Cervical ESI Quinke Style

[sdnuser001]

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Wanted to ask the hive a theoretical question. If one were to perform a cervical ILESI using a quinke needle with micro advancement technique and tiny drops of contrast with each advancement then would you be able to enter at a more cephalad level like C4-5 or C5-6? I would think the hypothetically poor ligament integrity at these levels wouldn't be a contraindication given that you don't use LOR with the quinke technique?

 

[MitchLevi]

Wanted to ask the hive a theoretical question. If one were to perform a cervical ILESI using a quinke needle with micro advancement technique and tiny drops of contrast with each advancement then would you be able to enter at a more cephalad level like C4-5 or C5-6? I would think the hypothetically poor ligament integrity at these levels wouldn't be a contraindication given that you don't use LOR with the quinke technique?

No.

C7-T1.

 

[bedrock]

Wanted to ask the hive a theoretical question. If one were to perform a cervical ILESI using a quinke needle with micro advancement technique and tiny drops of contrast with each advancement then would you be able to enter at a more cephalad level like C4-5 or C5-6? I would think the hypothetically poor ligament integrity at these levels wouldn't be a contraindication given that you don't use LOR with the quinke technique?

Sounds like a great way to paralyze the patient.

 

[Laryngospasm]

A lot of things are possible in pain management, what you will find is few of them are worth the risk or the time. If you do this although well intentioned and something goes wrong it will not go well for you.

 

[mdo1738]

Even if you could, why? Use a few cc’s of normal saline with your steroid, and we all know it spreads a few levels up

 

[TheLoneWolf]

Nope.

C7-T1 and you can always thread an epidural catheter to your level of choice after.

 

[MD87]

Could you? Yes.

Should you? No reason to.

As others have said medication flows up multiple levels due to how small the epidural space is in the cervical spine. Several studies have shown this. Also, it’s not just about ligament integrity. There isn’t always adequate epidural fat above c7/T1. As seen in this case report, sometimes there isn’t even any at c7/T1.

Assessment of epidural fat at C7-T1 with image review prior to cervical interlaminar epidural steroid injections

In 2015, the Multidisciplinary Pain Workgroup suggested that cervical interlaminar epidural steroid injections should “be performed at C7–T1, but preferabl

academic.oup.com

If you review imaging ahead of time and see epidural fat at a higher level, then yes, it is likely that this could be done at a higher level without complication, but again, as said previously, no real reason to do it.

 

[knoxdoc]

Microadvancement is a great idea until the patient provides a complimentary macro movement.

 

[MitchLevi]

Microadvancement is a great idea until the patient provides a complimentary macro movement.

What?

 

[knoxdoc]

If the patient thrashes when you are trying to thread a quincke into a 3mm wide epidural space, that's bad.

 

[MitchLevi]

If the patient thrashes when you are trying to thread a quincke into a 3mm wide epidural space, that's bad.

Ever used this technique?

It is true more often than not my pts don't feel this injxn.

Not that it didn't hurt, they commonly don't feel it at all.

I'm doing 5-8 per week and I've done that for 3 yrs now.

Your scenario has yet to happen to me.

 

[Ducttape]

bad idea.

remember the quincke is a sharp tip needle.

the reason anesthesiologists use Touhys is because of the dull tip and less likely to penetrate and cause a wet tap.

you are using a sharp pointed needle at a site with less epidural fluid, relying on imaging that at best we should consider macro in its image intensity.

 

[Doctodd]

That first drop of contrast that didn’t go epidural will obscure the view….and a BIG NO to quinke needles for cesi.

Sounds like you are PMR…..Cesi’s are among the most difficult procedures we do. If you weren’t trained for it, just stick to facets.

 

[MD87]

That first drop of contrast that didn’t go epidural will obscure the view….and a BIG NO to quinke needles for cesi.

Sounds like you are PMR…..Cesi’s are among the most difficult procedures we do. If you weren’t trained for it, just stick to facets.

In CLO it will not be obscured at all.

 

[Ferrismonk]

If the patient thrashes when you are trying to thread a quincke into a 3mm wide epidural space, that's bad.

Ever heard of anchoring your needle?

bad idea.

remember the quincke is a sharp tip needle.

the reason anesthesiologists use Touhys is because of the dull tip and less likely to penetrate and cause a wet tap.

you are using a sharp pointed needle at a site with less epidural fluid, relying on imaging that at best we should consider macro in its image intensity.

