Which size tuohy needle do you use?

Started by painfre
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painfre

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Which size tuohy needle do you use? I use 18g from arrow kit for Lumbars and 20g for cervical ESI. I went for MILD course in the weekend where I met a physician who said that he uses 22G tuohy needle for Lumabr and cervcials? Any thoughts on this ?
 
I think we were in the course together. I use 22ga for lumbars (when they're not too fat and I need a longer needle) and cervicals, have done so for 2 years, would never go back to fatter gauges again.
 
Thanks for your answer. I will switch over to 20 and 22 too. Were you in the afternoon session ?
 
What's the advantage of 22g? I assume less pain (but can be reduced with local) and less likely to have PDPH (but does it make any difference if it's 20g vs 22g?). On the other hand, 20g probably give you more definitive LOR.

I use both both, but default if 20g.
 
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mid|ine said:
Only relevant if performing blind ESIs. Not to mention this was a study to evaluate the use, so this was their first 100 uses. I have performed thousands with 22g and am quite confident with them.
Click to expand...

I like 22g. But 20g "feels" better for me, at least in the neck...
 
This is not a pissing contest.
As long as it's not a 27G or a 14G, and as long as it is FGCE, then it is correct.
Blind is not SOC.
No contrast is not SOC (can be appropriate if allergy to contrast.)

Only my opinions.
 
Just ordered the 22g to check it out. As a fellow found 18g easier to use for hanging drop than 20g but now just use LOR for CESIs.
 
18 guage for lumbar, thoracic and cervical ILESI. Get a better feel with the bigger needle.
 
Which brand do you use. I wanted to try 20G 5" HAvels Tuohy needle, for a obese pt of mine today, but the needle was so thin and flimsy I have to go back to 18G tuohy from my arrow kit.
 
Would not suggest the hanging drop technique due to positive pressures measured in the cervical epidural space in both prone and sitting positions
http://www.ncbi.nlm.nih.gov/pubmed/20693880

Additionally there is more potential risk of dural damage or potentially cord damage due to the hanging drop technique requiring an additional 2mm needle advancement over LOR
http://www.ncbi.nlm.nih.gov/pubmed/10690148

This implies the dura is being tented in, with displacement of spinal fluid as the means of the hanging drop technique mechanism creating the negative pressure.

There may also be no loss of resistance if there is midline needle placement due to the ligamentum flavum clefts that occur in 50% of C7T1 and 65% of C6/7 placement. (Lirk)

Therefore for cervical placement, neither LOR or hanging drop techniques are accurate. The lateral fluoro view frequently sucks no matter how much you tug on the arms of the patient or have them shrug their shoulders or balance their corpulant bodies precariously on an oakworks frame. Therefore I suggest serial advancement under fluoroscopy using the contralateral oblique approach. The lamina are easily appreciated and the ligamentum flavum is approximately 2mm thick (assuming no spinal stenosis) anterior to the lamina. The LOR technique (with saline, thank you) is used as a confirmatory test rather than the primary marker of the epidural space.
 
completely agree. 18 gauge needle and OBL view is the best way to safely do a cervical.
Although since the LOR isn't the definitive final confirmation of location with cervicals, I can understand why people do cervical ESI with a smaller gauge needle and checking contrast spread every 1-2 milimeters once they get right next the ligament.

Although anyone doing hanging drop cervicals sans fluoro in the 21st century should lose his license.
 
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any pictures on how to do cervical ESI with oblique approach? haven't been exposed to it before, but sounds interesting.
 
drpainfree said:
any pictures on how to do cervical ESI with oblique approach? haven't been exposed to it before, but sounds interesting.
Click to expand...


gotta say the 60 degree contralateral oblique is something, along with plastic LOR, that has made cervicals much easier (thank you SDN). you can almost always see the lamina in the oblique, and almost never (in my "husky" indiana patients) in the lateral.

i pretty much start injecting contrast if i dont get LOR anywhere near where I think it should be...better a smudge of contrast then a cord stick.
 
I'm confused with the pictures included in the website: Figure 7 shows oblique view, and Figure 8 shows lateral with contrast injected. I don't really see much difference between the two.

