Preferred LOR technique

[Pain Applicant1]

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Anyone willing to revisit this?

1. Glass vs Plastic
2. Air vs Saline
3. Continuous vs Intermittent pressure

I've used both plastic and glass with both air and saline. My preference is plastic as I don't really like the gritty feeling that glass syringes give. I also prefer air as it has a much crisper feel and if you see fluid you can be more certain that it's CSF.

Are your techniques the same in the cervical and lumbar spine? Any thoughts?

 

[SSdoc33]

cheap 3 mL plastic syringes with saline only.

air is compressible, and there is a theoretical risk of pneumocephalus with air. try it with just saline and the plastic. i think you'll be surprised at the ease and the feel

 

[PMR 4 MSK]

Pulsator plastic syringe, with air, continuous light pressure. 6" extension tubing b/w needle and syringe.

How many ways can we skin this cat...?

 

[painstop]

Plastic syringe with air and intermittent pressure. I've done all the various modalities mentioned and this works well for me.

 

[painMD24]

I currently use a glass syringe with 2mL of NS and a 1mL of air. I haven't ever tried a plastic syringe.

 

[mdvol]

you might as well bring up which size syringe 3cc, 5cc, 10cc?

 

[pjuer]

Glass with saline, intermittent

 

[painMD24]

you might as well bring up which size syringe 3cc, 5cc, 10cc?

5mL glass syringe

 

[Aether2000]

Epilor or pulsator with 3 cc saline + 1cc saline above the saline but also use extensive oblique fluoro during cervical ilesi

 

[onewithpain]

I like a 10 cc pulsator with air and about 1/2 cc saline. I can often see the saline start to disappear before feeling the LOR.

 

[powermd]

Pulsator with constant pressure, saline and an air bubble. I agree with whoever said they feel they can detect the saline movement a little sooner this way. You see it even before you feel it.

I like using the cheap plastic BD 5 cc syringes as well, same technique. I like the crisp LOR these provide.

For those of you doing intermittent pressure, does this mean you are advancing through the LF blindly with no pressure on the syringe during advancement? Doesn't that sound like a recipe for a wet tap?

 

[lobelsteve]

10cc plastic. 4cc nss and air. AP to lamina, walk off paramedian, 1cc lidocaine. Football view. 1mm advancement with left hand on skin, pulling needle in. Right hand steadies syringe but does not advance needle at all. Intermittent loss check every mm.

 

[drf]

Pulsator plastic syringe, with air, continuous light pressure. 6" extension tubing b/w needle and syringe.

How many ways can we skin this cat...?

Syringe-6' tubing-needle sounds interesting. Is it a big bore tube? Do you inject thru it as well? What is the reasoning? For live fluoro injections I use a microbore tubing. I doubt it would have an accurate LOR?

 

[wscott]

Is there an advantage with using a Pulsator syringe?

 

[SSdoc33]

For those of you doing intermittent pressure, does this mean you are advancing through the LF blindly with no pressure on the syringe during advancement? Doesn't that sound like a recipe for a wet tap?

contant pressure sounds like a recipe for a wet tap to me. intermittent allows you to advance REALLY slowly, but with constant, you are just pushing, pushing pushing, and then WHOOPS, sorry sir, you may not be ever able to control your bladder again. my bad. you still feel a clean LOR.

 

[Pain Applicant1]

For those of you doing intermittent pressure, does this mean you are advancing through the LF blindly with no pressure on the syringe during advancement? Doesn't that sound like a recipe for a wet tap?

contant pressure sounds like a recipe for a wet tap to me. intermittent allows you to advance REALLY slowly, but with constant, you are just pushing, pushing pushing, and then WHOOPS, sorry sir, you may not be ever able to control your bladder again. my bad. you still feel a clean LOR.

This is interesting. I would think you would be more likely to get a wet tap using intermittent pressure. You can push slow with constant pressure also.

 

[PMR 4 MSK]

Is there an advantage with using a Pulsator syringe?

