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To the Editor, Identification of bony landmarks by palpation can be difficult in obese pregnant women, and obesity is associated with higher epidural catheter failure rates [1]. Ultrasound may help offset the challenges of epidural catheter placement in obese patients [2], but few studies have compared it to landmark palpation in morbidly obese (body mass index, BMI ≥40) patients. In the palpation group, there were two cases of paresthesia during epidural needle placement, one unilateral block requiring catheter adjustment (epidural catheter pulled back 1 cm, no reinsertion required), and one unintentional dural puncture resulting post-dural puncture headache (declined epidural blood patch).

We developed an innovative method for ultrasound-assisted thoracic epidural catheter placement and assessed its potential to reduce procedural duration for trainees. A cadaveric observational study and a clinical randomized controlled trial. Sapporo Medical University Hospital. A total of 52 adult patients scheduled for thoracic or abdominal surgery and four cadavers. Patients were randomly assigned to either group receiving conventional palpation (conventional group) or combination of the ultrasound examination and conventional palpation (ultrasound group). The primary outcome was total procedure time (sum of skin marking time and needling time) by trainees. The secondary outcomes were (1) skin marking time, (2) needling time, (3) multiple skin punctures, (4) needle redirection, (5) complications, and (6) failed cases. Through dissection of four cadavers, the most dorsal site of the transverse process root was identifiable by ultrasound and the reliable indicator of the interlaminar space. We devised ultrasound-assisted middle thoracic epidural catheter placement utilizing the most dorsal sites of bilateral transverse process roots as anatomical landmarks. Trainees in the ultrasound group had significantly longer skin marking time and significantly shorter needling time than those in the conventional group (107 [87–158] vs 46 s [34–54] s, p < 0.001 and 197 [156–328] vs 341 [303–488] s, p = 0.003). Consequently, there was no significant difference between the two groups in total procedure time (326 [263–467] s vs 391 [354–533] s, p = 0.167). Moreover, the probability of trainee failure in epidural anesthesia was significantly lower in the ultrasound group (2/26 [17.7 %] vs 10/26 [38.5 %], p = 0.019). Our novel technique for thoracic epidural catheter placement resulted in expedited needling and enhanced success rates among trainees, although there was no significant difference between total procedure time when using ultrasound guidance and that when using conventional palpation. •The most dorsal site of the transverse process root was identifiable by ultrasound.•The transverse process root was a reliable landmark of the interlaminar space.•We developed an innovative method for thoracic epidural catheter placement.•Our novel technique expedited needling among trainees.•Our novel technique enhanced success rates among trainees.

IntroductionThe Microsoft HoloLens is a head-mounted mixed reality device, which allows for overlaying hologram-like computer-generated elements onto the real world. This technology can be combined with preprocedural ultrasound during thoracic epidural placement to create a visual of the ideal needle angulation and trajectory in the users’ field of view. This could result in a technically easier and potentially safer alternative to traditional blind landmark techniques.MethodsPatients were randomly assigned to one of two groups: (1) HoloLens-assisted thoracic epidural technique (intervention—group H) or (2) traditional thoracic epidural technique (control—group C). The primary outcome was needling time (defined as skin puncture to insertion of epidural catheter) during the procedure. The secondary outcomes were number of needle punctures, number of needle movements, number of bone contacts, and epidural failure. Procedural pain and recovery room pain levels were also evaluated.ResultsEighty-three patients were included in this study. The primary outcome of procedure time was reduced in the HoloLens group compared with control (4.5 min vs 7.3 min, p=0.02, 95% CI), as was the number of needle movements required (7.2 vs 14.4, p=0.01), respectively. There was no difference in intraprocedure or postprocedure pain, bone contacts, or total number of needle punctures. Three patients in the control group experienced epidural failure versus one patient in the HoloLens group.ConclusionsThis study shows that thoracic epidural placement may be facilitated by using a guidance hologram and may be more technically efficient.Trial registration number NCT04028284.

