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"Emergency medicine" 8 (71) 2015

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An Anatomical Study of Epidural Dye Spread after Caudal Injection in Adults

Authors: Kolomachenko V.I. - Kharkiv Medical Academy of Postgraduate Education, Ukraine

Categories: Medicine of emergency

Sections: Specialist manual

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Summary

Каудальная эпидуральная анестезия имеет ряд преимуществ для хирургии тазобедренного сустава. На 17 свежих трупах пунктировалось сакральное эпидуральное пространство и вводилось 20 мл 0,01% раствора метиленовой синьки. У трех трупов синька оказалась в парасакральном пространстве. После успешной каудальной инъекции (на 14 трупах) эпидуральное пространство было окрашено на уровнях S1 и L5 у 14 (100 %) трупов, на уровне L4 — у 13 (93 %), L3 — у 12 (86 %), L2 — у 9 (64 %), L1 — у 5 (36 %), T12 — у 3 (21 %) трупов и на уровнях T11–T5 — лишь у одного (7 %) трупа. Выводы: каудально впрыснутый раствор в объеме 20 мл надежно омывает копчиковые, крестцовые и нижние поясничные спинальные корешки, однако необходима надежная идентификация эпидурального пространства различными методами.

Каудальна епідуральна анестезія має низку переваг для хірургії кульшового суглоба. На 17 свіжих трупах пунктувався сакральний епідуральний простір і вводилося 20 мл 0,01% розчину метиленової синьки. У трьох трупів синька опинилася в парасакральному просторі. Після успішної каудальної ін’єкції (на 14 трупах) епідуральний простір був зафарбований на рівнях S1 та L5 у 14 (100 %) трупів, на рівні L4 — у 13 (93 %), L3 — у 12 (86 %), L2 — у 9 (64 %), L1 — у 5 (36 %), T12 — у 3 (21 %) трупів і на рівнях T11–T5 — лише в одного (7 %) трупа. Висновки: каудально впорснутий розчин в об’ємі 20 мл надійно омиває куприкові, крижові та нижні поперекові спінальні корінці, однак потрібна надійна ідентифікація епідурального простору різними методами.

Caudal epidural anesthesia has a range of advantages for hip surgery. In 17 fresh cadavers, the sacral epidural space was punctured, then 0.01% methylene blue dye, 20 ml, was injected. In three cadavers the dye was in parasacral space. After successful caudal injection (in 14 cadavers) the epidural space was dyed at S1 and L5 levels in 14 (100 %) cadavers, at L4 level in 13 (93 %), at L3 in 12 (86 %), at L2 in 9 (64 %), at L1 in 5 (36 %), at T12 in 3 (21 %) cadavers, and at T11–T5 levels in 1 (7 %) cadaver only. In conclusion, caudally injected solution 20 ml surely bathes the coccygeal, sacral, and lower lumbar spinal roots, however distinct identification of the epidural space is necessary using various methods.


Keywords

ортопедическая хирургия, каудальная анестезия.

ортопедична хірургія, каудальна анестезія.

orthopedic surgery, caudal anesthesia.

Introduction

Hip surgery including total hip arthroplasty have always been a challenge to anesthesiologists because of traumatic operation, impaired hemostasis as a result of obligatory thromboprophylaxis, advanced patient age, frequent concurrent diseases. Besides, orthopedic patients are very disposed to the major post-operative complications: deep venous thrombosis, pulmonary embolism, blood transfusion requirements, pneumonia, and respiratory depression [7]. Regional methods (spinal, epidural, peripheral nerve blocks) are rather popular for this patient population due to their advantages over general anesthesia [1, 12].

The advantages of peripheral nerve blocks for hip surgery include minimal hemodynamic shifts, absence of urinary bladder disfunction and the danger of epidural hematoma. However, peripheral nerve blocks have several disadvantages: technical difficulties of multiple nerve blocks, high and sometimes dangerous local anesthetic doses. Besides, total hip arthroplasty requires anesthetizing of not only the lumbar plexus, fit for one-puncture psoas compartment blockade [2], but also of several nerves (sciatic, upper and lower gluteal) originating from the sacral plexus.