It slides easier than a regular syringe - far less pressure to use it.

 

[SSdoc33]

This is interesting. I would think you would be more likely to get a wet tap using intermittent pressure. You can push slow with constant pressure also.

think about pushing against something like a thin piece of leather with a needle. if there is constant pressure, the leather (in this case ligamentum flavum) will tent, then pop thru. when it pops thru, the ligamentum flavum will recoil, and you would be deeper than you would be if it didnt tent at all. this is how i think about it at least. with intermitent pressure, you can poke thru this leather (ligamentum flavum) without the tenting effect, b/c it is more of a quick stabbing motion that a slow constant pressure

 

[lobelsteve]

think about pushing against something like a thin piece of leather with a needle. if there is constant pressure, the leather (in this case ligamentum flavum) will tent, then pop thru. when it pops thru, the ligamentum flavum will recoil, and you would be deeper than you would be if it didnt tent at all. this is how i think about it at least. with intermitent pressure, you can poke thru this leather (ligamentum flavum) without the tenting effect, b/c it is more of a quick stabbing motion that a slow constant pressure

Sounds good in theory, but does it hold true in vivo?
And no, I'm not trying this one out on myself.

 

[PMR 4 MSK]

Sounds good in theory, but does it hold true in vivo?
And no, I'm not trying this one out on myself.

I'll try it on you. Who has an epiduroscope I can use?

 

[powermd]

contant pressure sounds like a recipe for a wet tap to me. intermittent allows you to advance REALLY slowly, but with constant, you are just pushing, pushing pushing, and then WHOOPS, sorry sir, you may not be ever able to control your bladder again. my bad. you still feel a clean LOR.

The debate here seems to surround the benefits of constant versus intermittent feedback as to the moment of LOR during advancement. Please convince me how exactly intermittent feedback with none during needle advancement is safer than slowly advancing with constant feedback provided by a head of pressure on the syringe.

I don't buy the "tenting the dura" hypothesis. 1. With constant pressure you probably get LOR the instant the needle peeks through the LF, and thanks to epidural fat, there should be a small buffer zone before you "tent" the dura. 2. Even if you do come near the dura, you still have a column of ejecting fluid buffering you from it. With intermittent pressure, you could push well past the LF before your next tap on the syringe, particularly if the space is tight.

 

[SSdoc33]

The debate here seems to surround the benefits of constant versus intermittent feedback as to the moment of LOR during advancement. Please convince me how exactly intermittent feedback with none during needle advancement is safer than slowly advancing with constant feedback provided by a head of pressure on the syringe.

I don't buy the "tenting the dura" hypothesis. 1. With constant pressure you probably get LOR the instant the needle peeks through the LF, and thanks to epidural fat, there should be a small buffer zone before you "tent" the dura. 2. Even if you do come near the dura, you still have a column of ejecting fluid buffering you from it. With intermittent pressure, you could push well past the LF before your next tap on the syringe, particularly if the space is tight.

you are not tenting the dura, you'd be tenting the ligamentum flavum. using intermittent pressure allows you to move much slower once you enter the ligament. it seems to me that there is just a lot more force behind the needle with constant pressure, so you could pop thru thr ligament and dura before you realize how far you've gone.

im quite certain that there is not a "right" answer here.

 

[lobelsteve]

you are not tenting the dura, you'd be tenting the ligamentum flavum. using intermittent pressure allows you to move much slower once you enter the ligament. it seems to me that there is just a lot more force behind the needle with constant pressure, so you could pop thru thr ligament and dura before you realize how far you've gone.

im quite certain that there is not a "right" answer here.

As long as it is in the epidural space, it is the correct approach.
Whatever you trained on and are most comfortable with is going to be your best technique. Really, just try and change and see how the results go. Either wet taps or injecting behind the flavum, or taking 10 minutes longer to verify.

I like intermittent pressure with 1mm incremental advancement. I do not understand how you can perform continuous advancement and LOR and not increase risk for needle sliding in too far if there is sudden LOR. But that's why I do it the other way. I once switched from 18G Tuohy to 20G Tuohy and did not like the loss of feel of resistance. No bad outcomes, but bothered me enough to switch back after a few weeks.

