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Neuraxial Block

Longitudinal Paramedian Scan at the L2-3

 

Transverse Process Location

 


Distinguishing features:

  1. Each transverse process (TP) casts a hypoechoic bony shadow underneath a hyperechoic bony outline.
  2. The psoas muscle (PsMM) is visualized between the transverse processes.

 

2. Characteristics of the L5-Sacrum Interspinous Space

 

Transverse Scan at the L5-S1 Interspinous Space

 



 

Transverse Scan at the Sacrum

 



 

Longitudinal Paramedian Scan at the L5-S1 Interspace

 


LF/dura = ligamentum flavum/dura complex

 

3. Post Laminectomy

 

  • Scan over the laminectomy scar to capture both the transverse and longitudinal view. Notice the absence of spinous processes.

    •  

    Arrowheads = laminectomy scar

Longitudinal scan showing the hyperechoic dura sac which is pulsatile in real time scanning; the subarachnoid space is anechoic.
Transverse scan showing the circular dura sac (arrowheads); it is pulsatile in real time.

 

4. Lumbar Scoliosis (Convex to the Right)

 

A patient with severe scoliosis with an obvious convex curvature to the right. The midline interspinous space is difficult to define by palpation alone.
A. A transverse scan showing the midline spinous process (SP) and the lamina (L) on the right side. The lamina on the left side is not visualized. The transverse processes (TP) are visualized on both sides.
B. A transverse scan showing the midline interspinous space (note the absence of the bone shadow) and visualization of the ligamentum flavum/dura (LF/D) complex (a hyperechoic line) and the posterior longitudinal ligament/vertebral body (PLL/VB) complex (a hyperechoic line) deeper. Note the PLL/VB line is not midline but shifted to the right indicating the scoliotic spine is convex to the right.

 

SELECTED REFERENCES

 

Adult Neuraxial Blocks

  • Arzola C, Davies S, Rofaeel A, Carvalho JC: Ultrasound using the transverse approach to the lumbar spine provides reliable landmarks for labor epidurals. Anesth.Analg. 2007; 104: 1188-92.
  • Ferre RM, Sweeney TW: Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. Am.J.Emerg.Med. 2007; 25: 291-6.
  • Whitty RJ, Maxwell CV, Carvalho JC: Complications of neuraxial anesthesia in an extreme morbidly obese patient for Cesarean section. Int.J.Obstet.Anesth. 2007; 16: 139-44.
  • Druhan SM, Shiels WE, Kang DR, Elton SW, Koranyi K: Successful sonographically guided drainage of epidural abscess. AJR Am.J.Roentgenol. 2006; 187: W512-W514
  • Yoon JS, Sim KH, Kim SJ, Kim WS, Koh SB, Kim BJ: The feasibility of color Doppler ultrasonography for caudal epidural steroid injection. Pain 2005; 118: 210-4
  • Peng P W, Rofaeel A. Using ultrasound in a case of difficult epidural needle placement. Can J Anaesth 2006; 53: 325-326.
  • Ali M E, Laurito C E. Ultrasound guidance for epidural catheter placement: a coming of age? J Clin Anesth 2005; (17): 235-236.
  • McLeod A, Roche A, Fennelly M. Case series: Ultrasonography may assist epidural insertion in scoliosis patients. Can J Anaesth 2005; (52): 717-720.
  • Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005; (94): 7-17.
  • Peterson M A, Abele J. Bedside ultrasound for difficult lumbar puncture. J Emerg Med 2005; (28): 197-200.
  • Yoon J S, Sim K H, Kim S J, Kim W S, Koh S B, Kim B J. The feasibility of color Doppler ultrasonography for caudal epidural steroid injection. Pain 2005; 118: 210-214.
  • Chen C P, Tang S F, Hsu T C, Tsai W C, Liu H P, Chen M J, Date E, Lew H L. Ultrasound guidance in caudal epidural needle placement. Anesthesiology 2004; 101: 181-184.
  • Grau T, Leipold R W, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of combined spinal-epidural anaesthesia. Eur J Anaesthesiol 2004; 21: 25-31.
  • 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; 50:1047-1050.
  • Lang S A, Tsui B, Grau T. New avenues of epidural research. Anesth Analg 2003; 97: 292-293.
  • Grau T, Leipold R W, Delorme S, Martin E, Motsch J. Ultrasound imaging of the thoracic epidural space. Reg Anesth Pain Med 2002; 27: 200-206.
  • Grau T, Leipold R W, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in obstetric epidural anesthesia. J Clin Anesth 2002; 14: 169-175.
  • Moon S H, Park M S, Suk K S, Suh J S, Lee S H, Kim N H, Lee H M. Feasibility of ultrasound examination in posterior ligament complex injury of thoracolumbar spine fracture. Spine 2002; 27:2154-2158.
  • Grau T, Leipold R W, Horter J, Conradi R, Martin E O, Motsch J. Paramedian access to the epidural space: the optimum window for ultrasound imaging. J Clin Anesth 2001;13: 213-217.
  • Grau T, Leipold R W, Conradi R, Martin E. Ultrasound control for presumed difficult epidural puncture. Acta Anaesthesiol Scand 2001; 45: 766-771.
  • Grau T, Leipold R W, Horter J, Martin E, Motsch J. Colour Doppler imaging of the interspinous and epidural space. Eur J Anaesthesiol 2001; 18: 706-712.
  • Grau T, Leipold R W, Horter J, Conradi R, Martin E, Motsch J. The lumbar epidural space in pregnancy: visualization by ultrasonography. Br J Anaesth 2001; 86: 798-804.
  • Grau T, Leipold R W, Conradi R, Martin E, Motsch J. Ultrasound imaging facilitates localization of the epidural space during combined spinal and epidural anesthesia. Reg Anesth Pain Med 2001; 26: 64-67.
  • Nader-Djalal N, Reedy R, Bacon D R. Doppler guidance for epidural catheter placement. Reg Anesth Pain Med 1998; 23: 326-328.
  • Rhodes D W, Bishop P A. A review of diagnostic ultrasound of the spine and soft tissue. J Manipulative Physiol Ther 1997; 20:267-273.

