Interlam. Glass/plastic; saline/air What do you use?

[wscott]

Just curious;

What do you use for interlaminars?
Glass or plastic LOR?
Saline, air, or water?

And why?

Thanks

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[lobelsteve]

I've used glass, epilor silicone, and plain old plastic.
I've used air for SCS and NSS-PF for ESI's.

I did not like the feel of the silicone or the cost of the glass. I use cheap plastic 10cc syringes as my LOR syringe.

I use NSS because it feels good compared to air and it is readily available.

People will use what they trained on or have become comfortable with.
The science does not discriminate until it comes to wet taps. But that is a function of needle type and gauge- and probably a separate thread...

 

[wscott]

A few other points;

If you do get a dural puncture, not using air will save the patient from the bad headache associated with air embolus.

I've also heard that using saline with SCS is avoided as it offers a conductive medium which may confuse the specificity of stimulation. I don't know if this is true or not.

Any more points/counterpoints on this one?

 

[lonelobo]

I find it hard to believe a cc or so of normal saline is going to affect
the conductive medium?

Everyone I know uses NS for SCS.

 

[Ligament]

Incidence of dural puncture is the same for air and NS loss of resistance. Air is 7x more likely to cause post dural puncture headache *symptoms*. Therefore if you are *good* at saline LOR you should probably do that. I was trained with air, am good at it, so thats what I use.

Regarding saline with SCS; you can use sterile water. As it is free of electrolytes, it is non conductive and theoretically will not mess with the SCS as much as NS.

A few other points;

If you do get a dural puncture, not using air will save the patient from the bad headache associated with air embolus.

I've also heard that using saline with SCS is avoided as it offers a conductive medium which may confuse the specificity of stimulation. I don't know if this is true or not.

Any more points/counterpoints on this one?

 

[mehul_25]

we use the Braun Perifix Plastic LOR syringes and saline. Used glass in residency...didnt like it compared to the plastic. They used to stick once in awhile and I personally felt like we got more false loss compared to plastic.

Here is the link for the syringe...
http://www.bbraunusa.com/index.cfm?uuid=43225F93D0B759A1E31C98738F522875

 

[ParaVert]

glass, plastic, they're really the same. With glass, I was taught in anesthesia residency to wet the plunger with saline for better slide.

Truth is, the more important question to answer is whether or not it is better to use intermittent pressure or continuous pressure on the plunger while advancing. I was trained to use air and intermittent pressure in residency, but I now use air/saline mix with continuous pressure while advancing. Just watch the bubble--if it expands, you're in.

 

[deco]

There is an excellent review published years ago in RA&PM which concluded that using saline instead of air is safer and, accordingly, LOR with air should be proscribed for good. Actually many American Anesthesiologists who were taught to use air are changing to saline.

 

[Jcm800]

A few other points;

If you do get a dural puncture, not using air will save the patient from the bad headache associated with air embolus.

I've also heard that using saline with SCS is avoided as it offers a conductive medium which may confuse the specificity of stimulation. I don't know if this is true or not.

Any more points/counterpoints on this one?

This is why i use saline, less chance of pneumocephalus, and i have had the saline thing with SCS happen to me. I use air only now for SCS. Saline for the rest...

 

[Jcm800]

I've used glass, epilor silicone, and plain old plastic.
I've used air for SCS and NSS-PF for ESI's.

I did not like the feel of the silicone or the cost of the glass. I use cheap plastic 10cc syringes as my LOR syringe.

I use NSS because it feels good compared to air and it is readily available.

People will use what they trained on or have become comfortable with.
The science does not discriminate until it comes to wet taps. But that is a function of needle type and gauge- and probably a separate thread...

just as clarification, you use a cheap plastic 10cc LOR syringe? not a like a BD generic syringe, right?

 

[Jcm800]

I find it hard to believe a cc or so of normal saline is going to affect
the conductive medium?

Everyone I know uses NS for SCS.

believe it. two things, saline, like 2-3 cc. Its when you arent sure, you get a loss, you check again, you chekc a third time, and by that time its like 3 cc of saline...


also wet taps... that CSF will screw you up. Done that also. No stimulation, didnt know what to do. impedience were fine, replaced the leads, etc. everything i could do, i idid. Still no stim. Anchored, taped, sent to the recovery area, sat patient up, and waited. got stimulation....

 

[deco]

I have been using a normal plastic 5 ml syringe and a 22G spinal needle Yale BD for my last 2000 or so IL epidurals (L,C and T) uneventful. I am using saline and always check on cross-table in case of doubt about depth, inject dy to asses the ensuing dispersal and that's all folks!

