Figure 3 - available via license: Creative Commons Attribution 4.0 International
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1) the lamina, (2) the dura mater, (3) epidural catheter tip. The arrow is within the vertebral venous plexus, showing the catheter tip was pierced into the vertebral venous plexus
Source publication
We herein provide an analysis of lumbar epidural catheterization, which outlines a detailed anatomical description of the epidural anatomy, and may improve the success rate of neuraxial cannulation.
Lumbar epidural catheters were placed in 50 adult embalmed cadavers. After catheterization, the lumbar dura and connecting structures between the epidu...
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Objectives:
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Citations
... Most regional block, such as spinal anesthesia and epidural anesthesia, can obtain good anesthetic effect during the operation, facilitate the operation, and control the pain well after the operation. Combined spinal epidural anesthesia (CSEA) is a combination of subarachnoid block and epidural catheter indwelling [8,9]. Combined spinal epidural anesthesia has the advantages of rapid onset and good analgesic and muscle relaxation effect and is widely used in orthopaedic surgery [10]. ...
Objective:
Combined spinal epidural anesthesia (CSEA) is applied to lower limb orthopaedic surgery in the elderly. This study is aimed at exploring the effect of CSEA in orthopaedic surgery of elderly patients.
Methods:
A total of 40 elderly patients with femoral fracture needing hip replacement or femoral head replacement in our hospital from June 2021 to June 2022 were selected as the research objects. The subjects were divided into observation group (n = 20) and control group (n = 20) by random number table method. The control group was given epidural anesthesia, while the observation group was given CSEA. Hemodynamic indexes (heart rate (HR) and mean arterial pressure (MAP)), visual analogue scale (VAS) pain score changes, anesthetic effects, and postoperative complications were compared between the two groups.
Results:
After operation, the observation group had lower HR and MAP values than the control group (P < 0.05). The dosage of local anesthetics in the observation group was significantly less than that in the control group (P < 0.05). The onset time and improvement time of sensory block in the observation group were significantly faster than those in the control group (P < 0.05). The observation group had a lower VAS score than the control group (P < 0.05). There was no significant difference in Bromage score or incidence of complications between the two groups (P > 0.05).
Conclusion:
The use of CSEA has good anesthetic effect. It has the disadvantage of no headache after traditional spinal anesthesia, is not limited by time, and can be used for postoperative analgesia, which is more suitable for the anesthesia of lower limb orthopaedic surgery in the elderly.
... The meningovertebral ligament is a web-like anatomical structure that links the dorsal side of the dura with the lamina and ligament flavum. [16][17][18] This ligament can vary in thickness and shape ranging from thin strips to thick sheets, and is primarily distributed in the midline or near the midline surface. Insufficient dissection of this structure may be the main mechanism of injury. ...
Study Design
Retrospective study.
Objectives
Unilateral biportal endoscopic surgery (UBES) is a popular surgical method used to treat degenerative spinal diseases because of its merits, such as reduced tissue damage and outstanding visual capacity. However, dural injury is the most common complication of UBES with an incidence rate of 1.9% to 5.8%. The purpose of this study was to analyze the pattern of dural injury during UBES and to report the clinical course.
Methods
We retrospectively reviewed the medical and radiographic records of surgically treated patients who underwent UBES at a single institute between January 2018 and December 2019.
Results
Fifty-three patients, representing 67 segments, underwent UBES. Seven dural injuries occurred, and the incidence rate was 13.2%. Among 16 far lateral approaches, 2 dural injuries of the exiting roots occurred and were treated with fibrin sealant reinforcement. Among 51 median approaches, dural injury occurred at the thecal sac (n = 3) and traversing root (n = 2). A dural injury of the shoulder of the traversing root was treated with a fibrin sealant; however, a defect in the thecal sac required a revision for reconstruction. The other 2 thecal sac injuries were directly repaired via microscopic surgery.
Conclusions
Dural injury during UBES can occur because of the various anatomical features of the meningo-vertebral ligaments. Direct repair of the central dural defect should be considered under microscopic vision. A linear tear in the lateral dura or root can be controlled with a simple patchy reinforcement under endoscopic vision.
