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Use of fluoroscopy and contrast to increase the success rate of caudal injections
- Amar Karmarkar (28 October 2005)
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Amar Karmarkar, specialist registrar wythenshawe hospital
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Dear Editor, We read with interest the article by N. Senoglu and colleagues (1). It is rightly mentioned in this article that there is a failure rate of 25% in performing caudal injections even in experienced hands without the use of fluoroscopy. The failure rate will be higher in those with altered anatomy. The equilateral triangle and interphalyngeal joint (proximal or distal) techniques are very useful in places where one does not have the facilities of fluoroscopy, or where it is time consuming, not practical or contraindicated to use fluoroscopy. Apart from variation in the anatomy, there is huge variations in the techniques and drugs used. There is also a large variation in the type of needle used and use of fluoroscopy. Negative aspiration of blood and CSF does not rule out intravenous and intrathecal injection respectively. In spite of needle being in the caudal epidural space, we found large variations in the spread of the contrast i.e. intravenous, intrathecal, subperiosteal and subdural. Although there are various techniques to identify the caudal epidural space i.e. ultrasound (2) and nerve stimulator (3), we found that the use of fluoroscopy (AP and lateral views) and contrast has an accuracy of around 95%. Hence we perform all the caudal injections under fluoroscopy control and use a radioopaque contrast dye for the final confirmation of the needle position i.e. spread of contrast from the sacral foramina or a Christmas tree appearance. A.Karmarkar. South Manchester University Hospitals. E-mail: acarrom@yahoo.co.uk 1) N. Senoglu, M. Senoglu, H. Oksuz et al. Landmarks of the sacral hiatus for caudal epidural block: an anatomical study. Br J Anaesth 2005; 95: 692-5. 2) Chen, Carl P.C, Tang, Simon F.T, Hsu, Tsz- Ching et al. Ultrasound guidance in caudal epidural needle placement. Anaesthesiology 2004; 101: 181-4. 3) Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation of caudal needle placement using nerve stimulation. Anaesthesiology 1999; 91: 374-8. Conflict of Interest:None declared |
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