 

[PMR 4 MSK]

I hold pressure on the syringe and advance slowly. The instant you are epidural, you get LOR. You stop advancing at the same time. It's not like you keep going at 92 mph until the needle comes out the anterior side of the vertebral column.

If you advance without pressure on the needle, I feel that is you highest risk of wet tap. Whether you do intermittent moving of the needle complimented with intermittent pressure at the same time, or constant pressure and advancement, you should get the same results. To each his own.

Keep skinning the cat.

 

[Mister Mxyzptlk]

Disposable paper syringes filled with saline, but you have to work fast.

 

[Aether2000]

Are these the inexpensive LOR syringes ("Lousy Obama Radical" TM) that I have been hearing about? Of course to Obama, loss of resistance meant the AMA caving in to support him... 🙂

 

[powermd]

you are not tenting the dura, you'd be tenting the ligamentum flavum. using intermittent pressure allows you to move much slower once you enter the ligament. it seems to me that there is just a lot more force behind the needle with constant pressure, so you could pop thru thr ligament and dura before you realize how far you've gone.

im quite certain that there is not a "right" answer here.

I see where you are misunderstanding me. "Constant pressure" means pressure during each incremental advancement. That doesn't necessarily mean constant movement, or rapid needle passage. I actually go very slowly once the needle is engaged in LF.

I'm right handed, and I advance the needle with my left fingertips which sit flush against the skin, so there is minimal chance of moving deeper than intended. My right hand is on the syringe and plunger, ensuring a head of pressure exists during advancement. Often I see LOR in the fluid movement before I feel it.

 

[powermd]

On a slightly different topic, the situation that causes me the most anxiety is the following:

Cervical epidural, approaching LF, clearly deep enough to expect engagement (needle protruding beyond lamina in reverse oblique), false losses (superficial dye flow), deep engagement, much deeper than expected LOR- epidural dye flow.

Usually happens in big guys. Had one today. Me no likey.

Comments?

 

[lobelsteve]

I see where you are misunderstanding me. "Constant pressure" means pressure during each incremental advancement. That doesn't necessarily mean constant movement, or rapid needle passage. I actually go very slowly once the needle is engaged in LF.

I'm right handed, and I advance the needle with my left fingertips which sit flush against the skin, so there is minimal chance of moving deeper than intended. My right hand is on the syringe and plunger, ensuring a head of pressure exists during advancement. Often I see LOR in the fluid movement before I feel it.

Ditto. But with pulsing pressure and not constant. Can't see a safer way- if the left hand slips the needle doesn't. If sudden loss advancement limited to 1mm.

 

[SSdoc33]

On a slightly different topic, the situation that causes me the most anxiety is the following:

Cervical epidural, approaching LF, clearly deep enough to expect engagement (needle protruding beyond lamina in reverse oblique), false losses (superficial dye flow), deep engagement, much deeper than expected LOR- epidural dye flow.

Usually happens in big guys. Had one today. Me no likey.

Comments?

no doubt about it. cervical ILESI is the most butt-puckering procedure I do (i dont do Cerv TFESI). i hate advancing past where i think i shoudl be -- despite what the flow pattern looks like

your technique is actually very similar to the "intermittent pressure" that i described. i just advance with 2 hands - check - advance with 2 hands - check. i typically feel the needle pop thru, so i know when i check for LOR, im rarely surprised.

 

[Ligament]

You guys got it all wrong. Just advance until the patient has 4 limb parasthesias. Withdraw 1mm. Inject. done.

 

[epidural man]

Anyone willing to revisit this?

1. Glass vs Plastic
2. Air vs Saline
3. Continuous vs Intermittent pressure

I've used both plastic and glass with both air and saline. My preference is plastic as I don't really like the gritty feeling that glass syringes give. I also prefer air as it has a much crisper feel and if you see fluid you can be more certain that it's CSF.

