Spinal anesthesia for Total Knee arthroplasty

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Doughy315

Doughy315

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I am practicing in the Midwest. I seem to struggle with trying place a spinal in the large obese patients ( 130 kg ) anyone have any tips or advance. I seem to always hit bone. I tried to feel for spinous process but it difficult on these large patients.
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B-D 22 gauge Quincke needle-you eliminate the warping through soft tissue/adipose with a wimpy 25/27 g needle. I have yet to see a PDPH from this needle-probably done around 500 spinals for THR/TKR with this needle as well.
 
PainDrain said:
Use a touhy needle as an introducer and do your spinal through the touhy.
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This type of cse spinal is far more commonly associated with neurologic damage. Still rare but about 20 times the risk of a regular spinal.

USS is not bad advice but there is a learning curve. You have to start with slim people.
Paramedian with a 22g would be my favourite. Only go 1cm off what you think* is midline.

Posture and positioning is obviously important esp for midline attempts but how best to do this is hard to explain
 
Agreed - a 22g spinal needle is a good way to go.

On a related note, my colleagues argue that they've never seen PDPH with this needle when used on this patient population (fluffy patients).
 
Newtwo said:
This type of cse spinal is far more commonly associated with neurologic damage. Still rare but about 20 times the risk of a regular spinal.

USS is not bad advice but there is a learning curve. You have to start with slim people.
Paramedian with a 22g would be my favourite. Only go 1cm off what you think* is midline.

Posture and positioning is obviously important esp for midline attempts but how best to do this is hard to explain
Click to expand...

Note, I am not talking about doing a CSE where a catheter is placed following the spinal, just using the touhy as a guide. Catheter placement after spinal will obviously increase the risk of neurological damage because of possibility of cath migration.
 
Doughy315 said:
I am practicing in the Midwest. I seem to struggle with trying place a spinal in the large obese patients ( 130 kg ) anyone have any tips or advance. I seem to always hit bone. I tried to feel for spinous process but it difficult on these large patients.
Click to expand...

if you struggle with the 25 g in the kit, just grab a 22 g and go for it. Much easier to maneuver and redirect. I try not to start with a 22 g because it does increase your risk of PDPH, but in older patients and fatter patients the risk is less anyway. I'd ballpark it around 1/500-1/1000 in an obese older population for joint surgery. We see PDPH once in a blue moon in these and we do plenty of spinals for these patients every day of the week.
 
Doughy315 said:
I am practicing in the Midwest. I seem to struggle with trying place a spinal in the large obese patients ( 130 kg ) anyone have any tips or advance. I seem to always hit bone. I tried to feel for spinous process but it difficult on these large patients.
Click to expand...
Why is doing a spinal so important to you?
I mean if the patient is "fluffy", and obviously a spinal is going to be challenging, why on earth do you want to torture yourself and your patient?
Do lateral popliteal sciatic + femoral blocks and do what you do best: GA! (I am assuming you know how to do GA). This could be ETT or LMA based on patient and its mainly to cover any tourniquet pain.
Do what makes your life easy and makes you look like a rock star.
 
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Nap3 for the risks of cse. The reason behind the risk was hypothesized in a Canadian article. It was only a hypothesis however.

In the UK in 07 to 09 Cse's accounted for only 6% of neuraxial technique but accounted for 40% of the closed claims cases approx iirc.
The feeling being that the bend on the touhy drives the spinal needle cephalad and into the cord, on a baseline of an already epidural attempt that is a level or 2 higher than one thinks. I don't think the soft catheter of a full cse is implicated.
It's retro spectrum case report analysis so not exactly rct evidence but about the best I know of
 
Our surgeons are so **** slow we give almost everyone ga s for fractured hips. I'd imagine your elective population couldn't be much less sick than ours. Fatter maybe but equal **** shows.

No compelling evidence for spinals anymore in hips or knees
The joint mix local anaesthesic seems to work really well.
 
Newtwo said:
Nap3 for the risks of cse. The reason behind the risk was hypothesized in a Canadian article. It was only a hypothesis however.

