Cervical procedures and risk

[emd123]

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Is there any way to reduces the risk of catastrophe with cervical procedures to near zero (I know zero risk is impossible)?

If one uses fluoro with contrast with careful loss of resistance technique (never hanging drop), avoids a transformational approach (always interlaminar), uses non-particulate/dex, blunt tip needles, avoids IV/heavy sedation, always aspirate prior to injection, what level of risk remains when performing cervical epidurals?

Also, which of these techniques are most important for risk reduction? Which am I forgetting?

 

[PinchandBurn]

some would add contralateral oblique....I wouldnt start doing this yet, because your needle looks more anterior than it really is when you first start off.

 

[Ligament]

Two things very important IMHO:
1. DSA
2. Contralateral oblique view.

 

[lobelsteve]

I am not enamored with DSA. It makes things easier to see when flow is in the wrong place.
But there are no arteries in the posterior epidural space.

1. Don't do CTFESI
2. Use larger bore needles (much less likely to advance without feeling it)
3. Use contrast
4. Always use C7-T1 or T1-T2
5. Do not use sedation
6. Always touch T1 (or T2) lamina before considering going to ligament.
7. Go lateral or CLO (football view) when walking off lamina
8. Inject contrast under lateral first, then protect your needle when tech/nurse is going AP
9. Save AP/Lat images on every case.

 

[specepic]

Great thread

I think safety with all cases, esp CESI starts with careful review of the MRI. The MRI is so helpful showing you the thickness of the ligament and what levels have a useable posterior epidural space. Some folks are A OK for C6-7 and some need T1-2 and the MRI will tell you. I use partic steroid and no DSA. I shoot contrast early when in doubt as I'd rather see it superficial than IT. I love COL. It is quick and easy and it works. I have not done a lateral for ILCESI in over a year

There is a pain guy (or more?) In my state that does ILCESI at all levels. I see reports on C3-4 ILCESIs.

Not sure if mentioned above but I also never use local in the injectate. I will do in the lumbar for hot radics but not neck.

 

[PinchandBurn]

totally agree with SPEC.


Before any cervical ESI....i PERSONALLY, even if it's a busy schedule, look at the MRI. DO NOT rely on the radiologist's report on this.

I want to mk sure that hte level I'm going to is ok. But generally speaking going to T1/2 or C7/t1 is ok...

 

[facets]

Is there any way to reduces the risk of catastrophe with cervical procedures to near zero (I know zero risk is impossible)?

If one uses fluoro with contrast with careful loss of resistance technique (never hanging drop), avoids a transformational approach (always interlaminar), uses non-particulate/dex, blunt tip needles, avoids IV/heavy sedation, always aspirate prior to injection, what level of risk remains when performing cervical epidurals?

Also, which of these techniques are most important for risk reduction? Which am I forgetting?

I think contralateral oblique is important, forget lateral it is exercise in futility, dislocating shoulders, and overdosing everyone in the room with radiation, especially you since your hip or crotch in right by the beam. Ipsilateral oblique makes the needle look way anterior and will scare the crap out of you. On contralateral you will see a nice string of pearls and after 1/4 cc of contrast a nice stripe. Some of the guys here have posted nice photos

 

[Jcm800]

Maybe I am rash or cocky, but I don't feel any increased risk doing cervical procedures... I treat them all the same.

 

[Ligament]

Another tip, when in CLO view, inject 0.1 cc of contrast DORSAL to the ligamentum flavum, then advance in very small increments until LOR and inject your contrast again. You now have proof you injected just as lig. flav. was passed, and went no further than needed. It also is confirmation you have hit lig. flav.

You now have a ligamentum flavumogram.

This is all under CLO. I no longer use lateral views for anything other than documentation.

BE VERY AWARE OF THE GEOMETRY ISSUES WHEN USING CLO.

I've attached an image. This is just something I threw together in the past 5 minutes. I'll try to find a better one. Think it gets my point across.

The arrow is pointing at the contrast which is DORSAL to the lig. flavum.

 

[PinchandBurn]

Another tip, when in CLO view, inject 0.1 cc of contrast DORSAL to the ligamentum flavum, then advance in very small increments until LOR and inject your contrast again. You now have proof you injected just as lig. flav. was passed, and went no further than needed. It also is confirmation you have hit lig. flav.

You now have a ligamentum flavumogram.

This is all under CLO. I no longer use lateral views for anything other than documentation.

BE VERY AWARE OF THE GEOMETRY ISSUES WHEN USING CLO.

I've attached an image. This is just something I threw together in the past 5 minutes. I'll try to find a better one. Think it gets my point across.

The arrow is pointing at the contrast which is DORSAL to the lig. flavum.

nice pics Ligament.

That needle looks rather small. Are you using a spinal needle for your ESI?