... The placement of a new catheter was performed at the same lumbar space (L3-L4) by the same anesthesiologist with an identical epidural set (Perifix® set, 18-gauge Thuoy needle, 20-gauge catheter, B. Braun Melsungen AG, Germany). especially when considering that anatomically epidural catheters at thoracic level are less prone to knotting -due to the lower frequency of meningovertebral ligaments compared to the lumbar region (7). These figures have not been confirmed by other publications. ...
Knotting is a well-known but rare complication of the use of epidural catheters. We report the case of a knotted catheter successfully removed by simple traction, after determining its ultimate tensile strength. We reviewed the case reports published since 1979. We assessed the prevalence of this complication, the impact of placement technique on a knot’s occurrence, the value of the different imaging modalities, and the one of various techniques used for catheter removal. A knotted catheter can often be removed intact with steady and gentle traction. Before pulling on an entrapped catheter and to avoid breakage, it may be useful to assess its ultimate tensile strength on its free extremity or another identical catheter. Limiting the length of a catheter threaded in the epidural space during its insertion seems to be the best way to avoid knots.
... Dorsal meningovertebral ligaments are found between the dural sac and ligamentum flavum or lamina, and up to 44% are reported at the L3/L4 interspace. 1 These ligaments may obstruct the advance of an epidural catheter, resulting in a high incidence of catheter coiling, and causing uneven distribution of local anesthetic solution -all contributing to epidural failure. Epidural hemorrhage during spinal surgery has also been reported in the presence of these placed ligaments. ...
... 21, 22 Other advantages for the paramedian approach include less dependence upon spine flexion and fewer complications in non-pregnant adults. 23 There are only a few studies so far comparing the median and paramedian approach to block success. ...
... Uchino 22 reported that the lateral catheter deviation is easy to occur on soft-tip design. Jiang 23 reported his anatomical assessment of epidural lumbar by performing epidural catheter on cadavers. By median technique approach, 50 cadavers were inserted an epidural catheter. ...
Introduction: The installation of an epidural catheter can be perform by median or paramedian techniques with the aim of position the epidural catheter tip being posterior to the epidural space. The goal of this study was to compare the location and position of the epidural catheter tip placed by the median technique compared to the paramedian technique by using fluoroscopy method.
Patients and Methods: Fifty patients aged 18- 65 years who underwent lower abdominal surgery and lower extremities surgery are classified into two groups by consecutive sampling. The first group consists of those who were inserted epidural catheter by median technique approach, and the second group by paramedian technique approach. From the fluoroscopy imaging, the catheter position was classified into one the the following: anterior, posterior, and lateral.
Result: In median approach, the epidural catheter tip were placed 16% anteriorly, 20% posteriorly, and 64% laterally. In the paramedian approach, the epidural catheter tip were placed 4% anteriorly and 96% posteriorly. The paramedian approach is more superior to median technique in terms of expected epidural catheter tip position (p
... Anatomical variations or abnormalities can lead to incorrect identification of a given lumbar interspace. 2,3 Moreover, during pregnancy, obesity and edema often obscure anatomical landmarks and lead to increased failure rate (5%-20%). [4][5][6] Therefore, a failed block and vertebra contact can occur with the loss of resistance (LOR) technique, where the operator feels the loss of resistance pressure between the ligamentum flavum and the epidural space with an auxiliary air or saline-filled syringe to determine the epidural space. ...
Ultrasound guidance for epidural block has improved clinical blind-trial problems but the design of present ultrasonic probes poses operating difficulty of ultrasound-guided catheterization, increasing the failure rate. The purpose of this study was to develop a novel ultrasonic probe to avoid needle contact with vertebral bone during epidural catheterization. The probe has a central circular passage for needle insertion. Two focused annular transducers are deployed around the passage for on-axis guidance. A 17-gauge insulated Tuohy needle containing the self-developed fiber-optic-modified stylet was inserted into the back of the anesthetized pig, in the lumbar region under the guidance of our ultrasonic probe. The inner transducer of the probe detected the shallow echo signals of the peak-peak amplitude of 2.8 V over L3 at the depth of 2.4 cm, and the amplitude was decreased to 0.8 V directly over the L3 to L4 interspace. The outer transducer could detect the echoes from the deeper bone at the depth of 4.5 cm, which did not appear for the inner transducer. The operator tilted the probe slightly in left-right and cranial-caudal directions until the echoes at the depth of 4.5 cm disappeared, and the epidural needle was inserted through the central passage of the probe. The needle was advanced and stopped when the epidural space was identified by optical technique. The needle passed without bone contact. Designs of the hollow probe for needle pass and dual transducers with different focal lengths for detection of shallow and deep vertebrae may benefit operation, bone/nonbone identification, and cost.