Pediatric Neuraxial Blocks

  • Kil HK, Cho JE, Kim WO, Koo BN, Han SW, Kim JY: Prepuncture ultrasound-measured distance: an accurate reflection of epidural depth in infants and small children. Reg Anesth Pain Med 2007; 32: 102-6.
  • Willschke H, Bosenberg A, Marhofer P, Willschke J, Schwindt J, Weintraud M, Kapral S, Kettner S: Epidural catheter placement in neonates: sonoanatomy and feasibility of ultrasonographic guidance in term and preterm neonates. Reg Anesth Pain Med 2007; 32: 34-40.
  • Park JH, Koo BN, Kim JY, Cho JE, Kim WO, Kil HK: Determination of the optimal angle for needle insertion during caudal block in children using ultrasound imaging. Anaesthesia 2006; 61: 946-9.
  • Tsui BC: Innovative approaches to neuraxial blockade in children: the introduction of epidural nerve root stimulation and ultrasound guidance for epidural catheter placement. Pain Res Manag 2006; 11: 173-80.
  • Willschke H, Marhofer P, Bosenberg A, Johnston S, Wanzel O, Sitzwohl C, Kettner S, Kapral S: Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique. Br J Anaesth. 2006; 97: 200-7.
  • Huang J. Disadvantages of ultrasound guidance in caudal epidural needle placement. Anesthesiology 2005; 102: 693-694.
  • Marhofer P, Bosenberg A, Sitzwohl C, Willschke H, Wanzel O, Kapral S. Pilot study of neuraxial imaging by ultrasound in infants and children. Paediatr Anaesth 2005; 15: 671-676.
  • Ozer Y, Ozer T, Altunkaya H, Savranlar A. The posterior lumbar dural depth: an ultrasonographic study in children. Agri 2005; 17: 53-57.
  • Rapp H J, Folger A, Grau T. Ultrasound-guided epidural catheter insertion in children. Anesth Analg 2005; 101: 333-9.
  • Roberts S A, Galvez I. Ultrasound assessment of caudal catheter position in infants. Paediatr Anaesth 2005; 15: 429-432.
  • Roberts S A, Guruswamy V, Galvez I. Caudal injectate can be reliably imaged using portable ultrasound--a preliminary study. Paediatr Anaesth 2005; 15: 948-952.
  • Chawathe M S, Jones R M, Gildersleve C D, Harrison S K, Morris S J, Eickmann C. Detection of epidural catheters with ultrasound in children. Paediatr Anaesth 2003; 13: 681-684.
  • Kiechl-Kohlendorfer U, Unsinn K M, Schlenck B, Trawoger R, Gassner I. Cerebrospinal fluid leakage after lumbar puncture in neonates: incidence and sonographic appearance. Am J Roentgenol 2003;181:231-234.

 

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