Other question, that I'm trying to understand as I learn to do the CLO is, how much do you oblique? What's your end point when obliquing? I've tried to look this up. I saw an article in Pain Medicine from last month. IT didnt really explain how much to oblique. Obviously, the degree you have to oblique is going to be patient dependent, but is there some anectodotal 'end point" that you use?

Thanks

 

[Ligament]

nice pics Ligament.

That needle looks rather small. Are you using a spinal needle for your ESI?

Other question, that I'm trying to understand as I learn to do the CLO is, how much do you oblique? What's your end point when obliquing? I've tried to look this up. I saw an article in Pain Medicine from last month. IT didnt really explain how much to oblique. Obviously, the degree you have to oblique is going to be patient dependent, but is there some anectodotal 'end point" that you use?

Thanks

Thank you.

I use 25ga. 3.5" Touhy needles with a 5" extension tube hooked up to a 3cc luer lock syringe filled with contrast and air. The LOR is a combination of contrast and air bubbles, but confirmed on CLO view. I learned this from an ISIS higher up.

The obliquity is roughly 45degrees, but do not use that as gospel. Basically start there, then rock back and forth a few degrees until the bony margins of the target lamina are maximally crisp. They should look ovoid in appearance, with sharp margins. Do this a few times and you will see what I mean.

 

[PinchandBurn]

Thank you.

I use 25ga. 3.5" Touhy needles with a 5" extension tube hooked up to a 3cc luer lock syringe filled with contrast and air. The LOR is a combination of contrast and air bubbles, but confirmed on CLO view. I learned this from an ISIS higher up.

The obliquity is roughly 45degrees, but do not use that as gospel. Basically start there, then rock back and forth a few degrees until the bony margins of the target lamina are maximally crisp. They should look ovoid in appearance, with sharp margins. Do this a few times and you will see what I mean.

wow...25G touhy...didnt know they came that small. I routinely use a 20G touhy, I thought that thing was small !

The LORTA must be subtle as heck wtih something that tiny. Probably nice to use for a CTFESI since theoretically you shouldnt be able to cannulate an artery with that, but again, I'm sure people have....

Neat.

 

[Ligament]

wow...25G touhy...didnt know they came that small. I routinely use a 20G touhy, I thought that thing was small !

The LORTA must be subtle as heck wtih something that tiny. Probably nice to use for a CTFESI since theoretically you shouldnt be able to cannulate an artery with that, but again, I'm sure people have....

Neat.

LOR is not as subtle as you'd expect (I was surprised), since I'm using a 3cc syringe...more force generated.

Reasoning behind 25 ga touhy is to minimize cord trauma if intramedullary needle placement occurs, god forbid.

 

[Pain Applicant1]

I am not enamored with DSA. It makes things easier to see when flow is in the wrong place.
But there are no arteries in the posterior epidural space.

1. Don't do CTFESI
2. Use larger bore needles (much less likely to advance without feeling it)
3. Use contrast
4. Always use C7-T1 or T1-T2
5. Do not use sedation
6. Always touch T1 (or T2) lamina before considering going to ligament.
7. Go lateral or CLO (football view) when walking off lamina
8. Inject contrast under lateral first, then protect your needle when tech/nurse is going AP
9. Save AP/Lat images on every case.

Great thread

I think safety with all cases, esp CESI starts with careful review of the MRI. The MRI is so helpful showing you the thickness of the ligament and what levels have a useable posterior epidural space. Some folks are A OK for C6-7 and some need T1-2 and the MRI will tell you. I use partic steroid and no DSA. I shoot contrast early when in doubt as I'd rather see it superficial than IT. I love COL. It is quick and easy and it works. I have not done a lateral for ILCESI in over a year

There is a pain guy (or more?) In my state that does ILCESI at all levels. I see reports on C3-4 ILCESIs.

Not sure if mentioned above but I also never use local in the injectate. I will do in the lumbar for hot radics but not neck.

Another tip, when in CLO view, inject 0.1 cc of contrast DORSAL to the ligamentum flavum, then advance in very small increments until LOR and inject your contrast again. You now have proof you injected just as lig. flav. was passed, and went no further than needed. It also is confirmation you have hit lig. flav.

You now have a ligamentum flavumogram.

This is all under CLO. I no longer use lateral views for anything other than documentation.

BE VERY AWARE OF THE GEOMETRY ISSUES WHEN USING CLO.

I've attached an image. This is just something I threw together in the past 5 minutes. I'll try to find a better one. Think it gets my point across.

The arrow is pointing at the contrast which is DORSAL to the lig. flavum.

Brilliant posts! Thanks for posting, very helpful.

 

[NJPAIN]

Do you find COL useful is you are using a straight midline approach or only if using a paramedian approach and walking off of the lamina?

 

[lobelsteve]

Do you find COL useful is you are using a straight midline approach or only if using a paramedian approach and walking off of the lamina?

Due to the all too often lack of a midline ligament, a true midline approach can never be recommended and offers no benefit over a paramedian approach.

