title: Single-operator real-time ultrasound-guidance to aim and insert  a lumbar epidural needle.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  This small study demonstrates the feasibility of the ultrasound-guidance technique. Areas for further development are identified for both ultrasound software and physical design.
authors.affiliation: Department of Electrical and Computer Engineering, University of British Columbia, 2332 Main Mall, Vancouver, BC, Canada. denis.tran@gmail.com
authors.forename: Denis
authors.initials: D
authors.lastname: Tran
authors.forename: Allaudin A
authors.initials: AA
authors.lastname: Kamani
authors.forename: Elias
authors.initials: E
authors.lastname: Al-Attas
authors.forename: Victoria A
authors.initials: VA
authors.lastname: Lessoway
authors.forename: Simon
authors.initials: S
authors.lastname: Massey
authors.forename: Robert N
authors.initials: RN
authors.lastname: Rohling
mesh_terms: D000328:Adult; D000465:Algorithms; D000767:Anesthesia, Epidural / Q000295:instrumentation / Q000379:methods*; D000773:Anesthesia, Obstetrical / Q000295:instrumentation* / Q000379:methods*; D002585:Cesarean Section; D005260:Female; D006801:Humans; D009339:Needles; D013129:Spinal Puncture / Q000295:instrumentation / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods*