Difficult Spinal in Obese Patient- Crash course with Dr. Hadzic

00:46 Factors associated with difficult spinal
02:09 Spinal needles
02:48 Anatomy
03:12 Anatomy of needle insertion
04:31 Steps for success in large BMI patients
07:14 Summary
Difficult lumbar punctures and difficult spinal or epidural anesthesia frequently cause complications in patients with a large body mass index (BMI). Traumatic needle placements as well as multiple attempts during a neuraxial blockade have been related to neuraxial complications, ranging from a bad experience for patients all the way to neurologic injury. It's generally easier to perform spinal punctures in younger patients, which is to be expected due to lesser incidence of spinal deformities, osteophytes, and better tissue compliance during the procedure in most cases.
However, larger patients may have poorly palpable interspinous space. In these patients, determining the space for needle introduction can be difficult, leading to multiple attempts and failures. In this video, Dr. Hadzic demonstrates the role of ultrasound, the technique, and the choice of equipment that can facilitate spinal anesthesia in patients with difficult landmarks or a large BMI. The video is richly animated with NYSORA’s reverse ultrasound anatomy (RUA) illustrations and is a great educational tool for students and practitioners alike. This video is a must-watch.
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Disclaimer:
Medicine is an ever-changing science. As new research and clinical experience broaden, changes in treatment and drug therapy are required. The authors and publishers have checked with sources believed to be reliable in efforts to provide accurate information within the available or accepted standards of care. However, given the possibility of human error or changes in medical practice, neither the authors nor the publisher, nor any other party involved in the preparation of this platform warrants that the information contained herein is in every aspect accurate or complete, and they disclaim all responsibility for any errors or omissions for the results obtained from the use of the information contained in this work. Readers are advised to confirm the information contained herein with other sources. For example, readers are advised to check the product information of each drug mentioned, and that any information contained on NYSORA's KZbin channel is accurate.

[@nysoravideo]

DO NOT MISS OUT OUR NEW VIDEOS, SUBSCRIBE HERE: kzbin.info

[@scottrobinson2678]

A little more commentary regarding the ultrasound anatomy here would be extremely valuable.

[@DRBLUESNYC]

Will do next time around. Thanks for watching.

[@animeanibe]

@@DRBLUESNYC Thank you Dr. Hadzic. Looking forward to that.

[@Motivational.Quotes10k]

kzbin.info/www/bejne/gJilk6aGi5qEesU Here is a good ultrasound landmark technique presentation.

[@Gigson12]

Nysora is the best KZbin channel in anaesthesia teaching and demonstration.

[@XtortionGaming]

This looks amazing. I personally had such a painful and awful experience when this got done to me years back when they needed a sample. Absolutely horrid. This looks like it went so calmly and painless

[@dianaaugustine5438]

I had a very similar experience to you when I had my c-section. Mind you, they were going in blind and doing multiple attempts. I'm definitely going to loose some weight before I have another baby. One of the worst experiences of my life. I just needed to see what it's supposed to be like with out the screaming and vomiting in pain.

[@Summerdelight1983]

Very informative video. Thank you ,Sir. Please keep it up 👍

[@SpaceCat80]

I've had this kind of anesthesia three times and I'm larger than this patient. I'm so glad I had this option because I was terrified of general anesthesia. I'm getting kidney stone removal surgery and I'm going to request spinal anesthesia again since it was so successful last time.

[@CHRIS-tg5cn]

How about just losing weight?

[@waiki8223]

Awesome, thank you so much Dr Hadzic! I love Luer lock (instead of slip that comes in the kit) 3 cc syringe.

[@nysoravideo]

Glad it was helpful!

[@Robert-pm6bm]

Nicely done! Y'all made that look very easy!

[@nysoravideo]

Thank you!

