Just curious;
What do you use for interlaminars?
Glass or plastic LOR?
Saline, air, or water?
And why?
Thanks
What do you use for interlaminars?
Glass or plastic LOR?
Saline, air, or water?
And why?
Thanks
A few other points;
If you do get a dural puncture, not using air will save the patient from the bad headache associated with air embolus.
I've also heard that using saline with SCS is avoided as it offers a conductive medium which may confuse the specificity of stimulation. I don't know if this is true or not.
Any more points/counterpoints on this one?
A few other points;
If you do get a dural puncture, not using air will save the patient from the bad headache associated with air embolus.
I've also heard that using saline with SCS is avoided as it offers a conductive medium which may confuse the specificity of stimulation. I don't know if this is true or not.
Any more points/counterpoints on this one?
I've used glass, epilor silicone, and plain old plastic.
I've used air for SCS and NSS-PF for ESI's.
I did not like the feel of the silicone or the cost of the glass. I use cheap plastic 10cc syringes as my LOR syringe.
I use NSS because it feels good compared to air and it is readily available.
People will use what they trained on or have become comfortable with.
The science does not discriminate until it comes to wet taps. But that is a function of needle type and gauge- and probably a separate thread...
I find it hard to believe a cc or so of normal saline is going to affect
the conductive medium?
Everyone I know uses NS for SCS.
I have been using a normal plastic 5 ml syringe and a 22G spinal needle Yale BD for my last 2000 or so IL epidurals (L,C and T) uneventful. I am using saline and always check on cross-table in case of doubt about depth, inject dy to asses the ensuing dispersal and that's all folks!
This is why i use saline, less chance of pneumocephalus, and i have had the saline thing with SCS happen to me. I use air only now for SCS. Saline for the rest...
I have been using a normal plastic 5 ml syringe and a 22G spinal needle Yale BD for my last 2000 or so IL epidurals (L,C and T) uneventful. I am using saline and always check on cross-table in case of doubt about depth, inject dy to asses the ensuing dispersal and that's all folks!
so a regular old plastic syringe? that comes in a packet in the all sizes with the black rubber plunger? im just asking because i have never seen or tried this, but man it would be economical...
i use the el cheapo plastic guys with the black plunger and feel that it gives a BETTER LOR than the fancy syringes when used with saline. never had a problem with it. give it a shot (so to speak), i think you'll be surprised.
next intralaminar i do i will try that. im a little nervous since the only interlaminars i do are in the neck just about, so i will wait till i do one in the lumbar spine...Just a 5 cc? have you ever used saline with it?
So instead of saline, why not just use contrast? That way when you lose resistance, you also have a nice epidurogram to confirm placement without changing syringes?
So instead of saline, why not just use contrast? That way when you lose resistance, you also have a nice epidurogram to confirm placement without changing syringes?
1) false loss dorsal to the ligament. 2) it would discourage you from injecting until you are certain you have engaged. In the setting of attenuated or even absent ligaments, I personally would be biased to go deeper to avoid messing up my image, and would be far more likely to end up with a wet tap.So instead of saline, why not just use contrast? That way when you lose resistance, you also have a nice epidurogram to confirm placement without changing syringes?
I know some guys use 5cc syringes so as not to confuse the two clear solutions. My staff always puts saline at 12 o'clock on the tray, lido on the left, and the steroid on the right (no, we don't get pre-made trays)
for SCS: Once I am close to the epidural space, I place the guide wire into the tuohy needle. When you enter the epidural space, the guidewire will thread (similar to seldinger technique). This skips the saline step all together.
QUOTE]
Hey mille
That's interesting you brought that up. Apparently that's the neurosurgeon's way to find the epidural space.
Went to a SCS course recently and they stated many neurosurg's use that method since they were never introduced to the LOR with syringe method.
The other reason to do it your way is that you can confirm everything since you are using fluro right in front of you.
My question though, isnt it easier to accidentally pierce the dura? And/or have you been able to 'cannulate' any other space falsely? I'm sure you were able to 'correct' it since you had fluro.
for SCS: Once I am close to the epidural space, I place the guide wire into the tuohy needle. When you enter the epidural space, the guidewire will thread (similar to seldinger technique). This skips the saline step all together.
QUOTE]
Hey mille
That's interesting you brought that up. Apparently that's the neurosurgeon's way to find the epidural space.
Went to a SCS course recently and they stated many neurosurg's use that method since they were never introduced to the LOR with syringe method.
