What to do when the needle encounters the bone during spinal or lumbar puncture
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- Опубліковано 2 лют 2023
- Have you ever experienced or witnessed a “difficult” spinal puncture in a young, slim patient with landmarks visible from a mile? In these cases, no matter what you do, you always seem to hit the bone. In fact, I will dare to say that most struggles with spinal that I have witnessed were in skinny patients with easy landmarks. In this video, you will learn 4 specific tips and techniques that will make your next spinal anesthesia or lumbar puncture MUCH easier and more predictable. Here’s the KEY to success when the needle hits bone all the time. Ask yourself: Which bone is preventing me from placing the needle successfully? Or which osseous structure is on my way to the subarachnoid space? In this video we first review the anatomical structures the needle is passing through when performing a midline approach to spinal anesthesia or lumbar puncture: Skin, SQ tissue, Supraspinous ligament, Interspinous ligament, Ligamentum flavum, Dura, Subarachnoidal space. Dr Hadzic then moves on to describe WHAT you need to do AFTER encountering the bone on your way to the CSF in 4 typical scenarios.
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Medicine is an ever-changing science. As new research and clinical experience broaden, changes in treatment and drug therapy are required. The authors and publishers have checked with sources believed to be reliable in efforts to provide accurate information within the available or accepted standards of care. However, given the possibility of human error or changes in medical practice, neither the authors nor the publisher, nor any other party involved in the preparation of this platform warrants that the information contained herein is in every aspect accurate or complete, and they disclaim all responsibility for any errors or omissions for the results obtained from the use of the information contained in this work. Readers are advised to confirm the information contained herein with other sources. For example, readers are advised to check the product information of each drug mentioned, and that any information contained on NYSORA's UA-cam channel is accurate.
And may I also add that every time I hit a bone I ask the patient on which side they feel it and I use that to correct my direction and I helps 100 % of the time.
I have never actually tried that - but will and will give you feedback! Greetings, and thank you for watching!
@@DRBLUESNYC yes me too. I'll ask if wrong direction encounters me ahead.
Unfortunately, I found that not helpful.
So when pt says “ I feel it on the right” you go to the left and that’s where the good area is? This makes no sense. How about paramedian approaches?
Patient who is scared and possibly in pain - sometimes lots of pain- is very little help and I’m sorry to say that nothing in life works 100%.
@@DRBLUESNYC ou7oyû9
2 cm 6 cm 8 cm inside different scenarios, very beautifully explained
OMG…this is the best explanation of why we struggle to do a spinal…many many thanks. Can you please make a video about paramedian spinal and practical tips for novices as well as experiences anesthetists.
The best teacher
thanks to Dr. Hadzic for this excellent explanation about difficult spinal . But one point I may disagree. in my 38 years of anesthesia experience i did redirect the needle caudally too and I was successful .
These tips are SO invaluable!!! THANK YOU!!!
Very useful video. If you are performing the lumbar puncture in lateral position and flexing the spine and bringing the flexed knees close to abdomen, make sure both the shoulders and both the knees are exactly in the same vertical axis. The purpose is to prevent rotation of the spine which can make orientation of the needle more difficult.
We really appreciate your feedback! Thank you!
I really appreciate for these very educational tips
I wish I knew this in my first year of residency...Extremely useful tips. Thank you!
Great to hear. Greetings, and thank you for watching!
What an amazing explanation
Very useful. Thank you!
Thanks bud. Much needed at a much vital time. Gratitude!!!
High on demand video.. Thank you Dr. Hadzic for sharing this video 👍 really helpful!
Great. Greetings, and thank you for watching!
Awesome! You are indeed a Chief of service. Thank you.
Thank you for your comment! Greetings!
What a perfect explanation! Helped a lot, thank you so much.
Hi Louise, Glad it helped! Greetings!
Always helpful . Thanks Dr. Hadzic
Glad it was helpful!
You do a great job, bravo for your professionalism👏
Thank you! Cheers!
Thank you for giving logical explanation. Honestly I didn't know where is the needle when hitting bone. I will keep this in mind now.
Hi Rehana, Thank you for your comment. Greetings!
@@nysoravideo Can you please tell why shouldn't we redirect vertically without pulling out completely? I do that I lot but if that is wrong I need to correct myself before causing harm to the patient
very helpful indeed thank you
Glad it was helpful!
wow - this was excellent!
