Air over saline LOR technique

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NJPAIN

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Who wants to explain to this old guy the technique and advantages of “ air over saline” for LOR? I’ve used air, I’ve used saline and I’ve used hanging drop. Don’t really like any of them in the cervical spine so I’ve been using puffs of contrast in CLO view. It works but not too pretty.
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NJPAIN said:
Who wants to explain to this old guy the technique and advantages of “ air over saline” for LOR? I’ve used air, I’ve used saline and I’ve used hanging drop. Don’t really like any of them in the cervical spine so I’ve been using puffs of contrast in CLO view. It works but not too pretty.
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I’ve tried air, saline, with glass and plastic LOR syringes. I think I get the best sensitivity from a glass syringe with minimal saline just to lube the glass up, and getting LOR to air.
A lot of times the little bit of air gives a decent little air epidurogram in CLO even before you add contrast.

My background is anesthesia and I had to unlearn the instinct to dump a bunch of saline into the epidural space with my LOR
 
I start with saline and infrequently switch to air for some patients with really squishy ligamentum flavum
 
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No air over saline fans?? Everyone’s one or the other?
 
Saline in plastic syringe for ILESI.
Guide wire for SCS.
 
I use air over saline. I think it gives both a visual and tactile component. Purely on feel I think air may be better.

I use it but rely on contrast for CESI.
 
I think there’s some anesthesia studies out there that support equal efficacy of air or saline as long as you’re using what you are most comfortable with.
I trained with saline for ESI and air for SCS. Now I use a 3 mL syringe with contrast for ESIs. With the small syringe and no air bubble in it you get pretty good tactile feedback for LOR. SCS I still use air.
 
ragnathor said:
I use air over saline. I think it gives both a visual and tactile component. Purely on feel I think air may be better.

I use it but rely on contrast for CESI.
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How do you use it? Continuous pressure on plunger or intermittent? What’s the visual?

You don’t use it at all for cervical?
 
Air, plastic pulsator syringe, continuously tapping plunger. If I ger LOR but appears too superficial inject 1 mL saline and see if LOR maintained.
 
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I use contrast in a 3cc plastic syringe for LOR.
 
NJPAIN said:
How do you use it? Continuous pressure on plunger or intermittent? What’s the visual?

You don’t use it at all for cervical?
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Continuous. I would say I can see the air compressed and then decompress with loss, but perhaps it is just movement I'm conditioned to - either way I'm used to it and find it visually easier than air or saline alone.

I use LOR with majority of CESI but always enter CLO and confirm with contrast. If I have any questionable loss or feel even a touch on fluoro deep I'll use intermittent contrast.
 
NJPAIN said:
No air over saline fans?? Everyone’s one or the other?
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PGY3 applying pain, but every attending I've been with at my institution does air over saline in a plastic syringe for loss of resistance. I've never done anything else for ILESI. Constant slight pressure on plunger with one hand while advancing very slight intervals with the other hand. Then switch to contrast injected thru a tube while fluoro is live, followed by steroid injection thru the tube.

One thing I've noticed is that a lot of people here seem to not do live fluoro during contrast injection, but rather still images for contrast. Is this just to reduce radiation exposure over a career? Usually it's on for less than three seconds just to watch the spread.
 
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PainApp2021 said:
PGY3 applying pain, but every attending I've been with at my institution does air over saline in a plastic syringe for loss of resistance. I've never done anything else for ILESI. Constant slight pressure on plunger with one hand while advancing very slight intervals with the other hand. Then switch to contrast injected thru a tube while fluoro is live, followed by steroid injection thru the tube.

One thing I've noticed is that a lot of people here seem to not do live fluoro during contrast injection, but rather still images for contrast. Is this just to reduce radiation exposure over a career? Usually it's on for less than three seconds just to watch the spread.
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Interesting.
How about in the OR for epidural catheters?
 
NJPAIN said:
Interesting.
How about in the OR for epidural catheters?
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I'm PM&R-- I haven't been in the OR for years (vs procedure suite, at least) 🤣. Unfortunately I don't have any advanced procedure experience yet either.
 
all saline for me since that's how I trained, switched from glass in fellowship to plastic in practice. maybe I should try air.
 
When I was a fellow I tried doing saline in a glass syringe and I ended up spilling it all over the patient's back.

Ever since then I do air in a plastic syringe. Only drawback to it I've seen is that trainees consistently try to slam 5ccs of air in as soon as they get loss regardless of what I tell them beforehand. Makes me cringe every time.
 
use primarily saline mixed with a small amount of contrast (so I don't have to do extra fluoro image just to show contrast spread).

a case during residency - not involving me - where air was used for epidural placement lead to severe post-procedure headache and documented pneumocephalus.
 
