Cervical injections

[Mister Mxyzptlk]

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your procedural methods, medical knowledge, and medical technology will be obsolete in 5 years or less essentially negating whatever fellowship you did.

Really? I'm still using skills and knowledge over 30 years old. Did the brachial plexus change course when I wasn't looking? Have there been major breakthroughs in Tuohy needle design? Did morphine stop alleviating pain?

The changes I've seen have been incremental, not quantum changes that render previous techniques or knowledge obsolete. They are add-ons.


Training isn't just acquisition of skill and knowledge. It is training of the mind - how to approach problems, how to think, how to evaluate new concepts. It's the difference between being a physician and being a mechanic with an M.D.

To use an example from anesthesia: You have the skills to intubate. You have knowledge about open globe injuries and about risk of aspiration. You know about pediatric physiology. It's the training that teaches you to thread them together when you're confronted with the dreaded "pediatric full stomach open eye".

Good training is all about good thinking. Some people are born that way but most of us have to be taught. I can tell you from my case reviews for the medical board that the thinking part seems to need the most improvement.

 

[Jcm800]

To play devils advocate (I also think hanging drop is antiquated) but say you are using the hanging drop, I would think it issafe if FLUORO is the main guide. Meaning on lateral view as you approach where you wouldvexpect the loss, and if you don't see it, you should stop and inject contrast. If you get an epiduragram does it matter if it was hanfging drop or LOR. Neither technique should be the primary endpoint, it should be visualization....

Sitting is also antiquated, no lateral...
Having done a blind sitting cesi, uggh. Why would anyone do that when prone is clearly better.

The technique of touching lamina then walking in and not doing a lateral I think is also antiquated. This is basically the way we did blind thoracic epidural catheters in the sitting position for surgery...if you are using fluoro you don't need to touch lamina, because once you get the right trajectory, the lateral will be there, or even better using contralateral oblique...

Whatever. Everyone is late for the barbecue, so I have nothing to do but give my my opinion.

 

[PMR 4 MSK]

Blind shots miss a certain % of the time. Some studies suggest around 25%. Blind Shoulder injections miss. Blind knee injections miss. And blind epidural injections will miss. Some will be too shallow, others too deep, some too lateral.

If the patient's condition is so severe that it warrants risking pithing the cord, doesn't it warrant image guidance? Especially when it is so readily available?

I could see if you are 100 miles from the nearest hospital and cant afford fluoro in your office, or your hospital is so Podunk that it can't afford fluoro. Then yeah, you could maybe justify a blind injection.

Otherwise, why take the risks without the confirmation your medication went where you wanted it to go?

 

[Pain Applicant1]

Depends on the position: in the prone position, the cervical epidural pressures are positive, and fluid drops can move down the needle via gravity into the epidural space, overcoming small positive pressures during LOR placement. In the sitting position, if the needle is horizontal, and the cervical epidural pressures are positive, then the only way a drop of fluid would enter the epidural space is if the dura is tented....
So you are correct, there are some physiological explanations for the loss of the fluid that may vary with position of the patient, needle position, etc.
Many of us, including me, first learned the hanging drop technique as the only means of accurately predicting epidural space entry. But given the advancement in knowledge, it exists as an archaic (but fun) historical technique.

In residency we did prone CESI with LOR but in my fellowship program we did them sitting with hanging drop. However, the needles were not horizontal with either one. Although the patient would be sitting, the neck was flexed and resting on the table and this position would allow for a more vertically placed needle. We used Weiss needles which have more of a blunted tip and wings and the loss of the hanging drop was visible. This was done underneath fluoro guidance and contrast helped confirm our location.

Do you think that this technique is also archaic? I think I've come to like the sitting hanging drop technique better but am interested in what your thoughts are.

 

[geauxg8rs]

the only technique that works for me is the same as the only med that works for my patients (only cause PERCOCET did not spell out any cool technique).

LORTABS
Loss Of Resistance To Air Bubble/ Saline.

 

[Aether2000]

The hanging drop technique depends on the presence of or creation of a negative epidural pressure to cause auto-aspiration of the drop suspended at the end of a relatively horizontal needle. The technique you describe is really more of a LOR since there is a fluid column exerting positive pressure which exceeds posterior cervical epidural pressure once the ligamentum flavum is penetrated. The presence of the column of fluid would override the small positive pressures measured in the posterior epidural space of patients in the prone position and therefore initiate the disappearance of the fluid drop in the hub of the Tuohy (or Hustead if you are a heavy metal guy).
In any case, neither LOR nor hanging drop technique are sufficient to protect the patient from inadvertant cord pithing, so I would encourage all to learn the contralateral oblique technique of fluoroscopic imaging for cervical interlaminar epidural injections or have an excellent visualization of the spinolaminar line in the lateral view, either should be used during live needle advancement. These techniques could save a cord penetration or an inadvertant and neurologically devastating injection into the cord in an attempt to confirm placement with contrast rather than with bony anatomy....

 

[Mister Mxyzptlk]

In the sitting position the cervical epidural pressure is usually but not always slightly negative. The lumbar epidural pressure will be positive. And yet when I was in training and we did hanging drop for labor epidurals in the sitting position (how much higher can the lumbar epidural pressure go?) it worked.

Based on this simple clinical observation I have to conclude that hanging drop works by tenting the dura and thereby tempting fate.

I am working on a new technique whereby you advance until CSF comes out and then 3 mm less.

 

[lobelsteve]

I am working on a new technique whereby you advance until CSF comes out and then 3 mm less.

Works for L-spine.
For C-spine: Advance in the midline until arms/legs jerk at same time, backup 6mm, shoot contrast. Alternate method is advance until you hit lamina, wiggle North between lamina. Advance until you contact bone. Pull back 1mm. Perfect anterior epidural flow.

 

[Aether2000]

The technique used in the 1960s before the development of LOR technique was exactly that....penetration of the dura and obtain CSF, then retract until no more CSF was seen.....

 

[SSdoc33]

Do you think that this technique is also archaic?

yes. if your attendings wont teach you, teach yourself