Dural puncture avoidance

IPSIS: Formerly the Spine Intervention Society
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jwalker12 said:
Lobel/Mitch
When doing your technique and you feel resistance when injecting the contrast do you keep pushing or take this as ligament engagement and then advance? Almost as if you are doing intermittent LOR?
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I use continuous pressure, not puffs of contrast, though I often do both. About an hour ago I did both.

The problem is you'll get stuck in the LF, and pulling back may actually dislodge your needle posteriorly or anteriorly through it. Sometimes you're pulling and pushing the LF forward and backward and slow pressure on the contrast will suddenly result in crisp epidural flow, or posterior flow.

Do NOT just keep advancing.
 
MitchLevi said:
I use continuous pressure, not puffs of contrast, though I often do both. About an hour ago I did both.

The problem is you'll get stuck in the LF, and pulling back may actually dislodge your needle posteriorly or anteriorly through it. Sometimes you're pulling and pushing the LF forward and backward and slow pressure on the contrast will suddenly result in crisp epidural flow, or posterior flow.

Do NOT just keep advancing.
Click to expand...
The resistance will always be higher than with your touhy, but you should never apply high pressure. If there is not slow flow seen on serial images and resistance, you are probably in ligament or needle is occluded. No one has been injured by an extra puff of contrast in the paraspinal musculature to my knowledge.
 
cowboydoc said:
The resistance will always be higher than with your touhy, but you should never apply high pressure. If there is not slow flow seen on serial images and resistance, you are probably in ligament or needle is occluded. No one has been injured by an extra puff of contrast in the paraspinal musculature to my knowledge.
Click to expand...
Or in cord…..
 
MitchLevi said:
I use continuous pressure, not puffs of contrast, though I often do both. About an hour ago I did both.

The problem is you'll get stuck in the LF, and pulling back may actually dislodge your needle posteriorly or anteriorly through it. Sometimes you're pulling and pushing the LF forward and backward and slow pressure on the contrast will suddenly result in crisp epidural flow, or posterior flow.

Do NOT just keep advancing.
Click to expand...
So you have extension tubing connected or syringe with contrast directly on the 25G?

In addition, would one be faulted for deviated from standard of care if God forbid you did hit the cord with a cutting needle?

For those of you using LOR, do you guys use slip tips or leur locks? Any advantages of one over the other?
 
jwalker12 said:
So you have extension tubing connected or syringe with contrast directly on the 25G?

In addition, would one be faulted for deviated from standard of care if God forbid you did hit the cord with a cutting needle?

For those of you using LOR, do you guys use slip tips or leur locks? Any advantages of one over the other?
Click to expand...

Extension tubing for all epidurals under all circumstances. That is the single most important safety step in the procedure. Not worried about standard of care because loss of resistance lies.
 
jwalker12 said:
So you have extension tubing connected or syringe with contrast directly on the 25G?

In addition, would one be faulted for deviated from standard of care if God forbid you did hit the cord with a cutting needle?

For those of you using LOR, do you guys use slip tips or leur locks? Any advantages of one over the other?
Click to expand...
For me, no extension tubing. I hold the needle steady instead. And always Luer locks. I hate slip tips. Absolutely despise them. Probably goes back to being a first year anesthesia resident doing a spinal in the middle of the night for an urgent c section, and the slip tip popped out and I sprayed the meticulously prepared spinal injectate all over myself, the patient, and my attending.
 
I finally did a C7-T1 CESI via the Lobel method today. It did go smoothly.

I had two issues. 1- it is very easy for the little puffs of contrast to block your view right when you are trying to cross the LF.
2- I'm still worried about how much cranial spread I achieved, despite applying a significant angle to both the needle entry and tip of the need to encourage cranial spread.
IMG_8371.jpg

IMG_8372.jpg
 
bedrock said:
I finally did a C7-T1 CESI via the Lobel method today. It did go smoothly.

I had two issues. 1- it is very easy for the little puffs of contrast to block your view right when you are trying to cross the LF.
2- I'm still worried about how much cranial spread I achieved, despite applying a significant angle to both the needle entry and tip of the need to encourage cranial spread.
View attachment 400404
View attachment 400401
Click to expand...
Tighten up the collimation and pic can be even prettier.
 
bedrock said:
I finally did a C7-T1 CESI via the Lobel method today. It did go smoothly.

