Anesth Pain Med.  2021 Oct;16(4):322-328. 10.17085/apm.21060.

Real-time ultrasound guided thoracic epidural catheterization: a technical review

• Lee JH
• Kim DH
• Koh WU

• KMID: 2524443
• DOI: http://doi.org/10.17085/apm.21060

Abstract

Thoracic epidural analgesia is known to have superior perioperative pain control over intravenous opioid analgesia in open abdominal surgery and is an essential enhanced recovery after surgery component in major abdominal surgeries. Recently, the ultrasound-guided thoracic epidural catheter placement (TECP) technique has drawn attention as an alternative for the traditional landmark palpation-based TECP or fluoroscopic-guided TECP technique due to the equipment’s improvement and increased popularity. However, only a small number of studies have introduced the advantages and usefulness of ultrasound-guided TECP. Moreover, a certain level of ultrasound-guided in-plane technique is required to perform this technique. Thus, to apply ultrasound-guided TECP correctly and reduce the likelihood of side effects and complications, the practitioner must have a thorough understanding of the anatomical region, optimal block positioning, device selection, and management. In this technical review, the authors have compared the advantages and disadvantages of ultrasound-guided TECP to traditional techniques and described its technical aspects from patient positioning, ultrasound probe selection and scanning, needle insertion under ultrasound guidance, and successful thoracic epidural catheter insertion confirmation through ultrasound imaging. Additionally, the recommended epidural catheter tip placement level with the extent of its injectate epidural spread is further described in this review in reference to a recent prospective study published by the authors.

Keyword

Catheterization; Epidural analgesia; Thoracic vertebrae; Ultrasonography

Figure

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  Fig. 1. Location of the ultrasound probe and the corresponding ultrasound views and its movements to obtain proper ultrasound views. (A) The probe positioned in midline to identify the spinous process (SP) of target spine level. (B) The probe moves laterally from the SP to obtain corresponding Laminae (L). (C) The probe laterally tilts to obtain the paramedian sagittal oblique view. L resembling wave-like structures and superior articular process (SAP) of inferior vertebrae between the L are seen in this view. (D) The probe slightly laterally tilts to obtain the paramedian sagittal oblique view. The ligamentum flavum (LF) and posterior dura of the posterior complex (PC) are seen as linear hyperechoic structures between the L in this paramedian sagittal oblique view. If the interlaminar space is wide enough, anterior complex (AC) may be seen. (E) A decrease in the height of L of the inferior vertebral body as compared to that in the paramedian sagittal oblique view is observed when the cephalad end of the probe is pivoted medially. (1) Position of probe and surface anatomy of the posterior thoracic level: posterior aspect view. (2) Position of probe for image 1 on the artificial spine model. (3) Position of probe and surface anatomy of the posterior thoracic level: inferior aspect view. (4) Position of probe for image 3 on the artificial spine model. (5) Ultrasound image of linear probe. (6) Ultrasound image of curved probe.

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  Fig. 2. Real-time ultrasound views for needle. PC indicate the posterior complexes. The arrow and open arrow indicate the epidural needle and the needle tip, respectively. PC: posterior complex, SP: spinous process, L: laminae.

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