As a practising anaesthetist with a special interest in ultra-sound, I have found professor Chins videos extremely useful and practical. I have performed many spinal anaesthetics over the years however his videos have allowed me to refine my technique and provide a higher standard of care, particularly in the more challenging patient.Today I had a 92 yo for a knee replacement . Her lumbar spine was difficult to feel. I could not feel spinous processes hardly at all and midline by palpating was difficult to determine. Incorporating ultrasound and professor Chins advice I was able to determine midline with ultrasound and achieve lumbar puncture much more easily than I expected . Thanks again .
Excellent demonstration with apt description of the most widely performed procedure ! Your paraspinous approach is very useful for difficult spinal as well as difficult epidural. I found it useful even for thoracic epidural . Millions thanks for the superb videos and for sharing the pearls of wisdom.
Thank you for your comments! Yes - I too use the same paraspinous principles for thoracic epidural insertion. Check out the video on using ultrasound to assist thoracic epidural insertion where I discuss this.
Thank you for the comment. I recommend also checking out the series on the paraspinous approach and finding opportunities to practice this - I make it a priority for my trainees and it is my go-to approach in the difficult spine. th-cam.com/play/PLrTgRae0xlkN2Tucs5gZ2JePSqafcNdDn.html&si=f1Gac3XEEmh357HH)
Kind sir! Could you please make a wonderful video about thoracic epidural anesthesia (midline and paramedian)? The youtube has very few videos, and they are very brief without all these priceless explanations that you provide. Your videos have GREATLY improved my regional block peformance. G-d bless you!
Should the introducer needle be advanced through its entire length? In thin patients, can it cause a dural tap if the entire length of the introducer has been inserted? Secondly, should the spinal needle be rotated 360 degrees after obtaining csf flow? Also, in the video, you have held only the spinal needle and not supported the introducer needle while attaching the syringe and injecting the drug. Wouldn't there be a risk of needle migration during these steps if the introducer is not supported? These are few queries because our basic training in India is with the quincke needle. Hence we are quite confused which fingers to use to support the needle and which needles to support. Thanking you in anticipation
1)I insert it only as far as is needed to have it firmly anchored - which means into the interspinous ligament for midline, or paraspinal muscles for paraspinous approach. As long as they are not obese, I usually have 0.5-1cm still protruding. The main reason not to insert to its entire length is so that I can manipulate the introducer to change needle trajectory if required. It's unlikely to cause dural tap in adult patients since the length of a spinous process is at least 3cm. But worth being mindful of. 2)I always rotate the needle as a habit. No downside, and it often improves flow. 3) The key is to hold the spinal needle in position, so that is what should be held and stabilized during injection. The introducer is irrelevant at this final stage. During insertion however, we hold the introducer because it is responsible for "aiming" at the target - think of it like the barrel of the gun, and the spinal needle like the bullet/missile (just shoots in and out). But once the spinal needle has reached its target, it becomes the only thing you need to control to keep it in the target.
@@KiJinnChin thank you so much Dr Chin for your detailed reply. It has cleared all doubts. Appreciate your patience and the brilliant videos you put up here. Stay blessed
@@Clarkson350 more often than not, especially in older patients, simply because some degree of cranial angulation is needed to walk off into the space. Nothing wrong with (gentle) bony contact, as long as you have a good idea of what you’re touching and where to go next. It’s an expected part of the process. I don’t often have to do a second needle insertion point through skin though, which is a different thing from needle passes/ redirections. Scouting with your LA infiltration needle usually takes care of that aspect of starting off in the right place.