I had two issues. 1- it is very easy for the little puffs of contrast to block your view right when you are trying to cross the LF.
2- I'm still worried about how much cranial spread I achieved, despite applying a significant angle to both the needle entry and tip of the need to encourage cranial spread.
Click to expand...
Awesome. Did you do intermittent or continuous? 25g? What were your thoughts on this vs LOR, will you do this going forward?
 
Intermittent. 25G

If the choice was between this and regular LOR at C7-T1, I would definitely choose the 25G technique.

But I’m still worried it may not spread to higher cervical segments or treat severe foraminal stenosis as well as my CESI with catheter technique. But I also haven’t done a double blinded study, lol, so I don’t know for sure.

My catheters have become more expensive and the CESI catheter technique takes more time, and I’m not reimbursed for either one.

For a while, I may just do the 25G CESI technique for patients on federal or state WC insurance and the use my catheter technique for patients on commercial insurance, since I’m paid double by commercial insurance which compensates my extra time and materials costs to do a CESI with catheter.
 
your pics look good. Inject steroid take a pic after in clo and see how high your diluted contrast goes.

It’s tight in there. gonna go. If infrequent c3-4 issue and fails cesi and absolutely need -do ur catheter or ctfesi at that level

I do all mine a T1-2 and seems to work fine
 
bedrock said:
But I’m still worried it may not spread to higher cervical segments or treat severe foraminal stenosis as well as my CESI with catheter technique. But I also haven’t done a double blinded study, lol, so I don’t know for sure.
Click to expand...
McCormick did the study. Made no difference.
 
nvrsumr said:
your pics look good. Inject steroid take a pic after in clo and see how high your diluted contrast goes.

It’s tight in there. gonna go. If infrequent c3-4 issue and fails cesi and absolutely need -do ur catheter or ctfesi at that level

I do all mine a T1-2 and seems to work fine
Click to expand...

Thank you. I’ll do that.

Two questions about your last comment.
1- do you run into commercial insurances that ever deny a T1-T2 ESI for a cervical radic, like someone posted on SDN?

2- I understand an T1-T2 ILESI for older or post surgical spines. But why do an T1-T2 on a 35 year old with a C5-C6 disc and a normal C7-T1 level?
 
Your outcomes will be identical using 25g technique vs catheter, at least in the long term. In the short term you're probably gonna have a few pts you think would have done better using the catheter, but that's only because the 25g technique is new to you. Your medication has legs, and does not stay where you left it when you're done injecting.

Here is one benefit of this technique: I’ve done 3 CESI since 8:01.

IMG_6816.jpeg
 
Last edited:
I've switched to the Lobel 25 CESI technique the past 2 years with similar ease/effectiveness per others experience. Big fan of it.

The past month I've had 3-4 cases where the needle seems to be clogged or have very high pressure. Never had that happen before. Assuming the needle is clogging with Depo? Needle doesn't seem to be moving back into LF and have good epidural flow but half way through injecting the steroid it clogs. Anyone see this with Depo 40 vs 80 vs any other explanation?

Case from today that clogged below.

1743524529117.png
 
runfastnow said:
I've switched to the Lobel 25 CESI technique the past 2 years with similar ease/effectiveness per others experience. Big fan of it.

The past month I've had 3-4 cases where the needle seems to be clogged or have very high pressure. Never had that happen before. Assuming the needle is clogging with Depo? Needle doesn't seem to be moving back into LF and have good epidural flow but half way through injecting the steroid it clogs. Anyone see this with Depo 40 vs 80 vs any other explanation?

Case from today that clogged below.

View attachment 401500
Click to expand...
Switch to Celestone?
You are a little right to left in your start to finish, but looks good on lateral. Appears a little deep but since going to 50 degree CLO for most everything, it is either a thin line or not yet in.
Also: collimate.
 
Definitely not the best approach - slid more lateral than I really wanted but skittish lady I didn't want to poke around too much.

Thanks for the tips.
 
runfastnow said:
I've switched to the Lobel 25 CESI technique the past 2 years with similar ease/effectiveness per others experience. Big fan of it.