The advantages of neuraxial blocks (spinal or epidural) include their technical simplicity, a possibility of vast anesthesia with one injection; reduction of postoperative mortality, deep vein thrombosis (by 44%), pulmonary embolism (by 55%), transfusion requirements (by 50%), pneumonia (by 39%), respiratory depression (by 59%), myocardial infarction and renal failure [14]. Finally, the use of epidural analgesia to manage post-operative pain became routine. The disadvantages of both spinal and epidural anesthesia are arterial hypotension, urinary bladder disfunction and the danger of epidural hematoma or other rare but potentially devastating complications [3, 14].

Caudal epidural anesthesia is more safe than other epidural techniques, such as interlaminar and transforaminal approaches, due to lower risk of too high segmental level, arterial hypotension, accidental dural puncture, and epidural hematoma after the use of anticoagulants, because the epidural venous plexus is gathered in the anterior part of the sacral canal and generally ends at the S4 level or lower [6, 8]. It can be successfully used, in combination with lumbar plexus blockade, for hip surgery [9, 12] in adolescents [15] and geriatric patients [7, 16], even in patients with ankylosing spondylitis [5] or having limited cardiac reserve [10].

However, the failure rate of the traditional caudal injection technique, preformed blindly, has been reported to reach 20%-38%, because of difficult anatomic landmark identification in adults, especially in obese ones [6, 8].

Aim

The aim of our study was to assess the spread of methylene blue solution in water as a model of local anesthetic solution after caudal injection in adults.

Materials and Methods

In 17 fresh unbalsamed cadavers, with height (Mean ± SD) 154 ± 12 cm and body mass 69 ± 22 kg, the sacral epidural space was punctured with styletted needle through sacrococcygeal membrane, at 70-80° angle to skin in ventral and cranial direction. After ‘pop’ feeling the needle was bent to intergluteal cleft and moved 1-2 cm forward. Then 0.01% methylene blue dye, 20 milliliters, was injected. During anatomical preparation, with sacrotomy, lumbar laminectomy, and dural dissection, the dye spread through subarachnoid, epidural, parasacral, and paravertebral spaces was analysed.

Study Results and Discussion

The dye solution was successfully injected into caudal epidural space of 14 (82%) cadavers only. In three cadavers the dye was in parasacral space because at our early attempts we used the ‘pop’ feeling only for epidural space identification. After including the ‘loss of resistance’ and the ‘whoosh’ test, with an injection of approximately 2 ml of air through the caudal needle, and a ‘whoosh’ being heard via a stethoscope placed over the thoracolumbar spine as a useful guide to successful needle placement [11], all our caudal injections became successful.

After successful caudal injection (in 14 cadavers) the epidural space was dyed at S1 and L5 levels in 14 (100%) cadavers, at L4 level in 13 (93%), at L3 in 12 (86%), at L2 in 9 (64%), at L1 in 5 (36%), at T12 in 3 (21%) cadavers, and at T11-T5 levels in 1 (7%) cadaver only, the last belonging to a young woman of asthenic type (Figure 1).

Thus, the dye aqueous solution as a model of local anesthetic have always enclosed the L5 segment and all sacral segments, so the caudal blockade must include lumbosacral trunk, too. Especially as a significant portion of the solution flew out of epidural space through intervertebral foramina along the spinal nerve roots (Figure 2).  

In the majority of cases (64%), the solution reached L2 level, with intensive coloration of dura mater and vertebral laminae; therefore the dye was seen on sacral anterolateral surfaces and L4-L5 vertebral bodies (Figure 3).

At the same time, the dye solution never got to subarachnoid space (Figure 4).

Our results agree with the English study of the anatomy of the caudal space using magnetic resonance imaging [4], which showed that in adults the mean volume of the caudal space excluding the foraminae and dural sac was 14.4 milliliters (range: 9.5 to 26.6 milliliters). So, 20 milliliters of local anesthetic solution can anesthetize the whole sacral plexus in most patients.

Failures after our early attempts of caudal injection are in accordance with the data of others [6, 8]. In adults, the success rate may be as low as 62-80% [6, 8]. However, in children, it is in the order of 96%, as the anatomical landmarks tend to be more reliable [1, 13].

The ‘whoosh’ test was developed in 1992 as a useful guide to successful needle placement [11]. It involves the injection of approximately 2 ml of air through the caudal needle, with a ‘whoosh’ being heard via a stethoscope placed over the thoracolumbar spine if placement is correct. It was subsequently shown that the ‘whoosh’ test was superior to clinical judgement in detecting successful needle placement [13]. It has also been advocated as a teaching aid for anesthesiologists new to the technique of caudal anesthesia [13].

