C7-1 vs C6-7 CESI

[HyperSonic]

Not trying to be snarky.

With the 25G quinke, I advance in CLO. Needle tip is advanced until close, puff of contrast shows still outside ligaments. Advanced 1mm, feel tight ligamentum flavum on needle and resistance to contrast, then advance 1mm and release of resistance to contrast injection. See contrast in epidural spread. Any deviation you withdraw, reassess, and try again. Hanging drop or LOR with contrast at the end just for confirmation just isn't as good.

If you're afraid of a sharp needle, I get that, but if I'm anywhere near a cord injection, a lot has gone wrong.

FWIW, I use saline and dex only in CESI. Never had any chest pressure complaints.
Dex concerns with benzoyl alcohol/PEG are avoided altogether by using preservative-free dex.

I would like to warn young colleagues on that technique. It might be great in experienced hands. CLO is a great view, but it could be tricky depending how close the needle to the midline and even more tricky if the needle crossed the midline after fluoro was rotated to the CLO after AP without proceduralist realizing that. Also this technique sounds too lengthy for me, too many “inject, withdraw, reassess ( but it’s my humble opinion),- usually regular CESI does not take more than 3 fluoro shots for me total.

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[callmeanesthesia]

I would like to warn young colleagues on that technique. It might be great in experienced hands. CLO is a great view, but it could be tricky depending how close the needle to the midline and even more tricky if the needle crossed the midline after fluoro was rotated to the CLO after AP without proceduralist realizing that. Also this technique sounds too lengthy for me, too many “inject, withdraw, reassess ( but it’s my humble opinion),- usually regular CESI does not take more than 3 fluoro shots for me total.

And I would very strongly warn younger (and older) colleagues against doing a CESI in only 3 fluoro shots. CLO is a revolution in the safety of CESI. Yes, just like anything else, you could hurt someone if you don’t know what you’re doing. The problem with other techniques of CESI is that it’s very easy to hurt someone even if you do know what you’re doing.

Here’s my technique. Maybe it’s because I’m anesthesia trained but I still like to feel LOR. I don’t rely on it though. I basically go for as many safety guardrails and indicators as possible.

Target top edge of T1 lamina, on the side of the worst pain. Skin local. 22g tuohy down to touch lamina, slight medial angulation. Reorient superior while keeping finger on needle shaft to advance minimally farther than the depth of lamina. Go to CLO. Advance to a few mm posterior to VLL. Attach 3 mL syringe containing about 1.5 mL contrast. Advance using LOR-type technique but injecting very minimal volume. Fluoro shots when close to or crossing VLL to check contrast spread. Often can feel the needle tip engage in ligament and then pop through thanks to non-quincke tip. Almost always a distinct loss of resistance. Usually can see on fluoro the exact point I need to reach. When I attach the syringe there’s a bubble in the needle hub, and often I’ll see that bubble drop into the needle when I enter the epidural space, giving a hanging drop-like effect.

 

[DrMDAware]

And I would very strongly warn younger (and older) colleagues against doing a CESI in only 3 fluoro shots. CLO is a revolution in the safety of CESI. Yes, just like anything else, you could hurt someone if you don’t know what you’re doing. The problem with other techniques of CESI is that it’s very easy to hurt someone even if you do know what you’re doing.

Here’s my technique. Maybe it’s because I’m anesthesia trained but I still like to feel LOR. I don’t rely on it though. I basically go for as many safety guardrails and indicators as possible.

Target top edge of T1 lamina, on the side of the worst pain. Skin local. 22g tuohy down to touch lamina, slight medial angulation. Reorient superior while keeping finger on needle shaft to advance minimally farther than the depth of lamina. Go to CLO. Advance to a few mm posterior to VLL. Attach 3 mL syringe containing about 1.5 mL contrast. Advance using LOR-type technique but injecting very minimal volume. Fluoro shots when close to or crossing VLL to check contrast spread. Often can feel the needle tip engage in ligament and then pop through thanks to non-quincke tip. Almost always a distinct loss of resistance. Usually can see on fluoro the exact point I need to reach. When I attach the syringe there’s a bubble in the needle hub, and often I’ll see that bubble drop into the needle when I enter the epidural space, giving a hanging drop-like effect.

