Identification of the subarachnoid space has traditionally been achieved by either a blind landmark-guided approach or using prepuncture ultrasound assistance. To assess the feasibility of performing spinal anaesthesia under real-time ultrasound guidance in routine clinical practice we conducted a single center prospective observational study among patients undergoing lower limb orthopaedic surgery. A spinal needle was inserted unassisted within the ultrasound transducer imaging plane using a paramedian approach (i.e., the operator held the transducer in one hand and the spinal needle in the other). The primary outcome measure was the success rate of CSF acquisition under real-time ultrasound guidance with CSF being located in 97 out of 100 consecutive patients within median three needle passes (IQR 1–6). CSF was not acquired in three patients. Subsequent attempts combining landmark palpation and pre-puncture ultrasound scanning resulted in successful spinal anaesthesia in two of these patients with the third patient requiring general anaesthesia. Median time from spinal needle insertion until intrathecal injection completion was 1.2 minutes (IQR 0.83–4.1) demonstrating the feasibility of this technique in routine clinical practice. 1. Introduction Since the first description of spinal anaesthesia in humans by Bier in 1898 [1] the identification of the subarachnoid space has traditionally been achieved by an anatomical landmark guided approach. While surface anatomical landmarks are useful, they are nevertheless surrogate markers. They may be difficult to palpate in obese patients as well as those with edema. Landmark-based approaches do not take into account all anatomical variations or abnormalities, and frequently lead to incorrect identification of a given lumbar interspace [2]. Accurate identification of the subarachnoid space is paramount as multiple attempts at needle placement may cause patient discomfort, higher incidence of spinal hematoma [3], postdural puncture headache [4, 5], and trauma to neural structures [6–8]. Having alternative approaches may help improve success and mitigate the limitations of the current techniques. Neuraxial sonography allows the operator to preview spinal anatomy, identify midline, and determine the interspace for needle insertion. Even if the preliminary scout scan has already been shown to be helpful [9], a real-time ultrasound guided approach may further improve on the limitations of the ultrasound-assisted pre-puncture techniques. In particular this technique avoids the potential for error in the process of
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