The use of air in the epidural space is probably best avoided in children as it may be associated with neurological damage; there has also been a report of probable venous air embolism in a child following the use of an air ‘whoosh’ test [13]. In 2003, the ‘swoosh’ test, a modified ‘whoosh’ test for children, was proposed [13]. It avoids the injection of air by performing auscultation during injection of the local anaesthetic solution. During insertion of the caudal block, a stethoscope was placed over the lower lumbar spine and the presence or absence of an audible ‘swoosh’ noted [13].

Besides, in clinical setting, paresthesias during injection [1] or ultrasound scanning [6] may further improve successfulness of caudal anesthesia.                                                                      

Conclusions

Caudally injected solution in 20-ml volume surely bathes the coccygeal, sacral, and lower lumbar spinal roots, however distinct identification of the epidural space is necessary, using various methods.

In future, a radiological study of sacrally injected solution spread in adults is feasible. 


Bibliography

1. Суслов В.В., Тарабрин О.А., Хижняк А.А., Фесенко У.А., Фесенко В.С. Эпидуральная анестезия и аналгезия. — Х.: СІМ, 2011. — 256 с.

2. Хвисюк О.М., Фесенко В.С., Завеля М.І., Хвисюк О.М. Анестезія в ортопедії та травматології. — Х.: Прапор, 2006. — 416 с.

3. Bauer M., George J.E. 3rd, Seif J., Farag E. Recent advances in epidural analgesia // Anesthesiol. Res. Pract. — 2012. — Vol. 2012. — P. 309219.

4. Crighton I.M., Barry B.P., Hobbs G.J. A study of the anatomy of the caudal space using magnetic resonance imaging // Br. J. –Anaesth. — 1997. — Vol. 78, № 4. — P. 391-395.

5. Deboard J.W., Ghia J.N., Guilford W.B. Caudal anesthesia in a patient with ankylosing spondylitis for hip surgery // Anesthesio–logy. — 1981. — Vol. 54, № 2. — P. 164-166.

6. Doo A.R., Kim J.W., Lee J.H., Han Y.J., Son J.S. 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. — Vol. 28, № 2. — P. 122-128.

7. El Gendy H.A., Elsharnouby N.M. Ultrasound guided single injection caudal epidural anesthesia of isobaric bupivacaine with/without dexamethasone for geriatric patients undergoing total hip replacement surgery // Egypt. J. Anaesth. — 2014. — Vol. 30, № 3. — P. 293-298.

8. Gupta M., Gupta P. Ultrafluoro guided caudal epidural injection: An innovative blend of two traditional techniques // Saudi J. –Anaesth. — 2015. — Vol. 9, № 2. — P. 221-222.

9. Kita T., Maki N., Song Y.S., Arai F., Nakai T. Caudal epidural anesthesia administered intraoperatively provides for effective postoperative analgesia after total hip arthroplasty // J. Clin. Anesth. — 2007. — Vol. 19, № 3. — P. 204-208.

10. Kose E.A., Ozturk A., Ates G., Apan A. Caudal epidural block for elderly patients who have limited cardiac reserve // Turk. J. Med. Sci. — 2012. — Vol. 42, Sup. 1. — P. 1347-1351.

11. Lewis M.P., Thomas P., Wilson L.F., Mulholland R.C. The 'whoosh' test. A clinical test to confirm correct needle placement in caudal epidural injections // Anaesthesia. — 1992. — Vol. 47, № 1. — P. 57-58.

12. Nishio S., Fukunishi S., Juichi M., Sahoko K., Fujihara Y., Fukui T., Yoshiya S. Comparison of continuous femoral nerve block, caudal epidural block, and intravenous patient-controlled analgesia in pain control after total hip arthroplasty: a prospective randomized study // Orthop. Rev. — 2014. — Vol. 6, № 1. — P. 15-19.

13. Orme R.M., Berg S.J. The 'swoosh' test — an evaluation of a modified 'whoosh' test in children // Br. J. Anaesth. — 2003. — Vol. 90, № 1. — P. 62-65.

14. Rodgers A., Walker N., Schug S., McKee A., Kehlet H., van Zundert A., Sage D., Futter M., Saville G., Clark T., MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials // BMJ. — 2000. — Vol. 321, № 7275. — P. 1493.

