steering 25g needles

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For those out there that love their 25g spinals.... how? I find that regardless of whether I bend the tip or keep it straight, I very frequently have my needle flopping around like a piece of spaghetti when I'm trying to do an MBB with them. When my initial placement is perfect and I can essentially dive entirely coaxial to target, it's fine. Otherwise I have a very hard time making it go where I want to go. When I switch to a 22g, I have no problems hitting the bullseye.

I want to like the 25g because I'm sure it's theoretically less painful for patients, but at this point, using no local with a noodle 25g fishing around for a target has seemed consistently much less comfortable than local plus 22g.
 
I pretty much exclusively use 25G for MBB's, TFESI, and joints, that's what we did in fellowship. The main advice I have is continue to get reps with it if you want to get better.

I always bend the tip. Do you ever try corkscrewing it down when you have good placement and are near the target? If the needle does flop around, have you tried bowing the needle at the middle to make more dramatic adjustments quickly?
 
a bent tip 25g is very difficult to control through tough skin, spastic muscle, or fibrous tissue around the spine. it will kink when sometimes some additional pressure is needed. no way around it other than to use a larger needle
 
BobBarker said:
Just use 23g and forget about them. I just use them for mbbs on small ladies if I have them available for the same reasons you stated.
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Agree with bob.

I used to use both, but now I just use 23G quincke for everything. TFESI, MBB, SIJ, caudal.

Best of both worlds. A 23G is thinner and more gentle to patients than a 22G, but a 23G is much easier to steer compared to 25G.
 
It's easiest to use 25 gauge after you have established a gunbarrel approach - then corkscrew it. It's more challenging when getting to the deeper layers if you haven't established a true approach. I spend more relative effort before I hit those facial layers.

I found that bending helps a bit but only if I don't get that good initial direction. And by then it's too late. Corkscrewing a bent needle doesn't work well...


I use 25 gauge for mbb but 22 for everything else (the system hasn't gotten any 23s).
 
I keep an arc on the needle (belly) the entire time and use the steering bent tip as well as the arc to get to the target. A syringe is always on the needle and I hold the syringe in my right hand resting on the drape. My left hand advances the needle.
 
I think it depends on the brand too. BD 25G needles with a bent tip work just fine after you're used to them. Sometimes we get generic 25G which do not steer well at all. I use 22G for TFESI but 25G for everything else.
 
I only use 25 g. I've found away to make it work pretty well and efficiently. Less painful than using a 22 g imo. Just keep practicing and you'll get it.
 
Even a 22G you don't need local. I stopped numbing with them a year ago and have had zero issues whatsoever. Just gotta be deliberate with your needle poke and its totally fine.

I use 25G for MBB, SGB, SIJ and other joints. 22G for TFESI.
 
Baron Samedi said:
Even a 22G you don't need local. I stopped numbing with them a year ago and have had zero issues whatsoever. Just gotta be deliberate with your needle poke and its totally fine.

I use 25G for MBB, SGB, SIJ and other joints. 22G for TFESI.
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Your patients are much tougher than mine. Mine can’t even handle the “freezing” chloroprep
 
What needle and gauge do you all use for celiac plexus blocks?
 
Baron Samedi said:
Even a 22G you don't need local. I stopped numbing with them a year ago and have had zero issues whatsoever. Just gotta be deliberate with your needle poke and its totally fine.

I use 25G for MBB, SGB, SIJ and other joints. 22G for TFESI.
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I do the same. 22g only for TFESI. or for anyone that needs a longer needle (we dont have long 25g needles).

PMROralBoards said:
What needle and gauge do you all use for celiac plexus blocks?
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22g chiba
 
22G for deeper structures (sympathetic blocks, SIJ, hip articular branch blocks) or injection with particular steroids. Spritz of topical local with anything 22G or thicker. I'll sometimes switch to a 22G once in a blue moon if there is significant osteophytosis en route to NF for a TFESI.

25G for everything else - no topical local needed. Would use a 23G if it was available in my setting and not give topical local.