I appreciate your thoughtful response.

I do not doubt your skills and expertise.

It’s tough to capture the complete essence and all subtleties and nuances of a procedure with words.

I would caution again relying on touching lamina, though. I know you do not use that as a “backdrop” or safety measure. However, I personally find it safer to advance closer to the epidural space in the CLO view. I personally frequently find myself going from clo back to AP ish more than once to make sure.

My fear with any physician relying on touching the lamina is they may skive off and go past it inadvertently.

In addition, and you never said this, is I know someone who relied on touching lamina for a lumbar SCS and failed to realize or appreciate there was no lamina.

In terms of the LOR technique all I can say is I echo what others have said: don’t assume you need to go deeper, don’t sedate, when in doubt use contrast and take a shot, use PF dex, and never assume you’ll have a nice crisp LOR (use the darn tube). When in doubt give a test dose of lido and wait 90-120 seconds and also examine the patient in Pacu. Nothing new here.

I will say I’m surprised there’s not more of a discussion about placement of the head. Not sure if there’s consensus here. Happy to hear thoughts.

 

[callmeanesthesia]

I appreciate your thoughtful response.

I do not doubt your skills and expertise.

It’s tough to capture the complete essence and all subtleties and nuances of a procedure with words.

I would caution again relying on touching lamina, though. I know you do not use that as a “backdrop” or safety measure. However, I personally find it safer to advance closer to the epidural space in the CLO view. I personally frequently find myself going from clo back to AP ish more than once to make sure.

My fear with any physician relying on touching the lamina is they may skive off and go past it inadvertently.

In addition, and you never said this, is I know someone who relied on touching lamina for a lumbar SCS and failed to realize or appreciate there was no lamina.

In terms of the LOR technique all I can say is I echo what others have said: don’t assume you need to go deeper, don’t sedate, when in doubt use contrast and take a shot, use PF dex, and never assume you’ll have a nice crisp LOR (use the darn tube). When in doubt give a test dose of lido and wait 90-120 seconds and also examine the patient in Pacu. Nothing new here.

I will say I’m surprised there’s not more of a discussion about placement of the head. Not sure if there’s consensus here. Happy to hear thoughts.

I do a lot of CESIs (but that doesn’t mean I take them lightly). I’m fairly cautious in hitting lamina - pretty much aiming for the upper middle, not the upper edge. Then I hold that point on the needle and redirect up, to the same depth. It will typically put me about 1 cm posterior.
I forgot to mention I never do these under IV sedation. Patients who ask for sedation are prescribed Xanax (typically max 1 mg for under 65, 0.5 mg for over 65).
You mention giving a test dose of lidocaine - why?? You mean test to see if you’re going to get a high spinal? Are you talking about lumbar instead? That seems far out of character for your otherwise very conservative post. I do not add any local to the injectate.

 

[HyperSonic]

And I would very strongly warn younger (and older) colleagues against doing a CESI in only 3 fluoro shots. CLO is a revolution in the safety of CESI. Yes, just like anything else, you could hurt someone if you don’t know what you’re doing. The problem with other techniques of CESI is that it’s very easy to hurt someone even if you do know what you’re doing.

Here’s my technique. Maybe it’s because I’m anesthesia trained but I still like to feel LOR. I don’t rely on it though. I basically go for as many safety guardrails and indicators as possible.

Target top edge of T1 lamina, on the side of the worst pain. Skin local. 22g tuohy down to touch lamina, slight medial angulation. Reorient superior while keeping finger on needle shaft to advance minimally farther than the depth of lamina. Go to CLO. Advance to a few mm posterior to VLL. Attach 3 mL syringe containing about 1.5 mL contrast. Advance using LOR-type technique but injecting very minimal volume. Fluoro shots when close to or crossing VLL to check contrast spread. Often can feel the needle tip engage in ligament and then pop through thanks to non-quincke tip. Almost always a distinct loss of resistance. Usually can see on fluoro the exact point I need to reach. When I attach the syringe there’s a bubble in the needle hub, and often I’ll see that bubble drop into the needle when I enter the epidural space, giving a hanging drop-like effect.