The reason the touhy is used for LOR is because it's dull and you can feel the tissues better as you advance, not because it won't cut dura.

That first drop of contrast that didn’t go epidural will obscure the view….and a BIG NO to quinke needles for cesi.

Sounds like you are PMR…..Cesi’s are among the most difficult procedures we do. If you weren’t trained for it, just stick to facets.

I use 25G quinke for every CESI. Easier and safer than a 17/20G touhy with LOR, even with CLO you still need to lean into a touhy sometimes. A 25g quinke is almost painless, they don't jump.

 

[epidural man]

That first drop of contrast that didn’t go epidural will obscure the view….and a BIG NO to quinke needles for cesi.

Sounds like you are PMR…..Cesi’s are among the most difficult procedures we do. If you weren’t trained for it, just stick to facets.

I thought everyone was all gaga about using these tiny cutting needles in the neck. We have several threads about it. It seems all the rage now.

 

[epidural man]

Nope.

C7-T1 and you can always thread an epidural catheter to your level of choice after.

You must be new here (I know you're not.....)

But people said SEVERAL times in this forum - don't thread a catheter. It is just WAY to risky and dangers lurk at every corner!

Which I don't understand and haven't been given a great answer.

Why would a catheter be soooooo dangerous, but a big old SCS lead is just fine? I've never understood.

I love the idea of threading the catheter. I am really stupid however, and apparently just can't figure out why it is the most risky thing on the planet.

 

[bedrock]

You must be new here (I know you're not.....)

But people said SEVERAL times in this forum - don't thread a catheter. It is just WAY to risky and dangers lurk at every corner!

Which I don't understand and haven't been given a great answer.

Why would a catheter be soooooo dangerous, but a big old SCS lead is just fine? I've never understood.

I love the idea of threading the catheter. I am really stupid however, and apparently just can't figure out why it is the most risky thing on the planet.

Cervical Catheter gives great spread to C2 every time if you want that or great unilateral foraminal spread depending on angle of catheter. And that’s with advancing the catheter only to C6-C7.

 

[Ducttape]

Ever heard of anchoring your needle?


The reason the touhy is used for LOR is because it's dull and you can feel the tissues better as you advance, not because it won't cut dura.


I use 25G quinke for every CESI. Easier and safer than a 17/20G touhy with LOR, even with CLO you still need to lean into a touhy sometimes. A 25g quinke is almost painless, they don't jump.

i was taught in anesthesiology residency that blunt tip needles were safer due to less potential damage to the dura rather than differences in tactile feel in advancement. i looked for reference in support of your or my understanding, and find no reference or study that supports either position.


noncutting needles may cut as much as cutting needles, when they cut, but sharp point needles are clearly more associated with PDPH.

Postdural Puncture Headache - NYSORA

Postural headaches following interventions that disrupt meningeal integrity are most commonly labeled postdural puncture headaches (PDPHs). This terminology has been officially adopted in the International Classification of Headache Disorders and is used in this chapter. However, use of the word...

www.nysora.com

Needle tip design is also a major influence, with “noncutting” needles clearly associated with a reduced incidence of PDPH when compared with “cutting” (usually Quincke) needles of the same gauge (Figure 7). In general, noncutting needles have an opening set back from a tapered (“pencil-point”) tip and include the Whitacre, Sprotte, European, Pencan, and Gertie Marx needles. Adding to this somewhat-confusing terminology, noncutting needles are sometimes still incorrectly referred to as “atraumatic” needles, this despite being shown with electron microscopy to produce a more traumatic rent in the dura than cutting needles (perhaps resulting in a better inflammatory healing response). The influence of needle size on risk of PDPH appears to be greatest for cutting needles (in other words, the reduction seen in the incidence of PDPH between 22- and 26-gauge sizes is greater for cutting than noncutting needles).

Postdural puncture headache - PMC

Postdural puncture headache (PDPH) is a common complication after inadvertent dural puncture. Risks factors include female sex, young age, pregnancy, vaginal delivery, low body mass index, and being a non-smoker. Needle size, design, and the ...

www.ncbi.nlm.nih.gov

Needle design, size, and direction​

The type and size of needle are also important factors in PDPH, given that research clearly demonstrates that larger dural tears result in a higher incidence of this condition. Cutting needles (Quincke needles) are associated with a higher incidence of PDPH compared to blunt or pencil-point needles (Sprotte and Whitacre needles). Schmittner et al. [31] and Gisore et al. [32] confirmed the significantly lower incidence of PDPH with pencil-point needles compared to Quincke cutting needles in similar studies (1.7% vs. 6.6%, P = 0.02 and 4.5% vs. 24.2%, P = 0.042). A modification of the Quincke (Atraucan) needle is also available, with a cutting point and a double bevel to cut a small dural hole and then dilate it. Several studies have confirmed that the bigger the needle, the greater the incidence of PDPH [19,33,34,35]. With Quincke needles, the incidence and severity of PDPH is directly related to the size of the needle. A similar effect may occur with pencil-point needles.

