- Today I'm going to demonstrate a caudal
epidural steroid injection.
This is a variation on the technique
of a lumbar epidural steroid injection.
With the probe in this location
we can see the following
anatomic structures,
the coccyx, the sacrococcygeal ligament,
and the sacral cornua.
The indicates the entry
at the sacral hiatus.
The needle is placed thusly,
performing the block.
Indications for this procedure include
patients with lumbar spinal stenosis,
lumbar radiculopathy, and any other cause
of radiating low back and leg pain.
In this particular case
the caudal epidural
steroid approach is utilized to reduce
the need for loss of resistance syringes,
fluoroscopic radiation
exposure to the patient,
and removal of the need
for ionic contrast.
The same benefit can be
achieved utilizing ultrasound.
In this particular case,
I'm going to be using
a SonoSite C60 probe because of it's
curvy linear shape, which will facilitate
viewing of the sacral anatomy.
This is key for the demonstration
of the relevant anatomy and ultimate
placement of the needle for successful
completion of the procedure.
The settings are set for
5.6 centimeter depth,
obviously this is patient specific.
A larger patient may
require a deeper depth.
The other setting is the musculoskeletal
setting or the M-S-K setting.
This provides the best bony enhancement
and as we'll see, we'll need to be passing
a needle between two bony plates
and this setting facilitates
the best view of this.
In order to facilitate
placement of the patient
for the procedure it is necessary to have
the patient in the prone
position as seen here.
This is a typical position
that would normally
be used for a lumbar
epidural steroid approach.
One key difference however,
is the need to move
the gluteal folds so that
access to the sacral hiatus
which is the key target is facilitated.
In this particular case, you can see that
the gluteal folds have
been taped down and away
in a cadual fashion to the patient.
We now have a clean access point
within the two gluteal folds in order
to facilitate a proper block,
the following equipment is required.
A chlorhexidine prep
for sterile technique,
a local anesthetic syringe with a 27-gauge
one and a half inch needle for local
anesthetic placement, preferably
1% bicarbonate lidocaine,
buffered lidocaine, a syringe containing
the epidural steroid
mix, which is composed
of 1%, one cc, lidocaine, six
cc's of bacteriostatic saline
and then 40 to 80 milligrams
of triamcinolone Kenalog,
which is a particulate steroid.
The needle utilized to enter the space
is a three and a half inch spinal needle.
For the conclusion of the procedure,
it will be necessary to
have sterile four by four
for cleanup, and then a
simple bandaid will suffice
to cover the entry site.
Placement of a copious amount of gel
for coupling, aqueous
coupling is important
to enhance resolution on the screen.
And then, contact is made in the midline.
Because there is anatomic
variation in the midline
physiologically, a sagittal view and then
gently rocking the probe
in the oblique direction
can help find the Spinous Processes
of the sacral space.
And then, the probe is moved caudally
and very clearly, the sacral
hiatus comes into view.
There is a superior plate
and an inferior plate
and in between them is the sacral hiatus.
I'll demonstrate where
that access point is.
The needle is angled thusly.
At this point, I would
utilize the local anesthetic
to perform a local anesthetic
track down to this level.
Removing that, I would then
place the three and a half
inch 25-gauge spinal needle along the same
anesthetized track and then
once between the two plates,
I would attach my local
anesthetic and steroid mix.
- [Voiceover] The needle
is visible as this view
is in the long axis.
The sacral plate is clearly visible,
diving anterior and cephalad.
Once the injectate enters the canal,
the color Doppler shows
the fluid perturbation,
confined within the sacral epidural space,
indicating a successful injection,
without need for contrast or xray.
- Once the injectate is done,
and the images recorded as necessary
for the medical record,
the probe is removed.
The needles are removed.
The area is cleaned
and then place a bandaid over the wound.
And thus, this concludes
a successfully placed
caudal epidural steroid injection.
