Threshold for Difficult Spinal

[gasresident1]

Seemingly had a stretch of just brutal spinals. 230kg and could barely sit up, seemingly fused back, too old/frail to sit up and no CSF coming back lateral position, etc. My threshold from going from Spinal kit with introducer to 22G Quincke is short. My threshold for grabbing the Tuohy needle is now even shorter. Just curious what everyone's threshold is here for waving the white flag and going general.

I mean this mainly for hips/knees/foot and ankle. I almost always CSE in OB regardless.

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[coffeebythelake]

Seemingly had a stretch of just brutal spinals. 230kg and could barely sit up, seemingly fused back, too old/frail to sit up and no CSF coming back lateral position, etc. My threshold from going from Spinal kit with introducer to 22G Quincke is short. My threshold for grabbing the Tuohy needle is now even shorter. Just curious what everyone's threshold is here for waving the white flag and going general.

I mean this mainly for hips/knees/foot and ankle. I almost always CSE in OB regardless.

I usually try a few times, and I am quick to go with the tuohy for those big patients.
If after 10-15 minutes it doesn't work I ask for a colleague to help if they are available.
There must be a pretty compelling reason why GA should be avoided for me to continue further attempts,
Obv if this was a labor epidural or c-section spinal, that changes the calculus.
Otherwise tube.

 

[ProwlerturnGas]

Yep. Tuohy sooner rather than struggle on. Spinal through Tuohy.

 

[Anesthesia_Guy]

Three minutes. After that I just throw my hands in the air and shout "it's impossible!", blame the patient, then induce GA.

 

[abolt18]

Had an attending who would regularly tell a patient after we struggled for a prolonged period of time "I'm sorry, but this is just exceptionally difficult due to your size." And he'd say it in the calmest and gentlest voice ever. This is usually a couple tries before giving up.

 

[Lecithin5]

Had an attending who would regularly tell a patient after we struggled for a prolonged period of time "I'm sorry, but this is just exceptionally difficult due to your size." And he'd say it in the calmest and gentlest voice ever. This is usually a couple tries before giving up.

God I’d love to say that to such patients. Too bad I would get instantly cancelled.

 

[ucladoc2b]

Frustrated anesthesiologist is an absolute contraindication to spinal anesthesia in the joint room.

I use 10 minutes or when I count 10 eye rolls from the circulator.

 

[Beeftenderloin]

If it’s because the orthopedic surgeon requested it (for a total joint or whatever) no more than 5 minutes/2 levels.

If it’s because I believe it’s the safest anesthetic for the patient (which is rare outside of OB) I’ll spend considerably longer.

 

[coffeebythelake]

God I’d love to say that to such patients. Too bad I would get instantly cancelled.

The delivery is what matters.

 

[dabears505]

In private practice where the blocks often times don't work anyway, I look at the clock when I start and spend exactly 7 minutes trying. Unless I have some compelling reason to do the spinal such as critical aortic stenosis, I will abandon and do general. I likely would end up doing spinal and general anyway so I have low threshold.

 

[coffeebythelake]

In private practice where the blocks often times don't work anyway, I look at the clock when I start and spend exactly 7 minutes trying. Unless I have some compelling reason to do the spinal such as critical aortic stenosis, I will abandon and do general. I likely would end up doing spinal and general anyway so I have low threshold.

You would do a spinal for critical aortic stenosis?! Whyyy

 

[dabears505]

Lol I wrote that just for you coffeebythelake

 

[coffeebythelake]

Lol I wrote that just for you coffeebythelake

Must be that duramoph spinal for postop pain control that I keep hearing about

 

[Ronin786]

I'd never done a paramedian spinal, but had a partner knock a spinal in 5 seconds on someone I'd spent 10 minutes on. I've been trying to get a lot more practice with them for these tough situations and old backs.

 

[CD125]

I'd never done a paramedian spinal, but had a partner knock a spinal in 5 seconds on someone I'd spent 10 minutes on. I've been trying to get a lot more practice with them for these tough situations and old backs.

Really? They’re pretty straightforward and don’t require a ton of nuance. Paramedian epidurals on the other hand..

 

[coffeebythelake]

I'd never done a paramedian spinal, but had a partner knock a spinal in 5 seconds on someone I'd spent 10 minutes on. I've been trying to get a lot more practice with them for these tough situations and old backs.

with spinals it's all about trying to visualize or predict where the spinal space is. I mean you are purposefully trying to puncture the dura. The technique doesn't need to be nuanced like an epidural

 

[DrOwnage]

In private practice I wouldn't even think twice about going straight to general on a 230kg person. Repositioning the patient and not giving them a ton of versed helps too. When they participate and round their back properly and hold it, it helps soooo much.