Ducttape said:
use primarily saline mixed with a small amount of contrast (so I don't have to do extra fluoro image just to show contrast spread).

a case during residency - not involving me - where air was used for epidural placement lead to severe post-procedure headache and documented pneumocephalus.
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We had a fellow do this on CESI. Cool pneumoencephalogram at hospital, but full recovery. And that is not always the case.
 
air can be compressed. water cannot. i always get a clearer LOR with saline. i suppose it is how you train.

3 cc plastic cheapo syringe

and pneumocephalus is a legitimate concern, even if unlikely. the issue is that lots of patients get headaches after epidurals. most are a rxn to the steroid, but you dont need to even put pneumocephalus on your differential if you dont use air
 
Pneumocephalus isn't high on the differential diagnosis if you didn't slam several CCs of air into the subarachnoid space.

I probably put a maximum of 0.5cc of air in the epidural space when checking for loss. Even if its subarachnoid, any headache afterwards is probably CSF leak and unlikely to be a result of the air.
 
Baron Samedi said:
Pneumocephalus isn't high on the differential diagnosis if you didn't slam several CCs of air into the subarachnoid space.

I probably put a maximum of 0.5cc of air in the epidural space when checking for loss. Even if its subarachnoid, any headache afterwards is probably CSF leak and unlikely to be a result of the air.
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agreed.

try it with just saline. i think you will like it
 
Air, try to avoid injecting any significant volume. Problem I find with saline personally vs air is that in the longer smaller gauge tuohy there is a viscosity effect where there is a split second before the saline flows. I just don’t like that feeling.
 
The rationale for air over saline is you could bounce the plunger so it didn’t get stuck but still had most of the firmness of saline, and avoid pneumocephalus. If you know how to prep the glass syringe that doesn’t happen.
For landmark-based epidurals in the OR or L&D, my personal preference was strongly for the saline-only glass LOR syringe. About 3 mL, and the key was to cover the end of the syringe and apply pressure to drive saline up the side of the plunger and lubricate it. I tried air, and air over saline, but I felt like the compressibility of the air significantly reduced my sensitivity to the loss. Had an attending who personally received a pneumocephalus so she was pretty strongly against using air.
For fluoro-guided, especially with the use of CLO, I don’t think it really matters much. When I started out in practice I was using plastic LOR because the glass was so expensive, then I switched to just 3 mL syringe with contrast because you still get pretty good loss but it’s just a secondary backup to the fluoro.
 
callmeanesthesia said:
The rationale for air over saline is you could bounce the plunger so it didn’t get stuck but still had most of the firmness of saline, and avoid pneumocephalus. If you know how to prep the glass syringe that doesn’t happen.
For landmark-based epidurals in the OR or L&D, my personal preference was strongly for the saline-only glass LOR syringe. About 3 mL, and the key was to cover the end of the syringe and apply pressure to drive saline up the side of the plunger and lubricate it. I tried air, and air over saline, but I felt like the compressibility of the air significantly reduced my sensitivity to the loss. Had an attending who personally received a pneumocephalus so she was pretty strongly against using air.
For fluoro-guided, especially with the use of CLO, I don’t think it really matters much. When I started out in practice I was using plastic LOR because the glass was so expensive, then I switched to just 3 mL syringe with contrast because you still get pretty good loss but it’s just a secondary backup to the fluoro.
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do you have pics of the CLO for lumbar area?
 
I trained with glass and saline to LOR during residency/fellowship. No contrast. In the OR and L&D ward I have used both plastic and glass with both air and saline. These are my arguments:

AIR:
Pro: Better "feel" (Subjective), able to tell if CSF, simpler to prepare
Con: Possible pneumocephalus if using injection-of-air technique instead of loss-of-resistance technique, possible patchy block if using for anesthesia

SALINE:
Pro: Better "feel" (Subjective), no pneumocephalus, more reliable block if using for anesthesia
Con: Harder to tell if CSF, more labor intensive to prepare.

GLASS:
More expensive, more steps to prepare syringe. Glass plunger can slide out if the patient is sitting up and you're not careful.

PLASTIC:
Cheaper, simpler

In the OB ward and during SCS, I use plastic with air because it's less steps and more reliable for noticing CSF. In the pain clinic, I use 25G quinke and CLO with intermittent contrast. No LOR.
 
I recently switched from glass to plastic and saline. Sometimes the glass syringes have grit and a stopping point where you will miss loss. This isn't the case with plastic. Besides pneumocephalus, the loss of resistance with air is sometimes so dramatic that you end up squirting in a few cc's of air into epidural space which hurts in c spine.
 
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