Epidural steroid injections (ESI) are frequently used to treat lumbosacral radicular pain, but the solute spread in the epidural space needs further investigation. This semi-blind, randomized study assessed clinical outcomes and contrast spread patterns between the parasagittal interlaminar (PIL) and transforaminal (TF) approaches in 79 adults with low back pain. Participants were randomly assigned to receive either TF-ESI (3 ml) or high-volume PIL-ESI (10 ml). All procedures were performed under fluoroscopic guidance. Contrast spread was evaluated by a blinded pain specialist, and clinical outcomes, including analgesia, patient satisfaction, and quality of life, were measured at two weeks, one month, two months, and six months post-treatment. Results showed no differences in baseline characteristics between groups. There were no statistically significant differences between the two groups in mean pain intensity at baseline and six months after treatment ( p  = 0.590 and 0.484, respectively). Pain relief, satisfaction, quality of life, and contrast spread to the anterior epidural space did not differ over six months. However, the TF group required significantly more fluoroscopic images ( p  < 0.001). High-volume PIL-ESI provides clinical efficacy and anterior contrast distribution equivalent to TF-ESI, with fewer fluoroscopic images needed.

Abstract BACKGROUND Spinal epidural arteriovenous fistulas (SEDAVFs) are an increasingly recognized form of spinal vascular malformation and are distinct from spinal dural arteriovenous fistulas (SDAVFs). Differentiating between these 2 entities is important as operative strategies often differ based on angioarchitecture. OBJECTIVE To compare demographic, clinical, anatomic, and imaging findings of SDAVFs and SEDAVFs. METHODS Consecutive patients diagnosed and/or treated for SDAVF or SEDAVF at our institution between January 2000 and November 2018 were included. Data were collected on demographics, clinical presentation, and imaging findings. All cross-sectional and angiographic imaging were reviewed. To compare continuous variables, t-test was used Chi-squared was used for categorical variables. RESULTS A total of 169 patients were included. In total 47 patients had SEDAVFs and 122 patients had SDVAFs. Clinical presentation and magnetic resonance imaging (MRI) imaging findings were similar between the 2 groups. SEDAVF patients were significantly more likely to have an epidural venous pouch on gadolinium bolus MR angiography (MRA) (0.0% vs 92.1%, P < .0001). SEDAVFs were more commonly located in the lumbar and sacral spine than SDAVFs (85.1% vs 34.4%, P < .0001). When in the lumbar spine, SEDAVFs unlike SDAVFs were more likely to involve the most caudal segments (L4 and L5, P = .02). CONCLUSION SEDAVF share clinical and radiological findings similar to SDAVFS, including high T2 cord signal, cord enhancement, and perimedullary flow voids on conventional MRI. However, they have a characteristic appearance on spinal MRA and DSA with a pouch of epidural contrast. SEDAVFs are more commonly located in the lumbosacral spine.

Cervical interlaminar epidural injection (CILEI) is commonly used to treat acute or chronic pain that affects the head, neck, and upper extremities. Thus far, studies on CILEI have focused on determining the optimal volume of contrast medium or analyzing the spread of contrast medium during a CILEI. To our knowledge, few studies have attempted to assess the correlation between epidurogram patterns and clinical outcomes of CILEI. This study aimed to investigate the relationship between contrast medium spread and pain relief after a CILEI in patients who complained of neck and/or unilateral upper extremity pain. Retrospective cohort study. Tertiary university hospital. Patient demographics, pain duration, and radiographic findings, including cervical simple radiograph and magnetic resonance imaging, were reviewed from medical records. The spread pattern of contrast medium during a CILEI was analyzed based on anteroposterior (AP) and lateral fluoroscopic views. The spread pattern in the AP view was classified into 4 categories using predetermined anatomical references, including the medial border, bisector, and lateral border of the articular pillar at the targeted vertebral level. The spread pattern in the lateral view was divided into 2 groups based on whether the contrast medium was present at the ventral epidural space. Every CILEI procedure was performed under fluoroscopic guidance by skilled experts. A responsive outcome was defined as a reduction in the numeric rating scale for pain by more than 50% at one month postoperatively compared to preoperatively. Among 656 patients, 526 were excluded from the analysis according to predetermined criteria. The remaining 130 patients were analyzed, and 78 (60%) patients showed responsive results one month after a CILEI. According to a multivariable logistic regression analysis, the negative predictors of a CILEI were long symptom duration (P = 0.045), high grade of central stenosis (P = 0.022), and limited spread of contrast medium solely within the central canal in the AP view (P = 0.008). The limitations of this study include its retrospective design, absence of clinical parameters other than pain intensity, and short follow-up period. If the duration of symptoms is lengthy, central stenosis is severe, or contrast medium spread is limitedly solely within the central canal and does not reach the dorsal root ganglion any further, the outcome after a CILEI is likely to be poor. Therefore, efforts should be made to spread injectate around the dorsal root ganglion at the target level.

