Dural puncture avoidance

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Vasanervo

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How do you avoid dural puncture in ESI's when LOR is not felt? I had a wet tap today and was careful to advance slowly till LOR. I watched for the Ventral Interlamimar Line also. I'm still a fellow but feel horrible about this. Thanks.
 
first of all-- dont. its no big deal. most times there is no headache anyway. important to learn ILESI skills. then, do almost al of your lumbar epidurals using a TFESI approach.

make sure you use little puffs of contrast as you advance.
 
ive grown to prefer TFESI over ILESI as well.
that being said, if you feel that you're past the interlaminar line, there is no harm in trying some contrast and seeing where you are at.
there are many times that I do not feel a clear LOR but the contrast has clear epidural flow.
 
+1 on contrast. We're you too midline and in cervical where they're are LF gaps? Was your CLO angle off giving you false comfort on depth before checking contrast? Needle gauge? Loss can be very subtle, hard to feel with smaller ga
 
Something that helps is understanding the relationship between where you are medial-to-lateral and what that means in terms of where you should anticipate LOR in relation to the interlaminar line. Looking at a few axial slices will make that clear. Using a CLO rather than a lateral view mitigates this factor somewhat but it still can play a role.

I also always look at a T1 sagittal and get a feel for how big of an epidural space there is, how far it extends laterally, and how thick and crunchy the ligaments flavum looks.

This is just my own theory, but I feel like a thick LF probably increases the risk of clogging a tuohy and interfering with LOR feel. If I feel like I should have already had loss with either air or contrast and haven't sometimes I will re-stylet and try again.
 
was it LOR with air or saline? I’ve had a couple of patients with squishy ligamentum flavum that spits saline back at me. Did you get positive aspiration out of it, or did it just look like fluid welling up in the tuohy
 
The person who says they have never had a wet tap is a liar lol.. prefer tfesi for many reasons. Agree with contrast test. Also restylet to make sure nothing is stuck or clotted in the needle.
 
RoloTomassi said:
+1 on contrast. We're you too midline and in cervical where they're are LF gaps? Was your CLO angle off giving you false comfort on depth before checking contrast? Needle gauge? Loss can be very subtle, hard to feel with smaller ga
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There was some stenosis. It was hard to advance the needle. L5-S1. CLO angle was only 30 degrees.
 
SSdoc33 said:
first of all-- dont. its no big deal. most times there is no headache anyway. important to learn ILESI skills. then, do almost al of your lumbar epidurals using a TFESI approach.

make sure you use little puffs of contrast as you advance.
Click to expand...
Why do you (and others) prefer TFESI that much over ILESI? Assuming the former is with dex and latter with particulate.

I'd say I'm 90% ILESI. It's quicker for me, use particulate, and the patient is generally more comfortable. The 10% TFESI is either surgeon request, failed ILESI (rare for TFESI to work here in my experience), or at a fused segment (here tend to do caudal or ILESI below if possible unless 100% unilateral symptoms matching up perfectly with suspected dermatome).
 
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Agast said:
was it LOR with air or saline? I’ve had a couple of patients with squishy ligamentum flavum that spits saline back at me. Did you get positive aspiration out of it, or did it just look like fluid welling up in the tuohy
Click to expand...
I used air. It was welling up.
 
First you should be figuring out whether it was reasonable to expect you could do an ILESI. I'm shocked when people don't look at that T1 MRI on sagittal/axial cuts to visualize if there is some fat in the epidural space to get a needle into. It's a potential space in that it can be volume expanded, but it's still a tissue plane you have to be able to access without going straight into the CSF.
 
Orin said:
First you should be figuring out whether it was reasonable to expect you could do an ILESI. I'm shocked when people don't look at that T1 MRI on sagittal/axial cuts to visualize if there is some fat in the epidural space to get a needle into. It's a potential space in that it can be volume expanded, but it's still a tissue plane you have to be able to access without going straight into the CSF.
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I will do this more routinely.
 
it happens to everyone. if it happens a patient over 50, there is probably very minimal concern for complications such as PDPH.

