placing a spinal suggestions?

[heathermed]

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I've gotten such amazing and useful technical advice before so I figure I'd try another.

I'm having some trouble with spinals.

Almost at a 90% clip, I'm hitting bone. I am usually able to place the introducer cleany, but then when I put the needle in, I hit bone and have to adjust multiple times.

If anyone has any tips to improve, strategies to troubleshoot, suggestions or tricks of the trade that you felt is helpful when placing spinals, I would be very appreciative.

thank you very much in advance.
I look forward to your responses.

 

[EdPierce]

straddle the spinous process (the most superficial midline structure) between the second and third fingers on your left (feeling) hand. do this at multiple levels and generally feel around the back to ensure you know where midline is. midline is right at the center of the spinous process, between your two fingers.

so with your fingers on either side of the spinous process (say, for example, at L4 at the level of the iliac crest, insert your introducer slightly above where the top of the spinous process ends. (ie just above the lower process, absolutely midline, above L4 but below L3). Your introducer is your whole injection, however you place it will determine your spinal needle trajectory, so place it perpedicular to skin or slightly angled cranial just above (~.5cm) the L4 spinous process. Advance until you feel POP, csf will slowly come back, keep cool - brace both the introduce and the dangling spinal needle with the same feeling hand, whole them tight. get your spinal syringe and aspirate csf, give the whole injection, aspirate again at the end, inject it back again and pull everything out.

if you hit bone: are you midline? reassess. angle more cranial (pull the needle back until the spinal needle tip is inside the introducer, then use both as a unit to redirect more angled up slightly) try fishing off to one side of another (very slightly). lastly try another level.

 

[BobBarker]

Just place it a1/4 cm more superior than you are.

 

[Idiopathic]

you just arent between the two spinous processes. at L2-3-4 the opening is fairly straight if you can position the patient appropriately, and rarely more than a slight cephalad angulation. difficult spinals are one thing, but if you are seeing this routinely, then really focus on getting the patient to achieve proper position and place your introducer perpendicular TO THE SKIN. i.e. if they are leaning a little bit forward, take that angle with them (this is especially helpful with the epidural Touhy in this area). if they have a pronounced forward lean, its typical for us to want to place the touhy/introducer parallel to the bed or the ground, but this shortens our angle relative to the dura, and can mean we hit the superior spinous process rather than entering the epidural/intrathecal space.

anyway, perpendicular to the skin between the two spinous processes in the midline gives you your best shot at introduce placement to allow your spinal needle to advance through the dura. all three axises are kined up in an ideal fashion. you could also try a larger needle without the classic introducer like a 22g quincke but you may induce more headache and wont necessarily have more success

 

[Planktonmd]

Hitting bone is not bad!
Hitting bone means you are almost there.
2 possibilities:
1- You are aiming higher or lower of where you need to be: withdraw the needle to skin and adjust your vertical angle. always think of the spinous processes and the angles they form in the lumbar spine.
2- you are off midline: very common in obese patients... try to figure where the midline is by palpating the cervical or thoracic spine then drawing an imaginary line verical to the panty line... this should help... unfortunately most obese patients have some degree of scoliosis just to piss you off!

 

[BobBarker]

You have to remember your Type 2 mechanics!😉

 

[countingdays]

It's probably not your technique. I bet it's the patient.

Do what you do now but make the patient get in a better position.

 

[Dejavu]

It's probably not your technique. I bet it's the patient.

Do what you do now but make the patient get in a better position.

This.

You know when you are struggling and the staff guy puts on a pair of gloves and gets it right away? It's because of two things. First, they position the pt better (have someone with hands on the pt helping get their knees north and their chin south) and number B, they have watched where you have been trying, and they now know what not to do, they go some other direction and get it.

I always tell residents that when you struggle, think of better positioning first.

Here's something to try. Get an assistant, have the pt on the OR table simply sit up like they are doing a sit up. You go up to the head of the bed, drape, and then lay down on your elbows, with your feet sticking back, and you get a really steady base with your elbows and the best back bend ever. If you try to do this while bending your own back, your back may get sore, so lay down on your elbows behind the pt.

When you are done, there is no having to swing the legs and lay down the pt. You simply have the pt lay down straight back where they came from.

Watch people who sit up patients and then swing their legs to the side. The curve of the back disappears as soon as the legs go off the side of the bed. Leave them looking straight forward, with their legs straight out, and look at the nice curve in the lumbar spine.

You just have to be willing to go to the head of the bed to do the job.

Hopefully I did a good enough job explaining that method, to those who care.