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Efficacy and safety of ultrasound-guided versus landmark-guided neuraxial puncture: a systematic review, network meta-analysis and trial sequential analysis of randomized clinical trials
  1. Clístenes Crístian de Carvalho1,2,
  2. Willgney Porto Genuino1,
  3. Maria Clara Vieira Morais1,
  4. Heleno de Paiva Oliveira3,
  5. Adolfo Igor Rodrigues1 and
  6. Kariem El-Boghdadly4,5
  1. 1Academic Unit of Medicine, Federal University of Campina Grande, Campina Grande, Brazil
  2. 2Real Hospital Português, Recife, Pernambuco, Brazil
  3. 3Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil
  4. 4Department of Anaesthesia and Perioperative Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
  5. 5Centre for Human and Applied Physiological Sciences, King’s College London, London, UK
  1. Correspondence to Professor Clístenes Crístian de Carvalho, Federal University of Campina Grande, Campina Grande, Brazil; clistenescristian{at}


Background Data suggest that preprocedural ultrasound may improve the efficacy of central neuraxial puncture. However, it remains uncertain whether these findings can be extended to various clinical scenarios, including diverse patient populations and the application of real-time ultrasound guidance. Additionally, it is unclear whether ultrasound-guided techniques improve safety and patient-centered outcomes.

Methods We searched six databases for randomized trials of adult patients undergoing neuraxial puncture, comparing real-time ultrasound, preprocedural ultrasound, and landmark palpation for efficacy, safety and patient-centered outcomes. Our primary outcome was a failed first-attempt neuraxial puncture. After two-person screening and data extraction, meta-analyses were conducted and the Grading of Recommendations Assessment, Development and Evaluation approach was applied to assess the certainty of evidence.

Results Analysis of 71 studies involving 7153 patients, both real-time ultrasound (OR 0.30; 95% credible interval (CrI) 0.15 to 0.58; low certainty) and preprocedural ultrasound (OR 0.33; 95% CrI 0.24 to 0.44; moderate certainty) showed a significant reduction in the risk of a failed first neuraxial puncture. Real-time ultrasound had the best performance for preventing first-attempt failures (low certainty evidence). Although real-time ultrasound was also the leading method for reducing the risk of complete neuraxial puncture failure, the results did not show a statistically significant difference when compared with landmark palpation. Preprocedural ultrasound, however, significantly reduced the odds of complete puncture failure (OR 0.29; 95% CrI 0.11 to 0.61). These ultrasound-guided approaches also contributed to a reduction in certain complications and increased patient satisfaction without any other significant differences in additional outcomes. Trial sequential analysis confirmed that sufficient information was achieved for our primary outcome.

Conclusions Ultrasound-guided neuraxial puncture improves efficacy, reduces puncture attempts and needle redirections, reduces complication risks, and increases patient satisfaction, with low to moderate certainty of evidence. Despite real-time ultrasound’s high ranking, a clear superiority over preprocedural ultrasound is not established. These results could prompt anesthesiologists and other clinicians to reassess their neuraxial puncture techniques.

  • Ultrasonography
  • Anesthesia, Conduction

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  • X @clistenes_cc, @elboghdadly

  • Presented at The authors wish to acknowledge that a summary of this research was previously presented at the RA-UK Annual Scientific Meeting 2024.

  • Contributors CCdC helped conceive and design the study; screen the references; collect, analyze and interpret the data; draft, review and approve the manuscript. WPG, MCVM, HdPO and AIR helped conceive and design the study; screen the references; collect the data; review and approve the manuscript. KE-B helped interpret the data, contributed to the intellectual review and content of the manuscript and approved the final draft.

  • 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 KE-B or his institution has received funding from Fisher and Paykel Healthcare, GE Healthcare and PAION.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.