전문수련을 마치고 3년 동안 선수생활을 마치고 시작한 통증의학 임상강사님은 아직도 제 마음속에 참으로 힘든 기억으로 남아있습니다. 먼저, 본 논문을 작성해주신 신진우 교수님께 감사의 말씀을 전하고 싶습니다. 최성수 교수님은 제 전공의 동기입니다.
전공 때부터 우리 반 친구들에게 책을 읽어주고 지도해 준 믿음직한 형이었고, 제가 임상강사로 시작했을 때 저를 지도해 준 통증의학 교수였습니다. 그는 나에게 셀 수 없을 만큼 많은 교훈을 주었습니다. 교수님한테 배웠는데 아직 배울 게 너무 많아요. 가르쳐주신 내용 잊지 않고 후배들에게도 동기부여가 되도록 노력하겠습니다. 저도 교수님을 모범으로 삼아 인술을 수련하는 마취통증의학과 의사가 되도록 노력하겠습니다. 감사합니다.
지현의 두 아들에게 미안하고 고맙다는 말을 전하고 싶다. 그리고 지금의 저를 있게 하시고 늘 저의 결정을 믿어주시고 지지해주신 아버지 어머니께도 깊은 감사의 말씀을 전하고 싶습니다.
Determination of Optimal degrees for Contralateral Oblique View in Mid-Thoracic
11, 20-22; however, the use of the CLO view in the midthoracic region has not been investigated. The location of the needle tip in the CLO and lateral views was defined as: Level –2 (well posterior to the VILL), Level –1 (just posterior to the VILL), Level 0 (on the VILL), Level +1 (just anterior to the VILL), Level +2 (significantly before VILL) and Stage U (indeterminate stage; needle tip location could not be evaluated due to lack of visualization) (Figure 1-4). Visualization of the laminar margin using the angle measured with CLO was significantly clearer (Grade 1) compared with that in the CLO view at 40 and 50 degrees and the lateral view.
First, the needle tip was clearly visible in each CLO view, compared to the lateral view in the mid-thoracic region. Second, the laminar margin was visualized significantly well at the 60-degree CLO image and the CLO-measured angle image in the center of the thoracic region. Third, the needle tips in the CLO image were angled at 60 degrees and the CLO measured angle were all at or just anterior to the VILL in the mid-thoracic epidural space.
The ability to confirm the depth of the needle tip in relation to the epidural space can ensure safe TEE. If the needle tip was not in the epidural space, spread contrast posteriorly to VILL. In this study, the outcomes of the CLO measured view were not statistically different from those provided by CLO view at 60 degrees.
Randomized Trial for Comparison of Contralateral Oblique View at 60 degrees with
The results of Chapter 1 showed that the CLO view at 60 degrees provided clearer visualization and more consistent needle tip placement than the lateral view for mid-TEA. Therefore, it is speculated that CLO viewing at 60 degrees may be an optimal angle for mid-TEA. Thus, the aim of this study was to evaluate the clinical usefulness of the CLO view at 60 degrees compared to the lateral view when accessing the mid-thoracic epidural space.
Opaque and sealed envelopes with sequential study numbers hidden by the first investigator were given to the pain physicians who performed the midway through TEA on the day of the procedure. Prior to needle insertion, the AP view was aligned with the plane of the lower endplate of IVB. If the epidural needle encountered the laminae and could not be advanced, the needle was withdrawn and advanced again, changing the angle of the needle.
An interim analysis was planned 6 months after the start of the trial to verify the sample size based on the first attempt success rate and to evaluate the incidence of serious complications associated with the procedure. Comparison of the success rate of punch attempt success, final success and crossover trial between the two groups. This is the first randomized study to evaluate the clinical utility of the CLO view at 60 degrees compared with the lateral view in the mid-TEA.