 

[Southpaw]

You would do a spinal for critical aortic stenosis?! Whyyy

Lol well to be honest I’ll channel my SaltyDog here but in the right aortic stenosis patient for the right surgery I wouldn’t shy away from isobaric marcaine at all.

 

[coffeebythelake]

Lol well to be honest I’ll channel my SaltyDog here but in the right aortic stenosis patient for the right surgery I wouldn’t shy away from isobaric marcaine at all.

Must be a pretty important surgery to fix something else before fixing the critical AS.

 

[IMGASMD]

Must be a pretty important surgery to fix something else before fixing the critical AS.

Bone
Broken
Must fix.

 

[LivetoTell]

Over in OB, I'm lucky if I can get the pt to maintain the "arched" position for more than ten seconds. When I'm done, I rarely see any positional change after I tell them they can relax/ sit up. The OB nurses could care less.

 

[Lecithin5]

Over in OB, I'm lucky if I can get the pt to maintain the "arched" position for more than ten seconds. When I'm done, I rarely see any positional change after I tell them they can relax/ sit up. The OB nurses could care less.

Can’t forget the ‘great job!’ and ‘you did great!’ comments made by the nurses to the patient, who did not do a great job nor do great, and made placement miserable for me.

 

[Status Sciaticus]

You would do a spinal for critical aortic stenosis?! Whyyy

must be one of those PP things that doesnt happen in academia 😉

 

[coffeebythelake]

must be one of those PP things that doesnt happen in academia 😉

🤣🤣🤣

 

[narcusprince]

I'd never done a paramedian spinal, but had a partner knock a spinal in 5 seconds on someone I'd spent 10 minutes on. I've been trying to get a lot more practice with them for these tough situations and old backs.

Bro man the redirect is the critical skill. I work with Aas and crnas and I let them get first crack at the spinal. My secret is after they struggle go at a completely different level. Biggest problems I see is an inability to make moves that are high yield versus low yield. A downward deflection on your spinal or epidural never bears any fruit. In addition advancing the thuoy needle not engaged attached to the syringe is a setup for failure.

 

[Hoya11]

Seemingly had a stretch of just brutal spinals. 230kg and could barely sit up, seemingly fused back, too old/frail to sit up and no CSF coming back lateral position, etc. My threshold from going from Spinal kit with introducer to 22G Quincke is short. My threshold for grabbing the Tuohy needle is now even shorter. Just curious what everyone's threshold is here for waving the white flag and going general.

I mean this mainly for hips/knees/foot and ankle. I almost always CSE in OB regardless.

take a look at some lumbar spine xrays

for the most part, the lower you go, the more open the spaces..

the easiest is L5S1 or L45 just off midline

its easier to feel the bony spinous processes at the higher lumber/low thoracic levels, but the spaces are usually tighter.

i go low with a 25g, redirect upwards and slightly off midline to either side, several times at that level.

if no success move to a different level and also have several redirects.

after 2 levels i go to a 22g spinal. in OB I would maybe try a third level with the 25g.

i would not consider a tuohy helpful vs a 22g spinal personally.

if i cant get it with a 22 after 15 mins then abandon.

 

[deleted875186]

take a look at some lumbar spine xrays

for the most part, the lower you go, the more open the spaces..

the easiest is L5S1 or L45 just off midline

its easier to feel the bony spinous processes at the higher lumber/low thoracic levels, but the spaces are usually tighter.

i go low with a 25g, redirect upwards and slightly off midline to either side, several times at that level.

if no success move to a different level and also have several redirects.

after 2 levels i go to a 22g spinal. in OB I would maybe try a third level with the 25g.

i would not consider a tuohy helpful vs a 22g spinal personally.

if i cant get it with a 22 after 15 mins then abandon.

This. I find most people go quite high, up at L3-4 and likely L2-3, when the L5-S1 space is far and away the biggest space on every human, just can’t usually feel the spinous process. I will try L3-4 first, but if unsuccessful will often go down a space.

 

[coffeebythelake]

Lol I wrote that just for you coffeebythelake

I took you seriously because you didn't say "light GA"

 

[woopedazz]

Bro man the redirect is the critical skill. I work with Aas and crnas and I let them get first crack at the spinal. My secret is after they struggle go at a completely different level. Biggest problems I see is an inability to make moves that are high yield versus low yield. A downward deflection on your spinal or epidural never bears any fruit. In addition advancing the thuoy needle not engaged attached to the syringe is a setup for failure.