COL is always useful and obtained and recorded for every CESI.
Of course, nothing wrong with a true lateral when obtainable (stupid shoulders).

 

[SIIMS]

For those who can't coceptualize the CLO view there is an article in pain physician journal by mid atlantic spine done within the last year using this view for placement of SCS lead. It is the best article I have found to date showing contralteral oblique and the rationale. When I'm not at work I will try and find you the exact article.

For the last poster, I have refined my technique to straight midline if possible using a 22 gauge Tuohy with LOR but also as stated earlier utilizing the "ligamentum flavogram."

The reason I have had to adopt this approach is I do CESI at outreach clinics where their C-arm will not left oblique more than 30 degrees. I usually find 55 degrees plus or minus 10 is where I need to be. And I don't have time to re-arrange there already tiny exam rooms to bring Fluoro in from the other side .

I don't bother with lateral any more, I have a patient population where this is next to impossible to get a good view and quite frankly I'm sick of trying

If you do paramedian this is where the CONTRALATERAL part comes in to play, but if you are straight midline you can just right oblique technically speaking

 

[Ligament]

Due to the all too often lack of a midline ligament, a true midline approach can never be recommended and offers no benefit over a paramedian approach.
.

Fully agree. Folks, to repeat, there is often NO MIDLINE LIGAMENTUM FLAVUM.

Anesthesiology. 2003 Dec;99(6):1387-90.
Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline.
Lirk P, Kolbitsch C, Putz G, Colvin J, Colvin HP, Lorenz I, Keller C, Kirchmair L, Rieder J, Moriggl B.
Source
Department of Anesthesiology and Critical Care Medicine, University of Innsbruck, Austria. [email protected]
Abstract
BACKGROUND:
Cervical and high thoracic epidural anesthesia and analgesia have gained increasing importance in the treatment of painful conditions and as components of anesthetics for cardiac and breast surgery. In contrast to the hanging-drop technique, the loss-of-resistance technique is thought to rely on the penetration of the ligamentum flavum. However, the exact morphology of the ligamentum flavum at different vertebral levels remains controversial. Therefore, the aim of this study was to investigate the incidence and morphology of cervical and high thoracic ligamentum flavum mid-line gaps in embalmed cadavers.
METHODS:
Vertebral column specimens were obtained from 52 human cadavers. On each dissected level, ligamentum flavum mid-line gaps were recorded and evaluated with respect to shape and size.
RESULTS:
The following variations were encountered: complete fusion in the mid-line, mid-line fusion with a gap in the caudal part, mid-line gap, and mid-line gap with widened caudal end. The incidence of mid-line gaps at the following levels was: C3-C4: 66%, C4-C5: 58%, C5-C6: 74%, C6-C7: 64%, C7-T1: 51%, Th1-Th2: 21%, Th2-Th3: 11%, Th3-Th4: 4%, Th4-Th5: 2%, and Th5-Th6: 2%. The mean width of mid-line gaps was 1.0 +/- 0.3 mm.
CONCLUSIONS:
In conclusion, the present study shows that gaps in the ligamenta flava are frequent at cervical and high thoracic levels but become rare at the T3/T4 level and below, such that one cannot always rely on the ligamentum flavum as a perceptible barrier to epidural needle placement at these levels.

 

[jj337]

Anyone have a nice CLO pic that they would post? Finished fellowship a year ago and never did that.

 

[Ligament]

Anyone have a nice CLO pic that they would post? Finished fellowship a year ago and never did that.

There is one in this thread

 

[SIIMS]

http://www.painphysicianjournal.com/2011/march/2011;14;195-210.pdf

This was the article for those interested

 

[Ligament]

Should give credit to algosdoc for first publishing this technique in the ISIS newsletter a long time ago. Algos would you care to upload the article?

 

[jj337]

I'm an idiot... Found it.

 

[docnyc]

Steve, with a paramedian approach do you ever end up in the midline eventually on AP view or is it possible that you would miss flavum as well based on where the tip eventually ends?

What if you want bilateral spread from the approach? I have done midline approach (for bilateral spread), but will likely abandon it now. I always advance under lateral and if I dont get good engagement with the flavum as I'm getting anterior and expect to hit flavum, then I usually reapproach from a different entry point (same interspace). I have been out for a few years but also did not learn CLO in fellowship. Thanks for the pic Ligament.

Due to the all too often lack of a midline ligament, a true midline approach can never be recommended and offers no benefit over a paramedian approach.

COL is always useful and obtained and recorded for every CESI.
Of course, nothing wrong with a true lateral when obtainable (stupid shoulders).

 

[lobelsteve]

Steve, with a paramedian approach do you ever end up in the midline eventually on AP view or is it possible that you would miss flavum as well based on where the tip eventually ends?

