Rev Esp Anestesiol Reanim.

2017;64(8):460---466

Revista Española de Anestesiología

y Reanimación
www.elsevier.es/redar

REVIEW

Modern approach to an old technique: Narrative

revision of techniques used to locate the epidural
space夽,夽夽
N. Brogly ∗ , E. Guasch Arévalo, A. Kollmann Camaiora, E. Alsina Marcos,
C. García García, F. Gilsanz Rodríguez

Departamento de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain

Received 11 September 2016; accepted 23 November 2016

KEYWORDS Abstract Since the first description of the epidural technique during the 1920s, the continuous
Location; progress of knowledge of the anatomy and physiology of the epidural space has allowed the
Epidural space; development of different techniques to locate this space while increasing both the safety and
New techniques efficacy of the procedure. The most common techniques used today are based on the two main
characteristics of the epidural space: the difference in distensibility between the ligamentum
flavum and the epidural space, and the existence of negative pressure within the epidural space.
However, over recent years, technological advances have allowed the development of new
techniques to locate the epidural space based on other physical properties of tissues. Some
are still in the experimental phase, but others, like ultrasound-location have reached a clinical
phase and are being used increasingly in daily practice.
© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Published
by Elsevier España, S.L.U. All rights reserved.

夽 Please cite this article as: Brogly N, Guasch Arévalo E, Kollmann Camaiora A, Alsina Marcos E, García García C, Gilsanz Rodríguez F.

Visión moderna sobre una técnica antigua: revisión narrativa de técnicas de localización del espacio epidural. Rev Esp Anestesiol Reanim.
2017;64:460---466.
夽夽 This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on

this article can be made through the Internet by accessing the Education Section of the following web page: www.elsevier.es/redar
∗ Corresponding author.

E-mail address: nicolas0brogly@hotmail.com (N. Brogly).

2341-1929/© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U. All rights
reserved.
Narrative revision of techniques used to locate the epidural space 461

PALABRAS CLAVE Visión moderna sobre una técnica antigua: revisión narrativa de técnicas
Localización; de localización del espacio epidural
Espacio epidural;
Resumen Desde la primera descripción de la técnica epidural en los años 1920, el progreso
Nuevas técnicas
continuo en el conocimiento de la anatomía y de la fisiología del espacio epidural ha permitido
desarrollar diferentes técnicas de localización de este espacio para aumentar tanto la seguridad
como la eficacia del procedimiento. Las técnicas más utilizadas hoy en día se basan en las 2
principales propiedades descritas del espacio epidural: la diferencia de distensibilidad entre el
ligamento amarillo y el espacio epidural y la existencia de una presión negativa en el espacio
epidural. Sin embargo, en los últimos años, la evolución tecnológica ha permitido desarrollar
nuevas técnicas de localización basadas en otras propiedades físicas de los tejidos. Algunas de
ellas están todavía en una fase experimental, pero otras como las técnicas con ultrasonidos han
alcanzado una fase clínica y se está expandiendo su uso en la práctica diaria.
© 2017 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Publicado
por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction Traditional techniques for locating the