The other reason to do it your way is that you can confirm everything since you are using fluro right in front of you.
My question though, isnt it easier to accidentally pierce the dura? And/or have you been able to 'cannulate' any other space falsely? I'm sure you were able to 'correct' it since you had fluro.
You can falsely "cannulate" other spaces but it would be very unusual to insert the guidewire more than a few millimeters into a false space. Similar to placing a labor epidural during residency. If the catheter goes in more than a few centimeters than it is likely epidural. As you said, this is done under flouroscopic guidance. In my mind this is still a loss of resistance technique with the catheter encountering the loss of resistance.
Why do you think that this technique could cause a dural puncture? Most people who perform SCS use the guidewire at some point anyway. Why would placing the guidewire be any more hazardous than threading the stimulator lead?
You can falsely "cannulate" other spaces but it would be very unusual to insert the guidewire more than a few millimeters into a false space. Similar to placing a labor epidural during residency. If the catheter goes in more than a few centimeters than it is likely epidural. As you said, this is done under flouroscopic guidance. In my mind this is still a loss of resistance technique with the catheter encountering the loss of resistance.
Why do you think that this technique could cause a dural puncture? Most people who perform SCS use the guidewire at some point anyway. Why would placing the guidewire be any more hazardous than threading the stimulator lead?
well I suppose more theoretically...wouldnt one be using more 'force' to pierce through the ligamentum flavum inorder to be in the epidural space? Whereas, once you know sort of that you are in the epidural space you can 'more softly' glide the gidewire into the epidural space when you are just confirming.
Never tried this technique yet except on cadavers. I just learned about it. I dont think any attending would allow me to try this technique...sooo....I guess I have to wait a year.
i have never seen a guidewire pierce the ligamentum flavum but I guess anything is possible...
So this business of a 'pneumocephalus'....i dont think it is 'real' if you do LOR to air with about 2mL, at the most 3 mL. Yes, you can fill the plunger with 5mLs of air, but you shouldnt give more than say 3mL. Then I would just switch over to giving saline through the Touhy and then continue with your routine...
I've done perhaps 500-600 epidurals now, and this is how I've been doing them....never had a 'pneumocephalus' yet. I think you get those when you inject 'alot' of air.
i have seen a pneumocephalus after a surgical CSE, that was rip roaring. MRI should lots of air in the ventricles. They did not quantitiate, and i dont know if they can.
I spoke with the anesthesiologist and he told me that he was able to easily do the CSE, and that he used saline/air combo, no more than 1-2 cc of air... so i dont know...
interesting....question do u belive that
The fact that our practice discourages the use of dye for epidurals was another one... I'm working on that though.
I've changed over to plastic and saline/air since starting PP, and it's worked well so far. I put a good head of constant pressure on the syringe as I'm approaching. We have wide tables where I work, making lateral images a real pain, so I always take a paramedian approach and touch lamina to be sure of depth before hooking up the syringe. We're upgrading to modern tables soon, so that shouldn't be an issue once obtaining a lateral becomes convenient. I got used to approaching with a lateral to guide me during fellowship, so this was a tough transition. The fact that our practice discourages the use of dye for epidurals was another one... I'm working on that though. Some compromises I'm just not going to make for economy. Check out the August Pain Physician with the article about six French cases of paraplegia after some pretty innocuous sounding injections, including a high lumbar interlaminar.
As a CA-3 doing my 3rd month of OB (an "elective"), i have found that 1cc saline, 1cc air works well in a glass syringe. when I find the loss, I re-confirm the space with 2-3 more cc's of saline only.
if ya'll thread catheters (I know I won't in my pain fellowship next year, but just curious), how far do you thread it? I like to leave it in 5-6cm.
discouraging dye is crazy talk! it is part of the procedure. Do they want you to not use a needle for local either?
Without revealing too much, let's just say my boss trained in an austere environment where it was easy to become cavalier. The fact that he hasn't had any recognized complications in 10 years of practice gives him courage in his viewpoints- which include injecting the neuraxis in patients on Plavix!!!! This is another issue I put my foot down on. We'll be going ASRA guidelines all the way soon. There are still a few patients who expect injections even without stopping Plavix. They get real disappointed when I turn them away if my boss isn't around to do them- even after I explain my reasoning.
i say this with all seriousness....you need to get a new job....this guy is going to take you down.....why on earth are you continuing to work with him??????
No dye, neuroaxial blocks on patients with plavix, .....come on