Dural puncture avoidance

[CleanUp]

I do not think labor epidurals are in anyway similar to what we do, and I did a lot of thoracic catheters for CT surgery and trauma during my fellowship. We did acute pain, and yes I went in at 0300 to place bedside catheters in polytrauma pts. It has nothing to do with our field IMO.

I respectfully disagree.

I did about 15 epidurals a night. I learned how to calm the patient, how positioning is important, how to manage the room, how to check for complications, how to set up my tray, how to anticipate my next move, how to consider different injectates and most importantly how to appreciate using fluoro and taking my time which are two luxuries one doesn’t have on the L&D floor.

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[Baron Samedi]

For those interested in what an air epidurogram looks like, here's one I did this morning for a patient with hx of anaphylaxis with contrast. Attached are both pre- and post- air.

 

[MitchLevi]

I respectfully disagree.

I did about 15 epidurals a night. I learned how to calm the patient, how positioning is important, how to manage the room, how to check for complications, how to set up my tray, how to anticipate my next move, how to consider different injectates and most importantly how to appreciate using fluoro and taking my time which are two luxuries one doesn’t have on the L&D floor.

None of that has anything to do with loss of resistance.

That other stuff is great of course, don’t disagree with you. I’d add to it, I think high level room management is perhaps the most important skill.

 

[MitchLevi]

For those interested in what an air epidurogram looks like, here's one I did this morning for a patient with hx of anaphylaxis with contrast. Attached are both pre- and post- air.

2 gauge Tuohy?

 

[NVO]

In my 20th year in practice. Not sure labor epidurals in training equal what I have done in practice. But your post is telling about you as a physician. Direct visualization is superior to your feels. Didn't Lobel get his name on a blind vs image guided paper years ago/

The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data - PubMed

In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical...

pubmed.ncbi.nlm.nih.gov

I do not think labor epidurals are in anyway similar to what we do, and I did a lot of thoracic catheters for CT surgery and trauma during my fellowship. We did acute pain, and yes I went in at 0300 to place bedside catheters in polytrauma pts. It has nothing to do with our field IMO.

Labor epidurals do not equate to what you're doing in practice. How is my post telling? I am saying a lot of anesthesiologists probably stick with LOR cause thats what they're "used to" and am simply wondering if theres any ones out in practice that switched over. Thanks!

 

[MitchLevi]

Labor epidurals do not equate to what you're doing in practice. How is my post telling? I am saying a lot of anesthesiologists probably stick with LOR cause thats what they're "used to" and am simply wondering if theres any ones out in practice that switched over. Thanks!

I think everyone doing ILESI with but a small exception use LOR, so it isn’t an anesthesia thing vs PMR thing.

I was perfectly comfortable doing loss of resistance until late 2019, and I switched over to only opening a loss syringe if something is confusing to me or doesn’t look right.

The anesthesia labor epidural vs PMR thing probably isn’t real, at least not for the reasons so many ppl said in the past. I do not think it is an experience with LOR thing. There are probably data on this somewhere, but PMR or “Spine” programs were more likely to use TFESI rather than ILESI, but that is probably far more balanced now. A lot of that had to do with fear of particulates, preservatives injected into the dural sac and evidence that TFESI were more reliable at placing medication into the ventral epidural space than ILESI.

In my residency and fellowship, I did LOR and didn’t switch over to contrast only until I was several years into private practice.

Edit - I should say, yeah it is true a lot of anesthesiologists do ILESI for the reasons you mentioned, but my anesthesia pain fellowship was mostly TFESI, and most of my ILESI occurred during PMR residency, especially when I was at the VA with our program director. I bet I did more ILESI with him than my entire fellowship.

 

[Slowpoke]

For those interested in what an air epidurogram looks like, here's one I did this morning for a patient with hx of anaphylaxis with contrast. Attached are both pre- and post- air.

Haven't done an air epidurogram, could you point the differences you are looking for inthe pre vs post imaging?