The first description of a method for localizing the lumbar
epidural space using the difference in distensibility between
the yellow ligament and the epidural space was published by
Fidel Pagés in 1921. In this study, Pagés described how the
physician performing the technique would feel the needle
‘‘release’’ as soon as it entered the epidural space.1,2 The
technique was soon modified by Sicard and Forestier,3 who
were the first to attach a syringe with fluid to the needle and
exert continuous pressure on the plunger while the needle
advanced through the ligaments, until ‘‘the injection [. . .],
which was difficult, becomes as easy as if the needle were in
the subarachnoid space’’. Following this, the hanging drop
technique was described.4
At the lumbar level, loss of resistance techniques are cur-
rently the most widely used to locate the epidural space,
while at the thoracic and cervical level the hanging drop
technique is preferred. Residents learning this technique
must be constantly supervised due to the technical diffi-
culty involved. In fact, studies have shown that the learning
curve varies greatly among anaesthesiologists undergoing
their training in obstetric anaesthesia.5
In recent years, in parallel with manual of loss of
resistance techniques, new devices have been marketed
to help anaesthesiologists identify the epidural space
using visual or auditory indicators based on the differ-
ent physical properties of the epidural space. In this
narrative review, we will describe these different tech-
niques. The literature search was performed using PubMed,
and the most significant publications were identified using
the following search criteria in both English and Span-
ish: localization, epidural space, techniques, and labour
analgesia.
epidural space
Manual techniques
The first 3 techniques that were described in the 1930s are
today still the most widely used in practice due to their
simplicity and effectiveness.
Hanging drop technique. This was first described by
Gutierrez4 in 1930 and is still used today. It consists of
depositing a drop of saline solution on the tip of the nee-
dle. Once placed in the interspinous ligament, the needle
is advanced using both hands while visually monitoring the
drop. As soon as the needle enters the epidural space,
the anaesthesiologist feels it ‘‘release’’ and observes that
the drop of saline is aspirated by the needle. In the sit-
ting position, the negative pressure is highest at the dorsal
level, whereas at the lumbar level it disappears, espe-
cially in patients with hyperflexion and compression of the
abdominal contents. This is why identification of the lum-
bar epidural space is more difficult with this technique.2
In addition, the reliability of this method is limited by the
‘‘false hanging drop’’ phenomenon, described in approxi-
mately 2% of cases. In this case, the drop is aspirated due to
muscle movement during respiration, rotation of the spine,
or passage of the needle along the fascial planes, causing
the anaesthesiologist to mistakenly identify these struc-
tures as the epidural space. The needle may also become
obstructed, thus preventing identification of the epidural
space and increasing the risk of accidental dural puncture.6
Loss of resistance to fluid technique. The loss of resis-
tance to fluid technique has gained popularity in recent
years because it is believed to be safer than the air tech-
nique. However, the scientific evidence is not yet strong
462
enough to establish definitive conclusions.7 Because liq-
uid is incompressible, the sensation of loss of resistance
has been described by Bromage as ‘‘clear, unequivocal,
immediate and convincing as soon as the needle enters
the epidural space’’, making it, theoretically, the ideal
technique.2 Currently, distilled water and local anaesthet-
ics (LA) are contraindicated because of the neurotoxicity
and pain caused by the first when injected into the epidural
space,8 as well as the risk of high block or systemic toxicity
in the case of accidental dural or haematic puncture when
LA is used.9 At present, saline solution is usually used to
locate the epidural space in the loss of resistance to fluid
technique.10
Loss of resistance to gas technique. This technique is
based on the observation that while the needle is in the
yellow ligament, considerable force can be exerted on the
plunger without expelling air from the syringe. Once the
needle enters the epidural space, there is a loss of resistance
in the plunger and air can be injected into the space.2 The
epidural space can usually be located using no more than
3 ml of air.11 The use of CO2 12 and nitrous oxide have also
been studied, due to their greater diffusion capacity in tis-
sue. This would reduce the size of the bubbles in both the
epidural space and the vessels in case of vascular resorption,
thus maximizing the efficacy of the technique and reduc-
ing the risk of complications such as emphysema, spinal
compression or air injection in the retroperitoneum. How-
ever, the difficulty in preparing syringes with these gases has
limited their use in routine practice, and anaesthesiologists
who continue to use the loss of resistance to gas technique
