Great video as usual thanks. When you walk off the lamina do you angle the introducer uphill or do you pull it out and move it vertically a small amount?
@gavinsullivan9015 - In reference to the paraspinous approach, I usually start with small incremental cranial angulations. I only shift the insertion point if I have "walked" the needle to a cranial angle of >45 degrees from the perpendicular and am still contacting bone. As I was just explaining to my trainees, this usually means that our initial insertion point, rather than being at the level of the LOWER end of the interspinous space, was at the level of the UPPER end of the interspinous space. And thus our initial bony contact is with the lamina ABOVE the targeted interspace, rather than the lamina BELOW. At that point, if I believe this is what is happening, I will shift my insertion point "vertically" - i.e. to a more caudal location, usually 3-5mm, and begin again. I will try to upload a short video that illustrates this concept.
Thank you sir, i struggled with the clasic technique but i achieved succes with the technique that you described, i'm still at the learning curve and i hope i will get better. I wholeheartedly thank you for your amazing professional and in depth content.
Yes, in my experience this is HIGHLY likely with plain LA solutions at the L5-S1 (sitting or lateral position), unless you administer huge doses (see video at 4min in for the study that demonstrated this), This is why, for the last few years, I always use hypobaric LA created with addition of water, instead of plain solutions.
Yes this should work. Some of my trainees have told me that they often do this in crash c-sections to get enough height. The only caution is that I think in general many people may find being head down uncomfortable - so I would be mindful of that, and flatten them again if they complain. In this respect hypobaric and head-up positions have an advantage.
If i have to practice a spinal anesthesia for Caesarean surgery L5 S1 puncture with isobaric Bupivacaine 0,5 % is a good option when is it impossible to pass to upper level of vertebral column ? Is it too much exceeding a dosage about 25 mg or is better less 20 mg ? Thanks for the excellent video from Italy .
I don't practice OB - so this is a theoretical response based on my experience in non-OB. I think that if you used >15mg, you would have motor block for >4h. Which is not ideal. The aim is to get a high enough block for surgery. So I would NOT use ISOBARIC bupi at the L5-S1 space. Personally I would add 1ml of water to the chosen dose of isobaric bupivacaine (10-15mg as you see fit), to make it HYPOBARIC, and then lie them supine in a head-up position. You can also add some fentanyl (15mcg) for added quality of block. You can let surgeons prep, etc, which allows for onset time, then get them to test level before starting. I have no experience with administering HYPERBARIC bupivacaine at the L5-S1 level for LSCS (only for saddle blocks for anorectal surgery!), so I cannot say if this will spread cranially in the supine position - however I have been advised by some people that it works....
@@KiJinnChin thanks for your satisfying answer , i think its the best option . I think that a lombar puncture with bubivacaine hyperbaric al L5 S1 level dont reach upper level as sensitive block beacause it deposit and stays stopped in the lumbar lordosis , as you describe its to prefere ipobaric solution to reach the top.
In straightforward patients, I generally prefer GA for day surgery. I use a TIVA technique carefully titrated to depth, and have refined my practice to the point where I believe that, coupled with an analgesic block, it is really "sedation with a secured airway". Most of the potential downsides of a GA are non-existent. Whereas a spinal carries some potential disadvantages, including imperfect matching of surgical duration with spinal duration, delays in mobilization, urinary retention, TNS with lidocaine / mepivacaine, etc. This is not to say that I don't perform spinals where there is a clear benefit/advantage, especially for safety - but all else being equal, I personally lean towards GA.
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Great video as usual thanks. When you walk off the lamina do you angle the introducer uphill or do you pull it out and move it vertically a small amount?
@gavinsullivan9015 - In reference to the paraspinous approach, I usually start with small incremental cranial angulations. I only shift the insertion point if I have "walked" the needle to a cranial angle of >45 degrees from the perpendicular and am still contacting bone. As I was just explaining to my trainees, this usually means that our initial insertion point, rather than being at the level of the LOWER end of the interspinous space, was at the level of the UPPER end of the interspinous space. And thus our initial bony contact is with the lamina ABOVE the targeted interspace, rather than the lamina BELOW.