 

[Espn123]

Look up syrinx

 

[MitchLevi]

5 cervicals today, 3 yesterday and 1 tomorrow. Don't recall how many Tuesday. I think it was 3. (Half day procedures Tuesday-Fri). All with 25g needle. Typical week more or less. Prob 140-150 weeks of that (started 2019).

Yet to have a CSF leak using this technique. I have had one symptomatic cervical leak in private practice and that was a 20g Tuohy and it resolved on its own in 2 days. I believe that was 2018.

No one at any time in this forum (that I recall at least) has ever minimized the risk of cervical stimulation, so you can't say the "big ol SCS lead is fine," because it isn't.

Literally the procedure of last resort amongst 95% of doctors who do it.

Catheters can shear off into the pt. It happened to one of my cofellows during a caudal. She has catheter in her caudal space to this day.

It's also crazy to say there isn't added risk with a catheter. Most likely, one could use a catheter for an entire career and never have any issues (like particulates in the TFESI), but there are clearly risks.

Hematoma and dural tears clearly are higher risk, but there's a good chance you'll never see either in practice.

 

[Ferrismonk]

i was taught in anesthesiology residency that blunt tip needles were safer due to less potential damage to the dura rather than differences in tactile feel in advancement. i looked for reference in support of your or my understanding, and find no reference or study that supports either position.


noncutting needles may cut as much as cutting needles, when they cut, but sharp point needles are clearly more associated with PDPH.

Postdural Puncture Headache - NYSORA

Postural headaches following interventions that disrupt meningeal integrity are most commonly labeled postdural puncture headaches (PDPHs). This terminology has been officially adopted in the International Classification of Headache Disorders and is used in this chapter. However, use of the word...

www.nysora.com

Postdural puncture headache - PMC

Postdural puncture headache (PDPH) is a common complication after inadvertent dural puncture. Risks factors include female sex, young age, pregnancy, vaginal delivery, low body mass index, and being a non-smoker. Needle size, design, and the ...

www.ncbi.nlm.nih.gov

That's fair. Different hospital, different dogma.

Agree with you on the pencil point 100%, but that's for spinals. Hence we use whittacre/GertiMarx for spinals in OB. However, we also use a 24G or smaller, not 20 (or 17).

Our pain group also runs the OB anesthesia department. I do labor epidurals and spinals for sections all the time. My hospital does over 3K deliveries a year and PDPH from spinals almost never happens. They happen when someone skewers the dura with a 17G touhy.

 

[au bon pain]

And here I thought this thread was to announce the final publication of a case series (near-mythical at this point) detailing this technique along with AEs and outcomes…I keep hearing it’ll be published soon…

 

[lobelsteve]

And here I thought this thread was to announce the final publication of a case series (near-mythical at this point) detailing this technique along with AEs and outcomes…I keep hearing it’ll be published soon…

N=1200+
No complications.
No AEs.
1 episode of vascular flow (venous) with paramedian CeSI

 

[Ducttape]

That's fair. Different hospital, different dogma.

Agree with you on the pencil point 100%, but that's for spinals. Hence we use whittacre/GertiMarx for spinals in OB. However, we also use a 24G or smaller, not 20 (or 17).

Our pain group also runs the OB anesthesia department. I do labor epidurals and spinals for sections all the time. My hospital does over 3K deliveries a year and PDPH from spinals almost never happens. They happen when someone skewers the dura with a 17G touhy.

yet i get a PDPH from the ER or neurology colleagues roughly once a month....

but that is probably because of 1. technique and technical expertise 2. needle size 3. needle type (as we have been discussing)


needle size does make a difference, from what i found - but only when talking about the sharp point needles. a 25 gauge Quincke is much less likely to cause PDPH than a 22. that apparently does not hold true - as it says in that one link - for the pencil tip needles, where needle size is less indicative of risk for PDPH.

