Neuraxial anesthesia is a vital component of anesthesiology, providing regional anesthesia for diverse surgical procedures. Anesthesiologists recognize its pivotal role in relieving pain and discomfort; however, it presents administration challenges when utilized for patients with complex anatomies like obesity, scoliosis, or prior spinal surgery.

More than 3.5 million neuraxial anesthesia procedures are performed annually in the U.S., primarily in the labor and delivery department. Astonishingly, studies reveal that the optimal site for needle placement is accurately identified in as little as 14% of patients. With needle placement failure rates ranging from 20% to 80%, largely based on clinician skill, patient BMI, and age, complications such as repeated attempts, long-term pain, and — rarely — even paralysis are significant concerns.

Failure rates not only lead to increased healthcare costs, but also highlight the need for improved neuraxial and epidural anesthesia techniques. While ultrasound visualization is the key driver of more effective neuraxial anesthesia delivery, practical implementation issues hinder its widespread use. Consequently, many anesthesia providers continue to administer neuraxial anesthesia relying solely on spinal palpation to determine the injection site.

Technological advancements are emerging to address these limitations. By combining automated image guidance with enhanced bone imaging, these innovations offer promising solutions to enhance both patient safety and clinical efficiency.

This article provides an insightful overview of neuraxial imaging, explores the use of image guidance to improve needle placement in neuraxial anesthesia, and discusses how clinically validated technology helps optimize ultrasound guidance. These advancements are setting a new standard of care in neuraxial anesthesia placement, benefiting patients and healthcare providers alike.

Woman receiving lumbar epidural placement

The factors of epidural failure in neuraxial anesthesia

Neuraxial anesthesia is the preferred pain control method for labor and delivery because it enables active maternal participation. But as with any anesthesia, anesthesiologists must share the associated risks with patients prior to its administration — including potential long-term symptoms and serious consequences — which often leads to heightened patient anxiety.

As studies reveal, accurate identification of the appropriate intervertebral level through palpation occurs in only 14%-64% of cases, influenced by factors such as patient anatomy, provider skill, and experience. Patients with above-normal BMI face a significantly higher risk of epidural failure, as obese individuals often have less apparent spinal bony structures, resulting in first-attempt success rates as low as 50%. Patients with atypical spinal conditions like scoliosis or prior spinal surgeries are also at considerable risk for epidural anesthesia failure, and needle placement challenges are further compounded by age-related changes in the spine, including a higher prevalence of scoliosis and stenosis.

Misplacement of needles during anesthesia delivery compromises patient safety, resulting in issues such as prolonged backaches from needle trauma, ongoing “spinal headaches” caused by severe cerebrospinal leakage, and problematic cephalad spread of anesthetic. In rare instances, spinal hematomas can even lead to paralysis. Further, these challenges lead to additional adverse outcomes, such as prolonged procedures, multiple needle passes and redirects, patient dissatisfaction, and increased costs.

Anesthesiologists strive to navigate these anatomical complexities to provide safe and effective neuraxial anesthesia, and by incorporating advanced imaging technologies and techniques, such as ultrasound guidance, anesthesiologists can increase the opportunity to overcome these challenges, thereby improving patient experiences and outcomes.

ultrasound guidance imaging device

Ultrasound guided needle placement: Enhancing neuraxial guidance in challenging patient anatomy

Neuraxial ultrasound has emerged as a proven technology in the field of anesthesiology, providing anesthesiologists with a precise and reliable tool to navigate complex patient anatomies during neuraxial blockade procedures. Anesthesiologists are keenly aware of the transformative impact of ultrasound guidance on the accuracy, efficacy, success, and ease of performing neuraxial analgesic procedures.

Extensive clinical trials and numerous studies have unequivocally demonstrated the value of neuraxial ultrasound. Notably, it outperforms palpation in accurately identifying the appropriate intervertebral space for epidural administration and serves as a reliable predictor of needle insertion depth to the epidural space, reducing the number of attempts required for a successful procedure.

In the field of anesthesia, ultrasound guidance is progressively replacing palpation as the gold standard for central venous access, peripheral nerve blockades, and other needle guidance procedures. Technological advancements have significantly enhanced the precision of ultrasound guidance, driving this paradigm shift.

Despite the clear benefits of ultrasound guidance for neuraxial anesthesia placement, several challenges have hindered its widespread adoption:

  • Steep ultrasound learning curve. Anesthesiology providers require significant training to acquire and interpret ultrasound images, which may not align with their background. Studies show that learning curves for the modality are significant and that cost and scheduling constraints make utilizing trained sonographers or radiologists for anesthesiology procedures a challenge.
  • Bony anatomy. Ultrasound’s limitations in imaging bone structures and the complex physical properties of bone pose challenges for identifying specific landmarks. Interpretation of ultrasound images must account for these complexities.
  • Accessibility. Bedside availability of ultrasound is limited, particularly in labor and delivery settings. Standard ultrasound consoles are difficult to maneuver in cramped locations, while portable scanners optimized for soft-tissue imaging may not fully meet the requirements for neuraxial ultrasound.

Nevertheless, mounting clinical evidence underscores the numerous advantages of ultrasound guidance, and the emergence of spine-specific technologies designed to address existing barriers is paving the way for more accessible and comprehensive implementation. As a result, the neuraxial guidance landscape is evolving, offering a clear path toward enhanced patient care and improved outcomes, including:

Accuro Epidural Needle Placement Guidance Device

Reducing epidural failure rates with ultrasound-based guided needle placement

Accuro is the preeminent FDA-approved ultrasound-based system designed exclusively for neuraxial guidance. It combines automated 3D image spinal navigation with advanced image reconstruction, specifically optimized for bony anatomy. With its flexible, handheld form factor, the Accuro system offers anesthesia providers exceptional ease of use and convenience during neuraxial anesthesia procedures.

