Neuraxial anesthesia and analgesia techniques can be challenging in the obstetric patient. These techniques heavily rely on anatomic landmarks but the expected anatomic and physiologic changes of pregnancy impair the provider in discerning these accurately. There is exaggerated lordosis and edema, softer interspinous ligaments, narrowing of the epidural space, and a smaller intrathecal space; all of which increase the likelihood of failed block or an accidental dural puncture. Furthermore, patients may not be able to flex the lumbar spine and labor pain challenges their ability to maintain positioning during the procedure. To review the theory and steps of labor analgesia click here.
Enter lumbar ultrasound for guidance of neuraxial blocks. Ultrasound improves precision and efficacy. Contrary to the other chapters were bone was limiting our ability to see deeper structures, here our goal is to identify bony landmarks as they are surrogates for location and depth.
Lumbar Sono Anatomy
We must first take a look at two of the most common scanning planes. These are the transverse (in blue) and the paramedian sagittal oblique (PSO) plane (in red). The PSO plane is a paramedian sagittal plane (in green) except the probe is tilted towards midline as opposed to a line that is parallel the midline, as seen on the diagram.
Ideally a curved array the low frequency probe (3-5Mhz) should be selected and an initial depth of 7-8 cm chosen. We then recognize the bony structures that are imaged on these planes.
Recall that bony surfaces appear as hyperechoic or white linear structures with dense acoustic shadowing (black) beneath that completely obscures any deeper structures The diagrams and their corresponding ultrasound images are shown below for illustration purposes.
Imaging planes used in lumbar ultrasound. See text for details.
Paramedian Sagital Oblique (PSO) Plane
Lets first take a look at what we could possibly see with the use of a 3D model to have an understanding of the planes and orientation. The clips from the model below show the lumbar vertebrae and sacrum. The left portion of the model has all muscle layers while the right has only the bony layers which is what is of paramount importance to us. The probe is slightly angled towards the left on the sagittal plane to get the PSO plane. Notice that the second clip starts scanning from the sacrum. The model has been modified and used with from Z-anatomy.
The most useful feature of this technique is being able to identify the interlaminar space.
The ultrasound beam cuts the vertebra in such a way the spinous process is not visualized and the bony structures that we see displayed are the lamina.
The sloping hyperechoic laminae of the lumbar vertebrae form what has been described as the “sawtooth” pattern. The gaps between lamina represent the paramedian interlaminar spaces, through which other structures may be visualized. The posterior complex (letter C on the image) which is a combination of the ligamentum flavum, epidural space, and posterior dura often appear as a single linear hyperechoic structure.
The depth from skin to the posterior complex may be measured to provide an indication of the expected needle depth for neuroaxial anesthesisa. If the probe is slid in a caudad direction a single homogenous horizontal hyperechoic line of the sacrum comes into view. We can thus identify the interlaminar spaces if we can identify the sacrum and move upwards from it.
Paramedian Sagital Oblique ultrasound view of lumbar space and corresponding bony anatomy. In red, erector spinae muscle. A, erector spinae muscle, B, lamina, C, Posterior complex and D, Anterior complex (anterior dura, posterior longitudinal ligament and posterior aspect of the vertebral body or disk).
Transverse Plane- Interlaminar Transverse Space
Let's again first take a look at a 3D model so that we understand orientation of this window. The probe has been positioned in transverse plane and moved up and down the model. The first shows a slight tilt of the probe to allow for visualization of the soft tissues that would be obscured by the spinous process. We used Z-anatomy to collect these clips.
Now that you have identified the level where you can safely perform your neuraxial technique we can use the interlaminar space seen on the trasverse view to look at distances more closely. It is easier to manipulate the ultrasound probe with this view than the PSO.
The probe is centered around the space between two spinous processes and angled upwards so that the beam can go in between these bony structures. The hyperechoic lamina and articular processes can be seen deep and to the sides of the interspinous space. Immediately posterior to the interspinous ligament we can observe an hyperechoic line corresponding to the posterior complex (labeled E in the image) and even deeper, the anterior complex (labeled F). The hypoechoic space (between letters E and F) represents the intrathecal space. The contents we have defined represent the vertebral canal. The posterior complex may not be seen at times.
