LOR syringes

[Mr Kenobi]

Hey all. Just started doing procedures at a surgery center that is new to me. The LOR syringes they have are the ones pictured below on the left. Different than both the plastic and glass syringes I have used before. I typically like to use loss to saline but I have not been able to draw saline into these. Anyone use these? Am I missing something

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[oneforfighting]

What do you mean you have not been able to draw saline into them? As in you can’t withdraw the plunger while drawing up?

 

[SSdoc33]

very easy. dont use a LOR syringe. use a simple 5 ml or 3 mL plastic syringe. better feel and cheaper

at least try it once

 

[Mr Kenobi]

What do you mean you have not been able to draw saline into them? As in you can’t withdraw the plunger while drawing up?

I can withdraw the plunger fine, but only like .1cc of saline is pulled into the syringe before it fills with air. Like there is no suction when I pull the plunger to draw the saline. I typically draw up from the pop top glass saline in the epidural tray through a filter straw.

 

[SageCraft]

Once I went 3ml plastic syringe as LOR I never went back.

 

[au bon pain]

Hey all. Just started doing procedures at a surgery center that is new to me. The LOR syringes they have are the ones pictured below on the left. Different than both the plastic and glass syringes I have used before. I typically like to use loss to saline but I have not been able to draw saline into these. Anyone use these? Am I missing something View attachment 361629

I sometimes use the one on the left and use saline for cervical LOR. Make sure it’s hubbed snugly in the 18g in order to draw saline in.

 

[RoloTomassi]

I sometimes use the one on the left and use saline for cervical LOR. Make sure it’s hubbed snugly in the 18g in order to draw saline in.

Yeah I think hubbing non-Luers works. Or you can spray into your tray then stick the LOR in and draw up.

FWIW I think air is superior. Air epidurogram is nice in a low contrast world. No confusion of saline vs CSF.

 

[kstarm]

This can be irritating. Try having the plunger all the way withdrawn before entering the saline bottle, then push the plunger down and all that air into the bottle, you should notice an easier time getting the saline out.

 

[SSdoc33]

Yeah I think hubbing non-Luers works. Or you can spray into your tray then stick the LOR in and draw up.

FWIW I think air is superior. Air epidurogram is nice in a low contrast world. No confusion of saline vs CSF.

? air is compressible. water is not. i suppose you can get used to anything, but saline offers a cleaner LOR in my opinion. then there is the (albeit very minor) risk of pneumocephalus

 

[lobelsteve]

LOR: You mean under lateral fluoroscopy for SCS?
Why else would you do LOR?

 

[Pain Applicant1]

very easy. dont use a LOR syringe. use a simple 5 ml or 3 mL plastic syringe. better feel and cheaper

at least try it once

This, multiplied by 1000.

Don't waste money on someone trying to sell you something you don't need.

I use a 5 ml syringe. I put about 1 ml of NS in it and draw up about 1 ml of air. Works great every time. Once you get used to it you won't go back.

Best part about it if you're employed is that you'll be saving the hospital some money which they will surely pass on to you.

 

[au bon pain]

Yeah I think hubbing non-Luers works. Or you can spray into your tray then stick the LOR in and draw up.

FWIW I think air is superior. Air epidurogram is nice in a low contrast world. No confusion of saline vs CSF.

I prefer air too except in the neck where it's mix of 1cc saline and 1cc air; removing potential of pneumocephalus is worth it to me.

 

[au bon pain]

LOR: You mean under lateral fluoroscopy for SCS?
Why else would you do LOR?

I keep hearing that a paper detailing technique and outcomes from non-LOR ESI may be coming...for us mere mortals to be able to cite when deciding to give it a try...

 

[MD87]

Hey all. Just started doing procedures at a surgery center that is new to me. The LOR syringes they have are the ones pictured below on the left. Different than both the plastic and glass syringes I have used before. I typically like to use loss to saline but I have not been able to draw saline into these. Anyone use these? Am I missing something View attachment 361629

Yes. My colleague uses these. Hate them. When I get stuck using them, I get 5cc in another syringe and then inject it into this LOR syringe.

 

[lobelsteve]

I keep hearing that a paper detailing technique and outcomes from non-LOR ESI may be coming...for us mere mortals to be able to cite when deciding to give it a try...

N now over 1000

 

[Tboned]

OP, I use the same LOR syringe. Pain in n the rear to draw out of a vial.

