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Cervical Epidurals

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Nonphysiologic

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Hey,

So I've been getting a bit more used to cervical ESIs but they still scare the hell out of me when I'm looking for loss each and every time...I hope I eventually get used to it. Contralateral oblique technique seems to be the way to go imho.

I have a couple (a minority) of attendings that never ever do anything cervical and they say it's because the evidence for cervical epidurals vs conservative therapy isn't great and it's not worth the risk at all...what do you guys think about that? Also, does that fear ever go away? I'm always concerned while I'm looking for LOR I'll be using too much pressure and the needle will just slip through and the loss will be sudden and abrupt



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Taus

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I'm going to assume you're not an anesthesiologist (I am not either so don't take offense!). It took me a while in fellowship to get completely comfortable doing lor even in lumbar. Probably 6 months and several hundred interlams. Eventually you should get quite comfortable and confident in your lor technique on lumbar.


As for cervicals... Use clo strictly. Lock your fingers on skin firmly and barely roll your fingers together for minimal advancement per move. Frequent pictures. If get to or slightly beyond vill (ventral interlam line) and no loss... take loss off and use a puff of live contrast to proof safe posterior position dorsal to canal, if so, continue tiny moves and contrast puff til epidural. A healthy dose of fear on these is good to have. It fades to a degree over time but still every once in a while rears its head if a thick ligament forces me to use a lot of force 1-2 mm from cord or narrow window and getting snagged on os/lamina....

Evidence just fair.... but I've spared enough patients needing acdf to be worthwhile. I have several colleagues who don't do cervicals for one reason or another. If not comfortable then don't do them.


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Ligament

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    Good questions!

    If you are an ethical pain doc, your fear of cervical ESI will never go away. In fact, it may grow stronger over time as you hear about injuries, deaths, and lawsuits from your colleagues. I've been a pain attending for almost 10 years now and still hate this procedure.

    We all have had the same nightmares you describe of missing the LOR and advancing too far. We all have SDN's own algosdoc to thank for first publishing this technique as "Puttlitz's line" in the ISIS journal long ago. I don't thing algos gets enough credit for this. Thanks algos!

    "Dr Puttlitz brought it to my attention....apparently he got the idea from watching some of Dr Fuman's group, but Dr Puttlitz worked out the angles. I checked them and found them to be on the money. Regardless of who first thought of the concept, I wanted to get it into use ASAP since it provides fluoroscopic landmarks for cervical interlaminare ESI needle advancement instead of simply relying on the occasionally unreliable LOR as the sole determinate of tip advancement. Both Dr Furman and Dr Puttlitz are wonderfully innovative docs that strive to make our profession safer." -- algosdoc 2008

    That is why many of us have changed to contralateral oblique imaging only for interlaminar ESIs. Since changing to this technique, I feel much better about this procedure.

    Many of us have completely given up cervical transforaminal ESIs, hoping somebody develops a safer technique. I'm not criticizing those that perform CTFESI, there are pros and cons to consider.

    I agree, no cervical ESI, either interlaminar or transforaminal, is "worth" the paltry payment we get for the risk. On top of that, I book extra time for cervical ESIs, as I need to go slow and never be rushed. I offer cervical ILESIs to my patients in the hopes it may prevent them from cervical surgery, a procedure with far higher morbidity and mortality.

    Also, I generally do these procedures only at T1/T2 level now. Epidural space is greatest here. In case there is an obstruction, or no ligamentum flavum here upon review of MRI, I will go higher.

    Another tip; if you are doing a cervical ESI and anything spooks you...abort. Better to try another day.
     
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    Taus

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    Good questions!

    If you are an ethical pain doc, your fear of cervical ESI will never go away. In fact, it may grow stronger over time as you hear about injuries, deaths, and lawsuits from your colleagues. I've been a pain attending for almost 10 years now and still hate this procedure.

    We all have had the same nightmares you describe of missing the LOR and advancing too far.

    That is why many of us have changed to contralateral oblique imaging only for interlaminar ESIs. Since changing to this technique, I feel much better about this procedure.

    Many of us have completely given up cervical transforaminal ESIs, hoping somebody develops a safer technique.

