Skip to main content
SpringerLink
Log in

Ultrasound-Guided Neuraxial Anesthesia

  • Other Pain (N Vadivelu and AD Kaye, Section Editors)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

There has been a recent surge of interest in clinical applications of ultrasound, which has revolutionized acute pain management. This review is to summarize the current status of ultrasound utilization in neuraxial anesthesia, the most common type of regional anesthesia.

Recent Findings

Ultrasound-assisted and ultrasound-guided neuraxial anesthesia has improved clinical accuracy and patient safety through landmark identification including proper vertebral level and midline, as well as via measurements on neuraxial space. Direct needle or catheter visualization during the entire procedure has not yet been achieved consistently.

Summary

The recent introduction of ultrasound into neural anesthesia has clinical performance benefits and patient safety implications, with documented improvement on overall efficacy with higher first attempt success rate as well as less needle pass. More controlled studies are needed for the overall impact of ultrasonography in neuraxial anesthesia in obstetric and non-obstetric patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Goerig M, Bacon D, van Zundert A. Carl Koller, cocaine, and local anesthesia: some less known and forgotten facts. Reg Anesth Pain Med. 2012;37(3):318–24. https://doi.org/10.1097/AAP.0b013e31825051f3.

    Article  PubMed  Google Scholar 

  2. Gorelick PB, Zych D. James Leonard Corning and the early history of spinal puncture. Neurology. 1987;37(4):672–4.

    Article  CAS  Google Scholar 

  3. Wulf HF. The centennial of spinal anesthesia. Anesthesiology. 1998;89(2):500–6.

    Article  CAS  Google Scholar 

  4. Gogarten W, Van Aken H. A century of regional analgesia in obstetrics. Anesth Analg. 2000;91(4):773–5.

    Article  CAS  Google Scholar 

  5. Watson MJ, Evans S, Thorp JM. Could ultrasonography be used by an anaesthetist to identify a specified lumbar interspace before spinal anaesthesia? Br J Anaesth. 2003;90(4):509–11.

    Article  CAS  Google Scholar 

  6. Hingsox Robert A, Edwards Waldo B. Comprehensive review of continuous caudal analgesia for anesthetists. Anesthesiology. 1943;4(2):181–96.

    Article  Google Scholar 

  7. Bauer M, George JE, Seif J, Farag E. Recent advances in epidural analgesia. Anesthesiol Res Pract. 2012;2012:1–14. https://doi.org/10.1155/2012/309219.

    Article  Google Scholar 

  8. Meng T, Zhong Z, Meng L. Impact of spinal anaesthesia vs. general anaesthesia on peri-operative outcome in lumbar spine surgery: a systematic review and meta-analysis of randomised, controlled trials. Anaesthesia. 2017;72(3):391–401. https://doi.org/10.1111/anae.13702.

    Article  CAS  PubMed  Google Scholar 

  9. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. Br J Anaesth. 2003;91(5):718–29.

    Article  CAS  Google Scholar 

  10. Bakshi R, Mechtler LL, Kamran S, Gosy E, Bates VE, Kinkel PR, et al. MRI findings in lumbar puncture headache syndrome: abnormal dural-meningeal and dural venous sinus enhancement. Clin Imaging. 1999;23(2):73–6.

    Article  CAS  Google Scholar 

  11. Chui J, Craen RA. An update on the prone position: continuing professional development. Can J Anaesth. 2016;63(6):737–67. https://doi.org/10.1007/s12630-016-0634-x.

    Article  PubMed  Google Scholar 

  12. Kabore RAF, Traore IA, Traore SIS, Bougouma C, Augustin P, Ouro-Bang’na Maman AF. Broken needle during spinal anesthesia: an avoidable complication. Local Reg Anesth. 2018;11:111–3. https://doi.org/10.2147/lra.S175547.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Furness G, Reilly MP, Kuchi S. An evaluation of ultrasound imaging for identification of lumbar intervertebral level. Anaesthesia. 2002;57(3):277–80.

    Article  CAS  Google Scholar 

  14. Parra MC, Washburn K, Brown JR, Beach ML, Yeager MP, Barr P, et al. Fluoroscopic guidance increases the incidence of thoracic epidural catheter placement within the epidural space: a randomized trial. Reg Anesth Pain Med. 2017;42(1):17–24. https://doi.org/10.1097/aap.0000000000000519.