 

[MitchLevi]

It's not an air tight syringe, so withdraw back and forth and the air you inject into the vial of saline will rapidly fill the syringe.

I read Lobel's description of his cervicals with the 25g and no LOR.

I've used that technique exclusively for...what, 2 years now? I do a lot of CESI using this technique and it is superior to LOR.

Adverse event of n = 0.

 

[SgtThunderfistMD]

It's not an air tight syringe, so withdraw back and forth and the air you inject into the vial of saline will rapidly fill the syringe.

I read Lobel's description of his cervicals with the 25g and no LOR.

I've used that technique exclusively for...what, 2 years now? I do a lot of CESI using this technique and it is superior to LOR.

Adverse event of n = 0.

Can anyone link the technique strategy?

 

[lobelsteve]

Can anyone link the technique strategy?

Direct Visualization of Cervical Interlaminar Epidural Injections Using Sonography - PubMed

In this case series, we describe a novel ultrasound (US)-guided cervical interlaminar epidural steroid injections (CILESIs) procedure that does not depend on the loss-of-resistance method for epidural space identification. A needle is introduced into three US-identified structures (triple bar...

pubmed.ncbi.nlm.nih.gov

This is not it.
But holy Fack, this is insanity on many levels. See images. Almost threw up. Did punch my screen.
I will put together my technique article and submit by end of year.

 

[Ducttape]

ive used both.

frankly not a big fan of regular syringe. you can generate much more pressure and may be more likely to delude yourself in to thinking you have LOR with a regular syringe.

for that reason, i would caution between using a 1 cc and, instead suggest a 10 cc. go for the larger syringe for the LOR.


for these syringes, i find drawing out NS after it is poured out in to a well, not through a needle, is easier. bury the whole top of the syringe in to the pool of water and chant "Anál nathrach, orth' bháis's bethad, do chél dénmha"

 

[lobelsteve]

ive used both.

frankly not a big fan of regular syringe. you can generate much more pressure and may be more likely to delude yourself in to thinking you have LOR with a regular syringe.

for that reason, i would caution between using a 1 cc and, instead suggest a 10 cc. go for the larger syringe for the LOR.


for these syringes, i find drawing out NS after it is poured out in to a well, not through a needle, is easier. bury the whole top of the syringe in to the pool of water and chant "Anál nathrach, orth' bháis's bethad, do chél dénmha"

I use a plain 10cc for LOR to air in SCS. I find pulling back rather than pushing in gives me a better idea of if I am in. But nothing beats threading the lead in under lateral for safety.

 

[MitchLevi]

I use a plain 10cc for LOR to air in SCS. I find pulling back rather than pushing in gives me a better idea of if I am in. But nothing beats threading the lead in under lateral for safety.

FYI, I frequently do no LOR with SCS. I put the lead in the 14g, go CLO, and do the same thing as a CESI. You can feel the ligament.

Once I'm through ligament I go lateral.

LOR is obviously far more reliable with a 14g than say a 20 or 22g, but anyone who relies on LOR as a safety measure is fooling his or herself.

It's generally unreliable.

 

[deleted131481]

Does anyone use contrast in LOR syringe?

 

[Ducttape]

yes.

for non SCS - i use a combo of saline and contrast, usually a 3:1 ratio. limits contrast exposure, doesnt completely blur the image if you are too shallow - and i rarely am with using CLO and LOR.


some people have squishy ligaments, and that concerns me with SCS. so i find adding LOR to CLO and feel makes placement "more reliable" than not.

for SCS, i use air (one attending used saline because it may "lubricate" the Touhy....)

 

[callmeanesthesia]

I do LOR to contrast (no air) in a 3 mL syringe, with a 22g Tuohy. I’m anesthesia-trained so I still really prefer to have the extra tactile feedback as a backup. I can usually feel like needle tip pop through ligament, and feel the LOR to the contrast.
Where I trained it was saline/air in an LOR syringe and nobody there had adopted CLO yet. Horrifyingly, one attending didn’t even go lateral. Hated doing CESIs with him.

 

[GlowInTheDark]

I keep hearing that a paper detailing technique and outcomes from non-LOR ESI may be coming...for us mere mortals to be able to cite when deciding to give it a try...

Or for insurance companies to cite as evidence they should cut reimbursement

 

[MitchLevi]

Or for insurance companies to cite as evidence they should cut reimbursement

Go on...

 

[SgtThunderfistMD]

Can anyone link the technique strategy?