 

[SleepIsGood]

I have been using a normal plastic 5 ml syringe and a 22G spinal needle Yale BD for my last 2000 or so IL epidurals (L,C and T) uneventful. I am using saline and always check on cross-table in case of doubt about depth, inject dy to asses the ensuing dispersal and that's all folks!

u are using spinal needles to do an epidural?

 

[axm397]

This is why i use saline, less chance of pneumocephalus, and i have had the saline thing with SCS happen to me. I use air only now for SCS. Saline for the rest...

We used sterile water for SCS trials - apparently, that doesn't effect conductance as much as saline.

 

[Ligament]

Here in Washington, radiologists do more pain procedures collectively than dedicated Pain Medicine specialists. They almost always use spinal needles. I've never seen a report where they specify a touhy needle. Also, most use a hanging drop technique. I don't think I've ever read a report where loss of resistance was used.

 

[Finally M3]

When doing an interlaminar, glass syringe with saline, Tuohy needle.

Don't do em much tho.

 

[deco]

I have been using a spinal needle for the last 10 years but always used LOR with saline (normal plastic 5 ml syringe). In my residency training nobody used hanging drop technique for epidural detection. Actually, I don't think it's used anymore by Anesthesiologists at least by the Catalonian Spaniards (Barcelona). I read time ago in Anaesthesia jorunal that hanging drop was consistently associated with greater number of dural taps. Anyway, if one makes up his/her mind and uses an spinal needle: the LOR is very clearly felt and checking it on lateral projection you will gauge that everything is going properly. Btw, is more comfortable for the patient (only a 22G), they are happy, and much more cheaper!

 

[Jcm800]

I have been using a normal plastic 5 ml syringe and a 22G spinal needle Yale BD for my last 2000 or so IL epidurals (L,C and T) uneventful. I am using saline and always check on cross-table in case of doubt about depth, inject dy to asses the ensuing dispersal and that's all folks!

so a regular old plastic syringe? that comes in a packet in the all sizes with the black rubber plunger? im just asking because i have never seen or tried this, but man it would be economical...

 

[SSdoc33]

so a regular old plastic syringe? that comes in a packet in the all sizes with the black rubber plunger? im just asking because i have never seen or tried this, but man it would be economical...

i use the el cheapo plastic guys with the black plunger and feel that it gives a BETTER LOR than the fancy syringes when used with saline. never had a problem with it. give it a shot (so to speak), i think you'll be surprised.

 

[Jcm800]

i use the el cheapo plastic guys with the black plunger and feel that it gives a BETTER LOR than the fancy syringes when used with saline. never had a problem with it. give it a shot (so to speak), i think you'll be surprised.

next intralaminar i do i will try that. im a little nervous since the only interlaminars i do are in the neck just about, so i will wait till i do one in the lumbar spine...Just a 5 cc? have you ever used saline with it?

 

[deco]

Yes 5 ml normal plastic syringe, really clear LOR feeling but you are right better begin in safe waters, i.e. lumbar ones, but once you get confident you will be using it for your cervical and thoracic epidurals as well. Really economic. Anyway, I am always talking about 'ISIS epidurals', that is image-guided blocks never blinded!

 

[SSdoc33]

next intralaminar i do i will try that. im a little nervous since the only interlaminars i do are in the neck just about, so i will wait till i do one in the lumbar spine...Just a 5 cc? have you ever used saline with it?

i actually use a 3mL, but 5mL would work fine. load it up with saline and you are all set. no mess with the glass syringes, having to wet them beforehand, or those plastic ones with the large foam stopper that is awkward and can give you a false sense of security. there are less moving parts. its kind of like a car without power steering. you get a better sense for the feel of the road.

 

[PMR 4 MSK]

So instead of saline, why not just use contrast? That way when you lose resistance, you also have a nice epidurogram to confirm placement without changing syringes?

 

[Jcm800]

So instead of saline, why not just use contrast? That way when you lose resistance, you also have a nice epidurogram to confirm placement without changing syringes?

you always push a little of the fluid, saline, water, contrast in, as you are checking for resisitance, so sometime you will make it difficult to see if you are pushing hard with constant pressure...IMHO

 

[SSdoc33]

So instead of saline, why not just use contrast? That way when you lose resistance, you also have a nice epidurogram to confirm placement without changing syringes?

i guess you could once you are in the ligament, but id still want to start with saline so that i know where i am before i get there. id still have to switch, b/c i wouldnt want to muck around my field of view

 

[deco]

I am using the 5 ml syringue ( not filled up, only 4 ml saline) to detect the epidural space and when feeling the sudden LOR change it and inject 0.5 ml of dye with anoter, 2 ml, syringue then inject the 3-5 ml volume of steroid with my 10-ml syringue. Cannot get wrong.

