Neuraxial Ultrasound – Technical aspects & how to perform preprocedure scan



so in part two we're gonna talk in detail about how to actually perform this game before the procedure before going to more detail I want to review some terminology if you do a search of literature you will encounter these two word pre often for stereo complex and I'm Tara complex and the reason is under ultrasound it's very difficult to visualize structure separately individually they often have kind of grouped together so for example posterior complex is the combination between the ligamentum flavum and posterior Dora where's the anterior complex is the include the anterior and the posterior longitudinal ligament and the vertebral body so this could be my DS vocabulary when we talk about different structure and different view so we're gonna go over five you today three in the sagittal plane and two in the transverse plane and I color-coded here the one in the red the parasagittal oblique and transverse inter laminar or inter spinous mew these two are the two most important view but the other three is good to know as well so that we can obtain these two view and different people look at different structure it's gonna go we're gonna go over one by one individually so so in the let's start with the parasite chambers process view so this way we're looking at the transverse process we look at it multiple transverse process in a row and it will be manifested as this structure on the ultrasound image and this is this pattern is what we call it tried inside next let's look at the actual ultrasound image so pay attention to these hypoechoic structure over here so these are transverse process and as you can see this picture right here that's why we refer to this pattern as the tried inside so this video is not super helpful it's not the ultimate view to be won to obtain but like I said earlier is help you to know where you are so you can obtain the press actually later so next we're gonna talk about the articular process view and this we're gonna move it Tran user more medially to one a midline and we're looking at the ticular process it's in our picture we're gonna look at the superior and inferior articular process so basically the facet joint and the patent for this view gonna be this structure right here what we call a camel hump and let's take a look at an actual image right here these hypoechoic structure you know give this give us a shape similar to the camel hum that's what's the name come from and this video was a little bit i in my personal opinion it's a bit more important than trying to post process because this is gonna be the stepping stone for you to obtain the sax two oblique that we're gonna talk about now so when you obtain the africa articular process view what you don't want to move your trend ooh so all you have to do a tilt it to one emit light so you don't move it all just you don't slide it at all you just tilt it immediately to what a midline now you're looking through the spinal canal you can see the red right here so the yellow is the articular process view and the red is the parasagittal click view so now you can see we look in through the space and that's allowed to see deeper structure so this e a pattern for this view right here and these structure right here this curvature right here these are the laminar laminar the superficial line you see on the top right here gonna be I know laborers during here but realistically it should be label posterior complex like I talked about like really you see ligamentum flavum and the the doer to be visualized separately they often they often seem together and what we call like ice mentioned earlier previously for steer complex and then the deeper structure is the anterior complex again I look it's not oh just our image over here some labeling so here these these lamina lamina and these superficial line right here is your posterior complex these deep real line right here are your anterior complex and now look at a picture with less labeling again right here you're gonna have your lavender lamina Lavina superficial line right here gonna be your posterior complex for Styria complex and a deeper the deeper structure and a deeper hypoechoic like are gonna be anterior complex and so when you what do you do when so this is a very important view what can you identify this view so knowing this is your posterior come black which is the combination of your ligamentum flavum and your posterior so now you can measure the distant from the skin to the structure and that's gonna give you the distance to your ligamentum flavum and this is important if you're gonna do a place an epidural and there's a couple way you do it often time you would have like a like a ruler on the side you can tell you how many centimeter you ant you can estimate based on that ruler or you can use the caliber caliper on the ultrasound to measure more accurately so you here you're gonna know your distance and then here is the this view in this way we can we can also gonna mark our level as well so what you're gonna do is you're gonna line you're gonna bring your so the gap in between these so if these are laminar so the gap between these in your interspace so what you're gonna do when you bring these into spain into the middle screen make sure it line up with the the mid line the middle line on your own trend user and mark it so so you can mark your level and and you can see in this picture right here we can mark you can mark give market several level that way you can be solid in case you have to do you in case you need motorboat em and you can have you know you can you know ahead of time like where should be your level and this is a helpful as well because often time you know sometime you thought when you palpate the patient and you thought you in between us baby when you put a needle in you keep hitting us so by marking the inter spayed this way you know like vertically these lie correlate with the space and you are not on top of the spinous process so next week now we're moving on to now we're gonna rotate their transition ninety degree and go to and do the transverse train into the transverse plane first one we gonna talk about it spinous process view this view in this view to conducive i on top of the spinous process as you can see over here and let's see what it looked like on ultra cell so this is the image you're gonna have and the pattern we have in this view e conduct the traffic cone sign and you can see here so in here right here you see your spinous process over here you see a laminar but you see under here you don't really see much anything because remember the spinous process is the bony structure so it's obstruct all the deeper structure so this video