Embedded Files
Stanford Spinal Kit
Stanford Spinal Kit
PORTEX Spinal Tray : Contents
PORTEX Spinal Tray : Contents
25G Whitacre spinal needle
Glass syringe
18G introducer needle
Slip tip 3cc syringe for local
1% lidocaine
Spinal dose 0.75% bupivacaine + dextrose (hyperbaric solution)
Needles for local anesthetic
Gauze, drapes
Duraprep + sponge sticks for cleaning
Our kits frequently change...this is the best kit due to the drape being see through. The procedure is a landmarks based procedure - so if you can't see your landmarks it gets a bit harder!
Positioning of a patient for a spinal
Positioning of a patient for a spinal
Shoulders slumped down and relaxed
Neck tucked down
Lower back curved as much as possible. This is not "leaning forward" - it is more of a curling up position.
It is helpful to have their knees as high as possible - you can achieve this by putting a stool underneath their feet
Try these phrases for success
Like an angry cat
Like you are curling up around a beach ball
Like you are a shrimp
Improper positioning on the left. Proper on the right. Notice how the space is more accessiblee
Landmarks
Landmarks
Our main landmark on where to place the spinal is Tuffier's line - which is a line drawn at the top of the iliac crests across the back. It approximates the location of the L4 vertebral body. We usually choose the L3-4 or L2-3 spaces to place the spinal. Remember, the spinal cord ends at L1
Procedure description
Procedure description
After the patient is properly positioned, identify the L3-4 or L2-3 interlaminar space using Tuffier's line as your landmark. Mark the target by making a gentle indentation in the skin with a fingernail
Sterilize the back with chlorhexidine solution and apply the sterile drape
Numb up the skin with the provided lidocaine (place a nice generous skin wheel) and then proceed to numb the deeper tissue
Trying to stay as midline as possible, insert the 18G introucer needle. Use caution in extremely thin patients, as there is a possibility of entering the CSF with even the short introducer needle, causing a "wet tap"
Once the introducer needle is in place, insert the spinal needle. Advance until there is a slight change in the resistance felt by the needle. Some may describe it as a "pop." This is the feeling felt when piercing through the tough ligamentum flavum, and entering the subarachnoid space. Please note that in some patients you may not feel this, so if you are fairly deep with the spinal needle, it is appropriate to pause, withdrawal the spinal needle stylet, and check for the presence of CSF in the needle hub
Once there is clear flowing CSF coming through the needle hub, carefully attach the glass syringe with your spinal local anesthetic.
Gently and slowly aspirate - You do not need to aspirate much CSF - you are simply testing for the ability to easily draw fluid into the syringe which should be possible if your needle tip is in a pocket of fluid.
Once positive aspiration is confirmed, slowly inject your local anesthetic into the CSF.
Aspirate once more at the end to confirm that the entire dose was likely given all into the correct place.
Withdraw the spinal needle and introducer needle together - you are done!
Troubleshooting - OK so you didn't hit the target in one clean pass - thats OK! In fact, when you have to troubleshoot is when you will learn the most about placing spinals...
Troubleshooting - OK so you didn't hit the target in one clean pass - thats OK! In fact, when you have to troubleshoot is when you will learn the most about placing spinals...
If you hit os "shallow" - likely that you are hitting a spinous process. This is a good thing! The spinous process will lead you directly to the space if you go above or below it. The definition of "Shallow" will depend on the patient body habitus - but chances are if you are hitting os with even just the short introducer, it is probably a spinous process
If you hit os "deep"
Possibility that you are hitting the backend of a spinous process, and a small adjustment cephalad will gain you access to your target.
If you try to move cephalad and are still hitting os - you are probably off midline and hitting lamina. In this case, try to tap on the os gently with your spinal needle as you ask the patient if they can feel it on the left or right particularly. That information is often useful to adjust your needle trajectory in a left/right plane to then enter the space.
If you have troubleshooted a space and cannot get the spinal in, try a new space! Anatomically that space may not be favorable
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