What if you want bilateral spread from the approach? I have done midline approach (for bilateral spread), but will likely abandon it now. I always advance under lateral and if I dont get good engagement with the flavum as I'm getting anterior and expect to hit flavum, then I usually reapproach from a different entry point (same interspace). I have been out for a few years but also did not learn CLO in fellowship. Thanks for the pic Ligament.

I'll enter on the side of pathology. If bil sx then I'll go on more open side. Can start on left and cross midline in epidural space.

 

[PinchandBurn]

Steve, with a paramedian approach do you ever end up in the midline eventually on AP view or is it possible that you would miss flavum as well based on where the tip eventually ends?

What if you want bilateral spread from the approach? I have done midline approach (for bilateral spread), but will likely abandon it now. I always advance under lateral and if I dont get good engagement with the flavum as I'm getting anterior and expect to hit flavum, then I usually reapproach from a different entry point (same interspace). I have been out for a few years but also did not learn CLO in fellowship. Thanks for the pic Ligament.

docnyc

In fellowship, I too primarily did ILESI cervicals in the midline. Advanced under lateral,etc.

I think that's how it's mainly taught and done. I think when Steve and others say that Lig Flav may not be in midline, that's primarily referring to above C5/6. I remember reading an article in the ASA APSF newsletter that stated as such. If you are below C6/7 and are midline, it should be safe to be midline. Definitely, at C7/T1.

 

[101N]

docnyc

in fellowship, i too primarily did ilesi cervicals in the midline. Advanced under lateral,etc.

I think that's how it's mainly taught and done. I think when steve and others say that lig flav may not be in midline, that's primarily referring to above c5/6. I remember reading an article in the asa apsf newsletter that stated as such. If you are below c6/7 and are midline, it should be safe to be midline. Definitely, at c7/t1.

1+

 

[bedrock]

docnyc

In fellowship, I too primarily did ILESI cervicals in the midline. Advanced under lateral,etc.

I think that's how it's mainly taught and done. I think when Steve and others say that Lig Flav may not be in midline, that's primarily referring to above C5/6. I remember reading an article in the ASA APSF newsletter that stated as such. If you are below C6/7 and are midline, it should be safe to be midline. Definitely, at C7/T1.

I think it's okay to be midline as long as you are sure which space you're in. You do a midline CESI and you're sure the tip is in the epidural space, fine.

But for those inevitable midline cases on patient where your LOR is iffy and your contrast pattern unconvincing, I'd go paramedian before pushing a bad situation.

Personally, I don't want to switch my approaches mid-procedure.
I learned both approaches in fellowship and found the CLO to be far more reliable. I go paramedian to the most sympomatic side, and if the patient thinks that both sides "hurt just as much", I start with the side that looks worse on the MRI and may later do a second CESI paramedian to contralateral side if needed, but that's generally not required.

 

[Ligament]

I think when Steve and others say that Lig Flav may not be in midline, that's primarily referring to above C5/6. I remember reading an article in the ASA APSF newsletter that stated as such. If you are below C6/7 and are midline, it should be safe to be midline. Definitely, at C7/T1.

Nope, look below:

Anesthesiology. 2003 Dec;99(6):1387-90.
Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline.
Lirk P, Kolbitsch C, Putz G, Colvin J, Colvin HP, Lorenz I, Keller C, Kirchmair L, Rieder J, Moriggl B.
Source
Department of Anesthesiology and Critical Care Medicine, University of Innsbruck, Austria. [email protected]
Abstract
BACKGROUND:
Cervical and high thoracic epidural anesthesia and analgesia have gained increasing importance in the treatment of painful conditions and as components of anesthetics for cardiac and breast surgery. In contrast to the hanging-drop technique, the loss-of-resistance technique is thought to rely on the penetration of the ligamentum flavum. However, the exact morphology of the ligamentum flavum at different vertebral levels remains controversial. Therefore, the aim of this study was to investigate the incidence and morphology of cervical and high thoracic ligamentum flavum mid-line gaps in embalmed cadavers.
METHODS:
Vertebral column specimens were obtained from 52 human cadavers. On each dissected level, ligamentum flavum mid-line gaps were recorded and evaluated with respect to shape and size.
RESULTS:
The following variations were encountered: complete fusion in the mid-line, mid-line fusion with a gap in the caudal part, mid-line gap, and mid-line gap with widened caudal end. The incidence of mid-line gaps at the following levels was: C3-C4: 66%, C4-C5: 58%, C5-C6: 74%, C6-C7: 64%, C7-T1: 51%, Th1-Th2: 21%, Th2-Th3: 11%, Th3-Th4: 4%, Th4-Th5: 2%, and Th5-Th6: 2%. The mean width of mid-line gaps was 1.0 +/- 0.3 mm.
CONCLUSIONS:
In conclusion, the present study shows that gaps in the ligamenta flava are frequent at cervical and high thoracic levels but become rare at the T3/T4 level and below, such that one cannot always rely on the ligamentum flavum as a perceptible barrier to epidural needle placement at these levels.