Figure 8 doesn't really look like a lateral view though. Lateral cervical should show facet joints.

What does it mean by "shingled appearance" in "The tube is rotated to the contralateral oblique projection, approximately 45 degrees opposite the side of the needle entrance, until the laminae take on a shingled appearance"?

For all you doing CESI with contralateral oblique approach, do you mind to post some pictures?

Thanks for sharing this interesting technique.
 
6 French? Hilarious. Reminds me of the MILD course. That thing makes a Medtronic tunneler look like a toothpick!

FWIW, I LOVE to go far lateral on cervicals. I really try to get the contrast flow along the cervical epidural gutter. You can see roots enhance, and contrast wraps around anterior pretty well. It's my substitute for cervical TFESI. Since most of my cervicals are for unilateral arm pain from HNP, it makes sense to get the med as close to the pathology as possible. Additionally, the ligament is much more reliable laterally as compared to midline (thanks Algos).

Saw this technique in fellowship at private block shop. They called it "epiradicular" and billed as multilevel TFESI. Obviously fraud, but the technique is great.
 
algosdoc said:
Would not suggest the hanging drop technique due to positive pressures measured in the cervical epidural space in both prone and sitting positions
http://www.ncbi.nlm.nih.gov/pubmed/20693880

Additionally there is more potential risk of dural damage or potentially cord damage due to the hanging drop technique requiring an additional 2mm needle advancement over LOR
http://www.ncbi.nlm.nih.gov/pubmed/10690148

This implies the dura is being tented in, with displacement of spinal fluid as the means of the hanging drop technique mechanism creating the negative pressure.

There may also be no loss of resistance if there is midline needle placement due to the ligamentum flavum clefts that occur in 50% of C7T1 and 65% of C6/7 placement. (Lirk)

Therefore for cervical placement, neither LOR or hanging drop techniques are accurate. The lateral fluoro view frequently sucks no matter how much you tug on the arms of the patient or have them shrug their shoulders or balance their corpulant bodies precariously on an oakworks frame. Therefore I suggest serial advancement under fluoroscopy using the contralateral oblique approach. The lamina are easily appreciated and the ligamentum flavum is approximately 2mm thick (assuming no spinal stenosis) anterior to the lamina. The LOR technique (with saline, thank you) is used as a confirmatory test rather than the primary marker of the epidural space.
Click to expand...

Thank you algosdoc. As usual very interesting information and backed up by some literature.

I use a further confirmatory step after prone position CESI LOR to saline of attaching a 12" microbore tubing filled with saline and a snap lock at the distal end. Unlock the snap watch the drop of saline in the tubing and then resnap, remove tubing and inject contrast. Helps avoid a false LOR leading to a subsequent "blobogram". Anecdotally 99% of the time I get a good contrast pattern when I use this technique.

I was under the impression this "fluid column drop" was due to the negative pressure of epidural space. Since I am not using a hanging drop and hopefully not tenting the dura 10 times a week for the last 3 years(knock on wood never had a PDPH or obvious wet tap) what do you attribute this phenomena to?

Also if a ligmentum flavum cleft occurs at C7-1 50% of the time then that would seem to argue for using hanging drop instead as the LOR would be to hard to appreciate. Obviously LOR works so the clinical utility of this cleft anatomical finding is uncertain.

As a fellow we actually did our hanging drop CESIs with fluoro(when not at the VA clinic, but that's another story...) Interesting technique: Pt seated at head of the flouro table with forehead resting on raised table. C arm raised to max height flipped up and over patient. This provided an excellent lateral view as gravity helped keep the shoulders out of the way. Procedure then performed in "classic" blind hanging drop manner, with contrast confirmation, with physician in standing position. I probably did 50 of these as a fellow, there were 8 fellows and the fellowship had been around unofficially since the very early 80s. The N has to be close to 10K(ones done before early 90s were "blind") CESIs with hanging drop tech at this institution without a significant adverse (ie cord stick) outcome.