In the UK in 07 to 09 Cse's accounted for only 6% of neuraxial technique but accounted for 40% of the closed claims cases approx iirc.
The feeling being that the bend on the touhy drives the spinal needle cephalad and into the cord, on a baseline of an already epidural attempt that is a level or 2 higher than one thinks. I don't think the soft catheter of a full cse is implicated.
It's retro spectrum case report analysis so not exactly rct evidence but about the best I know of
Click to expand...

While I haven’t read the article, technique has a lot to do with the proposed mechanisms of injury. If you are anywhere near the cord level or jamming a spinal needle in Willy nilly through a touhy at the conus you need to check your technique.
 
Doughy315 said:
I am practicing in the Midwest. I seem to struggle with trying place a spinal in the large obese patients ( 130 kg ) anyone have any tips or advance. I seem to always hit bone. I tried to feel for spinous process but it difficult on these large patients.
Click to expand...

Make sure you aren't too low. Position as good as possible (tough, I know). You'll never get the needle past the bone if lordodic. Usually possible with 25G but I will do 22 paramedian with some frequency.
 
Avoid Quincke needles if possible:

Anaesth Intensive Care. 1992 Aug;20(3):322-5.
Whitacre 22-gauge pencil-point needle for spinal anaesthesia. A controlled trial in 300 young orthopaedic patients.
Lynch J1, Arhelger S, Krings-Ernst I, Grond S, Zech D.
Author information

Abstract
In a prospective study of 300 young orthopaedic in-patients (less than 40 years) given spinal anaesthesia through a 22-gauge Whitacre (n = 150) or a 25-gauge Quincke spinal needle (n = 150), we found a 5.3% and a 9.3% incidence of post-spinal headache (PSH) respectively. Females (10.6%) had a higher overall incidence of post-spinal headache than males (5.6%) with more than twice as many females being affected in the 25 than in the 22-gauge group (14.5% vs 6.1%). The average duration of post-spinal headache was less in the 22-gauge group (36 h vs 42.4 h) as was the incidence of severe headache. It is concluded that the Whitacre 22-gauge needle is more suited for spinal analgesia in young female patients due to its ease of handling and its lower incidence of post-spinal headache.
 
PainDrain said:
While I haven’t read the article, technique has a lot to do with the proposed mechanisms of injury. If you are anywhere near the cord level or jamming a spinal needle in Willy nilly through a touhy at the conus you need to check your technique.
Click to expand...
Well isn't that the thing?
In 130kg 'regular' tka patient I'm guessing you can be 11cm deep or more. This isn't a young parturient.
At that level there isn't much technique
 
I’ve always found the sitting position better for bigger patients.

But as soon as you swing the pt’s legs off the side of the table, you lose much of the benefit.

I get someone to help, then make the pt do a sit-up, with the legs straight out and still on the table. I go to the head of the table, get prone (almost), rest on my elbows, and I get the best curve of the spine at the target level that you will ever see. Added bonus, after you get done, all you need do is lay the pt straight back down. No swinging the legs.

Can’t do this alone though. The pt is vulnerable to falling off the table, admittedly, but in >25 yrs doing that way, that has never happened. Could though, so be cautious.

Also, obese patients and the elderly need some manual “encouragement “ to bend in the “sit-up” position. But it does work.
 
Dejavu said:
I’ve always found the sitting position better for bigger patients.

But as soon as you swing the pt’s legs off the side of the table, you lose much of the benefit.

I get someone to help, then make the pt do a sit-up, with the legs straight out and still on the table. I go to the head of the table, get prone (almost), rest on my elbows, and I get the best curve of the spine at the target level that you will ever see. Added bonus, after you get done, all you need do is lay the pt straight back down. No swinging the legs.

Can’t do this alone though. The pt is vulnerable to falling off the table, admittedly, but in >25 yrs doing that way, that has never happened. Could though, so be cautious.

Also, obese patients and the elderly need some manual “encouragement “ to bend in the “sit-up” position. But it does work.
Click to expand...

Just put a stool next to the OR table for them to put their feet on. This gets their knees bent and restores the lumbar kyphosis they lose with legs dangling. On OB I have them sit “Indian style” to accomplish the same thing.
 
