drpainfree

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anyone autoclave your glass LOR syringe? what setting do you use?

can't get used to plastic LOR, so will stay with glass. don't have autoclave yet, but plan to autoclave glass LOR syringe when I get one later.
 

Extralong

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ICesi - hanging drop
ILesi - prefer plastic, but why don't u just do a 4-5 lvl lumbar TFESI instead? ;)

I was trained with plastic, and probably am skewed towards that, tried the glass, just isn't my style. Sorry to derail the topic.
 

ampaphb

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How do you sterilize your RF probes if you don't have an autoclave?

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drpainfree

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ICesi - hanging drop
ILesi - prefer plastic, but why don't u just do a 4-5 lvl lumbar TFESI instead? ;)

I was trained with plastic, and probably am skewed towards that, tried the glass, just isn't my style. Sorry to derail the topic.
tried plastic LOR, not used to it, trained with glass since anesthesia days. I like to advance the needle with both hands, then tap for LOR, instead of advancing with one hand and pushing down on the plastic syringe plunger.
doing IESI for cervical with LOR and lumbar, mostly for central canal stenosis. Shall I explain to you why or direct the discussion to hanging drop on cervical IESI:p
 
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drpainfree

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doing RFA in ASC, have postponed long enough, think will finally get a neurotherm and autoclave in office soon. so the question on glass LOR syringe, one more reason to justify the cost of autoclave. i'm paying about $5 a piece on glass LOR.
 

Extralong

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:D:D
tried plastic LOR, not used to it, trained with glass since anesthesia days. I like to advance the needle with both hands, then tap for LOR, instead of advancing with one hand and pushing down on the plastic syringe plunger.
doing IESI for cervical with LOR and lumbar, mostly for central canal stenosis. Shall I explain to you why or direct the discussion to hanging drop on cervical IESI:p
.

Well, you can just do everything blind, and save the money on autoclaving the glass syringes. I mean, it's just a straight shorter into the epidural space. :D
 

nvrsumr

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ICesi - hanging drop
ILesi - .
Not to be personal but wtf? Have done. Not the best technique. Try clo with saline(i do saline and air as like feel) I am a big fan of learning different techniques and watch the hub of the needle for a small fluid column drop once past ligament prior to lor. Similar to the meniscus drop. Just a hint though. Often times i just use a modified lor with contrast now

I swtiched from glass in fellowship to a 5cc regular plastic based on this forum and havent looked back. though my contrast syringe is 3cc
 
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Extralong

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Not to be personal but wtf? Have done. Not the best technique. Try clo with saline(i do saline and air as like feel) I am a big fan of learning different techniques and watch the hub of the needle for a small fluid column drop once past ligament prior to lor. Similar to the meniscus drop. Just a hint though. Often times i just use a modified lor with contrast now

I swtiched from glass in fellowship to a 5cc regular plastic based on this forum and havent looked back. though my contrast syringe is 3cc
Nah, just throwing it out there, partially facetious. Lol. I'm a fan of trying new techniques, but ultimately, I use LOR plastic.
 

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Whats LOR? 25g CLO. Direct visualization with contrast before and after ligament. Hanging drop, so 70s.

I use plastic with air for scs cases. 14g really has more feel.
 

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Do you have much greater pressure potential with the smaller syringe? Should that be a concern?

Make sure the glass syringes you use are not single use only - ie are autoclave-able. Unfortunately, those won't be the cheap $5 ones.



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NJPAIN

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Whats LOR? 25g CLO. Direct visualization with contrast before and after ligament. Hanging drop, so 70s.

I use plastic with air for scs cases. 14g really has more feel.
How far are you advancing your 25 ga needle prior to starting to inject contrast? I'm still using an 18 ga Hustead but I am not using LOR but rather injecting contrast attached via a short extension tube. I start injecting contrast when I am 3/4 the way between the posterior edge of the lamina and the anterior laminar line. At times there is great resistance to injection and I have a great LOR and linear contrast pattern when I reach the anterior laminar line. However, frequently there is little resistance to injection and contrast starts spilling along the multifidi. I'm thinking that perhaps I should be advancing further before starting the contrast injection.
 

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I touch lamina of T1. Walk off superiorly and advance 2mm. Squirt contrast posterior. Advance to interlaminar line and every mm squirt a drop of contrast. Once epidural spread noted, good stuff goes in.
 
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drpainfree

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sure, for pregnant women, you can consider blind techniques for both c/l-spine esi. of course, i would never offer esi to a pre
Do you have much greater pressure potential with the smaller syringe? Should that be a concern?

Make sure the glass syringes you use are not single use only - ie are autoclave-able. Unfortunately, those won't be the cheap $5 ones.



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How do you know whether the glass syringe is autoclave-able? The packaging I have for the glass LOR doesn't say single-use only. What will happen if it's single-use and it's autoclaved?
 

ampaphb

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pacific-nuclear-test.jpg
 

Ducttape

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Nothing will happen to the glass. Probably.

That will happen is if you have a state reportable infection, it may feel as if the glass syringe has been inserted up your @&&


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Jcm800

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I like plain old 5 cc plastic syringe. Sometimes I connect the extension tubing to it and get lor from there. Half the time I use contrast to get LOR


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drpainfree

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when I do SCS I don't bother with LOR at all, I just use the guidewire since LOR is not reliable with 14G needle.

when you use contrast instead of LOR to test for epidural space, do you look on the lateral view? My c-arm doesn't produce great lateral view images, especially in thicker patient. so I'm not sure how reliable it would be to look at lateral view images for epidural space confirmation.
 