 

[ampaphb]

So instead of saline, why not just use contrast? That way when you lose resistance, you also have a nice epidurogram to confirm placement without changing syringes?

1) false loss dorsal to the ligament. 2) it would discourage you from injecting until you are certain you have engaged. In the setting of attenuated or even absent ligaments, I personally would be biased to go deeper to avoid messing up my image, and would be far more likely to end up with a wet tap.

2cc of saline in a 3 cc syringe for me. (followed by 3cc of contrast to asses flow, then 1cc of 1% lido test dose, wait a minute, then 3cc steroid mixed with marcaine).

I know some guys use 5cc syringes so as not to confuse the two clear solutions. My staff always puts saline at 12 o'clock on the tray, lido on the left, and the steroid on the right (no, we don't get pre-made trays)

 

[mille125]

for SCS: Once I am close to the epidural space, I place the guide wire into the tuohy needle. When you enter the epidural space, the guidewire will thread (similar to seldinger technique). This skips the saline step all together.


for lumbar ILESI: glass syringe with LOR to air (trained with it, trust it, minimal issues)
for cervical ILESI: hanging drop (superior technique in my hands)

 

[DigableCat]

I use 50/50 air/saline for a buoyancy effect. Our trays have been glass syringes as of late. Once you get used to one type, it's difficult to go back. But I've done it before.

I know some guys use 5cc syringes so as not to confuse the two clear solutions. My staff always puts saline at 12 o'clock on the tray, lido on the left, and the steroid on the right (no, we don't get pre-made trays)

Using pre-printed label packs has obviated that need for me. Although I always use a 3cc syringe for contrast, 5cc syringe for injectate, and 10cc syringe for local; for consistency purposes. And when in doubt, put both under the fluoro...zap...and presto! confusion eliminated.

 

[deco]

I was trained to use glass and special plastic (Braun tray) in my residency and used it for ages. When I began to perform image-guided epidurals in my practice changed to standard common plastic 5 ml syringues for each and every block in my prone-patients (also cervicals and so hanging drop does nit apply). I use 5 ml because I am feeling that 2-3 ml is not enough volume to ascertain (detect) the space, besides I prefer that shape, it fits between my fingers, 2 is too small and 10 too cumbersome. On the other hand I feel it with lidocaine instead of saline and I am taking advantage of it and block the field (skin/subcutaneous/muscle/lamina) en route to the ligamentun flavum. Never uses dye, its viscosity hammpers the touch feeling and it could easily ruin the fluoro image, no way.

 

[SleepIsGood]

for SCS: Once I am close to the epidural space, I place the guide wire into the tuohy needle. When you enter the epidural space, the guidewire will thread (similar to seldinger technique). This skips the saline step all together.


QUOTE]

Hey mille


That's interesting you brought that up. Apparently that's the neurosurgeon's way to find the epidural space.

Went to a SCS course recently and they stated many neurosurg's use that method since they were never introduced to the LOR with syringe method.

The other reason to do it your way is that you can confirm everything since you are using fluro right in front of you.

My question though, isnt it easier to accidentally pierce the dura? And/or have you been able to 'cannulate' any other space falsely? I'm sure you were able to 'correct' it since you had fluro.

 

[mille125]

for SCS: Once I am close to the epidural space, I place the guide wire into the tuohy needle. When you enter the epidural space, the guidewire will thread (similar to seldinger technique). This skips the saline step all together.


QUOTE]

Hey mille


That's interesting you brought that up. Apparently that's the neurosurgeon's way to find the epidural space.

Went to a SCS course recently and they stated many neurosurg's use that method since they were never introduced to the LOR with syringe method.

The other reason to do it your way is that you can confirm everything since you are using fluro right in front of you.

My question though, isnt it easier to accidentally pierce the dura? And/or have you been able to 'cannulate' any other space falsely? I'm sure you were able to 'correct' it since you had fluro.

