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      Correlation between depth of subarachnoid space in the lumbar region estimated by Stocker’s formula, ultrasound, and depth of needle insertion: A prospective observational study

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          Abstract

          Background and Aims:

          The main challenge in administration of spinal anesthesia in patients is the unpredictability of the exact skin to subarachnoid space depth (SSD). Approximation of SSD and needle length comes at the expense of patient comfort and multiple attempts increases complications. Our study aimed to evaluate the validity of Stocker’s formula to estimate SSD in comparison to ultrasonography and depth of needle insertion. We also aimed to determine an equation to describe the relationship between patient weight and SSD in an Indian population.

          Material and Methods:

          This was a prospective observational study. A total of 234 adults of American Society of Anesthesiologists (ASA) category 1 and 2 were selected for the study. The patients underwent spinal anaesthesia and SSD data were determined using weight-based Stocker’s formula (DS), ultrasonography (DU), and actual depth of needle insertion (DA). Correlation analysis was performed to determine variables that can predict the SSD. A linear regression was calculated to describe the relationship between patient weight and SSD. SSD data were determined using weight-based Stocker’s formula ultrasonography, and actual depth of needle insertion.

          Results:

          Mean SSD using Stocker’s formula, ultrasonography, and actual depth of needle insertion was 4.92 ± 0.6 cm, 4.47 ± 0.6 cm, and 4.81 ± 0.6 cm. Our study showed a significant correlation between Stocker’s formula and SSD measured by actual depth of needle insertion ( R 2 = 0.376). This was described by the derived formula: SSD (cm) =2.522+ [0.031 × weight (kg)].

          Conclusion:

          SSD correlates well with the weight of adult patients. Measurement with Stocker’s formula and actual depth showed better correlation than Stocker’s formula and ultrasonography. This is valuable in resource-poor areas with a lack of ultrasound machines or expertise in training.

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          Most cited references17

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          Perceived barriers in the use of ultrasound in developing countries

          Sachita Shah, Blaise A. Bellows, Adeyinka Adedipe … (2015)
          Background Access to ultrasound has increased significantly in resource-limited settings, including the developing world; however, there remains a lack of sonography education and ultrasound-trained physician support in developing countries. To further investigate this potential knowledge gap, our primary objective was to assess perceived barriers to ultrasound use in resource-limited settings by surveying care providers who practice in low- and middle-income settings. Methods A 25-question online survey was made available to health care providers who work with an ultrasound machine in low- and middle-income countries (LMICs), including doctors, nurses, technicians, and clinical officers. This was a convenience sample obtained from list-serves of ultrasound and radiologic societies. The survey was analyzed, and descriptive results were obtained. Results One hundred and thirty-eight respondents representing 44 LMICs including countries from the continents of Africa, South America, and Asia completed the survey, with a response rate of 9.6 %. Ninety-one percent of the respondents were doctors, and 9 % were nurses or other providers. Applications for ultrasound were diverse, including obstetrics (75 %), DVT evaluation (51 %), abscess evaluation (54 %), cardiac evaluation (64 %), inferior vena cava (IVC) assessment (49 %), Focused Assessment Sonography for Trauma (FAST) exam (64 %), biliary tree assessment (54 %), and other applications. The respondents identified the following barriers to use of ultrasound: lack of training (60 %), lack of equipment (45 %), ultrasound machine malfunction (37 %), and lack of ultrasound maintenance capability (47 %). Seventy-four percent of the respondents wished to have further training in ultrasound, and 82 % were open to receiving distance learning or telesonography training. Subjects used communication tools including Skype, Dropbox, emailed photos, and picture archiving and communication system (PACS) as ways to communicate and receive feedback on ultrasound images. Conclusions Health care providers in the developing world identify lack of training as a primary barrier to regular use of ultrasound in their practice. While equipment requirements including maintenance and cost of machines are also important factors, future research is warranted on best practices for training methods, including telesonography and distance learning to enhance ultrasound use in low-resource settings.
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            Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients.

