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To the Editor:-We have discovered a simple technique for guiding 20- to 22-gauge needles in soft tissue under fluoroscopy. This technique has proven helpful for placing the tip of the needle at the anterolateral aspect of vertebral bodies when performing lumbar sympathetic and celiac plexus blocks. Such blocks are challenging, even under fluoroscopic guidance because the target lies 5-7 inches beneath the skin, making the initial trajectory of the needle critical.
Bowing of the needle allows the tip of the needle to be “walked” into the proper location quickly with minimal trauma to tissues. For example, if the initial trajectory of the needle during a lumbar sympathetic block is too medial, causing the needle to make contact with the lamina of the vertebral body, the tip of the needle can be easily relocated more laterally. This can be accomplished by withdrawing the needle about 1 inch. Then, as shown in Figure 1, a horizontal force (parallel to the surface of the skin) is applied to the shaft of the needle in the medial direction at the surface of the skin. While maintaining this horizontal force on the shaft of the needle, the needle is advanced 1 inch back to its original depth in the tissue. Fluoroscopy confirms that the needle has a slight bow and that the tip of the needle has been moved laterally. This process is repeated until the needle is advanced to the anterolateral aspect of the vertebral body (Figure 2).
Figure 1. “Bowing” of the needle is accomplished by advancing the needle while applying a horizontal force to the shaft of the needle at the surface of the skin. The horizontal force is applied in a direction opposite to the desired direction of the tip of the needle.
Figure 1. “Bowing” of the needle is accomplished by advancing the needle while applying a horizontal force to the shaft of the needle at the surface of the skin. The horizontal force is applied in a direction opposite to the desired direction of the tip of the needle.
Figure 2. A lumbar sympathetic block is performed at L2 by “walking” the needle laterally using the bowing technique. A slight bow in the needle can be seen in the radiograph on the far right.
Figure 2. A lumbar sympathetic block is performed at L2 by “walking” the needle laterally using the bowing technique. A slight bow in the needle can be seen in the radiograph on the far right.
Similarly, if the initial trajectory of the needle places the tip of the needle too laterally, cephalically, or caudally to the target region, a horizontal force applied to the shaft of the needle at the surface of the skin, in a direction opposite to the desired direction of the tip of the needle, will result in the displacement of the tip of the needle in the desired direction. The lateral displacement of the tip of the needle can be up to 2 cm with each forward advance of the needle.
Anthony F. Kirkpatrick, M.D., Ph.D.
Manjul Derasari, M.D.
Vidyadhar Hede, M.D.
Department of Anesthesiology; University of South Florida College of Medicine; Tampa, Florida;akirkpat@com1.med.usf.edu
(Accepted for publication July 24, 1998.)