 

[Ligament]

1+

Anesthesiology. 2003 Dec;99(6):1387-90.
Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline.
Lirk P, Kolbitsch C, Putz G, Colvin J, Colvin HP, Lorenz I, Keller C, Kirchmair L, Rieder J, Moriggl B.
Source
Department of Anesthesiology and Critical Care Medicine, University of Innsbruck, Austria. [email protected]
Abstract
BACKGROUND:
Cervical and high thoracic epidural anesthesia and analgesia have gained increasing importance in the treatment of painful conditions and as components of anesthetics for cardiac and breast surgery. In contrast to the hanging-drop technique, the loss-of-resistance technique is thought to rely on the penetration of the ligamentum flavum. However, the exact morphology of the ligamentum flavum at different vertebral levels remains controversial. Therefore, the aim of this study was to investigate the incidence and morphology of cervical and high thoracic ligamentum flavum mid-line gaps in embalmed cadavers.
METHODS:
Vertebral column specimens were obtained from 52 human cadavers. On each dissected level, ligamentum flavum mid-line gaps were recorded and evaluated with respect to shape and size.
RESULTS:
The following variations were encountered: complete fusion in the mid-line, mid-line fusion with a gap in the caudal part, mid-line gap, and mid-line gap with widened caudal end. The incidence of mid-line gaps at the following levels was: C3-C4: 66%, C4-C5: 58%, C5-C6: 74%, C6-C7: 64%, C7-T1: 51%, Th1-Th2: 21%, Th2-Th3: 11%, Th3-Th4: 4%, Th4-Th5: 2%, and Th5-Th6: 2%. The mean width of mid-line gaps was 1.0 +/- 0.3 mm.
CONCLUSIONS:
In conclusion, the present study shows that gaps in the ligamenta flava are frequent at cervical and high thoracic levels but become rare at the T3/T4 level and below, such that one cannot always rely on the ligamentum flavum as a perceptible barrier to epidural needle placement at these levels.

 

[lobelsteve]

Thanks Lig.

And that's why whoever teaches the midline technique trained before we knew what dangers lurk beneath and clearly never bothered updating technique to reflect anatomy and procedural safety.

Heck, UPitt was teaching blind CESI when I interviewed in 2004.

Now if you are performing the entry under lateral or with good CLO- then LOR may not be that important to you. But for my comfort and the safety of my patients, I'll tap lamina with the Tuohy, walk off paramedian, and enter going lateral to medial, inferior to superior, with my gloved fingers holding the needle at the interface with skin, milking it 1mm deeper at a time.

 

[epidural man]

I am not enamored with DSA. It makes things easier to see when flow is in the wrong place.
But there are no arteries in the posterior epidural space.

1. Don't do CTFESI
2. Use larger bore needles (much less likely to advance without feeling it)
3. Use contrast
4. Always use C7-T1 or T1-T2
5. Do not use sedation
6. Always touch T1 (or T2) lamina before considering going to ligament.
7. Go lateral or CLO (football view) when walking off lamina
8. Inject contrast under lateral first, then protect your needle when tech/nurse is going AP
9. Save AP/Lat images on every case.

Agree,

Except I'm not sure about #1. I used to think that...

But according to Rathmel's talk at ASRA - as he reviewed the data from closed claimed data base... -

A HUGE majority of injuries during CTFESI have coame from direct spinal cord injury from needle trauma. In addition, in the majority of injury, moderate to deep sedation was used. Also, there are PLENTY of reports of injury using interlaminar approach.

It was my impression after hearing his talk that CTFESI are probably safer than the huge hype we have created about NOT doing them in the pain world.

I asked Rathmel if he still does TF in the neck, and he says yes, but with dex.

By the way, he said he knew of some cases of injury where DSA was used. It is sad that whoever did that doesn't publish their stuff.

I am still very uncomfortable no doubt, but maybe my level of discomfort isn't justified based on the evidence and incidence and mechanism of injury that we understand. Since then, I have done it one time - under CT guidance, combined with fluoro for live injection of contrast with DSA.

 

[bedrock]

Agree,

Except I'm not sure about #1. I used to think that...

But according to Rathmel's talk at ASRA - as he reviewed the data from closed claimed data base... -

A HUGE majority of injuries during CTFESI have coame from direct spinal cord injury from needle trauma. In addition, in the majority of injury, moderate to deep sedation was used. Also, there are PLENTY of reports of injury using interlaminar approach.

It was my impression after hearing his talk that CTFESI are probably safer than the huge hype we have created about NOT doing them in the pain world.

I asked Rathmel if he still does TF in the neck, and he says yes, but with dex.

By the way, he said he knew of some cases of injury where DSA was used. It is sad that whoever did that doesn't publish their stuff.

