Thankyou sensei. As a resident in anesthesia with only an experience of a few years, should i just stop practicing midline approach altogether and switch to practicing and hopefully perfecting this paraspinous approach for all my future epidurals and spinals? So that i may have an even greater accumulated experience and finesse later on? Or should i perfect the midline approach first and then start this?
I would recommend that you be comfortable with both. I agree with your sensible suggestion that you focus on midline first, then once you are competent in that, actively seek to learn paraspinous as the other arrow in your quiver. This way if you find yourself struggling with paraspinous in a given patient (as may happen early on in the learning curve), you can fall back to the more-commonly practiced midline approach.
How do you feel about using the introducer needle for infiltrating the LA? Given the anaesthesist leaves it in place pointing into the right direction one can immediately use the cannula to perform the spinal - no need to wait nor for a 2nd piercing of the skin. If there's a need for redirection of the introducer the LA will be in effect.
That’s a valid approach if you have an introducer that allows syringe attachment (e.g. the ones that come with many Pajunk needles). I would definitely recommend it; although I still like to use the smaller gauge needed for initial infiltration, as it may improve patient comfort. We use a kit that has an introducer that doesn’t allow a luer lock syringe connection, hence the method illustrated in most of my videos.
Another excellent one for the trainees, thanks prof. Your second patient video seems to have the patient very far away from the edge of the bed though. Was it in a ward setting?
Well spotted - yes, the second patient was a hip fracture patient being done in the ward bed prior to transfer to a fracture table. I often let the patient lean away from me, into a 'sloppy lateral" similar to a Sims position, which is (a) more stable, and (b) creates more space for my hands and the hub of the spinal needle. The angles just have to be compensated for the lean, to make sure they are relative to the patient's back, and not the environment.
Sir.....ive my real difficulties in giving lateral spinal.....coz im so so used to sitting position.....im able to give any difficult cases in sitting wether its midline or paramedian...but when lateral im totally unable...i lose my orientation. Even during my post graduate days i was taught in sitting. When cases like ortho comes i fail to take up because of this one single issue due to lack of confidence in lateral position and being impossible for sitting. Earlier i used to give lower limb blocks for analegesia and make them sitting and then give low dose spinal with ease...which is really time consuming..but others come and give direct lateral spinal and finish the case.... Anything can be done to practice lateral spinal??
@@baijunair1720 You said it in your last sentence - it takes practice. You have to embrace the discomfort of starting again from scratch, at the bottom of the learning curve. Choose easy patients first, and give yourself enough time. Learn how to place your hands, and how to make the movements that correspond to cranial angulation vs medial angulation, that are needed for accurate redirection. Be very deliberate in your practice, and self-analytical. Anyone can learn to do anything - it’s the mindset that matters.
Really sorry for the disturbance Sir. But in your spare time can you review this video by Dr epi california from 10 years back. It seems to be similar to your Paraspinous approach but the difference being the puncture site being just lateral to the upper edge of the lower spinous process. Could this approach also work? ua-cam.com/video/Vi0H-x9Z6h4/v-deo.htmlsi=g1LbjIM5PvT2RKFo Thank you again.
The general principle is to adopt the position that feels most ergonomic and comfortable for you. I tend to agree, I like to have the spine close to eye level when I am searching out my landmarks, infiltrating, and making the first insertion. Thereafter, however, I am personally most comfortable standing up, with my elbows down my my sides, and hands roughly at the level of my waist when I am handling the spinal needle. There are no specific rules around this - only the general principle that you consciously monitor yourself, and adapt to maximize your own abilities to handle the equipment with finesse and control.
You can do a median approach in any setting, and I did so for many years as my go-to. However, the paramedian approach is much more versatile in that it is likely to be successful where the median approach fails. e.g. the hip fracture patient who cannot sit up, or flex at the hips to open up the interspinous spaces; or indeed any patient with degenerative spine disease and narrowed spaces. So, I encourage anyone who is serious about being good at difficult spinals, to practice the paramedian technique. I t does take a certain amount of practice, to develop an instinct for the angles and the redirections when bone is contacted. But once this is acquired, it really levels you up from competence at lumbar neuraxial block to mastery. So to answer your question, the point of this video and the related material is to educate more practitioners on this valuable (IMO) technique.
If we can identify the spinous process and the interspinous space there is no need for paraspinal lumbar puncture.the problem is when the patient is obese and we cannot identify the spinous process and interspinous soace
@@raghavankrishnaswamy2580 While I agree with the value of the paraspinous approach in the obese patient (because it reduces the need for extreme precision, unlike a midline approach) - I do not agree with the first part of the statement. Anyone who has attempted enough spinals in elderly hip fracture patients with narrowed interspinous spaces from degenerative disease or suboptimal positioning, will appreciate how difficult it can be to negotiate the midline “channel” successfully to reach the interlaminar space, no matter how prominent the spinous processes may be.
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The definitive guide for para-spinous approach. Thank you very much for distilling decades of experience into a single video.
Thankyou sensei. As a resident in anesthesia with only an experience of a few years, should i just stop practicing midline approach altogether and switch to practicing and hopefully perfecting this paraspinous approach for all my future epidurals and spinals? So that i may have an even greater accumulated experience and finesse later on? Or should i perfect the midline approach first and then start this?