I dno, I do so many mid-thoracic epidurals I seem to benefit from downward deflections for spinals. My most common **** up is going too steep despite being lumbar.

 

[PpfSuxTube]

Seemingly had a stretch of just brutal spinals. 230kg and could barely sit up, seemingly fused back, too old/frail to sit up and no CSF coming back lateral position, etc. My threshold from going from Spinal kit with introducer to 22G Quincke is short. My threshold for grabbing the Tuohy needle is now even shorter. Just curious what everyone's threshold is here for waving the white flag and going general.

I mean this mainly for hips/knees/foot and ankle. I almost always CSE in OB regardless.

Same.
I actually grab both the touchy and the 22g @ the same time tho.

Then throw both in the bin as I grab the ET.
Works really well.

 

[PpfSuxTube]

Unless I have some compelling reason to do the spinal such as critical aortic stenosis

Please elaborate...

Ive done total spinals for AVR due to severe AS but its a bit of a production and you need plenty levo.

You do spinals on severe AS patients for non cardiac stuff?

 

[dabears505]

Please elaborate...

Ive done total spinals for AVR due to severe AS but its a bit of a production and you need plenty levo.

You do spinals on severe AS patients for non cardiac stuff?

I'm just joking man.

 

[woopedazz]

Thoughts on spinals for basal ganglia strokes?

 

[epidural man]

when the L5-S1 space is far and away the biggest space on every human,

This can be true -

However -

The lower spaces usually are more calcified.

 

[Urzuz]

This. I find most people go quite high, up at L3-4 and likely L2-3, when the L5-S1 space is far and away the biggest space on every human, just can’t usually feel the spinous process. I will try L3-4 first, but if unsuccessful will often go down a space.

Though this may be true, in my experience the L2-3 space is oftentimes more superficial and located on a more kyphotic area of the spine, so practically speaking it can be easier to access. Especially in the huge patient coming in to get their TKA (you know the patient I’m talking about), the excess fat in the lordotic area of the spine between L4-S1 can make spinals extremely challenging.

If I fail at L3-4 due to the space being too tight, I’ll go paramedian and/or move down a level. If I fail because even the XXL needle is too short, I’ll usually move up a level and try midline again.

 

[triggermaster]

That’s interesting. I pretty much feel the opposite. Higher up (L3-4) may be smaller but if you can feel the space better, you’ll be reliably in the midline and being off-midline is the problem most of the time when I take over from someone who’s struggling. Also it’s not as deep. Also scoliosis, if present, is usually worse the lower you go.

I go straight to CSE if the spinal needle from the kit doesn’t reach. A) it always works pretty much and B) smaller rural puncture.

take a look at some lumbar spine xrays

for the most part, the lower you go, the more open the spaces..

the easiest is L5S1 or L45 just off midline

its easier to feel the bony spinous processes at the higher lumber/low thoracic levels, but the spaces are usually tighter.

i go low with a 25g, redirect upwards and slightly off midline to either side, several times at that level.

if no success move to a different level and also have several redirects.

after 2 levels i go to a 22g spinal. in OB I would maybe try a third level with the 25g.

i would not consider a tuohy helpful vs a 22g spinal personally.

if i cant get it with a 22 after 15 mins then abandon..

 

[Hoya11]

That’s interesting. I pretty much feel the opposite. Higher up (L3-4) may be smaller but if you can feel the space better, you’ll be reliably in the midline and being off-midline is the problem most of the time when I take over from someone who’s struggling. Also it’s not as deep. Also scoliosis, if present, is usually worse the lower you go.

I go straight to CSE if the spinal needle from the kit doesn’t reach. A) it always works pretty much and B) smaller rural puncture.

You don’t have to be perfectly midline and in fact the spaces are bigger just off to the side a little

Also needle does not reach is a different problem than can not get spinal did to flimsy 25, and if it’s a needle doesn’t reach issue then I agree with your approach

 

[pgg]

with spinals it's all about trying to visualize or predict where the spinal space is. I mean you are purposefully trying to puncture the dura. The technique doesn't need to be nuanced like an epidural

I struggled mightily to put in a lumbar drain a couple weeks ago. Monster 14 g cutting needle and good landmarks in a 100ish kg guy. Chip shot!

In my defense he wasn't really holding still and twice reached back into my field to point out where it hurt.

I kept telling myself that wet tapping someone is the easiest thing in the world.

 

[pgg]

take a look at some lumbar spine xrays

for the most part, the lower you go, the more open the spaces.

Also - the lower you go, the less of an issue scoliosis tends to be.

