Paraspinous (Paramedian) Approach to Spinal & Epidural & LPs - Why and How to Do It

This video discusses the principles and advantages of the paraspinous (paramedian) approach to neuraxial blocks (or lumbar puncture). This is a tremendously useful technique that can be easily learnt with a good understanding and a little practice.
Originally presented at the Annual ESRA Congress in June 2022.
This video is for informational and educational purposes only. It is not a substitute for professional medical advice, or consultation with a health care professional.

[@iosebqvartskhava3406]

As an anesthesiology resident, I find your videos very informative and very instructive, thanks a lot and I am going to try my next spinal Anesthesia with ParaSPINOSE approach.

[@ralecosue]

Very helpful video for residents in training. Thank you!

[@user-ko1eq4ph5u]

i always use 27G for spinal block in my own practice. Most Thai patients are thin so midline approach is my preference with over 95% success rate. Also i am never really comfortable with the conventional paramedian technique but now as i saw your vdo tutorial showing less back pain for paraspinal technique, i will experiment and practice this technique more often. Thank you for sharing. This is a promising one!!!

[@DeepakJosephDr]

Thank you KJC. Now, I have been using thoracic spinals for those patients in whom GA is extremely risky for short runcal surgeries. I absolutely agree that paraspinal approach is most appropriate for thoracic. I was indeed trained to try the midline approach first before moving on to paraspinal approaches, but over time it became clear to me that I could find no reason to go paraspinal in the first place. Your videos are enlightening and reflect your thought process at performing these techniques. More power to you. Thank you for sharing this with the rest of the world, in particular with those who do are unable to attend conferences or workshops to understand the recent developments in the field of RA.

[@survivor7070]

how many cms do you go to the side? and do you also go caudally? Is the cranial angle placement of the needle as steep as for the median approach or much less steep? In other words do you insert the needle in thoracic epidural in a steeper cranial angle than you do in lumbar epidural?

[@husni1980]

Thanks for the video Jinn, great summary and illustrations. One thing of importance as well, is the relatively high incidence of midline flavum cleft leading to a potential dural puncture when placing an epidural needle midline.

[@KiJinnChin]

Good point! Thanks for sharing, my friend.

[@MrLiehus]

What do you mean by flavum cleft?

[@uramalakia]

Morning coffee and Your video. What a wonderful start of the day!

[@whousa642]

Beauty of academic anesthesia!

[@jamestan5263]

Great info! Supports my practice of paraspinous approach

[@abdoueid7195]

Thank you very much Excellent as all your videos Please we need a video about caudal anesthesia

[@timjackson7575]

This is such a well made video.

[@iamgoku2024]

Innovating and brilliant!

[@robertoblanco1581]

Thank you Dr Chin

[@drandrewtan]

Wonderful video thank you very much!

[@user-xn5oh4ih5z]

Thank you

[@wafaibrahim369]

Thanks for sharing ❤

[@babitasuryawanshi3685]

Maternity laparoscopy ditel surgery

[@MagisterGentis]

Thanks for the explanation. I have a question regarding this technique for spinal/subarachnoid block. Is this technique still possible while using a 27Ga spinal needle + introducer? Since these needles have a tendency to bend, I presume it would be more difficult to perform the "walking of the lamina". Whenever I see someone doing a paraspinous approach, it seems as if they are using larger bore needles (22 Ga) without an introducer, because they are stiffer and can be more easily redirected/guided past insertion point. And it's performed without an introducer. But doesn't that increase the likelihood of PDPH, especially in younger female patiënts?

[@KiJinnChin]

I have never tried it with a 27G needle, but it should be feasible. However as you correctly point out, the 27G needle will need more careful handling. I don't think it will be prone to more bending, as the passage of the needle through the muscles will be easier than through the midline ligaments. If contact with bone is carefully sensed, and excessive pushing on bone doesn't happen, there is no reason why the needle should bend more with the paraspinous vs midline approach. You can definitely do the paraspinous approach with 25G needles through introducer. A 22G is not essential at all. And interestingly enough, there are studies suggesting that in older people, it does not appear that a 22G Quincke increases the risk of PDPH vs a 25G pencilpoint.

[@dpatti11]

Do you still get the tactile feedback with a loss of resistance technique with a paraspinous approach for epidural?

[@KiJinnChin]

Yes, the tactile feedback from the epidural needle tip should be the same. You should be able to appreciate the tip travelling through softer muscle, and then contact with either (a) bone = lamina, or (b) flavum. Both of these should be distinguishable with practice and attention.

[@federicodurante3338]

👏🏻