Dural puncture avoidance

[bedrock]

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Thick ligament so not the prettiest flat line.

Thank you Steve.

 

[bedrock]

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

I’m typically more midline as well.

Can anyone speak to their rationale of being more or less midline using the 25G quincke technique for CESI?

 

[MitchLevi]

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.

I have virtually zero vagal episodes, and the CESI is the least likely procedure to cause problems in my practice. It’s the least painful, fastest and usually the smoothest procedure I do. If you’re gonna get a vagal it’s prob a lumbar TFESI on a hot radic in my experience.

I have thought about wearing a GoPro and filming one to post bc of how much I support this technique.

I’ve done them since Dec 2019 and I can’t understand why anyone would use a freaking 18-20g Tuohy for a cervical. You’re NOT sticking me with that needle.

 

[MitchLevi]

I’m typically more midline as well.

Can anyone speak to their rationale of being more or less midline using the 25G quincke technique for CESI?

It’s the same. No difference. Contrast midline or far lateral will look blobby and less clean, but a CESI using an IL approach is usually a bilateral injection.

 

[lobelsteve]

I’m typically more midline as well.

Can anyone speak to their rationale of being more or less midline using the 25G quincke technique for CESI?

Usual CESI patient is one level disk herniation at C-6. Bias the medicine to that side. No difference in procedure.

 

[bedrock]

Usual CESI patient is one level disk herniation at C-6. Bias the medicine to that side. No difference in procedure.

Usual CESI patient is one level disk herniation at C-6. Bias the medicine to that side. No difference in procedure.

It’s the same. No difference. Contrast midline or far lateral will look blobby and less clean, but a CESI using an IL approach is usually a bilateral injection.

Thanks Mitch. Understanding the contrast appearance with this technique midline vs paramedian vs lateral was the essence of my question.

 

[bedrock]

I have virtually zero vagal episodes, and the CESI is the least likely procedure to cause problems in my practice. It’s the least painful, fastest and usually the smoothest procedure I do. If you’re gonna get a vagal it’s prob a lumbar TFESI on a hot radic in my experience.

I have thought about wearing a GoPro and filming one to post bc of how much I support this technique.

I’ve done them since Dec 2019 and I can’t understand why anyone would use a freaking 18-20g Tuohy for a cervical. You’re NOT sticking me with that needle.

Please do the GoPro. I’d appreciate seeing you perform a CESI with this technique, start to finish.

 

[clubdeac]

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).

I second all of this. Only thing I would add is use contrast as your LOR fluid. It’s real time and saves a step and time

 

[Baron S]

Super cool! You can see it.

Any idea what intrathecal air would look like?

Thankfully, I don't have any pictures of that!

I googled pneumorachis and all the pictures I could find were either MRI or post-traumatic, largely in the epidural space.

Attached is a (very) short article that also has more picture examples, including in the cervical spine.

 

[Laryngospasm]

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.

At the very least try a 20g T. No need for 18.

 

[hopefulgasman]

At the very least try a 20g T. No need for 18.

I used an 18g exclusively in fellowship because my attendings attested to its better tactile feel, but now I use the 20g out of the kit and have not noticed a difference.

 

[RoloTomassi]

Here's an air epi, 1.5 mL.

 

[MitchLevi]

I have 7 CESI today. Totally forgot the GoPro. I'l take pics and try to step-by-step a few.

 

[MitchLevi]

Steep angle bc we had to cephalad tilt the c-arm a lot due to pt positioning. I am rarely this steep.

 

[lobelsteve]

Steep angle bc we had to cephalad tilt the c-arm a lot due to pt positioning. I am rarely this steep.
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Not deep, you are a little lateral, so it looks perfect.

 

[MitchLevi]

Not deep, you are a little lateral, so it looks perfect.

Steep, I'm not usually that steep of an angle.

 

[interjectionreflection]

Steep angle bc we had to cephalad tilt the c-arm a lot due to pt positioning. I am rarely this steep.
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Silly question but do you target the tip of the lamina line at the inferior or superior lamina before you inject contrast?

 

[specepic]

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

Neither. Pre-med them and use Omnipaque

 

[MitchLevi]

Silly question but do you target the tip of the lamina line at the inferior or superior lamina before you inject contrast?

It probably doesn’t matter, but I’d rather get in closer to C7 than T1. The flatter the approach the higher your medication is going to spread.

 

[bedrock]

Steep angle bc we had to cephalad tilt the c-arm a lot due to pt positioning. I am rarely this steep.
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Thank you for the photos. They are helpful.

If you remember the go pro in the future, I’d still be interested in seeing that.

 

[jwalker12]

Great thread everyone. I too have been reluctant to switch to the Lobel/Mitch method, it seems very good but for some reason just don't feel comfortable.
1 Did you guys start these in the lumbar spine before going to CESIs?
2 Do you curve the tip of the 25g or just come straight in?
3 Any advantage to coming in caudal to cephalad angle or straight down?
4 Does anyone actually have any good photos of intrathecal contrast spread in the cervical spine? I can't seem to find much online beside this: https://academic.oup.com/painmedicine/article/23/3/590/6395368 - which to me looks very similar to the epidural spread.
5 Do you avoid levels with a listhesis? Seems to be very high risk for wet tap?