I do spinals with Tuohy's but that's because I'm implanting a catheter in there for a long time. Folks do them with Tuohy's accidentally and if you're putting a proper lumbar drain in, you're probably using a Tuohy or something similar in the 13 to 16g range. I don't think the needle design is a critical issue in larger patients, but I would definitely recommend the use of a stiffer/thicker needle as it drives easier, so a 22g beats a 24 or 25.

If you're doing it blind and hitting bone, they can normally tell you laterality with that sensation unless they're sedated. Then it's just a matter of figuring out which part of the hopefully posterior elements of the spine you're touching. The big thing to appreciate is that when you adjust your needle in a person with a lot of layers, the needle directionality may not change if you don't pop out of one or two fascial planes, so come back a little further than you think you might need to, but at the same time, don't overadjust your angulation as those small movements shift it so much more at a deeper size.

For the original question though, you could just use the c-arm in the OR and move on with your life? These are ortho cases right so there's probably one in the room.

Bring 'em in, sit them up or have them on their side. C-arm to shoot PA/AP to get midline/needle/localization, and put whatever needle you want in between the bony windows.

Ultrasound is good if you don't like radiation/logistical issues, but learning curve is harder.
 
Orin said:
For the original question though, you could just use the c-arm in the OR and move on with your life? These are ortho cases right so there's probably one in the room.

Bring 'em in, sit them up or have them on their side. C-arm to shoot PA/AP to get midline/needle/localization, and put whatever needle you want in between the bony windows.

Ultrasound is good if you don't like radiation/logistical issues, but learning curve is harder.
Click to expand...

No C-arm in TKA's. Also, most hospitals won't let you use the c-arm without a flouro license (that may be state law dependent though).
 
Noyac said:
You had to go there didn’t you.
Click to expand...

I think you're actually a closet ultrasound lover. You like to brag about your landmark blocks and blind lines and generally make fun of us young whippersnappers with our fancy ultrasound machines, but secretly you go home and beat off to Sonosite brochures. 😀
 
After reading all the posts about CRNA's taking over and replacing physicians why not ask a CRNA, can't they do everything?
 
Dejavu said:
I’ve always found the sitting position better for bigger patients.

But as soon as you swing the pt’s legs off the side of the table, you lose much of the benefit.

I get someone to help, then make the pt do a sit-up, with the legs straight out and still on the table. I go to the head of the table, get prone (almost), rest on my elbows, and I get the best curve of the spine at the target level that you will ever see. Added bonus, after you get done, all you need do is lay the pt straight back down. No swinging the legs.

Can’t do this alone though. The pt is vulnerable to falling off the table, admittedly, but in >25 yrs doing that way, that has never happened. Could though, so be cautious.

Also, obese patients and the elderly need some manual “encouragement “ to bend in the “sit-up” position. But it does work.
Click to expand...
That my technique exactly.
 
SaltyDog said:
I think you're actually a closet ultrasound lover. You like to brag about your landmark blocks and blind lines and generally make fun of us young whippersnappers with our fancy ultrasound machines, but secretly you go home and beat off to Sonosite brochures. 😀
Click to expand...
Beating off is also for young whippersnappers.:whistle:
 
BLADEMDA said:
Avoid Quincke needles if possible:

Anaesth Intensive Care. 1992 Aug;20(3):322-5.
Whitacre 22-gauge pencil-point needle for spinal anaesthesia. A controlled trial in 300 young orthopaedic patients.
Lynch J1, Arhelger S, Krings-Ernst I, Grond S, Zech D.
Author information

Abstract
In a prospective study of 300 young orthopaedic in-patients (less than 40 years) given spinal anaesthesia through a 22-gauge Whitacre (n = 150) or a 25-gauge Quincke spinal needle (n = 150), we found a 5.3% and a 9.3% incidence of post-spinal headache (PSH) respectively. Females (10.6%) had a higher overall incidence of post-spinal headache than males (5.6%) with more than twice as many females being affected in the 25 than in the 22-gauge group (14.5% vs 6.1%). The average duration of post-spinal headache was less in the 22-gauge group (36 h vs 42.4 h) as was the incidence of severe headache. It is concluded that the Whitacre 22-gauge needle is more suited for spinal analgesia in young female patients due to its ease of handling and its lower incidence of post-spinal headache.
Click to expand...
Blade can you locate any studies where the Quincke was inserted vertically with regards to the cutting surface? I’d like to see that study.
 
