SCS trials in office (oral sedation/antibiotics)

[SgtThunderfistMD]

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Due to limited OR availability, will be doing SCS trials in office. Outside of localizing the tract with a 25g spinal needle (0.25% marcaine : 1% lidocaine mix) prior to the Tuohy needle, what PO meds do you guys use for sedation? Was thinking potentially 5-10mg valium, and a 5mg percocet.

For antibiotics, doing an IV won't be logistically smooth. Heard about potentially being able to do PO antibiotics before/during trial, instead of the IV ancef. Any recs there?

 

[RoloTomassi]

Due to limited OR availability, will be doing SCS trials in office. Outside of localizing the tract with a 25g spinal needle (0.25% marcaine : 1% lidocaine mix) prior to the Tuohy needle, what PO meds do you guys use for sedation? Was thinking potentially 5-10mg valium, and a 5mg percocet.

Should suffice. Most do fine with just local. I do 10 mL each side, lamina to skin.

For antibiotics, doing an IV won't be logistically smooth. Heard about potentially being able to do PO antibiotics before/during trial, instead of the IV ancef. Any recs there?

Do IM. Learned that here. I think @callmeanesthesia

 

[SgtThunderfistMD]

What's the IM dose of ancef?

 

[Ducttape]

same as IV. 1-2 gm im. based on body weight.

 

[MitchLevi]

IM Rocephin and PO Keflex/Clinda.

Val 10mg
Perc 5/7.5
Lido 1-2% + bupi 0.5% (I use epi in my local bc a few drops of bloody ooze into Tegaderm freaks pts out)

 

[RoloTomassi]

What's the IM dose of ancef?

Same as what you facility does IV. Ancef label says 1 gm IV or IM

 

[lobelsteve]

Should suffice. Most do fine with just local. I do 10 mL each side, lamina to skin.

Do IM. Learned that here. I think @callmeanesthesia

I do same but skin to lamina. 1% with epi for a few cc on each side then straight lido to lamina with 25g.
Rocephin 1g IM or Ancef 2g IV.

 

[callmeanesthesia]

IM Ancef 1-2g in the glute depending on weight. Dilute in sterile water per package instructions. Generally that’s the most painful part of the procedure. Same for kypho. Also can give clindamycin IM for PCN allergy.

The most important part is to use a spinal needle to anesthetize the lamina.

We give Xanax 2 tabs 0.5mg age <65, 0.25mg age 65+, and Norco 5/325, 1 pill prior to procedure, 1 for after if they’re sore.

 

[BobBarker]

Lido with epi. I have only been able to find .5% with epi so I do skin wheels and SQ with that and then numb to lamina by using a spinal needle with 2% mixed with some of the .5% with epi. I use a scalpel for skin nicks gotta have the epi in the mix. 10mg diazepam and 300-600mg gabapentin. I write a rx for the diazepam but just give them the gabapentin when they get to the office.

 

[MitchLevi]

Lido with epi. I have only been able to find .5% with epi so I do skin wheels and SQ with that and then numb to lamina by using a spinal needle with 2% mixed with some of the .5% with epi. I use a scalpel for skin nicks gotta have the epi in the mix. 10mg diazepam and 300-600mg gabapentin. I write a rx for the diazepam but just give them the gabapentin when they get to the office.

I mix my 1-2% lido 1:1 with 0.5% bupi with epinephrine too.

 

[Painologist]

I use 1% lido without epi to the lamina. I typically place an IV and give ancef but will occasionally give IM if they’re a difficult IV placement and don’t have my ultrasound ready. I rarely use any sedation but if needed will call in 5 mg Valium ahead of time. I also use oral antibiotics for duration of the trial.

 

[lobelsteve]

I use 1% lido without epi to the lamina. I typically place an IV and give ancef but will occasionally give IM if they’re a difficult IV placement and don’t have my ultrasound ready. I rarely use any sedation but if needed will call in 5 mg Valium ahead of time. I also use oral antibiotics for duration of the trial.