[@abrorvalihanov9787]

Thanks a lot Dr. Hadzic 👍 Please could you make a separate video on using ultrasound for spinal anesthesia. Best wishes from Uzbeksan

[@waniasuperstore4314]

Very useful information. Plz make a video regarding basics of ultrasound for various nerve blocks or procedures. Thank u

[@leressepillay3306]

I agree with Scott Robinson. Would like some information on how to identify the midline and depth with ultrasound. Thank you! P.S use your videos daily in my practice. Thank you so much.

[@DRBLUESNYC]

Hi Laresse - will do. Thank you for the feedback - it makes it worthwhile. Please share.

[@leressepillay3306]

@@DRBLUESNYC Hi. It's been 2 years since my comment above and I've since moved to North America where I am encountering many more morbidly obese patients for neuraxial anesthesia. This video and subsequent vidoes on tips and tricks - have been a IMMENSELY helpful! Thank You!

[@fhb1997]

Love the animations thanks!

[@nysoravideo]

Glad you like them!

[@Due152]

Thank you . I used to take a Tuohy needle for obese patients as an introducer and without Sono. Of course your way is much much netter…

[@hobbiesreturns4092]

Great idea.. Touhy gives a better feeling of needle path. Thanks. Will try in difficult cases.

[@Motivational.Quotes10k]

Pure genius doc . Bravo 👏

[@nysoravideo]

Hi Dan! Glad to hear this! Thanks!

[@animeanibe]

Would love to see a series on doing the common blocks in obese/MO patients. I'm sure that most of us are seeing increasing numbers of these patients, and blocks that are normally straightforward in normoweight individuals become quite challenging in the MO population.

[@nysoravideo]

Hi Animeanibe! thank you for inquiring. We really happy that you're interested in nudging us to complete the follow-up videos. The videos take quite some time but will promise will get back to this. In the meantime make sure you subscribe and share the channel with your colleagues so that we can all collectively collaborate and learn from each other. Greetings from NYSORA!!

[@uteschneider3349]

@@nysoravideo Mein adipöses (durch unerkannte und unbehandelte Hashimoto Thyreoiditis) Kind bekam wegen starken Kopfschmerzen nach EBV Infektion mit 14 Jahren eine Lumbalpunktion. Die Kinderärzte haben gezittert beim tasten und mehrmals gestochen, weil nichts kam. Danach wurden die Schmerzen beim stehen und laufen so unerträglich, daß er nicht mehr stehen konnte und sich sofort hinlegen mußte, egal wo er war, auch auf der Straße. Das war eine lange Zeit. Kein Arzt hat geholfen, wußte was es ist. Alle dachten er spinnt, hielten ihn für dick und weinerlich, überempfindlich Ich habe erst 20 Jahre später gelesen, daß es passieren kann wenn Liqor herausläuft. Ich verstehe zwar kein englisch, aber ich finde es gut was sie zeigen. Diese Methode sollten Ärzte kennen und können. Bei meinem Kind müßten noch Antikörperuntersuchungen im Liquor gemacht werden. Leider wurde der Liqor damals nicht aufbewahrt. Wegen großer Angst, das wieder falsch gestochen wird, lässt mein Kinnd diese Untersuchungen nicht machen. Es sagt, erst wenn ich abgenommen habe, bis die Ärzte richtig tasten können, lasse ich diese Untersuchung machen. (Es sind auch Einbrüche an Wirbelkörpern vorhande. Ich weiß nicht, ob es die Situation noch zusätzlich erschwert?) Zu meinen Starken Kopfschmerzen will ich nicht noch zusätzlich gelähmt sein. Das stehe ich nicht durch. Wird die Ultrschallmethode jetzt auch bei Lumbalpunktionen angewandt?

[@anaceciliacubasmendozasanc9326]

Thanks a lot Dr.

[@nysoravideo]

Most welcome!

[@The-advicer]

Nice video

[@JD-jg6ov]

It’s interesting to see American practice compared with Australian. It is universal practice in Australia (and the few hospitals I have worked in New Zealand) that all neuro-axial blocks require antiseptic handwash and complete glove and gown attire….not just sterile gloves. Certainly more convenient to not have to gown up! I wonder if there is a difference in infection rates?

