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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 3  |  Page : 285-291

A comparative study of skin to epidural distance at lumbar region using median and paramedian techniques


1 Department of Anaesthesia, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu State, Nigeria
2 Department of Anaesthesia, College of Medicine, University of Nigeria/University of Nigeria Teaching Hospital Ituku/Ozalla, Enugu State, Nigeria

Date of Submission26-Dec-2021
Date of Decision19-Mar-2022
Date of Acceptance12-Apr-2022
Date of Web Publication2-Jun-2022

Correspondence Address:
Adaobi O Amucheazi
Department of Anaesthesia, College of Medicine, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_23_22

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  Abstract 

Background: The median and the paramedian approaches are used to access the epidural space. Median approach is commonly used but can be technically difficult in certain patients. The paramedian approach is the alternative. Success rate during the blind procedure is determined by the skin to epidural distance (SED). SED in turn is affected by patients’ anthropometric characteristics. Prediction of the SED serves to determine the depth of needle advancement in order to improve the success rate. Objectives: The study compared the SED using median vs. paramedian approaches, the time required to access the epidural space, place the catheter, and investigate anthropometric factors which may have influenced this distance among the participants. Materials and Methods: The study was a blinded randomized controlled study. Following ethical approval and informed consent, 60 women scheduled for elective gynecological procedures were allocated to one of the two groups: Group M (median) (30) and Group PM (paramedian) (30). Results: The SED was longer using the PM approach. The mean time it took to gain access was shorter in the PM group. The mean SED increased as the body mass index increased in both groups (P < 0.0001). There was a significant association of anthropometric measurements with the SED using both approaches. Conclusion: The study showed that the SED was longer in the PM group. Also as the patient’s anthropometric measurements increased, so did the SED.

Keywords: Body mass index, epidural space, median, paramedian, skin


How to cite this article:
Achi JO, Amucheazi AO, Ajuzieogu VO, Onyeka TC. A comparative study of skin to epidural distance at lumbar region using median and paramedian techniques. Int J Med Health Dev 2022;27:285-91

How to cite this URL:
Achi JO, Amucheazi AO, Ajuzieogu VO, Onyeka TC. A comparative study of skin to epidural distance at lumbar region using median and paramedian techniques. Int J Med Health Dev [serial online] 2022 [cited 2022 Jul 1];27:285-91. Available from: https://www.ijmhdev.com/text.asp?2022/27/3/285/346429




  Introduction Top


Epidural anesthesia is commonly used both for surgery and pain management.[1],[2],[3] The goal for anesthetists using the epidural technique is to gain access to the epidural space to place the needle and catheter with as few attempts as possible in order to minimize patients’ discomfort. Though the lumbar epidural space can be accessed either via the midline or paramedian approach, the midline approach is more commonly used.[1],[4] This is because the width of the ligamentum flavum in the midline helps in the ease of access. But, the advancement of the needle via this approach may be impeded by bony midline structures or narrow lumbar spaces.[5],[6] The paramedian approach, though less popular, has been recognized to be easier and effective, especially in such difficult situations because it bypasses most of the bony structures.

However, a variety of factors such as waist circumference (WC), body mass index (BMI), and race have been said to influence the distance from the skin to epidural (SED). These factors may come to play whether the median or paramedian approach is used. The study was undertaken to investigate these factors and to provide data regarding this. Such data would be of immense value in our locality.

The purpose of the study was to compare the SED and the time required to successfully access the epidural space and place the catheter using the median vs. paramedian approaches. The study also aimed at investigating the anthropometric factors which may influence this distance among our local female population.


  Materials and Methods Top


For this prospective study, ethical clearance was obtained from the Hospital Research and Ethics Committee. Informed consent was obtained from each patient recruited. The sample size was calculated based on the formula for comparing means from two independent groups.[7]

The power of the study was 80% with a significance level of -5%, although provision of 10% was made for attrition. The sample size calculated was 60.

The inclusion criteria were women of American Society of Anesthesiologists (ASA) class I or II, 18–60-year-old undergoing gynecological surgery under epidural anesthesia at a tertiary hospital in Sub-Saharan Africa. Patients were excluded if they declined; were pregnant or unstable ASA III; had sepsis at point of injection; had a history of local anesthetic allergy or coagulation abnormalities; as well as had cardiac, neurological, or musculoskeletal diseases.

Selected patients were randomly allocated to one of the two groups using sealed envelopes: Group 1, M (n = 30) the median approach and Group 2, PM (n = 30) the paramedian approach.

