Dural puncture avoidance

[callmeanesthesia]

Comments about language barrier sounds a bit offensive! The technic of the cesi was described earlier in my post, same as a recipe for the injectat, since I am using a contrast I do not use the contralateral view, because it’s a vast of time and extra radiation. The distribution of the dye gives you a clear proof of where y are. When you see a drop sucked in, you stop advancing, and inject dye. On a very rear occasion you are not in the epidural space yet. As long as you have a caudal spread you can inject. There will be cord compression. I use 20g needle, it gives you a good feeling, does not bend, and you can adequately steer it if necessary. The whole thing takes 45 to 55 sec.

Wait, so you’re doing the whole thing in AP? Going to have to disagree with you there. CLO is much less radiation than lateral, only slightly more than AP, and allows near perfect visualization of the posterior edge of the epidural space.

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[mygalperin]

Monday I will post a pic

 

[lobelsteve]

Monday I will post a pic

Maybe comment on your formal training. Most of is have completed residency in Anes or PMR then did a fellowship in Pain (ACGME). Then went to teach and publish.

 

[mygalperin]

Why do I need to comment on my training. Is anything wrong in what I am saying???

 

[callmeanesthesia]

Why do I need to comment on my training. Is anything wrong in what I am saying???

If you’re doing cervical epidurals with AP fluoroscopy only, then yes. I’m not sure if training does play into it though. I had one faculty member in fellowship, ACGME-trained, who did them AP-only. Terrifying to do them with him. His motto was “inject at the first sign of loss of resistance.” Probably did a lot of interspinous ligament injections. Hadn’t paralyzed anyone as far as I knew.

 

[mygalperin]

You should read my posts more carefully, then you would not bring up some faculty. I USE!!! contrast first, and only than inject the medicine. Where interspinal lig injections fall into?

 

[mygalperin]

When you had your training, I only guess, we did those injections w/o fluoro , just by the touch, right? So a lot of those recommendations go back to those times. But technology went ahead, and since we do use mentioned above contrast and fluoro, we do not need all that nonsense, same as with transformational blocks

 

[lobelsteve]

When you had your training, I only guess, we did those injections w/o fluoro , just by the touch, right? So a lot of those recommendations go back to those times. But technology went ahead, and since we do use mentioned above contrast and fluoro, we do not need all that nonsense, same as with transformational blocks

Perhaps you do a good job. But your posts sound like you are a shot away from paralyzing someone.

Mygalperin=iceman

 

[mygalperin]

What make you said that?

 

[Taus]

You should read my posts more carefully, then you would not bring up some faculty. I USE!!! contrast first, and only than inject the medicine. Where interspinal lig injections fall into?

The problem with that is when that first change/loss of resistance occurs is intrathecal or in the spinal cord…. That contrast injection won’t save you. There are published case reports of intramedullary/cord injections.

I too had one attending who trained a long time ago do them in the manner you describe…(granted no local with injectate)…. But would not let the trainees do it that way. Back then, even seated in a chair with the head flexed, hanging drop, was utilized. He still had trainees use AP/CLO or at least AP/lateral. My senior partners trained before CLO. They have all since adopted it in the cervical spine.

We are all here to learn….

 

[BobBarker]

Dr Galperin, I think you would really like using CLO and once you get used to it would feel that it enhances patient safety and comfort for cervical epidurals while not adding any time to the procedure. I do agree that most of the time, a hanging drop does show you are in the epidural space first. I usually inject a bit of contrast even though I’m probably not in the epidural space and notice the drop move just prior to getting a loss of resistance.

 

[callmeanesthesia]

And if you’re concerned about affecting speed of procedures, just browse some of our other threads where BobBarker discusses his productivity, and set your mind at ease.

 

[mygalperin]

Interesting you said that, I also wanted to mention you times when we did it with pt sitting and the head flexed. Good old times.

 

[mygalperin]

I had a case , actually two in a very short time span, when pts developed a severe burning and numbness on the needle placement, both procedures were aborted, one went to her neurologist, and was admitted. No local deficit, just subjective complaints. MRI was negative. The proposed theory behind was that it was from the pressure from the needle tip.

 

[mygalperin]

You right about seen drop fluctuating, it happens just before you hit an epidural space, and than it’s gets sucked in. If I do not see that I injections a little bit of a dye to see where I am

 

[Taus]

I had a case , actually two in a very short time span, when pts developed a severe burning and numbness on the needle placement, both procedures were aborted, one went to her neurologist, and was admitted. No local deficit, just subjective complaints. MRI was negative. The proposed theory behind was that it was from the pressure from the needle tip.

Probably was tickling the cord, which “should” be mostly harmless if just stuck it. If, however, contrast was injected… That causes an iatrogenic syrinx and can be devastating.

Wouldn’t that be nice if there was a way to directly visualize your needle tip to confirm you’re safe in addition to the other tactile feedback techniques? That’s CLO view.

 

[GoBeers]

I had a case , actually two in a very short time span, when pts developed a severe burning and numbness on the needle placement, both procedures were aborted, one went to her neurologist, and was admitted. No local deficit, just subjective complaints. MRI was negative. The proposed theory behind was that it was from the pressure from the needle tip.

where was the burning and numbness located?

 

[mygalperin]

Palms