Ultrasound as a Screening Tool for Performing Caudal Epidural Injections

Abstract

Background:The caudal approach to the epidural space has been used for decades to treat low back pain caused by lumbosacral root compression. The use of fluoroscopy during epidural steroid injection is the preferred method for placing the needle more accurately in the sacral hiatus, but it carries the risk of radiation hazard.Objectives:The aim of the study was to assess the anatomical structure of the sacral hiatus and the feasibility of caudal epidural injections under ultrasound guidance.Patients and Methods:Two hundred and forty patients (male = 100, female = 140) with low back pain and sciatica who were candidates for caudal epidural injection were enrolled into this study. Ultrasound images of the sacral hiatus and bilateral cornua were obtained by a real-time linear array ultrasound transducer. The distance between bilateral cornua and the anterior and posterior wall of the sacrum were measured at the base (sacral hiatus). Under the guide of ultrasonography, we defined the injection successful if turbulence of medication fluid was observed in the sacral canal, but correct placement of the needle and injectant was confirmed on fluoroscopic view as the gold standard technique.Results:The epidurogram showed that the injection was successful in 230 of the 240 patients (95.8%). In eight patients, the injection was not in the correct place in the sacral canal. The sacral hiatus could not be identified by ultrasound images in only two patients who had a closed sacral hiatus identified by fluoroscopy. The mean distance of the sacral hiatus was 4.7 ± 1.7 mm and the mean distance between bilateral cornua was 18.0 ± 2.8 mm. The mean duration of the procedure was 10.8 ± 6.8 minutes. No major complication was observed in the next month.Conclusions:In conclusion, ultrasound could be used as a safe, fast and reliable modality to observe the anatomic variation of the sacral hiatus and to perform caudal epidural injections.

Caudal Epidural Block: An Updated Review of Anatomy and Techniques

“…Several studies from various ethnic populations have repeatedly reported very high successful rates (96.9–100%) of ultrasound-guided caudal injection [11, 12, 25–27]. The patient can be placed in prone or lateral decubitus position.…”

A simple approach for ultrasound-guided pararadicular injections in the sacral spine: a pilot computer tomography controlled cadaver study

“…Klocke et al [27] were the first to describe a sonographic method for identifying the sacral hiatus landmarks to facilitate real-time guidance of steroid injections into the caudal epidural space. Nikooseresht et al [13] and Kim et al [14] presented in a similar setting that ultrasound can be used as a screening tool for performing caudal epidural injections. Quite recently Kao et al demonstrated in their review article relevant anatomic features and variations of the sacral bone and the development of imaging guided techniques, also including the US-guided approach for performing caudal epidural injections [15], They used a longitudinal transducer position with the sacrococcygeal ligament as the sighted landmark.…”

“…Different approaches have already been described for the cervical [11] and lumbar spine [12], proving the feasibility and effectiveness of US-guided injections in the spine. However, concerning the sacral spine, only a few reports can be found in the literature [13][14][15][16].…”

Gambaran Penggunaan, Obat, Teknik, dan Permasalahan yang Dihadapi pada Blokade Kaudal di Kota Bandung Tahun 2016

“…Namun, penggunaan rutin teknik ini terhalang berbagai pertimbangan seperti paparan radiasi, biaya, dan kebutuhan akan lokasi khusus. 7 Saat dibandingdengan fluoroscopy, ultrasonografi memiliki keuntungan yaitu lebih mudah untuk dipelajari, bebas dari radiasi sehingga lebih memungkinkan untuk dilakukan pada berbagai kondisi, kejadian kebocoran vaskular yang lebih rendah, dan tingkat keberhasilan tindakan yang lebih tinggi. Hal-hal tersebut menjadikan ultrasonografi lebih cepat dan lebih mudah digunakan untuk tindakan anestesi kaudal.…”

“…Hal-hal tersebut menjadikan ultrasonografi lebih cepat dan lebih mudah digunakan untuk tindakan anestesi kaudal. [7][8][9] Melakukan blokade kaudal dengan blind technique memerlukan pengetahuan anatomi yang baik untuk menentukan landmarks. Teknik ini dinilai cepat dan mudah untuk dilakukan, namun kelemahan teknik ini dapat terjadi komplikasi serius berupa kerusakan saraf oleh tusukan langsung.…”