Dealing with calcified Ligamentum Flavum during SCS trial/implant

[FacetiousJoint]

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I am in my fellowship and lately have been having some difficult SCS trials/implants with getting LOR. I usually have no difficulty with traditional ILESI with saline/air plastic LOR, but been having difficulty with air only LOR. Also if the LF so calcified, I am having a hard time getting LOR. Would you all recommend getting LOR with the lead? I am in the south so the patients are quite large. We have to use the long medtronic green 6 inch coudes a lot of the time

There have been cases where my attending takes over and they are putting an extreme amount of pressure to get it, and I am afraid of wet tapping and especially very cautious in the C spine

 

[BobBarker]

It is good to be cautious always, never more so than the c spine. It is a tough thing. I have an implant last week in a lady who had a flavum that felt like a rock. Not looking forward to it. A lot of times I will go for tradition LOR, but once I flip into lateral I just use the lead.

 

[lobelsteve]

Have not gotten a LOR in years.
Engage ligament.
Go lateral for depth with lead in needle, advance in 1mm increments.
When lead threads posteriorly behind cord and ascends in canal, go back AP.

 

[Agast]

Enter at a different level. The LF is not uniform and can be thicker in some areas than others.

 

[BobBarker]

Good idea. My lady was way too hard bilateral at t12/L1. It was nerve wracking. I will try t11/12. Her back starts to get messy lower.

 

[RoloTomassi]

Green coude is also not very sharp. If you take a good trajectory, the straight pointy one works fine.

 

[Agast]

Cursing loudly also helps sometimes 😉

 

[PinchandBurn]

Have not gotten a LOR in years.
Engage ligament.
Go lateral for depth with lead in needle, advance in 1mm increments.
When lead threads posteriorly behind cord and ascends in canal, go back AP.

This is the best way to do it. I have done it this way for 15 years


LoR doesnt matter if the lead doesnt go in..but be very very slow before advancing a lot

 

[interjectionreflection]

Have not gotten a LOR in years.
Engage ligament.
Go lateral for depth with lead in needle, advance in 1mm increments.
When lead threads posteriorly behind cord and ascends in canal, go back AP.

Any reason you don't enter in CLO with this technique similar to ilesi and then do lateral to guide stim?

 

[lobelsteve]

Any reason you don't enter in CLO with this technique similar to ilesi and then do lateral to guide stim?

Nope, CLO or lateral is fine. For me and the rotating techs, the full lateral with ribs even is cleaner pic.

 

[Ducttape]

i always enter in CLO in trials. faster and easier to switch to AP in case another view is needed.

i get a lateral after final placement or if there are concerns before.

i do check for LOR but only as a matter of principle and my own comfort. would rather initially "push" with air than a solid lead. in addition, it might open things up a tiny bit.


make sure you have enough abdominal support. i find when there is reduced lumbar lordosis it is easier to get through ligamentum flavum.

 

[Orin]

I am in my fellowship and lately have been having some difficult SCS trials/implants with getting LOR. I usually have no difficulty with traditional ILESI with saline/air plastic LOR, but been having difficulty with air only LOR. Also if the LF so calcified, I am having a hard time getting LOR. Would you all recommend getting LOR with the lead? I am in the south so the patients are quite large. We have to use the long medtronic green 6 inch coudes a lot of the time

There have been cases where my attending takes over and they are putting an extreme amount of pressure to get it, and I am afraid of wet tapping and especially very cautious in the C spine

I assume those are Epimed 14g RX2 coude needles

Those come with add-on 'wings' that help to stabilize things and catch yourself if you're worried about it jumping. Often the wings are thrown out, but look to see if they are available. The design of the MDT curved or the coude needle should reduce the risk of a dural tap as the lower curve pushes the dura down somewhat as you advance. Realize though a lot of times you're hitting lamina and not ligament as the coude tends to shallow itself out quickly.

Agree with loss to the lead being more reliable. LOR/syringes are a holdover from blind anesthesia epidurals
Line yourself up in AP and swap to CLO

You should recognize the risk of a wet tap in obese patients or cervical cases is relatively low for a symptomatic headache
You should appreciate the amount of fat and CSF on the pre-op MRI at your target access levels to understand your safety margin

Fear is good, but don't turn off your brain.

 

[Taus]

i always enter in CLO in trials. faster and easier to switch to AP in case another view is needed.

i get a lateral after final placement or if there are concerns before.

i do check for LOR but only as a matter of principle and my own comfort. would rather initially "push" with air than a solid lead. in addition, it might open things up a tiny bit.


make sure you have enough abdominal support. i find when there is reduced lumbar lordosis it is easier to get through ligamentum flavum.

Yep. Always 2 pillows under belly. I do purely clo with the lead. It should pass easily, almost no force. If not, pull it back few mm into needle, advance needle and repeat.

 

[SgtThunderfistMD]

Also there is no reason not to use NS with trials/implants. Ive done it every time and had no impedance issues.

 

[BobBarker]

@Agast did her implant. Accessed t11/12 and it felt much, much better. Still cautious of course. I got access in lateral with tiny movements and the lead tip.

 

[DrSwede]

I use CLO for cervical ILESI routinely, but not for scs trials or lumbar ILESI.

Anyone have a few good pics of CLO use in lumbar esi or trials?

 

[Agast]

I use CLO for cervical ILESI routinely, but not for scs trials or lumbar ILESI.

Anyone have a few good pics of CLO use in lumbar esi or trials?

It looks the same. Tilt 40 degrees instead of 50 degrees.

 

[BobBarker]

I do AP/lateral for scs at t12/L1 and t11/12. AP/CLO at 45 degrees for LESI.

 

[DoYouEvenLiftBro]

I use CLO for cervical ILESI routinely, but not for scs trials or lumbar ILESI.

Anyone have a few good pics of CLO use in lumbar esi or trials?

Historically it’s around 45 clo
Do you do mild? Same view

 

[Ducttape]

i start 35 degrees. hate going more because that usually means the c-arm gets blocked by the side lead or comes up over the lead. but tilt image intensifier, take a pic and go more CLO until you can get a good view of the VIL that you are comfortable with.