L5/S1 discograms

[onechance]

Any advice/pearls regarding disco at this level. This seems to be the most challenging level of all, with max paresthesia. Dos and Donts in general.

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[NOSfan]

1. Square up the end plate.
2. Use live fluoroscopy when going oblique for extra-pedicular approach to get the optimal approach.
3. Use a two needle coaxial technique with a 6 inch or 8 inch 25-guage needle.
4. Slightly bend the tip to help you maneuver.

 

[Aether2000]

The above approach is the best. Targeting the superior border of the disc as you cross the SAP is less painful but more risky due to proximity of the exiting L5 spinal nerve. The inferior or mid points of the disc are safer targets but it does become slightly more painful as one moves inferiorly along the SAP.
Tricks: if a coaxial approach doesn't work you can try more of a bend on the last 1 cm of the needle (30 deg) then helicopter the needle to the lateral border of the SAP, then use the curve to help guide it medially and anterior into the disc. High iliac crest- use a 2 needle approach with one placed with a 30 deg cephalocaudad trajectory along the lateral border of the SAP, then use a second needle to target the needle tip of the first needle as a first approximation. Other tricks: transdural midline with a 15 deg bend in the needle or extradural intracanal approach moving the needle around the lateral border of the dura, then into the disc.

 

[lobelsteve]

Cranial tilt more. Rotate oblique more. Form a triangle between SaP, iliac, lower endplate of L5. Shoot the hole and turn medial.


Or just go transthecal down the middle. Ick

 

[facets]

This is a procedure in search of an indication IMHO. What are you going to do with the information?

 

[mid|ine]

Have any of you done transdural/thecal? I'm quite sure I did as a resident when doing blind spinals, but the thought just seems wrong and I don't know if it would be considered "standard of care".

 

[lovebailey2001]

Algos! What is Extradural-intercanal approach? and how can one possible do this.

 

[onechance]

How do you do extra dural, intracanal approach?? Landmarks of needle entry, Carm angle etc...
Pl share.

 

[NOSfan]

Have any of you done transdural/thecal? I'm quite sure I did as a resident when doing blind spinals, but the thought just seems wrong and I don't know if it would be considered "standard of care".

Transdural aka Transthecal approaches are still taught and used today. In fact, this was the "classic" approach. The various approaches are (extra-pedicular, transdural/transthecal and lateral)

Here's where one might be utilized:
1. Extensive os preventing a extra=pedicular or lateral approach
2. Hardware preventing other approaches.
3. Patient's anatomy in the way esp. at the L5-S1 level.

I recommend a 25-guage needle which is smaller than most standard LP needles (22 or 20-guague). Use similar approach as an LP with needle bevel parallel to entry and one a pass manner.

https://www.radiology.wisc.edu/sections/msk/interventional/Discography/index.php

 

[101N]

Transdural aka Transthecal approaches are still taught and used today. In fact, this was the "classic" approach. The various approaches are (extra-pedicular, transdural/transthecal and lateral)

Here's where one might be utilized:
1. Extensive os preventing a extra=pedicular or lateral approach
2. Hardware preventing other approaches.
3. Patient's anatomy in the way esp. at the L5-S1 level.

I recommend a 25-guage needle which is smaller than most standard LP needles (22 or 20-guague). Use similar approach as an LP with needle bevel parallel to entry and one a pass manner.

https://www.radiology.wisc.edu/sections/msk/interventional/Discography/index.php

1+. I've had to do a couple in folks who have had PLIFs with exuberant callus formation @ 5/1. If you have to do it remember: DO NOT MIX ANCEF WITH YOUR CONTRAST...

Pain Physician. 2004 Jan;7(1):103-6.
Intrathecal cefazolin-induced seizures following attempted discography.
Boswell MV, Wolfe JR.
Source
Pain Medicine Fellowship, Department of Anesthesiology, Case School of Medicine and University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, Ohio 44106, USA. [email protected]
Abstract
This report describes a 39 year-old woman who underwent attempted discography and intradiscal electrothermal therapy (IDET) of the L5/S1 intervertebral disc. The procedure was abandoned after multiple unsuccessful attempts to cannulate the disc. The case was complicated by at least two lumbar dural punctures, confirmed by injection of nonionic contrast that contained 12.5 mg/mL of cefazolin, included for prophylaxis of discitis. About 45 minutes later the patient developed severe back pain. Shortly thereafter she became progressively agitated and confused, and developed intractable seizures and coma. Despite aggressive treatment the patient could not be resuscitated and expired several hours later. Convulsions were initially attributed to an adverse reaction to meperidine and promethazine, given for the back pain, however this explanation proved to be untenable. In addition, the accidental administration of an ionic contrast agent, such as Hypaque(R), was excluded. Based on a detailed review of the case and the literature, it was concluded that the patient succumbed from an unintentional dose of intrathecal cefazolin, which had been diluted in the nonionic contrast agent that was used to confirm needle placement. Available evidence indicates that cefazolin is a potent epileptogenic agent when given intrathecally. The facts of the case and the evidence supporting the conclusion are presented. It is recommended that cefazolin not be mixed with the contrast agent used to document initial needle placement during discography.

 

[Aether2000]

Extradural interlaminar approach is performed with the patient in the lateral decubitus position and with a curve on the needle, last inch to the tip. The approach is via the up side, start at the midline and angle the needle to touch the lateral border of the upside lamina, the advance off the lamina and advance in the lateral epidural space over the lateral border of the dura. The dura will be displaced to the down side leaving a clear passage to the disc. Once in the annulus, the curve on the needle is used to readjust the needle tip in the centrum of the disc.

 

[lovebailey2001]

Algos can u plz post some of pix of this extradural, intralaminar approach! I am having difficulty in imagining the required curves in the needle, will there be two curves at the far end of needle? Also, what are possible indications of this approach...

 

[caedmon]

It's all about the banana bend

 

[Aether2000]

I will have to see if I can dig up some of my old pics of this. There is one bend in the needle only. The purpose is to be able to enter the disc when it is impossible to access using an extrapedicular approach due to SAP hypertrophy or posterior disc osteophyte overgrowth/narrow posterior disc space preventing ingress of the needle into the disc.

 

[101N]

Extradural interlaminar approach is performed with the patient in the lateral decubitus position and with a curve on the needle, last inch to the tip. The approach is via the up side, start at the midline and angle the needle to touch the lateral border of the upside lamina, the advance off the lamina and advance in the lateral epidural space over the lateral border of the dura. The dura will be displaced to the down side leaving a clear passage to the disc. Once in the annulus, the curve on the needle is used to readjust the needle tip in the centrum of the disc.

It would be interesting to do this post-myelogram to see where your needle, the dura, and the dural root sleeves actually are.

 

[PinchandBurn]

It would be interesting to do this post-myelogram to see where your needle, the dura, and the dural root sleeves actually are.

then do it, and post a pic


would be intersting to see

 

[101N]

then do it, and post a pic


would be intersting to see

I'd be a little concerned about flossing the dural root sleeve or encountering a conjoined root. It doesn't come up very often, but when it does I'll use a 25g and due a transdural approach using Vanco.