Orin said:
I do spinals with Tuohy's but that's because I'm implanting a catheter in there for a long time. Folks do them with Tuohy's accidentally and if you're putting a proper lumbar drain in, you're probably using a Tuohy or something similar in the 13 to 16g range. I don't think the needle design is a critical issue in larger patients, but I would definitely recommend the use of a stiffer/thicker needle as it drives easier, so a 22g beats a 24 or 25.

If you're doing it blind and hitting bone, they can normally tell you laterality with that sensation unless they're sedated. Then it's just a matter of figuring out which part of the hopefully posterior elements of the spine you're touching. The big thing to appreciate is that when you adjust your needle in a person with a lot of layers, the needle directionality may not change if you don't pop out of one or two fascial planes, so come back a little further than you think you might need to, but at the same time, don't overadjust your angulation as those small movements shift it so much more at a deeper size.

For the original question though, you could just use the c-arm in the OR and move on with your life? These are ortho cases right so there's probably one in the room.

Bring 'em in, sit them up or have them on their side. C-arm to shoot PA/AP to get midline/needle/localization, and put whatever needle you want in between the bony windows.

Ultrasound is good if you don't like radiation/logistical issues, but learning curve is harder.
Click to expand...
If we are resorting to c arm for a simple spinal for TKA than it may be time to just tube em and move on with life.
 
As some have touched on OP, have you ever done your spinal with a paramedian approach? That is my go to if I am struggling regardless of needle size/type etc....
 
We do most of our spinals with patient lateral (after they've gotten peripheral blocks). If I struggle at all with a Whitacre, I go pretty quickly to a paramedian approach using a Quincke. I think you get a lot more information from a paramedian than from a midline approach in these larger patients. Sometimes, I even use a two quincke's. One to mark midline (hit SP) and the other to do the procedure.

All of that said, we do a boatload of paramedian thoracic epidurals. So, I am extremely comfortable with this approach.

I am all for sitting a patient up early (or starting sitting) if there BMI is >40.

But, hell, I work in the south and we have some seriously ginormous patients. It's really kind of stupid.
 
Last edited:
The Physician Philosopher said:
We do most of our spinals with patient lateral (after they've gotten peripheral blocks). If I struggle at all with a Whitacre, I go pretty quickly to a paramedian approach using a Quincke. I think you get a lot more information from a paramedian than from a midline approach in these larger patients. Sometimes, I even use a two quincke's. One to mark midline (hit SP) and the other to do the procedure.

All of that said, we do a boatload of paramedian thoracic epidurals. So, I am extremely comfortable with this approach.

I am all for sitting a patient up early (or starting sitting) if there BMI is >40.

But, hell, I work in the south and we have some seriously ginormous patients. It's really kind of stupid.
Click to expand...
Why do you switch needles?
 
Last edited:
Noyac said:
Why do you switch needles?
Click to expand...
I can do a paramedian with a whitacre and introducer, but i do it for two reasons.

One, I feel I get more feedback with a Quinke. As I tell my residents, I am trying to draw a 3D stencil drawing of the patients spine to figure out where I am and where I need to be. Lamina, versus TP, versus spinous process, versus articular process, etc.

Two, the introducer shortens the length of the needle. I can get more length with a quincke and no introducer. On the BMI 40 patients this may be important.

Sent from my XT1710-02 using Tapatalk
 
The Physician Philosopher said:
I can do a paramedian with a whitacre and introducer, but i do it for two reasons.

One, I feel I get more feedback with a Quinke. As I tell my residents, I am trying to draw a 3D stencil drawing of the patients spine to figure out where I am and where I need to be. Lamina, versus TP, versus spinous process, versus articular process, etc.

Two, the introducer shortens the length of the needle. I can get more length with a quincke and no introducer. On the BMI 40 patients this may be important.

