1) Either side of the body

2) midline

How do you get someone ready for lateral position approach for SAB or Epidural? 

In other words... What types of things should you consider or do?

1) Back is arched

2) Pillow is placed under head to maintain vertical line

3) Body is placed, ideally, on the edge of the table.

4) Table height should be comfortable favoring a direct shot. 

5) Mark the site.

  Men have big nuts (just kidding)

1) Men- Big shoulders

2)  Women- Bigger hips

1) Depends on your preference

2) potential for injury

3) baricity of solution

How do you prep the lumbar region for SAB or epidural puncture?

Is it a sterile procedure?

- Yes it is a sterile procedure

1) Skin is prepped x 3 (betadine must remain on skin at least 1 minute).  Never wipe with alcohol as this neutralizes betadine.

2) Wiped with sterile gauze

3) sterile drape

4) Local anesthetic 1% lidocaine

True or false- Skin Wheel is spelled correctly.

What does one look like if done correctly?

False- Correct spelling:  Skin Wheal.

Looks like orange peel skin if done correctly.

1) Why would one utilize an introducer for spinal needles with Subarachnoid blocks?  

2) Do epidural needles require introducers?

1) The tensile strength of spinal needles (especially the 25,27 gauge) is poor.  Pushing against bone can easily bend needle.  Therefore introducer is utilized.

2) No

At what times may you consider not using and introducer for SABs?

1) The needle is not quite long enough and the introducer is taking up space.

2) The space is very small that needs to be maneuvered through.

1) easy to learn technique

2)  Identifiable structures

1) During a straight line approach- you encounter bone early on.  What should you do?

2) What would you do if you encountered bone later versus early on?

1) Pull needle back into introducer and redirect cephalid

2) Pull needle back into introducer and redirect caudad

1) Regarding Spinals... what feels like a needle going through an eraser?

2) Where are you if you feel a pop, click or give?

3) What do you do when #2 happens?

1) Passing a spinal needle through the ligamentum flavum

2) You have passed through the dura mater and the arachnoid mater into the subarachnoid space.

3) Remove the introducer wait for clear CSF.

1) "feel"

2) Smaller

1) What do some practitioners do to determine if they are in the subarachnoid space but have not visualized CSF return? 

2) If you have done the above and still have not visualized CSF what should you do?

1) - With stylet indicator on top

Rotate needle 360 degrees in 90 degree increments.

- Allow time for CSF return

- Should have good return. 

2) Place stylet and advance needle slightly- recheck-rotate needle.

1) When would you consider a paramedian approach for SAB?

2) What is the advantage?

1) Elderly that have decreased flexibility with degeneration and calcified ligaments

2) Aims for the largest area between the spinous processes, Avoids the calcified intraspinous ligament.

Skip is spazzing out one day because he doesn't remember how to do the paramedian approach.  What do you tell him in regards to the main steps of the procedure? 

4 main points:

1) Needle is inserted 1 cm or 1 fingerbreadth from midline (laterally) and caudad to the interspace. 

2) The needle is directed towards the spinal canal and angled slightly cephalad at a 10-15 degree angle. 

3) The feel is the same as the medial approach except that the intraspinous ligament is avoided.  Instead the needle penetrates the paraspinous muscles.  (little resistance initially)

4) Loss of resistance is more subtle with this approach.

Paramedian Approach:

1) If you encounter bone with your needle early on what's up? What should you do?

2) If you encounter bone deep what's up? What should you do?

1) You are likely in contact with the medial part of the lower lamina- your needle should be directed mostly upward.

2) The needle is usually in contact with the lateral part of the lower lamina and should be redirected only slightly upward or more towards midline.

Absolute Contraindications to SAB:

There are 9.

1) Pt Refusal

2) Septicemia or bacteremia

3) Unstable CNS Diseases

4) Infection at site of needle insertion

5) Increased ICP  (Squirt!)

6) Severe Hypovolemia

7) Bleeding disorder or Full Anticoagulation therapy

8) Aortic Stenosis

9) Allergy to local anesthetics. 

(should probably also avoid giving SAB to pts with IHSS--

Idiopathic Hypertrophic Subaortic Stenosis)

1) Untreated chronic HTN

2) Severe Spinal Column deformity

3) Minor Clotting abnormality (secondary to long term aspirin therapy or low molecular weight heparin)

4) Chronic headaches, backaches, or neuropathy.

1) Does the ink from a tramp stamp cause problems with SAB?

2) If you encounter one what should you do?

1) No data to indicate an increase in incidence of neuralgia or arachnoiditis.  However, in theory, a dirty inking could cause introduction of unwanted stuff. 

2) If you can find a non-inked spot use it.

If you must go through ink, do so in someone who had the tatoo placed 6-12 months prior to procedure.