 

[cowboydoc]

Great thread everyone. I too have been reluctant to switch to the Lobel/Mitch method, it seems very good but for some reason just don't feel comfortable.
1 Did you guys start these in the lumbar spine before going to CESIs?
2 Do you curve the tip of the 25g or just come straight in?
3 Any advantage to coming in caudal to cephalad angle or straight down?
4 Does anyone actually have any good photos of intrathecal contrast spread in the cervical spine? I can't seem to find much online beside this: https://academic.oup.com/painmedicine/article/23/3/590/6395368 - which to me looks very similar to the epidural spread.
5 Do you avoid levels with a listhesis? Seems to be very high risk for wet tap?

Personally, I do a more gentle curve with the 25g than I would with a MBB, as to not have a cutting swipe if it is to rotate.

I use the 25g in C and L spine, but occasionally have issue with osteophytes and degenerative anatomy in the L spine messing up the 25g. I don’t really see this in the Cspine.

I avoid levels with significant listhesis, more conservative in the Cspine.

 

[lobelsteve]

Great thread everyone. I too have been reluctant to switch to the Lobel/Mitch method, it seems very good but for some reason just don't feel comfortable.
1 Did you guys start these in the lumbar spine before going to CESIs?
2 Do you curve the tip of the 25g or just come straight in?
3 Any advantage to coming in caudal to cephalad angle or straight down?
4 Does anyone actually have any good photos of intrathecal contrast spread in the cervical spine? I can't seem to find much online beside this: https://academic.oup.com/painmedicine/article/23/3/590/6395368 - which to me looks very similar to the epidural spread.
5 Do you avoid levels with a listhesis? Seems to be very high risk for wet tap?

1 Did you guys start these in the lumbar spine before going to CESIs?

CESI before LESI, easier to see everything. Less arthropathy, less flavum

2 Do you curve the tip of the 25g or just come straight in?

Bent tip since day 1 (July 2004)

3 Any advantage to coming in caudal to cephalad angle or straight down?

Always start over bone. Bone is protecting the canal from you. I start over lamina and touch lamina 100% of the time. Then rotate tip and head North.

4 Does anyone actually have any good photos of intrathecal contrast spread in the cervical spine? I can't seem to find much online beside this: https://academic.oup.com/painmedicine/article/23/3/590/6395368 - which to me looks very similar to the epidural spread.

Only what google shows me

5 Do you avoid levels with a listhesis? Seems to be very high risk for wet tap?

See above, bone is your friend. I stay away from levels with severe stenosis. Listhesis, meh.

 

[MitchLevi]

I've had odd contrast patterns injecting levels where there is listhesis, so there have been times I've aborted and gone to T1-2 (add another 0.5-1cc saline). I don't intentionally avoid levels with listhesis though.

I do not like a perpendicular needle (at all), and the vast majority of the time I am decently flat in my trajectory because you will push more medication superiorly, obviously safer because your runway is longer to land your plane. The more perpindicular you are the smaller the space you have to work with once you clear the LF, and the more likely you are to create a puddle at C7-T1 and lose medication inferiorly. Does that actually matter? Probably not...I've had patients with C3 stenosis get sustained relief with a blob of injectate at C7, and I do believe the epidural space moves continuously as the epidural venous plexus engorges and drains cyclically throughout the day. I believe that slowly pushes your injectate superiorly over the next several hours. Don't really care to debate that either.

Always bend the needle tip; do not create a fishing hook. Slight bend makes everything easier, and it helps with the perpendicular vs flat trajectory issue.

I actually don't touch bone. I get early CLO no matter the body habitus.

 

[MitchLevi]

Personally, I do a more gentle curve with the 25g than I would with a MBB, as to not have a cutting swipe if it is to rotate.

I use the 25g in C and L spine, but occasionally have issue with osteophytes and degenerative anatomy in the L spine messing up the 25g. I don’t really see this in the Cspine.

I avoid levels with significant listhesis, more conservative in the Cspine.

I do not use 25g in the lumbar spine any longer, and instead use a 22g tuohy because my volume is greater in the lumbar spine (5cc or so), and I do not like pushing 5cc through a 25g needle because I'm worried about my hands over time. The resistance is significant. Agree on flimsy needle getting beaten up in the lumbar spine too. Definitely true.

 

[Ducttape]

yes for those who are worried - use a 22 tuohy.

ive used 25 gauge needles for other sites (joints etc) and it is extraordinarily frustrating when you are appropriately positioned but you cant push in meds because depo is clogging up the 25 gauge.

 

[lobelsteve]

 

[epidural man]

To those that use a 25g in the cervical spine -

If you were teaching fellows, would you teach this technique right out the gate - or would you want them to first develop a traditional LOR technique?

