The physiology of morbidly obese patients presents unique challenges when it comes to adapting medical procedures — including those that require anesthetization. Achieving successful neuraxial anesthesia can be particularly daunting due to impalpable landmarks and limited anatomical reference points. This case study presents a remarkable success story, showcasing how RIVANNA’s Accuro Neuraxial Guidance technology enabled the rapid placement of a neuraxial block in a morbidly obese parturient.

For this patient, faced with a history of failed epidurals and the imminent need for a cesarean delivery, Accuro played a pivotal role in identifying spinal midline and intervertebral spaces, facilitating the administration of a combination spinal-epidural (CSE) anesthetic with unparalleled precision. Accuro’s Neuraxial Guidance technology not only expedited the procedure; it also contributed to improved patient satisfaction, reduced complications, and the avoidance of general anesthesia.

This case study underscores the potential of Accuro Neuraxial Guidance technology to upgrade anesthesia practices, elevate patient outcomes, and maximize resources.


Neuraxial anesthesia administration in morbidly obese patients presents a heightened risk of procedural difficulty. The subject of this case study exhibited a body mass index (BMI) of 52, which is clinically recognized as morbidly obese. During labor, she received two consecutive epidurals from experienced anesthesia providers practicing the traditional pre-procedural palpation techniques. Neither epidural provided adequate bilateral pain control, and both required multiple attempts. Due to inadequate labor progression, a cesarean delivery was planned.

A preoperative assessment confirmed that both epidural attempts had failed and a third anesthetic would be required. Under normal circumstances, this patient was at high risk of receiving general anesthesia due to an inability to place a successful neuraxial block. Faced with concerns about a third failure and limited time to administer the neuraxial block, the attending anesthetist turned to Accuro to verify the ideal placement for the third epidural.

“Accuro is a practical, reliable, and easy-to-use tool that facilitates administration of neuraxial anesthesia — particularly in challenging cases,” says Beth Ann Clayton, DNP, MS, CRNA Assistant Professor of Clinical Nursing Program Director-Nurse Anesthesia Major University of Cincinnati, College of Nursing.


Using Accuro and relying on SpineNav3D technology to properly image the patient’s physiology, the anesthetist was able to take a visually informed approach to place the third epidural. Accuro facilitated rapid identification of spinal midline and detection of the intervertebral space in a morbidly obese patient with impalpable landmarks. The information provided by Accuro was not obtainable with palpation alone, as evidenced by the two prior failed epidural placements from providers who did not utilize image guidance.

“I’ve used Accuro numerous times on very high-BMI patients — greater than 60 or 70 — and it always minimizes attempts,” says Dr. Clayton. “On those patients, you don’t even know where to begin if you didn’t use something, because you can’t palpate anything on someone that large. A lot of the times, using Accuro, we were successful on the first attempt.”

With Accuro, the neuraxial block was placed quickly and successfully. The procedure was accomplished with less than two minutes of scanning, and the anesthetist was able to place a working CSE anesthetic after only one minor needle redirect. Total placement time took less than five minutes, and the CSE was verified to take effect as intended.

Accurate neuraxial placement avoided the use of general anesthesia and mitigated the potential for complications during labor and delivery. Moreover, the ability to administer neuraxial anesthesia with fewer needle insertions resulted in higher patient satisfaction.

Key takeaways

Traditional methods of placing a neuraxial block are too reliant on palpation alone and frequently lead to failed attempts, prolonged procedures, and an increased likelihood of resorting to general anesthesia.

Providers may consider the benefits of utilizing Accuro to improve patient and provider satisfaction, reduce costs for operating room time and anesthesia equipment, minimize patient complications, avoid general anesthesia, and improve speed-to-care.

To learn more about RIVANNA’s Accuro Neuraxial Guidance technology, please visit