Are your techniques the same in the cervical and lumbar spine? Any thoughts?

I use both.

Plastic and continuous in the prone position.

Glass and intermittent in the sitting, lateral, or blind techniques. I did a thoracic epidural today with intermittent and glass syringe.

The OB anesthesia trained guys over at the very busy women's hospital in my town all place their epidurals with continuous. They swear it is faster - and holy crap they are very fast - and their wet tap rate is very low to almost non-existant. They say the push of fluid once the LF is pierced pushes the dura away.

To help train me, they showed me this - you take a dart board, or something of similar consistency (to mimick the LF) and tape a tegaderm on the back side, then push your needle through the dart board and you get the loss when it comes out the other side - and you try not to puncture the tegaderm.

I touch down on lamina in the cervical region. There is no need to do this in lumbar as it is a slower technique. The dura is almost always thick in the lumbar region and easily sensed and engaged. Also, touching lamina is theoretically more uncomfortable.

 

[specepic]

Had my first wet tap in many months this week. It appeared to occur b/c the Tuohy clogged. I felt LF, checked location on lateral, yep, right spot, pull stylet, hook up, slowly advance (I use incremental method). Going , going, going....WTF. (Old guy with know v. thick LF anyway). No loss. Needle tip now looking a bit deep. Negative asp. and very firm resistance at glass syringe. Check to see if syringe action stuck, nope. For some reason it occurs to me to restylet and recheck asp. +CSF. Have never clogged a tuohy before, anyone else? (I use 20G unless obese then its a 18G 5".)

No headache. I completed procedure at one level above.

As an aside I likely get a higher wet tap rate with a 20G as it easier to slip past a thin LF (maybe 3-5 in the last 12 months, all lumbar) but have had no headaches and no appreciable outcome issues with those injections. Pt comfort with the 20G is excellent.

 

[lobelsteve]

Had my first wet tap in many months this week. It appeared to occur b/c the Tuohy clogged. I felt LF, checked location on lateral, yep, right spot, pull stylet, hook up, slowly advance (I use incremental method). Going , going, going....WTF. (Old guy with know v. thick LF anyway). No loss. Needle tip now looking a bit deep. Negative asp. and very firm resistance at glass syringe. Check to see if syringe action stuck, nope. For some reason it occurs to me to restylet and recheck asp. +CSF. Have never clogged a tuohy before, anyone else? (I use 20G unless obese then its a 18G 5".)

No headache. I completed procedure at one level above.

As an aside I likely get a higher wet tap rate with a 20G as it easier to slip past a thin LF (maybe 3-5 in the last 12 months, all lumbar) but have had no headaches and no appreciable outcome issues with those injections. Pt comfort with the 20G is excellent.

I think an 18G is less likely to clog/clot and less likely to cause a wet tap. But I bet it will be much more likely to cause PDPH should a wet tap occur.

 

[epidural man]

Had my first wet tap in many months this week. It appeared to occur b/c the Tuohy clogged. I felt LF, checked location on lateral, yep, right spot, pull stylet, hook up, slowly advance (I use incremental method). Going , going, going....WTF. (Old guy with know v. thick LF anyway). No loss. Needle tip now looking a bit deep. Negative asp. and very firm resistance at glass syringe. Check to see if syringe action stuck, nope. For some reason it occurs to me to restylet and recheck asp. +CSF. Have never clogged a tuohy before, anyone else? (I use 20G unless obese then its a 18G 5".)

No headache. I completed procedure at one level above.

As an aside I likely get a higher wet tap rate with a 20G as it easier to slip past a thin LF (maybe 3-5 in the last 12 months, all lumbar) but have had no headaches and no appreciable outcome issues with those injections. Pt comfort with the 20G is excellent.

It's never happened to me (yet), but I worried about it a lot and will frequently put the stylet in if things don't feel right - just like you did. Your story makes me feel better that I'm not just waisting time when I re-stylet the tuohy.