    Article  PubMed  Google Scholar 

  15. Shampo MA, Kyle RA. Karl Theodore Dussik—pioneer in ultrasound. Mayo Clin Proc. 1995;70(12):1136.

    Article  CAS  Google Scholar 

  16. Bogin IN, Stulin ID. Application of the method of 2-dimensional echospondylography for determining landmarks in lumbar punctures. Zh Nevropatol Psikhiatr Im S S Korsakova. 1971;71(12):1810–1.

    CAS  PubMed  Google Scholar 

  17. Currie JM. Measurement of the depth to the extradural space using ultrasound. Br J Anaesth. 1984;56(4):345–7.

    Article  CAS  Google Scholar 

  18. Bonazzi M, Bianchi De Grazia L, Di Gennaro S, Lensi C, Migliavacca S, Marsicano M, et al. Ultrasonography-guided identification of the lumbar epidural space. Minerva Anestesiol. 1995;61(5):201–5.

    CAS  PubMed  Google Scholar 

  19. Excellence NIfHaC. Ultrasound-guided catheterisation of the epidural space. 2008.

  20. •• Ghosh S, Madjdpour C, Chin K. Ultrasound-guided lumbar central neuraxial block. BJA Educ. 2015;16(7):213–20. https://doi.org/10.1093/bjaed/mkv048A resource for basic learning in ultrasound-assisted neuraxial anesthesia.

    Article  Google Scholar 

  21. de Filho GR, Gomes HP, da Fonseca MH, Hoffman JC, Pederneiras SG, Garcia JH. Predictors of successful neuraxial block: a prospective study. Eur J Anaesthesiol. 2002;19(6):447–51.

    Article  Google Scholar 

  22. Chin KJ, Perlas A, Chan V, Brown-Shreves D, Koshkin A, Vaishnav V. Ultrasound imaging facilitates spinal anesthesia in adults with difficult surface anatomic landmarks. Anesthesiology. 2011;115(1):94–101. https://doi.org/10.1097/ALN.0b013e31821a8ad4.

    Article  PubMed  Google Scholar 

  23. Dimaculangan DP, Mazer JA, Maracaja-Neto LF. Sonographic evaluation of lumbar interlaminar space opening in a variety of patient body positions for optimal neuraxial anesthesia delivery. J Clin Anesth. 2016;34:159–65. https://doi.org/10.1016/j.jclinane.2016.03.045.

    Article  PubMed  Google Scholar 

  24. Grau T, Leipold RW, Delorme S, Martin E, Motsch J. Ultrasound imaging of the thoracic epidural space. Reg Anesth Pain Med. 2002;27(2):200–6.

    Article  CAS  Google Scholar 

  25. Jones AR, Carle C, Columb M. Effect of table tilt on ligamentum flavum length measured using ultrasonography in pregnant women*. Anaesthesia. 2013;68(1):27–30. https://doi.org/10.1111/anae.12006.

    Article  CAS  PubMed  Google Scholar 

  26. Ramsay N, Walker J, Tang R, Vaghadia H, Sawka A. Flexion-rotation manoeuvre increases dimension of the acoustic target window for paramedian thoracic epidural access. Br J Anaesth. 2014;112(3):556–62. https://doi.org/10.1093/bja/aet385.

    Article  CAS  PubMed  Google Scholar 

  27. Brinkmann SG, Germain G, Sawka A, Vaghadia H. Is there a place for ultrasound in neuraxial anesthesia? Imaging Med. 2013;5(2):177–86.

    Article  CAS  Google Scholar 

  28. Kaushik V, Philip A, Russell WC. Ultrasound-guided central neuraxial blocks and peripheral nerve blocks in children. BJA Educ. 2014;15(3):154–9. https://doi.org/10.1093/bjaceaccp/mku025.

    Article  Google Scholar 

  29. Tsen LC. The all-seeing eye? Ultrasound technologies for neuraxial techniques. Anesthesiology. 2011;114(6):1274–6. https://doi.org/10.1097/ALN.0b013e31821b5859.

    Article  PubMed  Google Scholar 

  30. Kessler J, Moriggl B, Grau T. Ultrasound-guided regional anesthesia: learning with an optimized cadaver model. Surg Radiol Anat. 2014;36(4):383–92. https://doi.org/10.1007/s00276-013-1188-z.