You can falsely "cannulate" other spaces but it would be very unusual to insert the guidewire more than a few millimeters into a false space. Similar to placing a labor epidural during residency. If the catheter goes in more than a few centimeters than it is likely epidural. As you said, this is done under flouroscopic guidance. In my mind this is still a loss of resistance technique with the catheter encountering the loss of resistance.

Why do you think that this technique could cause a dural puncture? Most people who perform SCS use the guidewire at some point anyway. Why would placing the guidewire be any more hazardous than threading the stimulator lead?

 

[Disciple]

This is why I like using catheter for cervical ESIs. LOR and then see if the catheter slides up.

 

[SleepIsGood]

well I suppose more theoretically...wouldnt one be using more 'force' to pierce through the ligamentum flavum inorder to be in the epidural space? Whereas, once you know sort of that you are in the epidural space you can 'more softly' glide the gidewire into the epidural space when you are just confirming.

Never tried this technique yet except on cadavers. I just learned about it. I dont think any attending would allow me to try this technique...sooo....I guess I have to wait a year.

You can falsely "cannulate" other spaces but it would be very unusual to insert the guidewire more than a few millimeters into a false space. Similar to placing a labor epidural during residency. If the catheter goes in more than a few centimeters than it is likely epidural. As you said, this is done under flouroscopic guidance. In my mind this is still a loss of resistance technique with the catheter encountering the loss of resistance.

Why do you think that this technique could cause a dural puncture? Most people who perform SCS use the guidewire at some point anyway. Why would placing the guidewire be any more hazardous than threading the stimulator lead?

 

[mille125]

well I suppose more theoretically...wouldnt one be using more 'force' to pierce through the ligamentum flavum inorder to be in the epidural space? Whereas, once you know sort of that you are in the epidural space you can 'more softly' glide the gidewire into the epidural space when you are just confirming.

Never tried this technique yet except on cadavers. I just learned about it. I dont think any attending would allow me to try this technique...sooo....I guess I have to wait a year.






i have never seen a guidewire pierce the ligamentum flavum but I guess anything is possible...

 

[SleepIsGood]

So this business of a 'pneumocephalus'....i dont think it is 'real' if you do LOR to air with about 2mL, at the most 3 mL. Yes, you can fill the plunger with 5mLs of air, but you shouldnt give more than say 3mL. Then I would just switch over to giving saline through the Touhy and then continue with your routine...

I've done perhaps 500-600 epidurals now, and this is how I've been doing them....never had a 'pneumocephalus' yet. I think you get those when you inject 'alot' of air.

 

[lobelsteve]

So this business of a 'pneumocephalus'....i dont think it is 'real' if you do LOR to air with about 2mL, at the most 3 mL. Yes, you can fill the plunger with 5mLs of air, but you shouldnt give more than say 3mL. Then I would just switch over to giving saline through the Touhy and then continue with your routine...

I've done perhaps 500-600 epidurals now, and this is how I've been doing them....never had a 'pneumocephalus' yet. I think you get those when you inject 'alot' of air.

Seen one case on an IL-CESI using 10cc syringe with 3cc NSS, LOR obtained but not recognized by the fellow. Ongoing LOR attempted with air and Pneumoencephelogram obtained (not billed for). Severe headache presented and patient sent from clinic to ER for MRI brain. Sx resolved in 3-4 days.

I was not present in the clinic that day, but AMPA may have been. (No, not his case).

 

[ampaphb]

I heard about the case the following day, similar to Steve

 

[Jcm800]

i have seen a pneumocephalus after a surgical CSE, that was rip roaring. MRI should lots of air in the ventricles. They did not quantitiate, and i dont know if they can.

I spoke with the anesthesiologist and he told me that he was able to easily do the CSE, and that he used saline/air combo, no more than 1-2 cc of air... so i dont know...

 

[SleepIsGood]

i have seen a pneumocephalus after a surgical CSE, that was rip roaring. MRI should lots of air in the ventricles. They did not quantitiate, and i dont know if they can.

I spoke with the anesthesiologist and he told me that he was able to easily do the CSE, and that he used saline/air combo, no more than 1-2 cc of air... so i dont know...

interesting....question do u belive that

 

[Jcm800]

interesting....question do u belive that

yes. and now that i think about it, i have seen a pneumocephalus in the OR with a spinal anesthetic, from just the the little drop of air left in the syringe. It was quick and severe, and was gone very quickly, i was at the VA, "supervising" a junior resident do a spinal for some ortho case...

i dont remember much more, but after the case, no headache, but near immediate, and improved prtty quick, but he also got a bunch of narcs for the case...