The past month I've had 3-4 cases where the needle seems to be clogged or have very high pressure. Never had that happen before. Assuming the needle is clogging with Depo? Needle doesn't seem to be moving back into LF and have good epidural flow but half way through injecting the steroid it clogs. Anyone see this with Depo 40 vs 80 vs any other explanation?

Case from today that clogged below.

View attachment 401500
Click to expand...
I have noticed Depo 80 mg in a 25G has clogged up the last few months. It has even clogged me up with a 22 or 23G on occasion, forget which exactly. Two 40 mg vials works fine, though. We must be working with the same vials.
 
I've had it happen. Only with the 25 gauge needles. I tend to use 25s only for joints.

Use the introducer to try to clear the needle and put meds in smaller syringe and agitate the syringe aggressively. Or if push comes to shove, use dexa.
 
jwalker12 said:
So you have extension tubing connected or syringe with contrast directly on the 25G?

In addition, would one be faulted for deviated from standard of care if God forbid you did hit the cord with a cutting needle?

For those of you using LOR, do you guys use slip tips or leur locks? Any advantages of one over the other?
Click to expand...
slip tip as i trained with that and am most familiar with that feel
 
runfastnow said:
I've switched to the Lobel 25 CESI technique the past 2 years with similar ease/effectiveness per others experience. Big fan of it.

The past month I've had 3-4 cases where the needle seems to be clogged or have very high pressure. Never had that happen before. Assuming the needle is clogging with Depo? Needle doesn't seem to be moving back into LF and have good epidural flow but half way through injecting the steroid it clogs. Anyone see this with Depo 40 vs 80 vs any other explanation?

Case from today that clogged below.

View attachment 401500
Click to expand...
yes I was having a significant problem with depo clogging my needles the last few months and then the hospital said there was a huge national recall on the depo we were using and switched. Haven't had it happen since the switch. Prior to that it was happening a few times a week. Something definitely wasn't right
 
bedrock said:
Brand or generic?
Click to expand...
I just checked and it's generic. I believe it used to be brand. My 40 mg is still brand.
clubdeac said:
yes I was having a significant problem with depo clogging my needles the last few months and then the hospital said there was a huge national recall on the depo we were using and switched. Haven't had it happen since the switch. Prior to that it was happening a few times a week. Something definitely wasn't right
Click to expand...
Was this brand or generic? Do you know more details about the recall?
 
GatorCHOMPions said:
I just checked and it's generic. I believe it used to be brand. My 40 mg is still brand.

Was this brand or generic? Do you know more details about the recall?
Click to expand...
Good question. I unfortunately don’t really know
 
Y’all didn’t know?

They fly Steve out to Vatican City whenever pontiff needs a C-ESI

Steve is going to heaven one day; he will be publishing papers on angels with wing drop and comorbid winged scapulae
 
Do not use 25 g needle on the neck, it is more prone to faulse positive results, because on the neck there is more fat. If you are not sure where you are put some liquid into the needle, it will give you resistance again, the best technique on the neck is “hanging drop” with contrast conformation. As long as you have a caudat spread you will not cause a cord compression, so you can use volume - 2 ml kenalog 80mg, 2ml 0.25% bupivicaine and 2ml injectable normal saline, that will give you a good spread through the epidural space, just inject slowly.
 
mygalperin said:
Do not use 25 g needle on the neck, it is more prone to faulse positive results, because on the neck there is more fat. If you are not sure where you are put some liquid into the needle, it will give you resistance again, the best technique on the neck is “hanging drop” with contrast conformation. As long as you have a caudat spread you will not cause a cord compression, so you can use volume - 2 ml kenalog 80mg, 2ml 0.25% bupivicaine and 2ml injectable normal saline, that will give you a good spread through the epidural space, just inject slowly.
Click to expand...
This seems like literally the opposite of the advice I would give someone.

- I'm not a personal fan of the 25g needle in the neck, but whatever, if people want to do the lobel technique, go for it.
- Hanging drop is insanely inaccurate
- Agree with contrast confirmation
- Kenalog says on the bottle "not for epidural use"
- Local? During a CESI? Risk/benefit ratio is utterly skewed in the wrong direction.
 
I never use bupiv for any epidural outside of an inpatient or a spinal neurolytic block (which I haven't done in 5 + years). Too risky for paralysis.