    I agree, no cervical ESI, either interlaminar or transforaminal, is "worth" the paltry payment we get for the risk. I offer cervical ILESIs to my patients in the hopes it may prevent them from cervical surgery, a procedure with far higher morbidity and mortality.

    Another tip; if you are doing a cervical ESI and anything spooks you...abort. Better to try another day.

    Couldn't agree more. Abort or pull out and go T1-2.


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    Aether2000

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    Thanks Ligament! The CLO technique as worked out by Furman and others was an extraordinary advance in safety. Caveats: if you find the needle tip advancing beyond the ventral laminar line/posterior foraminal projection without obtaining a loss of resistance, then the needle tip is off midline and veering lateral and anterior following the anterior sloping lamina, is in a hypertrophied ligamentum flavum, is subdural/subarachnoid, or in the cord. The suggestion of using just a tiny puff of contrast (0.1ml) is an excellent idea especially since an intracord injection (but not midline cord penetration) may be detected before creating an iatrogenic syrinx with larger volumes of contrast. Cord penetration with an 18ga. needle may not result in any neurological deficits, but injecting even 0.5ml of contrast invariably will.
     
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    nvrsumr

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    Thanks to clo pioneers as well. I initially learned image guided cesi with a seated patient, c-arm "upside down" and me standing basically in-between. Wow.

    Lately clo cesi with contrast "puffs" if needed and no lor. Thanks sdn
     
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    NJPAIN

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    All of the preceeding posts are spot on.
    Speaking from nearly 24 years of experience, training as an anesthesiologist and several years as a program director. A healthy amount of fear of the CESI does NOT go away. Yes, there are one or two "wankers" here who will shake their heads and laugh at that. If you care about your patients you will fear harming them. I do NOT do a CESI on everyone who walks through the door with neck pain. I do try like crazy to avoid CESI in the ancient who have cervical stenosis, calcified ligaments and tight interlaminar spaces. Just not worth the stress, on me.

    If there was a Nobel Prize for pain medicine innovation, those involved in developing CLO would get it. The biggest advance in safety I have seen in this field. I try to incorporate throughout the spine, not just cervical. I used hanging drop for many years. I honestly never felt comfortable with LOR in the neck and felt I had more control with two hands on the needle using hanging drop. Now I come in 5 degrees oblique (per Furman), and advance until 3/4 way between dorsal and ventral interlaminar line. At that point I take a quick AP shot to make certain that I have not deviated laterally AND that I have not crossed the midline. Hook up short extension with 5 ml syringe of contrast and advance with small puffs of contrast. Half the time there is a lot of resistance to injection ( if using LOR I would have been OK ) and half the time there is virtually no resistance ( thus, LOR useless ) . I am trying to get the nerve to try the 25 ga quincke technique as it seems only to differ in the needle I am using. Might need to pay a visit to one of the guys on here utilizing it to convince myself. I am forever trying to refine my techniques based upon what I read on SDN and elsewhere. Drives the staff in the ASC a little crazy but they all come to me for treatment because they know that I stay current with my techniques and really care about the quality of my work.
     
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    SSdoc33

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    CESIs are routinely the most anus-puckering injection i do. the fear does not go away. ive tickled the cord once or twice, and it is scary.

    biggest tip i can give you: if you are not 100% sure where you are...... dont advance. it may sound obvious, but this is really the only way you will get in trouble.
     

    cbest

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    i agree that clo is very helpful with the cervical ILE. for midline procedures, how do you decide which side to oblique it to?

    CLO is inaccurate if going midline. Also, lig flavum less likely to be fused at midline so best not to go there. Jatinder Gill and Tom Simopoulos at BIDMC have published some excellent articles discussing and explaining CLO over the past few years. Highly recommend reading up on those!


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    Aether2000

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    It is accurate using a paramedian approah with the tip being midline. That way it doesnt matter which side the beam is angled and avoids the interspinous ligament cleft and the ligamentum flavum discontinuities.
     
