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Real-time ultrasound-guided low thoracic epidural catheter placement: technical consideration and fluoroscopic evaluation
  1. Doo-Hwan Kim,
  2. Jong-Hyuk Lee,
  3. Ji Hoon Sim,
  4. Wonyeong Jeong,
  5. Dokyeong Lee,
  6. Hye-Mee Kwon,
  7. Seong-Soo Choi and
  8. Sung-Moon Jeong
  1. Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (the Republic of)
  1. Correspondence to Dr Seong-Soo Choi, Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea (the Republic of); choiss{at}


Background and objective Thoracic epidural analgesia can significantly reduce acute postoperative pain. However, thoracic epidural catheter placement is challenging. Although real-time ultrasound (US)-guided thoracic epidural catheter placement has been recently introduced, data regarding the accuracy and technical description are limited. Therefore, this prospective observational study aimed to assess the success rate and describe the technical considerations of real-time US-guided low thoracic epidural catheter placement.

Methods 38 patients in the prone position were prospectively studied. After the target interlaminar space between T9 and T12 was identified, the needle was advanced under real-time US guidance and was stopped just short of the posterior complex. Further advancement of the needle was accomplished without US guidance using loss-of-resistance techniques to normal saline until the epidural space was accessed. Procedure-related variables such as time to mark space, needling time, number of needle passes, number of skin punctures, and the first-pass success rate were measured. The primary outcome was the success rate of real-time US-guided thoracic epidural catheter placement, which was evaluated using fluoroscopy. In addition, the position of the catheter, contrast dispersion, and complications were evaluated.

Results This study included 38 patients. The T10–T11 interlaminar space was the most location for epidural access. During the procedure, the mean time for marking the overlying skin for the procedure was 49.5±13.8 s and the median needling time was 49 s. The median number of needle passes was 1.0 (1.0–1.0). All patients underwent one skin puncture for the procedure. The first-pass and second-pass success rates were 76.3% and 18.4%, respectively. Fluoroscopic evaluation revealed that the catheter tips were all positioned in the epidural space and were usually located between T9 and T10 (84.2%). The cranial and caudal contrast dispersion were observed up to 5.4±1.6 and 2.6±1.0 vertebral body levels, respectively. No procedure-related complications occurred.

Conclusion Real-time US guidance appears to be a feasible option for facilitating thoracic epidural insertion. Whether or not this technique improves the procedural success and quality compared with landmark-based techniques will require additional study.

Trial registration number NCT03890640.

  • pain
  • postoperative
  • technology
  • pain management
  • ultrasonography

Data availability statement

Data are available upon reasonable request to the corresponding author.

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Data availability statement

Data are available upon reasonable request to the corresponding author.

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  • D-HK and J-HL are joint first authors.

  • Contributors D-HK—conception, design, and conduct of the study; analysis and interpretation of data; reporting; and writing (original draft preparation). J-HL—conception, design, and conduct of the study; interpretation of data; and writing (review and editing of the manuscript). JHS—data curation and acquisition. WJ—analysis and interpretation of data. DL—data curation and acquisition. H-MK—data curation and acquisition. S-MJ—planning, conception, and design of the study; supervision; and project administration. S-SC—planning, conception, design, and conduct of the study; writing (review and editing of the manuscript); supervision; and project administration. All authors critically revised the manuscript. All authors approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.