I am still very uncomfortable no doubt, but maybe my level of discomfort isn't justified based on the evidence and incidence and mechanism of injury that we understand. Since then, I have done it one time - under CT guidance, combined with fluoro for live injection of contrast with DSA.

I would agree that there have been plenty of bad outcomes with both TFESI and ILESI. Common factors generally apply to both. Excessive patient sedation and inadequate training.

By the way, he said he knew of some cases of injury where DSA was used. It is sad that whoever did that doesn't publish their stuff.

I don't know where Rathmell gets his unpublished information, but I've informally polled the last few ISIS presidents and they've never heard of a case with significant neurologic injury after a cervical TFESI performed by a physician using BOTH dex and DSA.

I performed many cervical TFESI during my fellowship, and I don't think a CTFESI with BOTH dex and DSA, (performed by someone trained to use DSA), is any riskier than a cervical ILESI. However, in today's legal climate, it's not worth the liability, and I do only a couple CTFESI a year, for very select situations.

 

[bedrock]

This thread is lawyer fodder and I request the mods move it to the physician-only forum-

 

[Aether2000]

Sedation is a scapegoat....with interlaminar ESI, it is easy to penetrate the cord close to the midline with absolutely no response in awake patients. It is only after injection of saline or air that the patient responds, and then it is too late...the damage is done. Less than one cc of saline will dissect up to 7 segments within the cervical cord. Cordotomies are performed with awake patients with absolutely no response at all since in the posterior middle 1/3 of the cord, there are no sensory fibers that are penetrated by the needle. Regarding sedation, there yet remain to be any valid studies demonstrating a difference between sedation vs non-sedation injuries, and this includes the closed claims studies. They are comparing apples with oranges, and attempting to draw inferences based on these illegitimate comparisons of different groups. Rathmell's latest adventure in statistical fantasy was recently published, and on first glance shows significant differences between sedation and non-sedation. But when one looks at the differing denominators and the group selection, it becomes clear this is more of the same nonsense in attempting to ascribe additional risk where there may be none. Anesthesiologists are so hypertimid of anything they personally would do that could cause risk to patients that they are willing to sacrifice patient comfort and tolerance of a procedure for their own self protection. Sedation is certainly not needed in all cases, but anesthesiologists that believe no risk from sedation is tolerable (even if the patient believes they are being tortured) have lost their way in medicine, and have forgotten the end goal is humane treatment of patients rather that CYA. If sedation is to be given on request of the patient, a documentation that sedation theoretically has some increased risk of needle injury will be sufficient in the chart. Of course use of techniques compatible with sedation are preferable, and having an understanding that if during needle placement with sedation there is excess movement or the patient becomes disoriented and uncooperative, that the procedure should be abandoned at that point.

 

[SSdoc33]

docnyc

In fellowship, I too primarily did ILESI cervicals in the midline. Advanced under lateral,etc.

I think that's how it's mainly taught and done. I think when Steve and others say that Lig Flav may not be in midline, that's primarily referring to above C5/6. I remember reading an article in the ASA APSF newsletter that stated as such. If you are below C6/7 and are midline, it should be safe to be midline. Definitely, at C7/T1.

if pinch says it, it must be true

 

[SSdoc33]

Sedation is a scapegoat....with interlaminar ESI, it is easy to penetrate the cord close to the midline with absolutely no response in awake patients. It is only after injection of saline or air that the patient responds, and then it is too late...the damage is done. Less than one cc of saline will dissect up to 7 segments within the cervical cord. Cordotomies are performed with awake patients with absolutely no response at all since in the posterior middle 1/3 of the cord, there are no sensory fibers that are penetrated by the needle. Regarding sedation, there yet remain to be any valid studies demonstrating a difference between sedation vs non-sedation injuries, and this includes the closed claims studies. They are comparing apples with oranges, and attempting to draw inferences based on these illegitimate comparisons of different groups. Rathmell's latest adventure in statistical fantasy was recently published, and on first glance shows significant differences between sedation and non-sedation. But when one looks at the differing denominators and the group selection, it becomes clear this is more of the same nonsense in attempting to ascribe additional risk where there may be none. Anesthesiologists are so hypertimid of anything they personally would do that could cause risk to patients that they are willing to sacrifice patient comfort and tolerance of a procedure for their own self protection. Sedation is certainly not needed in all cases, but anesthesiologists that believe no risk from sedation is tolerable (even if the patient believes they are being tortured) have lost their way in medicine, and have forgotten the end goal is humane treatment of patients rather that CYA. If sedation is to be given on request of the patient, a documentation that sedation theoretically has some increased risk of needle injury will be sufficient in the chart. Of course use of techniques compatible with sedation are preferable, and having an understanding that if during needle placement with sedation there is excess movement or the patient becomes disoriented and uncooperative, that the procedure should be abandoned at that point.

the one time i barely tickled the cord during a cervical ILESI, the patient felt an immediate shock-like sensation shoot into her arm and leg. i immediately withdrew and aborted the procedure, and there were no adverse sequella. this patient DEFINITELY felt it, and i would assume would have had a simiiar reaction with light sedation. god help both of us if she didnt have that reaction....