BobBarker

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Man, sometimes I feel like you are living in a different dimension than the rest of us.
 
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lobelsteve

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when I do SCS I don't bother with LOR at all, I just use the guidewire since LOR is not reliable with 14G needle.

when you use contrast instead of LOR to test for epidural space, do you look on the lateral view? My c-arm doesn't produce great lateral view images, especially in thicker patient. so I'm not sure how reliable it would be to look at lateral view images for epidural space confirmation.
Bigger needles make LOR more pronounced. Typically the loss of drag on a 14g tells you are in the epidural space.
 
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drpainfree

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Man, sometimes I feel like you are living in a different dimension than the rest of us.
You should try guidewire. been using glass LOR with 14g needle since fellowship, then started using coude curve needle, much easier to thread wires in and avoid anterior placement. but coude curve tip needle didn't give reliable LOR, so tried guidewire to test for epidural space. Then I realized quite a few times when I didn't get LOR with coude needle, but when inserting the guidewire, it went right in and the needle tip was already in the epidural space (advance the guidewire/coude needle on lateral view)!

Apparently it's a common practice in my area that scs reps always bring in coude needle and guidewire for scs cases.
 

DOctorJay

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I always use Coude. Always use plastic syringe for LOR to saline and get in with CLO view.


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BobBarker

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I can see using the coude's all of the time. I had an attending in fellowship that always used the epimed RX coude's. I don't remember any problem with LOR but it has been a long time. I just use the straight's that come with the lead and LOR to air with plastic LOR syringe. I definitely know when I get LOR. I have in my head that I hear a very soft farting noise when I get it.
 

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anyone autoclave your glass LOR syringe? what setting do you use?

can't get used to plastic LOR, so will stay with glass. don't have autoclave yet, but plan to autoclave glass LOR syringe when I get one later.
I use glass and use the kits with disposable ones. Occasionally autoclave a few for backup. Couldn't tell you what settings.
 

DOctorJay

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Timeoutofmind

Absolutely. Makes placement for your Coude super easy.


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NJPAIN

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I'm trying to use CLO for all ILESI including lower lumbar ILESI for stenosis. I am finding though that in the 70+ central stenosis crowd entering at L4-5 using a 45 degree CLO that my LOR is frequently occurring beyond the expected VILL (SLL). Not certain if it is the lordotic curve, a really thick ligamentum flavum or if 45 degrees is not enough oblique.


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lobelsteve

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I'm trying to use CLO for all ILESI including lower lumbar ILESI for stenosis. I am finding though that in the 70+ central stenosis crowd entering at L4-5 using a 45 degree CLO that my LOR is frequently occurring beyond the expected VILL (SLL). Not certain if it is the lordotic curve, a really thick ligamentum flavum or if 45 degrees is not enough oblique.


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Review the mri and you will know.
 
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Jcm800

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I often use the lead to access space with scs. Put 14 in, and get close then I put lead in the needle and see if it goes, if it does not, I push needle, and usually the give is so pronounced you know you are there and then just advance the lead to make sure. Doing this in lateral or COL. In LS spine, usually in lateral especially as you want the lead posterior etc...


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heathermed

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I apologize for the trouble, but could someone please give a further explanation on how to do the midline epidural with a 25g spinal needle and contrast rather than loss of resistance. Would 22g work as well? I've been using the standard touphy with lor so far.

Thank you
 

lobelsteve

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Epidurals are never done in the midline as the ligament often has gaps.

The writeup is detailed above and i think another thread as well. Simple stuff. As long as you trust your fluoro skills.
 

nvrsumr

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I learned seated position with fluoro during fellowship. Forget this technique as you will scare all the nurses at whatever asc you do procedures. The only benefit of seated is that it keeps the shoulders out of the way so wouldn't need clo
 
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NJPAIN

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I learned seated position with fluoro during fellowship. Forget this technique as you will scare all the nurses at whatever asc you do procedures. The only benefit of seated is that it keeps the shoulders out of the way so wouldn't need clo
I'm surprised at how many people are still doing these seated. We learned seated position no fluoro during residency and fellowship in the stone age. Taught them in the same fashion very early in my career and stressed the crap out of me every time.
 

nvrsumr

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Whats LOR? 25g CLO. Direct visualization with contrast before and after ligament. Hanging drop, so 70s.

I use plastic with air for scs cases. 14g really has more feel.
I likey. Fast. Are you using a quinke? Maybe I should use a sprotte?
 

MD87

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For those of you (lobelsteve) using Quinke needles for ILESI, is the 25g too flimsy to get through hypertrophied LF in the lumbar spine, or does the sharp tip slice through without much issue? In other words, if you see a lot of LF hypertrophy on MRI, would you consider switching to 22g?Thanks.
 

MD87

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His most recent post in "picture of the week" shows a t1/2 ILESI done with a 25 g quinke.
 

NJPAIN

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Oh, I don’t think he’s joking either


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lobelsteve

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25g. Quinke. It slices, it dices it steers. Have not needed a 22g outside of scar fro prior surgery.

I no longer trust or believe in LOR as useful for anything but SCS.
 

MD87

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Thanks! I'd imagine with a sharper needle that you'd be less likely to run into the issue I have every so often with a Tuohy needle when encountering a thick/calcified LF - you push and push and push and then the needle jumps forward a little more than I'd like when the relatively blunt tip finally pokes through the LF. I haven't had a wet tap yet (still a fellow), but it gives me A LOT of anxiety when it happens. I'll give this technique a try.