CLO, AP and Lateral Images

[Paindoc1]

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Can we start a thread with Posts of
1. Cervical Inter-laminar- AP/Lateral and CLO images?
2. Lumbar Inter-laminar- AP/Lateral and CLO images?
I would like to start using the CLO but not yet ready to abandon Lateral.

Also in order to get a good CLO image you should be paramedian correct? If more midline and looks great on lateral, it just doesn't always look great when I take a CLO image so I think I need to be more paramedian and oblique to the opposite side when I take the picture.
I am usually in zone 1 or 2.
Will post some pretty pictures of my own but I would love to start a thread of images.

 

[NJPAIN]

Can we start a thread with Posts of
1. Cervical Inter-laminar- AP/Lateral and CLO images?
2. Lumbar Inter-laminar- AP/Lateral and CLO images?
I would like to start using the CLO but not yet ready to abandon Lateral.

Also in order to get a good CLO image you should be paramedian correct? If more midline and looks great on lateral, it just doesn't always look great when I take a CLO image so I think I need to be more paramedian and oblique to the opposite side when I take the picture.
I am usually in zone 1 or 2.
Will post some pretty pictures of my own but I would love to start a thread of images.

What seems to be key is that the needle stay contra -lateral. If your needle crosses the midline you need to know that and then flip the II so that the II is contra lateral to where the needle tip is NOW. Also, I know everyone is concerned about fluoro time but I always check the AP more than once to make certain my needle doesn’t cross the midline.

Google “Practical Pain Management with Dr Lee”. It will take you to his YouTube videos. This guy has figured out how to effectively use the CLO view for lots of situations and procedures. Worth watching.

 

[Laryngospasm]

Once you go CLO you won’t go back. I never do lateral anymore for interlaminar.

 

[bedrock]

Once you go CLO you won’t go back. I never do lateral anymore for interlaminar.

Agree. Same here. Though I still use lateral for lumbar ILESI.

 

[Paindoc1]

What seems to be key is that the needle stay contra -lateral. If your needle crosses the midline you need to know that and then flip the II so that the II is contra lateral to where the needle tip is NOW. Also, I know everyone is concerned about fluoro time but I always check the AP more than once to make certain my needle doesn’t cross the midline.

Google “Practical Pain Management with Dr Lee”. It will take you to his YouTube videos. This guy has figured out how to effectively use the CLO view for lots of situations and procedures. Worth watching.

Thank you. He has great videos!

 

[NJPAIN]

Thank you. He has great videos!

I think if Nordstrom had a pain clinic that’s what it would look like - Dr Lee.

 

[chibadriver]

All interlaminars, can't beat the nice crisp line with CLO

 

[painfree23]

View attachment 336303
All interlaminars, can't beat the nice crisp line with CLO

Is that a tuoy?

 

[chibadriver]

Is that a tuoy?

Indeed.

 

[painfree23]

Indeed.

How much clo degrees in that pic?

 

[lobelsteve]

How much clo degrees in that pic?

Doesn't matter. But he is rotating over the top and started on the right side of the spine. You cannot use a number without knowing starting position and angle of attack to the ligament.

 

[chibadriver]

Doesn't matter. But he is rotating over the top and started on the right side of the spine. You cannot use a number without knowing starting position and angle of attack to the ligament.

How much clo degrees in that pic?

So long as your needle tip will traverse the ventral aspect of the contralateral lamina and not cross midline or venture deep into the gutter, the trajectory of the needle shouldn't matter so much... generally speaking, I usually end up about 30-35 degrees CLO in the cervical and~40 degrees CLO thoracolumbar.

 

[deleted131481]

So long as your needle tip will traverse the ventral aspect of the contralateral lamina and not cross midline or venture deep into the gutter, the trajectory of the needle shouldn't matter so much... generally speaking, I usually end up about 30-35 degrees CLO in the cervical and~40 degrees CLO thoracolumbar.

Doesn't matter. But he is rotating over the top and started on the right side of the spine. You cannot use a number without knowing starting position and angle of attack to the ligament.