    Article  PubMed  Google Scholar 

  31. Shaikh F, Brzezinski J, Alexander S, Arzola C, Carvalho JC, Beyene J, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. BMJ. 2013;346:f1720. https://doi.org/10.1136/bmj.f1720.

    Article  PubMed  Google Scholar 

  32. Arzola C, Mikhael R, Margarido C, Carvalho JC. Spinal ultrasound versus palpation for epidural catheter insertion in labour: a randomised controlled trial. Eur J Anaesthesiol. 2015;32(7):499–505. https://doi.org/10.1097/eja.0000000000000119.

    Article  PubMed  Google Scholar 

  33. Munhall RJ, Sukhani R, Winnie AP. Incidence and etiology of failed spinal anesthetics in a university hospital: a prospective study. Anesth Analg. 1988;67(9):843–8.

    Article  CAS  Google Scholar 

  34. Abdelhamid SA, Mansour MA. Ultrasound-guided intrathecal anesthesia: does scanning help? Egypt J Anaesth. 2013;29(4):389–94. https://doi.org/10.1016/j.egja.2013.06.003.

    Article  Google Scholar 

  35. Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for presumed difficult epidural puncture. Acta Anaesthesiol Scand. 2001;45(6):766–71.

    Article  CAS  Google Scholar 

  36. Liu Y, Qian W, Ke XJ, Mei W. Real-time ultrasound-guided spinal anesthesia using a new paramedian transverse approach. Curr Med Sci. 2018;38(5):910–3. https://doi.org/10.1007/s11596-018-1961-7.

    Article  PubMed  Google Scholar 

  37. Chin KJ, Chan VW, Ramlogan R, Perlas A. Real-time ultrasound-guided spinal anesthesia in patients with a challenging spinal anatomy: two case reports. Acta Anaesthesiol Scand. 2010;54(2):252–5. https://doi.org/10.1111/j.1399-6576.2009.02112.x.

    Article  CAS  PubMed  Google Scholar 

  38. Lee PJ, Tang R, Sawka A, Krebs C, Vaghadia H. Brief report: real-time ultrasound-guided spinal anesthesia using Taylor’s approach. Anesth Analg. 2011;112(5):1236–8. https://doi.org/10.1213/ANE.0b013e31820ec53c.

    Article  PubMed  Google Scholar 

  39. Conroy PH, Luyet C, McCartney CJ, McHardy PG. Real-time ultrasound-guided spinal anaesthesia: a prospective observational study of a new approach. Anesthesiol Res Pract. 2013;2013:1–7. https://doi.org/10.1155/2013/525818.

    Article  Google Scholar 

  40. Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of combined spinal-epidural anaesthesia. Eur J Anaesthesiol. 2004;21(1):25–31.

    CAS  PubMed  Google Scholar 

  41. Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time ultrasound-guided paramedian epidural access: evaluation of a novel in-plane technique. Br J Anaesth. 2009;102(6):845–54. https://doi.org/10.1093/bja/aep079.

    Article  CAS  PubMed  Google Scholar 

  42. Prasad GA, Tumber PS, Lupu CM. Ultrasound guided spinal anesthesia. Can J Anaesth. 2008;55(10):716–7. https://doi.org/10.1007/bf03017749.

    Article  PubMed  Google Scholar 

  43. Chong SE, Mohd Nikman A, Saedah A, Wan Mohd Nazaruddin WH, Kueh YC, Lim JA, et al. Real-time ultrasound-guided paramedian spinal anaesthesia: evaluation of the efficacy and the success rate of single needle pass. Br J Anaesth. 2017;118(5):799–801. https://doi.org/10.1093/bja/aex108.

    Article  CAS  PubMed  Google Scholar 

  44. Brinkmann S, Mitchell CH, Hocking G. Assessment of a single-operator real-time ultrasound-guided epidural technique in a porcine phantom. Can J Anaesth. 2012;59(3):323–4. https://doi.org/10.1007/s12630-011-9642-z.

