{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T22:36:41Z","timestamp":1775860601137,"version":"3.50.1"},"reference-count":39,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2025,10,22]],"date-time":"2025-10-22T00:00:00Z","timestamp":1761091200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The association between ultrasound-assisted combined with conventional anatomical landmark paramedian spinal anesthesia regarding the first-pass success rate remains contentious. This study aims to clarify this relationship.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      In this retrospective cohort analysis of 146 patients with lower limb fractures, patients were divided into two groups based on their spinal anesthesia technique:ultrasound-assisted combined with conventional anatomical landmark (median or paramedian). The primary endpoint was the first-pass success rate, while secondary endpoints included total procedure time and discomfort score. Recorded covariates encompassed sex, age, BMI, ASA class, preoperative preparation time, pre-injury physical activity, number of needle insertions, pain intensity (VAS), satisfaction score, puncture-related pain, and postoperative low back pain. Outcomes were evaluated\n                      <jats:italic>\n                        <jats:italic>via<\/jats:italic>\n                      <\/jats:italic>\n                      logistic regression.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>After adjusting for potential confounders, the ultrasound-assisted paramedian approach demonstrated a significantly higher first-pass success rate (OR = 6.11, 95% CI 2.09\u201317.86, P\u2009=\u20090.001). Secondary benefits included reduced procedure duration and improved patient comfort. Sensitivity analysis using propensity score matching confirmed the robustness of the results (E-value\u2009=\u20094.379), indicating minimal influence from unmeasured confounders.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In patients with lower limb fractures, ultrasound-assisted paramedian spinal anesthesia using anatomical landmarks increased first-pass success rates, reduced procedural time, and improved patient comfort compared to the median approach.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0334455","type":"journal-article","created":{"date-parts":[[2025,10,22]],"date-time":"2025-10-22T17:30:16Z","timestamp":1761154216000},"page":"e0334455","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Association of ultrasound-assisted combined with conventional anatomical landmark paramedian spinal anesthesia and its impact on first pass success rate in patients with lower limb fractures- A retrospective cohort study"],"prefix":"10.1371","volume":"20","author":[{"given":"Congli","family":"Tian","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jing","family":"Xue","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Huiyan","family":"Cui","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-5173-2768","authenticated-orcid":true,"given":"Hongni","family":"Ding","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,10,22]]},"reference":[{"issue":"2","key":"pone.0334455.ref001","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1016\/j.bpa.2023.04.001","article-title":"Current indications for spinal anesthesia-a narrative review","volume":"37","author":"Balavenkatasubramanian, Senthilkumar","year":"2023","journal-title":"Best Pract Res Clin Anaesthesiol"},{"issue":"2","key":"pone.0334455.ref002","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1016\/j.bpa.2023.02.007","article-title":"Continuous spinal technique in surgery and obstetrics","volume":"37","author":"CM Kumar","year":"2023","journal-title":"Best Pract Res Clin Anaesthesiol"},{"issue":"3","key":"pone.0334455.ref003","doi-asserted-by":"crossref","first-page":"851","DOI":"10.1213\/ANE.0000000000001325","article-title":"Does preprocedural ultrasound increase the first-pass success rate of epidural catheterization before cesarean delivery? A randomized controlled trial","volume":"124","author":"MM Tawfik","year":"2017","journal-title":"Anesth