Paramedian lumbar epidural catheter insertion with patients in the sifting position is equally successful in the flexed and unflexed spine

Positioning for placement of an epidural catheter can be quite painful for patients with lower limb injuries. We randomly allocated 50 patients scheduled for surgery after lower limb injuries for placement of a lumbar epidural catheter in the sitting position with the back in the neutral unflexed position by either the midline or paramedian approach. If the approach failed after two attempts, patients were placed in a flexed-spine position, and the procedure was attempted again. Technical difficulties and complications were recorded. In 17 patients in the midline group, and 1 patient in the paramedian group, it was not possible to insert the needle initially, and a flexed-spine position was required (P < 0.05). The incidences of resistance to catheter insertion (eight versus one), paresthesia (seven versus zero), and appearance of blood in the catheter (six versus zero) were significantly more frequent in the midline compared with the paramedian approach. The midline group also experienced more discomfort than the paramedian group. We conclude that, with the patient sitting with an unflexed spine, it is usually possible to insert an epidural catheter with the paramedian approach.