 

[101N]

the one time i barely tickled the cord during a cervical ILESI, the patient felt an immediate shock-like sensation shoot into her arm and leg. i immediately withdrew and aborted the procedure, and there were no adverse sequella. this patient DEFINITELY felt it, and i would assume would have had a simiiar reaction with light sedation. god help both of us if she didnt have that reaction....

1+. It's hard to conceive of a 22g Touhy not disrupting the tracts sufficiently in an awake patient so that they'd merely lay there passively during their cordotomy.

 

[PMR 4 MSK]

the one time i barely tickled the cord during a cervical ILESI, the patient felt an immediate shock-like sensation shoot into her arm and leg. i immediately withdrew and aborted the procedure, and there were no adverse sequella. this patient DEFINITELY felt it, and i would assume would have had a simiiar reaction with light sedation. god help both of us if she didnt have that reaction....

I had almost an identical situation once. Scared the crap outta me.

 

[Jcm800]

the one time i barely tickled the cord during a cervical ILESI, the patient felt an immediate shock-like sensation shoot into her arm and leg. i immediately withdrew and aborted the procedure, and there were no adverse sequella. this patient DEFINITELY felt it, and i would assume would have had a simiiar reaction with light sedation. god help both of us if she didnt have that reaction....

i have tickled the cord plenty when i went at 5-6...

have not had a tickle since going to C7-T1 and COL

 

[101N]

I had almost an identical situation once. Scared the crap outta me.

I'll third this.

 

[epidural man]

Sedation is a scapegoat....with interlaminar ESI, it is easy to penetrate the cord close to the midline with absolutely no response in awake patients. It is only after injection of saline or air that the patient responds, and then it is too late...the damage is done. Less than one cc of saline will dissect up to 7 segments within the cervical cord. Cordotomies are performed with awake patients with absolutely no response at all since in the posterior middle 1/3 of the cord, there are no sensory fibers that are penetrated by the needle. Regarding sedation, there yet remain to be any valid studies demonstrating a difference between sedation vs non-sedation injuries, and this includes the closed claims studies. They are comparing apples with oranges, and attempting to draw inferences based on these illegitimate comparisons of different groups. Rathmell's latest adventure in statistical fantasy was recently published, and on first glance shows significant differences between sedation and non-sedation. But when one looks at the differing denominators and the group selection, it becomes clear this is more of the same nonsense in attempting to ascribe additional risk where there may be none. Anesthesiologists are so hypertimid of anything they personally would do that could cause risk to patients that they are willing to sacrifice patient comfort and tolerance of a procedure for their own self protection. Sedation is certainly not needed in all cases, but anesthesiologists that believe no risk from sedation is tolerable (even if the patient believes they are being tortured) have lost their way in medicine, and have forgotten the end goal is humane treatment of patients rather that CYA. If sedation is to be given on request of the patient, a documentation that sedation theoretically has some increased risk of needle injury will be sufficient in the chart. Of course use of techniques compatible with sedation are preferable, and having an understanding that if during needle placement with sedation there is excess movement or the patient becomes disoriented and uncooperative, that the procedure should be abandoned at that point.

Well it certainly isn't clear cut - this issue of sedation.

And I also think it is a hard pill to swallow that touching the cervical dorsal columns doesn't ellicit a response in an awake, non-sedated patient. If it is dead back there, how come SCS works?

Also, most of the problems with sedation are airway issues (from my understanding).

Sedation adds a complex layer - from NPO issues, to recovery issues, having a driver for the patient, IV placement, monitoring, all that stuff. I think financially, people like it because you can bill for it.

We are ******ed in our clinic - we make them all NPO and all have to have a driver, most get monitored and have an IV put in them (which I find completely ridiculous), but we can be wasteful and aren't consumed by profit. I rarely use sedation, but will if the patient requests it, or they are very nervous, or for certain procedures I use it almost always.

And by the way algosdoc, why would you make such a blanket statement about "anesthesiologist" or whatever? You have great things to say in this forum. I'm not sure what being PM&R, anesthesiologist, neurologist, Psych, black, white, hispanic, or albanian has to do with anything. I know most ya'all on this forum are PM&R and somehow have magical thinking that it makes a difference.....People are people. Some are reasonable, some are not. Some read a lot, some don't. I think fellowship training makes a big difference how someone thinks - not the initials behind their name.

 

[PinchandBurn]

if pinch says it, it must be true

You dont give up do you? I dont get what your beef is.


Now...fast forward to summer/spring 2011 APSF. More recent article.

http://www.apsf.org/newsletters/pdf/spring_2011.pdf

I saw the publication above that someone posted. The other reason that C6/7 and below is generally ok, is there's more epdural fat. Above C6/7 there is almost no epidural fat.