 

[AlvinKamara]

so wait, whats the consensus for what you guys do for Cervical ESIs for patients with anaphylactic contrast allergies? Air or Gad?

 

[lobelsteve]

so wait, whats the consensus for what you guys do for Cervical ESIs for patients with anaphylactic contrast allergies? Air or Gad?

Don't do it. This isn't curing cancer. Not worth the risk.

 

[Baron Samedi]

Haven't done an air epidurogram, could you point the differences you are looking for inthe pre vs post imaging?

This light part is expanded in the post.

 

[Slowpoke]

This light part is expanded in the post.

How much air do you usually introduce? and risks involved?

 

[Baron Samedi]

How much air do you usually introduce? and risks involved?

This was about 1CC. The biggest risk is being inadvertently intrathecal and risking a pneumocephalus.

 

[Slowpoke]

Are there reported cases of that with 1-2cc in a lumbar epidural ? Seems unlikely but the concern is definitely valid.

 

[Baron Samedi]

Are there reported cases of that with 1-2cc in a lumbar epidural ? Seems unlikely but the concern is definitely valid.

To be honest, I'm not sure how much volume you'd need to inject for someone to be symptomatic.

 

[bedrock]

If I’m worried about a serious contrast allergy with a lumbar ILESI, I just do LOR, aspirate to ensure no CSF, and then just inject the steroid +saline.

 

[MitchLevi]

You can also just a TFESI with dex and no contrast.

 

[GlowInTheDark]

Anyone using a normal 5 cc syringe for LOR as opposed to traditional LOR glass/plastic syringes?

3 ml syringe with contrast in it

 

[nvrsumr]

I loved the glass syringes coming out of fellowship. Had a whole ritual of bathing the plunger in saline and using extension tubing filled with saline that acted as a hanging drop after lor thru the 18g touhy then contrast and lots of little things that had to be exactly right. Probably drove the asc nurses crazy. Anyway that’s how I felt safe while doing cesi with the patient seated with head on end of table and carm tilted up above the patient in true lateral with me in the beam…

Now I do the modified Lobel. One 25g quinke, one 3 cc contrast syringe and one 3 cc steroid syringe. No local, lor to contrast in the 3 cc syringe with puffs along the way in clo.

Do what you feel safe doing.

 

[bedrock]

Can the docs who use the Lobel approach, please try to save and post here a series of flouro shots of the little puffs of contrast, and other x ray views as you go through this process?

 

[lobelsteve]

Can the docs who use the Lobel approach, please try to save and post here a series of flouro shots of the little puffs of contrast, and other x ray views as you go through this process?

I have an 88 y/o in for T12-L1 LESI at 1pm today. I can take a lot of pics on the C-arm.

 

[MitchLevi]

I don't have any CESI today, which is weird because I've got 5 of them tomorrow.

 

[lobelsteve]

I have an 88 y/o in for T12-L1 LESI at 1pm today. I can take a lot of pics on the C-arm.

Got busy. Will grab them off server tomorrow.

 

[plasma.]

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

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I was at the Boston IPSIS Lumbar Course. The instructors mentioned that even if they don't see epidural space at a certain level, eg L5-S1, as long as there isn't severe stenosis, they don't hesitate doing an ILESI at that level.

How do you guys go about planning an ILESI when looking at the MRI? Do you always want to see a good epidural space if performing an ILESI?

 

[ssmallz]

so wait, whats the consensus for what you guys do for Cervical ESIs for patients with anaphylactic contrast allergies? Air or Gad?

LOR saline using CLO. I don’t see any reason to avoid doing the procedure. Just advance very slowly and make sure keep checking that CLO and AP view. If you aren’t getting a good loss and looking a bit deep on imaging just abort. Discretion is the better part of valor and it’s not worth it.