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    Stim4me

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    When in doubt I back off and find a boney structure to target and calibrate ones depth. I use a paramedical technique and walk off the lamina the level below. This is also the plane where most false loss of resistance occurs. CLO has reduced my stress level and pulling down the patients arms to visualize ones depth seems medieval now...
     
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    Taus

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    For those who have switched to 25g Quincke from touhy... is it easier/less force needed to advance the 25 through flavum than a larger touhy? I absolutely hate how much force I have to sometimes use to advance through flavum in some pts w 20g touhy. Ie does the sharper n thinner tip of 25 Quincke make up for its flimsiness? Thx


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    Timeoutofmind

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    For those who have switched to 25g Quincke from touhy... is it easier/less force needed to advance the 25 through flavum than a larger touhy? I absolutely hate how much force I have to sometimes use to advance through flavum in some pts w 20g touhy. Ie does the sharper n thinner tip of 25 Quincke make up for its flimsiness? Thx


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    With CLO, do u guys just oblique " until the laminae are crisp"? that is what I have been doing. Is there some other way to determine optimal obliquity?
     

    cbest

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    50 for cervical and upper thoracic, 45 for lower thoracic and lumbar


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    Taus

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    With CLO, do u guys just oblique " until the laminae are crisp"? that is what I have been doing. Is there some other way to determine optimal obliquity?

    Several recent articles show that optimizing fluoro for clo by eye is not accurate. 50 degrees from true ap is optimal, though going slightly less than that is more conservative (needle looks deeper).



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    NJPAIN

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    With CLO, do u guys just oblique " until the laminae are crisp"? that is what I have been doing. Is there some other way to determine optimal obliquity?

    I either calculate off of cross sectional study or use 50 degrees. Paper a while back showed equally reliable


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    Timeoutofmind

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    I either calculate off of cross sectional study or use 50 degrees. Paper a while back showed equally reliable


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    That was my understanding as well. Here is my issue:

    When I was first learning the CLO technique, I would just go with AP and lateral. It would be a very clear-cut thing. Definite LOR. Perfect lateral picture. And then I would do 50° CLO and my needle would look ridiculously deep.

    Very confusing given the above how I can trust CLO or consider it to be as accurate as a lateral?
     

    lobelsteve

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    Ummm..

    CLO angle depends on what side of the body the C arm is as well as the needle. patient prone, Im on left, c arm on right. That makes 55 deg for left paramedian and 70 deg for right paramedian.

    25g has less effort to advance and is a cutting tip.
     

    bedrock

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    Ummm..

    CLO angle depends on what side of the body the C arm is as well as the needle. patient prone, Im on left, c arm on right. That makes 55 deg for left paramedian and 70 deg for right paramedian.

    I don't understand this. Wouldn't it be turning the C-arm 50 degrees oblique to the left if your needle is traveling right paramedian. However if needle is left paramedian, then your turn the C-arm 50 degrees right oblique?

    I don't get 55 degree one and 70 degrees the other?
     

    lobelsteve

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    I don't understand this. Wouldn't it be turning the C-arm 50 degrees oblique to the left if your needle is traveling right paramedian. However if needle is left paramedian, then your turn the C-arm 50 degrees right oblique?

    I don't get 55 degree one and 70 degrees the other?


    Depends how far over the top your c arm goes. if im on left of patient and c is on right, i rotate it towards lateral 55 clo if on left side of sp, and 70 deg if in right of sp.
     

    Ligament

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    For those who have switched to 25g Quincke from touhy... is it easier/less force needed to advance the 25 through flavum than a larger touhy? I absolutely hate how much force I have to sometimes use to advance through flavum in some pts w 20g touhy. Ie does the sharper n thinner tip of 25 Quincke make up for its flimsiness? Thx


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    I don't use a 25g Quincke but rather a 25g Touhy...I would say the force needed is USUALLY minimal. But if you are obtaining a ligamentum flavum-o-gram with contrast outline, you can visually see the ligamentum flavum dorsal margin and that eases my fears.
     

    Ligament

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    Several recent articles show that optimizing fluoro for clo by eye is not accurate. 50 degrees from true ap is optimal, though going slightly less than that is more conservative (needle looks deeper).



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    Does anybody happen to have these articles to share?
     