IntroductionFluoroscopy can improve the success rate of thoracic epidural catheter placement (TECP). Real-time ultrasound (US)-guided TECP was recently introduced and showed a high first-pass success rate. We tested whether real-time US-guided TECP results in a non-inferior first-pass success rate compared with that of fluoroscopy-guided TECP.MethodsIn this single-center, non-inferiority, randomized trial, the primary outcome was the comparison of the first-pass success rate of TECP between real-time US guidance (US group) and fluoroscopic guidance (fluoroscopy group). Secondary outcomes included time to identifying epidural space, procedure time, total number of needle passes, number of skin punctures, final success, and cross-over success.ResultsWe randomly assigned 132 patients to the allocated groups. The difference in the first-pass success rate between the groups did not exceed the non-inferiority margin of 15% (US group: 66.7% vs fluoroscopy group: 68.2%; difference −1.5%, 95% exact CI: −14.9% to 11.9%). The difference in the final success rate also did not differ between the groups (98.5% vs 100.0%; difference −1.5%, 95% exact CI: −4.0% to 1.0%). The time to identifying epidural space (45.6 (34–62) vs 59.0 (42–77) s, p=0.004) and procedure time (39.5 (28–78) vs 112.5 (93–166) s, p<0.001) were significantly shorter in the US group.ConclusionsReal-time US guidance provided a non-inferior success rate and shorter time spent on preparation and procedure compared with fluoroscopic guidance in TECP.Trial registration numberKCT0006521.

Background and ObjectivesThoracic epidural analgesia can reduce postoperative pain and cardiopulmonary morbidity, but it is associated with a high rate of clinical failure. Up to 50% of clinical failure is thought to be related to technical insertion. In this study, patients undergoing thoracic surgery were randomized to one of two catheter insertion techniques: fluoroscopically guided or conventional loss of resistance with saline/air. Our primary aim was to examine whether fluoroscopic guidance could increase the incidence of correct catheter placement and improve postoperative analgesia. Our secondary aim was to assess the potential impact of correct epidural catheter positioning on length of stay in the postanesthesia care unit and total hospital length of stay.MethodsThis randomized clinical trial was conducted at Dartmouth-Hitchcock Medical Center over 25 months (January 2012 to February 2014). Patients (N = 100) undergoing thoracic surgery were randomized to fluoroscopic guidance (n = 47) or to loss of resistance with saline/air (n = 53). Patients were followed for the primary outcomes of 24-hour morphine use, 24-hour numeric pain scores, and the incidence of epidural catheter positioning within the epidural space. Postanesthesia care unit and total hospital lengths of stay were evaluated as secondary outcome measurements and compared for patients with correct epidural catheter positioning and those without correct epidural catheter positioning.ResultsOne hundred patients were included in an intention-to-treat analysis. Numeric pain scores and 24-hour morphine consumption were no different between groups. Fluoroscopic guidance was associated with an increased incidence of epidural catheter placement within the epidural space compared with loss of resistance with air/saline [fluoroscopic guidance, epidural in 98% (46/47) versus loss of resistance with saline/air, epidural in 74% (39/53)]. There was a significant increase in correct catheter positioning with (odds ratio, 21.07; 95% confidence interval, 2.07-214.38; P = 0.010) or without (odds ratio, 16.15; 95% confidence interval, 2.03-128.47; P = 0.009) adjustment for potentially confounding variables. In an adjusted analysis, correctly positioned thoracic epidural catheters were associated with shorter postanesthesia care unit (5.87 ± 5.39 hours vs 4.30 ± 1.171 hours; P = 0.044) and total hospital length of stay (5.77 ± 4.94 days vs 4.93 ± 2.79 days; P = 0.031).ConclusionsFluoroscopic guidance increases the incidence of epidural catheter positioning within the epidural space and may reduce postanesthesia care unit and hospital lengths of stay. Future work should validate the effectiveness of this approach.This clinical trial is registered with ClinicalTrials.gov (NCT02678039).

