Pre-procedural Ultrasound Techniques Versus Conventional Landmark Technique of Spinal Anesthesia in Elderly Patients

Not Applicable

Completed

Interventions: Other: Ultrasound-guided paramedian technique
Other: Landmark technique
Other: Ultrasound-guided midline technique

Brief Summary: Traditionally, spinal anesthesia is performed using the palpation of bony landmark to identify the level and point of entry of the spinal needle. Recently, ultrasound imaging has become an increasingly popular procedure among anesthesiologists to guide neuraxial blockade. Most of the studies on pre-procedural ultrasound-guided neuraxial techniques are limited to a midline approach using a transverse median views. The parasagittal oblique view consistently offers better ultrasound view of the neuraxis compared to the transverse median view. However, it is still not evident whether these superior parasagittal oblique views will lead to an easier paramedian needle insertion. In the literature, there are no studies directly comparing the US-guided paramedian approach using the parasagittal oblique (PSO) view, the US-guided midline approach using the transverse median view, and the conventional landmark midline approach to perform spinal anesthesia in the elderly patients, in particular for the teaching of novice anesthesia residents.

Detailed Description: The aim of this study is to find out the optimal technique to perform spinal anesthesia by residents in training. Thus the investigators will compare preprocedural ultrasound-guided paramedian technique using parasagittal oblique view vs preprocedural ultrasound-guided midline technique using transverse median view vs landmark-guided midline technique of spinal anesthesia in the elderly population. Our hypothesis is that both preprocedural US-guided techniques are superior to the conventional landmark-guided midline technique with regard to ease of performance defined as success rate at first attempt, number of puncture attempts, spinal procedure time, and patient satisfaction.

Recruitment & Eligibility

Inclusion Criteria

Patients scheduled for surgery amenable to spinal anesthesia, aged more than 60 years, with American Society of Anesthesiologists physical status 1 to 4.

Exclusion Criteria

Patients who are unable to give consent, refuse spinal anesthesia, have spinal abnormalities (including scoliosis and previous spine operations with instrumentation) or have contraindications to spinal anesthesia, including allergy to local anesthetics or a bleeding diathesis

Arm && Interventions

Group	Intervention	Description
Ultrasound-guided paramedian technique	Ultrasound-guided paramedian technique	As intervention, patients in this group are administered spinal anesthesia based on preprocedural ultrasound-guided paramedian technique using parasagittal oblique view
Landmark technique	Landmark technique	As intervention, patients in this group are administered landmark guided midline spinal anesthesia.
Ultrasound-guided midline technique	Ultrasound-guided midline technique	As intervention, patients in this group are administered spinal anesthesia based on preprocedural ultrasound-guided midline technique using transverse median view

Primary Outcome Measures

Name	Time	Method
Rate of successful dural puncture on the first needle insertion attempt	up to 5 minutes from the start of insertion of the introducer of the spinal needle	Rate of successful dural puncture on the first needle insertion attempt which is defined as the percentage of successful dural puncture on the first introducer needle advancement through skin; each skin puncture by introducer is considered as a needle insertion attempt.

Secondary Outcome Measures

Name	Time	Method
patient satisfaction	5 min after completion of administration of SA:	Patient satisfaction will be scored as following: 1. Very good 2. Good 3. Satisfactory 4. Unpleasant 5. Very unpleasant
Number of spinal needle redirections	45 minutes	Spinal needle redirected without complete withdrawal of the introducer of the spinal needle from skin
Number of introducer needle insertion attempts	45 minutes from the start of insertion of introducer of the spinal needle	Number of introducer needle insertion attempts is defined as the number of times the introducer needle was withdrawn from the skin and reinserted.
spinal procedure time	60 minutes	In groups US, period beginning when probe is first placed on patient's back and ending when examination is complete. In group LM, period beginning when patient's back is palpated first and ending when examination is complete.
overall success rate in every technique	60 minutes from the start of insertion of introducer of the spinal needle	Overall success rate in every technique is defined as percentage of successful spinal anesthesia as evidenced by CSF flow through the spinal needle before spinal drug injection and a sensory block level \>T10 15min after injection of spinal drug.

Locations (1): American University of Beirut Medical center
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Beirut, Lebanon