 0.66). The duration of the ultrasound scan was 10 min at the beginning of the trial and 3 min for the last subjects. CONCLUSIONS: Paramedian ultrasound can be used to estimate the midline depth to the epidural space. The surrogate measures are not sufficiently correlated with the depth to the epidural space to recommend them as a replacement for the actual depth to the epidural space measurement.

Adaptive ultrasound imaging of the lumbar spine for guidance of epidural anesthesia.

Ultrasound imaging can help in choosing the needle trajectory for epidural anesthesia but anatomical features are not always clear. Spatial compounding can emphasize structures; however, features in the beam-steered images are not aligned due to varying speeds of sound. A non-rigid registration method, called warping, shifts pixels of the beam-steered images to best match the reference image. Linear prediction is used to find the warping vectors and decrease computational cost. An adaptive median-based combination technique for compounding is also investigated. The algorithms are tested on a spine phantom and human subjects. The results show a significant improvement in quality when using warping with adaptive median-based compounding.

Instrumentation of the loss-of-resistance technique for epidural needle insertion.

Epidural anesthesia is the most common form of anesthesia in obstetrics. The loss-of-resistance to saline injection is used to confirm when the needle tip enters the epidural space. This procedure is highly dependent on skill and expertise, so it is useful to quantify the tissue resistance during insertion. Sensors are used to measure the force and displacement of the plunger of the syringe and the pressure at the needle tip. A model is also developed to estimate the pressure from the force and displacement. Tests are first performed on porcine tissue to compare the continuous-pressure and intermittent-pressure versions of the technique and to compare the paramedian and midline needle approaches. The accuracy of the pressure model is 12% of peak pressure for the continuous technique and 20% for the intermittent technique. Significant differences in injection flow rate were also found for the muscle, interspinous ligament, and ligamentum flavum encountered in the two approaches. A small clinical study on human subjects was performed and again significant differences were found in flow rate for different tissues. These quantitative results improve the understanding of small differences in feel that have been previously known qualitatively and may help in the development of simulators.

Instrumentation for epidural anesthesia.

A low-cost, sterilizable and unobtrusive instrumentation device was developed to quantify and study the loss-of-resistance technique in epidural anesthesia. In the porcine study, the rapid fall of the applied force, plunger displacement and fluid pressure, and the oral indication of the anesthesiologists were shown to be consistent with the loss-of-resistance. A model based on fluid leakage was developed to estimate the pressure from the force and displacement measurements, so that the pressure sensor could be omitted in human studies. In both human (in vivo) and porcine (in vitro) subjects, we observed that the ligamentum flavum is less amenable to saline injection than the interspinous ligament.

Aerobatic flight effects on baroreflex sensitivity and sympathovagal balance in experienced pilots.

BACKGROUND: Aerobatic flights subject pilots to accelerations and, therefore, to heavy physical workloads. OBJECTIVE: Our aim was to document changes in spontaneous baroreflex sensitivity and disturbances of sympathovagal balance after exposure to "push-pull" accelerations. METHODS: During 30-min flights, five aerobatic pilots performed five series of descending spirals: first, 30 s under negative (-3 Gz max), and then 30 s under positive (+4 Gz max) G loading, climbing between each series to regain altitude. A stand-test was performed before (T0), immediately postflight (PF), 1 h (PF1), and 2 h after (PF2) the flight. A Finapres apparatus recorded heart rate (HR) and BP during the stand-tests. RESULTS: Resting HR was higher at PF than T0 in supine (11.2 +/- 5.3%, p < 0.01) and standing (11.0 +/- 4.9%; p < 0.05) positions. Sequence analysis of spontaneous baroflex sensitivity (BRS) and spectral analysis of HR variability showed that: a) supine spontaneous BRS did not differ between preflight and postflight, while parasympathetic modulation of HR variability tended to increase; and b) supine spontaneous BRS was higher at PF1 than PF (PF: 0.011 +/- 0.0014 ms x mmHg(-1), PF1: 0.015 +/- 0.0012 ms x mmHg(-1); p < 0.05) and parasympathetic modulation of HR variability (high frequency component) was higher at PF2 than PF (PF: 0.014 +/- 0.007, PF2: 0.039 +/- 0.009; p < 0.001). CONCLUSIONS: These findings may reflect a change in the sympathovagal balance during the second hour of recovery from repeated push-pull maneuvers.