Transforaminal injections- do you bend the needle tip?

[deleted993114]

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Just reading another thread and I got the impression (perhaps wrongly) that many people do not bend the tip of needles when doing a transforaminal injection. I have ALWAYS done that and was taught to do so at the very start in order to ease guidance of the needle and avoid the "Singer sewing machine" effect of withdrawing and reinserting needles to change direction.

I have usually used a 25 gauge blunt tipped needle and put a bend in it. I have never had a kink of the needle ever. When we used to do discograms, I did find that if one bent the 18 gauge introducer needle, that it was sometimes hard to get the long 22 bent needle through it. But rarely did one bend the introducer.

Am I in the minority in using bent tipped needles (I put the bend in myself- just the tip)? To each his own, but I would certainly find it hard to guide needles into tight areas without a bend, but that is the way I have always done them.

Bend or no bend?

 

[deleted185747]

I bend. I am also careful to not spin the hub without advancing whenever the needle tip is inside the foramen because the sides of a cutting tip like a quinke act like a saber.

 

[SSdoc33]

i think most people bend

 

[paindoc007]

Yes, always bend

 

[soccrwz]

for TFESI with tight foramen, I insert the 22G BD needle into the 18G needle opening and bend it to get a tight 15 degree curve, nice trick as the curve is very gentle and steerable but a smaller curve is achieved without bending by hand. Learned this from a national teacher

 

[Ligament]

always bend almost all Fluoro guided needles, except SIJ injections where I want a stiff needle so I can get tactile feedback as I wedge the needle in there.

I sometimes bend my u/s guided needle tips, but find its just not needed too often since I'm visualizing trajectory changes in real time.

I think the coolest way to do this stuff is like Windsor used to do it; clamp a hemostat on the hub and drive a straight needle in real time to the target in .5 seconds.

 

[clubdeac]

always bend almost all Fluoro guided needles, except SIJ injections where I want a stiff needle so I can get tactile feedback as I wedge the needle in there.

I sometimes bend my u/s guided needle tips, but find its just not needed too often since I'm visualizing trajectory changes in real time.

I think the coolest way to do this stuff is like Windsor used to do it; clamp a hemostat on the hub and drive a straight needle in real time to the target in .5 seconds.

That's how Depalma always did it too

 

[clubdeac]

for TFESI with tight foramen, I insert the 22G BD needle into the 18G needle opening and bend it to get a tight 15 degree curve, nice trick as the curve is very gentle and steerable but a smaller curve is achieved without bending by hand. Learned this from a national teacher

This is exactly what I do

 

[callmeanesthesia]

On a somewhat related note, what needle type do you all use? I trained with quincke and usually use 25g. When you reference blunt needles are you talking sprotte/pencan? And if so how much are you paying? I looked at those because I like the idea of reduced risk of nerve injury but from my supplier (Henry Schein) they were about $10 each.

 

[TIVAndy]

i guess i'm a minority. i use 5 inch 22g. no bending. just let the bevel and above skin maneuver drive the needle. in fellowship we were taught to bend

 

[deleted993114]

On a somewhat related note, what needle type do you all use? I trained with quincke and usually use 25g. When you reference blunt needles are you talking sprotte/pencan? And if so how much are you paying? I looked at those because I like the idea of reduced risk of nerve injury but from my supplier (Henry Schein) they were about $10 each.

I use a 25 g Whitacre.

 

[DOctorJay]

i guess i'm a minority. i use 5 inch 22g. no bending. just let the bevel and above skin maneuver drive the needle. in fellowship we were taught to bend

same here

 

[Ferrismonk]

5" 22G Quinke, bend. No introducer.

 

[SSdoc33]

always bend almost all Fluoro guided needles, except SIJ injections where I want a stiff needle so I can get tactile feedback as I wedge the needle in there.

I sometimes bend my u/s guided needle tips, but find its just not needed too often since I'm visualizing trajectory changes in real time.

