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Canadian Journal of Anesthesia 51:277-278 (2004)
© Canadian Anesthesiologists' Society, 2004

Correspondence

Ultrasound imaging in pediatric regional anesthesia

Hans-Jürgen Rapp, MD and Thomas Grau, MD

Heidelberg, Germany

To the Editor:

Real-time ultrasound (US) imaging can facilitate the performance of both peripheral or plexus blocks and neuraxial blocks1 in adults. Although US has been used as a screening tool for spinal anomalies in children,2 it has not been investigated in pediatric regional anesthesia.

Pediatric patients require sedation or anesthesia for regional blocks.3 This makes regional anesthesia more challenging and increases the risk.4

After approval of the local Ethics Committee and written informed consent, we evaluated US in infants. The US images were acquired under general anesthesia. We present the example of a six-month-old child scheduled for surgical reconstruction of anal atresia; the colostomy had been performed at ten days of age. For intra- and postoperative pain relief caudal block was used first and an epidural catheter was placed for the second procedure using US imaging.

A Logic 400 CL US machine (General Electric, Solingen, Germany) with a linear 7.5 MHz US probe was used. With the patient in a right lateral decubitus position US scanning was performed in longitudinal and transverse planes at sacral (S2), lumbar (L3–4), and thoracic (T6–7) levels at the age of one week and six months.

The intraspinal and extraspinal anatomy can be recognized easily (FigureGo). US imaging enables an exact representation of the epidural space and of the intrathecal structures, the dural sac and the cauda equina, with a high resolution. The nerve roots of the cauda equina are seen as a hyperechogenic signals and the longitudinal nerve roots are displayed as single fibres. The dura mater is defined by a typical double-layer hyperechogenic signal. Imaging at six months clearly demonstrates the cephalad regression of the dural sac. Increased calcification of the vertebral column causes a reduction of the available acoustic window.



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  		FIGURE Lumbar and sacral areas imaged at one week and six months.

 
The quality of real-time images via an acoustic window through the skeletal framework shows that US is useful for imaging neuraxial structures relevant to pediatric neuraxial anesthesia. The exact depth to the dura mater can be predetermined before needle advancement.5 Screening for congenital anatomical variations is possible and structures identified through this acoustic window enhance efficacy and safety. The quality of the images acquired in infants are superior to those in adults, possibly because of the smaller depth and poorly ossified structures. The use of real-time imaging can facilitate needle and catheter placement.

In conclusion, US imaging can make pediatric regional anesthesia easier and more secure. Important anatomical details relevant to neuraxial anesthesia can be visualized. In addition, it is a useful tool for teaching the principles of pediatric neuraxial regional anesthesia.

References

1 Peterson MK, Millar FA, Sheppard DG. Ultrasound-guided nerve blocks. Br J Anaesth 2002; 88: 621–4.[Free Full Text]

2 Dick EA, Patel K, Owens CM, De Bruyn R. Spinal ultrasound in infants. Br J Radiol 2002; 75: 384–92.[Abstract/Free Full Text]

3 Coley BD, Shiels WE 2nd, Hogan MJ. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture. Prediatr Radiol 2001; 31: 399–402.

4 Rose JB. Spinal cord injury in a child after single-shot epidural anesthesia. Anesth Analg 2003; 96: 3–6.[Free Full Text]

5 Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in obstetric epidural anesthesia. J Clin Anesth 2002; 14: 169–75.[Medline]




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