[@DRBLUESNYC]

Indeed, that is interesting. Such a rigorous antiseptic precaution would label our regional anesthesia practice impractical. Nearly 100% of all total joint replacement and lower extremity surgery patients receive spinal anesthesia. On average, that would be about 15-20 spinal anesthetics/day in the 4 orthopedic surgery only room. EPdiural anesthesia is done completely owned up as you describe in our institution. However, in a large OB practice in New York, where we did 6,000 deliveries/year - no gown was in the protocol for labor epidurals/CSE. I am unaware of any data on infections between the practices.

[@No-xh2cs]

This is great comparison information. I wonder if it's also because of the inherent antibacterial properties of local anesthetics? I know people also do bad things commonly such as not wiping vial tops before withdrawing meds and people aren't always careful when disconnecting and connecting epidural catheters aseptically. You would think the infection rate would be higher but it doesn't appear to be 🤷🏿‍♂️

[@knightkonstantin]

The best visualisation ever! Thank you from Russia!

[@waiki8223]

Он вообще просто лучший!!!

[@nysoravideo]

Thank you Константин Краснов!

[@nysoravideo]

@@waiki8223 Thank you!

[@jeremycollins]

Thanks for a great video and wonderful animation. For patients that size, my preference would be to use a Touhy needle as the introducer which would give me the option of placing a catheter at the same time. It could always be removed if not needed after surgery

[@DRBLUESNYC]

Absolutely. It is one of the best approaches and we have done it as standard many times. Keep in mind that you need a LONG epidural needle for this as well - in order to reach the epidural space and proceed with CSE. Basically, proceed with an epidural, once the loss of resistance is detected, pass the long atraumatic needle into the intrathecal space and inject a lower dose spinal anesthetic. Remove the spinal needle and insert the epidural catheter as an "insurance policy" so you can bring up the level to what is needed, or extend the block, as needed. In this case, we used a standard length Quincke needle to pass a more readily available 12 cm atraumatic needle. A different, both good options. Thank you for bringing this up. Greetings.

[@user-wu7mq7rn9s]

@@DRBLUESNYC thanks a lot very good tip

[@ParagMathurmd]

Good to see a familiar face Jeremy. Greetings from Boston.

[@jeremycollins]

@@ParagMathurmd been a while! Hope you’re well too

[@zakalobi80]

Ultrasound is usually used to mark the point of needle introduction. We need another video to use of ultrasound to guide needle introduction. Thank you for excellent case presentation.

[@dannamadura3751]

Dr Karmakar has several articles regarding real time USG spinal anesthesia

[@zakalobi80]

@@dannamadura3751 thank you

[@chaitanyasejekan482]

Thanks for the information 👍👍 Namaste 🙏🙏🙏

[@nysoravideo]

You're welcome 😊

[@wendybearcare6756]

Patient perspective here. During spinal for cesarean, after a number of very painful attempts, once the needle finally went in I felt a bolt shoot down into my heel. I was unable to put my heel down on the floor for about 6 months. Both anesthesiologist and OB denied that the needle would have been the cause. So thank you, I'm certain that was the issue. My BMI would have been around 35. It's fine now, slight relapse after 2nd cesarean but didn't last as long. Thankfully doesn't seem to be permanent.

[@ameerhamza-bk8du]

This is so interesting 😮😮😮❤

[@chennakesavulamadhukar4991]

Thank you very much sir 🙏🙏

[@nysoravideo]

Most welcome

[@kalajandiaz1549]

You are the Marlon Brandon of anestesia.

[@richaagarwal8224]

Kindly make a video on how to identify the midline, intervertebral space and depth to subarachnoid space. Really like your videos. They are quite informative. Thanks.