Same technique, just way quicker lol

 

[DrMDAware]

I do a lot of CESIs (but that doesn’t mean I take them lightly). I’m fairly cautious in hitting lamina - pretty much aiming for the upper middle, not the upper edge. Then I hold that point on the needle and redirect up, to the same depth. It will typically put me about 1 cm posterior.
I forgot to mention I never do these under IV sedation. Patients who ask for sedation are prescribed Xanax (typically max 1 mg for under 65, 0.5 mg for over 65).
You mention giving a test dose of lidocaine - why?? You mean test to see if you’re going to get a high spinal? Are you talking about lumbar instead? That seems far out of character for your otherwise very conservative post. I do not add any local to the injectate.

You’ve done a lot. Others likely have done far less. That’s why I caution against the touching the lamina.

But at the end of the day there are multiple safe ways to do this no doubt as long as the fundamental concepts are there.

Lido to check if intrathecal or vascular. It is a test dose not part of the injectate. Just another layer of safety.

I follow some (not all) the additional rules for safety per Furman.

 

[lobelsteve]

You’ve done a lot. Others likely have done far less. That’s why I caution against the touching the lamina.

But at the end of the day there are multiple safe ways to do this no doubt as long as the fundamental concepts are there.

Lido to check if intrathecal or vascular. It is a test dose not part of the injectate. Just another layer of safety.

I follow some (not all) the additional rules for safety per Furman.

I touch lamina 100% of time.
"Bone is your friend"
My technique uses the 25G to touch lamina then walkoff in CLO and injecting tiny amounts of contrast on the way through the ligament.
There are a multitude of safe ways. But there are safer ways.

 

[deleted131481]

Anyone have good pics of subdural pattern? Especially in CLO?

 

[DrMDAware]

I touch lamina 100% of time.
"Bone is your friend"
My technique uses the 25G to touch lamina then walkoff in CLO and injecting tiny amounts of contrast on the way through the ligament.
There are a multitude of safe ways. But there are safer ways.

Yes yes yes bone is home.

You’ve been doing it for awhile Steve I don’t doubt you are unsafe.

For some newer people or people who haven’t done as many I would still exercise caution.

The 25G is slick btw.

Many safe ways indeed

 

[HyperSonic]

Yes yes yes bone is home.

You’ve been doing it for awhile Steve I don’t doubt you are unsafe.

For some newer people or people who haven’t done as many I would still exercise caution.

The 25G is slick btw.

Many safe ways indeed

Agreed with that, caution, lots of caution.
I get goose bumps on my skin thinking that somebody could misinterpret CLO, advance 25G into cervical spinal cord, try to inject contrast and scratch his head thinking “what contrast spread is that”…

 

[callmeanesthesia]

Agreed with that, caution, lots of caution.
I get goose bumps on my skin thinking that somebody could misinterpret CLO, advance 25G into cervical spinal cord, try to inject contrast and scratch his head thinking “what contrast spread is that”…

That just drives home the point: there is no perfectly safe technique but there are safer ways. If I were teaching a fellow, I would teach them my technique or Steve’s (or both). You raise concerns about the “what-ifs” of touching lamina, but what do you recommend? Aim for the interlaminar opening and guess how deep before going CLO? Are you arguing that’s safer?

 

[Ducttape]

Not trying to be snarky.

With the 25G quinke, I advance in CLO. Needle tip is advanced until close, puff of contrast shows still outside ligaments. Advanced 1mm, feel tight ligamentum flavum on needle and resistance to contrast, then advance 1mm and release of resistance to contrast injection. See contrast in epidural spread. Any deviation you withdraw, reassess, and try again. Hanging drop or LOR with contrast at the end just for confirmation just isn't as good.

If you're afraid of a sharp needle, I get that, but if I'm anywhere near a cord injection, a lot has gone wrong.

FWIW, I use saline and dex only in CESI. Never had any chest pressure complaints.
Dex concerns with benzoyl alcohol/PEG are avoided altogether by using preservative-free dex.

technically, since you are using feel, you are kind of using LOR as part of your technique.

so i do the same thing with a 22g Touhy and use a combination of saline and contrast for the LOR "solution". using the LOR means i am less likely to get a blobogram if someone's ligament is soft and squishy, as does the diluted contrast solution.


from my standpoint, using Touhy and LOR syringe filled with saline + contrast gives me an additional advantage over just contrast injection and over LOR without contrast.

i dont think this is a clearcut delineation of "go until you get LOR then give contrast" vs "inject contrast and completely ignore that there is significant resistance to instillation".

