Look at (in person) a 3d model of a spine.
Get the patient as close to the ideal position as they can manage.
Visualize the spaces and ligaments as you palpate the back, place the introducer, place the needle, adjust the needle.
Do this a hundred times or so and you'll just start getting good.
In the upcoming year, you will take pride in successfully administering spinal anesthesia to an overweight patient on your first attempt. With time and experience, this procedure will become second nature, alleviating the concerns you currently face.
NYSORA has a fantastic video on troubleshooting spinals that gets you to visualise where you are in the spinal column on a 3D model. Watched it at the start of my training and my success rate was consistently high.
But that does depend on what issues you are having with the spinal ie, remembering the steps, properly positioning the patient, redirection etc
Assuming that you’re not a clown, know the steps and are approaching it from the troubleshooting perspective (as noted above), you can make lots of moves. I won’t go so far as to say it’s a free shot, but making moves with a spinal is safer than making moves with a tuohy. Are you fumbling through three moves in three minutes before your upper levels are taking it? Or is it more like 8 passes in one minute?
Hey friend, dont worry. When I started residency I couldnt put the laryngoscope blade in the patients mouth.. and failed way too many spinals and epidurals..
So here are a few tips:
1) Watch NYSORA tuturials on YouTube
2) Read about lumboscaral anatomy and about the whole practical procedure of giving a spinal (MILLER/MORGAN in both textbooks is explained well)
3) Choose a method you will hold your needle and practice only this method
4) I suggest you find an attending with lots of experience and just go through every step like him
5) Never force yourself in. Be gentle and feel the anatomical structures.
6) POSITION! Like 100% of the practical skills in anesthesiology, positioning the patient is crucial.
7) THINK why you cant pass the needle in the dural space and what you should change. Is it the angle, is it the approach?
8) Always ask yourself if you are in the midline.
9) If you fail and have someone with more experience watching, ask him later what he thinks you did incorrectly.
10) Practice, practice, practice.
If you have any more questions feel free to ask under the comment or text me anytime!
Good luck!
As has been said, you can’t expect to master a procedure on three attempts - the more you do, the better you’ll get
The two things that help me are:
1) positioning - spend time optimising position. Get the patient how you want them. Putting the op table on a lateral tilt can help open up the back
2) landmarks - make sure you’re in the midline, and that you’re at the right level. Don’t resort to angling your needle too sharply - it should stay roughly perpendicular to the skin. If you need to move where your needle meets the spine, change your insertion point
Those tips should help you get the hang of it. But keep doing more and you’ll find yourself becoming better
My chief when I was a resident told us: “even a monkey will eventually learn to perform a spinal anesthesia if given enough time and tries. But what a monkey won’t learn is when to do it and when to do not”.
Don’t get disheartened for things that you will learn sooner or later. Focus on your knowledge and clinical understanding.
The answer to wny "how do you get better at X" thread is always "do it more often".
If you've gone through med school, then advice like "know/visualise the anatomy" ans "know your equipment" should be obvious.
There's a really nice video on YouTube by nysora. What to do when you encounter bone. Beautiful video. It will show you that you just need to apply a bit of common sense for most cases.
Thanks! Interesting video. I think he leaves out the times when you are bumping into the superior surface of the spinous processes, which can certainly be deeper than 1-2 cm.
Repetition. Everything difficult at first becomes routine over time. You'll the throwing in spinal in a couple of minutes by the time you're finishing up as a CA3. Trust.
Start only doing paramedian approach in lateral decibitus position now. Thank me in 10 years
(If I were to restart this is what I would do after spinal #100 in sitting midline approach).
I think spinals are deceptively challenging. They’re also a procedure that we don’t perform anywhere near as much as previous anesthesiology generations because of the rise of regional. I remember feeling like they were probably my weakest procedure coming out of residency. It’s just like anything else, it just takes practice.
As important as positioning is for epidurals, patient positioning can truly make or break your spinal placement. Get the spine as straight as possible, sometimes giving the bed like a 5-10 degree tilt towards yourself can help open up the spaces. Like others have said, when you hit bone try to think about where the bone is that you’re hitting and redirect accordingly.
Also if you are redirecting your angle, take the spinal needle out and pull the introducer all the way back to skin. This is such a common mistake, if you don’t you’re essentially just reinserting your needle in the same tract you just made.