    Article  PubMed  Google Scholar 

  45. Kline J. Reliable needle visualization during ultrasound guided regional and vascular procedures. A simple solution to steep angle echogenicity loss with any ultrasound system, based on target depth. Anesthesia Ejournal. 2015;3(2). Available at https://anesthesiaejournal.com/index.php/aej/article/view/39. Accessed 14 Aug 2020

  46. Tsui B, Leipoldt C, Desai S. Color flow Doppler ultrasonography can distinguish caudal epidural injection from intrathecal injection. Anesth Analg. 2013;116(6):1376–9. https://doi.org/10.1213/ANE.0b013e31828e5e93.

    Article  PubMed  Google Scholar 

  47. Tsui B, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and adolescents: a review of current literature and its application in the practice of extremity and trunk blocks. Anesthesiology. 2010;112(2):473–92. https://doi.org/10.1097/ALN.0b013e3181c5dfd7.

    Article  PubMed  Google Scholar 

  48. Halpern SH, Banerjee A, Stocche R, Glanc P. The use of ultrasound for lumbar spinous process identification: a pilot study. Can J Anaesth. 2010;57(9):817–22. https://doi.org/10.1007/s12630-010-9337-x.

    Article  PubMed  Google Scholar 

  49. Silbergleit R, Mehta BA, Sanders WP, Talati SJ. Imaging-guided injection techniques with fluoroscopy and CT for spinal pain management. Radiographics. 2001;21(4):927–39; discussion 40-2. https://doi.org/10.1148/radiographics.21.4.g01jl15927.

    Article  CAS  PubMed  Google Scholar 

  50. Renfrew DL, Moore TE, Kathol MH, el-Khoury GY, Lemke JH, Walker CW. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR Am J Neuroradiol. 1991;12(5):1003–7.

    CAS  PubMed  Google Scholar 

  51. Kim WJ, Kim TH, Shin HY, Kang H, Baek CW, Jung YH, et al. Fluoroscope guided epidural needle insertioin in midthoracic region: clinical evaluation of Nagaro's method. Korean J Anesthesiol. 2012;62(5):441–7. https://doi.org/10.4097/kjae.2012.62.5.441.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Eidelman A, Shulman MS, Novak GM. Fluoroscopic imaging for technically difficult spinal anesthesia. J Clin Anesth. 2005;17(1):69–71. https://doi.org/10.1016/j.jclinane.2004.04.001.

    Article  PubMed  Google Scholar 

  53. Jee H, Lee JH, Kim J, Park KD, Lee WY, Park Y. Ultrasound-guided selective nerve root block versus fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: a randomized, blinded, controlled study. Skelet Radiol. 2013;42(1):69–78. https://doi.org/10.1007/s00256-012-1434-1.

    Article  Google Scholar 

  54. Park Y, Lee JH, Park KD, Ahn JK, Park J, Jee H. Ultrasound-guided vs. fluoroscopy-guided caudal epidural steroid injection for the treatment of unilateral lower lumbar radicular pain: a prospective, randomized, single-blind clinical study. Am J Phys Med Rehabil. 2013;92(7):575–86. https://doi.org/10.1097/PHM.0b013e318292356b.

    Article  PubMed  Google Scholar 

  55. Wang D. Image guidance technologies for interventional pain procedures: ultrasound, fluoroscopy, and CT. Curr Pain Headache Rep. 2018;22(1):6. https://doi.org/10.1007/s11916-018-0660-1.

    Article  PubMed  Google Scholar 

  56. Lee A. Ultrasound in obstetric anesthesia. Semin Perinatol. 2014;38(6):349–58. https://doi.org/10.1053/j.semperi.2014.07.006.

    Article  PubMed  Google Scholar 

  57. Saravanakumar K, Rao SG, Cooper GM. Obesity and obstetric anaesthesia. Anaesthesia. 2006;61(1):36–48. https://doi.org/10.1111/j.1365-2044.2005.04433.x.

    Article  CAS  PubMed  Google Scholar 

  58. Balki M, Lee Y, Halpern S, Carvalho JC. Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients. Anesth Analg. 2009;108(6):1876–81. https://doi.org/10.1213/ane.0b013e3181a323f6.

    Article  PubMed  Google Scholar 

  59. Wallace DH, Currie JM, Gilstrap LC, Santos R. Indirect sonographic guidance for epidural anesthesia in obese pregnant patients. Reg Anesth. 1992;17(4):233–6.