I use contrast in all my ILESIs but most of the time I know when I’m in or not before the contrast goes in so it doesn’t add a whole lot. It’s useful for times when you’re not sure but if you get a good loss you’re probably good to go

 

[cowboydoc]

In my 20th year in practice. Not sure labor epidurals in training equal what I have done in practice. But your post is telling about you as a physician. Direct visualization is superior to your feels. Didn't Lobel get his name on a blind vs image guided paper years ago/

The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data - PubMed

In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical...

pubmed.ncbi.nlm.nih.gov

Why did those Stanford folks and smart anesthesiologists put your name on their paper? Were you getting them coffee?

 

[cowboydoc]

Impeccable timing: yesterday had back to back reportedly severe contrast allergy pts. getting interlams. In CLO, looking for air epidurogram… Wet tap on first with 25g spinal. First in a long while.

Doubtful she’ll get a PDPH, but Murphy’s law at work, since I was flying out of town that afternoon.

 

[lobelsteve]

Why did those Stanford folks and smart anesthesiologists put your name on their paper? Were you getting them coffee?

When someone buys the new IPSIS Technical Manual, please post a pic of my name on the chapters....

https://www.ipsismed.org/general/custom.asp?page=techmanual

 

[MitchLevi]

A few from today:

PLT 79
25g 3.5"
Severe foraminal stenosis bilaterally C3-5, right C5-6 with C6 radic.

ACDF with vagal nerve stimulator.
Markedly severe foraminal stenosis left C5-7 with left C7 radic pattern.

 

[MitchLevi]

Another ACDF pt from today with severe left C5-7 foraminal stenosis

 

[plasma.]

Another ACDF pt from today with severe left C5-7 foraminal stenosis

View attachment 398810
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Amazing shots Mitch! Are these cervical ILESIs something you would offer to patients q3-4 months? Or do you mainly do them for diagnostic purposes prior to sending for operative management?

 

[CleanUp]

Any increased legal risk for doing the Lobel technique aka 25g spinal needle instead of a Touhey? I’m personally a huge fan of it.

 

[MitchLevi]

Amazing shots Mitch! Are these cervical ILESIs something you would offer to patients q3-4 months? Or do you mainly do them for diagnostic purposes prior to sending for operative management?

These are for pain management, and yesterday I did 5 CESI, and 4 were s/p ACDF. So, having surgery does not mean you have no pain moving fwd, which I’m sure you already know. I think 3 per year is reasonable, and everyone talks about Q3-4M injections but the reality is the vast majority of pts don’t routinely get 6 CESI over 2 years, and definitely not 9 over 3 yrs.

It may just be me, but it feels like CESI work better then LESI.

 

[MitchLevi]

Any increased legal risk for doing the Lobel technique aka 25g spinal needle instead of a Touhey? I’m personally a huge fan of it.

I thought about that when I switched over, but I can’t think of any reason why legal would be involved unless you did something completely outrageous like inject medication into their cord.

The fact of the matter is that LOR is unreliable, and contrast under fluoro is far safer. If you get a dural poke with a 25g needle the odds of you being called are nearly zero. It is unlikely you’ll have a PDPH.

Less likely to have a PDPH in the neck with any needle I guess.

 

[Ducttape]

needle size may a difference but the sharp point tips are more likely to cause PDPH. technically, other than not doing the procedure, using atraumatic and smaller needles is probably less likely to accidentally cause PDPH.

The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis - PubMed

Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles or ranked individual needles based on the pooled incidence of post-dural puncture headache. These analyses have suggested both...

pubmed.ncbi.nlm.nih.gov

The probability of post-dural puncture headache and procedural failure was lowest with 26-G atraumatic needles.

The 29-G cutting needle was more likely than three atraumatic needles to have the lowest odds of post-dural puncture headache, although with increased risk of procedural failure.

(which does agree with the gestalt that smaller needles are less likely to cause PDPH)

The probability rankings were: 26 atraumatic > 27 atraumatic > 29 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 23 cutting > 22 cutting > 25 cutting > 27 cutting = 26 cutting for post-dural puncture headache; and 26 atraumatic > 25 cutting > 22 cutting > 24 atraumatic > 22 atraumatic > 25 atraumatic > 26 cutting > 29 cutting > 27 atraumatic = 27 cutting for procedural success.