15. Schloss B., Martin D., Tripi J., Klingele K., Tobias J.D. Caudal epidural blockade for major orthopedic hip surgery in adolescents // Saudi J. Anaesth. — 2015. — Vol. 9, № 2. — P. 128-131.

16. Shin Y.S., Hur K., Kwak Y.R., Han C.D. Single caudal anesthesia for total hip replacement in geriatric patients // Korean J. Anesthesiol. — 1994. — Vol. 27, № 2. — P. 164-169.


1. Suslov V.V., Tarabrin O.A., Khizhniak A.A., Fesenko U.A., Fesenko V.S. Epidural Anesthesia and Analgesia. – Kharkiv: SIM, 2011. – 256 p.                                                                                                                                                                                                                                                                                                                                                                                                         

2. Khvysiuk O.M., Fesenko V.S., Zavelia M.I., Khvysiuk O.M. Anesthesia for Orthopedics and Traumatology. – Kharkiv: Prapor, 2006. – 416 p.

3. Bauer M., George J.E. 3rd, Seif J., Farag E. Recent advances in epidural analgesia // Anesthesiol. Res. Pract. – 2012. – Vol.2012. – P.309219.

4. Crighton I.M., Barry B.P., Hobbs G.J. A study of the anatomy of the caudal space using magnetic resonance imaging // Br. J. Anaesth. – 1997. – Vol.78, №4. – P.391-395.

5. Deboard J.W., Ghia J.N., Guilford W.B. Caudal anesthesia in a patient with ankylosing spondylitis for hip surgery // Anesthesiology. – 1981. – Vol.54, №2. – P.164-166.

6. Doo A.R., Kim J.W., Lee J.H., Han Y.J., Son J.S. 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. – Vol.28, №2. – P.122–128.

7. El Gendy H.A., Elsharnouby N.M. Ultrasound guided single injection caudal epidural anesthesia of isobaric bupivacaine with/without dexamethasone for geriatric patients undergoing total hip replacement surgery // Egypt. J. Anaesth. – 2014. – Vol.30, №3. – P.293-298.

8. Gupta M., Gupta P. Ultrafluoro guided caudal epidural injection: An innovative blend of two traditional techniques // Saudi J. Anaesth. – 2015. – Vol.9, №2. – P.221-222.

9. Kita T., Maki N., Song Y.S., Arai F., Nakai T. Caudal epidural anesthesia administered intraoperatively provides for effective postoperative analgesia after total hip arthroplasty // J. Clin. Anesth. – 2007. – Vol.19, №3. – P.204-208.

10. Kose E.A., Ozturk A., Ates G., Apan A. Caudal epidural block for elderly patients who have limited cardiac reserve // Turk. J. Med. Sci. – 2012. – Vol.42, Sup. 1. – P.1347-1351.

11. Lewis M.P., Thomas P., Wilson L.F., Mulholland R.C. The 'whoosh' test. A clinical test to confirm correct needle placement in caudal epidural injections // Anaesthesia. – 1992. – Vol.47, №1. – P.57-58.

12. Nishio S., Fukunishi S., Juichi M., Sahoko K., Fujihara Y., Fukui T., Yoshiya S. Comparison of continuous femoral nerve block, caudal epidural block, and intravenous patient-controlled analgesia in pain control after total hip arthroplasty: a prospective randomized study // Orthop. Rev. – 2014. – Vol.6, №1. – P.15-19.

13. Orme R.M., Berg S.J. The 'swoosh' test – an evaluation of a modified 'whoosh' test in children // Br. J. Anaesth. – 2003. – Vol.90, №1. – P.62-65.

14. Rodgers A., Walker N., Schug S., McKee A., Kehlet H., van Zundert A., Sage D., Futter M., Saville G., Clark T., MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials // BMJ. – 2000. – Vol.321, №7275. – P.1493.

15. Schloss B., Martin D., Tripi J., Klingele K., Tobias J.D. Caudal epidural blockade for major orthopedic hip surgery in adolescents // Saudi J. Anaesth. – 2015. – Vol.9, №2. – P.128-131.

16. Shin Y.S., Hur K., Kwak Y.R., Han C.D. Single caudal anesthesia for total hip replacement in geriatric patients // Korean J. Anesthesiol. – 1994. – Vol.27, №2. – P.164-169.

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