Analg"},{"issue":"4","key":"pone.0334455.ref004","doi-asserted-by":"crossref","first-page":"260","DOI":"10.4097\/kjae.2010.59.4.260","article-title":"Factors in patient dissatisfaction and refusal regarding spinal anesthesia","volume":"59","author":"WJ Rhee","year":"2010","journal-title":"Korean J Anesthesiol"},{"key":"pone.0334455.ref005","doi-asserted-by":"crossref","first-page":"110823","DOI":"10.1016\/j.jclinane.2022.110823","article-title":"Ultrasound-assisted spinal anesthesia: A randomized comparison between midline and paramedian approaches","volume":"80","author":"S-K Park","year":"2022","journal-title":"J Clin Anesth"},{"issue":"2","key":"pone.0334455.ref006","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1097\/AAP.0000000000000184","article-title":"Lumbar neuraxial ultrasound for spinal and epidural anesthesia: a systematic review and meta-analysis","volume":"41","author":"A Perlas","year":"2016","journal-title":"Reg Anesth Pain Med"},{"issue":"3","key":"pone.0334455.ref007","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1097\/EJA.0000000000001380","article-title":"Ultrasound increases the success rate of spinal needle placement through the epidural needle during combined spinal-epidural anaesthesia: a randomised controlled study","volume":"38","author":"B Tao","year":"2021","journal-title":"Eur J Anaesthesiol"},{"issue":"52","key":"pone.0334455.ref008","doi-asserted-by":"crossref","DOI":"10.1097\/MD.0000000000036695","article-title":"Administration of combined spinal epidural anesthesia with ultrasound-assisted positioning in obese patients undergoing open hysterectomy: a randomized controlled trial","volume":"102","author":"H Yang","year":"2023","journal-title":"Medicine (Baltimore)"},{"issue":"5","key":"pone.0334455.ref009","doi-asserted-by":"crossref","first-page":"356","DOI":"10.4103\/ija.IJA_446_20","article-title":"Real-time ultrasound-guided spinal anaesthesia vs pre- procedural ultrasound-guided spinal anaesthesia in obese patients","volume":"65","author":"PR Ravi","year":"2021","journal-title":"Indian J Anaesth"},{"issue":"4","key":"pone.0334455.ref010","doi-asserted-by":"crossref","first-page":"522","DOI":"10.4103\/joacp.JOACP_396_17","article-title":"A cohort study of anatomical landmark-guided midline versus pre-procedure ultrasound-guided midline technique of spinal anesthesia in elderly patients undergoing orthopedic surgery","volume":"35","author":"HH Narkhede","year":"2019","journal-title":"J Anaesthesiol Clin Pharmacol"},{"issue":"6","key":"pone.0334455.ref011","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1007\/s00540-024-03394-6","article-title":"Performance of the ratio of posterior complex length to depth measured by ultrasound as a predictor of difficult spinal anesthesia for elective cesarean delivery: a prospective cohort study","volume":"38","author":"J Shi","year":"2024","journal-title":"J Anesth"},{"issue":"10","key":"pone.0334455.ref012","doi-asserted-by":"crossref","first-page":"763","DOI":"10.1097\/EJA.0000000000001029","article-title":"Ultrasound-assisted vs. landmark-guided paramedian spinal anaesthesia in the elderly: a randomised controlled trial","volume":"36","author":"S-K Park","year":"2019","journal-title":"Eur J Anaesthesiol"},{"issue":"11","key":"pone.0334455.ref013","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2022-071253","article-title":"Comparison of ultrasound-guided and traditional localisation in intraspinal anesthesia: a systematic review and network meta-analysis","volume":"13","author":"Y Zhang","year":"2023","journal-title":"BMJ Open"},{"issue":"1","key":"pone.0334455.ref014","doi-asserted-by":"crossref","first-page":"23009","DOI":"10.1038\/s41598-023-50407-7","article-title":"Handheld ultrasound-assisted versus palpation-guided combined spinal-epidural for labor analgesia: a randomized controlled trial","volume":"13","author":"J Bae","year":"2023","journal-title":"Sci Rep"},{"key":"pone.0334455.ref015","article-title":"A randomized comparison between Accuro and palpation-guided spinal anesthesia for obese patients undergoing orthopedic surgery","author":"D Ghisi","year":"2019","journal-title":"Reg Anesth Pain Med"},{"issue":"10","key":"pone.0334455.ref016","doi-asserted-by":"crossref","first-page":"591","DOI":"10.12788\/jhm.3197","article-title":"Recommendations