 

[fathead88]

On a realistic level, all of these approaches are very safe. How many CESIs have been done collectively by everyone who has commented on this thread - 50k? 100k? 500k? Has anyone ever had a cord injection?

 

[DrMDAware]

That just drives home the point: there is no perfectly safe technique but there are safer ways. If I were teaching a fellow, I would teach them my technique or Steve’s (or both). You raise concerns about the “what-ifs” of touching lamina, but what do you recommend? Aim for the interlaminar opening and guess how deep before going CLO? Are you arguing that’s safer?

I agree there’s no perfectly safe technique.

My entire concern is if someone thinks they are going to touch lamina and they don’t.

There’s no guessing how deep you go. The AP is meant to get the hubogram and then advance in CLO. The CLO is for advancing.

Not arguing one way is safer.

 

[SSdoc33]

On a realistic level, all of these approaches are very safe. How many CESIs have been done collectively by everyone who has commented on this thread - 50k? 100k? 500k? Has anyone ever had a cord injection?

Ive tickled the cord on a cesi. Pt felt it shot down her arm and leg. Didnt inject anything. Got mri, pt recovered fully nearly immediately. But scary.

Maybe 8-10 years ago i did a cervical paraspinal TPI and injected the cord. Used a 1.5 25 guage and i guess it just got thru. Scariest professional situation of my career. Pt had weakness for about 2 weeks and then fully recovered. Got mri which showed cord edema/tract. Gave oral steroids. Saw her every several days for a while. She was incredibly understanding.

The biggest risk is injecting fluid while in the substance of the cord itself and hydrodissecting. As long as you arent using sedation, the risk of big problems is quite low. You will know if you are touching the cord or in the cord if the patient isnt sedated. They will jump or tell you. With the tpi, i did the shot so fast, i didnt know until it was done.

 

[epidural man]

Ive tickled the cord on a cesi. Pt felt it shot down her arm and leg. Didnt inject anything. Got mri, pt recovered fully nearly immediately. But scary.

Maybe 8-10 years ago i did a cervical paraspinal TPI and injected the cord. Used a 1.5 25 guage and i guess it just got thru. Scariest professional situation of my career. Pt had weakness for about 2 weeks and then fully recovered. Got mri which showed cord edema/tract. Gave oral steroids. Saw her every several days for a while. She was incredibly understanding.

The biggest risk is injecting fluid while in the substance of the cord itself and hydrodissecting. As long as you arent using sedation, the risk of big problems is quite low. You will know if you are touching the cord or in the cord if the patient isnt sedated. They will jump or tell you. With the tpi, i did the shot so fast, i didnt know until it was done.

This is shocking. Hard to imagine a 1.5 inch made it to the cord. That would be very scary. I would not have believed you if you had not gotten the MRI proof.

Have you mentioned this before? I remember something like this being mention and I switched to 1/2 inch needles for all cervical paraspinal TPIs

 

[lobelsteve]

I agree there’s no perfectly safe technique.

My entire concern is if someone thinks they are going to touch lamina and they don’t.

There’s no guessing how deep you go. The AP is meant to get the hubogram and then advance in CLO. The CLO is for advancing.

Not arguing one way is safer.

Hubogram? You dropping needles with two hands? Down the pipe view? When did you train? Where?

 

[Ducttape]

there was a study that looked at that and found it imminently possible to cause cord injury with 1.5 inch needle. ill try to find it.

 

[SSdoc33]

This is shocking. Hard to imagine a 1.5 inch made it to the cord. That would be very scary. I would not have believed you if you had not gotten the MRI proof.

Have you mentioned this before? I remember something like this being mention and I switched to 1/2 inch needles for all cervical paraspinal TPIs

5 years ago

https://forums.studentdoctor.net/threads/injection-complication-any-advice.1301312/#post-19807313

 

[Baron Samedi]

I do dry needling only with an acupuncture needle in cervical paraspinals. I think cord would be pretty tough to hit but in EMG training the ease of inadvertently ending up in foramen was a focus point.