 

[MitchLevi]

To those that use a 25g in the cervical spine -

If you were teaching fellows, would you teach this technique right out the gate - or would you want them to first develop a traditional LOR technique?

LOR first IMO. You need to know how to do LOR because there are times I do it if things just do not look right and I am second guessing myself. Happened this AM actually. I'll have a contrast pattern I simply do not trust, and I'll prove it using LOR as a double layer of accuracy.

The 25g Quincke technique DOES rely on a small amount of feel, albeit in a far more subtle way.

 

[bedrock]

I do not use 25g in the lumbar spine any longer, and instead use a 22g tuohy because my volume is greater in the lumbar spine (5cc or so), and I do not like pushing 5cc through a 25g needle because I'm worried about my hands over time. The resistance is significant. Agree on flimsy needle getting beaten up in the lumbar spine too. Definitely true.

I typically use depo for CESI. If I adopt this CESI technique, I think I’m going to either use a 23G Quincke or a 22G touhy.

I typical use a needle size at least 23G for procedures where I’m injecting depo. Saves my wrists and I agree with ducts comment about end procedure issues with 25G.

 

[MitchLevi]

I typically use depo for CESI. If I adopt this CESI technique, I think I’m going to either use a 23G Quincke or a 22G touhy.

I typical use a needle size at least 23G for procedures where I’m injecting depo. Saves my wrists and I agree with ducts comment about end procedure issues with 25G.

Depo through a 25g pushed with a 3cc syringe is no issue. No reason to use this technique if you’re not using a 25.

 

[callmeanesthesia]

Depo through a 25g pushed with a 3cc syringe is no issue. No reason to use this technique if you’re not using a 25.

Some of the generic depos will clog a 25g.

 

[BobBarker]

23g is the king of spinal needles.

 

[MitchLevi]

Some of the generic depos will clog a 25g.

They’ll clog 22 as well.

 

[BobBarker]

Branded depo 40mg is less than $5 at Henry Schein.

 

[Dr. Ice]

Did lobel/mitch approach with 25 gauge for cervical Ilesi today. Worked like a charm. Little tougher to push the meds to be expected but all good.

Thanks guys!

 

[MitchLevi]

Did lobel/mitch approach with 25 gauge for cervical Ilesi today. Worked like a charm. Little tougher to push the meds to be expected but all good.

Thanks guys!

3cc syringe?

Also, this is the Lobel technique, not mine.

 

[Dr. Ice]

3cc syringe?

Also, this is the Lobel technique, not mine.

5 cc syringe

 

[MitchLevi]

5 cc syringe

3cc

 

[Dr. Ice]

3cc

Next time

 

[Taus]

The amount of resistance force needed to squirt the depo and saline through 25 gauge needle and extension tube is the one thing I didn’t like when I tried it a few years ago. Made me nervous… and I also had a couple where I thought it was mixed flow epidural and intradural. I then bailed and haven’t tried it since. Perhaps I’ll revisit.

For me, the 20 gauge touhy is pretty quick and painless. Sometimes need to stop and add a little more local when reach lig flavum, then all clear. I put a little drop of contrast in the hub, go just shy of the VILL,1-2 moves and get lor feel and visual with drop contrast either epidural or still short, see that contrast go posterior, then 1-2 more moves.

 

[BobBarker]

@Taus you should try the du medical epidural kit. Really nice 20g Tuohy that seems very thin with an excellent generic Epilor syringe. $6.50
Tray.

 

[RoloTomassi]

@Taus you should try the du medical epidural kit. Really nice 20g Tuohy that seems very thin with an excellent generic Epilor syringe. $6.50
Tray.

Distribution unlimited? Do they have good prices on other stuff?

 

[BobBarker]

Yes. It can just be hit and miss on stock on the other items. I feel like they might get a bunch of stuff on closeout and resell it.

 

[1 Up]

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.

How much volume are you using? I'm probably at 2.5 cc. I use a 20 g Touhy. I get a vagal maybe 5% of the time.

 

[RoloTomassi]

How much volume are you using? I'm probably at 2.5 cc. I use a 20 g Touhy. I get a vagal maybe 5% of the time.

Seems high. Recall bias? Dex?

 

[MitchLevi]

How much volume are you using? I'm probably at 2.5 cc. I use a 20 g Touhy. I get a vagal maybe 5% of the time.

It’s prob way less than 5%

 

[Taus]

It’s prob way less than 5%

Yeah, that is surprisingly high. Unless the rate you see is a lot higher with your population on lumbar tfesi. That is my highest rate procedure, typically in the stereotypical population young muscled up dudes with tattoos with acute disc herniation and painful radic. I always remind them if they need another one to let us know ahead of time and I will send in some benzos. Really screws up the flow of the day…(triazolam ftw!)

 

[jwalker12]

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?

 

[lobelsteve]

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?

Pull back and inject contrast and see where it goes before advancing without knowing where the flow is.