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Purpose: Although pediatric epidural analgesia is a well-established technique used perioperatively. It is unclear whether a lumbar or caudal epidural is suitable for osteogenesis imperfecta (OI) patients, which may be associated with brittle bones and spine deformity. We conducted a retrospective study to investigate and compare the efficacy of the two continuous epidural techniques in pediatric patients undergoing lower extremity osteotomy surgery using a propensity score-matched analysis (PSMA). Patients and Methods: A total of 274 patients were included. Patients' age, weight, and height were adjusted using PSMA. 90 patients were matched for further analysis, with 45 patients in the lumbar epidural group (Group L) and 45 patients in the caudal epidural group (Group C). Pain scores were categorized into three grades: mild (0– 3), moderate (4– 6), and severe (7– 10), and compared between the two groups. Additionally, operation time, operation site, blood loss, scoliosis, oral analgesic medications, and catheter or nerve-related complications were compared. Results: There were no significant differences in operation time, operation site, scoliosis, and blood loss between the two groups. The percentage of moderate to severe pain during movement was significantly higher in Group L than in Group C, with 37.5% versus 17.5% on the second-day post-operation (P=0.039). However, no statistically significant difference was observed on other days. Additionally, there was no significant difference in oral medication consumption and complications between the two groups. Conclusion: Both lumbar and caudal epidural analgesia can be effectively used postoperatively, and a caudal epidural should be considered where performing a lumbar epidural is challenging in OI pediatric patients. Plain Language Summary: Osteogenesis imperfecta (OI) is a rare genetic disorder that affects the body's connective tissues, particularly the bones and ligaments. It is caused by abnormalities in type I collagen, which leads to skeletal fragility known as "brittle bones". This fragility can cause various issues, including an increased risk of fractures from minor trauma, limb deformities, and unusual fractures such as vertebral compressions. OI patients may also experience spinal manifestations such as scoliosis and kyphosis. Lumbar epidural analgesia has been found to be effective in providing pain relief for surgeries that involve the lower extremities. Additionally, caudal epidural analgesia has also demonstrated its effectiveness in providing postoperative analgesia for surgeries that affect the lower limbs. However, there is still debate about the safety of epidural analgesia in patients with skeletal dysplasias, especially those with OI. Despite this uncertainty, our center, which was supported by the Rare Diseases Public Welfare Organization, has successfully used epidural analgesia since 2015 in the southern part of China for OI surgeries. We conducted a retrospective study to share our experiences of nine years of practice and compare lumbar epidural with caudal epidural using a propensity score matching to balance basic demographics. We also compared the presence of scoliosis. Our findings suggest that both lumbar and caudal epidural analgesia can be safely used in OI patients. In cases where lumbar punctures may pose challenges due to potential spine deformities, the caudal route can be an alternative. [ABSTRACT FROM AUTHOR]

Background Caudal epidural prolotherapy injection has emerged as a successful treatment for managing chronic pain. This study is a prospective randomized, double-blinded clinical trial. It assesses and compares the effectiveness of prolotherapy versus steroid injection for pain relief in cases of failed back surgery syndrome (FBSS). It involved randomly assigning 90 patients with FBSS to one of two equal groups: steroids or prolotherapy. The VAS was used to measure pain as the primary outcome, while disability was measured by the Oswestry disability index (ODI). McGill Pain Questionnaire (MPQ) and complications were recorded as secondary outcomes.Results The VAS improved significantly from the baseline in both groups at all follow-up periods (p

Background: Literature on the efficacy and safety of erector spinae plane block (ESPB) in pediatric patients is limited. Hence, we aimed to compare ESPB versus caudal epidural block (CEB) in children undergoing abdominal surgery. Methods: In this patient and assessor-blind study, fifty-two ASA I-II patients, between 1 to 9 years of age, were randomized into groups of 26 each. ESPB group received unilateral or bilateral ultrasound (USG)-guided ESPB with 0.5 ml/kg of 0.25% bupivacaine per side. CEB group received USG-guided CEB with 1 ml/kg of 0.25% bupivacaine. The primary objective was to estimate the proportion of patients requiring postoperative rescue analgesia. The secondary objectives were to assess postoperative Face, Legs, Activity, Cry and Consolability (FLACC) scale scores, duration of analgesia, and consumption of rescue analgesic drugs. Results: More patients in the ESPB group (88.4%), compared to the CEB group (42.3%), required rescue analgesics (P value

Background: Literature on the efficacy and safety of erector spinae plane block (ESPB) in pediatric patients is limited. Hence, we aimed to compare ESPB versus caudal epidural block (CEB) in children undergoing abdominal surgery. Methods: In this patient and assessor-blind study, fifty-two ASA I-II patients, between 1 to 9 years of age, were randomized into groups of 26 each. ESPB group received unilateral or bilateral ultrasound (USG)-guided ESPB with 0.5 ml/kg of 0.25% bupivacaine per side. CEB group received USG-guided CEB with 1 ml/kg of 0.25% bupivacaine. The primary objective was to estimate the proportion of patients requiring postoperative rescue analgesia. The secondary objectives were to assess postoperative Face, Legs, Activity, Cry and Consolability (FLACC) scale scores, duration of analgesia, and consumption of rescue analgesic drugs. Results: More patients in the ESPB group (88.4%), compared to the CEB group (42.3%), required rescue analgesics (P value <0.001). FLACC scores in the ESPB group, though satisfactory, were inferior, to the CEB group. The duration of postoperative analgesia was shorter in the ESPB group by 9.54 h (95% CI: 4.51 to 14.57 h, P value <0.001). The median (IQR) consumption of rescue paracetamol was significantly higher in the ESPB group (20 mg/kg (10,20) compared to the CEB group (0.0 mg/kg (0.0,10) P value <0.001)). No adverse effects were reported. Conclusion: In children undergoing abdominal surgery, both ESPB and CEB were safe and efficacious. CEB provided a longer duration and better quality of analgesia. ESPB may be considered when CEB is contraindicated or difficult. [ABSTRACT FROM AUTHOR]

