Radiation exposure- particularly to the hands and eyes...

[minstral]

SHould this be a concern for someone considering pain medicine?
The doc iI've been learnign from gets a lot of hand exposure, much by his own choosing, (activiely manipulationg while under fluroscopy).
He says the leaded gloves just make the c-arm shoot out more.
He also "lost" his leaded eyewear.

in your expeience, is this a serious danger? anecdotally anyone you know get sick?
are other people just more careful?

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[lobelsteve]

SHould this be a concern for someone considering pain medicine?
The doc iI've been learnign from gets a lot of hand exposure, much by his own choosing, (activiely manipulationg while under fluroscopy).
He says the leaded gloves just make the c-arm shoot out more.
He also "lost" his leaded eyewear.

in your expeience, is this a serious danger? anecdotally anyone you know get sick?
are other people just more careful?

Try not to learn too much from this doc. He needs a refresher in radiation safety. Increased risk of cataracts, poor form putting his hands im fluoro.

 

[Columbus99]

I am also concerned about the risks to radiation exposure. I would like to do interventional pain mgt. Can you actually see out of those goggles? Is it like wearing a welder's helmet which makes everything very dark? And do the gloves interfere with your precision?

 

[Aether2000]

Only an utter fool would do live manipulation of anything with their hands in the beam. The radiation received is 50 times more than if the hands are moved a foot out of the beam. You should use your education from this physician as an example of exactly what-not-to-do.
Eye exposure is moderate in the AP view but if the beam is aimed contralateral oblique (rotated 30-45 degrees off the AP away from physician), the eye exposure is significant. Lateral views also produce significant eye exposure, especially with gigantic patients. Eyewear comes in glasses, goggles, or prescription glasses. None are shaded, and they do not interfere with the visualization for procedures.

 

[lobelsteve]

I like my glasses.
Non-Rx at barrier online
Paid by the practice.

I think gloves are a waste of money- I like extension tubing to keep my hands out of the beam.

A glove in the beam is worth 2 in the head. Or something like that. If a machine is on auto (and most are always on auto), a glove in the beam will raise the radiation output significantly.

 

[Doctodd]

good machines also have a pulse setting and a low dose setting which decrease the amount of radiation....i use glasses every time and have no problem seeing. I use gloves but that is mostly for scatter. The only thing he said correctly was that the machine will increase the dose if it needs to.

T

 

[ampaphb]

I think gloves are a waste of money- I like extension tubing to keep my hands out of the beam.

Extension tubing is not useful, in my experience, for precision needle placement. I do find it helps quite a bit once you are ready to inject, however.

 

[minstral]

Let me just say he's a very good doc in many aspects, gets good results in all procedures he does. injections, spinal cord stims, vetebra and kyphoplasties etc.etc. Why he is not more careful in this aspect I dont know, but duly noted for my future.

 

[lobelsteve]

Extension tubing is not useful, in my experience, for precision needle placement. I do find it helps quite a bit once you are ready to inject, however.

Some of us believe injecting contrast under live fluoro is beneficial.

Zinger.

 

[ampaphb]

Some of us believe injecting contrast under live fluoro is beneficial.

Zinger.

Almost all of us believe THAT!

 

[Tenesma]

- low pulse
- very rare shots except for contrast administration
- if doing multiple levels then use multiple needles at same time
- wear eye-shields (mine are light-weight and fit over my glasses and are pretty comfy)
- minimize lateral/contra-lateral obliques as much as possible
- have a good x-ray tech who understands what your goal is - that way you don't have to shoot over and over again

* there is no excuse for doing manipulation under fluoro with your hands in the way

* the longer the extension tubing the further away you can stand - i have microbore tubing that is about 18 inches long and only holds about 0.9ml of contrast (so not too much gets wasted)

 

[ampaphb]

if doing multiple levels then use multiple needles at same time

How does using multiple needles reduce radiation exposure?

 

[md2k]

When using multiple needles (3 or 4) you can place them and take spot pics with pulse. In between pics adjust your needles.

