Special technique of lumbar epidural block

Lumbar epidural block with unexpected mistakes

Lumbar epidural block(LEB) is the most popular block injection for low back pain / neuralgia disease. Many surgical physicians will train this block. So if you are a surgeon basically anyone can do it. However, LEB is actually more difficult than the imagination of the procedure, often mistakes.

Miss is a case where the injection does not enter the epidural space. Making a mistake will result in an ineffective injection. But there is no way for a doctor to investigate mistakes, so we can not tell whether it will not work for mistakes or not for success. In severe cases it is sometimes 100 times missed in 100 blocks.

Block penetration method

The style of this block is that the patient rounds up in a side-lying position and injects from the back. Recently, there are doctors saying “I can only do LEB under XP perspective”, but basically it is done without using perspective.

The median method of advancing the needle from between the spinous processes of the spine and the spinous process. There is a para-median method that advances the needle obliquely from the outside 1 to 2 cm from the outside. It is a technique that the para – medial method is overwhelmingly more difficult manually. For the elderly, the medial method becomes impossible because the spinous process spacing becomes zero. A doctor who can only do median method can not even stab a needle, so it becomes stuck. Because a general doctor can only do median method, he

The elderly can not block the spine. Indeed, the number of doctors who can block in the deformed spinal column of the elderly is extremely few.

Doctor needs ability to read XP

Even without the deformity of the spine, it is extremely difficult to do blocking if there is a scoliosis or twist. According to twist, the technique advancing with the angle of the needle is more difficult, the number of doctors that can do this is even more limited. There are surprisingly many patients with twist in the lumbar spine.

A doctor who does not observe firmly XP and does not do a twisted structure on his head, in the case of a patient with a twist in the lumbar vertebrae, can not advance the needle in place, , He will bruise the patient severely. And it will be the last to miss injection. Perhaps your lumbar spine is twisted if you miss LEB many times.

Approximate number of treatments

Depending on whether you are a doctor using a thick needle or a doctor using a thin needle, the limit number of treatment will change. With a thick needle (23 G or more), the risk of damaging the venous plexus of the epidural space, breaking the dura mater, bruising the periosteum, bleeding, infecting, etc. is higher than a thin needle. Three times would be the limit if a doctor without subtleness would do the treatment. However, if you use a thin 25G needle, that risk will decrease and you will be able to treat it for a long period of time. If the doctor can only do median method, long-term continuous should be avoided. The reason is that as the needle passes through the interspinous ligament it tends to become infected. Because the blood flow in the ligament is sparse, you should not stab a needle over and over again. In the para-medial method, since the needle passes through the muscles, it is resistant to infection and damage and withstands frequent treatment. In this way, I will keep in mind that the number of treatment limits will change depending on the skill level of the doctor.

No effect if mistakes are made

Mistakes often caused by epidural blocks are to inject medicine just before the ligamentum flavum. It is easy to be misunderstood as a epidural space because this is a sparse location of tissue binding. Even if a doctor makes a mistake, there is no way to recognize that it is a mistake, so often I think that “the block is successful”. The only way to recognize mistakes is to use a contrast medium and check whether there is any leak under fluoroscopy.

However, it is a bad foreign body in the body, not only places a burden on the liver and the kidneys but also there is a risk of causing anaphylactic shock, so it is a drug that I do not want to use as much as possible. In addition, since it is exposed to X-rays in XP fluoroscopy, this also has an adverse effect on the body. From the cost perspective it is impractical to use contrast media.

Absolutely effective epidural block

Lumbar epidural block will work a little if it is a lumbar spine disease. However, there are times when you make mistakes, so it’s definitely going to be a treatment that does not always work. A general doctor will not tell it to a patient even if there is a possibility of a mistake in the block. There is no way to check mistakes. But after I block, I ask the patient “Whether the pain relaxed?”, If not relaxing, judge it as a mistake and take the method “try again.”