In this case series, we investigated the feasibility of combining ultrasound and neurostimulation for inserting a stimulating epidural catheter in the thoracic epidural space through the caudal route in neonates. Twelve neonates undergoing tracheo-oesophageal fistula repair under general anaesthesia were studied. The catheter was visible on ultrasound as a hyperechoic dot in the epidural space. Inadvertent high placement was identified in two neonates with neurostimulation, in whom the catheter was withdrawn to the thoracic epidural space, and the position was confirmed on ultrasound. A 0.5 ml/kg bolus dose of 0.125% bupivacaine injected through the epidural catheter was imaged in real-time in the epidural space. Block was effective in 10 neonates; two needed an additional local anaesthetic (LA) bolus. To conclude, ultrasound with neurostimulation facilitates accurate positioning of the caudally placed epidural catheter to the mid-thoracic level in neonates. [ABSTRACT FROM AUTHOR]

Abstract Background Epidural administration of local anaesthetic agents provides good intraoperative antinociception for orthopaedic procedures of the pelvis and the pelvic limb. However, in cats the spinal cord extends approximately to the level of the first sacrococcygeal vertebra, and therefore the sacrococcygeal epidural could be a safer alternative to the lumbosacral epidural in cats. This case series describes perioperative analgesia and the haemodynamic status of seven client-owned cats that received sacrococcygeal epidural injection of 0.5% bupivacaine and underwent orthopaedic hind leg or pelvic surgeries under general anaesthesia. Case presentation Each cat received either 0.2 or 0.3 mL/kg of 0.5% bupivacaine with or without 0.2 mg/kg of morphine in the sacrococcygeal epidural space. Intraoperative antinociceptive response to surgical stimulus and haemodynamic changes were monitored and reported. Conclusion In these seven anaesthetised cats, 0.2 or 0.3 mL/kg of 0.5% bupivacaine, administered alone or in combination with morphine into the sacrococcygeal epidural space, enhanced antinociception so that intraoperative rescue analgesia was unnecessary in all but one cat. It also reduced the anticipated requirement for postoperative opioid use. However, a high incidence of hypotension was observed in the cats in this report, and hence intraoperative blood pressure monitoring should be considered mandatory in anaesthetised cats following epidural injection of local anaesthetic agents, regardless of injection site.

Background & Objectives: Caudal epidural and dorsal nerve penile blockade are commonly used for analgesia during and after hypospadias repair in children. Comparative studies to recommend the most effective block are in dearth. This study aims to compare penile block versus caudal block with bupivacaine for hypospadias repair in children in terms of post-operative effectiveness, pain management, and complications. Methodology: The study was conducted on 60 male children, aged 1-9 years, undergoing hypospadias surgery under general anesthesia. The subjects were randomly divided into two groups: (A: caudal block, n=30, and B: penile block, n=30). A postoperative pain assessment was conducted using FLACC scale until 24 hours post-surgery. Results: The patients from the A and B groups were comparable in age, weight, and ASA classification. All patients in the 2 groups did not feel pain post-operatively throughout the first 6 hours. One patient (3.4%) from each of the A and B groups started to feel pain 6 hours, and 9 hours, respectively after surgery. Eight patients (26.7%) in group A and 6 patients (20%) in group B felt pain throughout 6 to 24 hours after surgery. Four patients from group A and 1 patient from group B developed nausea and vomiting during the first 24 hours post-surgery. Conclusion: The penile blockade proved to be more effective in lowering postoperative pain scores, with fewer side effects, thereby decreasing the need for rescue analgesia. [ABSTRACT FROM AUTHOR]

In this case series, we investigated the feasibility of combining ultrasound and neurostimulation for inserting a stimulating epidural catheter in the thoracic epidural space through the caudal route in neonates. Twelve neonates undergoing tracheo-oesophageal fistula repair under general anaesthesia were studied. The catheter was visible on ultrasound as a hyperechoic dot in the epidural space. Inadvertent high placement was identified in two neonates with neurostimulation, in whom the catheter was withdrawn to the thoracic epidural space, and the position was confirmed on ultrasound. A 0.5 ml/kg bolus dose of 0.125% bupivacaine injected through the epidural catheter was imaged in real-time in the epidural space. Block was effective in 10 neonates; two needed an additional local anaesthetic (LA) bolus. To conclude, ultrasound with neurostimulation facilitates accurate positioning of the caudally placed epidural catheter to the mid-thoracic level in neonates.

Background & Objective: The management of lumbar disc herniation (LDH) may involve the surrounding tissues, and attract neovascularization facilitated macrophage aggregates. Epidural triamcinolone might have a half-life ranging from 10−31 days; 80 mg methylprednisolone might improve the pain up to 1 week. The higher doses of steroids will lead to adrenal cortex suppression and osteopenia. We evaluated the effect of treatment with 1500 international unit (IU) hyaluronidase followed by 20 mg triamcinolone at 2 weeks, and 3 and 6 months follow-up. Methodology: We enrolled seven males (38.9%) and 11 females (61.1%) with mean age 44 ± 23 y in the study. Eight (44.44%) subjects were younger than 51 y old, whereas the 10 (55.56%) subjects were ≥ 51 y old. Twelve (66.7%) subjects had had a bulged disc, and 6 (33.3%) subjects had disc protrusion. We injected 1500 international unit (IU) hyaluronidase followed by 20 mg triamcinolone at the site of disc lesion. Pain scores were measured with NRS scale and Oswestry Disability Index (ODI) scores at 2 weeks, and 3- and 6-months follow-up. Results: The NRS score improved at 2 weeks, 40% to 71.43%, at 3 months 60% to 100%, and 6 months 80% to 100%. And the Oswestry Disability Index (ODI) score was improved at 2 weeks from 23.5% to 68.18%), at 3 months from 39.13% to 100%, and at 6 months 82.35% to 100%. A significant association was observed between age older than 50 y old and ODI scores at 2 weeks followed up. Conclusions: The intra-epidural 1500 IU hyaluronidase before triamcinolone brings better results even though using a lower dose of triamcinolone. This approach showed the lower-cost better pain scores as compared to the routine use of heavy doses of triamcinolone for managing bulged and protruding LDH. [ABSTRACT FROM AUTHOR]

