A comparative study of Ultrasound guided Median, Paramedian and Modified Paramedian techniques for Spinal Anaesthesia in ELderly patients.

Due to an increasingly ageing population, the number of elderly who need surgical treatment under spinal anaesthesia is increasing(1,2). The mean age for spinal anaesthesia cohort for hip fracture repair demonstrated an increasing trend over time whereas the mean age of the general anaesthesia cohort did not. Studies have shown that the risk of many urinary system diseases( such as benign prosthatic hyperplasia, bladder tumours, urethral strictures) increase drastically with ageing. (3,4) Compared to general anaesthesia spinal anaesthesia has been recognised as providing greater haemodynamic stability, higher patient satisfaction, lower rate of opioid use, higher rate of opioid free recovery and lower maximum post anaesthesia care unit (pacu) pain scores.(4) Due to degeneration of the lumbar spine (bone hyperplasia, ligament calcification, intervertebral space stenosis, spinous process hyperplasia, etc) spinal anaesthesia in elderly patients might be difficult.(8-9) Multiple needle attempt may lead to a higher incidence of complications(post dural puncture headache, paraesthesia, hematoma and infection) increased patient discomfort and dissatisfaction.

There are two traditional techniques for spinal anaesthesia ( midline technique and paramedian technique) each of which has some advantages and disadvantages in terms of operation and application. Lots of anaesthesiologists proceed through paramedian approach because this approach bypasses most of the bony structures that may impede the advancement of the needle in midline approach. However, paramedian approach requires a sharpened three-dimensional insight as compared to the midline approach. We would encounter inferior articular processes and pedicle more close to needle pathway and less interlaminar foramen diameter in three dimensional structure especially in obese patients.(8)  Therefore, a new approach , the modified paramedian approach using the ultrasound guidance may improve success rate and decrease practice attempts and patient complications.

The purpose of the study is to explore the feasibility of ultrasound assisted modified paramedian technique for spinal anaesthesia in elderly when compared to midline and paramedian approach.

The Null Hypothesis of the study is that there will be no differences in first attempt success rates using ultrasound guidance for spinal anesthesia in elderly for midline , paramedian and modified paramedian approaches.

AIM:   The aim is to combine the advantages of two traditional methods (midline and paramedian), Improve the success rate of spinal anaesthesia, Reduce the time taken to puncture and the number of attempts and to facilitate the process of anaesthesia in elderly patients.

PRIMARY OBJECTIVE:  To determine the first attempt success rate.

SECONDARY OBJECTIVE:

To determine number of attempts

Number of needle redirections

Time taken to perform spinal anaesthesia

Time taken to ultrasound assisted location

The incidences of headache, backpain, nausea and vomiting within 24hrs after the operation.

REFERENCES:

Park SK, Yoo S, Kim WH, Lim YJ, Bahk JH, Kim JT. Ultrasound-assisted vs. landmark-guided paramedian spinal anaesthesia in the elderly: A randomised controlled trial. Eur J Anaesthesiol. 2019 ;36(10):763-771.

Maxwell BG, Spitz W, Porter J. Association of Increasing use of spinal anesthesia in hip fracture repair with treating an aging patient population. JAMA Surg. 2020;155(2):167–8.

Cao JL, Li JP, Yang X, et al. Transcriptomics analysis for the identification of potential age-related genes and cells associated with three major urogenital cancers. Sci Rep. 2021;11(1):641.

Westhofen T, Stief CG, Magistro G. Spinal versus general anesthesia for holmium laser Enucleation of the prostate of high-risk patients – a propensity-score-matched-analysis REPLY. Urology. 2022;159:189–90.

Zeng, W., Shi, Y., Zheng, Q. et al. Ultrasound-assisted modified paramedian technique for spinal anesthesia in elderly. BMC Anesthesiol. 2022; 22, 242.

Tien M, Kou A, Leppert JT, et al. Spinal anesthesia increases the rate of opioid-free recovery after transurethral urologic surgery. J Clin Anesth. 2020;60:109–10.

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