Cervical wet tap- Darn it

Had a lady with Cushingoid features for C7-T1 epidural. We tapped with 20G- first one in the neck so far. Gave the usual advice water, coffee. Will see her in 2 days time. In this lady- should I ask another provider to try or better to try myself as I know that her loss is very very subtle...

forums.studentdoctor.net

I actually found it, Ligament described it above. Only question--are you always doing this at C7-T1 regardless of which nerve root pain is emanating from?

 

[MitchLevi]

Cervical wet tap- Darn it

Had a lady with Cushingoid features for C7-T1 epidural. We tapped with 20G- first one in the neck so far. Gave the usual advice water, coffee. Will see her in 2 days time. In this lady- should I ask another provider to try or better to try myself as I know that her loss is very very subtle...

forums.studentdoctor.net

I actually found it, Ligament described it above. Only question--are you always doing this at C7-T1 regardless of which nerve root pain is emanating from?

All CESI for me are C7-T1.

No matter the level of pathology. With 2cc saline and 1cc steroid, I can cover the entire neck.

I have done C6-7, but usually do not.

 

[Ducttape]

agree. i did go gung ho and did C67 like twice in my career, but not any more. never did any other level.



then there is the question of semantics. i know a pain doctor who says he will do "a C34 epidural" injection, but enters at C7T1, and calls it C34... ostensibly because of spread of medication... it borders on fraud in my mind....

 

[Ferrismonk]

I trained with glass and saline to LOR and no laterals, but now I use plastic LOR syringe to air for labor epidurals and SCS leads. For those worried about pneumocephalus, remember that it's the loss-of-resistance technique, not injected of air technique. Any injectate should be minimal.

For CESI and LESI, I use 25G quinke as suggested by others in this forum. I insert in AP until bone or in ligament, then walk off and advance rest of way in CLO. I can feel the resistance while in ligament through my 25G/extension tubing/5mL syringe complex and when I'm close under fluoro, I will then advance very slowly until I feel a small give. Usually about 0.1mL contrast injected.

 

[deleted131481]

agree. i did go gung ho and did C67 like twice in my career, but not any more. never did any other level.



then there is the question of semantics. i know a pain doctor who says he will do "a C34 epidural" injection, but enters at C7T1, and calls it C34... ostensibly because of spread of medication... it borders on fraud in my mind....

There's a group that uses interlaminar approach with catheter - supposedly threads it through the foramen or close to and bills as transforaminal ESI (cervical or lumbar).

 

[SSdoc33]

Does anyone use contrast in LOR syringe?

yeah. saves a step

 

[nvrsumr]

Know a doc who had a patient with a contrast allergy today and did a cesi with 5cc syringe lor to air and saline. Did at least use flouroscopy for clo.

Same doc just pokes the scs wire thru the ligament for placement in clo.

 

[Ducttape]

um.... what is wrong with that?

i will do lumbar - has not come up with cervical yet - esi without contrast and only use LOR, if patient has documented anaphylactic reaction and they refuse prophylaxis.

you do know how we used to do cervical epidurals, right? sit in bed, bend forward, head on pillow on table that hopefully wouldnt move, palpate C7T1, and stick the needle in, use LOR or worse hanging drop. even with that barbaric a set up, there were very few neurologic disasters...

 

[Drd105]

LOR: You mean under lateral fluoroscopy for SCS?
Why else would you do LOR?

I have read so many posts of yours and cannot recall anything that would have told me you don’t do LOR. Are you just going by feel of ligament and contrast? CLO? I think I saw that you recently posted that you use 25G spinal needle…

 

[Drd105]

I do LOR to contrast (no air) in a 3 mL syringe, with a 22g Tuohy. I’m anesthesia-trained so I still really prefer to have the extra tactile feedback as a backup. I can usually feel like needle tip pop through ligament, and feel the LOR to the contrast.
Where I trained it was saline/air in an LOR syringe and nobody there had adopted CLO yet. Horrifyingly, one attending didn’t even go lateral. Hated doing CESIs with him.

I’ve worked with two people now who still do AP only

 

[lobelsteve]

I have read so many posts of yours and cannot recall anything that would have told me you don’t do LOR. Are you just going by feel of ligament and contrast? CLO? I think I saw that you recently posted that you use 25G spinal needle…

Paper coming. 25g CLO. No LOR. No feel. All imaging and contrast.

 

[MitchLevi]

Same doc just pokes the scs wire thru the ligament for placement in clo.