Aim: Coccydynia is defined as pain in the area of the coccyx. The initial treatment is conservative therapy, although several interventional treatments can be performed in patients who do not respond well. The purpose of this study is to evaluate the efficacies of ganglion impar blocks and caudal epidural steroid injections in the treatment of coccydynia. Materials and Methods: From January 2019 to June 2021, a retrospective review was conducted on 65 patients who underwent ganglion impar block (n = 25) or ganglion impar block and caudal epidural steroid injection (n = 40) for coccydynia. Pain scores at baseline and at the first and third months after the procedure were compared between two groups. Results: In both groups, a statistically significant decrease was found at the first and third months when post-injection Visual Analog Scale (VAS) scores were compared to the basal VAS scores (p < 0.05). However, no statistically significant difference was found between the groups at the first and third months (p = 0.39 and p = 0.82, respectively). Conclusion: Ganglion impar block is effective for patients with coccydynia in providing pain relief. However, the addition of caudal epidural steroid injection to the ganglion impar block in patients with coccydynia has no additional contribution to pain relief. [ABSTRACT FROM AUTHOR]

Background: Caudal epidural analgesia is a frequently performed regional block in childhood analgesia. However, its effects are limited by short duration of action using local anaesthetics alone. Objective: To evaluate the efficacy of caudal block in children using bupivacaine augmented with clonidine for elective inguinal herniotomy Methodology: This was a cross sectional study of children aged 2-6 years scheduled for elective inguinal herniotomy. Fifty-two children in American Society of Anesthesiologists (ASA) physical status I or II were randomly divided into two groups I(BS) and II(BC) of 26 each. Group I received plain bupivacaine with saline while group II received plain bupivacaine combined with clonidine. The outcome measure assessed was post-operative pain scores using Objective Pain Scale (OPS) and the results were analyzed using SPSS (Statistical Package for Social Sciences version 17 Chicago, Illinois) and presented as mean, frequencies and counts. Parametric data were compared using student's t- test. A p value of < 0.05 was considered significant. Results: The groups were comparable in terms of age, weight and height. The mean duration of analgesia in clonidine group (8.16 ± 1.70 hours) was significantly longer than saline group (4.00 ± 1.41 hours, p=0.001). Pain scores were lower in the clonidine group. There are no significant changes in the haemodynamic variables in both groups. Conclusion: This study demonstrated that the addition of clonidine to plain bupivacaine in a single shot caudal block prolonged the duration of postoperative analgesia without increasing the incidence of side effects. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to compare the effectiveness of caudal epidural with manipulation and ganglion impar block with manipulation in treating patients with coccydynia. Materials and Methods: In this retrospective study, patients (n = 60) were divided into two groups of 30 each. Group C (n = 30) received caudal epidural with transrectal manipulation, whereas Group G (30) received ganglion impar block with transrectal manipulation. Preprocedural and procedural Visual Analog Scale (VAS) scores for 10 days, 1, 3, and 6 months were recorded. Preprocedural painless sitting period and postprocedure painless sitting period in two groups were recorded. Results: Preprocedural VAS score was not statistically significant between the two groups (7.76 ± 0.63 vs. 7.6 ± 0.72; P = 0.16). There was no statistically significant difference in the VAS score after 10 days of the procedure in both the groups. Significant decrease in VAS score was observed in Group G than in Group C after 1, 3, and 6 months of the follow-up. The painless sitting period was increased in Group G than in Group C after 6 months of follow-up (79.33 ± 48.4 min vs. 144.16 ± 37.87 min; P < 0.0001). Recurrence was observed in six patients in Group C. No significant complications were observed in both the groups. Conclusion: Ganglion impar block with manipulation is more effective in improving pain sensation and painless sitting period in patients with coccydynia.

Background: Caudal epidural injection (CEI) is a commonly used procedure to treat back and leg pain secondary to nerve root irritation, predominantly in the context of spinal canal stenosis. Key to a successful outcome is correct needle placement. Although fluoroscopic guidance confirms accurate needle placement, it does not help in determining the starting point, which can lead to multiple needle insertions.Objective: This study aimed to determine the variability in size and position of the sacral hiatus and to identify reproducible surface landmarks to locate its position.Methods and Study Design: 250 human sacral bones were examined, measuring morphology and structure. Vernier callipers accurate to 0.1 mm were used for measurements. Results were analysed using SPSS statistical software.Results: Two specimens were excluded due to agenesis of the hiatus (0.8%). Of the remaining 248 specimens, it was found that the mean internal diameter of the sacral hiatus was 5.12 mm (SD 1.61). The position of the hiatus was variable but was most commonly found at the level of the fourth sacral vertebrae (62.9%, n = 156). Mean distance between the two superolateral sacral prominences was 64.15 mm (SD 6.5) and between superolateral sacral prominences (left and right) and apex of the hiatus were 63.21 mm (SD 10.9) and 63.34 mm (SD 10.87) respectively.Conclusion: Although there is a clear anatomical variance in the position and size of the sacral hiatus, this study suggests that surface anatomy landmarks can be used to form an equilateral triangle of which the inferior apex should correspond to the sacral hiatus. Knowledge of this surface anatomy may assist the correct location of the sacral hiatus and hence subsequently improve the efficacy of CEI. [ABSTRACT FROM AUTHOR]