The depth from skin to the posterior complex can then be measured with the built in caliper.
Interlaminal space view of lumbar space and corresponding bony anatomy. A, erector spinae muscle; B, interspinous ligament; C, transverse process; D, articular process or lamina; E, posterior complex;F, Anterior complex.
Steps to succeed with lumbar ultrasound
At this point the question in your mind is how to approach the space with a needle in your hand since it would seem you can't have the probe on these two axis simultaneously. And here there are two approaches.
1. Triangulation. One is with the use of triangulation to prescan and then proceed with epidural placement. First, define a safe lumbar level with the PSO plane (A on the image below), mark the space. Second, define the interspace level with the transverse plane and then mark that space (B on the image below). The entry point of the needle is the location these two lines intersect.
Triangulation to identify proper lumbar level (A) and then identify midline (B)
2. Real time use. The other option is to use the probe on your non dominant hand while having a needle on your right hand. We still need to define a safe lumbar level, then go orthogonal. At this point we infiltrate the skin with local and we can observe the needle tip on our screen. Next we use the epidural needle pointing down so that the beam transects the needle as it passes through the skin and compare the needle tip with regards to the deeper structures. This is an off plane approach. Now we remove the probe from our view, redirect the needle in a cephalad direction and continue.
Realtime use. On the left the interlaminar space has been selected and the provider anchors his non- dominant hand on skin. Local anesthesia can then be injected with a small 22 G needle on the skin and then advanced until the needle can be seen on the ultrasound screen. This identifies the needle trajectory in reference to the midline target. The same can be done with the actual 18G Tuohy needle. The ultrasound probe is then removed from the field and the needle's angle now changed to approach the epidural space.
Color Flow Doppler to Identify Epidural Space
Color flow Doppler may help you confirm you are in the epidural space. The images here show the pattern you expect to find after pushing saline and having the CFD function on to interrogate that interspace. The effect that is seen is that of aliasing as the twinkling artifact (rapid alternation of color) that seems to color the epidural needle as the saline is pushed. In these clips you are seeing a continuous clip although in real life the amount of time this is displayed is less than half a second.
Twinkling artifact seen when injecting saline after loss of resistance is felt. Notice the significant amount of aliasing seen on this clip and the artifact can be seen between the lumbar lamina. Notice the lower Nyquist limit on this clip.
The evidence on lumbar ultrasound
Ultrasound-guided technique improves the success and quality of epidural analgesia. The epidural failure rate (defined as inadequate analgesia requiring replacement of the epidural) appears lower in the ultrasound-guided technique. There is also a lower rate of incomplete analgesia with an ultrasound technique.
Ultrasound guided techniques also reduced the number of needle passes required for successful neuraxial blockade or significantly increased the first-pass success rate which in turn implies decreased technical difficulty with its use. The success rate of residents learning to perform labor epidurals is increased by the information provided from preprocedural ultrasound scan.
Ultrasound based techniques are also helpful in patients with poor or abnormal anatomic landmarks including patients with marked obesity, previous spinal surgery and instrumentation and spinal deformity.
The correlation between ultrasound-measured depth and actual needle insertion depth is very high regardless of how the measurements are taken. The 95% confidence limits for the difference is estimated from 5 to 15 mm.
Regarding the intervertebral space ultrasound may not be as accurate as magnetic resonance imaging or computed tomography and plain radiography of the lumbar spine. Ultrasound accurately identified a spinous process or intervertebral space only up to 76% of the time. However this inaccuracy is likely to be within one interspace of the true level, rather than two or three interspaces, as may occur with palpation of surface landmarks.
1. Ki Jinn Chin, Manoj Kumar Karmakar, Philip Peng, David S. Warner; Ultrasonography of the Adult Thoracic and Lumbar Spine for Central Neuraxial Blockade. Anesthesiology 2011; 114:1459–1485 doi: https://doi.org/10.1097/ALN.0b013e318210f9f8
2. Riveros-Perez E and all. Color your epidural: color flow Doppler to confirm labor epidural needle position. Minerva Anestesiol 2019 Apr;85(4):376-383. doi: 10.23736/S0375-9393.18.13175-0. Epub 2018 Nov 22.