Patients’ weight in kilograms was obtained using a standard scale, whereas the height in meters was determined with patients standing on a flat floor and resting the heels, buttocks, and occiput against the wall. The BMI was calculated with the following formula: weight in kg/height in m2. The WC was measured 2 cm above the umbilicus. The WC/height (WC/H) ratio was calculated.

Obesity was classified using BMI in kg/m2 as follows: normal BMI: 18.5–24.9, pre-obese BMI: 25.0–29.9, obese class I BMI: 30.0–34.9, obese class II BMI: 35.0–39.9, and obese class III BMI: >40.0.[8]

For both groups, the number of attempts, the SED, the time taken to identify the space, and the time taken to successfully insert the epidural catheter were documented. The loss of resistance (LOR) technique with saline was used. All procedures were performed by one researcher.

At the point when the tip of the epidural needle touched the skin, the investigator performing the epidural signaled readiness to a blind observer (who was positioned in front of the patient and unable to see the procedure) by saying the word “START.”The blinded observer responded by starting a stopwatch and confirmed the word “START,”at which time the investigator pierced the skin with the epidural needle. Identification of the epidural space by LOR was signaled by the investigator saying “STOP”at which time the blinded observer stopped the stopwatch and recorded the time. The time needed to insert the catheter was measured by saying “START”to the blind observer when the tip of the catheter was introduced into the hub of the epidural needle and “STOP”when the mark corresponding to 15 cm on the catheter reached the hub of the epidural needle. After inserting the catheter, a mark was made on the Tuohy needle just at the point where it touched the skin, with a sterile red marker. The needle was then withdrawn with a counter pressure on the catheter to avoid pulling it out along with the needle. The distance between the mark and the tip of the Tuohy needle was taken as the SED. This was measured using a Vernier caliper by another assistant.

For the PM group, epidurals were performed at a point 1.5 cm lateral to the inferior border of the spinous process of L4. Data obtained were entered in the data collection form.

Data collected were keyed into the Statistical Package for Scientific Solution (SPSS) Computer Software version 20.0 for Windows. Mean SD was used in the analysis of calculation for age and weight of the patient. The results were presented as frequencies, percentages, and display findings. Independent t-test was applied to test the demographic characteristics of subjects according to the approach and relationship between SED and time to LOR and catheter insertion. The χ2 was used to analyze ease of access. Analysis of variance was applied to analyze the relationship between SED and WC, Kruskal–Wallis test to compare mean SED and BMI, and Fisher’s exact test to analyze ease of access to epidural space in both approaches. Linear regression analyzed the relationship between WC/H ratio and SED (dependent variable), whereas multivariate regression/correlation analysis was used to show the relationship between SED and independent variables WC/H ratio, WC, BMI, and age. A P-value less than 0.05 was considered statistically significant.


  Results Top


All the 60 women completed the study. The mean age in the median group was 38.0 (SD=8), whereas in the paramedian group, it was 35.8 (SD=5.3). The difference between the mean age in the two groups was not statistically significant (P = 0.214). The mean BMI ± SD in the median group was 31.4 ± 5.8 kg/m2, whereas in the paramedian group it was 29.3 ± 3.5 kg/m2. Also, the difference in both groups was found not to be statistically significant (P = 0.09). In the median group, 15 (50.0%) were pre-obese and in the paramedian group, 17 (56.9%) were pre-obese. The difference between the mean WC/H ratio in the median approach group (0.6 ± 0.1) and paramedian approach group (0.6 ± 0.0) was not statistically significant (P > 0.999) [Table 1].
Table 1: Demographic characteristics of subjects

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The mean SED in the median group was 5.1 ± 0.8 cm, whereas that of the paramedian group was 5.2 ± 0.5 cm (P > 0.05). Time of LOR in paramedian and median approaches was 23.8 ± 4.6 and 33.4 ± 11.2 s, respectively (P < 0.0001). Mean time of catheter insertion was 15.1 ± 1.6 s for Group M and 15.2 ± 2.7 s in the paramedian group (P = 0.906) [Table 2].
Table 2: Mean distance from skin to epidural space distance, time of LOR, and time of catheter insertion

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The relationship between the SED (cm) and WC (cm) in the median and the paramedian approaches showed that as the WC increased, so did the SED in both groups: F = 9.611, P = 0.0001 and F = 3.963, P = 0.007, respectively.

