Furman SCS Technique

[sdnuser001]

I was reading through the Furman chapter on SCS trials and found the described technique to be pretty intriguing. Essentially ipsilateral obliquing a touch and caudally tilting as much as possible so that you don't really have to guess where to start like you often do when going out of plane in AP. I have often found that the traditional starting point of 3 o'clock one and a half pedicle belows often isn't a flat enough angle, particularly on larger patients.

Does anyone do their trials with this technique? And pros and cons to the more traditional approach taught at workshops?

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[MitchLevi]

If you want to end up anterior or in the gutter you approach at angle.

 

[bedrock]

Agree with Mitch. Furman is overall very good, but I would not use this technique for SCS.

 

[DoYouEvenLiftBro]

If really wanted you can measure angle on mri

 

[MitchLevi]

Am I crazy or is that diagram labeled incorrectly?

 

[Taus]

Enter 2 levels down. Go clo early and adjust trajectory to exact angle needed. Easy.

 

[Dr. Ice]

I trained under him. That is what he taught, but I never liked it. Since then I’ve adopted more of the 2 sometimes 2.5 levels below intended entry point and have never looked back.

 

[CleanUp]

I trained under him. That is what he taught, but I never liked it. Since then I’ve adopted more of the 2 sometimes 2.5 levels below intended entry point and have never looked back.

So to be clear for entry at t12-L1 you make skin puncture with the needle at L3 pedicle or halfway bw L3 and L4?

 

[lobelsteve]

How about you people stop guessing and look at pre-procedure imaging to determine best location to start to get yourself the best chance of a 30 degree needle entry.
Not rocket science. Every patient is not going to be in Netter. Use the pics to guide the trajectory.

 

[MitchLevi]

Isn't this mislabeled? Am I dumb? Is that just a lot of tilt?

 

[drg123]

Thanks for bringing this up. As a fellow, I read this and noticed that it is not at all how everyone does this. Essentially though, I think this approach is just using the C-arm to do what we do manually from an AP view - create a paramedian and caudad to cephalad trajectory, and because the C-arm is adusted in this way, you just do a gun-barrel co-ax approach. I like @lobelsteve rec to just use the MRI to estimate the entry point for the desired entry angle. I think it's easier from the AP view so you can adjust medial-lateral if needed.

Relatedly, do you all hit lamina first then 'walk off'. I prefer using CLO as a depth gauge, and I guess hitting lamina gets you close to the IL space while still in AP safely so that you don't drift too much medial or lateral while in CLO. Many of my attendings don't use any kind of depth view.. just AP and LOR the whole time. Thoughts?

 

[MD87]

Isn't this mislabeled? Am I dumb? Is that just a lot of tilt?
View attachment 378693

A ton of tilt. Confusing. Which is why no one does it this way.

 

[lobelsteve]

Isn't this mislabeled? Am I dumb? Is that just a lot of tilt?
View attachment 378693

 

[BobBarker]

Lots of docs mistake t11/12 and t12/l1. Including Dr Furman apparently.

 

[RoloTomassi]

It's correct, just bad diagram. SP above green dot is T12. Y'all are looking at it like it's a regular AP but he's tilting it so much you're looking under the SP. Showing some lamina would help prevent confusion.

 

[BobBarker]

Yes, absolutely recommend walking off lamina. An entry walking off lamina, same angle as the shoulder of the spinous process is hard to mess up.

 

[drusso]

It's all high school trig. Place a spinal needle just posterior to the target using Furman's approach, then go to AP, square up your end plates, and post a picture of what you got.

 

[epidural man]

Thanks for bringing this up. As a fellow, I read this and noticed that it is not at all how everyone does this. Essentially though, I think this approach is just using the C-arm to do what we do manually from an AP view - create a paramedian and caudad to cephalad trajectory, and because the C-arm is adusted in this way, you just do a gun-barrel co-ax approach. I like @lobelsteve rec to just use the MRI to estimate the entry point for the desired entry angle. I think it's easier from the AP view so you can adjust medial-lateral if needed.

Relatedly, do you all hit lamina first then 'walk off'. I prefer using CLO as a depth gauge, and I guess hitting lamina gets you close to the IL space while still in AP safely so that you don't drift too much medial or lateral while in CLO. Many of my attendings don't use any kind of depth view.. just AP and LOR the whole time. Thoughts?

Goal is to walk of Lamina -

I teach fellows so this is a must.

However, If I am doing it, I aim for lamina, but am totally fine if I miss it and can enter in CLO. I find that fellows have difficulty with CLO advancement (and sometimes myself) because you lose laterality. Often If I don't keep constant midline pressure, I'll end up too lateral. The CLO view tricks you to thinking everything is okay with needle tip placement. Fellows are not good at this (keeping the laterality question in their head as they advance.)

 

[Baron Samedi]

I check a CLO as soon as I access to verify that I am, in fact, epidural and that the leads are posterior. I don't think it helps you too much when gaining access and can lead to lateral entry like epidural man mentioned.