What do you do for hemostasis at skin?

 

[Painologist]

What do you do for hemostasis at skin?

Pressure lol. I don’t do a skin nick like someone mentioned above. Very little bleeding.

 

[lobelsteve]

Pressure lol. I don’t do a skin nick like someone mentioned above. Very little bleeding.

Do you hammer a 14g through the skin?

 

[Ronin1]

Do you hammer a 14g through the skin?

Make a hole with an 18 gauge needle. No need for a scalpel.

 

[Painologist]

Do you hammer a 14g through the skin?

I’ve never had any trouble with the 14g needle.

 

[masterPain]

Lido with epi. I have only been able to find .5% with epi so I do skin wheels and SQ with that and then numb to lamina by using a spinal needle with 2% mixed with some of the .5% with epi. I use a scalpel for skin nicks gotta have the epi in the mix. 10mg diazepam and 300-600mg gabapentin. I write a rx for the diazepam but just give them the gabapentin when they get to the office.

Why in the world do you make a skin nick for SCS trial?

 

[BobBarker]

I don’t like how the skin pulls back on the needle if you use a 18g to nick the skin.

 

[drrosenrosen]

Why in the world do you make a skin nick for SCS trial?

The same reason most of us do anything - because that's how I was shown to do it 15 years ago.

Seriously, though, I've tried without and I don't feel like I have as much maneuverability with the needle

 

[BobBarker]

exactly. I feel like the skin is trying to explant my needle. Can’t let go once you get access or the skin will pull the needle back 3mm.

 

[Agast]

I’ve never made a skin nick for the tuohy. Maybe adjust your angle of approach? If I can do it without force I feel like there can’t be /that/ much resistance

 

[Taus]

The same reason most of us do anything - because that's how I was shown to do it 15 years ago.

Seriously, though, I've tried without and I don't feel like I have as much maneuverability with the needle

After my local, I stick it with an 18 gauge needle. Dilates it plenty for the 14g introducer needle. Occasionally still some elbow grease needed, particularly if a lot of scar tissue from prior spine surgical incision.

 

[BobBarker]

My scs technique is perfect. I’m right and you guys are all wrong.




😂 j/k but probably not ever changing. The reps told me that I was an outlier also. Me and the guy who taught me SCS.

 

[MitchLevi]

😂 j/k but probably not ever changing. The reps told me that I was an outlier also. Me and the guy who taught me SCS.

I'm sure you're very high level, but those reps bro. They say something extremely complimentary to each of us during every interaction. That's taught to them.

I did an implant the other day and the rep said, "Well, that's got to be the record for the fastest implant."

Such BS.

 

[BobBarker]

Oh, I didn’t take it as a compliment. But yes, I could do the worst job on the easiest patient, “Great job doc! Some really tough anatomy but you got it done! I’m going to grab you a Sonic drink! The usual?”

 

[callmeanesthesia]

I'm sure you're very high level, but those reps bro. They say something extremely complimentary to each of us during every interaction. That's taught to them.

I did an implant the other day and the rep said, "Well, that's got to be the record for the fastest implant."

Such BS.

I figured it’s because they cover the university too so they’re used to having to sit through 3 hour cases. Anything less than that becomes a blessing.

 

[paindoc007]

I'm sure you're very high level, but those reps bro. They say something extremely complimentary to each of us during every interaction. That's taught to them.

I did an implant the other day and the rep said, "Well, that's got to be the record for the fastest implant."

Such BS.

Yup. Yet, I still wait for my compliment when I finish the trial. You become conditioned to expect it.

Similar to Taylor Swift cut-away during a football game. When they do it, it’s annoying. When they DONT , we’re like where is my Taylor shot??” 😂

 

[RoloTomassi]

 

[MitchLevi]

I figured it’s because they cover the university too so they’re used to having to sit through 3 hour cases. Anything less than that becomes a blessing.

You know what...You just changed my opinion.