Alternative to cervical interlam esi

[hyperalgesia]

So I have a question. I’ve had my fair share of CESIs that felt great however looked deep on CLO primarily bc I inadvertently crossed midline. I’ve had a few though that looked deep even though they appeared midline in AP. I chalked this up to not having a true AP or not obliquing enough on my CLO. If the loss felt right I’ll still inject. So my question is, if you’re going slow and using an 18g touhy there’s no way you could pith the cord and or inject into the cord without the patient screaming out in pain? I always inject slowly and if there’s any question I’m talking to the patient the entire time assessing their status

To me this is where sedation (lack of) is critical.

I heard second hand about a closed claim where the cord was penetrated, and contrast demonstrated the flow was intracord, AND after that, steroid was injected directly into the cord, all of this recorded on fluoro images, while pt was heavily sedated.

I would expect the patient to notice their cord being touched but you never know if they took their own sedation or whatever.

Personally, I'm a big fan of the tuohy, aligned with the bevel dorsal, at least when exiting the LF. I think you are unlikely to damage the cord if you do make contact.

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[Ligament]

To me this is where sedation (lack of) is critical.

I heard second hand about a closed claim where the cord was penetrated, and contrast demonstrated the flow was intracord, AND after that, steroid was injected directly into the cord, all of this recorded on fluoro images, while pt was heavily sedated.

I would expect the patient to notice their cord being touched but you never know if they took their own sedation or whatever.

Personally, I'm a big fan of the tuohy, aligned with the bevel dorsal, at least when exiting the LF. I think you are unlikely to damage the cord if you do make contact.

Use a 25ga touhy to minimize mechanical trauma. If you do not use LOR to air or saline and just rely on contrast images, it works well.

 

[Agast]

I heard second hand about a closed claim where the cord was penetrated, and contrast demonstrated the flow was intracord, AND after that, steroid was injected directly into the cord, all of this recorded on fluoro images, while pt was heavily sedated.

What does contrast into the cord look like? A localized blob?

 

[Taus]

What does contrast into the cord look like? A localized blob?

That’s what I would of thought, and based on some case reports of seen previously, but that has changed after the Sis case presentation.

 

[clubdeac]

The question is, has there ever been a case of cord injection in an non-sedated patient. I would think the patient would be screaming in pain before you could cause any permanent neurological injury, right? Plus in your scenario above, once you've injected contrast into the cord it's already too late. Don't matter what it looks like. Damage is done

 

[epidural man]

No cervical catheters. They pierce the dura quite easily.

Can you elaborate? Has this been described?

I find it hard to imagine the soft-tipped catheter pierces the dura, but the stiff SCS lead doesn't ever.

 

[epidural man]

Not sure I could ever let go of LOR in CESI. Nor will I stop using 18g needles.

 

[BobBarker]

I have pierced the dura in the lumbar spine with the smaller Epimed catheter multiple times.

 

[lobelsteve]

I have pierced the dura in the lumbar spine with the smaller Epimed catheter multiple times.

Yeah, but you were doing it to show off and let out the evil humours...

 

[callmeanesthesia]

Not sure I could ever let go of LOR in CESI. Nor will I stop using 18g needles.

Try the 22g tuohy some time. I’m anesthesia-trained like you so I was used to 18g. Takes a few times to get used to but you still get excellent LOR. I don’t even use the LOR syringe any more - just a 3 mL syringe with contrast. Still lots of tactile feedback, but an order of magnitude less risk of PDPH, and easier to slip into tighter interlaminar openings. I’d say most of the time I can feel the “loss” of the needle slipping through the ligament before I inject, just like with the 18g. The feel is a little more subtle but you get used to it, and I think the trade off of reduced risk of trauma to dura or cord and reduced discomfort is worth it.