Reduces exposure to pt and physician, and cuts procedure time by at least 50%

 

[Tenesma]

let's say you are going to do a 3 level MBB - you place all 3 needles at the same time and advance all three before shooting fluoro - look at image - re-position each individually - then re-advance...

i thought this was a no-brainer - guess not

 

[Ligament]

let's say you are going to do a 3 level MBB - you place all 3 needles at the same time and advance all three before shooting fluoro - look at image - re-position each individually - then re-advance...

i thought this was a no-brainer - guess not

This is common practice but only amongst those with advanced skills and a desire to reduce radiation...many people still simply do not care...

 

[ampaphb]

This is common practice but only amongst those with advanced skills and a desire to reduce radiation...many people still simply do not care...

I believe my skills are sufficient to perform these tasks, but do not see how any fewer images are required - clearly I am just being dense

it seems to me that it takes the same number of images to place a second and third needle regardless of whether needle #1 has already been placed in position

 

[lobelsteve]

I do not see any way it can reduce radiation. As far as procedure time, the only benefit would be the 10-30 seconds it takes to place a needle can be done while the adjacent level is cooking.

 

[Tenesma]

let's say it take 0.2-0.3 seconds per needle for a lumbar MBB - if you were doing each needle separetely.

now if you do three needles at the same time you can cut your fluoro time by 2/3!!!

i take a fluoro with markers - adjust markers (in my case it is the tip of a 16g needle) - this takes about 0.2 secs -

then i place 3 needles

then i fluoro to confirm needles are generally in correct area

then i advance all three needles

then i fluoro to confirm to make sure each needle is going to its intended target

then i re-advance all needles

usually by this time i am very close to the target

i re-fluoro to confirm good positioning

voila - very little fluoro compared to doing one needle at a time...

please tell me i am not the only one (beside ligament) doing this...

 

[minstral]

Great discussion guys... keep it up.
I tell my mentor I read about this somewhere as way to imrpove effeciency and reduce expsure.

 

[Ligament]

Yes Tenesma this is the way I do it as well...

let's say it take 0.2-0.3 seconds per needle for a lumbar MBB - if you were doing each needle separetely.

now if you do three needles at the same time you can cut your fluoro time by 2/3!!!

i take a fluoro with markers - adjust markers (in my case it is the tip of a 16g needle) - this takes about 0.2 secs -

then i place 3 needles

then i fluoro to confirm needles are generally in correct area

then i advance all three needles

then i fluoro to confirm to make sure each needle is going to its intended target

then i re-advance all needles

usually by this time i am very close to the target

i re-fluoro to confirm good positioning

voila - very little fluoro compared to doing one needle at a time...

please tell me i am not the only one (beside ligament) doing this...

 

[PMR 4 MSK]

let's say it take 0.2-0.3 seconds per needle for a lumbar MBB - if you were doing each needle separetely.

now if you do three needles at the same time you can cut your fluoro time by 2/3!!!

i take a fluoro with markers - adjust markers (in my case it is the tip of a 16g needle) - this takes about 0.2 secs -

then i place 3 needles

then i fluoro to confirm needles are generally in correct area

then i advance all three needles

then i fluoro to confirm to make sure each needle is going to its intended target

then i re-advance all needles

usually by this time i am very close to the target

i re-fluoro to confirm good positioning

voila - very little fluoro compared to doing one needle at a time...

please tell me i am not the only one (beside ligament) doing this...

So I finally decided to try it this way, and wow, it does make things much faster! Rad time much lower too. Call me slow...

 

[mille125]

let's say it take 0.2-0.3 seconds per needle for a lumbar MBB - if you were doing each needle separetely.

now if you do three needles at the same time you can cut your fluoro time by 2/3!!!

i take a fluoro with markers - adjust markers (in my case it is the tip of a 16g needle) - this takes about 0.2 secs -

then i place 3 needles

then i fluoro to confirm needles are generally in correct area

then i advance all three needles

then i fluoro to confirm to make sure each needle is going to its intended target

then i re-advance all needles

usually by this time i am very close to the target

i re-fluoro to confirm good positioning

voila - very little fluoro compared to doing one needle at a time...

please tell me i am not the only one (beside ligament) doing this...

makes perfect sense to me

 

[Mister Mxyzptlk]

A 25g 3.5" spinal needle costs about $3 (we are in the wrong business in case you haven't already noticed). 100 procs/month using 2 extra needles costs about $600.