on the use of ultrasound guidance for adult lumbar puncture: a position statement of the society of hospital medicine","volume":"14","author":"NJ Soni","year":"2019","journal-title":"J Hosp Med"},{"issue":"4","key":"pone.0334455.ref017","doi-asserted-by":"crossref","first-page":"479","DOI":"10.3390\/healthcare9040479","article-title":"Pre-Procedural lumbar neuraxial ultrasound-a systematic review of randomized controlled trials and meta-analysis","volume":"9","author":"T Sidiropoulou","year":"2021","journal-title":"Healthcare (Basel)"},{"issue":"9","key":"pone.0334455.ref018","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1136\/rapm-2024-105547","article-title":"Efficacy and safety of ultrasound-guided versus landmark-guided neuraxial puncture: a systematic review, network meta-analysis and trial sequential analysis of randomized clinical trials","volume":"50","author":"CC de Carvalho","year":"2025","journal-title":"Reg Anesth Pain Med"},{"key":"pone.0334455.ref019","article-title":"CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials","volume":"340","author":"CONSORT Group","year":"2010","journal-title":"BMJ"},{"issue":"3","key":"pone.0334455.ref020","doi-asserted-by":"crossref","first-page":"399","DOI":"10.1080\/00273171.2011.568786","article-title":"An introduction to propensity score methods for reducing the effects of confounding in observational studies","volume":"46","author":"PC Austin","year":"2011","journal-title":"Multivariate Behav Res"},{"issue":"5","key":"pone.0334455.ref021","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1177\/17407745211028588","article-title":"Covariate adjustment in subgroup analyses of randomized clinical trials: a propensity score approach","volume":"18","author":"S Yang","year":"2021","journal-title":"Clin Trials"},{"issue":"28","key":"pone.0334455.ref022","doi-asserted-by":"crossref","first-page":"3661","DOI":"10.1002\/sim.6607","article-title":"Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies","volume":"34","author":"PC Austin","year":"2015","journal-title":"Stat Med"},{"issue":"6","key":"pone.0334455.ref023","doi-asserted-by":"crossref","first-page":"680","DOI":"10.1097\/01.EDE.0000081989.82616.7d","article-title":"Marginal structural models as a tool for standardization","volume":"14","author":"T Sato","year":"2003","journal-title":"Epidemiology"},{"issue":"13","key":"pone.0334455.ref024","doi-asserted-by":"crossref","first-page":"2672","DOI":"10.1002\/sim.10078","article-title":"On variance estimation of the inverse probability-of-treatment weighting estimator: A tutorial for different types of propensity score weights","volume":"43","author":"A Kostouraki","year":"2024","journal-title":"Stat Med"},{"issue":"4","key":"pone.0334455.ref025","doi-asserted-by":"crossref","first-page":"272","DOI":"10.4103\/ija.ija_775_21","article-title":"A comparative study of ultrasound assisted versus landmark technique for combined spinal-epidural anaesthesia in patients undergoing lower limb orthopaedic surgery","volume":"66","author":"MA Khan","year":"2022","journal-title":"Indian J Anaesth"},{"issue":"1","key":"pone.0334455.ref026","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1186\/s12871-019-0726-6","article-title":"A novel approach to neuraxial anesthesia: application of an automated ultrasound spinal landmark identification","volume":"19","author":"TT Oh","year":"2019","journal-title":"BMC Anesthesiol"},{"issue":"3","key":"pone.0334455.ref027","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1213\/ANE.0000000000004600","article-title":"Ultrasound-assisted versus landmark-guided spinal anesthesia in patients with abnormal spinal anatomy: a randomized controlled trial","volume":"130","author":"SK Park","year":"2020","journal-title":"Anesth Analg"},{"issue":"5","key":"pone.0334455.ref028","doi-asserted-by":"crossref","first-page":"1097","DOI":"10.1016\/j.bja.2023.09.006","article-title":"Comparative efficacy of ultrasound guidance or conventional anatomical landmarks for neuraxial puncture in adult patients: a systematic review and network meta-analysis","volume":"132","author":"Y Kamimura","year":"2024","journal-title":"Br