Dural puncture avoidance

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mygalperin said:
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.
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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.
 
mygalperin said:
Why do I need to comment on my training. Is anything wrong in what I am saying???
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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.
 
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?
 
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
 
mygalperin said:
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
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Perhaps you do a good job. But your posts sound like you are a shot away from paralyzing someone.

Mygalperin=iceman
 
mygalperin said:
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?
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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….
 
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.
 
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.
 
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.
 
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
 
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mygalperin said:
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.
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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.
 
mygalperin said:
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.
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where was the burning and numbness located?
 
Hey do you guys have your steroid premed protocol for patients with contrast allergies. I may be changing my ways thanks to SDN.
 
Air arthrogram
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What are you guys doing when encountering brutally thick/calcified ligamentum flavum in the lumbar spine and no alternative interlaminar approach? Muscling through it? Switching to a TFESI or caudal? Aborting and moving on to the next patient?
 
Ducttape said:
for injections where contrast is unavoidable, i still do prednisone 50 mg 13, 7 and 1 hour prior to injection and benadryl 50 mg 1 hour prior.

for injections where contrast may not be necessary, the patient and i decide on whether to premed or not use contrast.
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Thank you this is what I was looking for. Interestingly, I was at a party last night where I was able to hang out with some of our interventional radiologists soi posed the question to them. They are telling me that this protocol is pretty much useless against true full-blown anaphylactic reactions, which I didn’t realize. Are you guys still using it for those types of patients? Also, he told me he still uses Gad for his spine patients with contrast allergies. He even said they will still do MR myelograms with very low-dose gad which I couldn’t believe.
 
clubdeac said:
Thank you this is what I was looking for. Interestingly, I was at a party last night where I was able to hang out with some of our interventional radiologists soi posed the question to them. They are telling me that this protocol is pretty much useless against true full-blown anaphylactic reactions, which I didn’t realize. Are you guys still using it for those types of patients? Also, he told me he still uses Gad for his spine patients with contrast allergies. He even said they will still do MR myelograms with very low-dose gad which I couldn’t believe.
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It would blunt an anaphylactic reaction but they might still need epi. Depends on the severity. Also radiology deals with rapid IV bolus of 10s to 100s of mL of contrast. Someone with an IgE mediated reaction gets that, no amount of Benadryl will protect them.

Here is probably the most up to date and comprehensive review you’re going to find (disclaimer, haven’t read the whole thing myself yet, just found it based on looking for an answer for this thread)

 
callmeanesthesia said:
It would blunt an anaphylactic reaction but they might still need epi. Depends on the severity. Also radiology deals with rapid IV bolus of 10s to 100s of mL of contrast. Someone with an IgE mediated reaction gets that, no amount of Benadryl will protect them.

Here is probably the most up to date and comprehensive review you’re going to find (disclaimer, haven’t read the whole thing myself yet, just found it based on looking for an answer for this thread)

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Gracias
 
Baron S said:
What are you guys doing when encountering brutally thick/calcified ligamentum flavum in the lumbar spine and no alternative interlaminar approach? Muscling through it? Switching to a TFESI or caudal? Aborting and moving on to the next patient?
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If I can't gently go through, it's caudal for me. I can't remember a time when I was able to punch through heavy calcification.

I had a pt the other day, tried a few times, then tried another level and got a wet tap. The day was just not going great so I aborted. The pt fully understood. There's a lot that goes into the decision - never cut and dry.

There's got to be a name for when you feel the summation of the situation and environment is no longer favorable...
 
hyperalgesia said:
If I can't gently go through, it's caudal for me. I can't remember a time when I was able to punch through heavy calcification.

I had a pt the other day, tried a few times, then tried another level and got a wet tap. The day was just not going great so I aborted. The pt fully understood. There's a lot that goes into the decision - never cut and dry.

There's got to be a name for when you feel the summation of the situation and environment is no longer favorable...
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“The better part of valor is discretion.”
 