I don't think I'm following. Correct me if I'm wrong:

I use CLO for CESI 50-55 degrees, midline or barely off. If I am 45 degrees the needle looks deep, if 60-65 degrees the needle looks shallow. If I were to go more lateral from midline with my needle then I need a more shallow angle on CLO.

Lumbar CLO I use 45-50 degrees.

Measuring on MRI would be the only way to get the exact angle but this range is generally good enough.

 

[chibadriver]

I don't think I'm following. Correct me if I'm wrong:

I use CLO for CESI 50-55 degrees, midline or barely off. If I am 45 degrees the needle looks deep, if 60-65 degrees the needle looks shallow. If I were to go more lateral from midline with my needle then I need a more shallow angle on CLO.

Lumbar CLO I use 45-50 degrees.

Measuring on MRI would be the only way to get the exact angle but this range is generally good enough.

Ah! No, you are correct. I should have said 55-60 CESI and ~50 LESI, not sure why I reported the inverse angle. I should have posted a picture and left it alone. My poor rad techs...

 

[kstarm]

What seems to be key is that the needle stay contra -lateral. If your needle crosses the midline you need to know that and then flip the II so that the II is contra lateral to where the needle tip is NOW. Also, I know everyone is concerned about fluoro time but I always check the AP more than once to make certain my needle doesn’t cross the midline.

Google “Practical Pain Management with Dr Lee”. It will take you to his YouTube videos. This guy has figured out how to effectively use the CLO view for lots of situations and procedures. Worth watching.

I watched a few of the videos. Thanks for the resource. I noticed he doesn't use local for any of the injections. Are people moving away from this? Usually if the needle is 22g or bigger diameter I'll use 1% lido first.

 

[callmeanesthesia]

I watched a few of the videos. Thanks for the resource. I noticed he doesn't use local for any of the injections. Are people moving away from this? Usually if the needle is 22g or bigger diameter I'll use 1% lido first.

Same. Usually no local for 25g. Usually local for 22, always for 18g (RF).

 

[cbest]

45 for lumbar and lower thoracic. 50 for cervical and upper thoracic. This is straight from Gill et al. Needle must be paramedian for CLO to work properly. If midline, it’ll look deep. If 30-35, it’ll look deeper than it actually is. If 60, it’ll look more shallow than it actually is. Read all the articles from Jatinder Gill et al. you can about CLO, contrast patterns, etc.

 

[Paindoc1]

What seems to be key is that the needle stay contra -lateral. If your needle crosses the midline you need to know that and then flip the II so that the II is contra lateral to where the needle tip is NOW. Also, I know everyone is concerned about fluoro time but I always check the AP more than once to make certain my needle doesn’t cross the midline.

Google “Practical Pain Management with Dr Lee”. It will take you to his YouTube videos. This guy has figured out how to effectively use the CLO view for lots of situations and procedures. Worth watching.

Thank you... I did it! Cervical makes sense to me but in the lumbar w CLO I just can’t see where the epidural space should be ... it’s not hugging the VILL the way it does in cervical on the CLO if you are at the edge of the spinous process

 

[Paindoc1]

I don't think I'm following. Correct me if I'm wrong:

I use CLO for CESI 50-55 degrees, midline or barely off. If I am 45 degrees the needle looks deep, if 60-65 degrees the needle looks shallow. If I were to go more lateral from midline with my needle then I need a more shallow angle on CLO.

Lumbar CLO I use 45-50 degrees.

Measuring on MRI would be the only way to get the exact angle but this range is generally good enough.

So for lumbar do you stay with in the spinous process edge ever so slightly paramedian? Bc I agree when starting out too lateral in AP then when you switch to CLO if looks sooo deep ... so I do what you said above for cervical 50-55 degrees CLO but stay just close to midline as possible
Struggling w the lumbar to see a crisp line hugging the lamina on CLO

 

[Paindoc1]

View attachment 336303
All interlaminars, can't beat the nice crisp line with CLO

In this image were you just off midline paramedian at the edge of the spinous process on AP when you hit the LF? If so, how far do you oblique the xray? How many degrees?