[@nysoravideo]

Hello, thanks for your feedback. We've already covered these topics in some of our past videos which you can see at the following links: Neuraxial Spinal Anesthesia Ultrasound assisted: kzbin.info/www/bejne/b5DNnaFrZsmJoKM Difficult spinal, needle as the examining tool: kzbin.info/www/bejne/oKOsfZumqJ6Ul5o Spinal anesthesia: How to use Guide Needle: kzbin.info/www/bejne/o5K9gJegitlmptk

[@DRDRDR7809]

Why does the ultrasound image on the video have a depth set at 7.1cm, but it mentions the spinal needle passed at 10.5cm. Do you only use the ultrasound to guide placement partially into the interspinous ligament?

[@mhoudmonier786]

ممتاز

[@PetsNPatients]

Looks like radio frequency oblations. Have had much success with those. Is flouroscopy used, Ah ultrasound! It can be done, expert anesthesiologist with much experience needed for sure. Is this an orthopedic patient?

[@anesthesia101online]

😳 make it look so easy !😅

[@marzenawojcik-rys7346]

Brilliant

[@nysoravideo]

Thank you!

[@evelyncarrero8148]

Guides for long 25 spinal needles??

[@dic5822]

tips for obese Spinal: Sit position Give midazolam 2 mg and fentanyl 50 ug iv , decrase pain and anxiety. Use big needle number 25.

[@nysoravideo]

Hi Dic! Thank you for sharing. Greetings!

[@UsmanKhan56100]

What if we only reassure the obese patient just before procedure to relieve anxiety and infiltrate subcutaneous tissue lidocaine and then use two needle technique as Dr hadzik used in this video? It will reduce number of drugs used making it less complicated and lowers financial burden as well.

[@plips71755]

I don’t understand this sitting up method. It looks like an easy procedure for the patient. Now maybe what I had done was different from what you are doing here for a difference reason. I can’t imagine doing it sitting up. I had foraminal spinal epidurals, but also had a lumbar puncture at same hospital, different doctor , can’t remember why they did LP checking the fluid but they did it with me leaning over something seemed like a padded “bar” they could adjust for height?? Like below for the foraminal epidural, I was sorta in a fetal position and in both procedures, they said it opened the spine up. I know at home when I get really bad, if I lay in a fetal position and put ice on my lower back, where the pain starts, it really helps. I don’t remember as much about the LP as it was only once. Where the foraminal epidurals, there were a number of those when the pain got to where I couldn’t handle it. I haven’t had these for a number of years but am past due for one now but I need an MRI and have developed such severe claustrophobia and a intolerance to restraint so we have to do them under general anesthesia. The last one for my brain in beginning of year left me with a lung bleed and then a lung infection that took a while to get cleared up so not anxious to go through this again. They said I was a tough intubation, never had this issue for other GA surgeries so not sure what was going on with me. Though this time, not on blood thinners due to stroke and having a TAVR due to a birth defect with the aortic valve. Also since the doctor I liked so much who was so easy and caring has retired, I don’t know what type of doctor, their experience level, attitude and their technique. So a bit scared. I’m a large female patient with a BMI above 54-55, in my 60s, with severe stenosis L5-S1 and other issues in the spine all the way up but not bad unless things have changed. My issue comes from a cyst or tumor- has been called both but it’s really a cyst (has never grown or increased in size except when filled with fluid) and has been confirmed with multiple MRI. When I have put too much stress on my back too much sitting, standing, walking, not enough ice, and I start getting “shockies” from back, down the butt, leg all the way to the feet and sometimes my toes curl weirdly. As the back is stressed and cyst fills with fluid, thus the nerve is further compressed. They do foraminal spinal epidurals using fluoroscope to do the spinal epidurals. Nerve blocks didn’t help me. Dr. Finnegan had a neurosurgeon check my MRIs and he said this “cyst” is wrapped around the sciatic nerve and there wasn’t a safe way to remove the cyst. The area of the cyst is right above where the sciatic nerve splits so my pain can and does affect both legs. But back to the video - they do mine and in fact I think the doctor (now retired Dr. Maurice Finnegan in the the US at St Mary’s hospital in Richmond, VA ) did all his patients this way. He was an intervention radiologist. If I remember correctly, he worked on a lot stroke patients where they were putting in medicine in the brain but I don’t remember much about that, it was a brief conversation with him just trying to relax me on my first procedure with him as he knew I was scared to death I would have the same situation as I had with the other doctors in their office - will never ever have them done except in the hospital with an interventional radiologist, or maybe an anesthesiologist. Except now medical doctors type anesthesiologists aren’t doing general anesthesia - there is a nurse anesthesiologists doing it with one of MD doctor going back and forth between all the patients. My worry is what happens when two plus patients need assistance to stay alive, who does the one anesthesiologist go to? I think it’s a bad thing and patients will suffer the change in policy to save a few dollars. It’s like regular care - too many PA or NP rather than an actual doctor. Some even have their own office. I’m sorry, I would rather have someone who has gone through all the years of training for regular MD and then their specialty training. The doctor I liked and had for my epidurals paid a lot of attention to my pain and if there was even the slightest- he stopped and put in more pain med. He also “buffered” his solution - said it kept it from stinging and causing the patient stinging and pain that wasn’t necessary. But he had me lay on my tummy with a pillow or two under my stomach, and a wedge under my legs, placed from knees down. The pillow under my tummy caused my back to arch over almost like a fetal position. As far as I could tell he did all his patients like this, and he did a number of injection on me and in this position. The doctor prior to him had me in so much pain, with another doctor with her elbow in my back to keep me down and the other doctor doing the injection. I was screaming so much my sister heard me in the waiting area and I sobbed for 10-15 minutes before I could settle enough to walk out from the leg pain. This office was normally a very busy office but on treatment days they only scheduled treatment patients and basically there was time in between so patients didn’t overlap sitting in waiting area. After one I knew why. He just told you to Buck it up, it will be over in just couple minutes. I should have reported that doctor. He let the first pain medication be put in while he was on the phone and didn’t come in for a good 30-40 minutes to do the injection of the steroids By that time, he was in a hurry and didn’t want to go through the first procedure again and felt like there was enough left to do the trick. The other doctor kept insisting but he just said hold her down and on he went. I thought I was going to die. But Dr. Finnegan was terrific, never really hurt and always had a nurse’s hand to squeeze if needed or to catch if I was saying ouch and to see if I held my hand in the air indicating I was getting some little shocks so it could be better relayed to the doctor at which time more pain med was placed. So with that information, is that maybe why they did it on my tummy sorta curled up in fetal position rather than sitting?