===

you can reduce or almost eliminate catheter shear apparently, and logically, if you remove the needle and the catheter concurrently.

my problem with catheter for epidurals (yes, i have done a few) - the cost and the concern of adding additional steps to the procedure that really has little impact in the overall results from the injection.

 

[MD87]

Interesting article that I somehow missed from 2020... another reason to not go above C7-T1.

Cervicothoracic Epidural Venous Anatomy Explains Fulminant Hematomas

Dear Editor,

academic.oup.com

 

[Baron S]

PDPH is less common in the cervical spine to begin with due to less hydrostatic pressure. If you look at the rates of PDPH after the suboccipital (C1-C2) technique for myelograms, they are significantly less than with LPs. It's the same reason that you can cause a dural puncture with a 14G tuohy at T12-L1 and they'll often be asymptomatic, while a wet tap with a more caudal ESI will cause a PDPH more often.

The risk of a CESI isn't PDPH. It's cord injury, hematoma, abscess.

 

[MitchLevi]

6'4" 340 lbs just now.

Here's another from this AM. Yall should do this technique.

 

[myrandom2003]

Can you explain this technique more? Possibly post the incremental pictures you took?

 

[epidural man]

6'4" 340 lbs just now.

View attachment 375193View attachment 375194

Here's another from this AM. Yall should do this technique.

View attachment 375195

Why?

 

[MitchLevi]

Why?

Faster
Simpler
Pt usually feels nothing
Smaller diameter hole - Smaller bleeding risk despite it being a Quinke, less likely to get PDPH (rare in the neck anyways IMO).

Did many CESI with Tuohy/LoR. Never going back.

 

[epidural man]

Faster
Simpler
Pt usually feels nothing
Smaller diameter hole - Smaller bleeding risk despite it being a Quinke, less likely to get PDPH (rare in the neck anyways IMO).

Did many CESI with Tuohy/LoR. Never going back.

I buy some of that. Not sure how it is faster or simpler.

 

[MitchLevi]

I buy some of that. Not sure how it is faster or simpler.

Have you done it?

It is clearly faster, simpler, requires less manipulation of the needle, fewer steps, and the pt rarely feel anything. I didn't say it isn't painful...They rarely feel anything.

I did a ton of Tuohy/LoR before swapping over.

 

[epidural man]

Have you done it?

It is clearly faster, simpler, requires less manipulation of the needle, fewer steps, and the pt rarely feel anything. I didn't say it isn't painful...They rarely feel anything.

I did a ton of Tuohy/LoR before swapping over.

I have not. I’m scared to try. Small guage cutting needle on the neck…

Do you use a LOR syringe?

 

[MitchLevi]

I have not. I’m scared to try. Small guage cutting needle on the neck…

Do you use a LOR syringe?

No LoR. It's a 25g 3.5" (95% of the time), with ext tubing attached to a syringe full of Isovue-200.

Remove Isovue-200 syringe and replace with 2cc normal saline + 80mg Depo.

 

[Dr. Ice]

I still like my 22 gauge tuohy..

 

[bedrock]

I still like my 22 gauge tuohy..

I still like my 18 gauge plus cath. I can see why mitch and steve like the small quincke technique.

But I just don't see the same kind of superior spread in those shots, that I get in everyone one of my CESI plus cath shots. Quick entry at T1-T2 because more space/less concern, quick soft 20G catheter to C6-C7, and the spread is incredible. I can either paint the unilateral C5-C7 nerve roots or just get ideal cranial spread to C2-C3 every time, depending on the catheter angle.

 

[MitchLevi]

The whole reason I like Quincke goes against a catheter.

The smaller the presence in the epidural space the better, and I want there to be a smaller number of "moves" made in the process...Having said that, if I needed a CESI I'd be okay with you doing it with a catheter. Just pull the needle and catheter simultaneously please.

 

[Ducttape]

i did a few using 25 gauge quincke, but encountered difficulty with injecting the depo, i think due to that specific formulation of depo we were using at the time. had same pressure needed for SIJ.

im okay generating a lot of force to get depo out for an SIJ, but not so for an epidural. i switched back to the 22 gauge Touhy and essentially use the same CLO technique, but with puffs of contrast/saline through an LOR syringe.

 

[SSdoc33]

i did a few using 25 gauge quincke, but encountered difficulty with injecting the depo, i think due to that specific formulation of depo we were using at the time. had same pressure needed for SIJ.

im okay generating a lot of force to get depo out for an SIJ, but not so for an epidural. i switched back to the 22 gauge Touhy and essentially use the same CLO technique, but with puffs of contrast/saline through an LOR syringe.