 

[Ducttape]

not the best, sorry, best I could dreg up in this office, and I wasn't exactly midline, but...

C arm was oblique 40 degrees. should have been a few more degrees more, but once you get comfortable, you kind of can guess where your needle tip should be with respect to the degree of obliquity and where the VILL is.

I do puffs of contrast, but I still rely on using the LOR for those puffs of contrast, so I know I am getting very low resistance when contrast goes in. it is a lot harder giving contrast using a 8 ml LOR syringe than a 3 cc luer lock syringe, and that provides, in my mind, a safety measure.

obviously, the line to imagine in this case is the same as the contrast line... I imagine that line from point to point before I give contrast, so when it shows up, there is an internal cheer...

 

[deleted131481]

So for lumbar do you stay with in the spinous process edge ever so slightly paramedian? Bc I agree when starting out too lateral in AP then when you switch to CLO if looks sooo deep ... so I do what you said above for cervical 50-55 degrees CLO but stay just close to midline as possible
Struggling w the lumbar to see a crisp line hugging the lamina on CLO

In general I've had the same hesitancy with going far lateral on lumbar and getting a good CLO view.

After reviewing some of those articles I have saved that are mentioned above which are excellent, I believe if you are going far lateral on lumbar, you will need a less oblique angle to get that nice VILL onCLO view. So instead of 45-50 maybe 40-45 degrees.

As in Ducttape's post and others more experienced, I think one gets more comfortable not having the exact angle. This is the case for me in cervical, just need to start doing lumbar CLO more.

 

[Taus]

So for lumbar do you stay with in the spinous process edge ever so slightly paramedian? Bc I agree when starting out too lateral in AP then when you switch to CLO if looks sooo deep ... so I do what you said above for cervical 50-55 degrees CLO but stay just close to midline as possible
Struggling w the lumbar to see a crisp line hugging the lamina on CLO

I can’t say that I’ve seen an issue on clo going far lateral paramedian on lumbar. I typically bisect the spinous process process and medial edge of lamina unless trying to salvage a failed tfesi for foraminal hnp where I’ll go really far lateral, skirting under lamina laterally. As long as measuring from true AP, I’ve followed the Gill articles on 50 Cervical, 45 lumbar. If bevel past line put in puff of contrast to prove still dorsal (often seen with hypertrophic lig flavum).

the VILL visualization - draw line connecting from most ventral portion of lamina above and below (will be superior portion of lamina). I tend to focus on superior/ventral portion of lamina below.

 

[chibadriver]

Here's a cervical example ~ 50 degrees

 

[lobelsteve]

Here's a cervical example ~ 50 degrees

View attachment 336476View attachment 336477

Looks good. But colimate.

 

[callmeanesthesia]

Looks good. But colimate.

Now there’s something we can agree on. The picture is far crisper if you collimate. Much better needle tip localization.

The AP is not quite AP - is the CLO 50 degrees from that? If so I’d guess it’s actually a little less than 45 degrees

 

[cbest]

With proper use of CLO, it doesn’t matter if you’re a little off of midline or far lateral. The X-ray beam cuts through the lamina the same and the needle tip in relation to that beam is the same. 45 for lumbar, 50 for cervical. Read the Gill articles.

 

[deleted131481]

With proper use of CLO, it doesn’t matter if you’re a little off of midline or far lateral. The X-ray beam cuts through the lamina the same and the needle tip in relation to that beam is the same. 45 for lumbar, 50 for cervical. Read the Gill articles.

It does matter, but I suspect you are quite experienced and the difference insignificant for you. See below:

Optimal Angle of Contralateral Oblique View in Cervical Interlaminar Epidural Injection Depending on the Needle Tip Position - PubMed

During CILESIs, a contralateral oblique (CLO) view at 60 degrees is superior to other angles for visualizing the epidural space when the needle tip is placed in the interlaminar space and within the spinous processes margin. When the needle tip is placed in the interlaminar space and lateral to...

pubmed.ncbi.nlm.nih.gov

 

[Laryngospasm]

That article doesn’t reference anything other than the angle of CLO relative to either spinous process margins or lateral to spinous process margins.

