To the Editor: Access to caudal epidural canal is the first step in several chronic pain management procedures including sacral neuroplasty, percutaneous adhesiolysis, and spinal endoscopic adhesiolysis. It can be difficult to identify sacral hiatus by palpation of anatomical landmarks in the adult population. We propose a fluoroscopy‐guided approach for caudal epidural injection in three simple steps using the direction‐depth‐direction principle. Patient is placed in a prone position and the lumbosacral region is prepped and draped in a sterile fashion. All three steps are performed using both the antero‐posterior and ‐lateral fluoroscopic views. Step 1: Sacral hiatus is identified as a radiolucent depression underlying the deficient posterior sacral wall in lateral view ( Figure 1 ). 1 Fluoroscopy‐guided caudal epidural injection. Step 2: Site of needle entry is the center of this radiolucent depression, either in midline or 1–2 cm lateral to midline, as per requirement of the procedure ( Figure 1 ). Needle entry is made in the lateral view at an angle of 45° with respect to the horizontal plane; the dorsal aspect of the ventral plate of the sacrum is contacted. The needle position is also confirmed in antero‐postrior view. Loss of resistance is usually felt after penetrating the sacrococcygeal ligament. Step 3: The needle is slightly withdrawn and the angle of insertion is flattened to 20–30°. The needle is then advanced inside the sacral canal under sequential lateral fluoroscopic views ( Figure 1 ). The final needle position is confirmed by contrast injection in antero‐posterior and ‐lateral views; contrast spread helps in ruling out intrathecal or intravascular needle placement.
Pain Practice – Wiley
Published: Jul 1, 2010
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