Iranian Red Crescent Medical Journal

Published by: Kowsar

Determination of the Optimal Angle for Needle Insertion During Caudal Epidural Steroid Injection in Adults Using Ultrasound Imaging

Erhan Gökçek 1 , * and Ayhan Kaydu 1
Authors Information
1 Department of Anesthesiology and Reanimation, Diyarbakır Selahaddin Eyyübi State Hospital, Diyarbakir, Turkey
Article information
  • Iranian Red Crescent Medical Journal: August 2018, 20 (8); e65056
  • Published Online: September 15, 2018
  • Article Type: Research Article
  • Received: December 12, 2017
  • Revised: December 27, 2017
  • Accepted: January 23, 2018
  • DOI: 10.5812/ircmj.65056

To Cite: Gökçek E, Kaydu A. Determination of the Optimal Angle for Needle Insertion During Caudal Epidural Steroid Injection in Adults Using Ultrasound Imaging, Iran Red Crescent Med J. 2018 ; 20(8):e65056. doi: 10.5812/ircmj.65056.

Copyright © 2018, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited
1. Background
2. Objectives
3. Methods
4. Results
5. Discussion
  • 1. Praveen P, Remadevi R, Pratheeba N. Caudal epidural analgesia in pediatric patients: comparison of 0.25% levobupivacaine and 0.25% ropivacaine in terms of motor blockade and postoperative analgesia. Anesth Essays Res. 2017;11(1):223-7. doi: 10.4103/0259-1162.200231. [PubMed: 28298789]. [PubMed Central: PMC5341641].
  • 2. Conn A, Buenaventura RM, Datta S, Abdi S, Diwan S. Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician. 2009;12(1):109-35. [PubMed: 19165299].
  • 3. Manchikanti L, Cash KA, Pampati V, McManus CD, Damron KS. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician. 2004;7(1):81-92. [PubMed: 16868617].
  • 4. Dalens B, Hasnaoui A. Caudal anesthesia in pediatric surgery: Success rate and adverse effects in 750 consecutive patients. Anesth Analg. 1989;68(2):83-9. [PubMed: 2913854].
  • 5. Orme RM, Berg SJ. The 'swoosh' test an evaluation of a modified 'whoosh' test in children. Br J Anaesth. 2003;90(1):62-5. [PubMed: 12488381].
  • 6. Renfrew DL, Moore TE, Kathol MH, el-Khoury GY, Lemke JH, Walker CW. Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR Am J Neuroradiol. 1991;12(5):1003-7. [PubMed: 1719788].
  • 7. Barham G, Hilton A. Caudal epidurals: the accuracy of blind needle placement and the value of a confirmatory epidurogram. Eur Spine J. 2010;19(9):1479-83. doi: 10.1007/s00586-010-1469-8. [PubMed: 20512512]. [PubMed Central: PMC2989280].
  • 8. Aggarwal A, Kaur H, Batra YK, Aggarwal AK, Rajeev S, Sahni D. Anatomic consideration of caudal epidural space: A cadaver study. Clin Anat. 2009;22(6):730-7. doi: 10.1002/ca.20832. [PubMed: 19637298].
  • 9. Sekiguchi M, Yabuki S, Satoh K, Kikuchi S. An anatomic study of the sacral hiatus: A basis for successful caudal epidural block. Clin J Pain. 2004;20(1):51-4. [PubMed: 14668657].
  • 10. Park JH, Koo BN, Kim JY, Cho JE, Kim WO, Kil HK. Determination of the optimal angle for needle insertion during caudal block in children using ultrasound imaging. Anaesthesia. 2006;61(10):946-9. doi: 10.1111/j.1365-2044.2006.04795.x. [PubMed: 16978308].
  • 11. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Hanna A, Rittenberg J, et al. Complications of fluoroscopically guided caudal epidural injections. Am J Phys Med Rehabil. 2001;80(6):416-24. [PubMed: 11399002].
  • 12. Yue WM, Tan SB. Distant skip level discitis and vertebral osteomyelitis after caudal epidural injection: A case report of a rare complication of epidural injections. Spine (Phila Pa 1976). 2003;28(11):E209-11. doi: 10.1097/01.BRS.0000067280.29261.57. [PubMed: 12782996].
  • 13. Senoglu N, Senoglu M, Oksuz H, Gumusalan Y, Yuksel KZ, Zencirci B, et al. Landmarks of the sacral hiatus for caudal epidural block: an anatomical study. Br J Anaesth. 2005;95(5):692-5. doi: 10.1093/bja/aei236. [PubMed: 16155035].
  • 14. Aggarwal A, Aggarwal A, Sahni D; Harjeet. Morphometry of sacral hiatus and its clinical relevance in caudal epidural block. Surg Radiol Anat. 2009;31(10):793-800. doi: 10.1007/s00276-009-0529-4. [PubMed: 19578805].
  • 15. Janjua S, Ali S, Afridi JA, Iqbal A, Iqbal A, Ghaffar A, et al. Effects of caudal epidural steroid injection for low back pain and sciatica. Pak Armed Forces Med J. 2017;67(Suppl-1).
  • 16. Bansal V, Siddhartha PV, Rao H, Ray B. Is caudal epidural steroid injection effective in chronic low back pain due to multiple lumbar disc prolapse? A prospective study. Orthop J Mp Chapter. 2017;23(1).
  • 17. Chen CP, Tang SF, Hsu TC, Tsai WC, Liu HP, Chen MJ, et al. Ultrasound guidance in caudal epidural needle placement. Anesthesiology. 2004;101(1):181-4. [PubMed: 15220789].
  • 18. Raghunathan K, Schwartz D, Connelly NR. Determining the accuracy of caudal needle placement in children: A comparison of the swoosh test and ultrasonography. Paediatr Anaesth. 2008;18(7):606-12. doi: 10.1111/j.1460-9592.2008.02529.x. [PubMed: 18616491].
  • 19. Doo AR, Kim JW, Lee JH, Han YJ, Son JS. A comparison of two techniques for ultrasound-guided caudal injection: The influence of the depth of the inserted needle on caudal block. Korean J Pain. 2015;28(2):122-8. doi: 10.3344/kjp.2015.28.2.122. [PubMed: 25852834]. [PubMed Central: PMC4387457].
  • 20. Maniquis Smigel L, Dean Reeves K, Jeffrey Rosen H, Patrick Rabago D. Vertical small-needle caudal epidural injection technique. Anesth Pain Med. 2016;6(3). e35340. doi: 10.5812/aapm.35340. [PubMed: 27826539]. [PubMed Central: PMC5097855].
  • 21. Dere K, Akbas M, Bicerer E, Ozkan S, Dagli G. A complication during caudal steroid injection. J Back Musculoskelet Rehabil. 2009;22(4):227-9. doi: 10.3233/BMR-2009-0236. [PubMed: 20023355].
  • 22. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011;12(5):726-31. doi: 10.1111/j.1526-4637.2011.01077.x. [PubMed: 21392252].
  • 23. Sullivan WJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P, et al. Incidence of intravascular uptake in lumbar spinal injection procedures. Spine (Phila Pa 1976). 2000;25(4):481-6. [PubMed: 10707395].
  • 24. Fukazawa K, Matsuki Y, Ueno H, Hosokawa T, Hirose M. Risk factors related to accidental intravascular injection during caudal anesthesia. J Anesth. 2014;28(6):940-3. doi: 10.1007/s00540-014-1840-8. [PubMed: 24823700].

Featured Image:

Creative Commons License Except where otherwise noted, this work is licensed under Creative Commons Attribution Non Commercial 4.0 International License .
Readers' Comments