versaitle_kat said:
For the pro's out there - any tips or advice for increasing the likelihood of success with SAB in the lateral position. I know it will come with time and repetition, but any help would be greatly appreciated. Thanks in advance.
The paramedian approach is a great thing....especially in the elderly where disc spaces are small. Usually works the best with a 22" needle...with a 25" you cant usually use an introducer since you'll run out of needle, and without an introducer, a 25" warps when you advance it...it can be done, but is easier with a 22"...which, in the arena I use the paramedian approach (elderly spinals for hips, etc) the bigger needle isnt an issue.
Find the level you wanna be at, say L2 L3 and make a mark of the superior portion of L3's spinous process with your thumbnail. Thats the inferior portion of your selected disc space. Your goal is to start out (albeit lateral to) in the inferior disc space area, hence giving yourself some "superior-space-leeway".
Prep the area. Now look at your thumb mark. Take your 25" local anesthesia-filled syringe, visualize a spot about 3/4 of an inch lateral to the mark and make your skin weal. I always go to the right cuz I'm better that way. Leave the 25" needle in the skin, pop the syringe off, put the 21" needle on your local syringe. Now while directly looking at the 25" needle still in the skin, pull it out and place the 21" needle in the exact same spot. Before advancing, point the needle slightly medial and superior. Advance and localize. The 21", in addition to putting in local along the future track of the spinal needle can be used to fine tune the future path. Hit bone? Pull almost all the way out, aim more superior (drop the syringe a little), maybe a little more medial, etc.
When youre done, pull off the syringe, leaving the 21" needle in.
Now take your 22" needle, and while directly looking at the local needle, pull it out and place the spinal needle in the exact spot. Now replicate the path you took with the 21" local needle.
So you start about 3/4" lateral to the bottom spinous process of the selected space. Take the tip of the spinal needle, push just slightly into the skin, and before advancing, point a little medial and a little superior. Advance. Hit bone, pull almost all the way out and fine-tune your path. A little more superior. A little more medial. Etc etc.
Takes practice but once you hit a couple, at least in the elderly, youll come to the conclusion that its probably easier than the midline approach.