Achieving accurate epidural access during surgery is challenging, with failure rates reported as high as 40%. The loss of resistance (LOR) technique remains the standard but relies heavily on the clinician's tactile sense, which can lead to inaccuracies. The EpiFaith® (Flat Medical) syringe, designed with a visual LOR cue, aims to enhance the accuracy of physicians' attempts to achieve epidural access. This study aimed to evaluate the usability and accuracy of the EpiFaith® syringe for epidural access at the cervical, thoracic, and lumbar levels. The syringe was tested by 2 physicians-one with prior clinical experience using the device and one who would use it for the first time-on cadaver models. A cadaveric study was conducted by 2 providers who tested the EpiFaith® syringe across multiple spinal levels. The study was carried out in medical facilities equipped with cadaveric simulation and fluoroscopic imaging. Five fresh adult cadavers were used, with both providers performing epidural access procedures at spinal levels from C7 to S1. One provider had prior experience using the EpiFaith® syringe, while the other had none. Each procedure used 1 mL of normal saline for LOR detection, and successful epidural access was confirmed using contrast and fluoroscopy. Variables recorded included injection site, number of attempts, first-attempt success rates, device usage, and instances of false LOR. The experienced provider (Provider 1) performed procedures on 16 spinal levels across 4 cadavers, achieving a 100% first-attempt success rate with no false LOR events. The inexperienced provider (Provider 2) performed procedures on 7 spinal levels, achieving a 57.1% (4/7) first-attempt success rate, with 3 false LOR events (30%). Provider 2 accessed the epidural space successfully after adjusting the technique in response to false LOR signals. Cadaveric models lack normal physiological conditions, and the small sample size limits generalizability. Further studies in live settings are needed to validate the EpiFaith® syringe's clinical utility and learning curve. The EpiFaith® syringe is an effective tool for achieving epidural access, particularly for experienced clinicians. Even inexperienced users can adapt to the device's feedback to access the epidural space successfully. Further clinical validation is necessary to confirm the syringe's potential to improve procedural accuracy and reduce false LOR events in real-world settings.

Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adults. It is performed by inserting a needle through the sacral hiatus to gain entrance into the sacral epidural space. Using conventional blind technique, the failure rate of caudal epidural block in adults is high even in experienced hands. This high failure rate could be attributed to anatomic variations that make locating sacral hiatus difficult. With the advent of fluoroscopy and ultrasound in guiding needle placement, the success rate of caudal epidural block has been markedly improved. Although fluoroscopy is still considered the gold standard when performing caudal epidural injection, ultrasonography has been demonstrated to be highly effective in accurately guiding the needle entering the caudal epidural space and produce comparative treatment outcome as fluoroscopy. Except intravascular and intrathecal injection, ultrasonography could be as effective as fluoroscopy in preventing complications during caudal epidural injection. The relevant anatomy and techniques in performing the caudal epidural block will be briefly reviewed in this article.