Thanks, we are happy you found it useful. Have you subscribed to our newsletter? www.nysora.com/newsletter/
Thanks for all your help
My pleasure
I experienced that just yesterday. Thanks for the advice.
Glad it helped!
Recently this video helped me to get spinal in 105kgs female Pt. Thank u so much!
Hi Satyashila! Thank you so much for your kind words; we really appreciate your feedback. Greetings!
Wow
Very interesting and helpful
Excellent video and great tips!!!
Hi Kavitha! Glad you enjoyed it!
This is one of the best clinical observations regarding spinal anaesthesia I've come across...Hats off to you sir for reading our minds and presenting solutions for it
Thank you! Which additional videos would you like to see here?
@@nysoravideo spinal anaesthesia in lateral decubitus position...hip surgery, ischio-rectal abscess, inflamed piles
Very nicely presented. Thanks.
Hi there! Glad you liked it!
Thank you Dr. Hadzic. Im an Anaesthetic resident and your video helped me to realize some of my mistakes so the next time I believe I will do better. 😊🙏
That is so great to hear, we all live an learn. Please let us know next time how it went! Best.
Great tips Dr hadzic thank you. Looking forward to see more videos from nysora
Hi Ernad! More to come!
I finally understand the importance of this video, great job doctor!4
Glad it was helpful! Where do you practice?
Great explanation
Greetings, and thank you for watching!
Super informative! Many thanks
Hi Ali! Glad it was helpful!
Excellent material
Thank you! We are happy you found it useful.
I would challenge the idea of "removing your needle and reinserting" we need to think of our patient in these situations and realize you can pull skin as much as 2cm in any direction with minimal discomfort to your patient, almost to a completely different interspace, without making a new puncture (unnecessary risk for infection, tissue trauma, and the patient likely isn't localized where you are moving to re-puncture). If you simply think you're a little too low or too high (hitting bone shallow) withdraw the needle but not completely out of the skin, and pull the skin to where you want to reposition. Something I learned from the best neuraxial practitioners I've trained with that helps with hitting bone deep is letting go of the needle and seeing which way it is naturally hanging, this will give you insight into which direction your flimsy/thin spinal needle may have drifted or been deflected and will help you correct it back to midline. "leading" with your introducer and even tenting the skin inward on bigger patients as you drive in deeper will also make your needle less likely to drift once it's ahead of the introducer. Great video!
Hi Austin, Thank you for sharing! Greetings!
I appreciate these tips. Infact, patient's position also matters alot while doing lumber puncture/intrathecal approach. Correction of position while keeping in mind the alignment of vertebrae will take you right inside the intrathecal space.
Yes, in my experience the correct patient position is the major point to success.
Yes. Often time - a simple reposition will be adequate to change the outcome = using the same needle insertion point.
Amazing explanation! Will definitely try it out and update..thanks for the video
Glad it was helpful, please let us know how it went. We wish you a lot of success.
This video helped me a lot. Thanks Nysora
Hi Saeek hasan! So kind of you, and we are really glad you are enjoying our work. Greetings!
Dear Dr Hadzic, by following your tips I did my first successful LP today! Thanks for the teaching 😊
Hi VyewVyew! Glad to hear this! Thanks!
@@nysoravideo Just did my 2nd successful one unsupervised using exactly the advice in this video- hit bone superficially in midline, took entire needle out and moved down 1cm, easy LP ;)
Thank you. Your video has been very much helpful
Glad it was helpful!
An important thing I find useful is withdrawing the introducer needle almost completely out to change the direction of the target direction. Many of us we don’t pull the introducer fully out and that results in kinking of the spinal needle itself or no expected change in direction of target.
Totally agree. Thank you for the great suggestion - will incorporate in the next video!
That's right, by observation of my colleagues, I noticed this, and when changing the angle, I withdraw the needle until I feel it regains its straight shape, then change a little bit the angle.
@@karimham7073what you are feeling when you withdraw the needle and you feel the “straightening” is the needle tip retracting past the most superficial layer of the lumbar dorsal fascia. This anchors the needle, if you don’t retract past this any attempt to redirect the needle will be unsuccessful.
Thanks again.
Thank you very much!!!
Very precise and Informative.
Glad it was helpful!
this video is so advantage, thank you.
Glad it was helpful!
Hi. I wanted to ask a question unrelated to this: During IV therapy, the blood flows to the IV line after the bottle getting empty or due to imbalanced pressure is there any issues with regards to that or is there any other procedure during which similar blood flow process occur?.
