title: Can continuous low current electrical stimulation distinguish insulated needle position in the epidural and intrathecal spaces in pediatric patients?
abstract: BACKGROUND
  Muscle twitches elicited with electrical stimulation (6-17 mA) during epidural insertion indicate correct epidural needle placement while muscle twitches at a lower current (<1 mA) may indicate intrathecal needle placement. This study examined whether applying continuous electrical stimulation at 6 mA could indicate needle entry into the epidural space without inadvertently penetrating the intrathecal space.
  
  
  METHODS
  After institutional review board (IRB) approval, 10 pediatric patients scheduled for lumbar puncture were studied. Following sedation with propofol, an insulated 24-gauge Pajunck unipolar needle was inserted through an 18-gauge introducer needle placed at the L4-5 interspace. The needle was first connected to a nerve stimulator (6 mA) and advanced. At the first sign of muscle twitching, needle advancement was stopped and the threshold current for motor activity was determined. The current was then turned off, the stylet was removed and the needle checked for cerebrospinal fluid (CSF). If CSF was not present, the needle was advanced into the intrathecal space (as confirmed by the presence of CSF). Ten pediatric patients (ASA II or III) aged 7.8 +/- 4.3 years (2.8-16.0 years) were studied.
  
  
  RESULTS
  All patients had two distinguishable threshold currents as the needle advanced. The mean threshold current to elicit muscle twitch in the presumed epidural space was 3.84 +/- 0.99 mA. CSF was not present in any of the patients at this location. The mean threshold current in the intrathecal space was 0.77 +/- 0.32 mA. The average estimated distance from the first threshold location to the intrathecal space was 3 mm. All muscle twitches were at the L3-5 myotomes. Nine muscle twitches were unilateral and one was bilateral.
  
  
  CONCLUSIONS
  Monitoring with an insulated needle with electrical stimulation at 6 mA may prevent unintentional placement of epidural needles into the intrathecal space.
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada. btsui@ualberta.ca
authors.forename: Ban C H
authors.initials: BC
authors.lastname: Tsui
authors.forename: Alese M
authors.initials: AM
authors.lastname: Wagner
authors.forename: Kirsten
authors.initials: K
authors.lastname: Cunningham
authors.forename: Shirley
authors.initials: S
authors.lastname: Perry
authors.forename: Sunil
authors.initials: S
authors.lastname: Desai
authors.forename: Robert
authors.initials: R
authors.lastname: Seal
mesh_terms: D000767:Anesthesia, Epidural / Q000295:instrumentation / Q000379:methods*; D002648:Child; D004558:Electric Stimulation; D006801:Humans; D007278:Injections, Spinal / Q000295:instrumentation / Q000379:methods*; D009119:Muscle Contraction / Q000502:physiology; D018482:Muscle, Skeletal / Q000502:physiology; D009339:Needles; D009369:Neoplasms / Q000601:surgery; D013129:Spinal Puncture / Q000379:methods*