Thoracic epidurals

[toughlife]

Any tips on how to have success with thoracic epidurals. I have attempted three and I usually go the paramedial way but I can never get it. Today I tried a T8-T9 medially, then paramedially. When paramedial, I make sure I go straight in with the needle, hit the lamina, walk up it and then turning medially looking for the loss of resistance but I can't get it. The lumbars are relatively easy but I can't get the thoracic ones if my life depended on it.
I have great luck with the lumbar ones.

Any advice?

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[johankriek]

Any tips on how to have success with thoracic epidurals. I have attempted three and I usually go the paramedial way but I can never get it. Today I tried a T8-T9 medially, then paramedially. When paramedial, I make sure I go straight in with the needle, hit the lamina, walk up it and then turning medially looking for the loss of resistance but I can't get it. The lumbars are relatively easy but I can't get the thoracic ones if my life depended on it.
I have great luck with the lumbar ones.

Any advice?

forget paramedian approach go midline.. point your needle a little more cephalad than you would a lumbar approach and do hanging drop technique.. place a drop of saline at hub of needle.. and as you enter epidural space the drop will get sucked in.. no equivocal loss of resistance there.. hanging drop is the way to go for thoracic epidurals...

 

[toughlife]

forget paramedian approach go midline.. point your needle a little more cephalad than you would a lumbar approach and do hanging drop technique.. place a drop of saline at hub of needle.. and as you enter epidural space the drop will get sucked in.. no equivocal loss of resistance there.. hanging drop is the way to go for thoracic epidurals...

Interesting. I've never heard of the drop of saline approach. I've using the glass syringe where I put 2cc of saline and advance the epidural needle while applying pressure to the syringe plunger and wait for it to slide easily and push all the saline in. I've was told that if you use air, you can cause a pneumocephalus. Thanks for the tip though. Hopefully the attending will let me try it.

 

[2ndyear]

I have had relatively good luck with the paramedian approach. I am being taught to go 1 cm from the spinous process and finding the lamina. From there, it's not too big a turn medially, almost straight in, 10 degrees medially at the most. If you turn to far medially you really don't know where you are and never find the ligament. I've placed a few midline and it seemed like a valid technique, but technically difficult because of the cephalad angle of the needle.

 

[jetproppilot]

Any tips on how to have success with thoracic epidurals. I have attempted three and I usually go the paramedial way but I can never get it. Today I tried a T8-T9 medially, then paramedially. When paramedial, I make sure I go straight in with the needle, hit the lamina, walk up it and then turning medially looking for the loss of resistance but I can't get it. The lumbars are relatively easy but I can't get the thoracic ones if my life depended on it.
I have great luck with the lumbar ones.

Any advice?

Rarely have I had to go paramedian but its a good alternative. Just takes practice, Tough. The one caveat to remember is that theres a higher incidence of false loss of resistance. So if it only feels "kinda right", it probably isnt. Redirect and try again.

 

[toughlife]

Rarely have I had to go paramedian but its a good alternative. Just takes practice, Tough. The one caveat to remember is that theres a higher incidence of false loss of resistance. So if it only feels "kinda right", it probably isnt. Redirect and try again.

ah. I was told that when it feels "kinda right" you could be in the pleura for all you know. It really is a skill to master and I am sure I will spend the next four years of residency making sure I get it right. Thanks though peeps.

 

[VolatileAgent]

steep, baby, steep. median and steep angle. we do a LOT of these where i'm at, and fortunately we get a lot of practice. have tried many different ways and, i agree with jet. you gotta go median, and the angle is much steeper than you can initially imagine. look at a model of a spine (a 3D model of an actual spine) and place a needle on that spine where you want to go. then, look at it from the side. now, imagine interspinous ligament and all those medial layers and remember how steep that angle was. also, look at where you are with the tuohy. practice bumping superiorly and inferiorly as well as bumping against pedicle on the model. then, shut your eyes and do it.

may sound ridiculous, but it helped me a lot. and, i rarely miss a thoracic epidural anymore, even on a major fatty (where you sometimes need "the saber" - a.k.a. the 15cm tuohy).

 

[IN2B8R]

Pssst, ask answine to teach ya the paramedian approach

 

[VolatileAgent]

Pssst, ask answine to teach ya the paramedian approach

yeah, he's still around. but, greensmith is doing most of the funky regional stuff now.

 

[DrDre']

Greensmith was at my alma matar. You guys are lucky to have him!

yeah, he's still around. but, greensmith is doing most of the funky regional stuff now.

 

[VolatileAgent]

Greensmith was at my alma matar. You guys are lucky to have him!

yeah, the dude has more energy than any 50-year-old i've personally ever known. and, he's a very bright guy.

 

[johankriek]

hanging drop..

 

[nimbus]

I always go paramedian and, like 2ndyear, go barely off midline next to the spinous process. For me this has been easier, hit less bone. Also use the 22gx1.5 inch local needle to scout my trajectory before I stick in the tuohy.

As an aside, I have had 3 unequivocal wet taps doing thoracic epidurals because of mushy LOR. The ligament is just not as thick at this level with a paramedian approach. Hanging drop is probably a sensible technique. Funny thing is not a single patient got even a remote hint of a headache. Anyone else share this experience?

 

[Noyac]

Screw the hanging drop. Why do something different from your usual. I don't even do the hanging drop for my cervical epidurals. It's a waste of "my" time.

 

[militarymd]

Greensmith was at my alma matar. You guys are lucky to have him!

Are you guys talking about Eric Greensmith?

 

[johankriek]

Screw the hanging drop. .

hanging drop.. you will fall in love once you see how easy it is....

 

[DrDre']

Yes, he was at UI prior

Are you guys talking about Eric Greensmith?

 

[Noyac]

hanging drop.. you will fall in love once you see how easy it is....

I know how easy it is. I have done it many times. I don't do it any longer.

 

[VolatileAgent]

Yes, he was at UI prior

now we have him at hmc/psu. he's our acute pain director. we're lucky to have him.

 

[militarymd]

Eric is ex-Navy, I took over his job after he left NMCP in Virginia.

 

[TIVA]

Johan,

Is the hanging drop technique good in lumbar epidurals as well? Or just thoracics?

TIVA