The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis - PubMed

Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles or ranked individual needles based on the pooled incidence of post-dural puncture headache. These analyses have suggested both...

pubmed.ncbi.nlm.nih.gov

here, needle size didnt seem to make a difference but there was difference in atraumatic vs traumatic needles.

For the first comparison, the use of traumatic needles showed a higher risk of onset of PDPH compared to atraumatic needles (36 studies, 9378 participants, risk ratio (RR) 2.14, 95% confidence interval (CI) 1.72 to 2.67, I2 = 9%).

In the second comparison of traumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH, with the exception of one study comparing 26 and 27 gauge needles (one study, 658 participants, RR 6.47, 95% CI 2.55 to 16.43).

In the third comparison of atraumatic needles, studies comparing various sizes of large and small gauges showed no significant difference in effects in terms of risk of PDPH.

(I took the liberty of dividing the paragraphs to make it easier to read.

 

[lobelsteve]

Any increased legal risk for doing the Lobel technique aka 25g spinal needle instead of a Touhey? I’m personally a huge fan of it.

Not copyrighted so free to use this technique.

 

[Ducttape]

in terms of legal risk, there should be no legal risk with regards to the technique. it is a published technique and within if not the standard of care.


with regards to the choice of needle, using a traumatic needle is within the physician's purview and within the standard of care.


unless you are going to use the same size needle you use for a chest tube....

 

[callmeanesthesia]

needle size may a difference but the sharp point tips are more likely to cause PDPH. technically, other than not doing the procedure, using atraumatic and smaller needles is probably less likely to accidentally cause PDPH.

The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis - PubMed

Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles or ranked individual needles based on the pooled incidence of post-dural puncture headache. These analyses have suggested both...

pubmed.ncbi.nlm.nih.gov

(which does agree with the gestalt that smaller needles are less likely to cause PDPH)

The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis - PubMed

Post-dural puncture headache is one of the most undesirable complications of spinal anaesthesia. Previous pairwise meta-analyses have either compared groups of needles or ranked individual needles based on the pooled incidence of post-dural puncture headache. These analyses have suggested both...

pubmed.ncbi.nlm.nih.gov

here, needle size didnt seem to make a difference but there was difference in atraumatic vs traumatic needles.





(I took the liberty of dividing the paragraphs to make it easier to read.

Those articles are comparing atraumatic spinal needles though - pencil point. The tuohy still has a sharp leading edge so unless you turn it 90 degrees to be parallel to the dural fibers, PDPH is more likely with a larger tuohy than a 25g quinke.

Bevel direction and postdural puncture headache: a meta-analysis - PubMed

Our meta-analysis indicates that with use of a cutting needle, insertion in a parallel/longitudinal fashion may significantly reduce the incidence of PDPH, although the reasons for this decrease are unclear.

pubmed.ncbi.nlm.nih.gov

(That said, I still use a 22g tuohy, and little puffs of contrast from a 3 mL syringe, which also gives me a palpable LOR most of the time to tell me I’m in before fluoro confirms it. Since I’ve had several times where I knew I was in based on LOR but the contrast went in a vein and disappeared, I like the extra confirmation)

 

[Ducttape]

tuohy does have a sharp point but is considered an atraumatic needle. "less traumatic" is probably the most apropos statement.

the second study suggested that needle size did not significantly matter.

 

[clubdeac]

Are there situations when using the 25g that you don’t get a nice crisp line?

 

[lobelsteve]

Are there situations when using the 25g that you don’t get a nice crisp line?

Needle tip laterally and extraepidural flow.

 

[bedrock]

Thanks for the pics guys, but I had requested some pics of the look of the puffs of contrast before and after you reached the epidural space.

(So more pics than just the usual final CLO shot)

Thank you for your help.