Background and Aims: Caudal epidural block (CEB) is commonly performed using surface landmark-based technique in the paediatric patients, with a good success rate. Failure to perform CEB is usually attributable to anatomic variations. The aim of this study was to perform measurements of the anatomical landmarks that are generally used to perform CEB and find a relation between these measurements and successful needle placement. Methods: This was an observational study that included 114 patients, aged up to 15 years. Ultrasonography (USG) scan of the sacrococcygeal region with measurement of cornu height, skin to cornu distance, inter-cornu distance (ICD), vertical and oblique size of hiatus were done. Needle placement for CEB was done using the usual palpatory hiatal approach. Needle position was checked by using ultrasound. Spearman correlation coefficient and multi-variate logistic regression were used for measuring the correlation and predictors of correct needle placement, respectively. Results: Correct placement of needle was found in 84% patients. Statistically significant correlation was found between all the anatomical parameters. Regression analysis revealed that only ICD had a statistically significant contribution (OR1.67, 95% CI 1.024-2.7; P = 0.04) in predicting an incorrect needle placement. If ICD was less than 12.5 mm, it predicted a difficult needle placement; all the children were less than 1.5 years in age; AUC was 77%, P = 0.001, sensitivity 83% and specificity 76.5%. Conclusion: ICD can be used as predictor of difficult needle placement for CEB. USG guidance may be of help while performing CEB in children less than 1.5 years. [ABSTRACT FROM AUTHOR]

Context: Regional anesthesia may attenuate adverse physiological stress responses associated with cardiothoracic surgery. In this study, hemodynamic stress response at the different time of surgical stimuli was compared between patients receiving general anesthesia (GA) along with caudal epidural analgesia with GA with intravenous analgesia in pediatric population undergoing open-heart surgery. Aims: This study aims to compare the hemodynamic response at the different time of surgical stimuli and postoperative pain score, in pediatric patients undergoing open-heart procedures. Settings and Design: We designed a prospective randomized controlled trial to study hemodynamic effects between Group I and Group II. Fifty patients were randomly allocated equally into Group I (GA + caudal epidural) and Group II (GA + intravenous analgesia) by sealed envelope technique. Subjects and Methods: After obtaining approval from Institutional Ethical Committee, this prospective study was conducted in 50 American Society of Anesthesiologist Classes II and III pediatric patients aged between 1 and 12 years posted for cardiac surgery in our institution. Statistical Analysis: ANOVA, two-way ANOVA, and Student's test. Results: The heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure variations were compared between Groups I and II at different time intervals. The variations were found to be significantly higher at the time of skin incision and 2 min after skin incision in Group II as compared to Group I. Pain score was compared between the groups and was found to be significantly lower with Group I (2.5 ± 1.2) as compared to Group II (4.6 ± 1.7), P = (0.004). Conclusions: Caudal analgesia with GA (Group I) was found to have better hemodynamic control and significantly better postoperative pain relief in the first 24 h after awakening.

Background: Caudal epidural block combined with general anesthesia remains a popular choice of anesthesia for both supraumbilical and infraumbilical surgeries. More recently transversus abdominis plane block performed under ultrasound guidance is being described as an effective technique for postoperative analgesia for lower abdominal surgeries. The present study aims to compare the efficacy of ultrasound –guided TAP block and caudal epidural for paediatric infraumbilical surgeries. Aims and Objectives: To compare the duration and efficacy of postoperative pain relief between TAP block and caudal epidural block in children undergoing lower abdominal surgeries. Methods: Fifty children of age group 2-7 years undergoing lower abdominal surgeries were randomized to groups T and C. All patients were given general anesthesia as per standardized anesthesia protocol. Group T were given ultrasound guided TAP block with 0.5 ml.kg-1 of 0.2% Ropivacaine. Group C were given 1 ml.kg-1 of 0.2% ropivacaine as caudal block. All the children were assessed using FLACC scale. Their vitals, pain scores, duration of postoperative analgesia and requirement of supplemental analgesics were noted. Results: Rescue analgesic requirement was significantly less in Group T compared to Group C. Mean postoperative analgesia time was significantly more in Group T (342 mins) as compared to Group C (198 mins). Conclusion: Ultrasound guided TAP block provides better postoperative analgesia after loer abdominal surgeries in children. [ABSTRACT FROM AUTHOR]

Caudal anesthesia is commonly used a regional anesthesia technique for sub-umbilical surgeries in pediatrics and for chronic pain management in adults. Ultrasound guided caudal epidural block improves the success rate with minimizes complications. We report a patient who underwent lateral sphincterotomy under ultrasound guided caudal epidural anesthesia and developed transient urinary incontinence with prolonged perineal sensory loss postoperatively. [ABSTRACT FROM AUTHOR]

Background: Lumbar spinal stenosis (LSS) is the most common indication for lumbar surgery in elderly patients. Epidural injections of calcitonin are effective in managing LSS., Objectives: This study aimed to compare the efficacy of transforaminal and caudal injections of calcitonin in patients with LSS., Methods: In this double-blind randomized clinical trial, LSS patients were divided into two equal groups (N = 20). The first group received 50 IU (international units) of calcitonin via caudal epidural injection (CEI), and the second group received 50 IU of calcitonin via transforaminal epidural injection (TEI). The Visual Analogue Scale (VAS) and Oswestry Low Back Pain Disability Questionnaire (ODI) were used to assess the patient's pain and ability to stand, respectively. Visual Analogue Scale and ODI scores were recorded and analyzed., Results: The results showed that caudal and TEIs of calcitonin significantly improved pain and ability to stand during follow-up compared to before intervention (P < 0.05). Additionally, CEI of calcitonin after 6 months significantly reduced pain in LSS patients compared to TEI of calcitonin (P < 0.05). However, no significant difference was observed between the two epidural injection techniques in improving the patient's ability to stand (P > 0.05)., Conclusions: The results of the study indicate that epidural injection of calcitonin in long-term follow-up (6 months) had a significant effect on improving pain intensity and mobility in patients with LSS, and its effect on pain in the TEI method was significantly greater than that in the CEI method., Competing Interests: The authors declared no conflicts of interest., (Copyright © 2024, Rahimzadeh et al.)