Accuro delivers:

  • A reduced learning curve. With Accuro, providers with minimal ultrasound experience benefit from effective image guidance. The system relies on automated 3D navigation of the lumbar spine to identify relevant landmarks. Based on these landmarks, it computes, visualizes, and pinpoints the optimal needle insertion point and other relevant data. Its algorithms use proven image-processing techniques, including pattern recognition and image segmentation.

    Academic medical centers and teaching hospitals can easily integrate the Accuro image-guided neuraxial technique into their curriculum through the Teach-Accuro program, allowing students to acquire the essential skills needed to perform neuraxial procedures using ultrasound in a task-based approach, which results in the prompt generation of actionable information.   

    The Accuro solution is also supported by a suite of TRUE-VIEW™ training models — optically transparent, acoustically realistic tissue-mimicking material constructed into a true-to-form spinal canal, enabling clinicians to practice landmark identification and see clearly how Accuro’s navigation correlates with the spine. These modules serve as an effective means of integrating neuraxial ultrasound into teaching procedural neuraxial anesthesia without compromising the quality of the core skills each resident must acquire.

    Take advantage of a free evaluation and trail to see first-hand how this clinically validated solution for epidural and spinal anesthesia guidance helps improve first-attempt success, especially in challenging patient populations, enhancing patient experiences and outcomes.
  • Enhanced spinal anatomy image reconstruction. Supporting the automated navigation is an innovative image reconstruction technology which compensates for ultrasound’s distortion of bony structures — providing a significant increase in bone-to-tissue contrast as compared to conventional ultrasound technology. This data is presented to the user as an enhanced, easy-to-understand image, further guiding clinical decision-making.

Using a preprocedural scouting approach, Accuro is gently guided along the patient’s spine to identify key markers, including the midline and interlaminar space at the desired vertebral level. These crucial landmarks, along with calculated depths to the spinous process and epidural space, are displayed as overlays in real time on the device’s screen. Anesthesia providers can then mark these precise locations, enabling accurate and guided neuraxial anesthesia placement. Mounting evidence supports Accuro’s significant improvement in first-attempt success rates and the needle insertion process, as compared to traditional palpation-based methods.

Accuro’s effectiveness and user-friendly design have earned the trust of over 200 healthcare practices in the U.S. alone. The increasing product adoption facilitates an image-driven standard of care in neuraxial anesthesia, provides easier access to image-guided approaches for needle insertion, and fosters the development of similar technologies to enhance placement techniques.

Accuro ultrasound guided neuraxial anesthesia placement device being used

Proven clinical benefits of Accuro for neuraxial epidural needle guidance­­

Ongoing clinical trials and research consistently demonstrate the efficacy of Accuro as compared to traditional palpation-based methodology, including:

  • Improved first-attempt success rates and needle passes
  • Enhanced patient satisfaction
  • Reduced needle insertion, identification time, and complications
  • Increased automated measurement accuracy

Accuro’s superior performance benefits not only experienced providers but also trainees and novice users, with clinical evidence firmly establishing Accuro as an effective and easily accessible tool that facilitates improved patient outcomes.

Expanding neuraxial anesthesia access to rural hospitals and clinics

One of the greatest advantages of Accuro is its broadening of access to neuraxial anesthesia, particularly to rural hospitals and clinics lacking the resources or budget for extensive medical equipment. In these settings, where access to specialized medical equipment is often limited, healthcare practitioners face significant challenges in delivering procedures like neuraxial anesthesia — and their patients with obesity or scoliosis, who require tailored anesthesia solutions, may find their options more limited or riskier.

Accuro’s precision and accuracy can help revolutionize the community health and critical access hospital landscape by offering a cost-effective solution, providing rural healthcare practitioners greater opportunity to offer their communities a viable and safe neuraxial anesthesia option.

Compact and portable, Accuro is an ideal solution for rural providers with space constraints and limited resources. Unlike large, cumbersome ultrasound machines, Accuro is a small, affordable solution that can be easily transported and utilized in various clinical settings, increasing accessibility and enabling healthcare practitioners in remote areas to provide accurate needle placement to their patients without requiring an extensive infrastructure or financial investment.

By expanding access to neuraxial anesthesia, Accuro empowers healthcare practitioners in underserved areas to provide optimal pain relief and anesthesia to a broader patient population, improving patient outcomes and enhancing the overall quality of care rendered.

Navigate challenging patient anatomies with greater precision and ease

Ultrasound technology, including the Accuro system, has proven invaluable in addressing complex patient anatomy challenges in neuraxial anesthesia. As studies consistently demonstrate, ultrasound-guided procedures lead to improved success rates, reduced complications, and enhanced patient experiences.

Accuro takes it one step further: The system’s transformative potential extends beyond just accuracy — promoting patient well-being and satisfaction — especially for those with limited options or increased risks due to challenging anatomical characteristics.

By incorporating ultrasound guidance in neuraxial anesthesia administration, anesthesiologists can now navigate challenging patient anatomies with precision and ease, achieving improved outcomes and procedural efficiency. Accuro is a trusted and clinically proven innovation that enhances patient safety, expands access to neuraxial anesthesia, and advances the standard of care in anesthesiology.

To learn more about how Accuro neuraxial guidance makes epidurals faster, easier, and safer — especially in patients with complex anatomies — contact RIVANNA today. Use Teach-Accuro® to reliably train students and residents with clinically proven technology.