    Aether2000

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    I have always used 60 deg oblique from the true AP for inferior cervical epidural interlaminar injections. Start with the beam true AP, advance until superiomedial lamina is contacted, then rotate to 30 deg from the coronal plane = 60 deg from sagittal plane and then advance to the posterior foraminal line. Using a paramedian approach from either side with the needle tip ending up in the midline it doesnt matter whether you start left or right paramedian nor does it matter whether a left or right oblique is used....the final position, depth, and images are identical. CLO is made far more complex by trying to overthink the technique. If there is no LOR within one mm anterior to the posterior foraminal line then check an AP. If the tip is midline then you may have a hypertrophied yellow ligament or plugged needle lumen with fat/ligament. If you are not midline, redirect the tip to midline.
     
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    bedrock

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    Depends how far over the top your c arm goes. if im on left of patient and c is on right, i rotate it towards lateral 55 clo if on left side of sp, and 70 deg if in right of sp.

    so are you saying that you prefer to oblique 70 degrees and would do that on both sides if you could, but your C-arm only goes to 55 degrees on the left?
     

    lobelsteve

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    so are you saying that you prefer to oblique 70 degrees and would do that on both sides if you could, but your C-arm only goes to 55 degrees on the left?

    Im not sure how far over the top it goes but anything more than 15 degrees is in my way. If on left side, 55 seems best. If injecting on right side, 70 seems best.

    So CLO on left and ILO on right. But I almost always start left side over lamina and touch lamina. If I want more med on one side I will either stay left or cross midline as i walk off lamina.
     

    dhcofc

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    Here's an example from this week. Much clearer than lateral usually.

    IMG_2472.JPG
     

    Taus

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    I just walk around to other side of table, same as c arm when doing a right cesi. II obliqued 50 left is then not in my way...


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    lobelsteve

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    1.jpeg
    55 CLO in ligament

    2.jpeg
    Near true AP at completion, right of midline

    4.jpeg
    Advanced in 1mm increments into epidural space, 4mm in front of left pedicle shadow, epidural flow under left C7 pedicle noted as well as some vascular uptake on right of neck. Notice how far away from the vertebral body the needle is at this point. Notice the right sided pedicle border shadow and how I am 1mm in front of it.

    3.jpeg
    And this is what you get on a true lateral. That might be part of her bra or a necklace, but just to the right of it you can see the contrast in the posterior epidural space flowing superiorly. And if I did not point that out, no one could know it.
     
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    Aether2000

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    View attachment 211792 55 CLO in ligament

    View attachment 211795 Near true AP at completion, right of midline

    View attachment 211793 Advanced in 1mm increments into epidural space, 4mm in front of left pedicle shadow, epidural flow under left C7 pedicle noted as well as some vascular uptake on right of neck. Notice how far away from the vertebral body the needle is at this point. Notice the right sided pedicle border shadow and how I am 1mm in front of it.

    View attachment 211794 And this is what you get on a true lateral. That might be part of her bra or a necklace, but just to the right of it you can see the contrast in the posterior epidural space flowing superiorly. And if I did not point that out, no one could know it.
     

    epidural man

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    You guys using small gauge needles are nuts.

    And you guys using small cutting needles are CRAZAAAAAY!

    17/18gauge needle for me.

    To the OP. Doing a well placed, controlled CESI separates a trained pain physician from a CRNA doing a weekend course.

    I think they work great. I think for radicular pain caused by impingement, they can be very helpful!

    Also, you guys are looney with your CLO angles.

    The idea with CLO is to put the lamina ON PHOS.

    Take a look at these two examples I just looked at - I pulled up the first two MRI's I could find. The cervical lamina is almost ALWAYS a steeper angle than lumbar (hence - a LESS angled CLO). Sometimes, lumbar lamina are almost flat (hence a very angled CLO) and cervical are sometimes very steep.

    CLO cervical.jpg
    lumbar CLO.jpg
     

    epidural man

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    But this brings up a good point. You should look at the lamina angle before your CESI - and that will give you a good idea of where your best CLO picture will be.