J Anaesth"},{"issue":"11","key":"pone.0334455.ref029","doi-asserted-by":"crossref","first-page":"924","DOI":"10.4103\/ija.IJA_327_19","article-title":"Preprocedural ultrasound as an adjunct to blind conventional technique for epidural neuraxial blockade in patients undergoing hip or knee joint replacement surgery: a randomised controlled trial","volume":"63","author":"K Jain","year":"2019","journal-title":"Indian J Anaesth"},{"key":"pone.0334455.ref030","article-title":"Influence of age, laterality, patient position, and spinal level on the interlamina space for spinal puncture","author":"J Bae","year":"2019","journal-title":"Reg Anesth Pain Med"},{"issue":"5","key":"pone.0334455.ref031","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1093\/bja\/aex108","article-title":"Real-time ultrasound-guided paramedian spinal anaesthesia: evaluation of the efficacy and the success rate of single needle pass","volume":"118","author":"SE Chong","year":"2017","journal-title":"Br J Anaesth"},{"issue":"2","key":"pone.0334455.ref032","doi-asserted-by":"crossref","first-page":"131","DOI":"10.11152\/mu-1699","article-title":"Facet joint degeneration adversely affects ultrasound imaging of the lumbar spine","volume":"21","author":"K Srinivasan","year":"2019","journal-title":"Med Ultrason"},{"issue":"10","key":"pone.0334455.ref033","doi-asserted-by":"crossref","first-page":"750","DOI":"10.4103\/ija.ija_276_21","article-title":"Correlation of preprocedural ultrasound estimated epidural depths in transverse median and posterior sagittal oblique view and body mass index with procedural epidural depths in patients scheduled for surgery under lumbar epidural anaesthesia","volume":"65","author":"H Awasthi","year":"2021","journal-title":"Indian J Anaesth"},{"issue":"8","key":"pone.0334455.ref034","doi-asserted-by":"crossref","first-page":"803","DOI":"10.1007\/s11916-024-01262-2","article-title":"Lumbar puncture complications: a review of current literature","volume":"28","author":"AE Reis","year":"2024","journal-title":"Curr Pain Headache Rep"},{"issue":"12","key":"pone.0334455.ref035","article-title":"Predictors of failed spinal arachnoid puncture procedures: an artificial neural network analysis","volume":"14","author":"HMR Karim","year":"2022","journal-title":"Cureus"},{"issue":"1","key":"pone.0334455.ref036","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1186\/s12871-019-0882-8","article-title":"Preprocedural ultrasound versus landmark techniques for spinal anesthesia performed by novice residents in elderly: a randomized controlled trial","volume":"19","author":"MS Rizk","year":"2019","journal-title":"BMC Anesthesiol"},{"issue":"3","key":"pone.0334455.ref037","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1097\/EJA.0000000000001383","article-title":"European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): peripheral nerves blocks and neuraxial anaesthesia","volume":"38","author":"E Boselli","year":"2021","journal-title":"Eur J Anaesthesiol"},{"issue":"8","key":"pone.0334455.ref038","article-title":"Point-of-Care ultrasound: a vital tool for anesthesiologists in the perioperative and critical care settings","volume":"16","author":"A Dhir","year":"2024","journal-title":"Cureus"},{"issue":"2","key":"pone.0334455.ref039","doi-asserted-by":"crossref","first-page":"400","DOI":"10.1213\/ANE.0000000000005778","article-title":"Real-Time ultrasound-guided versus ultrasound-assisted spinal anesthesia in elderly patients with hip fractures: a randomized controlled trial","volume":"134","author":"L Chen","year":"2022","journal-title":"Anesth Analg"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0334455","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,22]],"date-time":"2025-10-22T17:30:23Z","timestamp":1761154223000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0334455"}},"subtitle":[],"editor":[{"given":"Ramada Rateb","family":"Khasawneh","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2025,10,22]]},"references-count":39,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2025,10,22]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0334455","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,22]]}}}