LOR is fine to use (those who poo poo LOR are actually technically using the feel of it when they try to give their puffs of contrast). i would suggest using LOR with saline mixed with some contrast. for 3 ml of saline, ill add about 0.5-1 ml contrast so it is rather dilute but will show up fine on images. this also reduces overall contrast given to patient.

fluoro image in CLO, visualize the tip approaching the VLL. advance, give LOR syringe a slight compression to see if you get LOR and to see if any saline/contrast flows, and take image to visualize where you are and whether to advance further.

and if you are truly worried about pdph, use a blunt needle such as a Tuohy.
 
Needle type was not mentioned in first post. With Tuohy, I was trained to constantly bounce my thumb on syringe after minimal insertion depth. This way if you hit ligament without feeling it you will see and feel LOR. IMO, folks that insert needle until they feel ligament, pass it and then test for LOR are asking for trouble. Wet taps happen but if you are exceeding 1% incidence that is not acceptable as an attending.
 
Ducttape said:
it happens to everyone. if it happens a patient over 50, there is probably very minimal concern for complications such as PDPH.

LOR is fine to use (those who poo poo LOR are actually technically using the feel of it when they try to give their puffs of contrast). i would suggest using LOR with saline mixed with some contrast. for 3 ml of saline, ill add about 0.5-1 ml contrast so it is rather dilute but will show up fine on images. this also reduces overall contrast given to patient.

fluoro image in CLO, visualize the tip approaching the VLL. advance, give LOR syringe a slight compression to see if you get LOR and to see if any saline/contrast flows, and take image to visualize where you are and whether to advance further.

and if you are truly worried about pdph, use a blunt needle such as a Tuohy.
Click to expand...
Thank you very much. I will try these.
 
pastafan said:
Needle type was not mentioned in first post. With Tuohy, I was trained to constantly bounce my thumb on syringe after minimal insertion depth. This way if you hit ligament without feeling it you will see and feel LOR. IMO, folks that insert needle until they feel ligament, pass it and then test for LOR are asking for trouble. Wet taps happen but if you are exceeding 1% incidence that is not acceptable as an attending.
Click to expand...
I use intermittent compression on the glass syringe.
 
Vasanervo said:
I use intermittent compression on the glass syringe.
Click to expand...
if im not mistaken, you are 6-7 months in on your fellowship? try to work with some other docs

get rid of the glass. i find LOR is better with saline b/c it is not compressible. lot of ways to skin a cat, but you definitely dont need the glass

there is no consensus on this, but i find that TFESI is just a better injection in general
 
SSdoc33 said:
if im not mistaken, you are 6-7 months in on your fellowship? try to work with some other docs

get rid of the glass. i find LOR is better with saline b/c it is not compressible. lot of ways to skin a cat, but you definitely dont need the glass

there is no consensus on this, but i find that TFESI is just a better injection in general
Click to expand...
I prefer saline over air. Our attendings are quite rigid. I'm also starting to enjoy TFESI, more so than ILESI. Still would only do ILESI in the neck.
 
Vasanervo said:
There was some stenosis. It was hard to advance the needle. L5-S1. CLO angle was only 30 degrees.
Click to expand...
I avoid L5/S1 interlaminar epidural placements. In fact, I can't recall a single wet tap in my department at another level.


Ligament is usually very thin at this level and anatomy (because of spina bifada occulta and transitional anatomy and all the other variants) is often variable. AND, on MRI, the space is always much smaller than other levels - and more often than not - barely noticable on MRI. Don't believe me? Start noticing on your T1 sag views and compare the L3/4 and L4/5 spaces to L5/S1.

1738884878829.png


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1738885174470.png
 
CLO. 20g Tuohy or a smaller spinal needle. Contrast in 3 mL syringe. Gentle pressure on plunger as I advance into space. Haven’t used a glass syringe in months.

Goes without saying, but don’t do this technique with gadolinium.
 
epidural man said:
I avoid L5/S1 interlaminar epidural placements. In fact, I can't recall a single wet tap in my department at another level.