    I am always surprised when I hear of pain physicians not looking at MRI's and only reading reports.
     

    epidural man

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    Also to the OP - I wanted to add.

    Do not do CESI under sedation. I know people say that the cord has no sensation - but if that is the case, why is a syrinx painful sometimes? Also, I just think injecting the cord would feel really weird. Finally, there isn't really a good clinical reason to do sedation with these cases. There is good incentive for reimbursement - but not clinically.
     

    epidural man

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    Does anybody happen to have these articles to share?

    I'm not sure I have read the articles referenced - but here is an article I use to explain the view (which is really hard to explain actually.....) to the fellows and residents.

    It is written by the SDN pain group's beloved dickhead Bogduk. Enjoy. (jk.....)
     

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    • Contra lateral oblique for epidural.pdf
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    Aether2000

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    The cord has no sensation between the dorsal root entry zones on either side. These extend about 25% of the diameter of the cord, therefore 50% of the posterior cord does not demonstrate a response when entering the cord posteriorly. This is why cordotomy patients do not respond to the needle being placed into the cord from a posterior approach. Injection into the cord however MAY produce elicit a response, even with small amounts of injectate, since there is an instant compression of nerves from inside the cord. A syrinx results in a gradual compression of nerves from within the cord, and results in neuropathic arthropathies in 25%, mainly of the upper extremity, equivalent to a Charcot joint. There are other diffuse dysesthesias with a syrinx.
     
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    Nonphysiologic

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    Wow awesome insight guys thanks so much.....also, have u guys noticed even if a person is really skinny I've personally never seen LOR before 4CM?


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    cbest

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    ImageUploadedBySDN1481477650.823337.jpg


    ImageUploadedBySDN1481477665.556813.jpg


    Please make sure you're measuring properly for planning of injection. These photos from Gill et al should help.


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    NJPAIN

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    View attachment 211834

    View attachment 211835

    Please make sure you're measuring properly for planning of injection. These photos from Gill et al should help.


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    Good point. I am having difficulty finding an app that easily allows the measurement to be made. Can't seem to do with utility that is part of radiology viewer. Frequently I print out image and measure off of hard copy


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    Aether2000

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    Ok just for fun...lets look at the contrarian argument against measurement of MRI angles: 1. Techs operating the equipment do not have the skills nor measurement capabilities to differentiate between 53 vs 59 vs 48 degrees.The markings on the C are too far apart to obtain such rotary discrimination and the techs are frequently trigonometrically challenged. 2. Unless the patients head is being held in a neuroframe with bony cortex pins, the can and do rotate off center during a procedure. 3. Viewing the angles are useful on MRI but as pointed out above not all viewers have goniometric measurements avaiable. Are you really planning on cancelling an interlaminar injection if there is a radiology report that shows no central spinal stenosis or posterior cord displacement? 4. Unless you plce your needle down the beam starting directly in the center of the radiographic field, your needle angles will not approach the measured angles from MRI. Ok...let the bullets fly :)
     
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    SSdoc33

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    2 things: #1 if you end up midline on a CESI, it doesnt matter which side you start from. this left vs. right stuff is useless. you stand on the left, the c arm is on the right. always enter from the left. much easier that way. dont walk around the machine.

    #2. if you stick the cord, the patient will jump. they will feel a little zap into their arm and usually their leg. the posterior cord itself may be insensate, but the stuff around it (pia maybe) isnt. if you touch the cord -- both you and the patient will know.
     
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    epidural man

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    2 things: #1 if you end up midline on a CESI, it doesnt matter which side you start from. this left vs. right stuff is useless. you stand on the left, the c arm is on the right. always enter from the left. much easier that way. dont walk around the machine.

    #2. if you stick the cord, the patient will jump. they will feel a little zap into their arm and usually their leg. the posterior cord itself may be insensate, but the stuff around it (pia maybe) isnt. if you touch the cord -- both you and the patient will know.
    They won't feel it if they are deeply sedated.
     
