Conventional anatomical landmark versus preprocedural ultrasound for thoracic epidural analgesia: A systematic review and meta-analysis

Sharapi M., Mahfouz A., Philip K., Mektebi A., Albakri K.

Journal of Perioperative Practice, 2023 (ESCI) identifier

  • Publication Type: Article / Review
  • Publication Date: 2023
  • Doi Number: 10.1177/17504589231181974
  • Journal Name: Journal of Perioperative Practice
  • Journal Indexes: Emerging Sources Citation Index (ESCI), Scopus, CINAHL, MEDLINE
  • Keywords: Epidural needle redirection, First-puncture success rate, Landmark-based thoracic epidural, Preprocedural thoracic ultrasound, Thoracic epidural placement
  • Kütahya Health Sciences University Affiliated: No


Background: Thoracic epidural analgesia is the gold standard for major thoracic and abdominal surgeries. Aim: Ultrasound-guided and landmark-based thoracic epidural insertion are compared in this systematic review. Methods: Randomised controlled trials were sought in six databases for a systematic review and meta-analysis. With a 95% confidence interval, a fixed-effects model calculated risk ratio or mean difference. Cochrane risk of bias assessed bias. Four randomised controlled trials were examined. Findings: Preprocedural ultrasound increased thoracic epidural placement first-puncture success rate (risk ratio = 1.28, 95% confidence interval (1.05 to 1.56), p value = 0.02) and decreased the need for two or more skin punctures (mean difference = −2.41, 95% confidence interval (−3.34 to −1.47), p value = 0.00001). The ultrasound group reduced needle redirections (risk ratio = 0.6, 95% confidence interval (0.38 to 0.94), p value = 0.02). The epidural block success rate was equal in both groups (risk ratio = 1.02, 95% confidence interval (0.96 to 1.07), p value = 0.6). Conclusion: Thoracic epidural insertion is improved by ultrasound but not the success rate. Quality research with larger samples is needed to emphasise these conclusions.