Sir i have a question.....How to locate the interspinous ligament with local anaesthetic needle....? Do o have to shift the direction of syringe right or left or do i have to push skin with my two finger right and left ? Please answer
1) place index and middle fingertips on either side of spinous processes. At this point the APPROXIMATE midline is between your fingertips 2) Insert LA needle and raise subcut wheal with 1-2ml to numb the skin for comfort 3) Insert LA needle deeper now - this is to determine whether the trajectory is in the interspinous ligament or off to one side in the muscle - the answer comes when you try to inject. If you can't inject - congratulations, you have found the interspinous ligament and can use the same trajectory to place the spinal introducer/needle. If you can inject, you are in muscle and off to one side 4) start to search in a left-right pattern for the interspinous ligament. Do NOT angle the syringe (which I think is what you are asking). You want to make a parallel shift (see video and it will be obvious why you don't want to angle your needle). You could make a new skin puncture to the left or right of your first one - but there is no need - use the mobility of the skin to shift the needle insertion point slightly left/right relative to the underlying bone. Just make sure you have withdrawn the tip into the subcut tissues before you shift the skin with your fingertips. 5) repeat the insertion and trial injection. Keep making the small parallel shifts until you obtain the resistance to injection. Putting the effort into searching pays off with the older patient who has narrowed interlaminar spaces. And after a while, it becomes second nature, and very quick and easy. Note: the only time you would angle the needle is if you believe the spine is rotated - i.e. scoliotic. See the video on scoliotic spine for more details.
Thanks alot sir.... Sir one more question about a problem that i encounter... In obese patients when we are unable to palpate any spinous process or vetebrae how to find the space with minimum punctures.....? I am a first year resident so still i find difficulty sometimes in giving spinal mostly in obese and short heighted patients as i always hit bone no matter where i move my spinal needle
@@srk341717 here is where I encourage you to use ultrasound if it is available to you. See my videos - th-cam.com/video/KXTaP9PVZW0/w-d-xo.html (obesity), th-cam.com/video/vgitdMn8RnI/w-d-xo.html ( basic US for midline approach). Alternatively, I have also been successful with just a controlled incremental approach, usually with a 22G long Quincke needle for its rigidity and ease of redirection. And I sometimes deliberately do a paraspinous/paramedian approach, as redirection into the space is actually easier - you know that you are not in the midline (and not worrying about it), touching lamina, and you can "walk" into the space. See my video on paraspinous approach - th-cam.com/video/Ui7rKs5fyYg/w-d-xo.html
In older people sometimes the CSF pressure is low. With a pencil point needle, sometimes the cauda equina may be partially obstructing the orifice and impeding the flow. Here is my usual practice if CSF flow is absent/sluggish: (1) rotate / spin the needle 180-360 degrees, sometimes a few times; (2) wait and watch - if there is a fluid meniscus, and it is moving even slowly, I will accept that and inject carefully WITHOUT attempting to aspirate so as not to dislodge the needle; (3) if there is no fluid, advance slightly further, perhaps even contact bone which is the anterior wall of the canal, then with the stylet out of the needle, withdraw in small increments, pausing and rotating the needle to see if CSF starts to flow.
@@KiJinnChin Thank you very much sir and I'm so happy for your answer. Forgive me l'm not good at English. Today I was practice spinalanesthesia. 71kg. 165cm. Pregnancy women 38weeks 18G needle(introducer) , 27G pencil point needle L3~4, sitting position 0.5% bupivacaine heavy 11mg result was terribly poor In case of sitting position How much increase of injection dosage?? If it is ridiculous question, Forgive me sir
As a practising anaesthetist with a special interest in ultra-sound, I have found professor Chins videos extremely useful and practical. I have performed many spinal anaesthetics over the years however his videos have allowed me to refine my technique and provide a higher standard of care, particularly in the more challenging patient.Today I had a 92 yo for a knee replacement . Her lumbar spine was difficult to feel. I could not feel spinous processes hardly at all and midline by palpating was difficult to determine. Incorporating ultrasound and professor Chins advice I was able to determine midline with ultrasound and achieve lumbar puncture much more easily than I expected . Thanks again .
I'm so glad to hear that you were able to impact this patient's care for the better. Never stop learning, that's my motto too!
Excellent demonstration with apt description of the most widely performed procedure !
Your paraspinous approach is very useful for difficult spinal as well as difficult epidural.