In fellowship we talked about Rathmell's publication at a journal club. his latest publication on cervicals doesnt tell us much information as there is no denominator in a closed claims database. It's merely observation and notation of some potential complications. I can also tell you from first hand, at his program they do not do a lot of highly interventional procedures.

I think his publcation is helpful, no doubt. But I think as long as one is careful, big catastrophies can be avoided. No doubt, bad things happen, even when you do everything right.

 

[SSdoc33]

You dont give up do you? I dont get what your beef is.

my beef is your crappy information. once or twice is one thing, but when you repeatedly support stances which are misleading or patently wrong, ill speak up. now, whenever i see one of your posts, i automatically think the info must be shady.

this is a forum to voice opinions, and you are certainly welcome to do that. However, it is also a forum that we docs use to improve themselves as phsyicians and increase our knowledge base. i suggest carefully considering your posts if you do not wish to be criticized.

and im not gonna go back thru all of your mistakes because, quite frankly, i dont want to spend 2 hours doing it.

 

[Aether2000]

Basic anatomy 101. The dura is innervated but the posterior cord and surface of the brain lack sensory innervation. If the patient felt a needle "tickling the cord", it was due to dural distension, not cord compression or penetration due to inadequate fluroscopic imaging not recognizing where the end of the needle is. Brain surgery does not require any anesthesia once through the dura. SCS does not work because c fibers or a delta fibers are activated. That is not the mechanism.

 

[Tenesma]

best way to have ZERO risk - don't do the injection... i hate doing cervicals for the above mentioned reasons and will only do them if I don't have any other options?

personally, if i had a bad cervical disc that didn't improve with meds/time/therapy or if evidence of weakness, would just go straight for ACDF...

 

[specepic]

Basic anatomy 101. The dura is innervated but the posterior cord and surface of the brain lack sensory innervation. If the patient felt a needle "tickling the cord", it was due to dural distension, not cord compression or penetration due to inadequate fluroscopic imaging not recognizing where the end of the needle is. Brain surgery does not require any anesthesia once through the dura. SCS does not work because c fibers or a delta fibers are activated. That is not the mechanism.

1) Last I checked no one really knows why SCS works (there are lots of 'theories'), no?

2) Of course the brain and spinal cord are very different. Where is your source (anatomy text or otherwise) that the posterior cervical cord will not feel pain?

 

[bedrock]

personally, if i had a bad cervical disc that didn't improve with meds/time/therapy or if evidence of weakness, would just go straight for ACDF...

Really?

I also hate cervicals for all the same reasons, but if I had a cervical radic with no or mild weakness, and had failed first-line conservative options, I'd still get a CESI or two before going for ACDF and jump-starting the inevitable adjacent segment disease.

 

[SIIMS]

There is a lot of talk about ligamentum flavum location on this thread. Not a lot of talk about cervical epidural fat location. I don't know why anyone would ever attempt a C5-6 CILESI injection unless for some reason you were actually able to appreciate any epidural fat on T1 imaging. In my experience of all the cervical MRI's I have ever viewed there is almost never any fat at this level and almost never any at C6-7 hence C7-T1 and even T1-2 is the target area. Now if you view the images carefully here most of the epidural fat is midline, clearly disappears on sagittal imaging scrolling only a few mm's left and right of midline.

So my question is if you are using Fluoroscopy and comfortable with your views wether it be CLO or lateral wouldn't your best chance of avoiding a bad event (wet tap, pithing cord, pneumocephalus, SCI, etc.) be at midline?? Honest question, please no telling me I'm a dumb***** or anything

Also, out of fellowship now so no access to Pubmed, Scopus, etc., is there any reported case in the literature whatsoever on a bad event from CTFESI using DEX and not the typical particulate steroids used??? I am in an ortho group that does occasionally request this procedure, not often, but does occur. I use DSA and DEX and abort if vascular after reposition one time (just my thing) and live to play a different day. I organized a journal club during fellowship that looked at all the rare but devastating complications and still kind of crap my pants doing them but just wondering if anything published with bad outcomes doing this procedure and using DEX?

 

[101N]

Basic anatomy 101. The dura is innervated but the posterior cord and surface of the brain lack sensory innervation. If the patient felt a needle "tickling the cord", it was due to dural distension, not cord compression or penetration due to inadequate fluroscopic imaging not recognizing where the end of the needle is. Brain surgery does not require any anesthesia once through the dura. SCS does not work because c fibers or a delta fibers are activated. That is not the mechanism.

Overly simplistic comparison. Brain surgery on the cortex is insensate but the cortex is grey matter not white. The surface of the cord is white matter with tracts. Trespass there causes a paresthesia in an awake pt. Trespass and injection causes a traumatic syrinx.

Even though the cord is insensate, neuropathic pain following a cord injury is the norm.