If you just use 1 needle at a time you can use your savings to buy a 1-hour "date" with a 4-diamond escort from the Emperor's Club every other month (or you could before Elliot Spitzer ruined it for everybody).

It's all about priorities.

 

[Tenesma]

my 25g 3.5 inch needles are $2.70... if using 2 extra needles (ie: $5.40) allows me to move along quicker and squeeze more procedures into my time slot (2hrs/day) then it is a minimal expense... not to mention less radiation for me and patient...

 

[Doctodd]

are you guys talking about plain old spinal needles?....i think i just asked my rep about this last week, but my 3" 25 or 22G cost $1.65 or so. Who are you guys using?

T

 

[Mister Mxyzptlk]

T - I don't know offhand what I pay. I just went to Google shopping and that seemed what they were going for - a little under $3 each. I think $1.65 is a great price. Are they made in China from recycled lead toys?

Tenesma - My post was in jest, but let's play it out - just how many seconds are you saving for your $5 extra cost?

Suppose you save 20 seconds per case, which I think is on the high side. You'd need to do 45 cases to squeeze out an extra 15 minute procedure and the added needle cost would be $225.

You would also have to do these these multi-needle cases consecutively. If you did 3 of these multi-needle procedures during the course of a morning you are only buying yourself 1 minute.

There's also the problem of parallax since only one needle can be in the center.

The real benefit is the radiation safety.

 

[Tenesma]

parallax hasn't been too much of an issue because the needles tend to be in the middle 2/3rds of screen

time yourself with 1 needle and then with 3 needles simultaneously - while the fluoro-time difference is measured in seconds - we are talking about minutes in actual time difference...

 

[Doctodd]

My needle prices are from PSS for whoever wants them....$41.29 for a box of 25 for the PSS generic brand needles and the other name brand is 33.75 for a box of 20.

T

 

[lobelsteve]

This is for MBB's.

How about the cost of RF needles. I've seen prices range from $19-44 per needle. So using 3 of these per case would be quite costly. I guess that's called macroeconomics.

 

[Mister Mxyzptlk]

I went through my x-ray logs and I average about 1.5 - 2 minutes of fluoro for 3 MBBs bilaterally. How can I save "minutes"?

 

[Tenesma]

60 to 90 seconds of fluoro for 3 MBB bilaterally??????

holy cow - i am hoping you mis-spoke, because 3 MBB bilaterally is about 8-10 seconds (occasionally goes to 14 secs) for me... 60-90 secs is a LOT of fluoro time... please clarify.

 

[Mister Mxyzptlk]

I asked my office manager to get me the times.I'll go back and check it myself. Some of that could be explained by the difference in technique, since one would expect your way to reduce fluoro time by 2/3.

Nonetheless, if your total fluoro time is 10 secs how does reducing fluoro time by 2/3 save you "minutes"? One would think the number of needle manipulations would be the same no matter how much fluoro you use.

 

[Tenesma]

i think we are talking about two different time measurements

total procedure time: time to get in room, patient on table, prep/drape, do procedure, get patient off the table and out of room, and room turnaround for next case

total fluoro time: time spent with my foot on the pedal.

measure your total procedure time with 3 needles and then with 1 needle... also make sure that you aren't sticking with old habits - you HAVE to adjust all three needles towards the target between each fluoro pulse...

i do the same thing with RF - arguably the needles are more expensive, but again the time i shave off allows me to squeeze in another procedure...

also patient satisfaction is up because the procedure goes by quicker for them (remember i don't use sedation).

 

[Mister Mxyzptlk]

S = fluoro shot
M = needle movement

Assumption: 3 needle movements per level.

Three needles at once:

S-M-M-M
S-M-M-M
S-M-M-M

This is 3 fluoro shots and 9 needle movements

One at a time:

S-M, S-M, S-M
S-M, S-M, S-M
S-M, S-M, S-M

9 fluoro shots and 9 needle movements

Unless doing these 3 at a time makes you somehow more facile, you are still taking the same time for needle movements. The only difference is in the fluoro time. You gave us a value of 10 secs for fluoro, so I'll triple that for the single-level method, which adds 20 secs.