LOR with contrast and extension tubing, advance slowly. best of both worlds

 

[MD87]

I have used this technique a few times and agree with what others have said - it works well.
Does anyone do this for lumbar? I wonder if thick ligament would make it challenging with a flimsy needle.

 

[MitchLevi]

I have used this technique a few times and agree with what others have said - it works well.
Does anyone do this for lumbar? I wonder if thick ligament would make it challenging with a flimsy needle.

I don't like lumbar bc it's (on avg in my pt pop) a deeper target, and 25g 5" needles are flimsy and awkward. I use them for TFESI though.

 

[clubdeac]

I'm afraid of going lower than what I trained with (18g) b/c of the lack of district LOR feel. The loss is so noticeable with an 18g even though I know it's huge for the neck

For you guys using a 22g or heaven forbid a 25g, I assume your going completely off of imaging and not LOR. Is this correct?

 

[lobelsteve]

I'm afraid of going lower than what I trained with (18g) b/c of the lack of district LOR feel. The loss is so noticeable with an 18g even though I know it's huge for the neck

For you guys using a 22g or heaven forbid a 25g, I assume your going completely off of imaging and not LOR. Is this correct?

There is no LOR with a 25g. Technique described several times in the forums. I am about 2000 CESI with this technique. (Need staff to pull numbers since I last looked.) I have a rough draft on technique, but need to fluff for article with history of CESI and CTFESI, false LOR, hanging drop, blind, etc.

 

[epidural man]

Those of you who use the small gauge cutting needle for cervical epidural access, what do you see as the advantage over a larger guage Tuohy, besides possible discomfort?

@MitchLevi has said it is faster and simpler.

I like speed but not at cost of safety. Is it safer? If you do think it is safer, why is that, or how is that?

How come it is faster and simpler? What are the steps that are cut as compared to a larger gauge needle using LOR?

I’d like to try it. But…

What if I cause a significant problem? I don’t think the use of such a small guage cutting needle is defensible…am I wrong in that?

I know IR guys have been doing it for years.

 

[Dr. Ice]

Hard to change clinical practice after years of success without complications doing what you do. We should always be forever students and learn from others. The technique Steve and Mitch describe is awesome. I’m not gonna change what I do with regards to this procedure because with a 22 gauge touhy, my patients feel nothing and I’ve never tapped anyone with probably over 6-8k cervical esi performed even with larger gauge needles….and no one is getting sedated

 

[callmeanesthesia]

I'm afraid of going lower than what I trained with (18g) b/c of the lack of district LOR feel. The loss is so noticeable with an 18g even though I know it's huge for the neck

For you guys using a 22g or heaven forbid a 25g, I assume your going completely off of imaging and not LOR. Is this correct?

22g Tuohy. Still feel LOR most of the time. I use a 3 mL syringe with contrast (about 1.5 mL) for the LOR. Little puffs of contrast and frequent fluoro shots, but I like the Tuohy for the additional tactile feedback vs a spinal needle. Often can feel the needle tip pop through ligament before injecting, and sometimes see a bubble in the hub drop in like a hanging drop.

 

[lobelsteve]

If you ever accidentally are too anterior and poke a cord, you do it with a 25G and not a 20G (avg size for CESI).
Less potential risk.
Hanging drop useless.
LOR inaccurate.
Direct visualization in CLO: contrast outlines outside the epidural space and advance in 1mm increments until posterior epidural line of contrast.

 

[DOctorJay]

No LoR. It's a 25g 3.5" (95% of the time), with ext tubing attached to a syringe full of Isovue-200.

Remove Isovue-200 syringe and replace with 2cc normal saline + 80mg Depo.

do you have a preference for which way the bevel is positioned?

 

[Ducttape]

If you ever accidentally are too anterior and poke a cord, you do it with a 25G and not a 20G (avg size for CESI).
Less potential risk.
Hanging drop useless.
LOR inaccurate.
Direct visualization in CLO: contrast outlines outside the epidural space and advance in 1mm increments until posterior epidural line of contrast.

yet if you do poke the cord, it may be preferable to skewer it with a duller needle tip than a sharp cutting one.

the good thing about this discussion is that, in the hands of a skilled practitioner, the likelihood of a cord injury is so low to start with.

i use a combination of the 2. i use a 22 gauge Touhy with LOR syringe, with saline and contrast mixed (to reduce the amount of contrast), and advance wiith very slight pressure and intermittent fluoro.