Shabana Z Shafy,1 Mohammed Hakim,1 Mauricio Arce Villalobos,1 Gregory D Pearson,2,3 Giorgio Veneziano,1 Joseph D Tobias1,4 1Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Department of Plastic Surgery, Nationwide Children’s Hospital, Columbus, OH, USA; 3Department of Plastic Surgery, The Ohio State University, Columbus, Ohio, USA; 4Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, Ohio, USA Abstract: Duchenne muscular dystrophy (DMD), first described in 1834, is an X-linked dystrophinopathy, leading to early onset skeletal muscle weakness. Life expectancy is reduced to early adulthood as a result of involvement of voluntary skeletal muscles with respiratory failure, orthopedic deformities, and associated cardiomyopathy. Given its multisystem involvement, surgical intervention may be required to address the sequelae of the disease process. We present a 36-year-old adult with DMD, who required anesthetic care during surgical debridement of an ischial pressure sore. Given his significant respiratory muscle involvement, ultrasound-guided caudal epidural anesthesia was used instead of general during the surgical procedure. The technique and its applications are discussed, with particular emphasis on the feasibility and safety of using regional anesthetic techniques in patients with DMD. Keywords: Duchenne’s muscular dystrophy, caudal epidural, regional anesthesia

Introduction: Caudal epidural is a commonly performed regional anesthetic technique in children. In adults, the high-failure rates associated with landmark-based techniques deter its widespread use. Fluoroscopy-guided caudal epidural steroid injections are widely used as a treatment modality in chronic back pain. Ultrasound (US) guidance has been shown to be equally effective as fluoroscopic-guided caudal injections. We aimed to assess the feasibility of US guided caudal epidurals as a sole anesthesia technique in adult patients undergoing minor anorectal procedures. Subjects and Methods: Fifty consecutive adult patients undergoing elective minor anorectal procedures were recruited for this study. Eligible patients received US-guided caudal epidural and success rates, surgical patient and surgeon's comfort were assessed using validated tools. Any adverse events were also observed. Results: The block was successful in all patients. One patient had pain in the perianal region requiring skin infiltration. All patients were either highly satisfied or satisfied of the procedure. Surgeons rated the surgical conditions as highly satisfied (90%), satisfied (8%), or unsatisfied (2%). Two patients rated the caudal injections were of moderate pain, rest all rated it as mildly painful. One patient experienced a single episode of urinary incontinence. Conclusion: US-guided caudal epidural can be considered as an option for anorectal procedures of short duration with acceptable success rates, surgical conditions, and patient comfort. [ABSTRACT FROM AUTHOR]

Context: Pain resulting from failed back surgery syndrome (FBSS) is generally resistant to physiotherapy and pharmacological treatment. Objective: The aim of this study is to evaluate the effect of adding calcitonin to local anesthetic and steroids during ultrasound-guided caudal epidural injection for patients suffering from FBSS. Patients and Methods: Fifty-six patients were randomly allocated into two equal groups. All patients underwent ultrasound-guided caudal epidural injection. Group A received 40 mg (1 mL) methylprednisolone +9 mL lidocaine 0.5% + 1500 iu hyaluronidase in 10 mL normal saline, whereas Group B received 40 mg (1 mL) methylprednisolone +9 mL of 0.5% lidocaine + 1500 iu hyaluronidase in 5 mL normal saline + 50 iu calcitonin in 5 mL normal saline. Results: A statistically significant decrease in visual analog scale, Oswestry Disability Index, and analgesic consumption was recorded in Group B as compared to Group A at 1, 2, and 3 months interval. No side effects were reported in Group A, whereas patients belong to Group B experienced nausea (2 cases), and diuresis for 24 h was detected in two cases. Conclusion: The addition of calcitonin to epidural steroid and local anesthetic injection resulted in better Oswestry disability scale, diminished pain intensity, and less analgesic consumption. [ABSTRACT FROM AUTHOR]

Objective: To compare the analgesic efficacy of transforaminal epidural vs. caudal epidural approaches for unilateral lumbar radiculopathy. Study Design: Quasi experimental study. Place and Duration of Study: Department of Pain Medicine, Combined Military Hospital (CMH) Rawalpindi, from Jul 2017 to Mar 2018. Methodology: Total 96 patients of unilateral radiculopathy were randomly assigned into two equal groups. Group A (n=48) received transforaminal epidural injection of local anesthetic 2.5ml of 0.125% bupivacaine with steroid triamcinolone 40mg and group B received caudal epidural injection Local anesthetic 25ml of 0.125% bupivacaine with triamcinolone 40mg. Pain score was assessed at 0 (PRe procedural baseline), 4, and 12 weeks intervals after intervention by using numerical rating scale and values at 0 and 12 weeks compared for analysis. Results: Mean numerical rating scale pain score in group A and group B were 7.5 ± 0.99 and 3.1 ± 1.6, 7 ± 1.10 and 5.55 ± 1.0 at 0 and 12 week respectively. There was a reduction in mean pain score from baseline to 12 week in both the groups with statistical significance more in group A compared to group B (p<0.05). Conclusion: Pain relief score was found to be statistically significant in transforaminal epidural as compared to caudal epidural for unilateral radiculopathy at 12 weeks post procedure. [ABSTRACT FROM AUTHOR]

