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This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Copyright (c) 2025 Iskandar Khalid, Shahridan Mohd Fathil, Manoj Kumar Karmakar
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Abstract
Central neuraxial blocks (CNB) remain a cornerstone of modern anaesthesia, yet traditional landmark-based techniques carry inherent limitations in accuracy and safety. Ultrasound-guided CNB has emerged as a transformative technique, offering improved first-pass success, shorter procedure times, fewer needle passes, and decreased incidence of complications such as inadvertent dural puncture and paraesthesia. Despite compelling evidence supporting these advantages, global adoption of ultrasound-guided CNB remains limited. Surveys across North America, Europe, and Asia consistently reveal underutilisation, suggesting significant barriers to implementation. This editorial explores the multifactorial impediments to wider ultrasound-guided CNB adoption, including logistical issues such as cost and equipment access, workflow disruptions in high-volume settings, the complexity of spinal sonoanatomy, and a steep learning curve requiring structured training. Cultural resistance to change and inadequate institutional support further hinder progress. Drawing from change management models, we propose strategies to overcome individual and systemic inertia. The proliferation of portable ultrasound devices and training dissemination by younger, ultrasound-proficient practitioners are expected to drive change. Ultimately, formal certification pathways and sustained advocacy will be essential to achieving mainstream adoption of ultrasound-guided CNB.
References
Sivakumar RK, Karmakar MK. Spinal sonography and central neuraxial blocks. Best Pract Res Clin Anaesthesiol. 2023;37(2):209-242. https://doi.org/10.1016/j.bpa.2023.04.008
Chin KJ, Karmakar MK, Peng P. Ultrasonography of the adult thoracic and lumbar spine for central neuraxial blockade. Anesthesiology. 2011;114(6):1459-85. https://doi.org/10.1097/ALN.0b013e318210f9f8
Chin A, Crooke B, Heywood L, Brijball R, Pelecanos AM, Abeypala W. A randomised controlled trial comparing needle movements during combined spinal-epidural anaesthesia with and without ultrasound assistance. Anaesthesia. 2018;73(4):466-473. https://doi.org/10.1111/anae.14206
Perlas A, Chaparro LE, Chin KJ. Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis. Reg Anesth Pain Med. 2016;41(2):251-260. https://doi.org/10.1097/AAP.0000000000000184
Kamimura Y, Yamamoto N, Shiroshita A, et al. Comparative efficacy of ultrasound guidance or conventional anatomical landmarks for neuraxial puncture in adult patients: a systematic review and network meta-analysis. Br J Anaesth. 2024;132(5): 1097-1111. https://doi.org/10.1016/j.bja.2023.09.006
Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. Br Med J (Clin Res Ed). 2013;346:f1720. https://doi.org/10.1136/bmj.f1720
Jayanth MN, Arumulla SP, Kesana P, Kandukuru KC, Basireddy HR, Peddi S. Preprocedural ultrasonography as an adjunct to landmark technique for identification of epidural space in parturients for labor analgesia. Saudi J Anaesth. 2023:17(1):18-22. https://doi.org/10.4103/sja.sja_141_22
Kakde A, Chia P, Tan HS, Sultana R, Tan CW, Sng BL. Factors associated with an inadvertent dural puncture or post-dural puncture headache following labour epidural analgesia: A retrospective cohort study. Heliyon. 2024;10(6):e27511. https://doi.org/10.1016/j.heliyon.2024.e27511
Sidiropoulou T, Christodoulaki K, Siristatidis C. Pre-Procedural Lumbar Neuraxial Ultrasound-A Systematic Review of Randomized Controlled Trials and Meta-Analysis. Healthcare (Basel). 2021;9(4):479. https://doi.org/10.3390/healthcare9040479
Young B, Onwochei D, Desai N. Conventional landmark palpation vs. preprocedural ultrasound for neuraxial analgesia and anaesthesia in obstetrics - a systematic review and meta-analysis with trial sequential analyses. Anaesthesia. 2021;76(6): 818-831. https://doi.org/10.1111/anae.15255
Karmakar MK, Li X, Ho AM, Kwok WH, Chui PT. Real-time ultrasound-guided paramedian epidural access: evaluation of a novel in-plane technique. Br J Anaesth. 2009;102(6):845-854. https://doi.org/10.1093/bja/aep079
Chong SE, Mohd Nikman A, Saedah A, et al. Real-time ultrasound-guided paramedian spinal anaesthesia: evaluation of the efficacy and the success rate of single needle pass. Br J Anaesth. 2017;118(5):799–801. https://doi.org/10.1093/bja/aex108
