This case report describes a successful establishment of IT access with preprocedural ultrasound imaging (ultrasound-assisted technique). Since spinal anesthesia is usually performed by the landmark technique at a high success rate, ultrasonography is not often employed to perform spinal anesthesia on a daily basis. However, recent reports have shown that using an ultrasound-assisted technique reduces both the number of attempts as well as complication rates [8]. In a systematic review including studies of diagnostic lumber puncture (LP) in emergency departments, ultrasound-assisted LP was associated with a higher success rate, less traumatic LPs, and less procedural time spent [9]. Park et al. reported a reduction of the number of needle passes with ultrasound-assisted spinal anesthesia for patients with mostly mild scoliosis and some moderate to severe scoliosis [10]. Chin et al. also reported a reduction of needle passes with preprocedural ultrasound imaging for patients with obesity, moderate to severe scoliosis, and previous spinal surgery [11].
CT images and X-rays show how the spine looks and where a possible passage to the intrathecal space is. However, these images may not be of help when a patient is positioned for intrathecal puncture. Ultrasound imaging obtained immediately before the puncture with the patient positioned for treatment should improve the understanding of the anatomy and help reduce the number of needle passes and possible complications. This is particularly important when patients might well have to repeatedly undergo spinal punctures.
Intrathecal access is not limited to lumbar spine. In some institutions, cervical punctures have been used for intrathecal nusinersen injections [3, 12]. A recent paper described successful ultrasound-guided cervical punctures for nusinersen administration in adolescents who had severe scoliosis and spinal instrumentation in the lumbar spine [4]. However, cervical punctures are rarely conducted and are challenging with potential risk of spinal cord injury and neurological complications. In contrast, lumbar punctures are much more common and safer and, thus, should be tried first with ultrasound even when the access appears extremely difficult.
We did not conduct a real-time ultrasound-guided procedure due to technical difficulty. In a study that investigated feasibility of real-time ultrasound-guided spinal anesthesia, the authors showed a possible reduction in “difficulty” in patients scheduled for lower limb surgery [13]. Real-time guided puncture has a possible advantage in patients with severe scoliosis because an ultrasound-assisted technique only provides the insertion point and angle that the operator should memorize. The feasibility of using real-time ultrasound-guided technique in patients with severe scoliosis, however, remains to be investigated.