Encouraging results from this interim analysis showed that the CLO view improved first attempt and final mid-TEA success rates. Although the use of the fluoroscopic AP and lateral view has been standard practice, more recent attention has been directed toward the use of the CLO view to determine needle depth during the interlaminar epidural approach. The CLO view appears to be a viable alternative to the traditional fluoroscopy view for epidural access.28, 30 Using a scientific geometric analysis of the CLO view, Gill et al. A CLO view at 60 degrees can provide clear visualization of the needle tip and laminar margin in the midthoracic region.
These properties of the CLO view can make the needle tip avoid the lamina without periosteal contact, achieving a higher first-attempt success rate (69.6%) and improving the accuracy (100%) of mid-TEA in this study . From this location, the tip of the needle should be advanced with the LOR; then, the epidural space can be taken to VILL or just beyond VILL as soon as possible, making the operator anticipate the location at which the LOR can be accessed. This residual knowledge of needle depth, anticipated to achieve epidural access, serves as a safety measure against false negative LOR,8 preventing a ventral aberrant.
Although there were no serious complications in this interim analysis, the interpretation of the safety of the CLO view should be treated with caution until the evaluation for complications is studied with an adequate sample size.
Real-Time Ultrasound-guided Epidural Access in Low-Thoracic region: Technical
In addition, the real-time US-TECP has recently been introduced, interest in which is increasing due to its visualization of needle throughput and the possibility of improved success rates14. Subsequently, the cephalic end of the probe rotated medially (Fig. 3-1.C), after which the height of the laminae of the lower vertebral body decreased compared to that of the paramedian sagittal oblique view. This point could ensure that the path of the epidural needle tip was not interrupted by the laminae (Fig. 3-1.H).
Once the target interlaminar space was identified, the center of the interlaminar space and the cephalad and caudal ends of the probe were marked on the overlying skin. Melsungen, Germany) was inserted from the caudal end of the probe and advanced in a planar view under real-time US guidance until the needle tip reached anterior to the posterior complex at the interlaminar space. In addition, the needle tip was not always visible despite the use of real-time ultrasound guidance at this depth.58 Therefore, to ensure the safety of the procedure, needle movement under real-time ultrasound guidance must be stopped in the anterior part of the posterior complex.
If an epidural catheter was present outside the epidural space, swelling around the laminae could be checked. Positioning of the ultrasound probe corresponding to the ultrasound images and handling of the ultrasound probe to obtain the appropriate ultrasound images. After real-time US-TECP, fluoroscopic assessment was performed to identify the catheter position.
In addition, the tip of the epidural catheter, located between T9-10, can ensure that the contrast medium is sufficiently distributed over the dermatome level corresponding to the surgical incision. Inserting an epidural catheter into the thoracic region is relatively more difficult than in other regions.35 Compared to the lumbar vertebrae, the longer spinous processes of the thoracic vertebrae, a sharp angle of the spinous process, and the greater distance between the skin and the epidural space make it difficult to access the thoracic epidural space. First, the precise vertebral level corresponding to the surgical incision can be identified by counting the ribs on the ultrasound images.63 Second, preprocedural ultrasound can improve the success rate of epidural catheterization.53 Placing an epidural catheter under real-time ultrasound is a step further in the future. process of ultrasound-guided epidural placement, which can provide the visualization of needle advancement with simultaneous identification of the epidural space between the target laminae.
In our experience, we are sometimes faced with the failure of the paramedian sagittal oblique view optimization to identify the posterior complex, especially in the mid-thoracic region above. If the physician determines that the paramedian sagittal oblique view optimization fails and the needle contacts the SAP, we recommend that the epidural needle be withdrawn to 1 cm above the laminae, after which the needle should be advanced more medially to allow access. get to the epidural space. If they were to participate in this study, the outcomes would change; therefore, evaluation of the clinical utility of the real-time US-TECP in obese patients is warranted.
Ultrasound imaging of the thoracic spine in the paramedian sagittal oblique plane: correlation between estimated and actual depth to the epidural space.
