Caudal Epidural Steroid Injection
| Caudal Epidural Steroid Injection | |
|---|---|
| Indication | Radicular leg pain |
| Syringe | 20mL |
| Needle | 21G 40mm, or 25G 50mm |
| Steroid | Must be dexamethasone, 15mg |
| Local | No local, add normal saline |
| Volume | L5: 10mL L3: 15mL Upper lumbar: 20mL |
- Thecal sac ends at S2 (PSIS level)
Ultrasound Guided Technique
- Position: prone with heels rotated laterally, and a cushion pillow is used as an iliac wedge.
- Identify sacral cornua at base of imaginary triange with thumb (needle will go between cornua)
- Obtain a transverse image for the sacral hiatus and dorsal sacrococcygeal ligament between the bilateral sacral cornua,
- Obtain a longitudinal view and advance needle at a 45 degree angle.
- Terminate needle advancement right after piercing the sacrococcygeal ligament. This is to avoid injection into the venous plexus and intrathecal injection in those with unusually low terminating dural sacs.
- Aspirate to ensure needle not penetrated thecal sac or blood vessel. If aspirate CSF then abort procedure and retry in one week.
Non-Ultrasound Guided Technique
- Find and mark cornuae
- Infiltrate lidocaine to overlying soft tissue
- Enter at midline, feel it penetrate the membrane, aspirate, slow i.e. over 10 mins inject contents
- Assess post procedure for improvement in provocative manoeuvres such as SLR and pain
- Monitor (IV access?) Empty bladder
Indications
Good evidence for radicular leg pain due to lumbar disc herniation. 72.5% complete or partial pain relief at 12 weeks in those with symptom duration of 4-52 weeks. Fair evidence for axial pain and spinal stenosis and post surgery syndrome
Risks
Infection, subcutaneous injection, spinal cord infarction, Radiculopathy <1:2,000 paraplegia 1:50,000, allergic reaction, intravascular injection (minimal risks with dexamethasone due to small particulate size), dural puncture with headache, PE, ADR from steroids, increased back pain (3.1%)
Aftercare
Monitor for allergy. Advised to keep active within pain limits, and is reassessed about 10 days later. Steroid remains in situ for about 2 weeks. Up to 3-4 injections may be performed before declaring the therapy a failure. Max 0.6mg/kg or 40mg dexamethasone per year.
See Also
Videos
References
Literature Review
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,
