LOR syringes

[DrMDAware]

Sorry I may have missed it can someone point me to the thread with the 25G technique? Thanks.

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[Drd105]

So today is the first day of the rest of my life- I went to grab a tuohy and there were none. Thought about rescheduling the patient. Thought about ferrismonk and Lobelsteve and especially the LOR? For SCS trial? Comment. Got my act together and pulled out my 25 and went for it. I feel like I just accomplished something really amazing thank you to everyone on the board who contributed to my success and thanks from the patient who felt nothing!

 

[drrosenrosen]

I agree. I finally decided to do it this way consistently for the past month or so. Patients are much happier as the procedure hurts less, and I've gotten very comfortable with the mechanics of it. Glad we have such a great place to share techniques like this.

 

[MitchLevi]

I've done several dozen SCS trials and implants with no LOR.

 

[drrosenrosen]

I've done several dozen SCS trials and implants with no LOR.

Do you just use the blank wire to tell when you're in?

 

[MitchLevi]

Do you just use the blank wire to tell when you're in?

Posterior and midline in the CLO view is consistent. The angle of the lead relative to the lamina. I get a lateral early. AP to steer.

Done this many times.

Same technique as the 25g CESI, but the lead is the contrast. Needle tip 1-2mm posterior to LF, stylet out, lead in...Microadvancements of the needle with slight pressure on the lead.

Very crisp feedback as you poke through with your lead.

Careful that your lead isn't sticking so far out of the needle that the LF denies the lead epidural entry and the lead folds over on itself.

You should have around 1-2 electrodes or so distance out of the needle so there is enough strength in the lead not to bend too much.

You COULD fracture your lead that way, especially if you're clumsy and ham fisting your lead against the lamina itself.

 

[nvrsumr]

1+ for scs lead lor

 

[lobelsteve]

Posterior and midline in the CLO view is consistent. The angle of the lead relative to the lamina. I get a lateral early. AP to steer.

Done this many times.

Same technique as the 25g CESI, but the lead is the contrast. Needle tip 1-2mm posterior to LF, stylet out, lead in...Microadvancements of the needle with slight pressure on the lead.

Very crisp feedback as you poke through with your lead.

Careful that your lead isn't sticking so far out of the needle that the LF denies the lead epidural entry and the lead folds over on itself.

You should have around 1-2 electrodes or so distance out of the needle so there is enough strength in the lead not to bend too much.

You COULD fracture your lead that way, especially if you're clumsy and ham fisting your lead against the lamina itself.

I hate the false lead LOR as it goes up 2-3 contacts and curls backwards behind the flavum.

 

[Asclepius186]

Posterior and midline in the CLO view is consistent. The angle of the lead relative to the lamina. I get a lateral early. AP to steer.

Done this many times.

Same technique as the 25g CESI, but the lead is the contrast. Needle tip 1-2mm posterior to LF, stylet out, lead in...Microadvancements of the needle with slight pressure on the lead.

Very crisp feedback as you poke through with your lead.

Careful that your lead isn't sticking so far out of the needle that the LF denies the lead epidural entry and the lead folds over on itself.

You should have around 1-2 electrodes or so distance out of the needle so there is enough strength in the lead not to bend too much.

You COULD fracture your lead that way, especially if you're clumsy and ham fisting your lead against the lamina itself.

What angle oblique do you find optimal at T12-L1 for CLO?

 

[lobelsteve]

What angle oblique do you find optimal at T12-L1 for CLO?

I go full lateral.

 

[MitchLevi]

What angle oblique do you find optimal at T12-L1 for CLO?

It's 45-50ish for me.

Honestly, I go 45 and adjust until the lamina is a nice little football shape.

Lateral is good too, but I like CLO. I just feel like I have a better ventral laminar line to better assess depth.

CLO with 2-3 sec of live fluoro.

Steve is right about the fact there may be times you think you're epidural but you're posterior to the ligamentum yet tracking superiorly. I find that a little more likely the more superior you are in the interlaminar space, where the resistance may actually be the lamina itself.

BTW - It's not like LoR to air or saline is slow. I still do LoR during ESI that looks weird using the other technique, and if I'm for some reason struggling with an SCS lead I'll still grab LoR on occasion.

Just have to know LoR is NOT reliable. The 14g Tuohy gives good loss of course. No mystery with that big ol needle.

 

[painfree23]

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

Damn really?? Cheaper too. Saline or air?

 

[MitchLevi]

Glass LoR is personally offensive to me.

 

[Laryngospasm]

I’ve done thousands with glass and thousands with plastic, glass requires Lubricating with saline to have good feel and is heavy and not suited as well to patients who are prone. Bounces around like an obese person trimming a palm tree. I just prefer the plastic now. However lumbar labor esis I don’t mind glass if need be. I’ve gotten what I consider to be proficient with thr traditional method and don’t have the balls to switch to Steve’s method.. lol

 

[SSdoc33]

Glass LoR is personally offensive to me.

when i see a fellow or a young attending break out the glass LOR syringe, then bathe it in saline and pump it a few times..... a little piece of me dies inside

 

[lobelsteve]

when i see a fellow or a young attending break out the glass LOR syringe, then bathe it in saline and pump it a few times..... a little piece of me dies inside

Kids today.