The lumbar epidural space in pregnancy: visualization by ultrasonography

Epidural anaesthesia is an important analgesia technique for obstetric deli very. During pregnancy, however, obesity and oedema frequently obscure anat omical landmarks. Using ultrasonography, we investigated the influence of t hese changes on spinal and epidural anatomy. We examined 53 pregnant women who were to receive epidural block for vaginal delivery or Caesarean sectio n. The first ultrasound imaging was performed immediately before epidural p uncture; the follow-up scan was done 9 months later. The ultrasound scan of the spinal column was performed at the L3/4 interspace in transverse and l ongitudinal planes, using a Sonoace 6000 ultrasonograph (Kretz (R), Marl, G ermany) equipped with a 5.0-MHz curved array probe. We measured two distanc es from the skin to the epidural space: the minimum (perpendicular) and the maximum (oblique) needle trajectory. The quality of ultrasonic depiction w as analysed by a numerical scoring system. An average weight reduction of 1 2.5 kg had occurred by the follow-up examination. During pregnancy, the opt imum puncture site available on the skin for epidural space cannulation was smaller, the soft-tissue channel between the spinal processes was narrower , and the skin-epidural space distance was greater. The epidural space was narrower and deformed by the tissue changes. The visibility of the ligament um flavum, of the dura mater and of the epidural space decreased significan tly during pregnancy. Nevertheless, ultrasonography offered useful pre-punc ture information. Thus far, palpation has been the only available technique to facilitate epidural puncture. Ultrasound imaging enabled us to assess t he structures to be perforated. We anticipate that this technique will beco me valuable clinically.