SummaryWe describe a previously unreported test to confirm accurate needle placement in caudal epidurals. Of 26 patients undergoing caudal epidural, 19 (73%) had correct needle placement as determined by epidurography. AN of these had a positive 'whoosh' test. There were no false positives. Key wordsAnaesthetic techniques, regional; caudal.Epidural injections of local anaesthetic agents and corticosteroids are widely used to provide symptomatic relief in patients suffering from low back disorders. The caudal route, although theoretically safer in that the risk of dural puncture is small, has the disadvantage that needle placement is less certain. We describe a clinical test to confirm the position of the needle in the epidural space, and assess the accuracy of the method using epidurography on a series of patients. MethodsPatients who were suffering from low back pain and sciatica were studied. Any patient having a contraindication to contrast media or radiological investigation was excluded from the study. Blood pressure and pulse measurements were made with the patient supine; they were then placed in the prone position and, under aseptic conditions, the sacral hiatus was palpated and the skin infiltrated with local anaesthetic (lignocaine 1% 2 ml). A 21G needle was inserted through the sacrococcygeal membrane, and aspiration performed to ensure that the needle had not penetrated a blood vessel or the dura. The operator then applied a stethoscope over the thoracolumbar region in the midline and listened as a volume of approximately 2 ml of air was injected. Our hypothesis was that if the needle was truly in the epidural space; then a 'whoosh' heard with the stethoscope upon injection would confirm the passage of air proximally in the epidural space; a positive test. Conversely, a needle position that lay outside the epidural space would not produce such a sound; a negative test.The position of the needle was confirmed by injecting 5 ml of contrast medium (Niopam 300) and taking plain X rays (AP and lateral) to detect the presence of contrast in the epidural space. If the position was confirmed, the therapeutic injection was performed; otherwise the needle was withdrawn and resited. Afterwards the patient was admitted to hospital overnight and routine observations performed. ResultsA total of 26 patients were included in the study ( Table 1). There were seven patients classified clinically as obese; six women (mean weight 81 kg) and one man (weight 117 kg). Of these patients, three had a positive test confirmed by epidurography. The other four patients had needle positions outside the sacral hiatus, confirming the difficulty of needle placement in obese patients. However, instead of a silent 'whoosh' test the operator heard a high pitched crackling sound with the stethoscope and was able to palpate air in the subcutaneous fat. This small series showed the 'whoosh' test to be both specific and sensitive. DiscussionThe caudal route of entry to the epidural space is preferred to the lumbar route by many practitio...

A 10-year-old boy struck a car bonnet following which his left shoulder got pinned under the wheel. No life-threatening injuries were identified. However, the patient sustained extensive abrasions to the back and the left shoulder, a closed deformity of the left clavicle and a swollen, but stable right knee. The patient was neurovascularly intact globally and all joints had a full range of motion. Plain radiographs suggested a possible greenstick fracture of the left clavicle, but also free gas within the left glenohumeral joint. Concern was raised of an unidentified open injury to the joint. CT was supportive of the finding of gas within the left glenohumeral joint, but ruled out the possible greenstick fracture as a spurious finding. There were no other injuries. The gas was within the left glenohumeral joint and was consistent with vacuum phenomenon. The injury was treated expectantly and the child made a full recovery.

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