Real-time ultrasound-guided versus landmark techniques for thoracic epidural placement in elderly patients: A randomized comparative study

Thoracic epidural placement (TEP) in elderly patients is technically challenging, and evidence comparing real-time ultrasound guidance (USG) with the conventional landmark (LM) technique remains limited. This study aimed to compare the technical performance and success rates between two approaches. Seventy-six elderly patients who were receiving thoracic epidural analgesia were prospectively enrolled and randomized to the USG (n = 38) or LM (n = 38) group. The primary outcome was first-pass success (FPS). The secondary outcomes included the number of needle passes and skin punctures, TEP time, preparation time, and total procedure time. The median age was 70 years in the LM group and 71 years in the USG group. Overall, TEP success was greater with US than with LM [94.7% vs. 81.6%], although the difference was not statistically significant (p = 0.15). Compared with the LM group, the USG group presented significantly greater FPS [55.3% vs. 26.3%; p = 0.02], fewer needle passes and skin punctures, and a trend toward shorter TEP times. The preparation time was longer in the USG group, but the total procedure time was similar between the groups. Real-time ultrasound guidance significantly improves procedural efficiency in thoracic epidural placement in elderly patients, particularly in term of first-pass success and needle-related performance. However, no statistically significant different in overall procedural success was observed compared with landmark-based technique. Register: Thai Clinical Trials Registry No: TCTR20220913004 Register date: 13/09/2022.