use only air.
Loss of resistance to saline combined with air. Some
authors recommend mixing air with saline in the low resis-
tance syringe to locate the epidural space. To optimize the
effectiveness of this technique and to improve the safety
of the device, a dual chamber needle has been designed to
separate the air from the saline.13 In this way, loss of resis-
tance is felt when the saline is injected into the epidural
space, while the air bubble constitutes a additional visual
aid, being compressed when the needle is still in the yellow
ligament, and returning to its original size when it enters
the epidural space.9
Instrumental techniques
A number of instruments have been developed to help the
anaesthesiologist identify the epidural space, although they
are rarely used in clinical practice for different reasons.
- Visual devices. Odom’s indicator2 is a capillary tube con-
taining a bubble of air that fits over the hub of the needle.
Pressure changes inside the needle are shown by the move-
ment of this bubble, making it possible to detect the
negative pressure present in the epidural space. However,
the device is fragile and wasteful, and these factors sig-
nificantly diminish its reliability and have limited its use
in mainstream practice.
- Auditory devices. The pressure difference has also been
used to design devices that emit an auditory signal when
the needle enters the epidural space, using, for example,
N. Brogly et al.
®
Figure 1 Episensor . Source: author’s image bank.
sound amplifiers connected to a stethoscope that repro-
duce a sound resembling a ‘‘bursting bubble’’.14
- Devices with electronic pressure sensors. De Andrés
®
et al.15 described the use of the Episensor (Palex SA,
Barcelona, Spain), invented by Espejo Martínez et al.16
This device has a negative pressure sensor sensitive to
variations of −1.5 cm H2 O that is connected by an exten-
sion cord to the Tuohy needle. The negative pressure
in the epidural space triggers a visual and acoustic sig-
nal that warns the anaesthesiologist that the target has
been reached (Fig. 1). Compared with loss of resistance
®
to saline,15 the Episensor required a greater number
of attempts and was associated with a higher incidence
of accidental punctures, although no differences were
observed in the quality of analgesia. A subsequent study
by the same group reported fewer complications with
®
the Episensor , but no statistically significant differences
were observed.17 The further development and use of this
technique has been limited by the inconclusive findings of
studies analysing its performance.
- The infusion drip technique. Baraka18 described this tech-
nique of identifying the epidural space using a simple
device that included a saline infusion set connected to the
hub of the needle (video 1 of the supplementary material
available in the online version). With the Tuohy nee-
dle in the intervertebral ligament, the drip is connected
to observe the gravity infusion of the saline solution.
When the needle enters the epidural space, the resis-
tance decreases significantly and the rate of flow in the
drip chamber accelerates as the saline is infused into the
epidural space. Although this system is easy to use and
locates the target quicker than the loss of resistance to
saline technique, with comparable analgesic quality,19 it
has never gained popularity and is rarely used in normal
practice.
- Balloon techniques. These systems identify the epidural
space by means of a rubber balloon inflated with air (Mac-
intosh balloon, Zalenka balloon)2 or physiological serum
(Agosti balloon)20 and connected to the Tuohy needle once
it is inserted in the intervertebral ligament (Fig. 2). When
Narrative revision of techniques used to locate the epidural space
Figure 2 Macintosh balloon technique. Source: author’s image bank.
the needle enters the epidural space, the loss of resistance
causes the balloon to deflate. These techniques have his-
torical importance, but are rarely used today. Air-inflated
balloons have been shown to be inferior to manual loss of
resistance techniques in terms of analgesia efficacy.9 In
contrast, saline-filled balloons showed no statistically sig-
nificant differences in the quality of the analgesic block.19
Techniques based on new technologies
Epidural pressure waveform monitoring
In 2001, Ghia et al.21 discovered a pulsatile pressure wave
when they connected pressure transducers to a normofunc-
tioning epidural catheter. De Medicis et al.22 confirmed
the excellent reliability of this technique in confirming the
correct placement of the epidural catheter, observing a
sensitivity of 81%, a specificity of 100%, a positive predic-
tive value of 100% and a negative predictive value of 17%.
Lennox et al.23 described a sensitivity of 97.5% and a speci-
ficity of 100% in thoracic epidurals when the transducer
was connected to the Tuohy needle. Sensitivity was 65.4%
and specificity was 88.9% when the measurement was per-
formed using the epidural catheter. Recently, Gong et al.24
monitored the epidural pressure waveform during Tuohy
needle progression, observing that when the needle passed
through the yellow ligament and entered the epidural space