 

[MitchLevi]

My C TPI are at most 1 cm deep, and I pull the needle out and spend the next 20 seconds massaging it into the tissue.

 

[DrMDAware]

Hubogram? You dropping needles with two hands? Down the pipe view? When did you train? Where?

What?

When I say hubogram I mean coaxial view.

Start 3-5 degrees oblique. Get coaxial view. Go CLO and get LOR

 

[lobelsteve]

What?

When I say hubogram I mean coaxial view.

Start 3-5 degrees oblique. Get coaxial view. Go CLO and get LOR

Old school.

 

[Painologist]

18 ga touhy, almost always touch down on lamina and walk off prior to using LOR in CLO. I‘m split 50% C6/7 and 50% C7/T1. If I know they have higher pathology, and have a good look at C7 I will go for C6/7. I genuinely notice a difference in outcomes between C6/7 and C7/T1. If it matters, I’m anesthesia trained and have used LOR thousands of times, but still don’t fully count on it. I will often check with contrast if I’m where I would typically expect loss. I use 80 mg depo with PF saline.

 

[MitchLevi]

18 ga touhy, almost always touch down on lamina and walk off prior to using LOR. I‘m split 50% C6/7 and 50% C7/T1. If I know they have higher pathology, and have a good look at C7 I will go for C6/7. I genuinely notice a difference in outcomes between C6/7 and C7/T1. If it matters, I’m anesthesia trained and have used LOR thousands of times, but still don’t fully count on it. I will often check with contrast if I’m where I would typically expect loss. I use 80 mg depo with PF saline.

18g in the neck is barbaric!

 

[DrMDAware]

Old school.

Ok.

 

[Painologist]

18g in the neck is barbaric!

Patients don’t even flinch. 0.5% lido.

 

[bedrock]

Patients don’t even flinch. 0.5% lido.

My patients regularly comment after their 18G touhy CESI, how much less painful it was compared to what they expected.

 

[MitchLevi]

25g you're done and they ask when you're gonna start.

 

[clubdeac]

25g you're done and they ask when you're gonna start.

I bet my 18g is less painful than your 25 😜

 

[MitchLevi]

I bet my 18g is less painful than your 25 😜

 

[RoloTomassi]

After the local is in I doubt there's much difference between 18 and 25. Biggest diff is likely the sensation or lack thereof at LOR

 

[bedrock]

I do most of my CESI, with 18G touhy at T1-T2, and run a soft 20G catheter to C6-C7. I notice that contrast will spread to C2, much more consistently if the tip of the cathether is at C6-C7, compared to C7-T1.

As you can see here, the other advantage to this technique is you can really direct depomedrol along the individual nerves basically a safe CTFESI with depomedrol.

 

[deleted131481]

View attachment 367627View attachment 367626

I do most of my CESI, with 18G touhy at T1-T2, and run a soft 20G catheter to C6-C7. I notice that contrast will spread to C2, much more consistently if the tip of the cathether is at C6-C7, compared to C7-T1.

As you can see here, the other advantage to this technique is you can really direct depomedrol along the individual nerves basically a safe CTFESI with depomedrol.

Can you share what tuoy/catheter?

 

[SSdoc33]

i was trained on a 17g touhy. in retrospect, it was a harpoon.

i will say that you have a much clearer LOR with a bigger needle. if you are heavily relying on LOR, then there is a problem, b/c there will be instances (1 in 20, 1 in 50?) where you wont have a true LOR.

ive settled in on a 20g touhy using both LOR and a bunch of pics.

no one right way to do a CESI, but there are lots of wrong ways

 

[bedrock]

Can you share what tuoy/catheter?

Mckesson generic 18G touhy plus this catheter, which only costs $5. Overall quite inexpensive even for in office procedures.

 

[lobelsteve]

Mckesson generic 18G touhy plus this catheter, which only costs $5. Overall quite inexpensive even for in office procedures.

View attachment 367734

Why is that still around if it expired almost a year ago?

 

[bedrock]

Why is that still around if it expired almost a year ago?

I took that photo 3 years ago.

 

[DubVille]

Makes sense. But whenever you get the chance can you send a snap of the T1 sequence where you feel there’s an adequate amount? I just was curious to get a baseline. Thanks

I wouldn't go at C6-7 in this instance. C7-T1 is the highest I would go.

