Lumbar contralateral oblique

[schmee90]

I was thinking about incorporating this view for interlaminars a bit more. There’s some great papers for cervical contralateral oblique anatomy, however anybody have a good article or book with good anatomy in it. Did a lit search and found some ok stuff.

Thank you in advance

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[CleanUp]

I do it all the time.

3-5 degrees oblique towards me

Then CLO for the angle, depth and LOR

 

[MD87]

I was thinking about incorporating this view for interlaminars a bit more. There’s some great papers for cervical contralateral oblique anatomy, however anybody have a good article or book with good anatomy in it. Did a lit search and found some ok stuff.

Thank you in advance

I do it for all of my ILESI. I (almost) never check a lateral. 50 degrees for cervical. 45 for lumbar.

 

[kstarm]

Some decent pictures here: Reliability and Safety of Contra-Lateral Oblique View for Interlaminar Epidural Needle Placement

You should be able to open the pdf and look at the pics. Like most spine procedures it is relatively easy when the anatomy is straightforward. With significant scoliosis or arthritis changes, I find I still sometimes need to go lateral and look at things in multiple angles.

 

[oneforfighting]

Do it all the time. Never taught in fellowship but made sense after doing it on all cervicals.

 

[Taus]

Some decent pictures here: Reliability and Safety of Contra-Lateral Oblique View for Interlaminar Epidural Needle Placement

You should be able to open the pdf and look at the pics. Like most spine procedures it is relatively easy when the anatomy is straightforward. With significant scoliosis or arthritis changes, I find I still sometimes need to go lateral and look at things in multiple angles.

I find scoli even easier w clo. Go to true AP then take 45 clo from there. Plus can precisely adjust needle trajectory bw lamina even w severe disc height and or assymetric collapse.

 

[kstarm]

I find scoli even easier w clo. Go to true AP then take 45 clo from there. Plus can precisely adjust needle trajectory bw lamina even w severe disc height and or assymetric collapse.

Thats true the needle trajectory is so much easier in CLO

 

[Inygma]

Love CLO for all my epidurals. I also do for SCS access. 45-55 CLO usually, mainly due to the different beds at the surg centers or clinic etc and getting a view

 

[Nargosi]

I do it for all of my ILESI. I (almost) never check a lateral. 50 degrees for cervical. 45 for lumbar.

This is exactly what I have done for the past year (for lumbar; I’ve always done cervical this way), and it is much better than lateral in 95% of patients.

 

[MitchLevi]

I never get laterals for interlaminars. It’s a useless view. AP and CLO.

 

[Taus]

This is exactly what I have done for the past year (for lumbar; I’ve always done cervical this way), and it is much better than lateral in 95% of patients.

Pretty much the only times this past decade I’ve gone to a lateral on interlam is to further sort out an odd contrast pattern, ie questionable IT or SD.

 

[BobBarker]

CLO so nice steering through tiny interlaminar openings painlessly.

 

[mdo1738]

I never do lateral for interlaminar. Left-of-midline needle placement and 45 degrees CLO, unless there’s a compelling reason for me to place my needle to the right (where my C-arm can only provide 30 degrees of CLO which is less than I prefer).

 

[schmee90]

Anybody have an article or source for lumbar CO anatomy? Cervical clog some great ones haven’t found much for lumbar

 

[PinchandBurn]

Does this satisfy LCD. Need 2 views. I guess they didn't specify which 2..

 

[drg123]

Graduating fellow. I always use CLO unless the anatomy is so abnormal or the interlaminar space so small that i need to stay in AP to thread through the little passageway. I just have that much more confidence advancing while seeing my ventral depth and especially when there isn't convincing LOR. Whereas my hands/feel would say advance, my eyes often say 'I'm already there'. And more times than not, when I push contrast, indeed I am. I will so though, depending on the anatomy and angle, the CLO can sometimes be deceptive as well, often looking too deep. There was a recent paper on cervical CLO describing what the needle looks like in a variety of placements: Contralateral oblique view can prevent dural puncture in fluoroscopy-guided cervical epidural access: a prospective observational study - PubMed. So I think feel and intuition and caution still important too, in addition to imaging.

Furman has a good image for LESI

 

[MitchLevi]

AP with LOR carries more risk than CLO with no LOR.

 

[Inygma]

I never do lateral for interlaminar. Left-of-midline needle placement and 45 degrees CLO, unless there’s a compelling reason for me to place my needle to the right (where my C-arm can only provide 30 degrees of CLO which is less than I prefer).

I always ask patients if a side hurts more, and enter that side. Thought being more medicine will be on the painful side. Prob just wishful thinking, but I do always sigh when right side is more painful knowing how obnoxious the CLO towards me is when doing my LOR, especially cervical.

 

[mdo1738]

I always ask patients if a side hurts more, and enter that side. Thought being more medicine will be on the painful side. Prob just wishful thinking, but I do always sigh when right side is more painful knowing how obnoxious the CLO towards me is when doing my LOR, especially cervical.

My fellowship had that dogma about doing the more painful side, but I have never seen any difference. I get the thought, but at the same time we’re giving enough volume that it’s surely spreading sufficiently to that side. Only way it might not is if high resistance to flow from severe foraminal stenosis, at which point TFESI is going to be the way to go, not changing the side of the needle for interlam. Perhaps others are seeing different results, but I just never saw a difference to justify switching the CLO to me, though I will still do one that way every now and then.