I found it useful even for thoracic epidural .
Millions thanks for the superb videos and for sharing the pearls of wisdom.
Thank you for your comments! Yes - I too use the same paraspinous principles for thoracic epidural insertion. Check out the video on using ultrasound to assist thoracic epidural insertion where I discuss this.
Great video for new a new trainee that has a hard time with spinals, especially in the elderly... Thank you very much!
Thank you for the comment. I recommend also checking out the series on the paraspinous approach and finding opportunities to practice this - I make it a priority for my trainees and it is my go-to approach in the difficult spine. th-cam.com/play/PLrTgRae0xlkN2Tucs5gZ2JePSqafcNdDn.html&si=f1Gac3XEEmh357HH)
this is so good. thank you for your videos. no one has taught me the anatomy and pitfalls so well
Great video Doc.. I've done hundreds of spinals and epidurals but always looking to improve. Excellent vid even for an experienced provider.
Thank you Doctor. I did 2 subarachnoid blocks today. Your tips are so useful.
Kind sir! Could you please make a wonderful video about thoracic epidural anesthesia (midline and paramedian)? The youtube has very few videos, and they are very brief without all these priceless explanations that you provide. Your videos have GREATLY improved my regional block peformance. G-d bless you!
Incredibly useful, thank you for putting in the time and effort to make this!
Excellent video. Doing my second spinal tomorrow. Thank you
Great job explaining this tips! Excellent visualization. Thanks
Thank you for the video, and also thank you for replying to the comments.
brilliantly explained. thank you.
Should the introducer needle be advanced through its entire length? In thin patients, can it cause a dural tap if the entire length of the introducer has been inserted? Secondly, should the spinal needle be rotated 360 degrees after obtaining csf flow? Also, in the video, you have held only the spinal needle and not supported the introducer needle while attaching the syringe and injecting the drug. Wouldn't there be a risk of needle migration during these steps if the introducer is not supported? These are few queries because our basic training in India is with the quincke needle. Hence we are quite confused which fingers to use to support the needle and which needles to support. Thanking you in anticipation
1)I insert it only as far as is needed to have it firmly anchored - which means into the interspinous ligament for midline, or paraspinal muscles for paraspinous approach. As long as they are not obese, I usually have 0.5-1cm still protruding. The main reason not to insert to its entire length is so that I can manipulate the introducer to change needle trajectory if required. It's unlikely to cause dural tap in adult patients since the length of a spinous process is at least 3cm. But worth being mindful of.
2)I always rotate the needle as a habit. No downside, and it often improves flow.
3) The key is to hold the spinal needle in position, so that is what should be held and stabilized during injection. The introducer is irrelevant at this final stage. During insertion however, we hold the introducer because it is responsible for "aiming" at the target - think of it like the barrel of the gun, and the spinal needle like the bullet/missile (just shoots in and out). But once the spinal needle has reached its target, it becomes the only thing you need to control to keep it in the target.
@@KiJinnChin thank you so much Dr Chin for your detailed reply. It has cleared all doubts. Appreciate your patience and the brilliant videos you put up here. Stay blessed
Hi Doc. How do you differentiate if it is csf return and not topical local anesthesia flowing back during the spinal?
excellent teaching sir
Thank you very much, very helpful.
Hi Sir,
After how much time patient regains consciousness is lower body after spinal anaesthesia if done for ureterscopy? Please reply 🙏. Thanks
Very helpful, Thanks!
Thanku doc..very informative video
Are there some cases where csf aspiration is easy but spinal anesthesia fails?
why
How often do you not get it on the first pass? Thanks
@@Clarkson350 more often than not, especially in older patients, simply because some degree of cranial angulation is needed to walk off into the space. Nothing wrong with (gentle) bony contact, as long as you have a good idea of what you’re touching and where to go next. It’s an expected part of the process.
I don’t often have to do a second needle insertion point through skin though, which is a different thing from needle passes/ redirections. Scouting with your LA infiltration needle usually takes care of that aspect of starting off in the right place.
