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Year : 2015  |  Volume : 9  |  Issue : 2  |  Page : 221-222

Ultrafluoro guided caudal epidural injection: An innovative blend of two traditional techniques

1 Medical Intensive Care Unit, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
2 Department of Anaesthesia, ESI Hospital, Okhla, New Delhi, India

Correspondence Address:
Dr. Mayank Gupta
14, Himvihar Apartment, Plot No. 8, I.P. Extension, New Delhi - 110 092
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-354X.152895

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Date of Web Publication10-Mar-2015

How to cite this article:
Gupta M, Gupta PG. Ultrafluoro guided caudal epidural injection: An innovative blend of two traditional techniques. Saudi J Anaesth 2015;9:221-2

How to cite this URL:
Gupta M, Gupta PG. Ultrafluoro guided caudal epidural injection: An innovative blend of two traditional techniques. Saudi J Anaesth [serial online] 2015 [cited 2022 Aug 16];9:221-2. Available from:


Epidural steroid injection (ESI) is the commonest interventional pain procedure performed worldwide. Caudal, transforaminal and interlaminal are the approaches available to access the epidural space. The caudal approach has the advantages of medication delivery atleast in part to anterior epidural space (unlike interlaminar, [Figure 1]) and reduced complication rates. [1] Lumbar radiculopathy and lumbar canal stenosis are the most common indications for performing caudal ESI. [2] Blind unguided caudal ESI is associated with significant failure rates (20-38%) and fraught with complications. [3],[4] Therefore, image guidance has become a norm rather than exception. Fluoroscopic guidance with contrast injection has decades of experience, literature support and is considered as the gold standard. [1],[2],[3],[4] The postulated advantages include ease of identification of sacral hiatus, accurate needle placement under vision, presence of a radiological end point for final tip position (S3) and tracking the contrast spread. However significant radiation hazard and associated biological side-effects to patient, physician as well as bystanders prevails during its usage. Radiation exposure to gonads of reproductively active age group is a particular concern. Ultrasonography (USG) is a relatively new imaging modality increasingly exploited for various image guided interventions. The advantages include portability, radiation free, ability to conduct procedure in unusual patient positions and unlike fluoroscopy, providing a clear view of sacrococcygeal membrane and real time passage of needle through it. [5] However disadvantages include difficult anatomic landmark identification in obese, inability to identify insertion depth, intravascular (5-9%)/intrathecal injection and learning curve in novices. [3],[4] The authors have devised an imaging guidance protocol that embrace the advantages of both imaging modalities, counterbalances each other's disadvantages and have termed it as "ultrafluoro guided caudal injection." The imaging protocol involves using USG as the primary imaging modality with fluoroscopic confirmation of correct needle tip position and dye spread.
Figure 1: Caudal epidural with anterior epidural dye spread in lateral view

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  1. Placing the patient in prone position with a pillow underneath.
  2. Sterile cleaning and draping including placing 5-12 MHz linear transducer probe in sterile sheath with application of sterile jelly.
  3. Scanning sacrococcygeal region in longitudinal and horizontal axis for identification of sacrococcygeal membrane and sacral cornu.
  4. Employing longitudinal section with in-plane technique for needle insertion and passage through sacrococcygeal membrane into epidural space.
  5. Taking an anterio-posterior fluoroscopic view and confirming final tip position below S3.
  6. Omnipaque dye injection under fluoroscopic control and noting epidural spread, its pattern and extent.
  7. Injection of 0.5% lignocaine with 40-80 mg methylprednisolone after obtaining epidurogram.

We conclude by saying that the USG and fluoroscopy should be considered complementary rather than an alternative to one another as their combined usage is associated with USG reduced radiation exposure, USG ability to conduct procedure in unusual patient positions, Fluoro identifying correct needle insertion depth; contrast spread as well as ruling out intravascular [Figure 2] or intrathecal contrast spread. In an era of increasing consumerism, peer and medico-legal scrutiny, multimodal imaging protocol may prove to be a safer alternative compared to the traditional practice of unimodal guided pain interventions.
Figure 2: Caudal epidural with intravascular dye spread

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  References Top

Manchikanti L, Cash KA, Pampati V, McManus CD, Damron KS. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician 2004;7:81-92.  Back to cited text no. 1
Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician 2007;10:185-212.  Back to cited text no. 2
Renfrew DL, Moore TE, Kathol MH, el-Khoury GY, Lemke JH, Walker CW. Correct placement of epidural steroid injections: Fluoroscopic guidance and contrast administration. AJNR Am J Neuroradiol 1991;12:1003-7.  Back to cited text no. 3
Price CM, Rogers PD, Prosser AS, Arden NK. Comparison of the caudal and lumbar approaches to the epidural space. Ann Rheum Dis 2000;59:879-82.  Back to cited text no. 4
Klocke R, Jenkinson T, Glew D. Sonographically guided caudal epidural steroid injections. J Ultrasound Med 2003;22:1229-32.  Back to cited text no. 5


  [Figure 1], [Figure 2]

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