At that point, if I believe this is what is happening, I will shift my insertion point "vertically" - i.e. to a more caudal location, usually 3-5mm, and begin again.
I will try to upload a short video that illustrates this concept.
@@KiJinnChin thanks appreciate the reply.
I just watched this presentation, excellent one. Did you upload the video you suggested or not yet?@@KiJinnChin
Extremely useful !
Thank you sir, i struggled with the clasic technique but i achieved succes with the technique that you described, i'm still at the learning curve and i hope i will get better. I wholeheartedly thank you for your amazing professional and in depth content.
I’m glad you are succeeding. Also recommend you read our article in BJA education available here - authors.elsevier.com/a/1iG9n7K3e2rzx7
Excellent, easy to remember.
Great stuff
Thanks for this
Superb!
Great content. Do you get a low block height when doing a L5/S1 spinal in the lateral position using plain bupivacaine?
Yes, in my experience this is HIGHLY likely with plain LA solutions at the L5-S1 (sitting or lateral position), unless you administer huge doses (see video at 4min in for the study that demonstrated this), This is why, for the last few years, I always use hypobaric LA created with addition of water, instead of plain solutions.
@@KiJinnChinHypobaric? That's quite clever.
@@uramalakia I cannot take credit for inventing it - it's an old-timer's trick apparently, but it's been a game changer for me.
I have a question. What if I Use a hyperbaric LA and afterwards a Trendelenburg position. Will i get a better spread of the LA ?
Yes this should work. Some of my trainees have told me that they often do this in crash c-sections to get enough height. The only caution is that I think in general many people may find being head down uncomfortable - so I would be mindful of that, and flatten them again if they complain. In this respect hypobaric and head-up positions have an advantage.
If i have to practice a spinal anesthesia for Caesarean surgery L5 S1 puncture with isobaric Bupivacaine 0,5 % is a good option when is it impossible to pass to upper level of vertebral column ? Is it too much exceeding a dosage about 25 mg or is better less 20 mg ?
Thanks for the excellent video from Italy .
I don't practice OB - so this is a theoretical response based on my experience in non-OB. I think that if you used >15mg, you would have motor block for >4h. Which is not ideal.
The aim is to get a high enough block for surgery. So I would NOT use ISOBARIC bupi at the L5-S1 space. Personally I would add 1ml of water to the chosen dose of isobaric bupivacaine (10-15mg as you see fit), to make it HYPOBARIC, and then lie them supine in a head-up position. You can also add some fentanyl (15mcg) for added quality of block. You can let surgeons prep, etc, which allows for onset time, then get them to test level before starting.
I have no experience with administering HYPERBARIC bupivacaine at the L5-S1 level for LSCS (only for saddle blocks for anorectal surgery!), so I cannot say if this will spread cranially in the supine position - however I have been advised by some people that it works....
@@KiJinnChin thanks for your satisfying answer , i think its the best option .
I think that a lombar puncture with bubivacaine hyperbaric al L5 S1 level dont reach upper level as sensitive block beacause it deposit and stays stopped in the lumbar lordosis , as you describe its to prefere ipobaric solution to reach the top.
Great video as usual, In daycare surgery, GA or SA do you choice for patient?. It's great if you make video about daycare surgeries.
In straightforward patients, I generally prefer GA for day surgery. I use a TIVA technique carefully titrated to depth, and have refined my practice to the point where I believe that, coupled with an analgesic block, it is really "sedation with a secured airway". Most of the potential downsides of a GA are non-existent.
Whereas a spinal carries some potential disadvantages, including imperfect matching of surgical duration with spinal duration, delays in mobilization, urinary retention, TNS with lidocaine / mepivacaine, etc.
This is not to say that I don't perform spinals where there is a clear benefit/advantage, especially for safety - but all else being equal, I personally lean towards GA.