Former clinical studies have reported the superiority of the landmark guided paramedian approach above the classical landmark guided midline approach for the continuous spinal anesthesia especially in the elderly. On the other hand, more recent clinical trials have suggested that the use of ultrasound to guide spinal anesthesia will be safer and more effective than the conventional palpation-guided technique.
The aim of this study will be to compare the conventional "blind" landmark paramedian approach to the ultrasound "modern" guided midline approach for the continuous spinal anesthesia in the elderly with hip fractures.
Patients will randomly divided into two groups:
Group(PML): will undergo conventional landmark guided paramedian continuous spinal anesthesia Group (MUS): will undergo ultrasound guided midline continuous spinal anesthesia
all consented patients aged over 65 years old scheduled to undergo surgery for hip fracture under continuous spinal anesthesia with American Society of Anesthesiologists ASA physical status classification from I to III
contraindications to spinal anesthesia ( allergy to local anesthetic, coagulopathy, infection at the site of injection)
previous history of lumbar spine surgery
per operative severe complication with conversion to general anesthesia
Parallel
conventional landmark paramedian technique
Procedure/Surgerya blind landmark scanning will be done and skin marking of the best palpable spinous process will be made. the site of injection will be determined by palpation. continuous spinal anesthesia will be performed via paramedian approach.
preprocedural ultrasound guided midline technique
Procedure/Surgerya preprocedural ultrasound scanning will be done, and skin marking of the best quality space will be made. the site of injection and the insertion angle of the needle will be determined by ultrasound. continuous spinal anesthesia will be performed via midline approach.
the difference in number of needle passes between the two groups
the number of forward advancements of the Tuohy needle in a given interspinous space (i.e withdrawal and redirection of Tuohy needle without exiting the skin)
number of spinal needle insertion attempts
the number of times the tuohy needle was withdrawn from the skin and reinserted
the rate of first pass success
a single needle insertion with no redirection
time for identifying landmarks
in group PML: time from which the anesthesiologist started palpating to identify the landmarks to the needle entry point marking in group MUS: time from which the ultrasound probe was placed on the skin to the needle entry point marking
time taken for performing continuous spinal anesthesia
time from first needle insertion to fixation of continuous spinal anesthesia catheter to patient skin
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