Thank you,Sir
Excellent
volume is too low.
Sir i have a question.....How to locate the interspinous ligament with local anaesthetic needle....?
Do o have to shift the direction of syringe right or left or do i have to push skin with my two finger right and left ?
Please answer
1) place index and middle fingertips on either side of spinous processes. At this point the APPROXIMATE midline is between your fingertips
2) Insert LA needle and raise subcut wheal with 1-2ml to numb the skin for comfort
3) Insert LA needle deeper now - this is to determine whether the trajectory is in the interspinous ligament or off to one side in the muscle - the answer comes when you try to inject. If you can't inject - congratulations, you have found the interspinous ligament and can use the same trajectory to place the spinal introducer/needle. If you can inject, you are in muscle and off to one side
4) start to search in a left-right pattern for the interspinous ligament. Do NOT angle the syringe (which I think is what you are asking). You want to make a parallel shift (see video and it will be obvious why you don't want to angle your needle). You could make a new skin puncture to the left or right of your first one - but there is no need - use the mobility of the skin to shift the needle insertion point slightly left/right relative to the underlying bone. Just make sure you have withdrawn the tip into the subcut tissues before you shift the skin with your fingertips.
5) repeat the insertion and trial injection. Keep making the small parallel shifts until you obtain the resistance to injection.
Putting the effort into searching pays off with the older patient who has narrowed interlaminar spaces. And after a while, it becomes second nature, and very quick and easy.
Note: the only time you would angle the needle is if you believe the spine is rotated - i.e. scoliotic. See the video on scoliotic spine for more details.
Thanks alot sir....
Sir one more question about a problem that i encounter...
In obese patients when we are unable to palpate any spinous process or vetebrae how to find the space with minimum punctures.....?
I am a first year resident so still i find difficulty sometimes in giving spinal mostly in obese and short heighted patients as i always hit bone no matter where i move my spinal needle
@@srk341717 here is where I encourage you to use ultrasound if it is available to you. See my videos - th-cam.com/video/KXTaP9PVZW0/w-d-xo.html (obesity), th-cam.com/video/vgitdMn8RnI/w-d-xo.html ( basic US for midline approach). Alternatively, I have also been successful with just a controlled incremental approach, usually with a 22G long Quincke needle for its rigidity and ease of redirection. And I sometimes deliberately do a paraspinous/paramedian approach, as redirection into the space is actually easier - you know that you are not in the midline (and not worrying about it), touching lamina, and you can "walk" into the space. See my video on paraspinous approach - th-cam.com/video/Ui7rKs5fyYg/w-d-xo.html
Thanks
First thanks for this video Sir
I have question
Sometimes i feel pop (?)
But there was no CSF.
What was wrong?
Please help me
In older people sometimes the CSF pressure is low. With a pencil point needle, sometimes the cauda equina may be partially obstructing the orifice and impeding the flow. Here is my usual practice if CSF flow is absent/sluggish: (1) rotate / spin the needle 180-360 degrees, sometimes a few times; (2) wait and watch - if there is a fluid meniscus, and it is moving even slowly, I will accept that and inject carefully WITHOUT attempting to aspirate so as not to dislodge the needle; (3) if there is no fluid, advance slightly further, perhaps even contact bone which is the anterior wall of the canal, then with the stylet out of the needle, withdraw in small increments, pausing and rotating the needle to see if CSF starts to flow.
@@KiJinnChin
Thank you very much sir
and I'm so happy for your answer.
Forgive me l'm not good at English.
Today I was practice spinalanesthesia.
71kg. 165cm.
Pregnancy women 38weeks
18G needle(introducer) , 27G pencil point needle
L3~4, sitting position
0.5% bupivacaine heavy 11mg
result was terribly poor
In case of sitting position
How much increase of injection dosage??
If it is ridiculous question,
Forgive me sir
very useful tips
Thanks for the video
Sound is very low
Super helpful thank you!