We do them.
Lawyers!? Private equity and finance is the scourge of the earth…
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All of the above. Thank you forgot about those. But yes. Lawyers too.
When i trained the lumbar drains were just epidural catheters inserted into the csf. Very easy for us to do in anesthesia.
We used to use the epidural kits and catheters for vascular cases and had a high rate of eventually being unable to pull CSF off, and so switched to a dedicated kit. Larger tuohy, styleted catheter, the whole magillah
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At the hospital I did residency the neurosurgery NPs would do the block in the ED for migraine patients using this device.I’m purely outpatient pain, private practice. Epidural blood patch pays about $160. Definitely not worth the time and risk. I’ve done a few when the patient really needed it but I avoid if possible. I agree with OP - don’t assume risk if you’re not getting paid for it.
Those of you stuck in that situation though, and not wanting to leave the patient totally hung out to dry (or a patient who has a legit PDPH but EBP contraindication), I highly recommend the Sphenopalatine ganglion block:
Images in Anesthesiology: Modified Cotton Swab Applicator... : Anesthesiology
An abstract is unavailable.
It’s low risk and not very technical. Any doctor should be able to do it. Basically you stick an 18g angiocath into a long hollow cotton swab, then stick it to the back of the nasopharynx, and put about 1-2 mL lidocaine down each side. I do it with the patient supine with head extended, with a pillow under their upper back, which allows the lidocaine to pool on the SPG. Immediate relief and relief can last for several days. Risk of nosebleed - lubing the tip of the swab, or at least moistening it with lidocaine, helps. As a bonus, it also works amazingly for migraine. Have them roll to the side and blow their nose after about 3-5 minutes.
Billing it is iffy and you probably won’t get paid much if anything - CPT 64999. There’s a dedicated CPT for SPG injection but it applies only if you use a needle to access the nerve.
If you can’t or don’t want to stick a swab 4 inches into their nose, you can put them in the neck-extended position and just put the angiocath on the syringe and drip 2 mL lidocaine down each nostril.
Bonus points if you convince the ER doctors they’ll get the patient out much faster if they just do the SPG block themselves instead of waiting for you.
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I really like this idea, but I’m surprised you’re able to get people to let you shove this thing so far back in their nose. I remember those early deep Covid swabs and wanted to die every time I had to have a test.I’m purely outpatient pain, private practice. Epidural blood patch pays about $160. Definitely not worth the time and risk. I’ve done a few when the patient really needed it but I avoid if possible. I agree with OP - don’t assume risk if you’re not getting paid for it.
Those of you stuck in that situation though, and not wanting to leave the patient totally hung out to dry (or a patient who has a legit PDPH but EBP contraindication), I highly recommend the Sphenopalatine ganglion block:
Images in Anesthesiology: Modified Cotton Swab Applicator... : Anesthesiology
An abstract is unavailable.
It’s low risk and not very technical. Any doctor should be able to do it. Basically you stick an 18g angiocath into a long hollow cotton swab, then stick it to the back of the nasopharynx, and put about 1-2 mL lidocaine down each side. I do it with the patient supine with head extended, with a pillow under their upper back, which allows the lidocaine to pool on the SPG. Immediate relief and relief can last for several days. Risk of nosebleed - lubing the tip of the swab, or at least moistening it with lidocaine, helps. As a bonus, it also works amazingly for migraine. Have them roll to the side and blow their nose after about 3-5 minutes.
Billing it is iffy and you probably won’t get paid much if anything - CPT 64999. There’s a dedicated CPT for SPG injection but it applies only if you use a needle to access the nerve.
If you can’t or don’t want to stick a swab 4 inches into their nose, you can put them in the neck-extended position and just put the angiocath on the syringe and drip 2 mL lidocaine down each nostril.
Bonus points if you convince the ER doctors they’ll get the patient out much faster if they just do the SPG block themselves instead of waiting for you.
It’s not the most comfortable. Those Covid swabs are dry and unlubricated though. It helps to get the swab wet with lidocaine.
Nothing special, and just anecdotal. Had a few patients in fellowship with PDPH after IT pump implant. Obviously didn’t want to blood patch that. Did SPG block and they had relief for several days and then gradual resolution of the headache after that.
Very interesting, thanks.
Done them a fair amount. I've found them to be successful maybe 50% of the time, but the ones that WERE successful, the ladies left the hospital and didn't come back. So it apparently provided enough relief to get them through the most acute phase. Also, lidocaine jelly on the swabs with slow advancement will get you back there pretty easily.