Background Caudal epidural anesthesia technique is a relevant method for postoperative analgesia in newborns, allowing for the reduction of drug-induced respiratory depression. The threading of a catheter is, however, uncommon in clinical practice. Our main purpose was to describe our experience regarding caudally inserted epidural catheters in neonates undergoing major abdominal surgery. Methods We included every full-term neonate undergoing surgery under combined caudal epidural-general anesthesia from 2017 to 2022 in our institution. After induction of general anesthesia, an ultrasound-guided caudal epidural injection was performed, and an epidural catheter was inserted for perioperative analgesia. An epidural bolus of ropivacaine was administered to every patient before the surgical incision, and an epidural infusion of ropivacaine 0.05% was administered for 24 hours. Results Retrospectively obtained data included six full-term neonates with American Society of Anesthesiologists (ASA) physical status II to IV. Intraoperatively, good analgesia was achieved without hemodynamic instability or need for additional systemic opioids after induction. At the end of surgery, five of the six neonates were extubated without adverse respiratory events. Postoperatively, effective analgesia was achieved in four cases with an epidural infusion of ropivacaine 0.05%, at a rate between 0.2 and 0.4 mg/kg/h, and intravenous paracetamol. Epidural pain control was not successful in one neonate, and thus an intravenous fentanyl infusion was added. The sixth neonate remained intubated for prolonged mechanical ventilation due to surgical complications, and thus an intravenous fentanyl infusion was introduced for sedation in the neonatal intensive care unit (NICU), not allowing to evaluate the effectiveness of the epidural infusion alone. No other complications related to the epidural catheters were reported. Conclusion Continuous caudal epidural analgesia may be a valuable technique with a low risk of complications, decreasing the incidence of respiratory adverse events in this patient population. Although more cases are needed for a stronger conclusion, it has become a useful analgesic strategy for major abdominal surgery in neonates in our institution., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Portela et al.)

Context: Regional anesthesia may attenuate adverse physiological stress responses associated with cardiothoracic surgery. In this study, hemodynamic stress response at the different time of surgical stimuli was compared between patients receiving general anesthesia (GA) along with caudal epidural analgesia with GA with intravenous analgesia in pediatric population undergoing open-heart surgery.Aims: This study aims to compare the hemodynamic response at the different time of surgical stimuli and postoperative pain score, in pediatric patients undergoing open-heart procedures.Settings and Design: We designed a prospective randomized controlled trial to study hemodynamic effects between Group I and Group II. Fifty patients were randomly allocated equally into Group I (GA + caudal epidural) and Group II (GA + intravenous analgesia) by sealed envelope technique.Subjects and Methods: After obtaining approval from Institutional Ethical Committee, this prospective study was conducted in 50 American Society of Anesthesiologist Classes II and III pediatric patients aged between 1 and 12 years posted for cardiac surgery in our institution.Statistical Analysis: ANOVA, two-way ANOVA, and Student's test.Results: The heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure variations were compared between Groups I and II at different time intervals. The variations were found to be significantly higher at the time of skin incision and 2 min after skin incision in Group II as compared to Group I. Pain score was compared between the groups and was found to be significantly lower with Group I (2.5 ± 1.2) as compared to Group II (4.6 ± 1.7), P = (0.004).Conclusions: Caudal analgesia with GA (Group I) was found to have better hemodynamic control and significantly better postoperative pain relief in the first 24 h after awakening. [ABSTRACT FROM AUTHOR]

Background: regional anaesthesia techniques are now established in the practice of pediatric anaesthesia. it is one of the most common techniques used for post-operative pain management in pediatric patients especially for urogenital, rectal, inguinal and lower extremity surgeries. Objective: to compare caudal and spinal anaesthesia in paediatrics regarding haemodynamics, efficacy (sensory block characteristics, motor block characteristics) post operative analgesia, surgeon's satisfaction, parents' satisfaction and complications incidence. Material and Methods: the present study was carried on100 patients, with age ranging from (6-12) and of ASA (american society of anaesthesia.) I, II classes undergoing infraubmliclal pediatric surgeries, patients in each group were randomly assigned to receive spinal or caudal epidural anaesthesia. Results: the demographic data of patients as regard age, sex and ASA classification showed no statistical significant difference between the two groups, where the study was designed to compare between the effectiveness of spinal anaesthesia with bupivacaine 0.3mg/kg and caudal anaesthesia with bupivacaine 2mg/kg(1ml/kg vol.) as a sole anaesthetic technique adequate for infraumblical pediatric surgeries below T10 as regard the sensory and motor block characteristics, perioperative haemodynamic effects, pain assessment, analgesic requirements, and both the surgeon ad parents satisfaction was assessed.the results showed the superiority of subarachnoid on achieving rapid onset of sensory blockade, intense motor blockade, on the other hand the caudal epidural had the advantage of longer post operative analgesic effect and lower post operative analgesic consumption, furthermore both techniques gained good degree of parent and surgeon satisfaction. Conclusion: if both techniques are correctly used and the anatomy of the patient is normal there is minimal risk of complications. [ABSTRACT FROM AUTHOR]

