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Welcome back to "Practical Pain Management with Dr. Lee!" We're delighted to have our Master and Practical Class attendees join us. We're unraveling a spectrum of techniques in our ongoing transforaminal technical series. These span from simple subpedicular methods ideal for younger individuals with regular spines to specialized strategies tailored for our elderly patients with unique spinal configurations. In upcoming discussions, we'll address the refinement of transforaminal injections that might not have fully reached their subpedicular destinations. Today, in Part 3, we spotlight the challenge of the needle needing to progress to the intended 6 o'clock position. Instead, we'll fine-tune our approach towards the circumneural sheath in the intervertebral foramen's external part. We'll also demonstrate the significance of verifying needle placement using the contralateral oblique perspective on the C-arm.
When carrying out the lumbar transforaminal subpedicular approach, you'll often face challenges like spinal deformities and limited space for guiding the needle. Even though there's a standard procedure, these obstacles can make it tricky to position the needle perfectly. Sometimes, achieving the ideal needle placement might seem out of reach, prompting the need for a change in approach. It's essential to be adaptable and ready to deal with various anatomical differences, whether it's the downward elongation of the transverse process, the outward growth of the superior articular process, or situations where the C-arm requires a considerable upward tilt.
During a previous session, we observed the needle veering off its course, influenced by the subtle contour of the transverse process's lower edge, causing it to miss the optimal position. I introduced a refined approach to guarantee a comprehensive contrast distribution within the circumneural sheath and epidural space. This method necessitates the initial positioning of the needle against the bone, followed by a slight downward tilt before steering it towards the intended path, facilitating fluid movement along the bone.
When analyzing from both the AP and contralateral oblique perspectives, if pinpointing the perfect position proves challenging, envision an imaginary line connecting the needle's touchpoint and the nerve root's lateral boundary. Maintaining an open line of communication with the patient is essential to guiding the needle toward this recalibrated target. Such interactions underscore the significance of keeping the patient alert and involved; resorting to sedation can be detrimental and escalate the potential for accidental nerve damage. Before committing to this adjusted target, conduct a preliminary injection with a minimal contrast volume. If satisfactory, proceed with a more substantial amount to enhance the visibility of the subpedicular, transforaminal, and epidural regions.
In this initial presentation, the subtle bone shadow of the transverse process's inferior border might be challenging to notice when observing through the ipsilateral oblique C-arm view. I located this shadow, which prompted me to make the skin puncture a bit lower than the usual entry point. Please diligently track the needle's progress and directional shifts displayed in different C-arm angles.
You'll witness the needle pausing right at the outer boundary of the pedicle's circular shadow. Visualizing the path of the nerve root, you'll then discern the contrast extending into the epidural space. Upon closely examining this contrast flow, it becomes evident that the needle's tip is situated in the posterior epidural area. This placement indicates that the needle has yet to traverse beyond the nerve root's upper margin into the anterior epidural section.
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26 авг 2024
