Hi! I started residency in anesthesiology and critical care about 1,5 months ago and lately having difficulties getting spinals done. At the beginning everything seemed to go alright, using lateral approach I gave 10-20 spinals, got the needle into the right place almost without second attempts but now almost all week I´m struggling to get needle in with 50% of the cases. Basically needle contacts bone in the late phase and no matter how I try, it happens again. It doesn't seem to depend on the patient's weight...Have this ever happened to you?
Difficulties with spinal
- Thread starter MarioJar
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When you say "lateral approach" do you mean para-median needle insertion or you mean that the patient is in lateral decubitus?
If you are hitting bone frequently it means that you are most likely off mid-line and hitting the lamina as a result.
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use the midline approach.
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Don't rush. Make sure you're confident of your landmarks before you start. Sure, on a 500 pounder this isn't going to happen, but that shouldn't normally be the case.
"To go fast, go slowly" - i.e., for each bit of time you spend landmarking, you'll save way more time fishing around wondering where on earth the destination went.
"To go fast, go slowly" - i.e., for each bit of time you spend landmarking, you'll save way more time fishing around wondering where on earth the destination went.
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Also confused by what you mean by lateral.
Positioning is key. Time to get the patient set up right is always well spent. Spinals should be easy in non obese people, even for newbies. If you're struggling there's a system or technique error.
Positioning is key. Time to get the patient set up right is always well spent. Spinals should be easy in non obese people, even for newbies. If you're struggling there's a system or technique error.
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When I was a resident at just about your level, I had a span of like 10 parturients who I was just hitting bone everywhere I place the needle. Turned out it was the ligamentum flavum and I just wasn't realizing what I was hitting. I felt some tough resistance and thought it was bone. Remember the ligament feels different in everyone. Whenever my junior residents say they are hitting bone, I ask them to make sure. Over time you will really learn to know what bone feels like (it's scratchy).
I agree with plank - you are probably hitting lamina if it is truly bone. I would try and get a spine model and play around with a spinal/epidural needle. It is really nice to keep that model in mind every time you pass the needle. Over time it becomes second nature and you can easily visualize where the needle is located.
I agree with plank - you are probably hitting lamina if it is truly bone. I would try and get a spine model and play around with a spinal/epidural needle. It is really nice to keep that model in mind every time you pass the needle. Over time it becomes second nature and you can easily visualize where the needle is located.
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This actually happened to me too, when I was learning epidurals - once I realized that was the problem it was kind of an "a-ha" moment and I rarely missed a neuraxial after that. Learning that I needed more force also helped me get over being so timid with the spinal needle. The spinal needle is small so it gets pushed around, bent, and stopped up by the ligament pretty easily. The nice thing about having such a small needle is that you can use a little more force and, if you're below the termination of the cord, it's unlikely you'll hurt anything even if you overshoot. Epidurals it's a different story.
I agree about using midline too, you'll have your landmarks better lined up and you'll be working in 2 dimensions instead of 3.
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If it is the size of the patient or they are deep you can use a Tuohy with loss of resistance then pass a spinal needle through. A Tuohy gives you better feel where you are. You are basically doing a CSE without placing the catheter. I find the bigger patients with bad or no landmarks that this is a good salvage technique. Keep practicing and try different techniques.
I saw a really neat sign at the place where my daughter used to take fencing lessons:
"A novice trains so they can get it right...a master trains so they can't get it wrong"
All the above are great tips.
1. Use midline--paramedian is advanced and for unattainable midline shots
2. If you use midline, often sitting up is the better position because it is easier to visualize midline and you don't have to deal with the "sag" of the spine when the patient is sideways
3. If you hit something hard and you push and the whole patient moves...it is bone (not ligamentum)
4. Use your local needle as a landmark finder--when you find ligament, unscrew the local syringe and leave the local needle as a placeholder as you reach for your spinal needle (probably Gertie needle)
5. If too much osteophytes (old arthritic patients), try L5-S1 interspace. It does not usually articulate and often has the biggest space and fewest osteophytes--just recall your chronic pain rotation when you do epidurals under fluoro--remember how big that looked?
6. Take a step back and reassess landmarks if you are stuck. Go back to basics and don't perserverate at the same level. Remember needle must come to almost skin before redirecting otherwise you are still committed to the same track.
hope this helps
"A novice trains so they can get it right...a master trains so they can't get it wrong"
All the above are great tips.
1. Use midline--paramedian is advanced and for unattainable midline shots
2. If you use midline, often sitting up is the better position because it is easier to visualize midline and you don't have to deal with the "sag" of the spine when the patient is sideways
3. If you hit something hard and you push and the whole patient moves...it is bone (not ligamentum)
4. Use your local needle as a landmark finder--when you find ligament, unscrew the local syringe and leave the local needle as a placeholder as you reach for your spinal needle (probably Gertie needle)
5. If too much osteophytes (old arthritic patients), try L5-S1 interspace. It does not usually articulate and often has the biggest space and fewest osteophytes--just recall your chronic pain rotation when you do epidurals under fluoro--remember how big that looked?
6. Take a step back and reassess landmarks if you are stuck. Go back to basics and don't perserverate at the same level. Remember needle must come to almost skin before redirecting otherwise you are still committed to the same track.
hope this helps