 

[lobelsteve]

I wouldn't go at C6-7 in this instance. C7-T1 is the highest I would go.

Not adequate. Need sag/ax T2 to determine.

 

[DubVille]

Not adequate. Need sag/ax T2 to determine.

None of the imaging centers include Axial T1. I don't trust myself to see small epidural space on axial T2, I can't always tell it apart from csf.

 

[painfree23]

I wouldn't go at C6-7 in this instance. C7-T1 is the highest I would go.

Can u explain what you mean by the picture? Not sure I understand how you can tell on that image?

 

[DubVille]

Can u explain what you mean by the picture? Not sure I understand how you can tell on that image?

My pointer is next to a tiny appearing epidural space. Too small for me to be comfortable targeting. So I would drop a level to C7-T1.

 

[DrSpine]

Identify C7-T1 Interlaminar space, go on side where there's more pain, anesthesize with 1% lido, go with 20g Touhy, advance a little. Enter CLO 45 degree view, keep advancing, once you get in between the spinous process going toward VILL, small squirt of contrast to verify where you're at, advance slowly with LOR/contrast, just past VILL you should be there, verify again with Contrast, then inject after two saved views. I do a bunch of CESIs every week, it used to be a lot scarier, but now I'm very comfortable with it. I say that with a caveat, it's never a comfortable experience to do one, no one should feel 'too cocky' with, but there's definitely a level of confidence that comes with it when you do it frequently.

3 shots seems way too little to me, but to each his/her own. Everyone has their way and comfort level.

 

[clubdeac]

Identify C7-T1 Interlaminar space, go on side where there's more pain, anesthesize with 1% lido, go with 20g Touhy, advance a little. Enter CLO 45 degree view, keep advancing, once you get in between the spinous process going toward VILL, small squirt of contrast to verify where you're at, advance slowly with LOR/contrast, just past VILL you should be there, verify again with Contrast, then inject after two saved views. I do a bunch of CESIs every week, it used to be a lot scarier, but now I'm very comfortable with it. I say that with a caveat, it's never a comfortable experience to do one, no one should feel 'too cocky' with, but there's definitely a level of confidence that comes with it when you do it frequently.

3 shots seems way too little to me, but to each his/her own. Everyone has their way and comfort level.

exactly how I do it

 

[lobelsteve]

Identify C7-T1 Interlaminar space, go on side where there's more pain, anesthesize with 1% lido, go with 20g Touhy, advance a little. Enter CLO 45 degree view, keep advancing, once you get in between the spinous process going toward VILL, small squirt of contrast to verify where you're at, advance slowly with LOR/contrast, just past VILL you should be there, verify again with Contrast, then inject after two saved views. I do a bunch of CESIs every week, it used to be a lot scarier, but now I'm very comfortable with it. I say that with a caveat, it's never a comfortable experience to do one, no one should feel 'too cocky' with, but there's definitely a level of confidence that comes with it when you do it frequently.

3 shots seems way too little to me, but to each his/her own. Everyone has their way and comfort level.

I'm a cocky, arrogant, narcissist. But not in the neck.

 

[Smokeydoc]

i was trained on a 17g touhy. in retrospect, it was a harpoon.

i will say that you have a much clearer LOR with a bigger needle. if you are heavily relying on LOR, then there is a problem, b/c there will be instances (1 in 20, 1 in 50?) where you wont have a true LOR.

ive settled in on a 20g touhy using both LOR and a bunch of pics.

no one right way to do a CESI, but there are lots of wrong ways

I agree that you should not depend on just the loss, in a LOR technique; however, using a 20g you will have a more faint/indistinguishable loss than a 18g and that can get you in trouble.

 

[lobelsteve]

I agree that you should not depend on just the loss, in a LOR technique; however, using a 20g you will have a more faint/indistinguishable loss than a 18g and that can get you in trouble.

Correct. Had to read 2x.

Bigger needle = bigger LOR feel.

 

[MitchLevi]

That's why I use 8g Tuohy at C4-5 and thread a catheter to C2.

 

[lobelsteve]

That's why I use 8g Tuohy at C4-5 and thread a catheter to C2.

Wuss. Retrograde ventriculostomy theough craniotomy and glide posterior to the cord at the axis.