"How-To" Guide - Paraspinous Lumbar Puncture / Spinal Anesthesia [Lateral Position]

This is a brief review of how to perform spinal anesthesia / lumbar puncture in the lateral position using the paraspinous (paramedian) approach. Note that the 2 operators featured here are junior trainees, which I hope helps to illustrate that this is a relatively simple technique yet tremendously useful in difficult patients.
Complement this with our comprehensive review article at BJA Education (authors.elsevier.com/a/1iG9n7... - free-to-access until 04 Feb 2024), and other videos in this channel.
Spinal Needle Handling - • Needle Handling Skills...
Ultrasound Imaging for Paraspinous Approach - • Ultrasound Imaging for...
Spinning on the AC - • "Spinning on the AC" -...
Paraspinous Approach to CNB [2019] - • Paraspinous / Paramedi...

[@muhammadabdullahshakeel]

The definitive guide for para-spinous approach. Thank you very much for distilling decades of experience into a single video.

[@natashadamour5494]

Since 2018 i had 27 lumber puncture for IIH 😢 this explanation looks so easy then in reality 😢 ce n'est pas facile

[@streen2000]

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?

[@KiJinnChin]

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.

[@doc.saturday]

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?

[@KiJinnChin]

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.

[@doc.saturday]

Thankyou sensei for your kind reply and feedback.

[@whocares7215]

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.

[@KiJinnChin]

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.

[@zakalobi80]

I found doing spinal in lateral position is much easier when operator is setting, what do you think, sir? Thank you for sharing this.

[@KiJinnChin]

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.

[@zakalobi80]

@@KiJinnChin Thanks.

[@muhammadabdullahshakeel]

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.

[@eses1131]

Why choose a paramedian approach in a lateral position? Why not just a median approach? Or just for educational purposes?

[@KiJinnChin]

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.