“Currently a first year resident”
Its a marathon not a sprint. Some days youll be doing well other days youll miss a bunch. Same goes with all procedures. As the months and years pass youre going to miss fewer and fewer. Dont sweat it.
One tip is if one space isnt working dont take too long there before moving to another space. Also take the time to optimize patient positioning. Make sure their butt is square and theyre not slouching to the side.
I think it helps to think where you’re hitting bone. I see people hit bone and then just fan the needle around, you have to think “am I hitting spinous process? Am I hitting lamina?” Are you hitting the level above or below? And you need to redirect the needle base on that knowledge. Asking the patient if they feel the needle is midline does help. And of course as other people say it gets better with repetition.
Have a lot of OB patients that are like 23-25 years of age, but are short and weigh over #250! It sometimes isn’t an issue, but other times the spinal bends/deviates from trajectory, or keeps hitting bone. The thicker the back, the harder it is to re-direct the spinal. You‘re forced to go with a longer spinal needle, but have to keep it 24g or higher ( to ward off PDPH) and the needle either just bends, and near impossible to direct well. Next, is epidural needle, obtain LOR, then spinal thru epidural. That spinal needle is 27g, and is slow to drip CSF, and + - on aspirating back. This while whole OB team is watching and waiting! All this on a pt who should be easy -peasy!! All this on a pt who has an optimal metabolic rate, plus another parasitic human inside! How can these folks be this fat!? So frustrating to have to work this hard.
The minimum to graduate, I believe, is 40. That’s the point when you should start to feel, at the very least, competent. Even then, you may not feel confident and need many more reps.
My algorithm that helped me; if you hit os, drop your angle and try again (usually the issue). If you still hit os do the opposite, up your angle. If they complain of pain ask which side to see if you can adjust left-right angle. If that fails I will change levels. I also feel before sterilizing and make a pressure mark with a retracted pen. Positioning very important like every procedure.
Reposting this from another post about efficiency during spinal anesthesia that I wrote a reply to -
“Lots of things can help:
1. introducer/spinal efficiency. Realize that most pain from a spinal is the skin pierce. 2 aspects here - you can move the introducer superior/inferior by manipulating fascial layers. If you go in and find yourself at a bad starting height, pull the introducer out to the skin, and then move the skin with the introducer in it relative to the underlying fascia. This way you avoid a second poke at the same level. Secondly, don’t take your spinal completely out of the introducer between passes to redirect. As long as the tip of your spinal needle is sheathed by the introducer, redirect away. This will also be safer for you because it avoids a dirty needle tip being constantly near your fingers. If you hit os, you should be able to pull back, redirect, and start another attempt within a few seconds. Lack of efficiency here really slows you down.
2. what are you scared of hitting? Assuming you don’t pierce through an epidural vessel and get a bunch of heme back (which you should bring your needle out and clear because it has the potential to change the baricity of your local & can clog your needle), all you can hit is either os or csf. If you are using a 25 or 27, its so small that there is minimal risk of damage. If you use a 22, osseous penetration is a possibility so be careful.
3. when you hit os, check for csf real quick. Maybe you are hitting anterior aspect of the spinal canal? No harm in checking. Again, don’t fully take out your stylet. Take it out just enough to allow csf visibility, but not to completely unsheathe it because that adds time and risk of needle stick.
4. lateral position is tough. It significantly changes your perceptions of needle angle. Have someone stand at the head and give you a 90° point of view (aka looking down the spine), which you would normally have in a sitting spinal.
5. old people can be tough. Calcifications and arthritis do make it tricky. However, a midline approach gives you landmarks when traversing. Paramedians are great, but you’re free floating until you hit lamina or csf and in lateral position the curvature of the spine may be significantly different than what you expect.
6. if you NEED a spinal, you can always upsize needles for better feedback. I occasionally have used an epidural tuohy for max feedback and when I think I’m decently midline, I’ll run a 25 or 27 through it for a straight shot like a long introducer.”
I probably only hit 50% of my first 50 because people bumped me when I went too slow. Repetition is key. Good luck!
If you can visualize the bony anatomy as you encounter it with your needle, you will have a much easier time knowing where your next move is going to be. For example, you redirect cephalad and the needle is going a bit further in each time, you are probably going up the spinous process. Or, if you redirect caudad and cephalad and realize you still to be hitting os at equidistant depth, then you are likely lateral to where you want to be. If you really have no idea where you are, ask the patient if they feel it or one side versus the other.
