Dural puncture avoidance

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bedrock said:
Most of the time I just skip contrast for patients with reported contrast allergies.

I will premedicate for most CESI. However, since I do my CESI with catheter, I can skip contrast even on those if needed.
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How do you afford catheters in PP?
 
MitchLevi said:
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.
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You keep extension tubing connected at all times during an epidural? Safety step for who? The patient?
 
po_boy said:
You keep extension tubing connected at all times during an epidural? Safety step for who? The patient?
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As soon as the 25g is on target I attach the purged cath ext tubing and inject contrast. All adjustments made from that point have the tubing in place.
 
po_boy said:
You keep extension tubing connected at all times during an epidural? Safety step for who? The patient?
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It’s the only step that is considered mandatory by SIS.

Once my needle is near my target and I have another one or two little adjustments to make I attach the tubing.

If you put contrast in the patient, then remove the tubing and attach just a syringe of your steroid, you’re increasing the likelihood you wet tap that pt or end up in a vessel.
 
MitchLevi said:
It’s the only step that is considered mandatory by SIS.

Once my needle is near my target and I have another one or two little adjustments to make I attach the tubing.

If you put contrast in the patient, then remove the tubing and attach just a syringe of your steroid, you’re increasing the likelihood you wet tap that pt or end up in a vessel.
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​

You would do this with even LOR technique?

Why not just attach contrast then steroid syringe directly to epidural needle?

How does the absence of tubing or removing tubing increase the likelihood you wet tap or end up in a vessel?
 
po_boy said:

​

You would do this with even LOR technique?

Why not just attach contrast then steroid syringe directly to epidural needle?

How does the absence of tubing or removing tubing increase the likelihood you wet tap or end up in a vessel?
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Touching the needle moves the needle.
Changing syringe on tubing eliminates this.
 
po_boy said:

​

You would do this with even LOR technique?

Why not just attach contrast then steroid syringe directly to epidural needle?

How does the absence of tubing or removing tubing increase the likelihood you wet tap or end up in a vessel?
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As S said, you're moving the needle in an uncontrolled manner, and if you think depressing the plunger doesn't move the syringe you're not paying attention. All of these movements can put you IT, vascular, posterior and out of the target area, etc.

It matters quite a bit.
 
I'm really not trying to be argumentative; just trying to understand.

Are you holding the needle in place with your non-dominant hand while you push the contrast or steroid through the tubing?

If I'm anchoring the needle with my non-dominant hand and not using tubing, I don't see how the needle would move enough to cause in issue.

I trained with tubing during fellowship for all ILESI and TFESI, but we were also going live with fluoro.

I do not use live fluoro for ILESI currently. Are y'all going live for either ILESI or TFESI?
 
po_boy said:
I'm really not trying to be argumentative; just trying to understand.

Are you holding the needle in place with your non-dominant hand while you push the contrast or steroid through the tubing?

If I'm anchoring the needle with my non-dominant hand and not using tubing, I don't see how the needle would move enough to cause in issue.

I trained with tubing during fellowship for all ILESI and TFESI, but we were also going live with fluoro.

I do not use live fluoro for ILESI currently. Are y'all going live for either ILESI or TFESI?
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I don’t think anyone is arguing man. You’re good.

Why use contrast if you’re not live? You can have vascular flow that you’ll miss.

The tubing is the ONLY step in a spine procedure that is “mandatory.” It is clearly safer and IMO you’re practicing outside what I would consider appropriate care.

No live contrast isn’t great either, but the tubing is a legit issue man. I would recommend you use it.
 
MitchLevi said:
I don’t think anyone is arguing man. You’re good.

Why use contrast if you’re not live? You can have vascular flow that you’ll miss.

The tubing is the ONLY step in a spine procedure that is “mandatory.” It is clearly safer and IMO you’re practicing outside what I would consider appropriate care.

No live contrast isn’t great either, but the tubing is a legit issue man. I would recommend you use it.
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Just to be clear: you're advocating for tubing and live fluoro for both CESI and LESI?
 
i advocate for tubing but live fluoro for interlaminars is probably not as necessary if you are seeing contrast appropriately on static images.

saves on radiation. yes maybe only a second or two, but each second is 15-30 seconds per day less radiation to your corneas and gonads...

now tfesi is different and live fluoro is important.
 