This method sounds easy, but it is actually difficult. The four reasons are described below. 1, admitting a mistake is that the doctor’s pride is hurt. It is common sense to not confess if there is no evidence of mistake. 2. Even if a doctor feels a mistake If the injection hurts, even if you ask “Please try again”, the patient may not allow it. 3, if the doctor admits a mistake it may be sued by the patient in the worst case. 4, The person who was difficult to enter at the first time is difficult to enter for the second time, so there is a possibility of repeating the mistake further in the recovery shot. And it took twice the time and you can not charge for that.

Challenging doctors admitting mistakes and trying block again requires a considerable courage and self-sacrifice spirit. Who will be doctors will show such self-sacrifice? I want to be true to my conscience. So I confess mistakes and block until I succeed. And I have skills and guts to do it. So I can “absolutely effective epidural block”. Conversely, if it is ineffective to be “an absolutely effective epidural block”, you can make a speculation that this pain is not a lumbar spine disease, and you will be able to find hidden diseases . In other words, the diagnostic technology also rises dramatically.

What you should not do with the epidural block

What the doctor should not do most in the epidural block is to break the dura and advance the needle further and make it into spinal anesthesia. When spinal anesthesia comes, blood pressure drops suddenly, and this causes several people to die each year. In Pain Clinic, there are cases where “legs do not move” for about 1 hour after lumbar epidural block. However, this “state that the legs do not move” is the evidence that broke the dura and inserted the medicine.

When breaking the dura, spinal fluid leaks from there, causing headaches and nausea, but this is called post spinal headache (PSH), which lasts about a week often and in some cases lasts almost a month. There is a risk that a needle enters into the medulla and infection may cause meningitis, and I think that it is most important thing in this block not to do duralgeal penetration.

However, at the work site it will penetrate the dura mater at a rate of approximately 10 – 20% or more. Therefore, it is inevitable that dural penetration is necessary. It is positioned as an inevitable complication in this block. However, the doctor should not do this block with such a thought. Because in my case the frequency of causing dural penetration is 1 to 2 cases in 10,000 cases. By swearing to the heart that “absolutely not to penetrate the dura mater”, it will not cause dural penetration.

The painful block is dangerous

If you insert a needle into the spinal cord or cauda equina and inject the medicine, the nerve may be destroyed and paralysis may remain forever. It is a complication that you should never do. However, immature physicians frequently give patients a strong pain when doing the block. Therefore, even if the patient complains about pain when stabbing a needle in the spinal cord, it may be difficult to distinguish whether it is an appeal of pain in the procedure or a needle stabbed in the spinal cord. Therefore, there is a high probability of causing the worst situation “Doctors who have pain at the time of injection do not notice when stabbing the spinal cord”. Therefore, the epidural block requires “a technique not to hurt”. The painful technique is directly linked to the high risk.

Epidural block injection method without pain

In the lumbar epidural block, the strongest pain comes out when the tip of the needle sticks to the periosteum. Usually, when performing an epidural block, the doctor performs local anesthesia, but since the medicine does not infiltrate to the depth of the periosteum, when the needle sticks to the periosteum it becomes acute pain.

In the case of a small skeleton, a deformed lumbar spine, or a twisted lumbar spine, the probability that the needle will enter the intervertebral foramen at a time is low. In the case of an immature physician, he repeatedly sticks a needle into the vertebral arch and articular process. And every time he gives a pain to the patient. To prevent this, it is necessary to perform local anesthesia to the vicinity of the vertebral arch with a cathellan needle or the like. The technique of the epidural block can not be “all the doctors equally”. That is a very big difference in technology between individuals.

Casualization of the lumbar epidural block

Because there is a risk as described above, the epidural block of the lumbar region is in the position of “block injections that should rarely be done”. However, reckless doctors are confident in themselves and doing this block prevents medical malpractice. Therefore, it is spreading the world that “it is better not to block the epidural lumbar block”.

However, if a skilled doctor is involved, this block becomes safe and highly effective block, and it will be able to receive it casually.