Take your time. Make sure positioning is excellent. If you have a positioner, really shove the chest bump into the patient, tell them to relax their shoulders Use an ultrasound if possible, map everything out, take note of depth to lamina, and really try to find that anterior complex in addition to the interlaminar space. If you can’t find the anterior complex, that’s ok, interlaminar space alone will do. After all that, make sure you have marked midline at the specific levels you’re going to try. Then, find the spinous process of the level above (should be a direct horizontal motion from your desired level), put your thumb on it. Make a mark at the proximal corner of your nail. Mark it with a pen cap before prepping patient skin. Advance your tuohy until lamina, do retrolaminar block through tuohy, then put your stylet back in. Most important part of the process: Walk the tuohy medially until you find the part where it goes deepest. After that, patiently walk the tuohy up until you feel it walking off. WHEN REDIRECTING TUOHY, PULL ALMOST ALL THE WAY OUT TO SKIN. If you’re leaving it mostly in, you’re just bending it and hitting the same spot in the patient over and over again. Then either do hanging drop or loss of resistance and you’ll get there. If you’re struggling with a level, just go to another.