Edit, just saw this followup post -

Also scoliosis, if present, is usually worse the lower you go.

What do you mean? That doesn't make sense to me. A space or two above the sacrum is going to be the closest to straight that a twisted spine is going to be.

 

[GassYous]

I struggled mightily to put in a lumbar drain a couple weeks ago. Monster 14 g cutting needle and good landmarks in a 100ish kg guy. Chip shot!

In my defense he wasn't really holding still and twice reached back into my field to point out where it hurt.

I kept telling myself that wet tapping someone is the easiest thing in the world.

Give him some versed and ketamine

 

[triggermaster]

Also - the lower you go, the less of an issue scoliosis tends to be.

Edit, just saw this followup post -



What do you mean? That doesn't make sense to me. A space or two above the sacrum is going to be the closest to straight that a twisted spine is going to be.

That’s fair. Sometimes is better sometimes it’s worse.

 

[triggermaster]

You don’t have to be perfectly midline and in fact the spaces are bigger just off to the side a little

Also needle does not reach is a different problem than can not get spinal did to flimsy 25, and if it’s a needle doesn’t reach issue then I agree with your approach

If you can’t get it with a flimsy 25 it’s because you are missing. -That’s where going higher and being better able to palpate the anatomy is helpful.

 

[Hoya11]

If you can’t get it with a flimsy 25 it’s because you are missing. -That’s where going higher and being better able to palpate the anatomy is helpful.

next time you run into that try a 22 at the same level before you go higher - i think you will find it steers a little better and helps change trajectory more effectively leading to success

 

[narcusprince]

I hate the long whitaker spinal needles. They tend to bend and are flimsy. A big concern in my practice we have cse kits. However some staff still choose to place 25 gauge needles through non cse Thouy needles. It definitely makes me concerned about needle sheering and metal shavings. Thoughts?

 

[Maz777]

I hate the long whitaker spinal needles. They tend to bend and are flimsy. A big concern in my practice we have cse kits. However some staff still choose to place 25 gauge needles through non cse Thouy needles. It definitely makes me concerned about needle sheering and metal shavings. Thoughts?

What is a non-CSE Tuohy needle? A Tuohy is a Tuohy. Nothing magical about the CSE kit Tuohys.

I've had no issues with the long 25g Whitacres through a regular Tuohy. You'd have to do something horribly wrong to shear your needle or shave off metal.

 

[narcusprince]

What is a non-CSE Tuohy needle? A Tuohy is a Tuohy. Nothing magical about the CSE kit Tuohys.

I've had no issues with the long 25g Whitacres through a regular Tuohy. You'd have to do something horribly wrong to shear your needle or shave off metal.

Cse Tuohy needles have 2 holes one for epidural catheter one for the spinal needle. Sounds like you got the wong hole….

 

[Maz777]

Cse Tuohy needles have 2 holes one for epidural catheter one for the spinal needle. Sounds like you got the wong hole….

Our CSE kits do not have that extra spinal hole. It's no longer a Tuohy needle then. It's a modified Tuohy. Never used those. Seems unnecessary and a way for B.Braun, etc. to sell more expensive kits to you.

A Whitacre follows the nature curvature of a Tuohy upon exiting. It's not going to shear or shave.

 

[Anesthesia_Guy]

Sounds like you got the wong hole….

That's what she said!

 

[DrAmir0078]

6 months Attending here with 203 Spinals I did and 349 GA; I had to convert to GA less than 10 times; my threshold is not a time, it is actually my attempts especially when it is impossible to switch to GA. One time had to do it 15 times (the patient is like over 125 kg with severe chest infection and emergency), but could get it, and another one had 10 attempts but she was elective and postpone... I use 23G quincke needle. If you are in the US, please use ultrasound.
My question guys, do you lido the area before needling?

 

[Maz777]

6 months Attending here with 203 Spinals I did and 349 GA; I had to convert to GA less than 10 times; my threshold is not a time, it is actually my attempts especially when it is impossible to switch to GA. One time had to do it 15 times (the patient is like over 125 kg with severe chest infection and emergency), but could get it, and another one had 10 attempts but she was elective and postpone... I use 23G quincke needle. If you are in the US, please use ultrasound.
My question guys, do you lido the area before needling?

Infiltrating lidocaine is uncommon in many areas of the world. Your technique is more common in many countries (no sedation, no infiltration, no introducer, 22-23g Quincke). Patients in the US are not as stoic as many patients elsewhere and demand sedation/lidocaine infiltration. Else, they jump around and it makes the spinal take much longer. I infiltrate everyone.