... In present results similar with the findings of Huanwei (7) and Nilesh et al (8) they mentioned that the extension of thick grey color dura matter from inferior surface of foramina magna of skull to the sacral region and below dura matter there is thin layer of arachnoid matter, then very thin layer of pia matter adhered strongly to the outer surface of spinal cord. Also, the dura matter pierced externally by transverse and oblique segmental spinal nerves which passes through epidural space to inside the intervertebral foramina. ...
The anatomical features of the human neonate spinal cord have been investigated. In this study, twenty of neonate cadavers were collected from the Forensic Medicine Unit of Kirkuk and Tikrit Teaching Hospital between October (2012) to December (2013) on twenty Iraqi males neonate cadavers with age ranging from 0-28 days to study the anatomical features of the neonate spinal cord. The dissection and performs of laminectomy of the cadaver, the anatomical study revealed that the cord covered by three meninges from external to internal included dura, arachnoid and pia matters, which extends from inferior aspect of foramina magnum to the sacral region. After cut up the dura and arachnoid, the tubular and cylindrical neonate spinal cord was observed with whitish to yellowish color, extending from the lower border of foramina magnum and terminates mostly at level of third lumbar vertebrae (L3) and others ends at the level of (L4). The spinal cord length was16.25 cm and divided into four different segments, the cervical cord forms (38.9)cm, thoracic part (78.7)cm, the lumbar part (26.5)cm and the sacral part (18.4)cm. The external surface of cord was consisted of the origin, of anterior and posterior nerve rootlets, present of the anterior median fissure and posterior median sulcus extends through the length of neonate spinal cord, the anterior spinal artery existing inside the anterior median fissure. Moreover, the external surface of spinal cord grossly not uniform it has two swelling called cervical and lumbosacral enlargements as well as the transverse and vertical dimensions were differ between the four segments. The aim of the present study was to compare the findings of the neonate spinal cord with that of the adult spinal cord based on anatomical parameter.
Background:
Proper fixation of an epidural catheter is necessary for desired drug effect and to prevent catheter displacement. Different techniques have been used for epidural catheter fixation. The aim of the study was to compare the relative efficacy of MicroporeTM surgical dressing, TegadermTM, and Lockit plus® in preventing lumbar epidural catheter migration in children.
Methods:
We studied 167 patients aged 5-16 years, for up to 48 hrs. after the elective abdominal or lower limb surgery. Patients were randomly assigned to one of three groups: 1) MicroporeTM surgical dressing (group M), 2) TegadermTM (group T), or 3) Lockit plus® (group L). Incidence and extent of epidural catheter migration in centimetres (cm); was compared at 24 and 48 hours post epidural fixation. Correlation between epidural catheter migration and patient characteristics, and relative incidence of complications in three groups was also analysed.
Results:
Incidence of catheter migration was 9.6% at 24 hours (group M: 7.1%, group T: 21.1% and group L: 0%) and 45.5% at 48 hours (group M: 66.1%, group T: 45.6% and group L: 24.1%). After 48 hours, absolute migration (mean migration rounded off to the nearest 0.5 cm) was least in patients in group L: 0.34 cm (1.39) compared to group M 1.22 cm (SD: 1.85) group T: 0.94 cm (1.94) (p = <0.001).
Conclusion:
Up to 48 hours after surgery, the Lockit plus® device demonstrated the less epidural catheter migration when compared to micropore surgical dressing or tegaderm in children undergoing elective abdominal or lower limb surgery.