I think the coolest way to do this stuff is like Windsor used to do it; clamp a hemostat on the hub and drive a straight needle in real time to the target in .5 seconds.

so your hand pushing a hemostat is more accurate than your hand alone? makes no sense. ive tried it and is like like trying to write by holding the pencil at the eraser.

 

[DODOCSS]

22 5" (no bend), more obliquity helps

 

[Ducttape]

apparently... live fluoro with hemostat to keep hand out of image. cone down, wear glove.

its supposed to be "quick" and efficient.

however, most of the charts I have reviewed using this technique have 60+ seconds for an SI and 120 seconds+ for a TF...

 

[deleted993114]

so your hand pushing a hemostat is more accurate than your hand alone? makes no sense. ive tried it and is like like trying to write by holding the pencil at the eraser.

Yes- I guess I don't understand what the advantage of the hemostat is. Can someone explain that to me? This is the first time I've ever heard of it.

 

[DODOCSS]

Yes- I guess I don't understand what the advantage of the hemostat is. Can someone explain that to me? This is the first time I've ever heard of it.

Radiation Risk to the Fluoroscopy Operator and Staff
Cosette M. Stahl1,2, Quinn C. Meisinger1,2, Michael P. Andre1,2, Thomas B. Kinney1,2 and Isabel G. Newton1,2



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[Ducttape]

use the hemostat to hold the needle anduse continuous fluoroscopy, advance the needle in real time. keeps hand out of the field.

 

[Doctodd]

yes bend it with the plastic condom sheath every time. Typically use 22G 3.5".....sometimes use 25g 2" cuz it doesnt go anywhere it wants like the 25G 3'5"

 

[DoYouEvenLiftBro]

always bend almost all Fluoro guided needles, except SIJ injections where I want a stiff needle so I can get tactile feedback as I wedge the needle in there.

I sometimes bend my u/s guided needle tips, but find its just not needed too often since I'm visualizing trajectory changes in real time.

I think the coolest way to do this stuff is like Windsor used to do it; clamp a hemostat on the hub and drive a straight needle in real time to the target in .5 seconds.

Side note, Isn’t he getting out of jail soon?

 

[Ligament]

Side note, Isn’t he getting out of jail soon?

I do not know any of his details.

 

[DODOCSS]

yes bend it with the plastic condom sheath every time. Typically use 22G 3.5".....sometimes use 25g 2" cuz it doesnt go anywhere it wants like the 25G 3'5"

must have skinny patients in soflo

 

[swamprat]

I always bend. Makes it that much easier if u need to make an adjustment when you’ve alrdy purchases some tissue. I also prefer 5” as I find that the average patient I see is obese and often have to hub or rent the skin if I don’t

 

[pmrmd]

60%: 25g quincke, bend it using the scabbard.
40%: 22g 5-inch. 5-1 and the fatty at L4-5, bend using the scabbard.

 

[epidural man]

I tell my fellows NOT to bend the needle (everyone else tells them to bend).

I tell them that bending the needle is a sign of weakness.

Bending is probably better -

But honestly, I want them to get VERY GOOD without the bend. They should be able to stear that needle with out the bend. And honestly - what I want them to do is get to the point where the first shot is a 'dot shot' and after that, use the bevel for tiny adjustments, and very little stearing is ever needed. That first shot is key.

 

[TIVAndy]

I tell my fellows NOT to bend the needle (everyone else tells them to bend).

I tell them that bending the needle is a sign of weakness.

Bending is probably better -

But honestly, I want them to get VERY GOOD without the bend. They should be able to stear that needle with out the bend. And honestly - what I want them to do is get to the point where the first shot is a 'dot shot' and after that, use the bevel for tiny adjustments, and very little stearing is ever needed. That first shot is key.

this is exactly what i teach also. being coaxial to begin with and with good fluoro view is crucial and 50% of the work done. the only times i do bend the needle is when i do deeper blocks - celiac plexus, lumbar sympathetic, hypogastric blocks that do not maneuver very well with bevel since needle has penetrated deep into the tissue plane