the pressure dropped abruptly and the pressure waveform
synchronized with the arterial pulse (video 2 of the sup-
plementary material available in the online version). Using
this technique, they achieved better sensitivity and speci-
ficity than the saline loss of resistance technique, increased
patient satisfaction, and a reduced failure rate and need for
repuncture.
Techniques using other visual indicators
The EpisureTM AutodetectTM (Indigo-Orb, Irvine, California,
USA) system is a low resistance syringe loaded with saline
and with an internal compression spring that applies
constant pressure on the plunger. The anaesthesiologist
connects this syringe to the Tuohy needle placed in the
yellow ligament, and progresses the needle by monitoring
the plunger, which retracts only when it enters the epidu-
®
ral space. The Epidrum system (Exmoor Innovations Ltd.,
Taunton, UK) (Fig. 3) comprises a plastic drum with an
463
elastic silicone diaphragm that is interposed between the
syringe and the Tuohy needle. When the Tuohy needle
is inside the ligament, the device is connected and air
is injected under low pressure to inflate the silicone
diaphragm. The sudden collapse of the diaphragm signals
the needle’s penetration into the epidural space, provid-
ing visual confirmation that the target has been reached.
Deighan et al.25 described more complications with the
®
Epidrum than with the low resistance syringe, with no dif-
ferences in analgesia efficacy, whereas Kim et al.26 showed
the system to be safer and faster than the low resistance
syringe, and with better analgesic results. These results
need to be confirmed due to the small sample size of the
studies, which had insufficient statistical power to evaluate
uncommon serious complications.
Ultrasound-guided techniques
With the introduction of ultrasound-guided techniques,
anaesthesiologists can now obtain anatomical images of the
spinal cord to guide them both before and during the admin-
istration of epidural anaesthesia. This has improved the
efficacy, accuracy, precision, reliability and safety of this
technique.27,28
Cork et al.29 were the first to describe the use of ultra-
sound in neuroaxial anaesthesia in 1980. They performed a
study in 36 patients in which they measured the distance
between the skin and the epidural space at the lumbar level
and compared this distance with that found using the loss of
resistance technique once the needle had entered the epidu-
ral space. The excellent correlation (r = 0.98; p < 0.001)
®
Figure 3 Epidrum system. Source: Kim et al.26
464
between this and the control technique formed the basis
for the development of ultrasound-guided obstetric anaes-
thesia.
Thanks to technological improvements, Grau et al.30 and
Arzola et al.31 were able to identify the yellow ligament
and confirm the reliability of the ultrasound-based measure-
ment of the epidural space-skin distance in parturients, even
though ultrasound landmarks are more difficult to identify
in this group than in non-pregnant patients.30 In obstetric
patients, the location of the epidural space prior to punc-
ture reduces the number of attempts needed, the number
of intervertebral spaces punctured in combined epidural-
intradural techniques,32 and the number of complications
arising from epidural puncture,33 although the procedure
takes longer using this approach.34
Grau et al.34 described better analgesic results and higher
parturient satisfaction when using ultrasound. These find-
ings were confirmed by the meta-analysis of Shaikh et al.,27
who found a combined block failure risk ratio of 0.21 (95%
CI: 0.10---0.43) in favour of ultrasound-guided localization.
The meta-analysis of Shaikh et al.,27 which included 1234
patients from 12 studies, showed that the use of ultra-
sound reduced the combined risk of failure of the technique
(OR = 0.20, 95% CI: 0.11---0.36) and traumatic procedure
(OR = 0.28; 95% CI: 0.13---0.61).
According to Lee,35 real-time ultrasound-guided puncture
has the advantage of allowing the anaesthetist to visualize
the tip of the needle and its position, verify the expansion of
the epidural space caused by the injection, and to locate the
epidural vessels, in spite of an increased risk of gel injection
in the epidural or intradural space. However, evidence from
further studies is needed to support the routine use of this
technique due to the high level of technical skill required.36
Grau et al.36 were the first to evaluate this technique
in 2004. Real-time ultrasound-guided puncture was sig-
nificantly more effective than loss of resistance (control
technique), but location of the epidural space was not sig-
nificantly superior with ultrasound. This study, with only 10
patients in each group, was too small to draw conclusions
regarding the advantages of real-time ultrasound due to a
lack of statistical power.
In 2013, Brinkmann et al.37 published a case series in
which they used a novel method that combines a global
positioning system with ultrasound technology (SonixGPSTM,
Ultrasonix, Richmond, BC, Canada) to guide the needle to a
target shown on the ultrasound screen. The technique was