No live fluoro for me except cervical TFESI (which I do very rarely) and no tubing except that one. Maybe it’s an anesthesia thing? We just hold the needle all the time for labor epidurals. As long as it’s a luer lok, I have no problem holding the needle still. Just have to stabilize your grip correctly.
 
callmeanesthesia said:
No live fluoro for me except cervical TFESI (which I do very rarely) and no tubing except that one. Maybe it’s an anesthesia thing? We just hold the needle all the time for labor epidurals. As long as it’s a luer lok, I have no problem holding the needle still. Just have to stabilize your grip correctly.
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Holding the needle has worked without fail since day one.

I’m open to new ideas and techniques. However, I fail to see how tubing adds anything to safety. If anything, there’s more of a chance of tugging on the tube and moving the needle IMO.
 
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po_boy said:
Holding the needle has worked without fail since day one.

I’m open to new ideas and techniques. However, I fail to see how tubing ads anything to safety. If anything, there’s more of a chance of tugging on the tube and moving the needle IMO.
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People way smarter and more experienced than anyone in this forum disagree.

Dude, if you do a TFESI anywhere in the spine, use tubing. Less important in the ILESI bc of the LF, and especially if you’re a caveman using an 18 or 20 Tuohy, but if you do a TF use the tubing bc it matters. You’ll also spare your hand radiation.
 
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MitchLevi said:
People way smarter and more experienced than anyone in this forum disagree.

Dude, if you do a TFESI anywhere in the spine, use tubing. Less important in the ILESI bc of the LF, and especially if you’re a caveman using an 18 or 20 Tuohy, but if you do a TF use the tubing bc it matters. You’ll also spare your hand radiation.
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I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
 
I’m looking for the actual study but that is good info..
 
I still do live flouro for TFESIs….. but not really sure need to.
 
callmeanesthesia said:
I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
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Right. Is anyone not using dex for TF?
 
callmeanesthesia said:
I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
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I wouldn’t begrudge you doing that if you’re using dex
 
callmeanesthesia said:
I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
Click to expand...

Agree. I don't do live flouro on anything besides SCS trials, sympathetic blocks, and S1 TFESIs with depo (all other TFESI levels with dex).
 
callmeanesthesia said:
I always use dex. Yes, I know there is one study case report of a cord infarct with dex. But that could have been from the needle itself, or air bubbles, or a mix that precipitates. But really if you’re only using dex, why do you need live fluoro? As long as the contrast is epidural you know that’s where most of the med is going. Think of how much extra radiation you get exposed to in your career.
Click to expand...
Agree. I really don't see the risk/benefit ratio for live flouro for TF using dex. I certainly don't use live for any IL procedure. If I'm simply uneducated and am missing some risk that this imparts to the patient, please let me know.
 
Ducttape said:
you really should be advancing on CLO because you cannot judge depth on AP imaging.

use lobel's technique - advance until contacting os of the inferior border, then switch to CLO. obviates need to switch back and forth.
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Use the 25g Quincke and walk off the lamina and most of your patients won't know you did anything until you say "Good job sir, we'll put a bandaid on your skin, lower the table and get you up. Give it 24 hours to start working, and we will see you in 6 weeks. No post procedure rules, just don't drive for the next two hours or so..."

"We're done?"

"Yep, good job."


1760185687273.png
 
MitchLevi said:
Use the 25g Quincke and walk off the lamina and most of your patients won't know you did anything until you say "Good job sir, we'll put a bandaid on your skin, lower the table and get you up. Give it 24 hours to start working, and we will see you in 6 weeks. No post procedure rules, just don't drive for the next two hours or so..."

"We're done?"

"Yep, good job."


View attachment 410518
Click to expand...
Any local?
 
MitchLevi said:
Use the 25g Quincke and walk off the lamina and most of your patients won't know you did anything until you say "Good job sir, we'll put a bandaid on your skin, lower the table and get you up. Give it 24 hours to start working, and we will see you in 6 weeks. No post procedure rules, just don't drive for the next two hours or so..."

"We're done?"

"Yep, good job."


View attachment 410518
Click to expand...
how do you walk off lamina with a crappy, flimsy 25g quincke needle, especially in thick necks?

do you mean pull back and then redirect?
 
I need to get some high end calipers and test my observation but I think the 20g du medical tuohys are about the size of a bd 23g Quincke in regards to outside diameter.
 