That is why I don't see how your technique can save "minutes" per procedure. Everything else is procedure-independent, except maybe the turnover is a little longer with your way because they have to open 2 extra needles.

(I also found out why my fluoro times came out so high. My RN quit a few weeks ago and I had a temp running the c-arm. She was recording the mA into the radiation log instead of the exposure time at the end of the case, so we had a bunch of 3 & 4 minute fluoro times recorded there. Nothing will ever be foolproof because fools are so clever.)

 

[Tenesma]

try it once and tell me what you think

 

[SSdoc33]

let's say it take 0.2-0.3 seconds per needle for a lumbar MBB - if you were doing each needle separetely.

now if you do three needles at the same time you can cut your fluoro time by 2/3!!!

i take a fluoro with markers - adjust markers (in my case it is the tip of a 16g needle) - this takes about 0.2 secs -

then i place 3 needles

then i fluoro to confirm needles are generally in correct area

then i advance all three needles

then i fluoro to confirm to make sure each needle is going to its intended target

then i re-advance all needles

usually by this time i am very close to the target

i re-fluoro to confirm good positioning

voila - very little fluoro compared to doing one needle at a time...

please tell me i am not the only one (beside ligament) doing this...

don't you then need 3 separate 16 gauge markers? if thats the case, then you are increasing your cost. if its not the case, and you place all 3 needles with the same marker, then you are essentially doing separate procedures up until this point and taking extra shots. agreed that after all the needles are placed, manipulating all 3 saves time and rads.

 

[Tenesma]

good point - i use one marker - the 16g needle that i use to draw up extra meds (it is in the kit already)

i use the marker to find the first spot - and place the needle

i place the marker for the 2nd spot - adjust the first needle and place the 2nd needle

i place the 3rd needle at an equivalent distance above the 2nd needle without using a marker

then the games start.

 

[NEPain]

This technique does sound like it might speed things up a little at the cost of extra needles, but my concern lies more with accurate placement.

I'm typically not happy unless my needle is in its final position under "tunnel vision", which would be impossible if I have three needles being placed. I would say the only way to know for sure where your tip is, is if you view the needle in "tunnel vision" and then do a lateral to assess depth.

 

[ampaphb]

Now now - you can't do 14 quality procedures in 2 hours if you are concerned about minor little details like accuracy.

Of course, in the case of MBB's, you can make up for that by using 0.75-1.0 cc of local at each level, as many of my colleagues in the community do, rather than the 0.3cc called for by ISIS guidelines.

 

[Tenesma]

ampa - i average 10 procedures in 2 hours - not 14

1) if you want to be speedy then you can use M. Stojanovic (MGH) technique of one-needle MBB - please review
A prospective crossover comparison study of the single-needle and multiple-needle techniques for facet-joint medial branch block.Reg Anesth Pain Med. 2005 Sep-Oct;30(5):484-90.

2) parallax not a real issue as long as your needles are primarily in the middle 2/3rds of intensifier

3) you can easily do all 3 needles in a co-axial view - you don't have to do one at a time for it to be truly co-axial - that makes no sense

4) all MBBs are done with tuberculin syringes with a total of 0.3ml for lumbar and have recently reduced cervical mbb to 0.2ml (after injecting 0.3ml of contrast it spreads everywhere including over into the neural foramen)...

 

[NEPain]

I probably shouldn't have used the word "impossible". Pt's often squirm when I inject skin local or if I use a 25 ga without local. Assuming no patient movement and accurate marking of entry point, then you're correct that all three can be co-axial views.

I've also found that in some patients, a good view of where I want my needle tip can't be obtained for L3,4,5 without changing my c-arm rotation. For MBB's, local spread probably compensates for lack of perfect accuracy, but for RF, I think that it is not uncommon to have a spine where it is not possible to get a good coax view of all three levels without moving the c-arm.

Do you mark your entry points before prepping or after?

 

[Tenesma]

after prep -

i am a bit more fastidious w/ positioning for RF - so my dorsal ramus L5 is usually at a different angle than the levels above