Background: Epidural anesthesia is widely used but remains challenging with landmark-based techniques. Anatomical variability of neuraxial structures complicates identification. Ultrasound allows visualization of neuraxial anatomy and needle trajectory, potentially improving accuracy and safety. We aimed to evaluate whether ultrasound-guided epidural placement improves first-pass success, procedural efficiency, and complication rates compared with landmark-based.
Methods: A systematized review of randomized controlled trials, prospective cohort studies, and meta-analyses was conducted using PubMed, Embase, Cochrane, CINAHL, EBSCO, and Open Evidence from database inception through 2025. Eligible studies included adults undergoing epidural procedures comparing ultrasound-guided with landmark-based techniques. Primary outcomes were first-pass success and complication rates. Secondary outcomes included needle attempts, needle passes, and procedural duration. Study selection followed PRISMA principles.
Results: Across studies including >7,000 adult patients, ultrasound-guided epidural placement consistently improved procedural success. Meta-analyses demonstrated increased first-pass success (RR 1.40, 95% CI 1.29–1.52; P < 0.001) and fewer attempts (MD −0.41, 95% CI −0.51 to −0.31; P < 0.001). Prospective studies reported fewer needle passes and shorter procedural time. In a thoracic epidural cohort (n = 128), first-pass success was 75%, first-attempt success 95%, and overall success 98%, with a median needling time of 59 seconds and no complications. Findings were consistent across study designs.
Conclusion: Ultrasound-guided epidural placement improves first-pass success and procedural efficiency while reducing needle manipulation and radiation exposure. This review consolidates contemporary evidence across neuraxial procedures, particularly in patients with difficult anatomy, although implementation may depend on operator experience and resource availability.
Methods: A systematized review of randomized controlled trials, prospective cohort studies, and meta-analyses was conducted using PubMed, Embase, Cochrane, CINAHL, EBSCO, and Open Evidence from database inception through 2025. Eligible studies included adults undergoing epidural procedures comparing ultrasound-guided with landmark-based techniques. Primary outcomes were first-pass success and complication rates. Secondary outcomes included needle attempts, needle passes, and procedural duration. Study selection followed PRISMA principles.
Results: Across studies including >7,000 adult patients, ultrasound-guided epidural placement consistently improved procedural success. Meta-analyses demonstrated increased first-pass success (RR 1.40, 95% CI 1.29–1.52; P < 0.001) and fewer attempts (MD −0.41, 95% CI −0.51 to −0.31; P < 0.001). Prospective studies reported fewer needle passes and shorter procedural time. In a thoracic epidural cohort (n = 128), first-pass success was 75%, first-attempt success 95%, and overall success 98%, with a median needling time of 59 seconds and no complications. Findings were consistent across study designs.
Conclusion: Ultrasound-guided epidural placement improves first-pass success and procedural efficiency while reducing needle manipulation and radiation exposure. This review consolidates contemporary evidence across neuraxial procedures, particularly in patients with difficult anatomy, although implementation may depend on operator experience and resource availability.