is not very helpful and the only thing helpful about his view is help you identify the midline because now you know where's the spinous process so that's pretty much the only use you have for this view and so if you rotate your to new serve from the parasites sagittal to the Chamber's for you and you got your spinous process view all you have to do is slide up and down too far into space and eventually you're gonna have theirs transfer into lamina or into spinous view which basically mean you looking at the interspace right now and this is a very very important view I will go into detail why and this is the pattern that we're gonna have and what we call is parent is the bad sign as you can see there's some resembling right here so in this side over here you're gonna see the posterior complex transverse process and terior complex and he is your articular process one thing was mentioning though is the posterior complex not as well visually in this view as the parasagittal oblique that we talked about earlier but you can use you can still see it but sometimes you may not see it so now look at a picture over here and you can see posterior complex it's not as well visual I like the press action of Bleek he had anterior complex your here's your transverse process here's your articular process and okay let's look another picture here this picture has less labeling so you can have a more realistic view of what actually looked like aa note to cell again or Siri complex trend very processed articular process anterior complex so what can you do in this view first of all you can identify mid line right here you can know a mid line you can often time more often you can see your posterior complex so you can measure the distance as well but like I say it's not as well visualized comparing to a parasite oblique so I think the Paris notches of lick is a better view to obtain a distance you ligamentum flavum but what happened by this view is help you predict your angle or the angle of your needle as you so when you when you if you have previously when you have the spinous process view and you slide up and down to find a space and when you find a spray-out sometime you have to tilt it a little bit to verify this view and when you able to obtain this view you want to notice the direction of your trend user the hang of your turn you set because this is gonna be the same angle you're gonna use for your needle so you see is a three piece important information that we can get in this view couple what about assessing the vertebral rotation in patient with scoliosis so before it inducer on a patient in the transverse view 10 versus plane you're gonna have like a picture like this but for whatever reason if you see a picture kind of tilt on this kind of rotate it then you you know the patient have some rotation of the some vertebral rotation and then what you're gonna do you're gonna rotate your trend user as well to bring the image back to the normal position and the amount of rotational inducer gonna tell you the direction of your needle when you perform spinal happy do as well so put it all together we're gonna watch to a quick video that I recorded to go over on the step that we talked about previously so oh one thing I want to mention is for this precision you want to use the low frequency wide transducer yvh inducer so start a couple centimeter three centimeter from midline try to fire try the inside your so here you have your tried inside which telling you that you're looking at the transverse process and then after that you were gonna move more medially to fire a particular process so watch my hands here so we're moving medially to find my articular process and here we go do we have the structure the camel hump pattern that tell us we had the articular process and when you have this view then you don't move you don't move your trend user anymore all you have to deal with to tilt it to warm it like to get your part of sachet or bleak view so see so we never run tooted and so this is our past sagittal bleak the quality of this image is not as good because I record through the phone but you can see right here this is your auntie posterior complex which is gonna tell you your distant to ligamentum flavum so you look over here this patient is about five centimeter so something important to know for your epidural placement you can also see if you want to be more accurate you can use your caliper on out your cell if you don't want to use the ruler over here and right here is your anterior complex right here the lamina the lamina the gap in between the lamina is your interspace so next what you're gonna do is gonna slide the transducer caudally to identify to defend your l5 s1 into space and then mark them so when you mark them you want to bring your into space in the middle of the screen and line them up with the middle the middle lie on your inducer and Markham will see him one second so now I'm gonna sly caudally to defy my l5 s1 level you see here I move might induce a little and I lost my view so I have a Texan attempt to maneuver and obtain to really obtain my parasagittal oblique view again so when I find my when I find my processor oblique view again then I just remember it just mark it lie to lie the into space in the middle screen and Markham and I assure you mark to a three space after that we're gonna we're gonna rotate ninety degree to the transverse plane and right here I we have the transverse spinous process like we talked about earlier so with that reduces right on top of the spinous process and like I say it's not a very helpful view or get all I tell you is the the midline so now we want to do is slide up or down to fly into space and then often time you have to tilt it a little to see you can obtain the part of the inter lamina in the spinous view and it took me a little bit of time to obtain image here and here is the batwing sign that we talked about so this is the anterior and posterior complex anterior complex articular process transverse process so you can measure so when you obtain this view then you want to notice the angle you want to mark the midline and knows the angle of your trend ooh sir this is gonna be the angle of your nito as well here I have a lot of quality jail so the marker doesn't stick so I'm using the back of our 18 gauge needle to mark my midline so after you mark your midline nose your nose your the angle of your needle then just then now you just connect the level that you mark in the parasagittal bleak and the midline you mark and the transverse into spine is brought in into spinous view so now this is gonna be the this is gonna be the entry love the entry point for your needle placement

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