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    Aether2000

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    They may not feel it at all or jump even if not sedated. The skin is innervated but not everyone feels pain on needle insertion through the skin.
     

    cbest

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    Ok just for fun...lets look at the contrarian argument against measurement of MRI angles: 1. Techs operating the equipment do not have the skills nor measurement capabilities to differentiate between 53 vs 59 vs 48 degrees.The markings on the C are too far apart to obtain such rotary discrimination and the techs are frequently trigonometrically challenged. 2. Unless the patients head is being held in a neuroframe with bony cortex pins, the can and do rotate off center during a procedure. 3. Viewing the angles are useful on MRI but as pointed out above not all viewers have goniometric measurements avaiable. Are you really planning on cancelling an interlaminar injection if there is a radiology report that shows no central spinal stenosis or posterior cord displacement? 4. Unless you plce your needle down the beam starting directly in the center of the radiographic field, your needle angles will not approach the measured angles from MRI. Ok...let the bullets fly :)

    No arguments algos. I don't typically measure angles on MRI. The 50 for cervical and 45 for lumbar has served me well and is a much nicer view than lateral. Even if the angles aren't perfect, you have a great idea about where the needle tip is and where LOR is expected.


    Sent from my iPhone using SDN mobile
     

    painconfidential

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    **BUMP**

    So I don't know whats going on. When I was finishing up fellowship I honestly mastered the inter laminar cervical epidural. In fact I thought it was easier than lumbar because of the CLO Technique. With lumbar I was somewhat struggling to get a good feel of the different tissues so I started to walk of lamina which was sometimes difficult especially in deeper patients.

    I was so confident that I was teaching the residents rotating and future fellows. All my cervicals (>200) were feeling so great. Id go into CLO, to to the VIL, and id get a great resistance and then subsequent loss......


    IDK what the hell happened since fellowship but since Ive been out on my own my confidence has plummeted. I do the same thing as I did in fellowship but for some reason I don't get a consistent and accurate loss at C7/T1 anymore. Im terrified of going to far and having a intracordal injection. So many times I think I get loss but I'm still out side knocking on the door when I check with contrast. Sometimes my needle looks way too deep even though Im sure Im midline and my CLO angle is between 55 and 60. Idk what to do this is now a problem. I don't trust my feel any more like I did during fellowship. I feel like the CLO is throwing me off now because I don't trust what I feel.

    Could someone do me a favor and outline where the CORD is approximately in a CLO image? Im so so terrified of a cord puncture. Ive been reading so many articles to try to get rid of my fear but I can't seem to shake it. Its nuts because honestly as a fellow I used to look forward to the cervical ESI because with CLO I was consistently getting great resistance and it'd always work perfectly and I had a sense of pride of mastering cervical. Idk what to do now :-/.
     

    willabeast

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    **BUMP**

    So I don't know whats going on. When I was finishing up fellowship I honestly mastered the inter laminar cervical epidural. In fact I thought it was easier than lumbar because of the CLO Technique. With lumbar I was somewhat struggling to get a good feel of the different tissues so I started to walk of lamina which was sometimes difficult especially in deeper patients.

    I was so confident that I was teaching the residents rotating and future fellows. All my cervicals (>200) were feeling so great. Id go into CLO, to to the VIL, and id get a great resistance and then subsequent loss......


    IDK what the hell happened since fellowship but since Ive been out on my own my confidence has plummeted. I do the same thing as I did in fellowship but for some reason I don't get a consistent and accurate loss at C7/T1 anymore. Im terrified of going to far and having a intracordal injection. So many times I think I get loss but I'm still out side knocking on the door when I check with contrast. Sometimes my needle looks way too deep even though Im sure Im midline and my CLO angle is between 55 and 60. Idk what to do this is now a problem. I don't trust my feel any more like I did during fellowship. I feel like the CLO is throwing me off now because I don't trust what I feel.