GoBeers said:
how do you walk off lamina with a crappy, flimsy 25g quincke needle, especially in thick necks?

do you mean pull back and then redirect?
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You hit it at an angle and usually don’t need to pull back and redirect. It’s a slight bit of pressure and it just slides off
 
MitchLevi said:
You hit it at an angle and usually don’t need to pull back and redirect. It’s a slight bit of pressure and it just slides off
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Did it take awhile to get used to the amount of pressure you have to generate to inject through the 25g? I think the tactile feel would freak me out the first few times
 
clubdeac said:
Did it take awhile to get used to the amount of pressure you have to generate to inject through the 25g? I think the tactile feel would freak me out the first few times
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This was me. I did not like exerting that much pressure/resistance through extension tube then 3.5” 25g quincke… kinda freaked me out, afraid tip in cord…. I bailed. 22g touhy to within 1mm vill under clo. 1-3 moves then lor. Occasionally some more local needed in supra/infra spinous ligs. Takes under a minute, least painful procedure I do
 
I know it’s been discussed before, but what volume of injectate are y’all using for CESI?
 
Taus said:
This was me. I did not like exerting that much pressure through extension tube then 3.5” 25g quincke… kinda freaked me out, afraid tip in cord…. I bailed. 22g touhy. Occasionally some more local needed in supra/infra spinous ligs. Takes under a minute, least painful procedure I do
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Yes exactly. I went to a 20g touhy. Should probably switch to 22 but is still hard after 15 yrs of using an 18g with that nice profound loss
 
po_boy said:
I know it’s been discussed before, but what volume of injectate are y’all using for CESI?
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I do a 3cc syringe with 80 Depo and saline, but my syringe gives me another 0.5cc, I’m doing 3-3.5cc.
 
The lack of feel with the tiny needle and the hydraulic power of a 3cc makes me nervous lol..
 
Laryngospasm said:
The lack of feel with the tiny needle and the hydraulic power of a 3cc makes me nervous lol..
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Plenty of feel. You come off the lamina and the LF will not let you inject anything so keep pressure on the plunger.
 
clubdeac said:
Yes exactly. I went to a 20g touhy. Should probably switch to 22 but is still hard after 15 yrs of using an 18g with that nice profound loss
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BobBarker said:
I need to get some high end calipers and test my observation but I think the 20g du medical tuohys are about the size of a bd 23g Quincke in regards to outside diameter.
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clubdeac said:
Did it take awhile to get used to the amount of pressure you have to generate to inject through the 25g? I think the tactile feel would freak me out the first few times
Click to expand...

Taus said:
This was me. I did not like exerting that much pressure/resistance through extension tube then 3.5” 25g quincke… kinda freaked me out, afraid tip in cord…. I bailed. 22g touhy to within 1mm vill under clo. 1-3 moves then lor. Occasionally some more local needed in supra/infra spinous ligs. Takes under a minute, least painful procedure I do
Click to expand...

Agree. I tried this several times with 25G and several times I had lots of resistance and on the CLO I got worried about depth and no good line when I injected contrast.

Appreciate bob barkers thoughts on the diameter of the 20G touhy vs 23G quincke. That might be a reasonable compromise.

Now having tried several cases, I don’t feel completely comfortable doing a CESI with a 25G quincke. I once brought up the idea of a increasing size to 23G quincke, but was told why bother.

Maybe just a 20G touhy is a reasonable middle ground.

I’ve always used 18G, but I’m think I’ll do a modified technique here as I’m not comfortable with the 25G due to what I said above. I ordered some 20G and 22G touhy last week and plan to compare.
 
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bedrock said:
Agree. I tried this several times with 25G and several times I had lots of resistance and on the CLO I got worried about depth and no good line.

Appreciate bob barkers thoughts on the diameter of the 20G touhy.

I’ve always used 18G, but I’m think I’ll do a modified technique here as I’m not comfortable with the 25G due to what I said above. I ordered some 20G and 22G touhy last week and plan to compare.
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Let us know after a couple weeks what you think. The loss is definitely not as distinct with a 20g
 
after thousands of ESIs (if not tens of thousands between all of us) with good old 18g and no issues, not sure what's the big deal at this point.
 
clubdeac said:
Let us know after a couple weeks what you think. The loss is definitely not as distinct with a 20g
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I use a 20g tuohy and don't bother with loss. I get to VILL on CLO and then advance and puff in .2cc contrast. Rinse and repeat until epidural pattern. Typically takes me 2 or 3 shots from starting point at VILL. Fewer if I have good tactile feel of LF from the get go. I'm sure using LOR would cut down on images but I also don't feel as safe doing it that way in the neck.
 
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