 

[Aether2000]

You are not wasting time restyletting. I had a dural puncture during a thoracic epidural injection once due to a plugged needle that occurred after entering the ligamentum flavum. Fortunately no cord damage but geesh!! It can happen.

 

[SSdoc33]

little trick: pierce the skin with the 18g used to draw up the meds, then withdraw it. this creates a little entry spot for your touhy, and it wont get clogged. now wet taps in 3+ years and counting

 

[SSdoc33]

Had my first wet tap in many months this week. It appeared to occur b/c the Tuohy clogged. I felt LF, checked location on lateral, yep, right spot, pull stylet, hook up, slowly advance (I use incremental method). Going , going, going....WTF. (Old guy with know v. thick LF anyway). No loss. Needle tip now looking a bit deep. Negative asp. and very firm resistance at glass syringe. Check to see if syringe action stuck, nope. For some reason it occurs to me to restylet and recheck asp. +CSF. Have never clogged a tuohy before, anyone else? (I use 20G unless obese then its a 18G 5".)

No headache. I completed procedure at one level above.

As an aside I likely get a higher wet tap rate with a 20G as it easier to slip past a thin LF (maybe 3-5 in the last 12 months, all lumbar) but have had no headaches and no appreciable outcome issues with those injections. Pt comfort with the 20G is excellent.

great reason to do a transforaminal. especially in the old codgers.....

 

[bedrock]

little trick: pierce the skin with the 18g used to draw up the meds, then withdraw it. this creates a little entry spot for your touhy, and it wont get clogged. now wet taps in 3+ years and counting

Good idea. I do that already to ease the initial pressure when starting SCS & RF needles, but I might to start using that for ILESI to prevent clogs.

 

[specepic]

little trick: pierce the skin with the 18g used to draw up the meds, then withdraw it. this creates a little entry spot for your touhy, and it wont get clogged. now wet taps in 3+ years and counting

That would not affect me b/c I do not remove the stylet until I hit LF but I appreciate the info. Maybe if I did them under U/S that would help...just kidding

 

[voltron]

we are spoiled and have glass syringes at one location, and I love them, but i'm ok with plastic. I usually just engage deeper layers in AP, then go lateral and advance to posterior elements, pull stylet and continuously advance with constant pressure. I'll use the 4x4 on the kit to grip the needle if my gloves are wet. Its pretty fast. Some places have 20's, some have 18's, some have 17's, thats the thing about pp..you have to be flexible!

 

[Jcm800]

contant pressure sounds like a recipe for a wet tap to me. intermittent allows you to advance REALLY slowly, but with constant, you are just pushing, pushing pushing, and then WHOOPS, sorry sir, you may not be ever able to control your bladder again. my bad. you still feel a clean LOR.

i use mainly constant pressure, but its mainly with imaging, then a little LOR. I love constant pressure. No wet taps in since i can remember (i may be asking for one) it depends on the situation... but since i am clearly the best there ever was, my way must be "right"

i will say it took me a while to get use to 20 and 22 gauge touhy needle, as the loss is not so profound compared to a larger, but eventually, your tactile sense catch up. if i use an 18 i feel like its a harpoon...

of note, i have found the "LOR" with just needle doing the intermittent thing often... especially with SCS, half the time, i just advance, and that needle is so big you can feel everything, i put the lead in the needle, and if i meet resistance, i just advance the needle a little more, if i think i should be there based on the lateral...no wet taps either with that.
i am ****ed tomorrow haha

 

[ampaphb]

Once I confirm I am midline in the AP, I advance in the lateral plane. IF my needle tip doesn't engage the ligament by the time I approach the posterior most aspect of the facets, I go back to the AP. If I have fallen off midline, then greater depth to engage the ligament is expected. If I really am midline, I go back to lateral, and start to inject contrast

I don't mind if the contrast spreads posteriorly in the lateral view, as it doesn't obscure my target. I have had 3 patients with incompetent ligaments where there was no appreciable loss. Had I waited to inject saline, the first structure that would have provided resistance would have been the dura.