Dural puncture avoidance

[Taus]

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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.

Try best of both worlds…. Put contrast in hub before attach lor syringe. You get the combination of visual and tactile.

 

[Laryngospasm]

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.

I do 20 gauge unless I have to break out the harpoon then I do 18g. Feel is very similar. Just not as much crunch to the lf.

 

[bedrock]

Plenty of feel. You come off the lamina and the LF will not let you inject anything so keep pressure on the plunger.

Mitch. Please clarify this part of the 25G technique for me.

You touch down on lamina, then advance to LF. I’m good with that.
But once you start advancing through the LF, are you using an LOR syringe or just a contrast syringe and pushing the whole time as you pass through the LF?

Thats what I do with an 18G touhy standard CESI, LOR technique.

I thought that the 25G quincke technique did not include any LOR technique?
I though it was touching down on lamina, then advancing to LF, and then injecting a puff of contrast on dorsal aspect of LF, and then advancing the 25G quincke needle 1-2 mm, trying to inject a puff of contrast, and repeat until you see epidural spread ?

 

[BobBarker]

My partner uses a 3ml syringe filled with contrast for LOR. Touches down on lamina and advances in CLO with a 20g.

 

[clubdeac]

My partner uses a 3ml syringe filled with contrast for LOR. Touches down on lamina and advances in CLO with a 20g.

This is what I do

 

[NVO]

My partner uses a 3ml syringe filled with contrast for LOR. Touches down on lamina and advances in CLO with a 20g.

This is what I do

extension tubing or no?

 

[BobBarker]

No extension tubing. We had some but it expired and the staff pitched it out.

 

[clubdeac]

extension tubing or no?

No tubing

 

[Taus]

C/t/l Tfesi…. I don’t see nixing live and tubing.

Interlam…. I’m considering making the change to no live dye anymore.

 

[MitchLevi]

Mitch. Please clarify this part of the 25G technique for me.

You touch down on lamina, then advance to LF. I’m good with that.
But once you start advancing through the LF, are you using an LOR syringe or just a contrast syringe and pushing the whole time as you pass through the LF?

Thats what I do with an 18G touhy standard CESI, LOR technique.

I thought that the 25G quincke technique did not include any LOR technique?
I though it was touching down on lamina, then advancing to LF, and then injecting a puff of contrast on dorsal aspect of LF, and then advancing the 25G quincke needle 1-2 mm, trying to inject a puff of contrast, and repeat until you see epidural spread ?

I do not like puffs.

I walk off lamina and inject dye when the needle is in the LF, hold slight pressure on the plunger and advance and retract the needle in micro movements. Contrast will suddenly be epidural. Yes, when you’re in the LF there are times retracting the needle advances the tip anteriorly through the LF.

Do a few and you’ll see it happen a lot of of the time. When you’re in the LF it is tiny movements forward, backward or no movements and just hold pressure on the syringe bc the contrast coming out of the needle will sometimes put your tip epidural.

I’ve done these with LOR and a Tuohy many, many times and gave it up bc this is faster and less painful in my hands.