Background: To reduce intraoperative use of volatile anesthetics, a successful caudal blockade affords the anesthesiologist this opportunity. The use of a narcotic-sparing approach may benefit the patient, with providing a better postoperative course with less nausea. Aim of the work: To compare the effects of plain levobupivacaine 0.25% 1 ml/kg and levobupivacaine 0.25% 1 ml/kg plus nalbuphine 0.1 mg/kg single-shot caudal epidural for perioperative pain relief in children undergoing surgeries of lower half of the body. Patients and methods: The study was conducted in Abou El-Reesh pediatric hospital, Cairo University, after approval of ethical committee and obtaining consent from parents on 40 patient aged 1–9 years scheduled for surgeries of lower half of the body. (Group L, n = 20): Caudal block was done in this group using levobupivacaine 0.25% with the dose of 1 ml/kg after induction of general anesthesia. (Group L + N, n = 20): Caudal block was done in this group using levobupivacaine 0.25% with the dose of 1 ml/kg and nalbuphine 0.1 mg/kg after induction of general anesthesia. Results: The time to first analgesia was significantly longer in Group L + N (P

Background: There continues to be a significant focus on the value of regional and neuraxial anesthesia techniques for adjunctive use when combined with general anesthesia. The reported advantages include decreased patient opiate exposure, decreased medication-related adverse effects, decreased postanesthesia recovery room time and hospital stay, and increased patient satisfaction. Materials and Methods: The authors present a case-controlled series evaluating the use of a single caudal epidural injection prior to incision as an adjunct to general anesthesia for the open repair of slipped capital femoral epiphysis. Opiate consumption, pain scores, and hospital stay were compared between the two cohorts of 16 adolescent patients. All patients received a demand-only patient-controlled opiate delivery system. Results: Although the failed block rate was high (31%), there was decreased opioid use in the perioperative arena as well as during the first 24 postoperative hours in patients who had a successful caudal epidural block. Furthermore, discharge home was possible in 27% of patients who received a caudal epidural block compared to 0% of patients who did not receive a caudal block. Conclusion: The potential utility of caudal epidural block as an adjunct to general anesthesia during major hip surgery in adolescents is presented. Factors resulting in a failed block in this patient population as well as the use of the ultrasound as an added modality to increase block success are reviewed.

Background: regional anaesthesia techniques are now established in the practice of pediatric anaesthesia. It is one of the most common techniques used for post-operative pain management in pediatric patients especially for urogenital, rectal, inguinal and lower extremity surgeries. Objective: to compare caudal and spinal anaesthesia in paediatrics regarding haemodynamics, efficacy (sensory block characteristics, motor block characteristics) post-operative analgesia, surgeon's satisfaction, parents' satisfaction and complications incidence. Material and Methods: the present study was carried on100 patients, with age ranging from (6-12) and of ASA(american society of anaesthesia.) I, II classes undergoing infraubmliclal pediatric surgeries, patients in each group were randomly assigned to receive spinal or caudal epidural anaesthesia. Results: the demographic data of patients as regard age, sex and ASA classification showed no statistical significant difference between the two groups, where the study was designed to compare between the effectiveness of spinal anaesthesia with bupivacaine 0.3mg/kg and caudal anaesthesia with bupivacaine 2mg/kg(1ml/kg vol.) as a sole anaesthetic technique adequate for infraumblical pediatric surgeries below T10 as regard the sensory and motor block characteristics, perioperative haemodynamic effects, pain assessment, analgesic requirements, and both the surgeon ad parents satisfaction was assessed.the results showed the superiority of subarachnoid on achieving rapid onset of sensory blockade, intense motor blockade, on the other hand the caudal epidural had the advantage of longer post-operative analgesic effect and lower post-operative analgesic consumption, furthermore both techniques gained good degree of parent and surgeon satisfaction. Conclusion: if both techniques are correctly used and the anatomy of the patient is normal there is minimal risk of complications. [ABSTRACT FROM AUTHOR]

Background & Objectives: Caudal epidural block is one of the safe, reliable and effective technique in pediatric patients but single shot caudal epidural block has short duration of analgesia that can be prolonged by addition of adjuvants like opioids, clonidine, neostigmine, ketamine ora 2 agonists along with local anesthetic agents. This prospective randomized study was conducted to assess the efficacy of addition of dexmedetomidine (1µg/kg) to caudal 0.25% ropivacaine (1ml/kg) for postoperative analgesia. Methodology: Sixty American Society of Anesthesiologists physical status I and II pediatric patients aged 6 months to 6 years were randomly allocated into two groups with 30 patients in each group: Group R (n = 30) received caudal 0.25% ropivacaine 1 ml/kg and normal saline (0.5 ml) while Group RD received caudal 0.25% ropivacaine 1 ml/kg + dexmedetomidine 1 µg/kg (0.5 ml). Postoperative pain (FLACC pain score), duration of analgesia, rescue analgesic requirement, postoperative sedation scores, and hemodynamic changes along with complications were recorded. Results: The duration of analgesia was significantly longer in Group RD (797.00 ± 59.20 min) compared to Group R (363.30 ± 31.44 min), (p < 0.0001). The total number of doses of rescue analgesic required were lesser in Group RD in comparison to Group R. The patients in Group RD achieved higher sedation scores than Group R, which was highly significant (p < 0.0001). In adverse effects, the incidence of postoperative agitation (6.66%), and PONV (3.33%) were seen only in Group R when compared to Group RD. Conclusion: Dexmedetomidine (1 µg/kg) can be used as an adjuvant to single shot caudal epidural using 0.25% ropivacaine (1 ml/kg) for effective postoperative analgesia in pediatric patients as it significantly prolonged the duration of analgesia along with reduced rescue analgesic requirement and minimal side effects. [ABSTRACT FROM AUTHOR]