 

[deco]

Each and everyone using air says that in his/her hands no more than 2 ml of air is needed to detect the epidural space but, as anyone knows, sometimes it is a difficult task to find the space (elderly people, thoracic spine, degenerative disc disease with hypertrofic facets..) and more volumes of air are injected 'in crescendo' until the pneumoencefalus ensues. A few of my hospital colleagues published a dramatic case years ago (Revista Española de Anestesia, Balcells et al; is indexed and has an English abstract). So change to saline in case you have not made up your mind yet, a friend advice!

 

[powermd]

I've changed over to plastic and saline/air since starting PP, and it's worked well so far. I put a good head of constant pressure on the syringe as I'm approaching. We have wide tables where I work, making lateral images a real pain, so I always take a paramedian approach and touch lamina to be sure of depth before hooking up the syringe. We're upgrading to modern tables soon, so that shouldn't be an issue once obtaining a lateral becomes convenient. I got used to approaching with a lateral to guide me during fellowship, so this was a tough transition.

 

[sweetalkr]

As a CA-3 doing my 3rd month of OB (an "elective"), i have found that 1cc saline, 1cc air works well in a glass syringe. when I find the loss, I re-confirm the space with 2-3 more cc's of saline only.

if ya'll thread catheters (I know I won't in my pain fellowship next year, but just curious), how far do you thread it? I like to leave it in 5-6cm.

 

[Ligament]

The fact that our practice discourages the use of dye for epidurals was another one... I'm working on that though.

Wow man, I'm sorry to hear about that. I hope these are not pain specialists with this opposition to contrast....?

 

[Jcm800]

I've changed over to plastic and saline/air since starting PP, and it's worked well so far. I put a good head of constant pressure on the syringe as I'm approaching. We have wide tables where I work, making lateral images a real pain, so I always take a paramedian approach and touch lamina to be sure of depth before hooking up the syringe. We're upgrading to modern tables soon, so that shouldn't be an issue once obtaining a lateral becomes convenient. I got used to approaching with a lateral to guide me during fellowship, so this was a tough transition. The fact that our practice discourages the use of dye for epidurals was another one... I'm working on that though. Some compromises I'm just not going to make for economy. Check out the August Pain Physician with the article about six French cases of paraplegia after some pretty innocuous sounding injections, including a high lumbar interlaminar.

discouraging dye is crazy talk! it is part of the procedure. Do they want you to not use a needle for local either?

 

[Jcm800]

As a CA-3 doing my 3rd month of OB (an "elective"), i have found that 1cc saline, 1cc air works well in a glass syringe. when I find the loss, I re-confirm the space with 2-3 more cc's of saline only.

if ya'll thread catheters (I know I won't in my pain fellowship next year, but just curious), how far do you thread it? I like to leave it in 5-6cm.

4-5 in the lumbar, 3 in the thoracic.

count on the touhy the notches, it is easier then "measuring"

 

[powermd]

discouraging dye is crazy talk! it is part of the procedure. Do they want you to not use a needle for local either?

Without revealing too much, let's just say my boss trained in an austere environment where it was easy to become cavalier. The fact that he hasn't had any recognized complications in 10 years of practice gives him courage in his viewpoints- which include injecting the neuraxis in patients on Plavix!!!! This is another issue I put my foot down on. We'll be going ASRA guidelines all the way soon. There are still a few patients who expect injections even without stopping Plavix. They get real disappointed when I turn them away if my boss isn't around to do them- even after I explain my reasoning.

 

[mille125]

Without revealing too much, let's just say my boss trained in an austere environment where it was easy to become cavalier. The fact that he hasn't had any recognized complications in 10 years of practice gives him courage in his viewpoints- which include injecting the neuraxis in patients on Plavix!!!! This is another issue I put my foot down on. We'll be going ASRA guidelines all the way soon. There are still a few patients who expect injections even without stopping Plavix. They get real disappointed when I turn them away if my boss isn't around to do them- even after I explain my reasoning.

i say this with all seriousness....you need to get a new job....this guy is going to take you down.....why on earth are you continuing to work with him??????

No dye, neuroaxial blocks on patients with plavix, .....come on

 

[sweetalkr]

i say this with all seriousness....you need to get a new job....this guy is going to take you down.....why on earth are you continuing to work with him??????

No dye, neuroaxial blocks on patients with plavix, .....come on

i agree with mille, but you must be making a lot of money to incur that risk. PM me if you quit, cuz i'll take your job jk