SCS Trial

[NeuroGuyIP]

I am a pain fellow and have had some difficulty with SCS trials. I find the most difficult aspect to be getting the Tuohy needle in the epidural space. I have been accessing at T12-L1, but enter skin one level below after using a 25 gauge 3.5 inch spinal needle to anesthetize a tract to the superior aspect of the L1 lamina. I enter at the medial aspect of the pedicle one level below and end up having a struggle getting epidural as I seem to be running into bone despite not appearing that way on the fluoroscopy screen and have to increase the angle of the Tuohy from the 30 degrees that I initially started. Any tips/advice would be greatly appreciated! Thanks everyone. I really appreciate how much of a good resource this message board is especially for neophytes like myself!


Sent from my iPhone using SDN mobile

---

Members don't see this ad.

 

[deleted472101]

I start at L2 middle pedicle to enter t12/L1 interspace.

Hit bone AP of L1 and then go lateral. I adjust the angle and then attach LOR syringe to Access epidural.

Tips:
-make sure your end plates are squared.
-put pillows under the abdomen!!!! This is key!!!
-You can always try a 6" and enter lower depending on depth and angle need.

 

[Taus]

I am a pain fellow and have had some difficulty with SCS trials. I find the most difficult aspect to be getting the Tuohy needle in the epidural space. I have been accessing at T12-L1, but enter skin one level below after using a 25 gauge 3.5 inch spinal needle to anesthetize a tract to the superior aspect of the L1 lamina. I enter at the medial aspect of the pedicle one level below and end up having a struggle getting epidural as I seem to be running into bone despite not appearing that way on the fluoroscopy screen and have to increase the angle of the Tuohy from the 30 degrees that I initially started. Any tips/advice would be greatly appreciated! Thanks everyone. I really appreciate how much of a good resource this message board is especially for neophytes like myself!


Sent from my iPhone using SDN mobile

Start 2 levels below, not 1. Makes a huge difference in terms of easy epidural access and smooth lead exit out of needle.

Use contralateral oblique to verify perfect trajectory through interlam window before starting loss. You'll sometimes see that despite AP looking good you're aiming right at one of the lamina.


Sent from my iPhone using SDN mobile app

 

[nvrsumr]

Enter below conus

 

[NeuroGuyIP]

Enter below conus

Fantastic responses. I love the comment about the contralateral oblique view. The Jatinder Gill article re contralateral oblique for cervical epidurals is outstanding and all of my faculty have us fellows use this view for cervical epidurals. Makes perfect sense to incorporate this for SCS trials in lumbar region as well. I also appreciate the comment re entering below the conus. Regarding the comment to start two levels below, do I need to use a longer Tuohy or is standard 9 cm one adequate?

 

[unchockey21]

I agree with Taus that your problem is likely starting too high. Our rule of thumb is starting at the medial aspect of the pedicle one level below if you can see the patient's spinous processes, the middle of the pedicle 2 levels below if you can palpate the SPs, and the lateral aspect of the pedicle 3 levels below if you've got Bubba on the table. Needless to say, not a lot of our patients fall into group 1.

 

[DOctorJay]

Below conus
Epimed Coude needle starting from left of midline
CLO after you get your trajectory correct in AP


Sent from my iPhone using SDN mobile

 

[cbest]

Below conus
Epimed Coude needle starting from left of midline
CLO after you get your trajectory correct in AP


Sent from my iPhone using SDN mobile

When you say below conus, does this mean you're entering at the L2-3 interspace? In fellowship, we almost always entered at T12-L1 and/or L1-2.

It makes complete sense to be careful around cord/conus with the big needle required for SCS trials but just wondering if you find having to drive the leads the extra one or two levels slows you down at all. Thanks in advance for the insight!


Sent from my iPhone using SDN mobile

 

[DOctorJay]

We're telling the OP to do that because he's having trouble and we want him to be safe as epidural access is the stated difficulty.

I enter T12-L1 or L1-2 with a coude and always use CLO so I know exactly where I am.


Sent from my iPhone using SDN mobile

 

[Taus]

Fantastic responses. I love the comment about the contralateral oblique view. The Jatinder Gill article re contralateral oblique for cervical epidurals is outstanding and all of my faculty have us fellows use this view for cervical epidurals. Makes perfect sense to incorporate this for SCS trials in lumbar region as well. I also appreciate the comment re entering below the conus. Regarding the comment to start two levels below, do I need to use a longer Tuohy or is standard 9 cm one adequate?

Re length: Use a 3.5" 22 or 25g Quincke to anesthetize entire tract.... if you reach targeted lamina without hubbing it, then standard 4.5" introducer needle should be fine. If not... use the 6".


Sent from my iPhone using SDN mobile app