In both the median and paramedian groups, as BMI increased so did mean SED (P < 0.0001 vs. P < 0.0001), respectively. Mean SED was highest among the obese class III categories in each group (6.5 ± 0.3 vs. 6.8 ± 0.0 cm). Scatter diagram was used to show the relationship between BMI and SED in the paramedian and median approach [Figure 1] groups. In the PM approach group, there was a statistically significant positive linear relationship and a moderate-to-strong positive correlation between SED and BMI (R=0.683; P < 0.0001). Adjusted R2 (0.447) indicated that 44.7% of the variability in the SED in this relationship was as a result of the variation of BMI in the PM approach group. Whereas in the median approach group, there was a statistically significant positive linear relationship and a strong positive correlation between SED and BMI (R=0.908; P < 0.0001). Adjusted R2 (0.818) indicated that 81.8% of the variability in the SED in this relationship was as a result of the variation of BMI in the median approach group.
Figure 1: Scatter diagram showing the relationship between body mass index in the median approach category and skin to epidural space distance (SED)

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With respect to WC, there was a statistically significant association between WC/H ratio and SED in the median approach and PM approach (P < 0.0001), respectively. Coefficient of determination R2 0.586 and 0.373 indicates that 58.6% and 37.3% of the variance in the SED in the median and PM approaches, respectively, were as a result of the WC/H ratio. Also, there was a statistically significant positive correlation between WC/H ratio and SED in the median and PM approaches (0.775 and 0.628, P < 0.0001), respectively.

Furthermore, multivariate regression analysis was carried out to determine their predictability among other variables [Table 3]. The result showed that WC, WC/H ratio, and BMI were independent predictors of SED in the paramedian approach (P < 0.0001; 0.034; 0.049), respectively, and age was not an independent predictor (P = 0.065). In the median approach, WC, WC/H ratio, and BMI were also independent predictors of SED (P < 0.0001; <0.0001; <0.0001), respectively, and age was not (P = 0.879).
Table 3: Multivariate regression analysis between WC/H ratio, WC, BMI, and age on SED

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The successful identification of the epidural space in the median and PM approaches was documented in [Table 4]. The first attempt success in the PM approach was 93.3%, whereas first attempt success in the median approach was 80.0% (P = 0.138). The success rate was higher at the first attempt in the PM (24%) (P = 0.941). At the second attempt, success rate of the median approach was 16.7% as against 6.7% in the paramedian approach. The remaining participant 1 (3.3%) was successful at the third attempt in the median approach category.
Table 4: Ease of access to the epidural space

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  Discussion Top


From the current study, the mean distance from the skin to the epidural space was found to be longer in the paramedian group, although not statistically significant. Also, participants with similar body weight, BMI, and WC had longer distance from the skin to the epidural space in the PM group than in the M group. In a study by Gosai et al.,[7] they revealed a similar finding of longer mean distance from the skin to the epidural space for the paramedian approach 4.67 ± 0.9 cm (4.01 ± 0.5 cm for the midline approach). Also, Vaishali and Sufala[10] in a study among elderly patients showed a longer mean distance from the skin to the subarachnoid space by the paramedian approach. These are in keeping with the values obtained in our study.

Ilori and Djunda[11] in Calabar, Nigeria reported a mean distance for the midline approach of 5.29 ± 0.06 cm which is in keeping with the values obtained in our study. Adachi et al.,[12] in their retrospective study of elderly and obese patients in Japan, reported a mean distance of 4.1 ± 0.9 cm in the lumbar region. Cha et al.[13] similarly reported a mean distance of 4.6 ± 0.69 cm among Korean adults. These values are lower than those demonstrated in our study. The shorter SED could be due to racial difference among the studied population, suggesting that African women have more truncal fat distribution than their Asian counterparts. The difference in the values affirms the racial influence in the distance from the skin to the epidural space.[14]

This study also shows that the time taken to identify the epidural space was significantly shorter in the paramedian group than that in the median group. This finding is in agreement with the findings of Liyakath Raja et al.[15] They reported faster time to access the epidural space with LOR in the paramedian group. This finding is also in agreement with that reported by Aswathy Vijay and Radhika,[16] Blomberg et al.,[5] and Rabinowitz et al.[17] This may be because the paramedian approach in bypassing bony structures provides quicker access. However, Leeda et al.[18] and Mossafa et al.[19] could not affirm that the paramedian approach was superior to the median approach with regard to timing of success.

This study also demonstrated that the mean time taken to insert the epidural catheter was slightly shorter in the median group 15.1 ± 1.6 s than that in the paramedian group 15.2 ± 2.7 s. This finding is in contrast to that of previous studies. Leeda et al.[18] reported a significantly faster catheter insertion time in the paramedian approach than in the median approach (9.0 ± 5.1 vs. 18.2 ± 6.2 s). Liyakath Raja et al.[15] also found that catheter insertion was significantly faster and easier using the paramedian epidural technique. Similarly, Gosai et al.,[7] Blomberg et al.,[5] and Jaucot[20] had similar observations. The observed difference may be due to racial factors.

