Paramedian approach to thoracic epidural after neuraxial ultrasound

This arrow in the graphic on the left shows the needle insertion site and angle for paramedian thoracic epidural needle placement after preprocedure neuraxial ultrasound. The midline and interlaminar space for the desired interspace are determined using ultrasound, and the skin is marked with corresponding vertical and horizontal lines. The needle should be inserted approximately 0.5 cm lateral to and 1.5 cm inferior (caudal) to the intersection of the two lines, aimed medially and at an angle of approximately 5 degrees from perpendicular to the skin. This graphic should be used in conjunction with UpToDate content on neuraxial ultrasound for anesthesia.