Ligament is usually very thin at this level and anatomy (because of spina bifada occulta and transitional anatomy and all the other variants) is often variable. AND, on MRI, the space is always much smaller than other levels - and more often than not - barely noticable on MRI. Don't believe me? Start noticing on your T1 sag views and compare the L3/4 and L4/5 spaces to L5/S1.

View attachment 398493

View attachment 398494

View attachment 398495
Click to expand...
Go far paramedian. Thecal sac usually tapers so much that you have ample room on the sides, very safe. Better chance of ventral flow too. I love L5-S1 IL for S1 radic due to lateral recess herniation, lasts longer than TF.
 
Yeah, basically all of my wet taps are at L5/S1. Tapped one person twice in the same session at that level. 😬
No headache.
 
BobBarker said:
Yeah, basically all of my wet taps are at L5/S1. Tapped one person twice in the same session at that level. 😬
No headache.
Click to expand...
Majority interlam I do are at 5-1. Elderly with 45 stenosis, and most 51 Hnp. If you could do a cervical Interlam it should be no concern at 51.

Of note, I do my loss air because that is how I was trained and I am very comfortable with the feel. I do, however, feel just the hub of the needle with contrast before loss. I often see the contrast go in before I actually feel a change. Take a still shot and it’s crystal clear on the screen in or out.

I do scs with the lead.
 
BobBarker said:
Yes, a little contrast in the hub is helpful. “Modified hanging drop”. Do most of my cervical esi’s like that.
Click to expand...
Agreed. I actually learned this by accident in first year as attending. In cervical, when I would feel any change in resistance, even if it looked shallow, I would do a live run with contrast. I would see it go posterior, put loss back on and proceed til true lor. Then I would see that little bit of contrast left in the hub go in the epidural space at true loss….. after a few times I was like why tf don’t I just do that from the start, avoid all that live contrast… game changer
 
Taus said:
Agreed. I actually learned this by accident in first year as attending. In cervical, when I would feel any change in resistance, even if it looked shallow, I would do a live run with contrast. I would see it go posterior, put loss back on and proceed til true lor. Then I would see that little bit of contrast left in the hub go in the epidural space at true loss….. after a few times I was like why tf don’t I just do that from the start, avoid all that live contrast… game changer
Click to expand...
This is exactly how I came to that technique, as well. I also do the vast majority of my SCS trials and implants by loss of resistance to lead.
 
For DCS Trials/implants: I might be in the minority here but I actually prefer doing LOR with PFNS. No risk of pneumocephalus like with LORA--- if inadvertent dural puncture (although rare). Also imagine two pieces of glass touching, moving them in opposition to each other, it is more challenging without a lubricant due to friction. Now put saline in-between the glasses with the same motion, they will move easier. I find it helps open the space to facilitate the lead with advancement. I've used this trick to open the space when threading the SCS lead, or DRG if resistance or not driving straight. Also if a wet tap develops you can use intrathecal or epidural saline as a "blood patch" and reduce the risk of PDPH.
 
RoloTomassi said:
Go far paramedian. Thecal sac usually tapers so much that you have ample room on the sides, very safe. Better chance of ventral flow too. I love L5-S1 IL for S1 radic due to lateral recess herniation, lasts longer than TF.
Click to expand...
I am not proud to say this, but I actually got a discogram doing this a few months ago. Patient had a large paracentral disc herniation, I did a far lateral ILESI (was unable to do a TFESI due to some insurance reasons). Never got LOR, never got CSF but was (unpleasantly) surprised to see disc pattern.
 
Baron Samedi said:
I am not proud to say this, but I actually got a discogram doing this a few months ago. Patient had a large paracentral disc herniation, I did a far lateral ILESI (was unable to do a TFESI due to some insurance reasons). Never got LOR, never got CSF but was (unpleasantly) surprised to see disc pattern.
Click to expand...
1738945391247.png

oof, sorry to hear that
 
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