Me too

 

[nvrsumr]

um.... what is wrong with that?

i will do lumbar - has not come up with cervical yet - esi without contrast and only use LOR, if patient has documented anaphylactic reaction and they refuse prophylaxis.

you do know how we used to do cervical epidurals, right? sit in bed, bend forward, head on pillow on table that hopefully wouldnt move, palpate C7T1, and stick the needle in, use LOR or worse hanging drop. even with that barbaric a set up, there were very few neurologic disasters...

i should have used magenta and I was one of those docs doing hanging drop in an exam room

 

[MD87]

I have read so many posts of yours and cannot recall anything that would have told me you don’t do LOR. Are you just going by feel of ligament and contrast? CLO? I think I saw that you recently posted that you use 25G spinal needle…

Contrast Spread Technique: Evolution

www.ncbi.nlm.nih.gov

Contrast Spread Technique

Dear Editor:

academic.oup.com

 

[Orin]

yeah. saves a step

I try it from time to time with glass LORs and if things take too long, I find that the contrast sometimes getting the plunger stuck, making LOR impossible until you notice the wet tap

 

[Drd105]

Contrast Spread Technique: Evolution

www.ncbi.nlm.nih.gov

Contrast Spread Technique

Dear Editor:

academic.oup.com

I don’t think I could bring myself to do this with “continuous pressure” but I have been using contrast puffs and not fully trusting the LOR if I didn’t get it while at a mm past the VILL. however I thought everyone was using the LOR syringe still. How is the feel of it different with the 25G vs my 20G Tuohy? Will I not be able to feel popping through the ligament with the 25G? And are you all using the 5 cc or 3cc plastic syringes as mentioned above?

 

[runfastnow]

Find a technique that is effective+safe and get really good at it. Many ways to skin a cat as long as you're safe and understand where/why of your needle positioning.

I do the SIS guidelines CLO 20g plastic LOR (5cc size) with 1-2mL saline technique OR the 25g technique mentioned here based on patient. Both work fine. Doing the 25g technique does make me feel "cool" though.

 

[RoloTomassi]

Find a technique that is effective+safe and get really good at it. Many ways to skin a cat as long as you're safe and understand where/why of your needle positioning.

I do the SIS guidelines CLO 20g plastic LOR (5cc size) with 1-2mL saline technique OR the 25g technique mentioned here based on patient. Both work fine. Doing the 25g technique does make me feel "cool" though.

What influences your decision?

 

[runfastnow]

What influences your decision?

Young or skinny or histrionic people without a lot of overall degenerative changes I’ll go for 25.

In older folks with really calcified LF or a lot of degeneration I’ll use 20. Have tried 25 and sometimes too flimsy to poke through. Just my experience.

 

[deleted875186]

Just use air, quicker, more sensitive, just get used to the bounce.

If saline must be used flip the saline and tap it out into a well, or draw up with filter needle or straw with a normal synringe and squirt into a well. The LOR syringes don’t draw meds well.

 

[RoloTomassi]

Young or skinny or histrionic people without a lot of overall degenerative changes I’ll go for 25.

In older folks with really calcified LF or a lot of degeneration I’ll use 20. Have tried 25 and sometimes too flimsy to poke through. Just my experience.

Thanks. Might try it out but I'm not really seeing what the advantage is over LOR other than cost.

LOR:
Pros:
-you are stopping immediately upon passing LF (not always the case with pressure technique which is dependent on your increments between puffs)
-air epidurogram (if no saline)
-fewer XR shots (I'm assuming, since you don't have to puff and shoot in small increments)
-less contrast (1 tiny puff after loss)
-navigate through calcifications

Cons:
-$$ Tuohy>25ga, LOR>3cc (the latter negated if using a regular syringe for loss)
-potential pneumo (extremely rare, minimized with small volume, negated with saline)
-risk for PDPH higher if IT due to bigger ga (never had one, knock on wood)
-slightly more painful potentially (bigger ga, "shock" when passing LF, but IL is very well tolerated overall)

 

[Dr. Ice]

Lor syringes are a huge waste of time and money

 

[Ferrismonk]

Pro: 25G quinke is almost painless.

Agree, it does feel "cool" and "modern" too.

Some in my group will numb the skin with 1% lido, use a 17G touhy with LOR, thread a catheter to desired level, inject contrast, then 0.25% bupi and depo. Meanwhile I use a standard tray and only need contrast and dex. No local at all.