Ultrasound Imaging Facilitates Spinal Anesthesia in Adults with Difficult Surface Anatomic Landmarks

Background: Poor surface anatomic landmarks are highly predictive of technical difficulty in neuraxial blockade. The authors examined the use of ultrasound imaging to reduce this difficulty. Methods: The authors recruited 120 orthopedic patients with one of the following: body mass index more than 35 kg/m(2) and poorly palpable spinous processes; moderate to severe lumbar scoliosis; or previous lumbar spine surgery. Patients were randomized to receive spinal anesthetic by the conventional surface landmark-guided technique (group LM) or by an ultrasound-guided technique (group US). Patients in group US had a preprocedural ultrasound scan to locate and mark a suitable needle insertion point. The primary outcome was the rate of successful dural puncture on the first needle insertion attempt. Normally distributed data were summarized as mean +/- SD and nonnormally distributed data were summarized as median [interquartile range]. Results: The first-attempt success rate was twice as high in group US than in group LM (65% vs. 32%; P < 0.001). There was a twofold difference between groups in the number of needle insertion attempts (group US, 1 [1-2] vs. group LM, 2 [1-4]; P < 0.001) and number of needle passes (group US, 6 [1-10] vs. group LM, 13 [5-21]; P = 0.003). More time was required to establish landmarks in group US (6.7 +/- 3.1; group LM, 0.6 +/- 0.5 min; P < 0.001), but this was partially offset by a shorter spinal anesthesia performance time (group US, 5.0 +/- 4.9 vs. group LM, 7.3 +/- 7.6 min; P = 0.038). Similar results were seen in subgroup analyses of patients with body mass index more than 35 kg/m2 and patients with poorly palpable landmarks. Conclusion: Preprocedural ultrasound imaging facilitates the performance of spinal anesthesia in the nonobstetric patient population with difficult anatomic landmarks.