The Korean Journal of Pain

The Korean Pain Society (대한통증학회)
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Ultrasonographic Measurement of the Ligamentum Flavum Depth : Is It a Reliable Method to Distinguish True and False Loss of Resistance?

  • Pak, Michael Hae-Jin (Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital) ;
  • Lee, Won-Hyung (Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital) ;
  • Ko, Young-Kwon (Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital) ;
  • So, Sang-Young (Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital) ;
  • Kim, Hyun-Joong (Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital)
  • Received : 2011.11.07
  • Accepted : 2012.01.11
  • Published : 2012.04.01
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Abstract

Background: Previous studies have shown that if performed without radiographic guidance, the loss of resistance (LOR) technique can result in inaccurate needle placement in up to 30% of lumbar epidural blocks. To date, no study has shown the efficacy of measuring the depth of the posterior complex (ligamentum flavum, epidural space, and posterior dura) ultrasonographically to distinguish true and false LOR. Methods: 40 cervical epidural blocks were performed using the LOR technique and confirmed by epidurograms. Transverse ultrasound images of the C6/7 area were taken before each cervical epidural block, and the distances from the skin to the posterior complex, transverse process, and supraspinous ligament were measured on each ultrasound view. The number of LOR attempts was counted, and the depth of each LOR was measured with a standard ruler. Correlation of false and true positive LOR depth with ultrasonographically measured depth was also statistically analyzed. Results: 76.5% of all cases (26 out of 34) showed false positive LOR. Concordance correlation coefficients between the measured distances on ultrasound (skin to ligamentum flavum) and actual needle depth were 0.8285 on true LOR. Depth of the true positive LOR correlated with height and weight, with a mean of $5.64{\pm}1.06cm$, while the mean depth of the false positive LOR was $4.08{\pm}1.00cm$. Conclusions: Ultrasonographic measurement of the ligamentum flavum depth (or posterior complex) preceding cervical epidural block is beneficial in excluding false LOR and increasing success rates of cervical epidural blocks.

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References

  1. Castagnera L, Maurette P, Pointillart V, Vital JM, Erny P, Senegas J. Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain. Pain 1994; 58: 239-43. https://doi.org/10.1016/0304-3959(94)90204-6
  2. Ferrante FM, Wilson SP, Iacobo C, Orav EJ, Rocco AG, Lipson S. Clinical classification as a predictor of therapeutic outcome after cervical epidural steroid injection. Spine (Phila Pa 1976) 1993; 18: 730-6. https://doi.org/10.1097/00007632-199305000-00010
  3. Rowlingson JC, Kirschenbaum LP. Epidural analgesic techniques in the management of cervical pain. Anesth Analg 1986; 65: 938-42.
  4. Waldman SD. Cervical epidural abscess after cervical epidural nerve block with steroids. Anesth Analg 1991; 72: 717-8. https://doi.org/10.1213/00000539-199105000-00032
  5. Williams KN, Jackowski A, Evans PJ. Epidural haematoma requiring surgical decompression following repeated cervical epidural steroid injections for chronic pain. Pain 1990; 42: 197-9. https://doi.org/10.1016/0304-3959(90)91162-C
  6. Abram SE, O'Connor TC. Complications associated with epidural steroid injections. Reg Anesth 1996; 21: 149-62.
  7. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine (Phila Pa 1976) 1998; 23: 2137-42. https://doi.org/10.1097/00007632-199810010-00020
  8. White AH. Injection techniques for the diagnosis and treatment of low back pain. Orthop Clin North Am 1983; 14: 553-67.
  9. Hogan QH. Epidural anatomy examined by cryomicrotome section. Influence of age, vertebral level, and disease. Reg Anesth 1996; 21: 395-406.
  10. Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine (Phila Pa 1976) 2002; 27: 509-14. https://doi.org/10.1097/00007632-200203010-00011
  11. Kim SH, Lee KH, Yoon KB, Park WY, Yoon DM. Sonographic estimation of needle depth for cervical epidural blocks. Anesth Analg 2008; 106: 1542-7. https://doi.org/10.1213/ane.0b013e318168b6a8
  12. Fredman B, Nun MB, Zohar E, Iraqi G, Shapiro M, Gepstein R, et al. Epidural steroids for treating "failed back surgery syndrome": is fluoroscopy really necessary? Anesth Analg 1999; 88: 367-72.
  13. Wulf H, Kibbel K, Mercker S, Maier C, Gleim M, Crayen E. Radiologic position control of epidural catheters (epidurography). An instrument of quality assurance for regional analgesia. Anaesthesist 1993; 42: 536-44.
  14. Cork RC, Kryc JJ, Vaughan RW. Ultrasonic localization of the lumbar epidural space. Anesthesiology 1980; 52: 513-6. https://doi.org/10.1097/00000542-198006000-00013
  15. Wallace DH, Currie JM, Gilstrap LC, Santos R. Indirect sonographic guidance for epidural anesthesia in obese pregnant patients. Reg Anesth 1992; 17: 233-6.
  16. 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. https://doi.org/10.1213/01.ane.0000250912.66057.41
  17. 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: 1876-81. https://doi.org/10.1213/ane.0b013e3181a323f6
  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: 201-5.
  19. Ferre RM, Sweeney TW, Strout TD. Ultrasound identification of landmarks preceding lumbar puncture: a pilot study. Emerg Med J 2009; 26: 276-7. https://doi.org/10.1136/emj.2007.057455
  20. Chin KJ, Perlas A, Singh M, Arzola C, Prasad A, Chan V, et al. An ultrasound-assisted approach facilitates spinal anesthesia for total joint arthroplasty. Can J Anaesth 2009; 56: 643-50. https://doi.org/10.1007/s12630-009-9132-8
  21. Grau T, Leipold RW, Delorme S, Martin E, Motsch J. Ultrasound imaging of the thoracic epidural space. Reg Anesth Pain Med 2002; 27: 200-6. https://doi.org/10.1097/00115550-200203000-00015
  22. Pandin P, Haentjens L, Salengros JC, Quintin J, Barvais L. Combined ultrasound and nerve stimulation-guided thoracic epidural catheter placement for analgesia following anterior spine fusion in scoliosis. Pain Pract 2009; 9: 230-4. https://doi.org/10.1111/j.1533-2500.2009.00275.x

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