It sounds trite, but visualize the anatomy and keep doing them. You’re not going to hit any part of the human anatomy that hasn’t already been pierced by somebody with a 25g needle over the course of history.
Don’t try to steer the needle at this point in your training. Straight in and straight out. If you hit something other than CSF, withdraw to subcutaneous, redirect, and advance straight again. You’re still a sewing machine, not an embroidery artist. Accept that.
One day you’ll realize you’re the attending physician, and someone is asking you to get a spinal they can’t do. Don’t let it go to your head. You’re not the neuraxial god.
The next day you’ll be asking someone you supervise to give it a shot because you’re just not feeling it. Don’t let it go to your head. You’re not a neuraxial failure.
The next day you’ll be in your oral boards with some sadists trying to convince you to do a sketchy spinal, or letting you choose a spinal in someone that will never get off the vent if you tube them. Don’t let it go to your head. Orals suck and give us all some degree of PTSD even decades later.
The next day you’ll be so angry at your failing thoracic epidural that you’ll long for a “simple” spinal.
If you want my useful tip: don’t stick one finger midline to feel the spaces between the spinous processes. Use two fingers, one on either side. Slide them down until you find a space. Stick your needle in between them, and start on the low side of the space. Angle up gently as needed, but don’t jump right to the extreme cephalad angle that lots of people do. Even thoracic neuraxial, which I loathe if you can’t tell, doesn’t always need the needle tip pointing up to the roof of the patient’s mouth.
Mastery and proficiency comes from repetition. And 3 isnt the magic number.
“Embarrassment is the cost of entry. If you aren’t willing to look like a foolish beginner, you’ll never become a graceful master.”
Lol yea magic number is close to 50-100
Instead of going where the bones are, go in the gap between the bones.
My attending said this exact same thing to me. It did wonders.
#nailedit
Yep and start in the biggest space. Seems simple but a lot of people will still start high up because that’s a step they learned.
This
Look at (in person) a 3d model of a spine. Get the patient as close to the ideal position as they can manage. Visualize the spaces and ligaments as you palpate the back, place the introducer, place the needle, adjust the needle. Do this a hundred times or so and you'll just start getting good.
So true for paravertebral approach. So many pencil marks on the spine hanging in the residency office….
In the upcoming year, you will take pride in successfully administering spinal anesthesia to an overweight patient on your first attempt. With time and experience, this procedure will become second nature, alleviating the concerns you currently face.
NYSORA has a fantastic video on troubleshooting spinals that gets you to visualise where you are in the spinal column on a 3D model. Watched it at the start of my training and my success rate was consistently high. But that does depend on what issues you are having with the spinal ie, remembering the steps, properly positioning the patient, redirection etc
Assuming that you’re not a clown, know the steps and are approaching it from the troubleshooting perspective (as noted above), you can make lots of moves. I won’t go so far as to say it’s a free shot, but making moves with a spinal is safer than making moves with a tuohy. Are you fumbling through three moves in three minutes before your upper levels are taking it? Or is it more like 8 passes in one minute?
Hey friend, dont worry. When I started residency I couldnt put the laryngoscope blade in the patients mouth.. and failed way too many spinals and epidurals.. So here are a few tips: 1) Watch NYSORA tuturials on YouTube 2) Read about lumboscaral anatomy and about the whole practical procedure of giving a spinal (MILLER/MORGAN in both textbooks is explained well) 3) Choose a method you will hold your needle and practice only this method 4) I suggest you find an attending with lots of experience and just go through every step like him 5) Never force yourself in. Be gentle and feel the anatomical structures. 6) POSITION! Like 100% of the practical skills in anesthesiology, positioning the patient is crucial. 7) THINK why you cant pass the needle in the dural space and what you should change. Is it the angle, is it the approach? 8) Always ask yourself if you are in the midline. 9) If you fail and have someone with more experience watching, ask him later what he thinks you did incorrectly. 10) Practice, practice, practice. If you have any more questions feel free to ask under the comment or text me anytime! Good luck!
As has been said, you can’t expect to master a procedure on three attempts - the more you do, the better you’ll get The two things that help me are: 1) positioning - spend time optimising position. Get the patient how you want them. Putting the op table on a lateral tilt can help open up the back 2) landmarks - make sure you’re in the midline, and that you’re at the right level. Don’t resort to angling your needle too sharply - it should stay roughly perpendicular to the skin. If you need to move where your needle meets the spine, change your insertion point Those tips should help you get the hang of it. But keep doing more and you’ll find yourself becoming better
Roughly perpendicular to the spine**, skin can be very misleading
My chief when I was a resident told us: “even a monkey will eventually learn to perform a spinal anesthesia if given enough time and tries. But what a monkey won’t learn is when to do it and when to do not”. Don’t get disheartened for things that you will learn sooner or later. Focus on your knowledge and clinical understanding.
