Caudal Epidural Block: An Updated Review of Anatomy and Techniques

Sheng-Chin Kao, Chia-Shiang Lin, Sheng-Chin Kao, Chia-Shiang Lin

Abstract

Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adults. It is performed by inserting a needle through the sacral hiatus to gain entrance into the sacral epidural space. Using conventional blind technique, the failure rate of caudal epidural block in adults is high even in experienced hands. This high failure rate could be attributed to anatomic variations that make locating sacral hiatus difficult. With the advent of fluoroscopy and ultrasound in guiding needle placement, the success rate of caudal epidural block has been markedly improved. Although fluoroscopy is still considered the gold standard when performing caudal epidural injection, ultrasonography has been demonstrated to be highly effective in accurately guiding the needle entering the caudal epidural space and produce comparative treatment outcome as fluoroscopy. Except intravascular and intrathecal injection, ultrasonography could be as effective as fluoroscopy in preventing complications during caudal epidural injection. The relevant anatomy and techniques in performing the caudal epidural block will be briefly reviewed in this article.

Conflict of interest statement

The authors declare that there is no conflict of interests regarding the publication of this paper.

Figures

Figure 1
Figure 1
Posterior view of sacrum.
Figure 2
Figure 2
Sagittal view of sacrum. SH: sacral hiatus; red double-ended arrow: anterior-posterior diameter of sacral hiatus at its apex.
Figure 3
Figure 3
Fluoroscopy-guided caudal epidural block. Proper needle tip placement was verified by observing spread of contrast medium within the epidural space without intravascular uptake. Arrows: needle.
Figure 4
Figure 4
Transverse ultrasound view of the sacral hiatus. The inset shows the position of the ultrasound transducer. BS: base of sacrum; SC: sacral cornua; SCL: sacrococcygeal ligament; SH: sacral hiatus.
Figure 5
Figure 5
Longitudinal ultrasound view of sacral hiatus. The inset shows the position of the ultrasound transducer. BS: base of sacrum; SCL: sacrococcygeal ligament; SH: sacral hiatus; arrows: needle.
Figure 6
Figure 6
Color Doppler ultrasonography in longitudinal view of sacral hiatus. A predominantly one-color spectrum is observed in the sacral hiatus during caudal epidural injection. The inset shows the position of the ultrasound transducer. BS: base of sacrum; SCL: sacrococcygeal ligament; SH: sacral hiatus.
Figure 7
Figure 7
Color Doppler ultrasonography in paramedian sagittal oblique view of the sacral and lumbar spine. The observed color spectrum suggests the flow of injectate reaching L4-5 level. The inset shows the position of the ultrasound transducer. L3L: L3 lamina; L4L: L4 lamina; L5L: L5 lamina; DS: dorsal surface of sacrum.