 

[Monterosso]

For views, I take AP, CLO, and a lateral view. I feel that's the safest and doesn't take much time.

In terms of approach, I feel classically a paramedian approach (cervical or lumbar) is used with CLO and also allows the injectate to have some laterality (i.e. if symptoms are more unilateral).

A straight midline approach (APZ1 in the figure below) will also work with CLO and if straight midline you can technically swing the C-arm to either direction for a CLO-type view. Often I feel the dye spread has some laterality even when the needle is midline. In that case one of the CLO views (right or left) will have a crisp line, whereas the other view will be less defined.

 

[chibadriver]

Now there’s something we can agree on. The picture is far crisper if you collimate. Much better needle tip localization.

The AP is not quite AP - is the CLO 50 degrees from that? If so I’d guess it’s actually a little less than 45 degrees

If I ipsilateral oblique to get a better approach (~5-10 deg) I usually still swing contra 60 deg from this point and see how it looks... Based on this discussion, I looked on couple patients on Friday after contrast injection and there seems to be a margin for error within 7.5 degrees oblique either direction for the needle tip just crossing the VILL. I will post some (*collimated) pictures. With significant ligament hypertrophy the VILL becomes a useless boundary marker but the CLO contrast pattern is still reassuring.

 

[Taus]

If I ipsilateral oblique to get a better approach (~5-10 deg) I usually still swing contra 60 deg from this point and see how it looks... Based on this discussion, I looked on couple patients on Friday after contrast injection and there seems to be a margin for error within 7.5 degrees oblique either direction for the needle tip just crossing the VILL. I will post some (*collimated) pictures. With significant ligament hypertrophy the VILL becomes a useless boundary marker but the CLO contrast pattern is still reassuring.

Yes. Measuring from true ap is key. Yes, there is some leeway on angle, but watt you want is an angle where lor is never BEFORE vill. Yes lig flavum hypertrophy can create lor ventral to vill. The Gill article does a good job covering this.

 

[strike5858]

Can someone share the hill article?

 

[Ducttape]

I can’t say that I’ve seen an issue on clo going far lateral paramedian on lumbar. I typically bisect the spinous process process and medial edge of lamina unless trying to salvage a failed tfesi for foraminal hnp where I’ll go really far lateral, skirting under lamina laterally. As long as measuring from true AP, I’ve followed the Gill articles on 50 Cervical, 45 lumbar. If bevel past line put in puff of contrast to prove still dorsal (often seen with hypertrophic lig flavum).

the VILL visualization - draw line connecting from most ventral portion of lamina above and below (will be superior portion of lamina). I tend to focus on superior/ventral portion of lamina below.

the last line is significant.

it matters less to me the degree of the obliquity as to the ability to "see" the VILL - when i go CLO, that is what i am looking for as the target line.

if i cant visualize that line well, then usually it means that i need to go more oblique.

 

[cbest]

It does matter, but I suspect you are quite experienced and the difference insignificant for you. See below:

Optimal Angle of Contralateral Oblique View in Cervical Interlaminar Epidural Injection Depending on the Needle Tip Position - PubMed

During CILESIs, a contralateral oblique (CLO) view at 60 degrees is superior to other angles for visualizing the epidural space when the needle tip is placed in the interlaminar space and within the spinous processes margin. When the needle tip is placed in the interlaminar space and lateral to...

pubmed.ncbi.nlm.nih.gov

It doesn’t matter. If the X-ray beam is cutting through the lamina, the needle tip will appear at roughly the same depth on a CLO view whether it’s a little bit lateral to the sagittal line or farther lateral. It is the same distance past the lamina so will appear about the same depth on CLO. Please read the Gill and Simopoulos articles discussing CLO view.