The current study also showed higher first attempt success rate in the paramedian group than in the median group. Ahsan-ul-Haq et al.[21] demonstrated success rate of 100% in the paramedian approach with first attempt when compared with success rate of 60% in the median approach. This is similar to the findings by Rabinowitz et al.[17] and Singh et al.[22] Mericq et al.[23] asserted that the paramedian approach had a success rate of 100% in elderly patients with spinal deformity when compared with 96.7% in the median approach. Griffin[24] reported more second attempts at epidural block in the median than in the PM approach. Out of the 165 patients recruited for the study, he reported 21 failures that required a second attempt (median 12 vs. paramedian 9). Several other studies had documented higher success rates at first attempt using the paramedian approach.[7],[16],[17] Liyakath Raja et al.[15] had results that differed from what was obtained in this study. They reported that the first attempt success rate was 60% for the paramedian approach and 84% for the median approach, with a second attempt of 98% for the PM approach and 100% for the median approach.

In addition, this study also demonstrated that as the BMI increased, SED also increased and was strongly positively correlated in both the median and PM approaches. This finding was comparable to that reported by Ilori and Djunda.[11] Adegboye et al.[2] also demonstrated a positive correlation between the SED and BMI (r = 0.30, P = 0.001). Kim et al.[25] in their study found that BMI was the biggest factor affecting depth of the epidural space. This finding was comparable to that reported by Chauhan et al.[26] They reported that the difference in SED in both groups was significant and positively correlated with the body weight and the BMI. Similarly, Brummett et al.[27] in a prospective observational study of 88 patients found a positive correlation between the depth of the epidural space and BMI (r = 1.13, P < 0.001). So et al.,[28] Eley et al.,[29] Clinkscale et al.,[9] and Komaljit et al.[30] have demonstrated a positive correlation between SED and BMI. This association between SED and BMI bears potentially significant patient impact as it allows the attending anesthetist to anticipate a longer SED and a possible difficulty in the epidural technique.

This study also demonstrated that as the body weight increased, so did the WC and SED. It was observed that as the WC increased, SED increased in both the groups. Also, we found that the SED was longer in the paramedian approach in participants with the same WC than that in the median approach. Participants with greater WC but of shorter heights had longer SED than those with similar heights but smaller WC. This result was similar in both the groups, although the SED was slightly longer in the paramedian group. Razavizadeh et al.[31] in their study on the relationship between patients’ anthropometric characteristics and the depth of the spinal needle insertion also demonstrated a significant correlation between the WC and depth from the skin to the subarachnoid space. Yoon et al.[32] in a study on correlation between epidural depth and physical measurement noted that epidural depth correlated positively with weight, WC, BMI, waist/height, and weight/height ratios. From their result findings, there was a significant correlation between WC/height ratio. Ilori and Djunda,[11] Adegboye et al.,[2] Kim et al.,[25] and Chauhan et al.[26] also reported similar findings.

In our study, height showed a negative correlation with SED. Komaljit et al.[30] noted that the mean depth of epidural space varied from 45.96 ± 8.22 to 48.90 ± 10.29 mm in both the median and paramedian groups with an increase in height from 141 to 180 cm. This finding is in disagreement with that of Adegboye et al.,[2] whose study also showed a similar finding to this study.


  Conclusion Top


From this study, the mean distance from the skin to the epidural space was longer in the paramedian group. This would serve as a guide to the anesthetist on how far to safely advance the epidural needle. Furthermore, the time taken to identify the epidural space was significantly faster in the paramedian, group whereas catheter insertion was faster in the median group.

The study also demonstrated that as the BMI, WC, and WC:HT ratio have positive correlation with SED in both the median and paramedian approaches.

Acknowledgement

We owe a debt of gratitude to our research assistants.

Authors’ contribution

Concept: JOA

Literature search: JOA

Manuscript drafting/revision: JOA, AOA, VOA, TCO

Final approval: JOA, AOA, VOA

This original article is the edited version of the Part 2 dissertation submitted to the National Postgraduate Medical College, Nigeria. This manuscript has been read and approved by all the authors. The requirements for authorship have been met by the authors and the manuscript represents honest work by the authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Clinkscale CP, Greenfield ML, Verance M, Polley LS An observational study of the relationship between lumbar epidural space depth and the body mass index in Michigan parturients. Int J Obstet Anaesth 2007;16:323-7.  Back to cited text no. 9
    
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Ilori IU, Djunda EK Influence of physical characteristics on skin to lumbar epidural space distance in Nigerian adults. Br J Med Medical Res 2016;17:1-6.  Back to cited text no. 11
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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