[@drayush2]

Fantastic video ,which probe you r using

[@DRBLUESNYC]

Curved probe. Sonosite.

[@TomBreazeal]

Is the cartoon demonstration, the needle is inserted with a decently large upward/diagonal angle. On the real patient, it looked like the provider went in straight. Can you comment on this?

[@UsmanKhan56100]

Two needle technique is good enough to protect patient from PDPH

[@awesome4334]

Can anyone explain to me why the back skin of the patient is slightly red with obvious cross-border?

[@chandrikakamath2707]

Skin prep

[@Mariciella]

Why shouldn't we go with the Quincke neddle all the way? If I don't hit the intrathecal space immediately, I could always "walk along" the lamina.

[@DRBLUESNYC]

Hi Maricella. Indeed - if the patient is aged over 60, going "all the way" is the best thing to do for all the reasons you mention. However, if the patient is deemed as a risk of PDPH, then giving it a try with a small gauge, bullet-tipped needle is prudent.

[@chantalbarry3023]

Moi je vais refaire une infiltration épidurale pour mon canal lombaire rétrécie et disques degeneratifs je suis sous morphine 10mg Immédiat je souffre pas opérable salutations Docteurs

[@knockoutdoctor]

Any suggestion about how to fix the position of the 27g needle inside the introducer? It moves forward when I'm trying to attach the syringe with anesthetic....

[@joestevenson5568]

Use your hands...

[@akramestreed9950]

what about lateral aproch for spinal anaesthesia using ultrasound machine.

[@nysoravideo]

HI Akram! Thank you for your interest. For more information, Subscribe to Nysora's Compendium of Regional Anesthesia here nysoralms.com/courses/nysora-compendium-of-regional-anesthesia/ and you can have all the information on Spinal Anesthesia. Greetings!

