Christopher Ciarallo, MD Denver Health/Children s Hospital Colorado CRASH 2016

Transcription

1 Distribution of the vertebral level of the intercristal line by ultrasonography Christopher Ciarallo, MD Denver Health/Children s Hospital Colorado CRASH 2016 Korean J Anesthesiol Sep;67(3):181 5 Anesthesiology. 114(6): , June Systematic Approach to Ultrasound-guided Neuraxial Blockade of the Adult Lumbar Spine: 7 steps 1. Preparation for scanning 2. PS transverse process view 3. PS articular process view 4. PS oblique view 5. Identify and mark intervertebral levels 6. Transverse interlaminar view 7. Mark needle insertion point for a midline approach

2 Ciarallo, Christopher, MD Transverse Process Trident Anesthesiology 2011; 114: Figure 4. Paramedian sagittal sonogram of the transverse process from the (a) water based spine phantom, (b) volunteers and (c) the Visible Human Project (cadaver) In the latter, the transverse processes of L3 and L4 have been shaded in green (c). Note how the acoustic shadow of the TPs produces the trident sign [3]. ESM, erector spinae muscle; PM, psoas muscle; TP, transverse process. Articular Process Camel Anesthesiology. 114(6): , Anesthesiology 2011; 114: June Figure 3. Paramedian sagittal sonogram of the articular process from the (a) water based spine phantom and (b) volunteers, and a representative anatomical slice from (c) the Visible Human Project (cadaver). A graphic overlay has been placed in (b) to illustrate the camel hump like appearance of the articular processes (the camel hump sign). AP, articular process; ESM, erector spinae muscle; FJ, facet joint; VB, vertebral body. Lamina - Horse Head / Sawtooth Anesthesiology 2011; 114: Figure 2. Paramedian oblique sagittal sonogram of the lamina (L3, L4, L5) from (a) the water based spine phantom and (b) volunteers, and a representative anatomical slice from (c) the Visible Human Project (cadaver). In the latter, the lamina has been shaded in green (c). Note the marker (needle) in contact with the lamina in the water based spine phantom (a). This was done to ensure that the lamina was being scanned and also helped in validating its sonographic appearance. A graphic overlay has been placed over the lamina in (a) to illustrate the horse head sign. AC, anterior complex; CE, cauda equina; ES, epidural space; ESM, erector spinae muscle; ILS, interlaminar space; ITS, intrathecal space; IVD, intervertebral disc; LF, ligamentum flavum; PD, posterior dura; SC, spinal canal; VB, vertebral body.

3 Acoustic Window Paramedian Sagittal Oblique Figure 6. Paramedian oblique sagittal sonogram of the lumbar spine at the L3/L4/L5 level. Note the acoustic shadow of the lamina and the acoustic window, which results from reflections of the ultrasound signal from the neuraxial structures within the spinal canal. ILS, interlaminar space. Figure 7. Paramedian oblique sagittal sonogram of the lumbar spine at the L3/L4/L5 level. The posterior epidural space is seen as a hypoechoic space (a few millimeters wide) between the hyperechoic ligamentum flavum and the posterior dura. Note that the posterior dura appears brighter and is also better visualized than the ligamentum flavum in this sonogram. ESM, erector spinae muscle; ILS, interlaminar space; LF, ligamentum flavum spinal anatomy Anesthesiology. 2011; 114(6): , 114: June 2011.

4 Anesthesiology. 114(6): , June FIGURE 3. Distribution of conclusive images at all interspinous levels in the right paramedian sagittal oblique plane (A) and in transverse median plane (B). Regional Anesthesia & Pain Medicine. 37(3): , May/June

5 With the subjects seated in the standard flexed position with legs supported and cradling a pillow, they were asked to rotate their shoulders to a 45 angle (a) Ultrasonography of the adult thoracic and lumbar spine for central neuraxial blockade. Chin KJ, Karmakar MK, Peng P. Anesthesiology Jun;114(6): Ultrasonography of the lumbar spine: sonoanatomy and practical applications. Darrieutort-Laffite C, Hamel O, Glémarec J, Maugars Y, Le Goff B. Joint Bone Spine Mar;81(2): Sonoanatomy relevant for ultrasound-guided central neuraxial blocks via the paramedian approach in the lumbar region. Karmakar MK, Li X, Kwok WH, Ho AM, Ngan Kee WD. Br J Radiol Jul;85(1015):e N. Ramsay et al. Br. J. Anaesth. 2014;112: Goal is to visualize gaps between bones, if US can get through, so can your needle. In transverse view, spinal cord should be at depth of TP Do not do parasagittal oblique too close to midline, the side of SP will confound the view