Thank you for you remarkable stepwise teaching approach ,, with your skillful appreciation of subtle visualizing tips and maneuvres using the ultrasound probe,, keep up the best practice👍🏼
Thank you for this great lesson, I am working in an ortophedic hospital from 2008 and In my opinion the 2 fingers technique isn't ideal . In my experience with one finger technique is easier an more reliable find and track the interspinal space. I insert the middle while am marking the insertion point whit my non-dominant thumb . In this way I can fix skin while exactly marking the inserting point. It is fun that till now I strongly suggest to my students to avoid using the 2 finger technique :-) I'll give a try to the 2 finger technique , who knows maybe after 15 years I could change my mind :-)
Thank you so much for these excellent videos that show how to use ultrasound in challenging obese patients. At one point you comment that the depth for neuraxial should be estimated as sacral edge plus 2 cm. However, if the anterior complex is the reflection off of the posterior part of the vertebral process wouldn't this be too deep? For estimating depth for the dura/posterior complex when you can't see it directly, it would seem to be just about the same depth as the transverse processes if you can see them or alternatively 2 cm shallower than the anterior complex. Please let me know if I have interpreted this correctly? Again, thanks so much for all your work and guidance with regional anesthesia! It is amazing to be able to learn from an expert.
Thanks for the comment. You are correct. I was trying to make a more practical point which may not have come across properly. First that the sacrum is always identifiable, and sets the depth at which you can expect to see anterior complexes - 2cm deeper. Yes, the posterior complex will be more superficial, probably about a cm or so "higher". This is more important when doing an epidural vs a spinal. Nevertheless by the time you factor in tissue compression, angulation of the needle, the studies on depth indicate that you should always allow for 1cm or so of error, and usually needle depth exceeds measured US depth. I tend to use US depth only as an estimate, to guide needle selection, and to give me a rough idea of when I might be approaching the space. Tactile endpoints are still key for me - sensing ligamentum flavum in particular.
Sir I'm not getting why were measuring as depth of sacrum +2 cm or depth to anterior complex in PSO view as distance to epidural/intrathecal space from skin; whereas it should be depth to posterior complex as distance to epidural/intrathecal space from skin??
Sometimes I will try with a long 25G first to reduce risk of PDPH, but if I find I have trouble keeping needle from flexing when trying to redirect and advance, I will switch to a 22G Quincke sooner rather than later.
If extra long needles are not available for some reason. Then to compensate for those few millimeters - is midline approach (Vs paramedian) with pressure application will improve success rate with USG assistance?
yes, you can get up to 1cm further depth of needle advancement if the subcutaneous tissues are compressible. Paramedian will always be a slightly longer trajectory, but how much depends on angle.
1:28 = General principles of US imaging in obesity
2:38 = Parasagittal oblique (PSO) view
6:39 = Transverse midline (TM) view
8:10 = AP and TP as surrogate indicator #1
9:40 = Absence of SP acoustic shadow as surrogate indicator #2
11:01 = Dynamic scanning of TM view
12:20 = Identifying SPs as surrogate indicator #3
14:14 = Paraspinous (paramedian) approach
15:02 = Tissue compression in obesity
16:10 = Needling phase
17:00 = Needle deflection
17:59 = Trajectory: Angle vs Depth
18:39 = Controlling skin movement
19:16 = Finding the midline
20:57 = Holding and manipulating the needle
24:17 = Final pointers
26:18 = Summary
27:23 = Bonus video: US-assisted rescue of difficult spinal
best explanation on this topic
Thank you for you remarkable stepwise teaching approach ,, with your skillful appreciation of subtle visualizing tips and maneuvres using the ultrasound probe,, keep up the best practice👍🏼
Invaluable learning, many thanks for your time and effort.
excellent video, very educational and illustrative, very useful for improving our practice
Thank you for this great lesson, I am working in an ortophedic hospital from 2008 and In my opinion the 2 fingers technique isn't ideal . In my experience with one finger technique is easier an more reliable find and track the interspinal space. I insert the middle while am marking the insertion point whit my non-dominant thumb . In this way I can fix skin while exactly marking the inserting point. It is fun that till now I strongly suggest to my students to avoid using the 2 finger technique :-) I'll give a try to the 2 finger technique , who knows maybe after 15 years I could change my mind :-)
Used this technique today, and it was incredibly helpful! Had the CSE in less than 5 min.
I'm really happy to hear that! Congrats! Imaging in the larger patient is much more challenging.
Will be more than happy to know your inputs (another video) on spinal in instrumented spine patients with USG. Thank you indeed in anticipation.
Thank you so much for these excellent videos that show how to use ultrasound in challenging obese patients. At one point you comment that the depth for neuraxial should be estimated as sacral edge plus 2 cm. However, if the anterior complex is the reflection off of the posterior part of the vertebral process wouldn't this be too deep?
For estimating depth for the dura/posterior complex when you can't see it directly, it would seem to be just about the same depth as the transverse processes if you can see them or alternatively 2 cm shallower than the anterior complex. Please let me know if I have interpreted this correctly?
Again, thanks so much for all your work and guidance with regional anesthesia! It is amazing to be able to learn from an expert.
Thanks for the comment. You are correct. I was trying to make a more practical point which may not have come across properly. First that the sacrum is always identifiable, and sets the depth at which you can expect to see anterior complexes - 2cm deeper. Yes, the posterior complex will be more superficial, probably about a cm or so "higher". This is more important when doing an epidural vs a spinal. Nevertheless by the time you factor in tissue compression, angulation of the needle, the studies on depth indicate that you should always allow for 1cm or so of error, and usually needle depth exceeds measured US depth. I tend to use US depth only as an estimate, to guide needle selection, and to give me a rough idea of when I might be approaching the space. Tactile endpoints are still key for me - sensing ligamentum flavum in particular.
@@KiJinnChin Excellent, thanks again.
Excellent lecture
Sir I'm not getting why were measuring as depth of sacrum +2 cm or depth to anterior complex in PSO view as distance to epidural/intrathecal space from skin;
whereas it should be depth to posterior complex as distance to epidural/intrathecal space from skin??
absolutely brilliant.
Great wonderful explanation
Thank you very much
In young obese do you still recommend quincke needle or pencil point needle? PDPH?
Sometimes I will try with a long 25G first to reduce risk of PDPH, but if I find I have trouble keeping needle from flexing when trying to redirect and advance, I will switch to a 22G Quincke sooner rather than later.
If extra long needles are not available for some reason. Then to compensate for those few millimeters - is midline approach (Vs paramedian) with pressure application will improve success rate with USG assistance?
yes, you can get up to 1cm further depth of needle advancement if the subcutaneous tissues are compressible. Paramedian will always be a slightly longer trajectory, but how much depends on angle.
WONDERFUL!!!!!