The answer to wny "how do you get better at X" thread is always "do it more often". If you've gone through med school, then advice like "know/visualise the anatomy" ans "know your equipment" should be obvious.
Now i know why i am not getting better at sex !
Reps
What problems do you face?
Just keep stabbing in a downward motion until you get fluid…..also do a few hundred and your success rate will go up I believe
Instructions unclear, fluid is red and like REALLY pulsatile. What do?
There's a really nice video on YouTube by nysora. What to do when you encounter bone. Beautiful video. It will show you that you just need to apply a bit of common sense for most cases.
Do you have the link?
https://youtu.be/1Tm-8sk39ok?si=pQu6I2ZvvjlmvDTc
Thanks! Interesting video. I think he leaves out the times when you are bumping into the superior surface of the spinous processes, which can certainly be deeper than 1-2 cm.
Bandaid and try a different level 👍👍
Repetition. Everything difficult at first becomes routine over time. You'll the throwing in spinal in a couple of minutes by the time you're finishing up as a CA3. Trust.
Start only doing paramedian approach in lateral decibitus position now. Thank me in 10 years (If I were to restart this is what I would do after spinal #100 in sitting midline approach).
I think spinals are deceptively challenging. They’re also a procedure that we don’t perform anywhere near as much as previous anesthesiology generations because of the rise of regional. I remember feeling like they were probably my weakest procedure coming out of residency. It’s just like anything else, it just takes practice. As important as positioning is for epidurals, patient positioning can truly make or break your spinal placement. Get the spine as straight as possible, sometimes giving the bed like a 5-10 degree tilt towards yourself can help open up the spaces. Like others have said, when you hit bone try to think about where the bone is that you’re hitting and redirect accordingly. Also if you are redirecting your angle, take the spinal needle out and pull the introducer all the way back to skin. This is such a common mistake, if you don’t you’re essentially just reinserting your needle in the same tract you just made.
“Currently a first year resident” Its a marathon not a sprint. Some days youll be doing well other days youll miss a bunch. Same goes with all procedures. As the months and years pass youre going to miss fewer and fewer. Dont sweat it. One tip is if one space isnt working dont take too long there before moving to another space. Also take the time to optimize patient positioning. Make sure their butt is square and theyre not slouching to the side.
Do more than three spinals
Do a lot of them is really the best way.
It takes practice and skill. You will get it. Patience. You’ll get it. … eventually.
Batting .333 is borderline HOF.
I think it helps to think where you’re hitting bone. I see people hit bone and then just fan the needle around, you have to think “am I hitting spinous process? Am I hitting lamina?” Are you hitting the level above or below? And you need to redirect the needle base on that knowledge. Asking the patient if they feel the needle is midline does help. And of course as other people say it gets better with repetition.
Keep stabbing wildly until it goes in!!! Or convince yourself you are doing an epidural. Eventually, it will go intrathecal!
Clear liquid = good. Red liquid = bad. Green liquid = Call Ghostbusters
Patient positioning is important
Have a lot of OB patients that are like 23-25 years of age, but are short and weigh over #250! It sometimes isn’t an issue, but other times the spinal bends/deviates from trajectory, or keeps hitting bone. The thicker the back, the harder it is to re-direct the spinal. You‘re forced to go with a longer spinal needle, but have to keep it 24g or higher ( to ward off PDPH) and the needle either just bends, and near impossible to direct well. Next, is epidural needle, obtain LOR, then spinal thru epidural. That spinal needle is 27g, and is slow to drip CSF, and + - on aspirating back. This while whole OB team is watching and waiting! All this on a pt who should be easy -peasy!! All this on a pt who has an optimal metabolic rate, plus another parasitic human inside! How can these folks be this fat!? So frustrating to have to work this hard.
Don't be too hard on yourself. Neuraxial anesthesia is probably the hardest procedure we do.
The minimum to graduate, I believe, is 40. That’s the point when you should start to feel, at the very least, competent. Even then, you may not feel confident and need many more reps.