25G is definitely floppier and takes practice -- main hangup I see in others at courses or my trainees is advancing too much too quickly when crossing different tissue planes particularly with trying to stay coaxial. Also less forgiving once bent.
 
25G 3” works better for MBB on thin patients. Have 22G 3” ready for everyone else. You will eventually know.
 
Baron Samedi said:
Even a 22G you don't need local. I stopped numbing with them a year ago and have had zero issues whatsoever. Just gotta be deliberate with your needle poke and its totally fine.

I use 25G for MBB, SGB, SIJ and other joints. 22G for TFESI.
Click to expand...
Nope I’ll pass on this advice. 22G almost always hurts and some patients won’t come back. Local definitely will keep patients happy. 25G hurts much less but I still use local.
 
Ferdog27 said:
Nope I’ll pass on this advice. 22G almost always hurts and some patients won’t come back. Local definitely will keep patients happy. 25G hurts much less but I still use local.
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Yep. Quite possible the worst advise on SDN ever. “Stopped numbing a year ago w/ zero issues”... Riiiiight…
 
I feel like such distinct differences can only be explained by an underlying difference in population. I don’t usually use skin local for 25g but I do usually for 22. I use 25g for MBB and TFESI if it will reach. Most of my RFs, kyphos, and stim trials are done in office with oral sedation. Still, It’s hard for me to comprehend the people on here who claim to never need to give sedation for any of their patients. I do maybe 5-10% of my RFs at the surgery center with IV sedation. I have a few (all patients on antiepileptics) who don’t even get sedated enough from reasonable quantities of fentanyl and versed, and I have to schedule them on an anesthesia day. In office, what do you do with the ones who scream and trash around as soon as you touch them with a needle? Or even the ones who get through it but are miserable the whole time? Do you just discharge them? Are they somehow absent from your population?
 
95% 23ga, 5% 22ga.
25 doesn't work well in younger patients with dense muscle who clench up with every needle movement. Fine for Medicare who's soft tissue is mush. 23 is best of both worlds. Still numb.
 
callmeanesthesia said:
I feel like such distinct differences can only be explained by an underlying difference in population. I don’t usually use skin local for 25g but I do usually for 22. I use 25g for MBB and TFESI if it will reach. Most of my RFs, kyphos, and stim trials are done in office with oral sedation. Still, It’s hard for me to comprehend the people on here who claim to never need to give sedation for any of their patients. I do maybe 5-10% of my RFs at the surgery center with IV sedation. I have a few (all patients on antiepileptics) who don’t even get sedated enough from reasonable quantities of fentanyl and versed, and I have to schedule them on an anesthesia day. In office, what do you do with the ones who scream and trash around as soon as you touch them with a needle? Or even the ones who get through it but are miserable the whole time? Do you just discharge them? Are they somehow absent from your population?
Click to expand...

maybe ive just dont so many that i dont GAF if they squirm..... but mostly, i get through the patients quickly. if you are fast, a little bee sting is tolerable. if you dig around for a while, then yeah, you do need to numb up everything.

i use no skin local for my mbbs, SIJ, hips, shoulders, or TFESIs. and use mostly 23g, sometimes 22g.

its not a problem.

never use sedation
 
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i would say that i have seen at least 10-15 new patients over the past couple of years who have left a competitor because "he never gave numbing medication"... irrespective of the size of the needle.
 
Ducttape said:
i would say that i have seen at least 10-15 new patients over the past couple of years who have left a competitor because "he never gave numbing medication"... irrespective of the size of the needle.
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If people ask “you’re going to numb me, right? I usually find it easiest to just say “of course” and quietly drop an extra syringe on the tray. Takes less time than explaining why I don't, and often those are the patients who are very tense anyway. A little lidocaine TPI for them as a bonus.

