Vertical Small-Needle Caudal Epidural Injection Technique

Abstract

BackgroundAnecdotal evidence suggests that a vertical small-needle injection method enters the caudal epidural space with comparable efficacy to cephalad-directed methods, with less intravascular injection.ObjectivesAssess the success rate of vertical caudal epidural injection using epidurography and the frequency of intravascular injection using a vertical small-needle approach.Patients and MethodsParticipants had chronic generalized non-surgical low back pain and either gluteal and/or leg pain and were enrolled in a simultaneous clinical trial assessing the analgesic effect of 5% dextrose epidural injection. A 25 gauge 3.7 cm hypodermic needle was placed at the sacral hiatus using a fingertip-guided vertical technique without imaging assistance, followed by fluoroscopic epidurography. Minimal needle redirection was allowed up to 10 degrees from the vertical plane if the initial epidurogram showed an extradural pattern, followed by repeat epidurography.ResultsFirst needle placement without imaging resulted in blood return in 1/199 participants and positive epidurography in 179/199 (90%). Minimal needle repositioning resulted in a positive epidurogram in the remaining 19 attempts. No intravascular injection patterns were observed.ConclusionsThis compares favorably to published success rates of fluoroscopically-guided technique and was well tolerated. Vertical caudal epidural injection may be suitable for combination with ultrasound-guided methods with Doppler flow monitoring.

Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain

“…This open-label study of serial caudal epidural D5W injections using a small-needle vertical technique 24 in patients with one of several different CLBP diagnoses had two main findings. First, participants reported consistent analgesia after each injection, which peaked within 15 min and lasted 48 h. Second, participants in all diagnostic groups, except peripheral neuropathy, reported clinically important and statistically significant improvements in pain and/or function at 12 months.…”

“…Caudal epidural injections of 10 mL of D5W were administered at the level of the sacral hiatus, using a 25-gauge 3.8 cm needle, and a vertical needle entry, with confirmation of epidural injection by epidurography. 24 Injections were performed by a fellowship-trained pain specialist (L.M.-S.) in an outpatient pain clinic.…”

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial

“…It is unclear if this is optimal for all patients, as the dermatomal pain level for each patient is not the same. Given an analgesic effect in participants with pain at and above the iliac crest level, which is supplied by T12-L1, this suggests that the 10 mL volume introduced vertically at the sacral cornua level ( 20 ) was sufficient to allow cephalad flow of dextrose. Injection of larger volumes of 5% dextrose and radiographic confirmation of the extent of rostral movement of dye merit additional study.…”

“…Inclusion criteria included 19 to 75 years old; simultaneous participation in a concurrent patient study of a vertical small needle caudal epidural injection technique ( 20 ); 6 months or more of self-reported moderate-to-severe CLBP including below the iliac crest as defined by a self-reported score of 5 or more on a 0 - 10 Numeric Rating Scale (NRS) in response to the question “What is the intensity of your back pain”; and failure of one or more non-injection therapies. NSAID use was not considered a modality of treatment.…”

“…Sterile preparation of the injection site was with 2.3% chlorhexidine gluconate/24% isopropyl alcohol. A vertical short needle technique was utilized for injection in the caudal epidural space, using a 25 gauge 3.8 cm needle with needle entry at or below the sacral cornua ( 20 ). A positive epidurogram confirmed needle placement in the caudal epidural space.…”