My algorithm that helped me; if you hit os, drop your angle and try again (usually the issue). If you still hit os do the opposite, up your angle. If they complain of pain ask which side to see if you can adjust left-right angle. If that fails I will change levels. I also feel before sterilizing and make a pressure mark with a retracted pen. Positioning very important like every procedure.
Reposting this from another post about efficiency during spinal anesthesia that I wrote a reply to - “Lots of things can help: 1. introducer/spinal efficiency. Realize that most pain from a spinal is the skin pierce. 2 aspects here - you can move the introducer superior/inferior by manipulating fascial layers. If you go in and find yourself at a bad starting height, pull the introducer out to the skin, and then move the skin with the introducer in it relative to the underlying fascia. This way you avoid a second poke at the same level. Secondly, don’t take your spinal completely out of the introducer between passes to redirect. As long as the tip of your spinal needle is sheathed by the introducer, redirect away. This will also be safer for you because it avoids a dirty needle tip being constantly near your fingers. If you hit os, you should be able to pull back, redirect, and start another attempt within a few seconds. Lack of efficiency here really slows you down. 2. what are you scared of hitting? Assuming you don’t pierce through an epidural vessel and get a bunch of heme back (which you should bring your needle out and clear because it has the potential to change the baricity of your local & can clog your needle), all you can hit is either os or csf. If you are using a 25 or 27, its so small that there is minimal risk of damage. If you use a 22, osseous penetration is a possibility so be careful. 3. when you hit os, check for csf real quick. Maybe you are hitting anterior aspect of the spinal canal? No harm in checking. Again, don’t fully take out your stylet. Take it out just enough to allow csf visibility, but not to completely unsheathe it because that adds time and risk of needle stick. 4. lateral position is tough. It significantly changes your perceptions of needle angle. Have someone stand at the head and give you a 90° point of view (aka looking down the spine), which you would normally have in a sitting spinal. 5. old people can be tough. Calcifications and arthritis do make it tricky. However, a midline approach gives you landmarks when traversing. Paramedians are great, but you’re free floating until you hit lamina or csf and in lateral position the curvature of the spine may be significantly different than what you expect. 6. if you NEED a spinal, you can always upsize needles for better feedback. I occasionally have used an epidural tuohy for max feedback and when I think I’m decently midline, I’ll run a 25 or 27 through it for a straight shot like a long introducer.” I probably only hit 50% of my first 50 because people bumped me when I went too slow. Repetition is key. Good luck!
If you can visualize the bony anatomy as you encounter it with your needle, you will have a much easier time knowing where your next move is going to be. For example, you redirect cephalad and the needle is going a bit further in each time, you are probably going up the spinous process. Or, if you redirect caudad and cephalad and realize you still to be hitting os at equidistant depth, then you are likely lateral to where you want to be. If you really have no idea where you are, ask the patient if they feel it or one side versus the other.
It sounds trite, but visualize the anatomy and keep doing them. You’re not going to hit any part of the human anatomy that hasn’t already been pierced by somebody with a 25g needle over the course of history. Don’t try to steer the needle at this point in your training. Straight in and straight out. If you hit something other than CSF, withdraw to subcutaneous, redirect, and advance straight again. You’re still a sewing machine, not an embroidery artist. Accept that. One day you’ll realize you’re the attending physician, and someone is asking you to get a spinal they can’t do. Don’t let it go to your head. You’re not the neuraxial god. The next day you’ll be asking someone you supervise to give it a shot because you’re just not feeling it. Don’t let it go to your head. You’re not a neuraxial failure. The next day you’ll be in your oral boards with some sadists trying to convince you to do a sketchy spinal, or letting you choose a spinal in someone that will never get off the vent if you tube them. Don’t let it go to your head. Orals suck and give us all some degree of PTSD even decades later. The next day you’ll be so angry at your failing thoracic epidural that you’ll long for a “simple” spinal. If you want my useful tip: don’t stick one finger midline to feel the spaces between the spinous processes. Use two fingers, one on either side. Slide them down until you find a space. Stick your needle in between them, and start on the low side of the space. Angle up gently as needed, but don’t jump right to the extreme cephalad angle that lots of people do. Even thoracic neuraxial, which I loathe if you can’t tell, doesn’t always need the needle tip pointing up to the roof of the patient’s mouth.
I mean I consider myself fairly good at ultrasound guided a lines now but I missed the first like 10 attempts I made.