Thoracic Epidural Needle
Jul 14, 2017
Thoracic Epidural Needle
Epidural needle and catheter insertion can be performed with the patient sitting or sideways. Identification of the midline is key to the success of epidural anesthesia and is more easily achieved when the patient is seated, especially for obese subjects.
The skin is anesthetized after bony landmarks are determined. Epidural anesthesia should be placed in the dermatome of the surgical incision, usually between T5 and T9. The midline approach to the epidural space passes sequentially through the skin, subcutaneous tissue, supraspinous and interspinous ligaments, and into the ligamentum flavum. Steeply overlapping thoracic spinous processes require considerable pin angles. The depth of the spinal canal from the skin varies with the level of the spine, amount of subcutaneous fat, body size, and angle of needle insertion, so no safe rule of thumb can be applied. Because of the steep arch of the ligamentum flavum, the spinal canal enters the spinal canal approximately 1 cm more in the midline than laterally, near the facet joints. The ligamentum flavum is 3 to 5 mm thick in the thoracic region and 5 to 6 mm thick in the lumbar region. If the needle remains at the midline, the ligamentum flavum is considered a thicker ligament than if the needle were allowed to be inserted midline and entered at the lateral extension of the ligamentum flavum. The problem is that the spines at T5-8 are significantly downward sloping, making midline access to the epidural space nearly impossible. This would require a paramedian approach rather than a midline approach.
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