Excellent video.
Hi Busters Verden! Thank you for your comment!
Thank you Dr Hadzic for this video. I'm a haematology resident, and we tend to do a lot of Lumbar punctures (for intrathecal chemotherapy). And your video made me confident about doing any of the difficult ones my colleagues or even my mentors had problems with. Thank you again !
Hi Karimham! So kind of you, and we are really glad you are enjoying our work. Greetings from NYSORA!
Thank you sir... very helpful...👍
Great. Thank you for the feedback. Greetings, and thank you for watching!
Amazing. Thank you.
Glad you liked it!
Very helpful!
Glad it was helpful!
Best way of explanation v informative ❤
Thank you so much 🙂
Excellent sir...u r super man!!!
Thanks a million
Greetings, and thank you for watching!
You are the best
Hi! In scenario 4, there is a risk of perforating some viscera?
Thank you for the tips! after watching this video, I went from getting 50% of my spinals to 100% of my spinals the very next day!
Wonderful, I am neurologist and I have learned a lot after seeing this video
Stay blessed and healthy
Thank You so much for your kind comment. We are glad you found it useful. What part of it did you find the most insightful?
I have to do lumbar puncture on patients for the first time tomorrow. I hope it goes well! Thank you for this video, wish me luck..
Thank you
You are very welcome. We are hear to share the knowledge. :)
Superb video
Thanks Rushikesh!
Wow This will help me a lot next time I will keep these key points in my ming and try
Hi Ikeam! Glad to hear this. Greetings!
This is so helpful!!! Thank you- Medical registrar from NZ :)
Glad to her that! Many regards to NZ!
Great video this
Hi Nischay! Glad you are enjoying the content. Appreciate your feedback!
At 4 c m depth , What do you mean by microdirection latetally while in video you directed needle medially...also if u mean going more laterally ,the needle will still hit lamina or facet joint
Pls explain
Another question is when operator will suspect that needle is gone into abdomen ?
Thanx
Thanks a lot sir I learned more new things from this vedio
Hi Ameer! Glad to hear that! Greetings from NYSORA!
Can you do a LP sat up then lay them down while the needle is in?
Shukran
When you do the micro-redirections, what angle do you take, 5 degrees or so? And is there a limit to how many micro redirections you perform before taking out the needle and reassessing
GREAT video @nysora BUT, these numbers you're citing for depth are very dependent on body habitus. Do you recommend a particular formula for getting a more accurate depth estimate? There are several published...
Hi Greg! Thank you for showing your interest in this topic, For more information, Subscribe to Nysora's Compendium of Regional Anesthesia nysoralms.com/courses/nysora-compendium-of-regional-anesthesia and you can have all the information about Spinal Anesthesia Techniques. Greetings!
dude what are you going to do with an accurate depth estimate. you cant measure the depth of the lumbar needle while doing the procedure . its trial and error
@@MrArjunsexy prior to starting
Excellent video, but please do the video about ultrasound subclavian central line. Would be great to watch!
Done - coming up next! Thank you fro the suggestion. Greetings, and thank you for watching!
Sir for normal patient and pregnancy patient how much doses we have to give that anawin heavy injection???
Excelent video and very usefull tips, and I also recomend another tip very useful too , It's to place the introducer needle with the syringe (LA or S.S 0.9%) for exploring and finding out de medial LINE (to feel de supra and interspinous ligament resistence ).And finally ... It would be intolerate the situation of seeing multiples punchures in a small area (in a diametre less than 1 cm ).Thanks !!
Agree!! Greetings, and thank you for watching!
How?
Great thanks for you doctor, I use to face this problem with skinny people.
Glad it was helpful!
It's exactly what I am looking for
Glad to hear this. Thank you!
Thanks a lot. A wonderful video. Indeed in the textbooks the 3D view is never described. Only the classical 2 D view . Many are mentally stuck in the habits of the past century …
Thanks for sharing! And we are very delighted you found the video useful. Best regards from us at NYSORA.
Great video - I'd 50-60% percent of difficult spinal is patient positioning. If yo can tilt the table towards you always helps!
Hi Mathias, Thank you for sharing your experience. Greetings!
When i had a spinal gor pain control during a hysterecyomy surgery i was under general anasthesia butvit was to help ppain after anasethologist sprayed my back with numbing gel i never felt it only funny feeling im left leg as it was going in but it was great no pain after surgery
Sir thanks a lot🙏
Most welcome!
