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Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adult. It is also used in postoperative pain management in children. The laminae of the fifth sacral vertebra fail to unite posteriorly to form a sacral hiatus, which is U — or V -shaped. The tubercles that represent the inferior articular processes make up the sacral corona and are connected inferiorly to the coccygeal cornua.
Sacral hiatus is covered by sacrococcygeal membrane from which epidural space lies anterior to it. The vertebral canal otherwise called as sacral canal runs throughout the greater pari of the bone; above, it is triangular in form; below, its posterior wall is incomplete due to non development of the laminae and spinous processes. The dural sac ends at SI and S2 vertebra. Epidural space which lies between two sacral plates contains sacral nerves, artery, vein, lymphatics and fat.
Damage to sympathetic nerve fibres may lead to sympathetic type pain in which neuropathtic pain is accompanied by signs of autonomic dysfunction including vasomotor instability and sudomotor sweating changes.
Once clinical diagnosis is made and planned for the procedure, then patient is prepared for procedure. Check for the availability of following materials before taking the patient inside the procedure room.
Anatomy The laminae of the fifth sacral vertebra fail to unite posteriorly to form a sacral hiatus, which is U — or V -shaped.
Progressive sensory deficit which includes increase in the area of sensory loss and increase in the quality of sensation as compared to normal area.
Moderate to severe debilitating pain not getting relieved with conservative treatment modalities both pharmacotherapy and non-pharmacological management.
Pain History Predominant back pain with non-dermatomal leg pain mostly limited up to knee: IDD, SI sacroiliac joint arthropathy, vertebral compression fracture, facet arthropathy, MPS, etc. Qnset: It is acute in case of trauma, large central disc, muscle sprain. However, in inflammatory pathologies it is more of a gradual onset.
Site: Disc, vertebral body and interspinous ligaments, bilateral facetjoint, coccygodynia mostly produces midline or axial pain however unilateral facet joints, sacroiliac joint dysfunctions and myofascial pain syndromes commonly presents with paramedian pain.
Radiation: Radicular pain mostly point towards pain of neural origin. It is derma-tological distributed. Piriformis myofascial pain can also mimic SI radiculopathy which needs to be thought of when we are thinking of L5-S1 PIVD Referred pain: It has nondermatological distribution and it is deep aching in quality.
Pain from spine musculature, ligaments, facet joint and sacroiliac joint can be referred to thigh rarely below the knee and in the rarest of case beyond ankle. It can also be seen in pathologies of abdominal origin like aortic pancreatitis, pelvic conditions like endometriosis, inflammatory bowl diseases retroperitojteal conditions like renal colic and pyelonephritis.
Walking increases pain in spinal canal stenosis both central and JateraLiadi-culopathies.
Dr. H. Hooshmand - Caudal Nerve Block
Walking does not increase the pain of facet and sacroiliac joint arthropathy. Standing increases pain in case of. Sitting to standing Facet joint pain, vertebral compression fracture.
Supine to sitting aggravates pain of vertebral compression fracture. Forward flexion IDD, ligaments sprain. Indication: Indication for caudal epidural block includes : Herniated disc with or without radiculopathy below L4 Discogenic pain below L4.
Radiculopathy below L4. Spondylolisthesis below L4. Spinal canal stenosis Failed back surgery syndrome Epidurolysis Contraindications Absolute contraindication includes: Local or systemic infection.
Coagulopathy and patient on anticoagulants without adequate recommended drug free period Lack of consent. Contrast solution like iohexol or iopomidol. Procedure steps Take AP image with X ray tube below the table and use automatic brightness mode and collimator if available. Remove needle and apply sterile dressing Observe lot 10 minutes for hypotension inside procedure room and once hemodynamicaly stable patient can be shifted to post procedure room Post procedure protocol Patient is observed lot 2 hours in post procedure room Monitor vitals every 10 minutes for first 30 minutes and every 30 minutes for next 1.