I am not a proponent of the above technique(vasovagal from that positioning was an issue) but I am a proponent of learning every "safe" way of performing the procedures we all do. There is always a particular patient/case where it will come in handy.

Thank you to all the contributors to this forum. I now use the contralateral oblique LOR to saline CESI 90% of the time based in part on what I have learned on this forum. Plus Im a CTFESI hold out anyway.... 😉
 
lol...love those TFESIs. The LOR is clearly more easily appreciated through a paramedian approach such as the contralateral oblique because the clefts are avoided. The lie directly in the midline whereas the needle enters the lig flavum off center....
 
As far as the contralateral oblique technique is concerned, I LOVE it. But what I love more is telling patients I learned it on the internet 😀
 
I forget, if you're needle is far lateral, in the gutter and you check the contralateral oblique view, will your needle look too deep or too superficial? Can you even rely on that view when going far lateral?
 
The oblique contralateral view safety depends on the tip of the needle being in the midline, entering the ligamentum flavum off center to arrive at the midline. If the needle tip is anterior to the posterior foraminal line (a line drawn across the posterior border of the neuroforminal projection) then the tip is either off center or you arre dealing with a very thickened ligamentum flavum. If the former is the problem and the tip is not too far off midline (1-2mm), then cautious advancement is possible. However if the tip is midline and within 1mm-2mm anterior to the posterior foraminal line, it would be better to withdraw and enter at another level. The approach placing the tip far off midline in the gutter can pith the cord or can pith the exiting nerve, and given the epidural space is usually largest at the midline, this is the safest location for the tip. However, one must view the MRI axial and sagittal views prior to performing the ESI because a HNP may rotate the entire cord one direction or another. The normal width of the epidural space in the cervical spine is 1-4mm only. Rotation or posterior displacement of the cord or thickening of the ligamentum flavum can further reduce this number.
 
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My partner, who's been in this game longer than I've been a doctor, has gone away from Tuohy and just uses a standard 22g quincke tip, advances down to lamina for depth, then walks off the lamina with LOR saline with extension tubing. I trained with 18g tuohy, epidural tray, glass LOR - very traditional technique. Has anybody ever used this technique? My partner claims excellent results - no false losses, no wet taps, etc.
 
drrosenrosen said:
My partner, who's been in this game longer than I've been a doctor, has gone away from Tuohy and just uses a standard 22g quincke tip, advances down to lamina for depth, then walks off the lamina with LOR saline with extension tubing. I trained with 18g tuohy, epidural tray, glass LOR - very traditional technique. Has anybody ever used this technique? My partner claims excellent results - no false losses, no wet taps, etc.
Click to expand...

I use quinckes and similar mostly. I try not to hit the lamina, but judge the depth in AP based on body habitus, go down about 1/2 to 2/3rds of what I would estimate is the depth to the epidural space. Then I stop, go lateral and advance to the LF, then mainly use LOR. Once there, I fluoro live with contrast, then inject steroid.

Wet taps very rare. False LOR sometimes - too shallow. But I'm quite slower than most of you and advance cautiously.
 
PMR 4 MSK said:
I use quinckes and similar mostly. I try not to hit the lamina, but judge the depth in AP based on body habitus, go down about 1/2 to 2/3rds of what I would estimate is the depth to the epidural space. Then I stop, go lateral and advance to the LF, then mainly use LOR. Once there, I fluoro live with contrast, then inject steroid.

Wet taps very rare. False LOR sometimes - too shallow. But I'm quite slower than most of you and advance cautiously.
Click to expand...

I touch lamina in 100% of LESI/CESI cases with the Tuohy. Bone is the second best determinate of depth. Lateral fluoroscopy is #1.
 
I was taught to do CESIs with a 22 ga and hanging drop, but there were times when the drop only quivered but never droppped so now I use the 22 with saline LOR.

I was listening to a disc of the last ISIS meeting and Dreyfuss said that he uses a 25 ga Touhy. I can't even find one but I like the idea of a smaller needle and so I'm tempted to try the quincke. The disc has some nice pictures of the contralateral view.

The shingled effect can be seen on the roof of your house, especially if you have roof tiles for shingles.
 
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