used to perform spinal injection in a paramedian plane using
an out-of-plane approach in 20 patients undergoing knee
arthroplasty. The device has not yet been used to locate
the epidural space, nor in pregnant patients, but it has suc-
cessfully guided dural puncture in 90% of cases, in 85% of
which puncture was achieved on the first attempt.
In 2014, Menacé et al.38 described the use of new straight
and curved echogenic Tuohy needles and compared them
with traditional Tuohy needles in a real-time lumbar epidu-
ral puncture model in cadavers. The curved echogenic Tuohy
needle significantly improved the anaesthesiologist’s qual-
ity of vision, suggesting that this type of material could
improve the results of epidural blocks performed in vivo in
parturients.
This technique, however, is limited in practice because
many anaesthesiologists working in maternity wards are
N. Brogly et al.
not currently qualified to use ultrasound due to lack of
equipment and training,39 mainly due budgetary restric-
tions. The technique also takes longer to perform and
requires additional personnel, a factor that increases the
cost of obstetric treatment.
Techniques based on the optical properties of the
epidural space
In recent years, new lines of research have opened up fol-
lowing the discovery of the reflective light properties of
different tissue layers. Using optical spectroscopy technol-
ogy, these spectra can be used to identify the different
structures traversed by the Tuohy needle.
In 2010, Ting et al.40 were the first to describe this
method in an experimental model in pigs. In this technique,
optical fibres that emit a light with wavelengths of 650 and
532 nm at the bevelled tip were contained in a Tuohy needle.
The fraction of reflected light is sent to a photodiode that
measures the amplitude. This study showed that the reflec-
tive amplitude of the yellow ligament is significantly higher
than that of the epidural space, regardless of the level of
the puncture.
Rathmell et al.,41 in an experimental model in pigs,
studied the spectrophotometric properties of the spine by
performing repeated epidural punctures under radiographic
control and measuring the absorption of light at visible and
near-infrared wavelengths at insertion depths of between
500 and 1600 nm. They identified an absorption peak at
1210 nm, consistent with lipids, that appeared when the
needle entered the epidural space. Spectral analysis per-
formed at each stage of needle progression also allowed
the researchers to identify the fraction of blood and lipid
in the tissue entering into contact with the tip of the nee-
dle. This technique suggested the possibility of diagnosing
vascular puncture, although more studies would be needed
to show its effectiveness with a sufficiently high level of evi-
dence. More evidence is also needed on absorption spectrum
of dural or conus medullaris punction in order to refine this
technique and use it for the diagnosis of epidural puncture
complications.
In 2012, Lin et al.42 used the technique described by Ting
et al.40 to create a decision support system based on the
optical signals emitted during epidural catheter insertion
at a depth of 650 and 532 nm: they developed an intelli-
gent recognition system of the epidural space by comparing
2 mathematical models, and demonstrated the superiority
of linear discriminant analysis over logistic analysis. The
results were comparable to the visual analysis performed by
the anaesthesiologist. However, data observed under clinical
conditions are needed to determine the value of this tool.
This technique is still under investigation, and cannot be
used in humans until it has been validated, due to technical
and economic factors.
Finally, it should be noted that all modern epidu-
ral space localization techniques have been designed to
improve the efficacy of epidural puncture and reduce the
associated complications. Many of the devices and tech-
nologies described are not routinely used in daily practice
for 3 reasons: lack of information, lack of training, and
lack of development on an industrial scale. Furthermore,
Narrative revision of techniques used to locate the epidural space
no solid evidence has been published to support their
effectiveness. Failure to develop these techniques could
also be due to economic considerations in the context of the
economic crisis currently affecting Europe. This is particu-
larly true of ultrasound-guided techniques. For now, the loss
of resistance and hanging drop techniques are the standard
methods for locating the epidural space, regardless of the
indication.
Ethical responsibilities
Protection of human and animal subjects. The authors
declare that no experiments were performed on humans or
animals for this study.
Confidentiality of data. The authors declare that no patient
data appears in this article.
Right to privacy and informed consent. The authors
declare that no patient data appears in this article.
Conflict of interests
The authors declare that they have not received funding and
have no conflicts of interest.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at doi:10.1016/j.redare.
2017.06.003.
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