© The Board of Management and Trustees of the British Journal of Anaesthesia 2004
CORRESPONDENCE |
Development of a difficulty score for spinal anaesthesia
Editor—Atallah and colleagues1 have omitted one critical piece of information. Was a midline or paramedian approach used? If a paramedian approach was used, then most of the difficulties they describe (lack of flexibility because of age, difficulty in palpating the spinous process, ‘radiological characteristics’, moderate increase in BMI) disappear.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 grateful to Dr Notcutt for his interest in our publication.1 I accept that it was not mentioned whether spinal anaesthesia was provided via a midline or paramedian approach. However, I strongly differ with his contention that a paramedian approach would have solved most of the difficulties.
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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With the popularity of spinal anaesthesia, trainees in the discipline have to be taught to adhere to the standards set up by the discipline. This is why the difficulty score was developed. I can assure Dr Notcutt that I never leave my trainees with a short sword.
Mansoura, Egypt
References
1 Atallah MM, Demian AD, Shorrab AA. Development of a difficulty score for spinal anaesthesia. Br J Anaesth 2004; 92: 354–60
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: 182–90[Web of Science][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: 447–51[CrossRef][Web of Science][Medline]
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