Chen L, Huang J, Zhang Y, et al. Real-time Ultrasound-Guided Versus Ultrasound-Assisted Spinal Anesthesia in Elderly Patients With Hip Fractures: A Randomized Controlled Trial. Anesth Analg. 2022;134(2):400-409. https://doi.org/10.1213/ANE.0000000000005778
Mahmoud Y, Walters M, Rizkallah K. B42 Survey of anaesthetists on the use of ultrasound for central neuraxial blockade on parturients. Reg Anesth Pain Med. 2022;47:A105-A106. https://doi.org/10.1136/rapm-2022-ESRA.117
Mathieu S, Dalgleish DJ. A survey of local opinion of NICE guidance on the use of ultrasound in the insertion of epidural catheters. Anaesthesia. 2008;63(10):1146-7. https://doi.org/10.1111/j.1365-2044.2008.05697.x
Bhatia K, Kochhar P, Clegg I, Maguire S. The availability and use of ultrasound in UK obstetric anaesthesia. Int J Obstet Anesth. 2016;25:91-2. https://doi.org/10.1016/j.ijoa.2015.10.001
Chui J, Lavi R, Hegazy AF, et al. Identifying barriers to the use of ultrasound in the perioperative period: a survey of southwestern Ontario anesthesiologists. BMC Health Serv Res. 2019;19(1):214. https://doi.org/10.1186/s12913-019-4040-2
Pharanitharan N, Chandini K. A Questionnaire-Based Survey of Perioperative Utilisation of Ultrasound among Anaesthesiology Residents. Int J Anesth Anesth. 2024;11. https://doi.org/10.23937/2377-4630/1410171
Ghosh SM, Madjdpour C, Chin KJ. Ultrasound-guided lumbar central neuraxial block. BJA Educ. 2016;16(7):213–220. https://doi.org/10.1093/bjaed/mkv048
Guidelines on Ultrasound Usage in Medical Practice 2022 [Internet]. Medical Radiation Surveillance Division, Ministry of Health Malaysia; [cited 2025 April 2]. Available from: https://www.moh.gov.my/moh/resources/maklumat%20terkini/2022/Surat_Pekeliling_KPK_Bil.22_2022_US_3Nov2022_.pdf
Terkawi AS, Karakitsos D, Elbarbary M, Blaivas M, Durieux ME. Ultrasound for the anesthesiologists: present and future. ScientificWorldJournal. 2013;20;2013:683685. https://doi.org/10.1155/2013/683685
Brinkmann S, Germain G, Sawka A, Vaghadia H. Is there a place for ultrasound in neuraxial anesthesia? Imaging Med. 2013;5(2):177-186.
El-Boghdadly K, Nair G, Pawa A, Onwochei DN. Impact of parallel processing of regional anesthesia with block rooms on resource utilization and clinical outcomes: a systematic review and meta-analysis. Reg Anesth Pain Med. 2020;45(9):720-726. https://doi.org/10.1136/rapm-2020-101397
Topor B, Oldman M, Nicholls B. Best practices for safety and quality in peripheral regional anaesthesia. BJA Educ. 2020;20(10):341-347. https://doi.org/10.1016/j.bjae.2020.04.007
Turbitt LR, Mariano ER, El-Boghdadly K. Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia. 2020;75(3):293-297. https://doi.org/10.1111/anae.14768
Hurst L, Mahtani K, Pluddemann A. Defining Value-based Healthcare in the NHS: CEBM report. May 2019. [Internet]; [cited 2025 April 2]. Available from: https://www.cebm.net/2019/04/defining-value-based-healthcare-in-the-nhs/
Kessler J. Education and training in ultrasound-guided neuraxial anaesthesia. Anaesth Intensive Care. 2014;42(4):447-8. https://doi.org/10.1177/0310057X1404200403
Neal JM, Brull R, Horn JL, et al. The Second American Society of Regional Anesthesia and Pain Medicine Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia: Executive Summary. Reg Anesth Pain Med. 2016;41(2):181-94. https://doi.org/10.1097/AAP.0000000000000331
Satapathy AR, Khalid IB, Fathil SM. Simulation in Regional Anaesthesia: A Narrative Review of Its History, Evolution and Future Prospects. J Clin Med. 2024;26;14(1):67. https://doi.org/10.3390/jcm14010067
Ramlogan R, Niazi AU, Jin R, Johnson J, Chan VW, Perlas A. A Virtual Reality Simulation Model of Spinal Ultrasound: Role in Teaching Spinal Sonoanatomy. Reg Anesth Pain Med. 2017;42(2):217-222. https://doi.org/10.1097/AAP.0000000000000537
Bell M. Lewin’s Change Management Model [Internet]; [cited 2025 April 2]. Available from: www.mindtools.com/pages/article/newPPM_94.htm
Rampersad SE, Low DK, Martin LD. Change Management in Modern Anesthesia Practice. Int Anesthesiol Clin. 2016;54(3):83-93. https://doi.org/10.1097/AIA.0000000000000101
Recommendations for Peripheral Nerve Blocks 2019 [Internet]. College of Anaesthesiologists, Academy of Medicine of Malaysia; [cited 2025 April 2]. Available from: https://www.acadmed.org.my/view_file.cfm?fileid=934
Recommendations for Ultrasound-Guided Vascular Access 2022 [Internet]. College of Anaesthesiologists, Academy of Medicine of Malaysia; [cited 2025 April 2]. Available from: https://www.acadmed.org.my/view_file.cfm?fileid=1047
Kim TE, Tsui BCH. Simulation-based ultrasound-guided regional anesthesia curriculum for anesthesiology residents. Korean J Anesthesiol. 2019;72(1):13-23. https://doi.org/10.4097/kja.d.18.00317