Journal Reading

Based on: Shaparin N, Jeffrey B, White RS, Kaufman AK. Bevel direction of epidural needles reliably predicts of catheter placement and
contrast in human cadavers: results of a pilot study. Jour of Clin Anestesia (2014) p1-4

Bevel direction of epidural needles

reliably predicts of catheter
placement and contrast in human
cadavers: results of a pilot study
Presented By:
Amri Mubarrok
Preceptor:
DEPARTMENT OF ANESTESIOLOGY AND INTENSIVE CARE
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ DR. MOHAMMAD HOESIN GENERAL HOSPITAL
2014

NAVIGATION KEY

Introduction

Material &
Method

Result

Discussion

INTRODUCTION
In lower extremity surgery, direction of catheter
insertion influences the efficacy of epidural
anesthesia
Bevel direction in epidural spaces correlates
with the directional spread of injectate
When catheter placed bevel of needle facing
cephalad direction in the mid thoracic & low-thoracic
spine : injected contrast spread preferentially in
cephalad direction

There are still limited data assessing the

direction flow on injectate
In this cadaver study, radiopaque contrast used to
confirm relationship between bevel orientation,
catheter direction and radiopaque contrast spread in
the lumbar region

Gambar 1. Pengaruh tekanan terhadap jaringan.2

MATERIALS & METHODS

Location: University of Medicine and Dentistry of New
Jersey
8 human cadavers divided
randomly

Group 1
4 cadavers; needle bevel
direction cephaled

Group 2
4 cadavers; needle bevel
direction caudad

Continued

Gambar 2. Gaya gesek yang dihasilkan saat pasien berada di tempat tidur
(A) pada pinggul (B) pada tumit.2

MATERIALS & METHODS

8 cadavers divided randomly

Group 1: cephaled

Group 2: caudad

Place proned to eliminate gravitational effects

Identifed L4-L5 interspace using posterior/superoir iliac creast as landmark
Cut down with 11 blade scapel until supraspinous ligament reached at L4-L5
interspace
Insert 18-gauge touhy epidural needle into laminar space
After epidural space entered, threaded single orifice catheter 4 cm into epidural
space

Inject 2 ml radiopage contrast (Omnipaque 300 GE Heathcare Inc. Priceton USA) &
obtain lumbar posteroanterior radiograph
Obtained direction of spread by remaining 1,8 mL contrast

RESULT
8 cadavers

Group 1: Cephaled

Excluded 1
cadaver due to
inability to access
epidural space
3 of 3 (100%)
flowed primarily
cephaled
direction

Group 2: Caudad

No excluded

3 cadavers flowed primarily

caudad
1 cadaver equally caudad &
cephalad

Catheter tip direction according to the radiograph corresponded directly with bevel
direction

DISCUSSION
Better outcome than
GA for total hip
replacement surgery

Advantage

Improve early
rehabilitation after
mayor knee surgeries

Preferred for patients

elderly/multiple
comorbidities

Epidural
analgesia

Disadvanta
ge

Sparring effect for

surgery involving
ankle & foot

Continued

DISCUSSION
Bevel orientation of
epidural needle

Tiso et al

Conflicting
result

Catheter placement
direction

Choi et al

28 patients, 3 cm lumbar

106 patients, 5 cm thoracic

epidural anestesia
80% concordance catheter
direction cephaled group
46% concordance caudad
group

epidural anestesia
63% concordance cephaled
group
22% concordance caudad
group

Narrow posterior depth of epidural space

in thoracic region increased resistance
thoracic epidural require greater
angulation affect catheter direction

Continued

DISCUSSION
Bevel orientation of
epidural needle

Hasnt
been
absolute &
conclusive

Direction of spread
of the injectate

Touhy needle direction has minor effect on injectate

spread

Yokohama
et alsoft &
Young
patients have
dura
& aerolar tissue
loose
Lumbar
epidural

when anestetic given,

analgesia
& aerolar
dura
Method:
needletissue
bevel only
pushed
allow to
directedaway
in cephalad
spread
in both cephalad &
direction
direction
caudad
Result: more
cephalad
Older
& thick
spreadgroup
than firm
caudad
dura & aerolar tissue
produced dominant
spread in direction of bevel
epidural needle

Park et al
3rd lumbar intervertebral
space anesthesia
correlate in patients >40
yo compared with 20 39
yo patients
No significant differences
in cephaled spread
between cephalad &
caudad group

Liu et al
20 patients for ankle
surgery/hemorhoidectomy
No significant differences
between groups in
characteristics of epidural
anesthesia (onset time,
duration, & anesthetic
level)

Continued

DISCUSSION
Bevel orientation of
epidural needle

Huffnangle et al

Bevel direction
cranial, caudal,
90right, 90left
lumbar region
Cephaled oriented
needle had
greatest success of
epidural analgesia
For sacral region,
mix cephaled &
caudad direction
preferable

Depending
level of
epidural
injection
Asato et al

Initial partial inj

caudad region &
cephalad inj
remainded
greater sacral
spread
Onset of sacral
dermatomal
coverage more
rapid when split
cephalad & caudad
direction inj

Achieving effective
epidural analgesia

Chou et al

Caudad
direction
resulted faster
onset & greater
anestesia
Excluded 15%
catheter due to
poor placement

This study

Caudal plane
direction allow
decreased
volume of local
anestesia

Discussion

LIMITATION OF STUDY
7 subjects

Small
sample size

Use human
cadavers

Dead human: fibrotic

changes of surrounding
tissue & epidural space
maintain catheter
direction
Live human: less rigid
tissue structure & epidural
fat pads allow catheter
placement change easily

Prone
position
May influence catheter
direction
Not feasible to place
cadavers sit/lateral decubitus
position
No study compared patients
position with ability thread
catheter & influence the

Discussion

CONCLUSION
This pilot study showed a strong relationship
between bevel orientation and catheter
direction
Catheter position does not reliably predict the
direction in which the injected fluid spreads in
all cadavers

THANK YOU