Ive just had my 3rd Lumbar and here in South Africa no Anaesthetic is given whatsover. First two were painful but certainly tolerable. The one I just had however was a disaster. He hit a nerve and I felt a sudden and excruciating bolt of pain from that point down my left leg. I actually screamed in pain. So he had to remove it and try again, which basically means I had to do it twice.
Great 👌
Greetings, and thank you for watching!
Any tips on how to prevent the catheter from shearing? I’ve had it shear once. Perhaps I turned the needle when I was pulling it out? Cant figure out what went wrong..
Thanks
No problem!
My anesthesiologist told that most of the problems are when he has patients that are unable to position themselves correctly. Young flexible patients are the best he said.
Sir can you teach about spinal epidural hematoma
What oseous structure was hit at depth of 6-8 cm( in scenario 3)...body of vertebrae?
¡El compendio en Español! Por favor 🙌🏻 Gracias 🙏
Multiple puncture sites! I have viewed several animations of this procedure. Something is wrong here. Could this procedure be updated? Ultrasound guidance or better as standard?
I researched this because a family member was administered incorrectly by a nurse causing possibly permanent nerve damage. She received compensation. She now has to live with Pregabalin pain drugs possibly for the rest of her life.
Which position is for doing lumbar puncture, sitting or lying?
After diagnosis of IIH doctors operated my husband and put TP shunt in spine to stomach. After operation eyes reports are good and improving day by day but after 1 month the headache and blurring In vision is back and now it's almost 8 month completed.. bluring vision and headache are still there. I visited lots of nurosurgeon and Neurologist no one can fine the coz of pain. MRI and plapdema are normal in reports.. please help please give suggestions I'm from india
I was terrified to get an epidural (kinda still am) with my firstborn. The anesthesiologist I had seemed really strange and talked like some surfer dude, so I didn’t have a ton of confidence in him, but I was in such excruciating pain I felt like I needed it. The morphine given to me only lasted 10 minutes since they limit you due to baby. I had no idea or could tell that anything was hitting bone until the anesthesiologist said, “Oh, I’m hitting bone.” I tried to stay still as possible but in my mind I was like, “OMG WHAT?!”
My second epidural for my secondborn was much better and I felt way more relief from the meds. with that one. Not sure if she just did a better job or what.
Now I’m about to have my third baby and am nervous again for this. My mom knew someone she worked with back-in-the-day that had some kind of partial paralyzation from an epidural. I’ve heard they’ve improved at least since then but anything dealing with my spine makes me nervous!
wow 👌
Please, please, please can you do my next one. My last two were crap 😢
Also I would think doing a spinal would involve lots of training? But then my surgical team managed to mess up my inguinal nerves.... meh
Lack of good planning
I just failed to perform a SAB/ LP today. After watching this vid now I am confident enough to perform my next case In Sha Allah. Thank You so much. May Almighty Allah grant you with reward.
Hi Arif! So kind of you, and we are really glad you are enjoying our work.Greetings from NYSORA!
Thank you so much.
Could you please present a similar approach on patients with scoliosis?
From my POV should imagine the spine position for easier approach
It helps if you palpate the spine top to bottom. The scoliotic spine not only bends but also twists, so what I've found helpful is palpating and imagining how the spine might look like underneath the skin.
And of course remember that a midline approach in a scoliotic patient isn't necessarily in the middle of the back but a bit off to one side.
Local asantesia is applied?? I am sure..yes.
Pay atencion: in the first cenarium ins’t wrong to try change the angle of needle, to put more cephalic, without out of skin. If you do many puncture the patient won’t to be well after surgery. The great problem is about position of patient. You need open the space inverting the lombar lordosis. This model on all cenarium is erect. The position of patient is 60-80% of success of puncture.
Pray for me that m able to perform lumber puncture, always unsuccessful 😢
Rock star
Rock and roll will never die! ;) That is me on bass guitar with my band! ua-cam.com/video/4-8iqe6ywkQ/v-deo.html
@@DRBLUESNYC I have your CD
Hi Angel! Glad to hear this! Thanks!
Feel the bone , become sure you r in midline, go ,up, you r in subarchnoid space
Nothing more or less use usg abddominal probe and mark the space or go little higher space became I never use any thickness less than 26 or 27 but higher you go you need experience