Dural puncture avoidance

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BoardingDoc said:
I use a 20g tuohy and don't bother with loss. I get to VILL on CLO and then advance and puff in .2cc contrast. Rinse and repeat until epidural pattern. Typically takes me 2 or 3 shots from starting point at VILL. Fewer if I have good tactile feel of LF from the get go. I'm sure using LOR would cut down on images but I also don't feel as safe doing it that way in the neck.
Click to expand...
Try best of both worlds…. Put contrast in hub before attach lor syringe. You get the combination of visual and tactile.
 
bedrock said:
Agree. I tried this several times with 25G and several times I had lots of resistance and on the CLO I got worried about depth and no good line when I injected contrast.

Appreciate bob barkers thoughts on the diameter of the 20G touhy vs 23G quincke. That might be a reasonable compromise.

Now having tried several cases, I don’t feel completely comfortable doing a CESI with a 25G quincke. I once brought up the idea of a increasing size to 23G quincke, but was told why bother.

Maybe just a 20G touhy is a reasonable middle ground.

I’ve always used 18G, but I’m think I’ll do a modified technique here as I’m not comfortable with the 25G due to what I said above. I ordered some 20G and 22G touhy last week and plan to compare.
Click to expand...
I do 20 gauge unless I have to break out the harpoon then I do 18g. Feel is very similar. Just not as much crunch to the lf.
 
MitchLevi said:
Plenty of feel. You come off the lamina and the LF will not let you inject anything so keep pressure on the plunger.
Click to expand...

Mitch. Please clarify this part of the 25G technique for me.

You touch down on lamina, then advance to LF. I’m good with that.
But once you start advancing through the LF, are you using an LOR syringe or just a contrast syringe and pushing the whole time as you pass through the LF?

Thats what I do with an 18G touhy standard CESI, LOR technique.

I thought that the 25G quincke technique did not include any LOR technique?
I though it was touching down on lamina, then advancing to LF, and then injecting a puff of contrast on dorsal aspect of LF, and then advancing the 25G quincke needle 1-2 mm, trying to inject a puff of contrast, and repeat until you see epidural spread ?
 
bedrock said:
Mitch. Please clarify this part of the 25G technique for me.

You touch down on lamina, then advance to LF. I’m good with that.
But once you start advancing through the LF, are you using an LOR syringe or just a contrast syringe and pushing the whole time as you pass through the LF?

Thats what I do with an 18G touhy standard CESI, LOR technique.

I thought that the 25G quincke technique did not include any LOR technique?
I though it was touching down on lamina, then advancing to LF, and then injecting a puff of contrast on dorsal aspect of LF, and then advancing the 25G quincke needle 1-2 mm, trying to inject a puff of contrast, and repeat until you see epidural spread ?
Click to expand...

I do not like puffs.

I walk off lamina and inject dye when the needle is in the LF, hold slight pressure on the plunger and advance and retract the needle in micro movements. Contrast will suddenly be epidural. Yes, when you’re in the LF there are times retracting the needle advances the tip anteriorly through the LF.

Do a few and you’ll see it happen a lot of of the time. When you’re in the LF it is tiny movements forward, backward or no movements and just hold pressure on the syringe bc the contrast coming out of the needle will sometimes put your tip epidural.

I’ve done these with LOR and a Tuohy many, many times and gave it up bc this is faster and less painful in my hands.
 
po_boy said:
Interesting that you move the needle back and forth.
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Learned that after doing an untold number of these. Total distance is like, maybe 0.5mm. There are many times that the needle is within the LF, and I don't move it any further and the keep pushing the plunger on the syringe and it suddenly becomes epidural.
 
So it is hydro dissecting the LF. Interesting.

I know with SCS trials I have pierced the final bit of LF with the lead and it accessed the epidural space. Makes it hard to steer.
 
Mitch are you using extension tubing with this? So 3cc syringe filled with contrast -> extension tubing -> 25g needle.
 
5cc contrast, extension tubing Braun 0.2ml priming volume, 25g Quincke.
Touch lamina from inferior to superior trajectory.
Go CLO. Shoot 1 drop contrast to prove you are not there.
Advance 1mm at a time and add a drop of contrast.
When you are through LF you get a fine vertical line in the epidural space.
Go AP and verify spread and assess for vascular flow.
Remove contrast syringe from tubing and inject your cocktail.
1cc saline and 1cc Dex or 1cc Celestone.
 
I touch mid point of the lamina, slide right off the top into the epidural space. I am probably doing around 5-10 per week, probably 5 years of this now. I much prefer it. The last pic I attached to this post is actually a really good picture of what a 25 Quincke does when you gently touch os, making sure the bent tip of the needle is facing superiorly and just add a little pressure...It just slides off into the LF.


1760356617740.png
1760356726663.png
1760356796970.png
 
Last edited:
i wont use a 25 gauge for any epidural after having had multiple episodes of depo clogging the syringe. and i dont like how wobbly they get.

at ASC - 22 gauge touhy. at office, currently 18 gauge but working to switch.
 
MitchLevi said:
I touch mid point of the lamina, slide right off the top into the epidural space. I am probably doing around 5-10 per week, probably 5 years of this now. I much prefer it. The last pic I attached to this post is actually a really good picture of what a 25 Quincke does when you gently touch os, making sure the bent tip of the needle is facing superiorly and just add a little pressure...It just slides off into the LF.


View attachment 410565View attachment 410566View attachment 410567
Click to expand...
When you steer the bent tip upwards and attach the tubing do you ever find with micro movements it's hard to see where bent tip is pointing? I tried this and found I had to remove the tubing to see where it was pointing but would appreciate if you have any other tips. I tried keeping it pointing one direction but sometimes it rotates without realizing
 
interjectionreflection said:
When you steer the bent tip upwards and attach the tubing do you ever find with micro movements it's hard to see where bent tip is pointing? I tried this and found I had to remove the tubing to see where it was pointing but would appreciate if you have any other tips. I tried keeping it pointing one direction but sometimes it rotates without realizing
Click to expand...
It's okay if it rolls. Once in the LF it shouldn't do that.
 
interjectionreflection said:
When you steer the bent tip upwards and attach the tubing do you ever find with micro movements it's hard to see where bent tip is pointing? I tried this and found I had to remove the tubing to see where it was pointing but would appreciate if you have any other tips. I tried keeping it pointing one direction but sometimes it rotates without realizing
Click to expand...
Rotate the ii 5degrees and the tip reappears.
 
callmeanesthesia said:
Even if there’s a tiny bit of lidocaine in there, what’s the harm? That’s a lot of extra fluoro over a career.
Click to expand...
To cord?…. Transient para, needing to change both patients and my pants while waiting for lido to wear off while on way to ED?
 
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