    Could someone do me a favor and outline where the CORD is approximately in a CLO image? Im so so terrified of a cord puncture. Ive been reading so many articles to try to get rid of my fear but I can't seem to shake it. Its nuts because honestly as a fellow I used to look forward to the cervical ESI because with CLO I was consistently getting great resistance and it'd always work perfectly and I had a sense of pride of mastering cervical. Idk what to do now :-/.
    Sounds like you are having a confidence crisis. Sort of like Maverick in "Top Gun". My guess is that your co-pilot (the X-ray tech) is no longer your trusted comrade from fellowship. My suggestion is to take the flouro course FOR XRAY TECHS that ISI offers. Best thing that ever happened for my practice, and probably for the x-ray techs where I wound up practicing :)
     

    MD87

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    A few things:
    #1) I just finished fellowship as well, so take what I say with a grain of salt. I'm PM&R, so a bit of a wimp and don't trust my hands as much as my eyes.
    #2) If your needle tip is truly midline (within the confines of the spinous process), use 60 degrees CLO. If your needle tip is paramedian (lateral to the spinous process), 50 degrees of CLO is more reliable.
    #3) If your needle tip is midline and you use 50 degrees CLO, or if your needle tip is paramedian and you use 60 degrees CLO, the needle will appear a good bit more ventral than the VILL when loss occurs, which can be unnerving (read the article below).
    #4) Don’t worry if you don’t feel loss. Just switch to contrast if things look too deep and the appearance of contrast in the LF or dorsal to that will provide you with reassurance. If your needle is truly midline, then you often times won’t get loss at all due to failure of the ligamentum flavum to fuse – all the more reason to use a paramedian approach at 50 degrees CLO in order to maximize your chance of getting a decent loss.
    #5) As suggested in #4, contrast is your friend. If you aren't getting good loss/feel, switch to contrast sooner rather than later. I always switch to contrast as soon as I'm just past the VILL if I haven't gotten loss yet. That way I know there's no way my needle is deep enough yet and so there's no chance of contrast injection into the cord. See Taus's comments above regarding numerous puffs of contrast as needed.

    This article is helpful:
    Optimal Angle of contralateral oblique view in cervical interlaminar epidural injection depending on the needle tip position. Jun Young Park. Pain Physician. 2017.
     

    SommeRiver

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    I don't trust LOR at all. I use contrast early.
     
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    hyperalgesia

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    **BUMP**

    So I don't know whats going on. When I was finishing up fellowship I honestly mastered the inter laminar cervical epidural. In fact I thought it was easier than lumbar because of the CLO Technique. With lumbar I was somewhat struggling to get a good feel of the different tissues so I started to walk of lamina which was sometimes difficult especially in deeper patients.

    I was so confident that I was teaching the residents rotating and future fellows. All my cervicals (>200) were feeling so great. Id go into CLO, to to the VIL, and id get a great resistance and then subsequent loss......


    IDK what the hell happened since fellowship but since Ive been out on my own my confidence has plummeted. I do the same thing as I did in fellowship but for some reason I don't get a consistent and accurate loss at C7/T1 anymore. Im terrified of going to far and having a intracordal injection. So many times I think I get loss but I'm still out side knocking on the door when I check with contrast. Sometimes my needle looks way too deep even though Im sure Im midline and my CLO angle is between 55 and 60. Idk what to do this is now a problem. I don't trust my feel any more like I did during fellowship. I feel like the CLO is throwing me off now because I don't trust what I feel.

    Could someone do me a favor and outline where the CORD is approximately in a CLO image? Im so so terrified of a cord puncture. Ive been reading so many articles to try to get rid of my fear but I can't seem to shake it. Its nuts because honestly as a fellow I used to look forward to the cervical ESI because with CLO I was consistently getting great resistance and it'd always work perfectly and I had a sense of pride of mastering cervical. Idk what to do now :-/.
    You may not be imagining things.
    If you're using a smaller gauge needle than you are used to, the LOR is MUCH less profound.
    If the LOR syringe is wider than you're used to, the LOR is MUCH less profound.

    For CESI, never use sedation. Only use dexamethasone (nonparticulate) and NS.
     

    dhcofc

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    Try contrast instead of saline for your LOR syringe. I use 0.5 mL of contrast in my loss of resistance syringe and then draw up about 0.5 ml of air. I use an 18g tuohy so I feel a crisp LOR. I don’t think smaller needles have quite as crisp LOR. If I have LOR in the epidural space and not false loss the fluoro image will reveal epidural spread. Simple. One step if you just use contrast as the LOR fluid.
     
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