Trainees are commonly surprised when they are taught the simple paramedian approach. They find that they can rapidly and successfully do a dural puncture on an elderly patient in the lateral position with a deflexed or even slightly extended spine. With this teaching goes proper guidance on their body position, use of the hands in holding a needle correctly, and economies in technique.
I have observed too many trainees who have been taught by the see one, do one, teach one method, and whose skills owe more to Quasimodo using a Roman short sword. No anaesthetist should be considered trained in spinal anaesthesia unless he/she is skilled in the paramedian approach for both subarachnoid and epidural blocks. Adequate training in identifying and managing possible difficulties is also essential, but a difficulty score is of little value.
Great Yarmouth, UK
I am sure that Dr Notcutt would agree with me that anaesthesia requires theoretical knowledge and manual dexterity. The provider of spinal anaesthesia should have optimal command of his/her psychomotor control. During his/her training, the provider should be exposed to midline and paramedian approaches. Which approach they use is left to their own discretion. We should never compel the provider to use a certain approach.
The paramedian approach is not simple as suggested by Dr Notcutt. Previous reports indicate that the midline approach has a higher success rate and required fewer attempts than the paramedian approach.2 Another study reported a higher frequency of use of the median than paramedian approach (1140 vs 341) at all levels of anaesthesia experience (6 months to 5 yr), with paraesthesia occurring only in the paramedian approach.3 Spinal anaesthesia is sometimes technically difficult (Fig. 1). After more than four decades of anaesthesia, I still occasionally find problems with it.
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Mansoura, Egypt
References
1 Atallah MM, Demian AD, Shorrab AA. Development of a difficulty score for spinal anaesthesia. Br J Anaesth 2004; 92: 35460
2 Kopacz DJ, Neal JM, Pollock JE. The regional anesthesia learning curve: what is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth 1996; 21: 18290[ISI][Medline]
3 DeOliveira GR, Gomes HP, da Fonseca MHZ, Hoffman JC, Pederneiras SG, Garcia JHS. Predictors of successful neuraxial block; a prospective study. Eur J Anaesthesiol 2002; 19: 44751[ISI][Medline]