techniques to reduce false loss of resistance while doing Cervical epidurals

[painfre]

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Are there any good techniques to reduce false loss of resistance while doing Cervical epidurals. I did a cervcial ESI recently and pt started having fasle loss of resistance after the needle is placed about 3cm deep from the skin. I knew that I am not in the epidural space by taking Oblique and lateral views. When I was in the epidural space about 6cm from the skin, I was unable to steer the Arrow Flex tip plus catheter in to the epidural space. I pulled the catheter out and injected epidural which showed good spread.

 

[Jcm800]

Are there any good techniques to reduce false loss of resistance while doing Cervical epidurals. I did a cervcial ESI recently and pt started having fasle loss of resistance after the needle is placed about 3cm deep from the skin. I knew that I am not in the epidural space by taking Oblique and lateral views. When I was in the epidural space about 6cm from the skin, I was unable to steer the Arrow Flex tip plus catheter in to the epidural space. I pulled the catheter out and injected epidural which showed good spread.

use a plastic syringe with only saline and the oblique 60 degree thing, and touch lamina. do most of the advancing in either the oblique or later view...All those things are helpful.

 

[lobelsteve]

Always go at C7-T1.
Always align AP with cranio-caudal tilt to open up the interlaminar space.
Always rotate slightly to the side you are entering and come in paramedian.
Always touch lamina of T1 to set depth. No need to go lateral or oblique until establishing contact with lamina. Bone gives no false resistance when encountered.

27G to raise wheal on skin
25G 3.5" to anesthetize down to lamina
18G 3.5" Tuohy to lamina, walk off superiorly and add 1cc lido before traversing the ligament.
Oblique (football view) and enter using LOR technique with NSS and air.
Inject 2cc contrast and save oblique and AP images while viewing live. If you have DSA, more power to you. If contrast spread is appropriate, test dose if you believe in it (I do), and then shoot your load (2cc NSS and 2cc Celestone for me).

Pull out and get on a band-aid.

 

[PMR 4 MSK]

Are there any good techniques to reduce false loss of resistance while doing Cervical epidurals. I did a cervcial ESI recently and pt started having fasle loss of resistance after the needle is placed about 3cm deep from the skin. I knew that I am not in the epidural space by taking Oblique and lateral views. When I was in the epidural space about 6cm from the skin, I was unable to steer the Arrow Flex tip plus catheter in to the epidural space. I pulled the catheter out and injected epidural which showed good spread.

I dont even start LOR until I'm in lateral and needle position look good. I keep the stylet in my 22 g until then.

The problem I have is looking good, getting LOR, injecting contrast and it's superficial. Now I have liquid in my tubing and needle, making it harder to judge if I'm too deep - intrathecal. however, what I do in those cases, is advance a liitle further until I'm sure I'm in LF, then slowly advance with Pulsator Syringe with light pressure, and when the contrast begins to move a little, I stop, shoot a picture and near invariably it's a perfect epidural straight line of contrast.

 

[clubdeac]

Always go at C7-T1.
Always align AP with cranio-caudal tilt to open up the interlaminar space.
Always rotate slightly to the side you are entering and come in paramedian.
Always touch lamina of T1 to set depth. No need to go lateral or oblique until establishing contact with lamina. Bone gives no false resistance when encountered.

27G to raise wheal on skin
25G 3.5" to anesthetize down to lamina
18G 3.5" Tuohy to lamina, walk off superiorly and add 1cc lido before traversing the ligament.
Oblique (football view) and enter using LOR technique with NSS and air.
Inject 2cc contrast and save oblique and AP images while viewing live. If you have DSA, more power to you. If contrast spread is appropriate, test dose if you believe in it (I do), and then shoot your load (2cc NSS and 2cc Celestone for me).

Pull out and get on a band-aid.

Steve, I was always told to pull out and then shoot my load? 🙄

 

[SSdoc33]

another little trick, FWIW, is to pierce the skin with the 18g that you use to draw up the meds. this creates a little space for the touhy to enter the skin, and you don't have a little skin plug messing things up. typically not a problem when you have the stylet in, but i have seen it.

i tend to shoot my load in the AP position. its just more a lot better for everyone that way -- interpret that as you will....

 

[drpainfree]

I thought people oblique AWAY from the side of entering to show better anatomy.

Always go at C7-T1.
Always align AP with cranio-caudal tilt to open up the interlaminar space.
Always rotate slightly to the side you are entering and come in paramedian.
Always touch lamina of T1 to set depth. No need to go lateral or oblique until establishing contact with lamina. Bone gives no false resistance when encountered.

27G to raise wheal on skin
25G 3.5" to anesthetize down to lamina
18G 3.5" Tuohy to lamina, walk off superiorly and add 1cc lido before traversing the ligament.
Oblique (football view) and enter using LOR technique with NSS and air.
Inject 2cc contrast and save oblique and AP images while viewing live. If you have DSA, more power to you. If contrast spread is appropriate, test dose if you believe in it (I do), and then shoot your load (2cc NSS and 2cc Celestone for me).

Pull out and get on a band-aid.

 

[lobelsteve]

Oblique towards side of entry 5 degrees from true ap to show a larger lamina as your target. Once on lamina, oblique other way to get football view.

 

[painfre]

Thanks for above responses. i usually do the same. 18g needle to make a opening in the skin, then use use 20 g 3.5 inch Tuohy, about 10 degrees paramedian, go in tunnel vision, Hit the superior edge of lamina and walk of lanmina and check depth by cotralateral 45 deg oblique view. Most of times I do not get epidural space immediately after crossing spinolaminar line and have to go 2-3 mm deeper. But Some times false LOR is felt immediately after cross the line even though you are not in the epidural space.

 

[MedZeppelin]

Can I ask a question? What exactly is the "Football" in the "Football View" contralateral oblique view?
The way I have trained to do cervicals is straight AP Midline, then lateral view to and through ligamentum using LOR syringe and 20 G touhy.
This whole contralateral view approach is new to me...
Thanks...

 

[lobelsteve]

Can I ask a question? What exactly is the "Football" in the "Football View" contralateral oblique view?
The way I have trained to do cervicals is straight AP Midline, then lateral view to and through ligamentum using LOR syringe and 20 G touhy.
This whole contralateral view approach is new to me...
Thanks...

http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2010.00829.x/abstract