And kenalog is the one steroid with a black box warning pertaining epidurals....
 
mygalperin said:
Do not use 25 g needle on the neck, it is more prone to faulse positive results, because on the neck there is more fat. If you are not sure where you are put some liquid into the needle, it will give you resistance again, the best technique on the neck is “hanging drop” with contrast conformation. As long as you have a caudat spread you will not cause a cord compression, so you can use volume - 2 ml kenalog 80mg, 2ml 0.25% bupivicaine and 2ml injectable normal saline, that will give you a good spread through the epidural space, just inject slowly.
Click to expand...
🙈

ummm.....

dont do this
 
mygalperin said:
Do not use 25 g needle on the neck, it is more prone to faulse positive results, because on the neck there is more fat. If you are not sure where you are put some liquid into the needle, it will give you resistance again, the best technique on the neck is “hanging drop” with contrast conformation. As long as you have a caudat spread you will not cause a cord compression, so you can use volume - 2 ml kenalog 80mg, 2ml 0.25% bupivicaine and 2ml injectable normal saline, that will give you a good spread through the epidural space, just inject slowly.
Click to expand...
Sensory testing mandatory for RFAs, hanging drop and kenalog for ESIs. How long ago did you do your training?

1744126052699.jpeg
 
mygalperin said:
Do not use 25 g needle on the neck, it is more prone to faulse positive results, because on the neck there is more fat. If you are not sure where you are put some liquid into the needle, it will give you resistance again, the best technique on the neck is “hanging drop” with contrast conformation. As long as you have a caudat spread you will not cause a cord compression, so you can use volume - 2 ml kenalog 80mg, 2ml 0.25% bupivicaine and 2ml injectable normal saline, that will give you a good spread through the epidural space, just inject slowly.
Click to expand...
And guess who is new and is not good? Yes, you are.
Might want to post where you trained and your experience.
 
BoardingDoc said:
This seems like literally the opposite of the advice I would give someone.

- I'm not a personal fan of the 25g needle in the neck, but whatever, if people want to do the lobel technique, go for it.
- Hanging drop is insanely inaccurate
- Agree with contrast confirmation
- Kenalog says on the bottle "not for epidural use"
- Local? During a CESI? Risk/benefit ratio is utterly skewed in the wrong direction.
Click to expand...
after the dilution in comes to 0.625% that in no way can cuse motor block, but gives a perfect pain relief immediately
 
mygalperin said:
after the dilution in comes to 0.625% that in no way can cuse motor block, but gives a perfect pain relief immediately
Click to expand...
This is not a remotely true statement. No one is talking about the local sitting in the epidural space. If you have any inadvertent intrathecal spread you will get a high spinal and not only have motor block, but can specifically have a block of the diaphragm.

We consider that to be something of a faux pas in these parts.
 
That is why you must use a dye to make sure that will not happened!!! Read my original post please
 
And whoever is guessing where am I they can google my name, it is not a secret!
 
What paralysis you are talking about? Temporary weakness of the limb? But it will be resolved in 30to 45 min, but it will give a prolonged effect of your inject at, and allow steroid to take effect, so your procedure will be effective from the time it was performed going forward w/o any time lapse.
 
Of course we are using contrast. And there’s nothing wrong with different opinions but the tone is objectionable. It sounds as if you’re coming here to tell us that we’re all doing it wrong. Perhaps it’s a language barrier?

Can you describe for us your cervical epidural technique? Are you truly relying on hanging drop to judge entry? Do you use contralateral oblique fluoroscopy? What size needle?
 
Comments about language barrier sounds a bit offensive! The technic of the cesi was described earlier in my post, same as a recipe for the injectat, since I am using a contrast I do not use the contralateral view, because it’s a vast of time and extra radiation. The distribution of the dye gives you a clear proof of where y are. When you see a drop sucked in, you stop advancing, and inject dye. On a very rear occasion you are not in the epidural space yet. As long as you have a caudal spread you can inject. There will be cord compression. I use 20g needle, it gives you a good feeling, does not bend, and you can adequately steer it if necessary. The whole thing takes 45 to 55 sec.
 
And by the way I never said anything about somebody being wrong. I just made a comments on somebody’s post.
 
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