Please post any tips/tricks for avoiding anterior lead placement

[Drd105]

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... persistent on multiple attempts
Thanks!

 

[Agast]

Go to lateral fluoroscopic view and withdraw slowly until you see where the problem started, then advance slowly while manipulating the lead until you make it past that area. Then switch back to AP fluoro.


If it’s anterior right out the gates, I take out the tuohy and re-enter at a more shallow angle.

 

[vadim1980]

... persistent on multiple attempts
Thanks!

Pray

 

[Drd105]

Go to lateral fluoroscopic view and withdraw slowly until you see where the problem started, then advance slowly while manipulating the lead until you make it past that area. Then switch back to AP fluoro.


If it’s anterior right out the gates, I take out the tuohy and re-enter at a more shallow angle.

It was anterior out of the gates every time every level…next time will get out the longer needle and try more shallow. Thank you

 

[Drd105]

Pray

100% did that lol

 

[Tramadeezy]

Shallow angle is key. I start 1 1/2 to 2 pedicles below entry point on just about every patient.

 

[Drd105]

Thanks- so are you usually using 6” for the average (decently hefty) patient?

 

[Agast]

It was anterior out of the gates every time every level…next time will get out the longer needle and try more shallow. Thank you

I also use the curved needle when possible, and I’ll turn the tip of the tuohy or add torque while I’m feeding the lead in, under lateral fluoro in an attempt to avoid restarting.

 

[Drd105]

I also use the curved needle when possible, and I’ll turn the tip of the tuohy or add torque while I’m feeding the lead in, under lateral fluoro in an attempt to avoid restarting.

Thanks so much, Agast

 

[Timeoutofmind]

I have done many many stims and have never seen it just dive anterior without also veering off laterally to one side or the other.

So I am assuming this is what was happening in your case?

some people advance the lead initially in the lateral view where you might not appreciate this whether or not it is veering off laterally from the midline. If that is the case, you could try advancing it in the AP view right off the bat and trying to keep it midline.

Another point: if it wants to go lateral to one particular side, try rotating the tip of the needle contralaterally. If still does…Sometimes peoples spines are complicated and I don’t think that the midline on flouro due to projectional issues often lines up to the millimeter with the actual anatomic midline

Pull the needle back a little bit and re-advance and enter the epidural space a mm or two lateral to where you had previously entered (directing it away from the side it was veering toward)

Don’t waste tons of time and increase the complication rate and radiation for the patient by struggling for 20 min at any given level. Troubleshoot as above a few times and just go to a different level.

 

[Drd105]

Yes you are correct- each time it veered lateral and then a few times it corrected to midline and I thought it was good but it was not. I always start advancing in AP right off the bat, never in lateral. I did try pulling back the needle and did change the direction of the hub, BUT did not attempt to enter the space more laterally so will try that next time. I did attempt on the opposite side and the level above as well. Thanks so much for the tips.

 

[RoloTomassi]

Agree with above. Since you did try multiple levels and other side, I would think that the angle isn't shallow enough. In average patient, with regular needles, hub gets pretty close to skin at the angle I go. If you seem to keep hitting something causing it to veer, the only tip I haven't seen mentioned above is you can try a saline flush.

 

[BobBarker]

As everyone stated, go as shallow as possible, try a curve tipped needle.



Or break out the DRG leads and post to LinkedIn.

 

[callmeanesthesia]

Had this recently with a trial - lead went diagonal across the epidural space, wouldn’t thread up without going anterior or along the nerve roots. Tried twice, saw it wasn’t going to work easily, re-placed the needle from about 2 cm further down on the skin, and a little more parallel to the spine for entry, threaded up no problem. I think the big thing is rather than spending 20 minutes trying to get it to thread at an angle it doesn’t want to, change your angle. Long needle or coude needle if you have to.

 

[drusso]

Shallow angle, Toughey as midline as possible. Use contralateral oblique view for LOR, back to AP for advancing.

 

[Taus]

Shallow angle, Toughey as midline as possible. Use contralateral oblique view for LOR, back to AP for advancing.

Agreed. Only thing to add is if using bent tip stylet make sure the tip is facing dorsal when it exits needle, where bevel is also facing dorsal.

 

[soccrwz]

I think injecting saline reduces the resistance help open the track better, shallow angle, other trick is get one in and use it as a bumper to run it up. Easier to switch between CLO and AP then ap then lateral; I still do laterals but and entry midline makes easier. Other trick is grab a 4x4 and manually curve the lead slightly, helps the steeribility from falling lateral

 

[TIVAndy]

if a lead swerves laterally and comes back, it almost always is anterior. other people gave good tips, insert shallow and try to stay mid course all the time. adjusting the angle of bevel sometimes helps

also to reduce radiation while having the benefit of live fluoro, i go to low dose pulsed and do live fluoro to drive the lead

 

[deleted875186]

I advance under AP, don’t let it ever go into the gutter. I have not had many leads go anterior, but perhaps have just not done enough. I always make sure epidural entry is close to midline, avoid crossing midline, shallow as noted above.


Can you post a pic of yojr initial epidural access. How bog was the patient?

 

[drrosenrosen]

I also have gone to using CLO for first entry into the space. A shallow angle of entry is the best way to get a good first crack at it. I try not to let it veer off to the side on AP or anterior on CLO; if it starts to do that, do something to adjust your angle (torque the needle, adjust the bevel, etc) before trying again

 

[Baron Samedi]

Have the fellow do it so they can troubleshoot it and you can stand in the back of the room and avoid all the radiation exposure.

 

[jwalker12]

Anyone have pictures of their CLO views when placing these? Would you mind sharing. thank you

 

[RoloTomassi]

Anyone have pictures of their CLO views when placing these? Would you mind sharing. thank you

I don't save those, but here's an L2-3 ILESI CLO. SCS lead looks pretty much just like the contrast line going cephalad, needle coming in at more shallow angle of course.

 

[Taus]

Anyone have pictures of their CLO views when placing these? Would you mind sharing. thank you

Take a look at this article and video.

Thoracolumbar Spinal Cord Stimulator Trial: Procedural Technique - PubMed

Spinal cord stimulator trials are indicated for the treatment of postlaminectomy syndrome with persistent severe back and limb pain which has failed conservative treatment options and where no further surgery is indicated. They are also indicated for refractory complex regional pain syndrome...

pubmed.ncbi.nlm.nih.gov

 

[jwalker12]

What level are most of you entering at? L1-2?

 

[DOctorJay]

I enter at T12-L1 or L1-2, also do the CLO entry

 

[DOctorJay]

Take a look at this article and video.

Thoracolumbar Spinal Cord Stimulator Trial: Procedural Technique - PubMed

Spinal cord stimulator trials are indicated for the treatment of postlaminectomy syndrome with persistent severe back and limb pain which has failed conservative treatment options and where no further surgery is indicated. They are also indicated for refractory complex regional pain syndrome...

pubmed.ncbi.nlm.nih.gov

I don't see the video

 

[jwalker12]

I don't see the video

Its at the bottom, here is the link: http://links.lww.com/CLINSPINE/A121