 

[lobelsteve]

Thanks for the pics guys, but I had requested some pics of the look of the puffs of contrast before and after you reached the epidural space.

(So more pics than just the usual final CLO shot)

Thank you for your help.

Thick ligament so not the prettiest flat line.

 

[BobBarker]

I usually have my needle tip more midline and don’t always get the thin line.

 

[clubdeac]

Do you guys get any loss when using the 25g needle

I get such great tactile feedback with my harpoon that I’ve been reluctant to switch

 

[lobelsteve]

Do you guys get any loss when using the 25g needle

I get such great tactile feedback with my harpoon that I’ve been reluctant to switch

No loss. And if I think I fell it, I ignore it. Direct visualization>the feels.

 

[1 Up]

You're going to get a couple of wet taps during fellowship. Don't sweat it. Since fellowship, I've had just one wet tap in my entire career by using the fellow technique:

1) Avoid injecting at levels whereby there is severe stenosis.

2) Stay near midline, but make sure you don't cross midline --> If you switched to CLO, but had to travel quite some distance to get to the VILL, you may have accidentally crossed midline, so don't be afraid to go back to AP to make sure you haven't crossed, then return to CLO, and proceed.

3) Make sure you have a true CLO. Dogma is 45 degrees for lumbar, 45-55 for cervical, but every patient is different. The lamina should be crisp.

4) Use a glass LOR syringe (I've found these are much more sensitive to pressure loss)

5) Advance under CONTINUOUS pressure with your LOR syringe. Not only is this more sensitive, but some believe that the pressurized water jet pushes the dura away the instant you enter the epidural space, thus protecting the dura from puncture.

6) When you advance, make sure your fingers grasp the needle at the skin, with the side of your palm/wrist resting/posting on the patient's back (this is for maximal control). Advancement should be made by "rolling" your thumb and index fingers (the fingers grasping the needle shaft). Advancement should not require anything but your fingers. If you're using your hand/wrist (or anything else), your advancements will be too coarse, and uncontrolled. Once you are at/near the VILL, advancements should be made in 1 mm (or less) increments, again, under continuous pressure.

7) Pay special attention to tissue feel. Once you get to that "connective tissue" feel, switch to LOR even if you aren't yet at the VILL.


With this, you shall not wet tap (much).

 

[epidural man]

For those interested in what an air epidurogram looks like, here's one I did this morning for a patient with hx of anaphylaxis with contrast. Attached are both pre- and post- air.

Super cool! You can see it.

Any idea what intrathecal air would look like?

 

[epidural man]

You can also just a TFESI with dex and no contrast.

Not sure I agree with his. Maybe depends on the level.

At T12, it is nearly impossible to do a SNRB as the contrast seems like it gets sucked into the epidural space no matter what you do.

At L5/S1, I feel like you have to really medialize the needle and even then, sometimes I can’t get the damn contrast in the epidural space.

My point is, sometimes a TFESi takes a little work and needle adjustment to get epidural flow and so without contrast, you may not get it in.

With LOR, you at least have pretty good data you are in the epidural space (if you can’t use contrast).

 

[epidural man]

This thread has reminded me to try and be more thoughtful to politicians who change their positions over time.

Why you ask?

Because when I first heard of some of you crazy kids doing cervical epidurals with cutting small needles, I thought - “no way, no how!”

But now I’m thinking, “I should probably try that”

 

[bedrock]

This thread has reminded me to try and be more thoughtful to politicians who change their positions over time.

Why you ask?

Because when I first heard of some of you crazy kids doing cervical epidurals with cutting small needles, I thought - “no way, no how!”

But now I’m thinking, “I should probably try that”

Good reference. Hopefully we all evolve. I must admit I’m now considering the Lobel approach for speed, reduced radiation, and less vagals. I get almost all my vagals from CESI even with PO Xanax and generous lido.

If I swap out my 18G Harpoon for a 25G acupuncture needle, I expect I’ll see less vagals.