I would recommend that you be comfortable with both. I agree with your sensible suggestion that you focus on midline first, then once you are competent in that, actively seek to learn paraspinous as the other arrow in your quiver. This way if you find yourself struggling with paraspinous in a given patient (as may happen early on in the learning curve), you can fall back to the more-commonly practiced midline approach.
Thankyou sensei for your kind reply and feedback.
How do you feel about using the introducer needle for infiltrating the LA? Given the anaesthesist leaves it in place pointing into the right direction one can immediately use the cannula to perform the spinal - no need to wait nor for a 2nd piercing of the skin. If there's a need for redirection of the introducer the LA will be in effect.
That’s a valid approach if you have an introducer that allows syringe attachment (e.g. the ones that come with many Pajunk needles). I would definitely recommend it; although I still like to use the smaller gauge needed for initial infiltration, as it may improve patient comfort. We use a kit that has an introducer that doesn’t allow a luer lock syringe connection, hence the method illustrated in most of my videos.
Another excellent one for the trainees, thanks prof. Your second patient video seems to have the patient very far away from the edge of the bed though. Was it in a ward setting?
Well spotted - yes, the second patient was a hip fracture patient being done in the ward bed prior to transfer to a fracture table.
I often let the patient lean away from me, into a 'sloppy lateral" similar to a Sims position, which is (a) more stable, and (b) creates more space for my hands and the hub of the spinal needle. The angles just have to be compensated for the lean, to make sure they are relative to the patient's back, and not the environment.
Sir.....ive my real difficulties in giving lateral spinal.....coz im so so used to sitting position.....im able to give any difficult cases in sitting wether its midline or paramedian...but when lateral im totally unable...i lose my orientation.
Even during my post graduate days i was taught in sitting.
When cases like ortho comes i fail to take up because of this one single issue due to lack of confidence in lateral position and being impossible for sitting.
Earlier i used to give lower limb blocks for analegesia and make them sitting and then give low dose spinal with ease...which is really time consuming..but others come and give direct lateral spinal and finish the case....
Anything can be done to practice lateral spinal??
@@baijunair1720 You said it in your last sentence - it takes practice. You have to embrace the discomfort of starting again from scratch, at the bottom of the learning curve. Choose easy patients first, and give yourself enough time. Learn how to place your hands, and how to make the movements that correspond to cranial angulation vs medial angulation, that are needed for accurate redirection. Be very deliberate in your practice, and self-analytical. Anyone can learn to do anything - it’s the mindset that matters.
Really sorry for the disturbance Sir. But in your spare time can you review this video by Dr epi california from 10 years back. It seems to be similar to your Paraspinous approach but the difference being the puncture site being just lateral to the upper edge of the lower spinous process. Could this approach also work?
ua-cam.com/video/Vi0H-x9Z6h4/v-deo.htmlsi=g1LbjIM5PvT2RKFo
Thank you again.
I found doing spinal in lateral position is much easier when operator is setting, what do you think, sir? Thank you for sharing this.
The general principle is to adopt the position that feels most ergonomic and comfortable for you. I tend to agree, I like to have the spine close to eye level when I am searching out my landmarks, infiltrating, and making the first insertion. Thereafter, however, I am personally most comfortable standing up, with my elbows down my my sides, and hands roughly at the level of my waist when I am handling the spinal needle. There are no specific rules around this - only the general principle that you consciously monitor yourself, and adapt to maximize your own abilities to handle the equipment with finesse and control.
@@KiJinnChin Thanks.
Since 2018 i had 27 lumber puncture for IIH 😢 this explanation looks so easy then in reality 😢 ce n'est pas facile
Why choose a paramedian approach in a lateral position? Why not just a median approach? Or just for educational purposes?
You can do a median approach in any setting, and I did so for many years as my go-to. However, the paramedian approach is much more versatile in that it is likely to be successful where the median approach fails. e.g. the hip fracture patient who cannot sit up, or flex at the hips to open up the interspinous spaces; or indeed any patient with degenerative spine disease and narrowed spaces.
So, I encourage anyone who is serious about being good at difficult spinals, to practice the paramedian technique. I
t does take a certain amount of practice, to develop an instinct for the angles and the redirections when bone is contacted. But once this is acquired, it really levels you up from competence at lumbar neuraxial block to mastery.
So to answer your question, the point of this video and the related material is to educate more practitioners on this valuable (IMO) technique.
If we can identify the spinous process and the interspinous space there is no need for paraspinal lumbar puncture.the problem is when the patient is obese and we cannot identify the spinous process and interspinous soace
@@raghavankrishnaswamy2580 While I agree with the value of the paraspinous approach in the obese patient (because it reduces the need for extreme precision, unlike a midline approach) - I do not agree with the first part of the statement. Anyone who has attempted enough spinals in elderly hip fracture patients with narrowed interspinous spaces from degenerative disease or suboptimal positioning, will appreciate how difficult it can be to negotiate the midline “channel” successfully to reach the interlaminar space, no matter how prominent the spinous processes may be.