References

    1. Dalens B., Hasnaoui A. Caudal anesthesia in pediatric surgery: success rate and adverse effects in 750 consecutive patients. Anesthesia and Analgesia. 1989;68(2):83–89. doi: 10.1213/00000539-198902000-00002.
    1. Orme R. M., Berg S. J. The ‘swoosh’ test—an evaluation of a modified ‘whoosh’ test in children. British Journal of Anaesthesia. 2003;90:62–65.
    1. Renfrew D. L., Moore T. E., Kathol M. H., El-Khoury G. Y., Lemke J. H., Walker C. W. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. American Journal of Neuroradiology. 1991;12(5):1003–1007.
    1. Stitz M. Y., Sommer H. M. Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine. 1999;24(13):1371–1376. doi: 10.1097/00007632-199907010-00016.
    1. Barham G., Hilton A. Caudal epidurals: the accuracy of blind needle placement and the value of a confirmatory epidurogram. European Spine Journal. 2010;19(9):1479–1483. doi: 10.1007/s00586-010-1469-8.
    1. Sekiguchi M., Yabuki S., Satoh K., Kikuchi S. An anatomic study of the sacral hiatus: a basis for successful caudal epidural block. Clinical Journal of Pain. 2004;20(1):51–54. doi: 10.1097/00002508-200401000-00010.
    1. Aggarwal A., Aggarwal A., Harjeet, Sahni D. Morphometry of sacral hiatus and its clinical relevance in caudal epidural block. Surgical and Radiologic Anatomy. 2009;31(10):793–800. doi: 10.1007/s00276-009-0529-4.
    1. Aggarwal A., Kaur H., Batra Y. K., Aggarwal A. K., Rajeev S., Sahni D. Anatomic consideration of caudal epidural space: A Cadaver Study. Clinical Anatomy. 2009;22(6):730–737. doi: 10.1002/ca.20832.
    1. Crighton I. M., Barry B. P., Hobbs G. J. A study of the anatomy of the caudal space using magnetic resonance imaging. British Journal of Anaesthesia. 1997;78(4):391–395. doi: 10.1093/bja/78.4.391.
    1. Senoglu N., Senoglu M., Oksuz H., et al. Landmarks of the sacral hiatus for caudal epidural block: an anatomical study. British Journal of Anaesthesia. 2005;95(5):692–695. doi: 10.1093/bja/aei236.
    1. Chen C. P., Wong A. M., Hsu C.-C., et al. Ultrasound as a screening tool for proceeding with caudal epidural injections. Archives of Physical Medicine and Rehabilitation. 2010;91(3):358–363. doi: 10.1016/j.apmr.2009.11.019.
    1. Nikooseresht M., Hashemi M., Mohajerani S. A., Shahandeh F., Agah M. Ultrasound as a screening tool for performing caudal epidural injections. Iranian Journal of Radiology. 2014;11(2) doi: 10.5812/iranjradiol.13262.e13262
    1. Kim Y. H., Park H. J., Cho S., Moon D. E. Assessment of factors affecting the difficulty of caudal epidural injections in adults using ultrasound. Pain Research and Management. 2014;19(5):275–279. doi: 10.1155/2014/679128.
    1. Park G.-Y., Kwon D. R., Cho H. K. Anatomic differences in the sacral hiatus during caudal epidural injection using ultrasound guidance. Journal of Ultrasound in Medicine. 2015;34(12):2143–2148. doi: 10.7863/ultra.14.12032.
    1. 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(1):23–26. doi: 10.1111/j.1365-2044.2009.06168.x.
    1. Senoglu N., Senoglu M., Ozkan F., Kesilmez C., Kizildag B., Celik M. The level of termination of the dural sac by MRI and its clinical relevance in caudal epidural block in adults. Surgical and Radiologic Anatomy. 2013;35(7):579–584. doi: 10.1007/s00276-013-1108-2.
    1. Paulsen R. D., Call G. A., Murtagh F. R. Prevalence and percutaneous drainage of cysts of the sacral nerve root sheath (Tarlov cysts) American Journal of Neuroradiology. 1994;15(2):293–297.
    1. Brull R., MacFarlane A. J. R., Chan V. W. S. Spinal, epidural, and caudal anesthesia. In: Miller R. D., editor. Miller's Anesthesia. Elsevier Health Sciences; 2015. pp. 1684–1720.
    1. Lewis M. P. N., Thomas P., Wilson L. F., Mulholland R. C. The “whoosh” test: a Clinical test to confirm correct needle placement in caudal epidural injections. Anaesthesia. 1992;47(1):57–58. doi: 10.1111/j.1365-2044.1992.tb01957.x.
    1. Eastwood D., Williams C., Buchan I. Caudal epidurals: the whoosh test. Anaesthesia. 1998;53(3):305–307. doi: 10.1046/j.1365-2044.1998.00327.x.
    1. Landers M. H., Aprill C. N. Epidural steroid injections. In: Lennard T. A., Vivian D. G., Walkowski S. D., Singla A. K., editors. Pain Procedures in Clinical Practice. 3rd. Elsevier Health Sciences; 2011. pp. 313–356.
    1. Sullivan W. J., Willick S. E., Chira-Adisai W., et al. Incidence of intravascular uptake in lumbar spinal injection procedures. Spine. 2000;25(4):481–486. doi: 10.1097/00007632-200002150-00015.
    1. Manchikanti L., Cash K. A., Pampati V., Mcmanus C. D., Damron K. S. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician. 2004;7(1):81–92.
    1. Klocke R., Jenkinson T., Glew D. Sonographically guided caudal epidural steroid injections. Journal of Ultrasound in Medicine. 2003;22(11):1229–1232. doi: 10.7863/jum.2003.22.11.1229.
    1. Chen C. P. C., Tang S. F. T., Hsu T.-C., et al. Ultrasound guidance in caudal epidural needle placement. Anesthesiology. 2004;101(1):181–184. doi: 10.1097/00000542-200407000-00028.
    1. Blanchais A., Le Goff B., Guillot P., Berthelot J.-M., Glemarec J., Maugars Y. Feasibility and safety of ultrasound-guided caudal epidural glucocorticoid injections. Joint Bone Spine. 2010;77(5):440–444. doi: 10.1016/j.jbspin.2010.04.016.
    1. Yoon J. S., Sim K. H., Kim S. J., Kim W. S., Koh S. B., Kim B. J. The feasibility of color Doppler ultrasonography for caudal epidural steroid injection. Pain. 2005;118:210–214.
    1. Park Y., Lee J.-H., Park K. D., Ahn J. K., Park J., Jee H. Ultrasound-guided vs. fluoroscopy-guided caudal epidural steroid injection for the treatment of unilateral lower lumbar radicular pain: A Prospective, Randomized, Single-blind Clinical Study. American Journal of Physical Medicine and Rehabilitation. 2013;92(7):575–586. doi: 10.1097/phm.0b013e318292356b.
    1. Chin K. J., Karmakar M. K., Peng P. Ultrasonography of the adult thoracic and lumbar spine for central neuraxial blockade. Anesthesiology. 2011;114(6):1459–1485. doi: 10.1097/ALN.0b013e318210f9f8.
    1. Dawkins C. J. An analysis of the complications of extradural and caudal block. Anaesthesia. 1969;24(4):554–563. doi: 10.1111/j.1365-2044.1969.tb02909.x.
    1. Sathianathan V., Dobby N. Rectal puncture complicating caudal blockade in a child with severe rectal distension. Paediatric Anaesthesia. 2015;25(10):1063–1065. doi: 10.1111/pan.12688.
    1. Fujikawa T., Murai S. Portal venous gas after a caudal block. BMJ case reports. 2014;2014 doi: 10.1136/bcr-2014-205381.
    1. Lee M. H., Han C. S., Lee S. H., et al. Motor weakness after caudal epidural injection using the air-acceptance test. Korean Journal of Pain. 2013;26(3):286–290. doi: 10.3344/kjp.2013.26.3.286.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe