Sprung J, Bourke D L, Grass J, Hammel J, Mascha E, Thomas P, Tubin I
Department of General Anesthesiology, Cleveland Clinic Foundation, OH 44195, USA.
Anesth Analg. 1999 Aug;89(2):384-9. doi: 10.1097/00000539-199908000-00025.
Anticipated technical difficulty is one factor that can influence the anesthesiologist's decision to perform neuraxial (spinal or epidural) blockade. Problems during the procedure may be associated with patient dissatisfaction, neurologic sequelae, or hematoma. We designed this study of 595 neuraxial blocks to determine whether any patient characteristics would be useful in predicting a difficult neuraxial block. Before the procedure, the following data were noted: demographic data, body habitus (normal, thin, muscular, obese), spinal landmarks (good = easily palpable spinous processes, poor = difficult to palpate spinous processes, none = unable to positively identify spinous processes), and spinal anatomy (assessed by inspection and examination as normal or deformed). We noted the technique, approach, needle type, needle gauge, etc. We also recorded whether the procedure was completed at the first (first-level success) or second spinal level and the total number of new skin punctures (attempts) necessary to complete the procedure. Of all the factors considered, the quality of landmarks best correlated with technical difficulty as measured by both first-level success and number of attempts. Abnormal spinal anatomy correlated with difficulty as measured by number of attempts. Body habitus also correlated with difficulty, but only as measured by number of attempts. There was no association between either measure of difficulty and any of the following: age, sex, spinal versus epidural, approach, needle type, needle gauge, or training level of the provider. Thoracic epidurals were less difficult than lumbar epidurals by both measures of difficulty. We conclude that body habitus does not seem to be the best predictor of technical difficulty. An examination of the patient's back for the quality of landmarks and obvious anatomical deformity better predicts the ease or difficulty of neuraxial block. Other factors seem to have little or no influence on the difficulty of neuraxial block procedures.
We studied a number of factors, including equipment, technique, and patient characteristics, that may indicate the ease or difficulty of performing neuraxial (spinal and epidural) blocks. Of these factors, only patient characteristics had significant predictive value. We found that an examination of the patient's back for the quality of landmarks and obvious anatomical deformity better predicts the ease or difficulty of neuraxial block than does body habitus.
预期的技术难度是影响麻醉医生决定实施神经轴阻滞（脊髓或硬膜外）的一个因素。操作过程中的问题可能与患者不满意、神经后遗症或血肿有关。我们设计了这项对595例神经轴阻滞的研究，以确定是否有任何患者特征有助于预测困难的神经轴阻滞。在操作前，记录了以下数据：人口统计学数据、体型（正常、消瘦、肌肉发达、肥胖）、脊柱标志（良好 = 棘突易于触及，差 = 棘突难以触及，无 = 无法明确识别棘突）以及脊柱解剖结构（通过检查评估为正常或畸形）。我们记录了技术、进针途径、针型、针的规格等。我们还记录了操作是否在第一（一级成功）或第二脊髓节段完成，以及完成操作所需的新皮肤穿刺（尝试）总数。在所有考虑的因素中，脊柱标志的质量与以一级成功率和尝试次数衡量的技术难度相关性最佳。异常的脊柱解剖结构与以尝试次数衡量的难度相关。体型也与难度相关，但仅以尝试次数衡量。难度的任何一种衡量指标与以下任何因素之间均无关联：年龄、性别、脊髓阻滞与硬膜外阻滞、进针途径、针型、针的规格或操作者的培训水平。两种难度衡量指标均显示，胸段硬膜外阻滞比腰段硬膜外阻滞难度小。我们得出结论，体型似乎不是技术难度的最佳预测指标。检查患者背部的脊柱标志质量和明显的解剖畸形能更好地预测神经轴阻滞的难易程度。其他因素似乎对神经轴阻滞操作的难度影响很小或没有影响。
我们研究了许多可能表明实施神经轴阻滞（脊髓和硬膜外）难易程度的因素，包括设备、技术和患者特征。在这些因素中，只有患者特征具有显著的预测价值。我们发现，检查患者背部的脊柱标志质量和明显的解剖畸形比体型更能准确预测神经轴阻滞的难易程度。
