MBB tip

[NJPAIN]

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I tried lateral. Very hard to visualize c6 and c7. It was quite nice for the more superior levels.

True. But with modified swimmer’s view it’s often not too difficult.

 

[Taus]

I tried lateral. Very hard to visualize c6 and c7. It was quite nice for the more superior levels.

https://www.painphysicianjournal.com/current/pdf?article=NTIxMg%3D%3D&journal=111

 

[Laryngospasm]

If all of my patients anatomy looked like the one in the article I would have the best job in the world.

 

[SommeRiver]

I do lateral on big people, but I don't like doing it. I am not always comfortable lining up the articular pillars. I do a lot of geriatric pts and the images in that article doesn't represent my reality of trashed spines.

I've tried tons of different positions and not found a reliable one yet.

We use pillows and blocks to prop up the neck/head.

Posterior MBB being less accurate is probably true.

 

[Taus]

If all of my patients anatomy looked like the one in the article I would have the best job in the world.

I understand what you’re saying but I have also used lateral almost exclusively for mbb the last 4-5 years. Most are on ancient spines. Not much rfa on younger outside occasional s/p whiplash. Just take a few mins to oblique image intensifier to line up posterior aspect articular pillars with the proper gap between spinolaminar line. Then tilt to head or feet to line up joint spaces. There will be some trial and error to get it right on each case, ie the way the body/head appears rotated may not be how you need to adjust c arm (may be all AA rotation) Also don’t worry about getting the entire c spine lined up. Just focus on the levels you are treating. Then the needle takes no time and is dead on accurate for mbb.

 

[Laryngospasm]

I will probably start practicing this on my slow days to see if I can get better.. I know it will take quite a while to get good at it.

 

[DOctorJay]

I understand what you’re saying but I have also used lateral almost exclusively for mbb the last 4-5 years. Most are on ancient spines. Not much rfa on younger outside occasional s/p whiplash. Just take a few mins to oblique image intensifier to line up posterior aspect articular pillars with the proper gap between spinous process. Then tilt to head or feet to line up joint spaces. Don’t worry about getting the entire c spine lined up. Just focus on the levels you are treating. Then the needle takes no time and is dead on accurate for mbb.

Do you grab the c-arm yourself or instruct the rad tech to make the movements?

 

[Taus]

Do you grab the c-arm yourself or instruct the rad tech to make the movements?

Instruct tech to make specific small moves like 2-3 degrees at a time.

 

[NJPAIN]

Taus is clearly the expert on this one. I have had far less experience with this than he since he kindly showed me the technique.

But I would say that I work in places with much less than stellar techs so I ALWAYS do all of the tilt and oblique myself, often live. Even when positioning looks great to me ( I try to keep pillow on the head only and off of the shoulder, make certain arm is not over stretched and patient is looking straight ahead) and I expect to need minimal adjustment, sometimes the initial image is way off, I need lots of adjustment and the correct direction is not clear initially.

 

[hyperalgesia]

Where can one buy this or do you have to add bicarb yourself?

I offered to try this with a very needle-phobic pt during mbbs. Literally, this one is buffered, this one is not. Again, buffered, not buffered. He said there was no difference. N=1.

 

[callmeanesthesia]

I offered to try this with a very needle-phobic pt during mbbs. Literally, this one is buffered, this one is not. Again, buffered, not buffered. He said there was no difference. N=1.

It makes a much bigger difference if you’re using lido with epi. The epi requires a much more acidic storage medium. I don’t use lido for most injections, where I use a 25g3.5” needle. I add bicarb to my local for RFA for faster onset. Maybe it stings a little less but I don’t see a clinically meaningful difference with or without from patient reactions.

 

[pmrmd]

Why no love for ethyl chloride? It’s quick and easy.

 

[SommeRiver]

I offered to try this with a very needle-phobic pt during mbbs. Literally, this one is buffered, this one is not. Again, buffered, not buffered. He said there was no difference. N=1.

My n is several thousand. It makes a difference.

 

[Taus]

My n is several thousand. It makes a difference.

I agree with this. I use it on local cases with a 20 or 22g needle... typically esi for hot radics. I think it makes a difference. I also don’t pay for it...

 

[deleted875186]

I have tried 25g quincke with no local, and 22G quincke with local through 27G needle in many people, most say the local with 22G was less painful.

I think it might be different with a 25G cutting needle, maybe the 25G quincke is not sharp enough.

 

[clubdeac]

Why no love for ethyl chloride? It’s quick and easy.

technically is ethyl chloride truly sterile? I don't know, I just get a little freaked out spraying anything on my sterile field other than chlorhexidine immediately prior to needle insertion. This fear may all be in my head though

 

[painfree23]

technically is ethyl chloride truly sterile? I don't know, I just get a little freaked out spraying anything on my sterile field other than chlorhexidine immediately prior to needle insertion. This fear may all be in my head though

I definitely agree. Especially for spinal procedures

 

[MD87]

technically is ethyl chloride truly sterile? I don't know, I just get a little freaked out spraying anything on my sterile field other than chlorhexidine immediately prior to needle insertion. This fear may all be in my head though

I don’t use it for this very reason. Having said that, my colleague has done probably 15k procedures using it and has never had an infection.

 

[pmrmd]

technically is ethyl chloride truly sterile? I don't know, I just get a little freaked out spraying anything on my sterile field other than chlorhexidine immediately prior to needle insertion. This fear may all be in my head though

This was evaluated about a decade ago. No change in sterility to the field. One study showed even less cultures from the field after vapocoolant.

 

[SommeRiver]

Definitely cheaper right?

 

[pmrmd]

All I said is quick and easy.

 

[Laryngospasm]

From a study on pubmed

Conclusion: Ethyl chloride bottles used in the clinical settings showed no bacterial or fungal contamination through their shelf life and routine use. The duration and amount of use did not affect sterility. Although the antimicrobial activity of ethyl chloride spray on skin is debated, ethyl chloride itself remains sterile through clinical use.

 

[Ducttape]

the effect of the ethyl chloride should last for more than a few seconds. it may give you some comfort to use a little chloroprep after spraying, without any detriment on anesthesia...

my only issue - someone else has to spray or you have to glove/reglove after using.