 

[clubdeac]

My fellowship had that dogma about doing the more painful side, but I have never seen any difference. I get the thought, but at the same time we’re giving enough volume that it’s surely spreading sufficiently to that side. Only way it might not is if high resistance to flow from severe foraminal stenosis, at which point TFESI is going to be the way to go, not changing the side of the needle for interlam. Perhaps others are seeing different results, but I just never saw a difference to justify switching the CLO to me, though I will still do one that way every now and then.

I’ve definitely seen a difference. Have had multiple patients that got great relief consistently from their unilateral pain by doing ipsilateral ILESIs and then only got a few weeks relief when I decided to or accidentally did an ILESI contralateral to their painful side. Almost universally they did much better when I went back and did the ipsilateral side again

 

[Tboned]

I agree if patient has unilateral pain, do a paramidline approach to that side and get that unilateral flow. It makes a difference in my hands

I’ve definitely seen a difference. Have had multiple patients that got great relief consistently from their unilateral pain by doing ipsilateral ILESIs and then only got a few weeks relief when I decided to or accidentally did an ILESI contralateral to their painful side. Almost universally they did much better when I went back and did the ipsilateral side again

 

[MD87]

I agree if patient has unilateral pain, do a paramidline approach to that side and get that unilateral flow. It makes a difference in my hands

Patients also don’t like it when they feel the medication going in on the wrong side.

 

[MitchLevi]

Why would you intentionally do a contralateral injxn?

 

[Taus]

Why would you intentionally do a contralateral injxn?

bc their c arm doesn’t oblique enough to left for clo. When I heard someone say that at SIS meeting several years ago re cesi with clo, I felt compelled to publish an article on that re flipping source and II on c arm (in pain medicine). Several other ways around it, moving the carm to head of bed, patient flipping head to toe, rotating table, etc.

If you want unilateral flow for ventral unilateral pathology, i.e. disc herniation… Please put the needle on that side.

 

[MitchLevi]

My C Arm doesn’t oblique all the way at one of our facilities. It’s fine. Airplane the bed and you can do it. Be careful. No biggie.

 

[PinchandBurn]

bc their c arm doesn’t oblique enough to left for clo. When I heard someone say that at SIS meeting several years ago re cesi with clo, I felt compelled to publish an article on that re flipping source and II on c arm (in pain medicine). Several other ways around it, moving the carm to head of bed, patient flipping head to toe, rotating table, etc.

If you want unilateral flow for ventral unilateral pathology, i.e. disc herniation… Please put the needle on that side.

So I have been told ideal CLO is 42 to 45 degrees.


Like previous poster. CLO to the right no problem. Left goes to just 30 or 35. So in those cases I sorta get to the lamina then do LORTA more slow and use contrast.

 

[RoloTomassi]

All good tips. Another is when you do a left side one and are CLO 40+ to the right, after snapping a pic after LOR, take it to only 30 and snap a pic to see where needle tip is and make a mental note.

 

[Centurion38]

CLO is garbage for accurate depth in lumbar spine. For cervical, works great.

I agree it can help guide you through the lamina on degenerated spines but there's other ways to do this.

 

[Taus]

CLO is garbage for accurate depth in lumbar spine. For cervical, works great.

please explain. I have found it to be the polar opposite in lumbar.

Granted… Still need to trust your hands with loss of resistance at the same time. I find most accurate point as the most ventral border of the lamina above the needle. Also, more often fair amount of ligamentum flavum hypertrophy in lumbar spine, which can scew things if present and have loss be more anterior

 

[MitchLevi]

CLO is garbage for accurate depth in lumbar spine. For cervical, works great.

I'm sorry, but this is simply not true.

 

[RoloTomassi]

For cervical, ipsi oblique is better than CLO. It's a great feeling when you think you've paralyzed the patient but then they're able to get right up off the table.

 

[MitchLevi]

For cervical, ipsi oblique is better than CLO. It's a great feeling when you think you've paralyzed the patient but then they're able to get right up off the table.

View attachment 389871

Man, enter the space more parallel too...Drive that medication superiorly. The perpendicular entry sucks.

Now that I've read a lot of these social media posts, if I ever need a pain procedure I'm going to ask the doctor what technique they use and can I see a few procedure pics. Seriously...That image scares TS outta me. I can't imagine why anyone would do that.

 

[Tboned]

Man, enter the space more parallel too...Drive that medication superiorly. The perpendicular entry sucks.

Now that I've read a lot of these social media posts, if I ever need a pain procedure I'm going to ask the doctor what technique they use and can I see a few procedure pics. Seriously...That image scares TS outta me. I can't imagine why anyone would do that.

Thought the same thing

 

[lobelsteve]

And no colimation. Both of those docs are $100k+ kol club.

 

[clubdeac]

And no colimation. Both of those docs are $100k+ kol club.

Are they really?!? That’s crazy. And why on earth would anyone get an ipsilateral oblique in this scenario? Am I missing something

 

[oreosandsake]

FWIW I’ve also seen doctors who should know better use CLO completely incorrectly and post bragging photos online of performing cervical ESI.


Ipsilateral oblique or CLO and then crossing midline with your needle eliminates the most useful information you can get from the view