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Official Satellite Symposium of the 12th World Congress of Pain

“Ultrasound Guidance for Diagnosis and Interventional Management of Pain”

 August 15-16, 2008  Glasgow, Scotland

International Experts, Didactic Lectures, Cadaver Workshops, Interventional Procedures, Musculoskeletal Ultrasound

For Further Information:

colin.mccartney@utoronto.ca

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Alright, What’s This About?

This is mostly about Vander Beek's Pet-Project, “Using Ultrasound on Epidurals” . In this section I want to cover the basics of my plan to use portable ultrasound to identify ideal approaches to epidural placement, especially in the difficult to manage patient.

The general idea is to provide a hi-tech fallback to failed conventional placement attempts in the patient that could really benefit from an epidural post-operatively.  In most other anesthesia-related procedures there is a fallback; arterial lines have the Smart-Needle, I.J. Lines have the Sonosite, Airway have plans A thru M... but the lonely epidural has nowhere to go but repeated sticks, more drugs, more delay until eventually failure is admitted to and capitulation follows.

My goal is to insert ultrasound survey into this process just before the failure and capitulation part.

Movies of Epidural Ultrasound Scans

Below you will find a movie of a transverse scan and a longitudinal (sagittal) scan of lumbar spine.

Ultrasound Use in Epidurals

In order to explain the principles of the proposed use of ultrasound to survey and guide placement of epidural needles and catheters, I've attached the proposal here --> “ Ultrasound Uses in Epidurals”

I hope this paper answers most of the questions about the formative portion of the development of this technique. At this point the procedure is far from complete but I believe it is ready to be developed and shows promise for the next part which is to obtain a lower frequency ultrasound probe and use it to investigate techniques in signal processing and interpretation.

Transverse Scans

With the ultrasound probe held transversely to the long axis of the spinal column, the probe is moved up along the vertebrae and tilted slightly cephalad and caudad to obtain the best views of the intervertebral spaces.

Click your mouse on the picture below to see a short video clip (24 sec.) of a transverse ultrasound scan of the lumbar vertebrae.

As the probe moves you see long thin elliptical vertical shadows starting at about 1 cm. in depth, these are the spinous processes which reflect the ultrasound energy obscuring any structures below. When the shadows of the spinous process disappear with the movement of the probe we begin to see structures below. Two bright structures flanking the center line of the scan at approximately 3 - 3.5 cms. are the facet joints. A bright horizontal band appearing in the centerline at about 5 cm. is the ligamentum flavum. Note as the scan moves it's possible to see a dark band below the ligamentum and a dimmer horizontal band beyond the darkness. These are the thecal space and the ventral dura.  

Longitudinal Scans

With the long axis of the ultrasound probe held against the long axis of the spinal column, the probe is then moved along that axis to view the spinous processes and inter-vertebral spaces as though looking down at a picket fence as you move along its length.

To see a short video clip of a longitudinal scan of the lumbar and lower thoracic vertebrae with audio narration, click on the picture below.

 The spinous processes produce characteristic shadows as they block the ultrasound energy, and then as the probe passes them and is over the intervertebral space the ultrasound energy “illuminates” the structures lying below. Note again at about 5 cms. in depth in the intervertebral space the appearance of the bright hyperechoic band of the ligamentum flavum.

Towards the end of the clip you can see the area below the ligamentum flavum illuminated showing the dark band of the thecal space and the distal bright band of the ventral dura.