    CAS  PubMed  Google Scholar 

  60. Sahin T, Balaban O, Sahin L, Solak M, Toker K. A randomized controlled trial of preinsertion ultrasound guidance for spinal anaesthesia in pregnancy: outcomes among obese and lean parturients: ultrasound for spinal anesthesia in pregnancy. J Anesth. 2014;28(3):413–9. https://doi.org/10.1007/s00540-013-1726-1.

    Article  PubMed  Google Scholar 

  61. Nassar M, Abdelazim IA. Pre-puncture ultrasound guided epidural insertion before vaginal delivery. J Clin Monit Comput. 2015;29(5):573–7. https://doi.org/10.1007/s10877-014-9634-y.

    Article  PubMed  Google Scholar 

  62. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in obstetric epidural anesthesia. J Clin Anesth. 2002;14(3):169–75.

    Article  Google Scholar 

  63. Vallejo MC, Phelps AL, Singh S, Orebaugh SL, Sah N. Ultrasound decreases the failed labor epidural rate in resident trainees. Int J Obstet Anesth. 2010;19(4):373–8. https://doi.org/10.1016/j.ijoa.2010.04.002.

    Article  CAS  PubMed  Google Scholar 

  64. Grau T, Bartusseck E, Conradi R, Martin E, Motsch J. Ultrasound imaging improves learning curves in obstetric epidural anesthesia: a preliminary study. Can J Anaesth. 2003;50(10):1047–50. https://doi.org/10.1007/bf03018371.

    Article  PubMed  Google Scholar 

  65. Creaney M, Mullane D, Casby C, Tan T. Ultrasound to identify the lumbar space in women with impalpable bony landmarks presenting for elective caesarean delivery under spinal anaesthesia: a randomised trial. Int J Obstet Anesth. 2016;28:12–6. https://doi.org/10.1016/j.ijoa.2016.07.007.

    Article  CAS  PubMed  Google Scholar 

  66. Costello JF, Balki M. Cesarean delivery under ultrasound-guided spinal anesthesia [corrected] in a parturient with poliomyelitis and Harrington instrumentation. Can J Anaesth. 2008;55(9):606–11.

    Article  Google Scholar 

  67. Ellinas EH, Eastwood DC, Patel SN, Maitra-D'Cruze AM, Ebert TJ. The effect of obesity on neuraxial technique difficulty in pregnant patients: a prospective, observational study. Anesth Analg. 2009;109(4):1225–31. https://doi.org/10.1213/ANE.0b013e3181b5a1d2.

    Article  PubMed  Google Scholar 

  68. • Perlas A, Chaparro LE, Chin KJ. Lumbar neuraxial ultrasound for spinal and epidural anesthesia: a systematic review and meta-analysis. Reg Anesth Pain Med. 2016;41(2):251–60. https://doi.org/10.1097/aap.0000000000000184A summary of current evidence that supports the usage of ultrasound in neuraxial anesthesia.

    Article  PubMed  Google Scholar 

  69. Perlas A. Evidence for the use of ultrasound in neuraxial blocks. Reg Anesth Pain Med. 2010;35(2 Suppl):S43–6. https://doi.org/10.1097/AAP.0b013e3181d2462e.

    Article  PubMed  Google Scholar 

  70. Soni NJ, Franco-Sadud R, Schnobrich D, Dancel R, Tierney DM, Salame G, et al. Ultrasound guidance for lumbar puncture. Neurol Clin Pract. 2016;6(4):358–68. https://doi.org/10.1212/cpj.0000000000000265.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Belavy D, Ruitenberg MJ, Brijball RB. Feasibility study of real-time three-/four-dimensional ultrasound for epidural catheter insertion. Br J Anaesth. 2011;107(3):438–45. https://doi.org/10.1093/bja/aer157.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Yale University, New Haven, CT, USA

    Jinlei Li, Ramya Krishna, David Lam & Nalini Vadivelu

  2. Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, NY, USA

    Yang Zhang

Authors
  1. Jinlei Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ramya Krishna
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yang Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David Lam
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nalini Vadivelu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jinlei Li.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Other Pain

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Li, J., Krishna, R., Zhang, Y. et al. Ultrasound-Guided Neuraxial Anesthesia. Curr Pain Headache Rep 24, 59 (2020). https://doi.org/10.1007/s11916-020-00895-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11916-020-00895-3

Keywords

Search

Navigation