I had one patient who came to me for a repeat RFA, deathly afraid about it because she said the previous doctor hadn’t numbed her for that. I had a hard time even believing it until I read on here about other people with similar experiences.
 
callmeanesthesia said:
If people ask “you’re going to numb me, right? I usually find it easiest to just say “of course” and quietly drop an extra syringe on the tray. Takes less time than explaining why I don't, and often those are the patients who are very tense anyway. A little lidocaine TPI for them as a bonus.

I had one patient who came to me for a repeat RFA, deathly afraid about it because she said the previous doctor hadn’t numbed her for that. I had a hard time even believing it until I read on here about other people with similar experiences.
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"it will hurt more to numb you up"

"there is numbing medicine in the injection"

cased closed.

but you do have to use local for RFs. even a 20g would be untenable with for RFs. without skin local
 
SSdoc33 said:
"it will hurt more to numb you up"

"there is numbing medicine in the injection"

cased closed.

but you do have to use local for RFs. even a 20g would be untenable with for RFs. without skin local
Click to expand...
"do they numb you for a flu shot? this is the same size needle."
 
DOctorJay said:
"do they numb you for a flu shot? this is the same size needle."
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yeah that concept doesnt work for everyone.

in truth, it takes so little time to give 0.1 ml 1% lidocaine that it is a nonissue for me. one hand holds the local, one hand holds the needle, and boom boom.
 
pastafan said:
No skin wheal. Local needle to hub and inject on way out. Much less painful.

Yes, I believe in using local for IV's. Especially anything larger than a 22g.
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I use this technique for my RFA cases. no complaint until I'm just about to exit the skin and that's when it hurts the most.
 
Ducttape said:
yeah that concept doesnt work for everyone.

in truth, it takes so little time to give 0.1 ml 1% lidocaine that it is a nonissue for me. one hand holds the local, one hand holds the needle, and boom boom.
Click to expand...
ok, so you're sticking the patient with a 25G needle to inject local so you can then stick them with a 25G needle

it's not a time issue it's a not necessary issue

but we all have our own style
 
Baron Samedi said:
If the patient specifically asks for it I'll numb for a 22G. If they don't ask, I just go for it and have had exactly zero issues with it.
Click to expand...
So your patient knows the difference between a 22g and a 25g? lol

We aren’t talking a knee injection with a 1.5” needle that barely needs to be redirected. A spinal 3” needle will need to be redirected and I don’t just use local for a skin wheal. I also numb the approximate tract I’ll be using, which is 1-2” deep. My 2-3 level mbb’s go through 1 skin wheal.
 
DOctorJay said:
ok, so you're sticking the patient with a 25G needle to inject local so you can then stick them with a 25G needle

it's not a time issue it's a not necessary issue

but we all have our own style
Click to expand...
I give local with a 27g 1.25” or a 30g 1”. 27g is super thin.
 
Ferdog27 said:
So your patient knows the difference between a 22g and a 25g? lol

We aren’t talking a knee injection with a 1.5” needle that barely needs to be redirected. A spinal 3” needle will need to be redirected and I don’t just use local for a skin wheal. I also numb the approximate tract I’ll be using, which is 1-2” deep. My 2-3 level mbb’s go through 1 skin wheal.
Click to expand...
Skill issue.
 
25g for MBB, ESI, TFESI: nothing
22g for SIJ, 5,6,7” TFESI: ethyl chloride
16g/18g RF: ethyl chloride

Ethylchloride is expensive but patients are annoying with sc anesthetic.
 
pmrmd said:
25g for MBB, ESI, TFESI: nothing
22g for SIJ, 5,6,7” TFESI: ethyl chloride
16g/18g RF: ethyl chloride

Ethylchloride is expensive but patients are annoying with sc anesthetic.
Click to expand...
no local for the RF?
 
pmrmd said:
I started putting anesthetic through cannula as I approach bone. Saves me a 25g spinal needle.
Click to expand...
ethyl chloride right to a 16g is aggressive. i like it.
 
That has always been my concern.

I tried looking it up but have not found any case reports of infection due to the spray.

However, it is not from a sterile container per se....
 
Put some alcohol in the refrigerator. Kill two birds with one stone. Problem solved.
 
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