[@mohanadal-talib2649]

Thx for your kind presentation, but I think we need a better video of the U/S to see exactly where the needle goes and how to identify each structure on the screen. Thx in advance

[@nysoravideo]

Hello, thanks for your feedback. Due to a lot of such comments, in the coming period we will make an update video with a focus on the US guidance. Until then, you can also watch some of our past videos that also explain US and anatomy for spinal anesthesia. Neuraxial Spinal Anesthesia Ultrasound assisted: kzbin.info/www/bejne/b5DNnaFrZsmJoKM Difficult spinal, needle as the examining tool: kzbin.info/www/bejne/oKOsfZumqJ6Ul5o

[@chle4658]

Chapeau!

[@afaffawzy]

👍👍👍

[@joshsteele5701]

A lot of doctors don't even try at bedside. Not even neurologists. They send them to IR. IR is not a fan of this.

[@josfrancis6029]

Iso bupivacaine is it enough to get good relaxation ? How long does it cover

[@Bushehri1]

Omg ! Does the patient with any painkiller? That's painful omg ! Why suffer? Why not fully anesthetic? Why his back with red color skin ? And at the end thank you so much for that video I'll think twice now before I gain weight omg this patient broke my heart God Help him and I wish that God will bless you doctor and give you heaven because you are helping people.

[@DRBLUESNYC]

Hey Jack, all patients receive adequate medication. Often times they do not feel or even remember anything being done. Best is - they do not have any pain after operation for some time and have time to get used to the upcoming pain that can be treated and treated with pain medications. Best

[@Bushehri1]

@@DRBLUESNYC ohh nice thank you so much sir, I learned a useful medical information from you now sir.

[@alexisdior90]

The red color is antiseptic solution. They use a local anesthetic first so you don’t feel the larger needle

[@gulnora3882]

Thank yuo UZBEKISTAN 2023

[@shahidrahathossain5199]

seems like mazic

[@azncmasta]

Did you perform this spinal in the pre op area or some sort of procedural area? It did not look like the OR to me.

[@joestevenson5568]

It's an anaesthetic room attached to the theatre, almost like a porch. I know lots of countries don't have them. They're standard here in the UK and Dr Hadzics facility clearly also has them.

[@aminsss]

Are there practical ways for obese patients without using an ultrasound machine?

[@DRBLUESNYC]

Yes. We will cover that in another video of using needle-bone contact to determine the location of the needle tip and guide accordingly. Regards

[@aminsss]

Thank you very much, our respected professional teacher 👍

[@wlamb9]

There’s no point in aspirating at the end. You’ve already injected and you’re not going to do anything differently at that point except lie the patient down and hope it works.

[@Gigson12]

We know that already.

[@wlamb9]

@@Gigson12 Did you watch the video? He recommended aspirating at the end. No need. But you knew that already.

[@Gigson12]

@@wlamb9 For you to be sure you are still in the right position

[@joestevenson5568]

​@@Gigson12Right, but it's too late to do anything if you're not.

[@Gigson12]

@@joestevenson5568 You can stop if u are out of the right place and that will still minimize the dose deposited

[@Gegemon100]

you removed the needle without an introducer, this is a mistake

[@bi0lizard1]

They make longer introducers for obese people.

[@panoschristodoulou8113]

There's no difficult spinal anesthesia. Just change the position of the patient. Put him on his side.

[@zaf2643]

I don’t have time to use ultrasound in a emergency caesarean section for fetal distress in a really obese pregnant lady 🤣

[@KYMom23]

I have a higher bmi & asked my doctor to do an ultrasound for my c section since I've had spinal block difficulties in past c sections & she told me we don't do that, I feel this is medical neglect but I can't go out of state for this procedure so I guess I'm at the hands of a barbarian & this will definitely be my last baby for this reason, they dig for 15-20 mins everytime it's ridiculously painful for no reason.