Sent from my XT1710-02 using Tapatalk
Click to expand...
I like the bluntness of the pencil points. I feel I get more feedback from this type of needle. Plus the complications are less.
Whitacre or Quincke needles--does it really matter.
Eriksson AL1, Hallén B, Lagerkranser M, Persson E, Sköldefors E.
Author information

Abstract
BACKGROUND:
Postdural puncture headache (PDPH) and backache are well known complications of spinal anaesthesia. The incidence of PDPH may be significant in young people (< 50 years). The present study was undertaken in order to compare the utility and complication rate of the Whitacre and Ouincke spinal needles.

METHODS:
During three years all patients who could comply, and who were to undergo spinal anaesthesia at the Department were asked to join this quality control study. Each one received a questionnaire including questions about discomfort and other possible side effects attributed to spinal anaesthesia. In each case, an extended anaesthetic record was filled out by the anaesthesiologist. About 50 anaesthesiologists at different educational levels were involved.

RESULTS:
The study includes 2598 cases, of which questionnaires were returned by 66%. Needles of the 25 G gauge size were used in over 90% of the cases. Multiple skin punctures were required more frequently in the Quincke than in the Whitacre group (P < 0.01). The number of insufficient blocks was also higher in the Quincke group (P < 0.01). There was a higher incidence of backache in the Quincke group (P < 0.05). In patients under 50 years, PDPH was more frequent following use of the Quincke needle (P < 0.05), whereas no difference between the needles in this regard was found among those over 50 years (P > 0.05).

CONCLUSIONS:
For routine clinical use the Whitacre needle appears to be associated with better performance and increased reliability. In younger patients the Whitacre needle have the additional advantage of decreasing the risk of postdural puncture headache.

So, it’s not just PDPH’s that we are trying to avoid.
 
I sit the patient straight up on the bed and lower the foot down to help them lean forward. Most obese people have several rolls of fat both horizontal and vertical. Where these valleys intersect is where the money is. 22g as long as they are older than 60.
 
cde said:
I sit the patient straight up on the bed and lower the foot down to help them lean forward. Most obese people have several rolls of fat both horizontal and vertical. Where these valleys intersect is where the money is. 22g as long as they are older than 60.
Click to expand...


Same. But I use 27g Whit with a 20g guide for almost everyone. Pull out 22g once or twice a year. In Vietnam I hear they use 29g. Different patient population but still.
 
nimbus said:
Same. But I use 27g Whit with a 20g guide for almost everyone. Pull out 22g once or twice a year. In Vietnam I hear they use 29g. Different patient population but still.
Click to expand...

I applaud your use of 27G W needle. That said, I haven't had to do a blood patch on anyone over the age of 30 using a 25G Whitacre in years. The incidence is quite low in experienced hands. Perhaps, the 27G W is worth the effort in the under 30 year old population but 1-2 patches per year out of a thousand or so spinals per year in OB is pretty good (for the overall practice not just me).

I would venture to state the the risk of a H/A from a routine Epidural (1% or so) is much greater than a severe H/A from an SAB using a 25G W. But, never say never as I've seen that one in a thousand patient more than a few times in my career and they never believe they are the exception to the norm.
 
do 22g whitacre needles need to be inserted with the help of an introducer like their 25g/27g counterparts?

if so, do all brands of 22g whitacres come with introducers or do u sometimes have to find one separately?
 
cleansocks said:
do 22g whitacre needles need to be inserted with the help of an introducer like their 25g/27g counterparts?
Click to expand...

You can go paramedian with a 25 without an introducer. We had one old timer staff in residency that would do all his spinals paramedian with a 25 Whit with no introducer and no skin local.
 
SaltyDog said:
You can go paramedian with a 25 without an introducer. We had one old timer staff in residency that would do all his spinals paramedian with a 25 Whit with no introducer and no skin local.
Click to expand...

cool! Wish I had those skillz and confidence
 
SaltyDog said:
You can go paramedian with a 25 without an introducer. We had one old timer staff in residency that would do all his spinals paramedian with a 25 Whit with no introducer and no skin local.
Click to expand...
With how flexible/breakable those things are that seems like it would be a royal pain. I've done a paramedian with a 25g whitacre utilizing the introducer. I've done midline (straight shot) without. I've never done a paramedian without one haha. Maybe I'll try this at some point.

(Pun intended).

Sent from my XT1710-02 using Tapatalk
 
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