Selective Nerve Root Block and blood thinners

[Dr. Ice]

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So do it in 60 sec with a 25

Lol

 

[bedrock]

I have respect for the 25G technique but still prefer CESI with catheter. Best clinical results of my career, which allows me to do less CESI, which is what I prefer.

 

[PinchandBurn]

Yep.



I do, and yes, the 25g via interlaminar approach is barely felt, but I use local bc I tell the pt I’m numbing them up when I advance the needle.

You know what's interesting.

When I use touhy needles patients never have felt a thing or rarely when I get into the epidural space.

With cutting needles like quinke, its painless until i pas through Lig Flavun. I shoot the dye and they do feel it..

 

[MitchLevi]

You know what's interesting.

When I use touhy needles patients never have felt a thing or rarely when I get into the epidural space.

With cutting needles like quinke, its painless until i pas through Lig Flavun. I shoot the dye and they do feel it..

Enter more parallel to the skin. Skinnier needle means higher velocity of medication coming out of the needle.

It’s the opposite for me, and the needle thing????

 

[au bon pain]

This morning I had an obese pt for a LESI…staff couldn’t find a six inch tuohy. I started to get excited to try the Steve approach with a spinal needle. But then staff found a six. Oh wells.
Is anybody aware of any published description of the Steve method?

 

[MD87]

This morning I had an obese pt for a LESI…staff couldn’t find a six inch tuohy. I started to get excited to try the Steve approach with a spinal needle. But then staff found a six. Oh wells.
Is anybody aware of any published description of the Steve method?

Contrast Spread Technique

Dear Editor:

academic.oup.com

Contrast Spread Technique: Evolution - PMC

pmc.ncbi.nlm.nih.gov

https://www.jotsrr.org/articles/algorithm-for-performing-cervical-epidural-steroid-injections-with-contrast-spread-technique.pdf

Yakov Perper is the only one to have published on this so far, i *think*

 

[au bon pain]

Contrast Spread Technique

Dear Editor:

academic.oup.com

Contrast Spread Technique: Evolution - PMC

pmc.ncbi.nlm.nih.gov

https://www.jotsrr.org/articles/algorithm-for-performing-cervical-epidural-steroid-injections-with-contrast-spread-technique.pdf

Yakov Perper is the only one to have published on this so far, i *think*

Thank you, will check these out.

 

[BobBarker]

So I do a mix up of all of the techniques fairly frequently. 20g Tuohy, touch down on lamina, rotate to CLO, tiny bit of contrast to confirm where I am, advance needle in CLO, looking for hanging drop, CLO, LOR, radiographic suspicion, all simultaneously. Typically, I will notice hanging drop about a half a mm before I get lor.

 

[callmeanesthesia]

So I do a mix up of all of the techniques fairly frequently. 20g Tuohy, touch down on lamina, rotate to CLO, tiny bit of contrast to confirm where I am, advance needle in CLO, looking for hanging drop, CLO, LOR, radiographic suspicion, all simultaneously. Typically, I will notice hanging drop about a half a mm before I get lor.

Same for me but 22g Tuohy. Not exactly hanging drop but the little bubble in the hub that drops in when you pop through ligament.

 

[au bon pain]

Figured I'd chime in with the highest level of evidence: a single anecdotal data point.

Readers digest version: A few weeks ago I did an ILESI on a patient who denied being on a thinner.
Well, it turns out he was actually on eliquis (though how consistently he takes it remains unclear).
On follow up he says he's doing great and using his Peleton apparently without a clinically significant epidural hematoma.

FWIW, I happened to have done this one with Lobel's 25g spinal technique.

 

[vadim1980]

So I know many of you are using a 25g, but are some of you using a 22g for these TFESI's while maintaining AC?

In addition, has almost everyone stopped holding blood thinners for cervical/thoracic mbbs/rfa as well, despite needle size? I used 18g.

Thanks in advance. You guys always help push me forward

I use 23g, smaller than 22g but more maneuverable than 25g

 

[bedrock]

Agree with others that 23G quincke is the king of pain needles. I use it for everything I can.

thoracic and lumber TFESI, caudals, lumbar MBB, SIJ, coccyx, hip etc.

 

[mygalperin]

Curious if anyone has a reference for anticoagulation guidelines for SNRB. My partner and I are having a discussion about if these are seen the same as TFESI from a legal perspective when it comes to blood thinners and risk. ASRA does not list SNRB as an injection type on their guidelines app.

Also, if I'm not mistaken, SIS guidelines say it's ok for TFESI on blood thinner, yeah?

Do not do it, it is probably safe, but if anything goes wrong they will eat you alive!

 

[MitchLevi]

Do not do it, it is probably safe, but if anything goes wrong they will eat you alive!

You’re more likely to cause a CVA or an MI than a significant bleeding event. Saying it a different way, you are more likely going to kill your pt if you stop their AC, especially if it is Coumadin.

 

[Dr. Ice]

Haven’t stopped them in years for most things. Unfortunately I have a feeling at my new gig (hopd) I will be stopping them for everything

 

[Status Sciaticus]

Haven’t stopped them in years for most things. Unfortunately I have a feeling at my new gig (hopd) I will be stopping them for everything

is it because of a beaurocracy thing?
What state?

 

[Dr. Ice]

is it because of a beaurocracy thing?
What state?

More like deep pockets rule. I don’t know for sure yet, but I get the feeling that for something where there is no official printed guideline on AC for spinal procedures they are likely to be very cautions and therefore require stopping for all neuroaxial procedures.

 

[Taus]

More like deep pockets rule. I don’t know for sure yet, but I get the feeling that for something where there is no official printed guideline on AC for spinal procedures they are likely to be very cautions and therefore require stopping for all neuroaxial procedures.

Yep. Deeper pockets, bigger target on the back. Very familiar.

 

[BobBarker]

Probably will just be physicians discretion.