Intracept S1-men

[bedrock]

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Any tricks you all use for S1 intracept in men with a narrow pelvis?

I always use a bevel tip at S1 and crank as hard to direct the tip medially once I clear the medial border of the pedicle. But (depending on bone quality) sometimes it is just impossible to get very close to midline before advancing too far ventral.

I'm getting fairly fast doing intracept at every level....except S1 in men. I was joking with the rep this week, that physicians should be paid double for doing S1 intracept in men!

I'm wondering if you all have any suggestions?

I'm going to be starting kyphoplasty soon, which I haven't done since fellowship. I'm wondering if there is a kypho instrument that could be helpful, such as the stryker curved kypho needle? It is typically used in osteoporotic bone, and my S1 issues are typically in younger men with denser bone.

I'm wondering if any of you have used another pain medicine tool (beyond the Relievant kit) that could help with tough S1 intracepts?

 

[callmeanesthesia]

Haven’t done intercept yet (meeting with a rep tomorrow), and maybe this is a crazy idea, but what about drilling or hammering through the iliac crest/PSIS?

 

[RoloTomassi]

My best advice is making sure your angle of approach is 35-40 degrees oblique, making sure you stop at the distal scallop, and if it still isn't turning as fast as expected due to hard bone, do the retraction method before it's too late.

 

[bedrock]

My best advice is making sure your angle of approach is 35-40 degrees oblique, making sure you stop at the distal scallop, and if it still isn't turning as fast as expected due to hard bone, do the retraction method before it's too late.

You can’t do a 35 degree oblique at S1 in a man with a narrow pelvis. That is the entire reason I started this thread.

Agree with distal scallop.

Please define the “retraction method”
Is it something besides pulling your instruments back and trying to force the tip more medial?

 

[PainandGain]

Square off the sacrum in outlet view. Oblique until the iliac crest is just about to the ala. my skin entry point is about in line with the L5 transverse process. Drop the beveled trochar down to the ala. Confirm trajectory in the lateral. Mallet across the S1 pedicle and stop at the scallop. Steer the J to your target. I’ve performed over 150 cases and that works 95% of the time.

 

[RoloTomassi]

You can’t do a 35 degree oblique at S1 in a man with a narrow pelvis. That is the entire reason I started this thread.

You can though. You just have to cephalad tilt until the crest is out of the way. Go past Ferguson to achieve this. This is the biggest tip.

Yes retraction is wiggling the introducer out partially to while keeping the J in to allow the J to turn faster.

 

[bedrock]

You can though. You just have to cephalad tilt until the crest is out of the way. Go past Ferguson to achieve this. This is the biggest tip.

Yes retraction is wiggling the introducer out partially to while keeping the J in to allow the J to turn faster.

Thank you.

I could see how that would help direct things medially more quickly. But would that not also give you a very steep caudal angle that would cause you to end up more inferior than the 40% target line for an S1 intracept?

 

[SpineandWine]

@Taus
Any suggestions on S1, pics

I’m trained (I bsed 5 patients on portal) but haven’t found good candidate.
Hopefully in next 3-4 months I’ll have a case or two lined up

 

[RoloTomassi]

Thank you.

I could see how that would help direct things medially more quickly. But would that not also give you a very steep caudal angle that would cause you to end up more inferior than the 40% target line for an S1 intracept?

Yes, you have to curve it back cephalad to counter the inferior trajectory. I'll try to find an example.

 

[Taus]

Thank you.

I could see how that would help direct things medially more quickly. But would that not also give you a very steep caudal angle that would cause you to end up more inferior than the 40% target line for an S1 intracept?

— You can much much more easily direct ceph /caudal as needed (rotate ica/t piece before mallet J and prn as advance) vs staying posterior without larger medial to lat angle of entry in hard bone at S1.
— Also make certain your stylet tip is close to medial border pedicle before enter S1 body. Minimize lat to medial distance needed to travel in s1 body. If it’s not close to medial border prior to enter vert body. would strongly rec you retract and adjust angle to make that happen.
— May need even bigger retraction as rolo detailed (those who used gen 2 equipment are more familiar w that move).

If you are still getting too anterior despite all that…

— put the bevel tip stylet back in, crank tip medial and drive ICA deeper into vert body like a kypho.

— Worst case scenario before bailing, perhaps after try other side…. Can go directly through iliac crest.

 

[DoYouEvenLiftBro]

Did this guy a few weeks ago (this is an old office pic) for intracept L3-S1, no way on earth to get the triangle oblique view at S1 so just started from an AP around the red and docked down then switched to lateral and adjusted from there as others mention, I can find the pics at the ASC if you really want

 

[RoloTomassi]

Guy with high crest on straight AP no tilt.

Ferguson, a bit more space. But after obliquing to 35, I had to tilt even more, hence the downward angle of the introducer on Ferguson.

Lateral. Tilt is beyond Ferguson. Slight curve cephalad to stay closer to 40% from SEP. Note skin entry is near where you would enter for L4. With this amount of tilt, C-arm II can be touching patient, if lordotic. Not the most dramatic example but you get the point.

 

[TIVAndy]

you can just refer out the L5 S1 involvement to your friendly competitor...