Baron S said:
What are you guys doing when encountering brutally thick/calcified ligamentum flavum in the lumbar spine and no alternative interlaminar approach? Muscling through it? Switching to a TFESI or caudal? Aborting and moving on to the next patient?
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I’m usually using 25 gauge, so I will sometimes switch to a touhy.

I had a calcified cervical, 425 lbs. 7 in needle recently. I changed angles and tried two levels, meeting stone wall throughout. Just called it a day.

“Everyone walks away.”-Furman
 
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cowboydoc said:
I’m usually using 25 gauge, so I will sometimes switch to a tough.

I had a calcified cervical, 425 lbs. 7 in needle recently. I changed angles and tried two levels, meeting stone wall throughout. Just called it a day.

“Everyone walks away.”-Furman
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I’ve had to call it a day several times. I just tell the patient and say I’ll keep trying my best to find something that’ll work for you. Patient has never gotten upset and I lost zero sleep that night.
 
clubdeac said:
Thank you this is what I was looking for. Interestingly, I was at a party last night where I was able to hang out with some of our interventional radiologists soi posed the question to them. They are telling me that this protocol is pretty much useless against true full-blown anaphylactic reactions, which I didn’t realize. Are you guys still using it for those types of patients? Also, he told me he still uses Gad for his spine patients with contrast allergies. He even said they will still do MR myelograms with very low-dose gad which I couldn’t believe.
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sounds like a fun party. was this discussion before or after keg-stands.

everyone who is stil doing caudals b/c they were trained that way: stop. just do an S1 TFESI. quicker, easier, and closer to the pathology. hardware is never in the way
 
SSdoc33 said:
sounds like a fun party. was this discussion before or after keg-stands.

everyone who is stil doing caudals b/c they were trained that way: stop. just do an S1 TFESI. quicker, easier, and closer to the pathology. hardware is never in the way
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It was at a neurosurgeons place so needless to say the bar and food were top notch

And who’s talking about caudals and S1 TFESIs. Did you forget to take your aricept this morning old man
 
SSdoc33 said:
sounds like a fun party. was this discussion before or after keg-stands.

everyone who is stil doing caudals b/c they were trained that way: stop. just do an S1 TFESI. quicker, easier, and closer to the pathology. hardware is never in the way
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I rarely do a caudal, but even after a 6-12 month hiatus can do it in about 2 minutes. These are consistently easier for me than S1. Outside of hardware shadow and feeling more comfortable using depo rather than dex, I can't think of a reason to do caudals for the reasons you stated.
 
clubdeac said:
Thank you this is what I was looking for. Interestingly, I was at a party last night where I was able to hang out with some of our interventional radiologists soi posed the question to them. They are telling me that this protocol is pretty much useless against true full-blown anaphylactic reactions, which I didn’t realize. Are you guys still using it for those types of patients? Also, he told me he still uses Gad for his spine patients with contrast allergies. He even said they will still do MR myelograms with very low-dose gad which I couldn’t believe.
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  1. An initial injection of contrast is required to confirm epidural placement, unless the patient has a contraindication to contrast. The subsequent epidural steroid injections should include corticosteroids and may be combined with anesthetics or saline.1

just fyi, thats from the LCD for epidurals. so document the contraindication. i also document shared decision making regarding prophylaxis vs no contrast.


as far as caudals, i do them occasionally, primarily for those patients where you cant manage to position a needle upright without hitting the c-arm.
 
I still don’t know of a good reason to do an ILESi at L5S1 (even though I’ll do them occasionally)

TFESI works great (although I believe dex is not nearly as good as particulate steroid), and caudals are easy and super fun.
 
I like L5-S1 IL for L5-S1 lateral recess herniations hitting descending S1 root.

My alternative for this is L5-S1, S1 TF w/dex, which sometimes doesn't work well or doesn't last, and I'll do IL and they have much better results.
 
L5-S1 IL is also the least likely potential for wet tap if you go paramedian. Nerve is the backstop, not the sac. Look at all that fat past the LF, doesn't matter if none dorsally midline.

Needle tip is right behind site of compression, do not need to worry about if flow is going up/down/medial enough, you are closer to target than any other injection and can use depo.
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