            Stephen Halpern, Mrinalini Balki, Luiz J. C. B. Carvalho … (2009)
            Prepuncture lumbar ultrasound scanning is a reliable tool to facilitate labor epidural needle placement in nonobese parturients. In this study, we assessed prepuncture lumbar ultrasound scanning as a tool for estimating the depth to the epidural space and determining the optimal insertion point in obese parturients. We studied 46 obese parturients, with prepregnancy body mass index (BMI) >30 kg/m(2), requesting labor epidural analgesia. Ultrasound imaging was done by one of the investigators to identify the midline, the intervertebral space, and the distance from the skin to the epidural space (ultrasound depth, UD) at the level of L3-4. Subsequently, an anesthesiologist blinded to the UD located the epidural space through the predetermined insertion point and marked the actual distance from the skin to the epidural space (needle depth, ND) on the needle with a sterile marker. The agreement between the UD and the ND was calculated using the Pearson correlation coefficient and a paired t-test. Bland-Altman analysis was used to determine the 95% limits of agreement between the UD and the ND. The prepregnancy BMI ranged from 30 to 79 kg/m(2), and the BMI at delivery was 33-86 kg/m(2). The Pearson correlation coefficient between the UD and the ND was 0.85 (95% confidence interval: 0.75-0.91), and the concordance correlation coefficient was 0.79 (95% confidence interval: 0.71-0.88). The mean (+/-SD) ND and UD were 6.6 +/- 1.0 cm and 6.3 +/- 0.8 cm, respectively (difference = 0.3 cm, P = 0.002). The 95% limits of agreement were 1.3 cm to -0.7 cm. Epidural needle placement using the predetermined insertion point was done without reinsertion at a different puncture site in 76.1% of parturients and without redirection in 67.4%. We found a strong correlation between the ultrasound-estimated distance to the epidural space and the actual measured needle distance in obese parturients. We suggest that prepuncture lumbar ultrasound may be a useful guide to facilitate the placement of epidural needles in obese parturients.
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              Ultrasound using the transverse approach to the lumbar spine provides reliable landmarks for labor epidurals.

              Luiz J. C. B. Carvalho, C. Arzola, Sharon Davies … (2007)
              Ultrasound imaging of the spine has recently been proposed to facilitate identification of the epidural space. In this study, we assessed the accuracy and precision of the transverse approach, using a "single-screen" method, to facilitate labor epidurals. We enrolled 61 patients requesting labor epidurals. Ultrasound imaging (transverse approach, 2-5 MHz curved array probe) identified the midline, the intervertebral space, and the distance from the skin to the epidural space (ultrasound depth/UD). During the epidural puncture, we recorded the success of the insertion point, and measured the distance to the epidural space to the nearest half-centimeter of the marked Tuohy needle (needle depth/ND). We calculated the agreement between UD and ND by the concordance correlation coefficient and Bland-Altman analysis with 95% limits of agreement. The average maternal age was 33 +/- 4.6 yr, body mass index 29.7 +/- 4.8, UD 4.66 +/- 0.68 cm, and ND 4.65 +/- 0.72 cm. The success of the insertion point was 91.8%, with no need to redirect the needle in 73.8% of the patients. The concordance correlation coefficient between UD and ND was 0.881 (95% CI 0.820-0.942). The 95% limits of agreement were -0.666 to 0.687 cm. We found a good level of success in the ultrasound-determined insertion point, and very good agreement between UD and ND. This suggests that our proposed ultrasound single-screen method, using the transverse approach, can be a reliable guide to facilitate labor epidural insertion.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Anaesthesiol Clin Pharmacol
                Journal ID (iso-abbrev): J Anaesthesiol Clin Pharmacol
                Journal ID (publisher-id): JOACP
                Journal ID (publisher-id): J Anaesthesiol Clin Pharmacol
                Title: Journal of Anaesthesiology, Clinical Pharmacology
                Publisher: Wolters Kluwer - Medknow (India )
                ISSN (Print): 0970-9185
                ISSN (Electronic): 2231-2730
                Publication date (Print): Oct-Dec 2022
                Publication date (Electronic): 09 September 2022
                Volume: 38
                Issue: 4
                Pages: 548-552
                Affiliations
                [1]School of Medicine, Saveetha Medical College and Hospital, Tamil Nadu, India
                [1 ]Department of Anaesthesia, Saveetha Medical College and Hospital, Tamil Nadu, India
                Author notes
                Address for correspondence: Dr. Reesha Joshi, Department of Anaesthesiology, Saveetha Medical College and Hospital, Saveetha Nagar, Thandalam, Chennai, Tamil Nadu - 602 105, India. E-mail: reesha.joshi@ 123456gmail.com
                Article
                Publisher ID: JOACP-38-548
                DOI: 10.4103/joacp.JOACP_691_20
                PMC ID: 9912904
                PubMed ID: 36778792
                SO-VID: 54277393-d388-40fb-bdec-68c9e24bd3eb
                Copyright © Copyright: © 2022 Journal of Anaesthesiology Clinical Pharmacology
                License:

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                Date received : 08 January 2021
                Date revision received : 30 May 2021
                Date accepted : 17 June 2021
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: spinal needle depth,stocker’s formula,subarachnoid space,ultrasonography
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: spinal needle depth, stocker’s formula, subarachnoid space, ultrasonography

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