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Ultrasound-assisted vs. landmark-guided paramedian spinal anaesthesia in the elderly

A randomised controlled trial

Park, Sun-Kyung; Yoo, Seokha; Kim, Won Ho; Lim, Young-Jin; Bahk, Jae-Hyon; Kim, Jin-Tae

European Journal of Anaesthesiology (EJA): October 2019 - Volume 36 - Issue 10 - p 763–771
doi: 10.1097/EJA.0000000000001029
Loco-regional anaesthesia

BACKGROUND Neuraxial ultrasound might improve the efficacy of spinal anaesthesia but this has not been tested for the paramedian approach in the elderly.

OBJECTIVE The current study aims to assess whether the ultrasound-assisted paramedian technique can decrease the number of needle passes required for success compared with the landmark-guided paramedian technique in the elderly.

DESIGN Randomised controlled study.

SETTING Single-institution, tertiary-level hospital in Seoul, Republic of Korea from October 2017 to January 2018.

PATIENTS Eighty patients aged at least 60 years undergoing orthopaedic surgery.

INTERVENTION All received paramedian spinal anaesthesia by either the landmark-guided or preprocedural ultrasound-assisted technique.

MAIN OUTCOME MEASURES The number of needle passes required for successful dural puncture.

RESULTS The number of needle passes (median [interquartile range]) was significantly lower (1.0 [1.0 to 2.0] vs. 4.5 [2.0 to 7.0]) and the success rate at first pass significantly higher at 65.0 vs. 17.5% in the ultrasound compared with the landmark group (both P < 0.001). The ultrasound-assisted technique required a longer time for establishing landmarks (117.5 s [85.5 to 150.7 s] vs. 17.5 s [14.0 to 23.0 s]) and for total procedure (181.5 s [133.5 to 212.5 s] vs. 92.5 s [62.5 to 176.5 s]) but a shorter time for administering spinal anaesthesia (39.5 s [31.5 to 71.3 s] vs. 77.0 s [45.8 to 136.5 s]; all, P < 0.001) than the palpation-guided technique. The ultrasound group showed lower periprocedural pain scores (3 [2 to 4] vs. 4 [4 to 6]; P = 0.009) and discomfort scores (2 [0 to 3] vs. 5 [2 to 6]; P = 0.003) than the landmark group.

CONCLUSION Compared with the landmark-guided paramedian technique, the ultrasound-assisted paramedian technique decreases the number of needle manipulations and periprocedural pain and discomfort scores in the elderly. Our results suggest that neuraxial ultrasonography facilitates the performance of spinal anaesthesia in the elderly.


From the Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea (S-KP, SY, WHK, Y-JL, J-HB, J-TK)

Correspondence to Jin-Tae Kim, Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea E-mail:

Published online 10 June 2019

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© 2019 European Society of Anaesthesiology