Korean J Pain.  2015 Apr;28(2):122-128. 10.3344/kjp.2015.28.2.122.

A Comparison of Two Techniques for Ultrasound-guided Caudal Injection: The Influence of the Depth of the Inserted Needle on Caudal Block

• Doo AR
• Kim JW
• Lee JH
• Han YJ
• Son JS

• KMID: 2278274
• DOI: http://doi.org/10.3344/kjp.2015.28.2.122

Abstract

BACKGROUND
Caudal epidural injections have been commonly performed in patients with low back pain and radiculopathy. Although caudal injection has generally been accepted as a safe procedure, serious complications such as inadvertent intravascular injection and dural puncture can occur. The present prospective study was designed to investigate the influence of the depth of the inserted needle on the success rate of caudal epidural blocks.
METHODS
A total of 49 adults scheduled to receive caudal epidural injections were randomly divided into 2 groups: Group 1 to receive the caudal injection through a conventional method, i.e., caudal injection after advancement of the needle 1 cm into the sacral canal (n = 25), and Group 2 to receive the injection through a new method, i.e., injection right after penetrating the sacrococcygeal ligament (n = 24). Ultrasound was used to identify the sacral hiatus and to achieve accurate needle placement according to the allocated groups. Contrast dyed fluoroscopy was obtained to evaluate the epidural spread of injected materials and to monitor the possible complications.
RESULTS
The success rates of the caudal injections were 68.0% in Group 1 and 95.8% in Group 2 (P = 0.023). The incidences of intravascular injections were 24.0% in Group 1 and 0% in Group 2 (P = 0.022). No intrathecal injection was found in either of the two groups.
CONCLUSIONS
The new caudal epidural injection technique tested in this study is a reliable alternative, with a higher success rate and lower risk of accidental intravascular injection than the conventional technique.

Keyword

Caudal anesthesia; Epidural injection; Low back pain; Sacral hiatus; Sacrococcygeal ligament; Ultrasound

MeSH Terms

Adult
Anesthesia, Caudal
Fluoroscopy
Humans
Incidence
Injections, Epidural
Injections, Spinal
Ligaments
Low Back Pain
Needles*
Prospective Studies
Punctures
Radiculopathy
Ultrasonography

Figure

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  Fig. 1 Longitudinal ultrasound image showing the final location of the needle in the conventional caudal injection group (A) and the new caudal injection group (B).

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  Fig. 2 Fluoroscopic AP image showing a characteristic epidural filling pattern (A) and inappropriate dispersion of the contrast dye (B).

• 

  Fig. 3 CONSORT diagram.

Reference

1. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician. 2012; 15:131–140. PMID: 22430650.

2. Sullivan WJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P, et al. Incidence of intravascular uptake in lumbar spinal injection procedures. Spine (Phila Pa 1976). 2000; 25:481–486. PMID: 10707395.

3. Fukazawa K, Matsuki Y, Ueno H, Hosokawa T, Hirose M. Risk factors related to accidental intravascular injection during caudal anesthesia. J Anesth. 2014; 28:940–943. PMID: 24823700.

4. Manchikanti L, Cash KA, Pampati V, McManus CD, Damron KS. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician. 2004; 7:81–92. PMID: 16868617.

5. Ergin A, Yanarates O, Sizlan A, Orhan ME, Kurt E, Guzeldemir ME. Accuracy of caudal epidural injection: the importance of real-time imaging. Pain Pract. 2005; 5:251–254. PMID: 17147588.

6. Kim SG, Yang JY, Kim do W, Lee YJ. Inadvertent dural puncture during caudal approach by the introducer needle for epidural adhesiolysis caused by anatomical variation. Korean J Pain. 2013; 26:203–206. PMID: 23614088.

7. Parr AT, Manchikanti L, Hameed H, Conn A, Manchikanti KN, Benyamin RM, et al. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician. 2012; 15:E159–E198. PMID: 22622911.

8. Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: a randomized, controlled, double blind trial with a two-year follow-up. Pain Physician. 2012; 15:273–286. PMID: 22828681.

9. Manchikanti L, Cash KA, McManus CD, Pampati V, Fellows B. Results of 2-year follow-up of a randomized, doubleblind, controlled trial of fluoroscopic caudal epidural injections in central spinal stenosis. Pain Physician. 2012; 15:371–384. PMID: 22996849.

10. Manchikanti L, Cash KA, McManus CD, Pampati V. Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain. J Pain Res. 2012; 5:381–390. PMID: 23091395.

11. Botwin K, Brown LA, Fishman M, Rao S. Fluoroscopically guided caudal epidural steroid injections in degenerative lumbar spine stenosis. Pain Physician. 2007; 10:547–558. PMID: 17660853.

12. Dere K, Akbas M, Bicerer E, Ozkan S, Dagli G. A complication during caudal steroid injection. J Back Musculoskelet Rehabil. 2009; 22:227–229. PMID: 20023355.

13. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011; 12:726–731. PMID: 21392252.

14. Yue WM, Tan SB. Distant skip level discitis and vertebral osteomyelitis after caudal epidural injection: a case report of a rare complication of epidural injections. Spine (Phila Pa 1976). 2003; 28:E209–E211. PMID: 12782996.

15. Ogoke BA. Caudal epidural steroid injections. Pain Physician. 2000; 3:305–312. PMID: 16906188.

16. Yoon JS, Sim KH, Kim SJ, Kim WS, Koh SB, Kim BJ. The feasibility of color Doppler ultrasonography for caudal epidural steroid injection. Pain. 2005; 118:210–214. PMID: 16213088.

17. Aggarwal A, Kaur H, Batra YK, Aggarwal AK, Rajeev S, Sahni D. Anatomic consideration of caudal epidural space: a cadaver study. Clin Anat. 2009; 22:730–737. PMID: 19637298.

18. Joo J, Kim J, Lee J. The prevalence of anatomical variations that can cause inadvertent dural puncture when performing caudal block in Koreans: a study using magnetic resonance imaging. Anaesthesia. 2010; 65:23–26. PMID: 19922508.

19. Aggarwal A, Aggarwal A, Harjeet , Sahni D. Morphometry of sacral hiatus and its clinical relevance in caudal epidural block. Surg Radiol Anat. 2009; 31:793–800. PMID: 19578805.

20. Stitz MY, Sommer HM. Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine (Phila Pa 1976). 1999; 24:1371–1376. PMID: 10404581.

21. Lewis MP, Thomas P, Wilson LF, Mulholland RC. The 'whoosh' test. A clinical test to confirm correct needle placement in caudal epidural injections. Anaesthesia. 1992; 47:57–58. PMID: 1536408.

22. Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation of caudal needle placement using nerve stimulation. Anesthesiology. 1999; 91:374–378. PMID: 10443599.

23. Nikooseresht M, Hashemi M, Mohajerani SA, Shahandeh F, Agah M. Ultrasound as a screening tool for performing caudal epidural injections. Iran J Radiol. 2014; 11:e13262. PMID: 25035698.

24. Chen CP, Tang SF, Hsu TC, Tsai WC, Liu HP, Chen MJ, et al. Ultrasound guidance in caudal epidural needle placement. Anesthesiology. 2004; 101:181–184. PMID: 15220789.