Background: Caudal epidural analgesia is a proven technique for providing analgesia for spinal surgeries. Prolonged pain relief with no motor blockade is desired for early mobilization. Objective: The objective of this study is to compare the effect of adding 1 µg/kg of clonidine to injection ropivacaine 0.2% with respect to duration of analgesia, hemodynamic effects, and associated side effects. Methodology: In this prospective double-blind study, a total of 60 patients undergoing lumbosacral spine surgery were randomized to receive 25 cc caudal epidural injection of either injection ropivacaine 0.2% (Group R, n = 30) or a mixture of injection ropivacaine 0.2% and injection clonidine 1 µg/kg (Group RD, n = 30) under general anesthesia after the patient was positioned prone for surgery. Visual analog scale (VAS) scores, heart rate, blood pressures, and time to rescue analgesia and sedation score were recorded at regular intervals for the first 24 h. Results: Mean VAS scores were significantly lower in the RC Group for up to 12 h following the caudal block. The time to first rescue analgesic was prolonged in the RC group compared to the R Group, and it was statistically significant. No clinically significant hemodynamic changes were noted in either of the groups. No other side effects were seen in both the groups. Conclusion: These results suggest that injection clonidine is an effective additive to injection ropivacaine for caudal epidural analgesia in lumbosacral spine surgeries. [ABSTRACT FROM AUTHOR]

Background Chronic lumbar radiculopathy has a lifetime prevalence of 5.3% in men and 3.7% in women. It usually resolves spontaneously, but up to 30% cases will have pronounced symptoms even after one year. Aims A prospective randomized single-blind study was conducted to compare the efficacy of caudal epidural steroid injection and selective nerve root block in management of pain and disability in cases of lumbar disc herniation. Methods Eighty patients with confirmed single-level lumbar disc herniation were equally divided in two groups: (a) caudal epidural and (b) selective nerve root block group, by a computer-generated random allocation method. The caudal group received three injections of steroid mixed with local anesthetics while selective nerve root block group received single injection of steroid mixed with local anesthetic agent. Patients were assessed for pain relief and reduction in disability. Results In SNRB group, pain reduced by more than 50% up till 6 months, while in caudal group more than 50% reduction of pain was maintained till 1 year. The reduction in ODI in SNRB group was 52.8% till 3 months, 48.6% till 6 months, and 46.7% at 1 year, while in caudal group the improvement was 59.6%, 64.6%, 65.1%, and 65.4% at corresponding follow-up periods, respectively. Conclusions Caudal epidural block is an easy and safe method with better pain relief and improvement in functional disability than selective nerve root block. Selective nerve root block injection is technically more demanding and has to be given by a skilled anesthetist. [ABSTRACT FROM AUTHOR]

The aim of the study was to evaluate the efficacy of clonidine in association with fentanyl as an additive to bupivacaine 0.25% given via single shot caudal epidural in pediatric patients for postoperative pain relief. In the present prospective randomized double blind study, 40 children of ASA-I-II aged 1-5 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either bupivacaine 0.25% (1 ml/kg) with fentanyl 1 g/kg and clonidine 1g/kg (group I) or bupivacaine 0.25% (1 ml/kg) with fentanyl 1 g/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamic parameters, and side effects or complications.Both the groups were similar with respect to patient and various block characteristics. Heart rate and blood pressure were not different in 2 groups. Significantly prolonged duration of post-operative analgesia was observed in group I (P=0.05). Side effects such as respiratory depression, vomiting and bradycardia were similar in both groups. The adjunction of clonidine to fentanyl as additives to bupivacaine in single shot caudal epidural in children may provide better and longer analgesia after infraumblical surgical procedures.

Background: The aim of the study was to compare the efficacy of clonidine and fentanyl as an additive to ropivacaine given via single shot caudal epidural in pediatric patients for postoperative pain relief. Materials and Methods: In the present double blind study, 90 children of ASA-I-II aged 3-8 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either ropivacaine 0.25% 1 ml/kg+clonidine 2 μg/kg (group I) or ropivacaine 0.25% 1 μl/kg+fentanyl 1 μg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamics, and side effects/complications. Results: Both the groups were similar with respect to patient and various block characteristics. The analgesic properties and hemodynamics were also comparable in both groups (P > 0.05). Side effects such as respiratory depression, vomiting bradycardia were significantly less in group I than group II (P < 0.05) ensuing more patient comfort. Conclusions: The analgesic properties of clonidine and fentanyl as additives to ropivacaine in single shot caudal epidural in children are comparable but clonidine offers a more favorable side effect profile. The use of clonidine as additive to ropivacaine in caudal epidural is superior choice to fentanyl because of lack of unwanted side effects and increased patient comfort.

We evaluated the analgesic efficacy, hemodynamic and respiratory safety of Clonidine when added to bupivacaine for caudal block. Forty children undergoing inguinal hernia repair were randomly given caudal injection with 0.75 ml.kg -1 of bupivacaine (0.25%) and clonidine 2 µg.kg -1 in Group C or 0.75 ml.kg -1 of bupivacaine (0.25%) alone in Group B after induction of anaesthesia. Postoperatively duration of analgesia, OPS score (observational pain / dis-comfort scale), Sedation score, heart rate and blood pressure were recorded. Duration of analgesia was significantly longer (p< 0.001) in Group C (10.25 hours) as compared to 4.55 hours in Group B. Bradycardia, hypotension and sedation were not observed in Group C. The addition of Clonidine in caudal blocks prolongs postoperativepain relief in children and is safe alternative to bupivacaine alone in paediatric daycare surgeries.

Background Caudal epidural block is commonly used as a safe, reliable, easy-to-administer technique for abdominal and lower limb surgeries in pediatric patients and allows rapid recovery from anesthesia with effective postoperative analgesia. The aim of our study was to compare the efficacy of clonidine versus fentanyl when used as an additive to ropivacaine during single-shot caudal epidural analgesia in pediatric patients for postoperative pain relief. Patients and methods This randomized prospective double-blind study was conducted on 60 children of American Society of Anesthesiologists grades I and II aged 1-7 years scheduled for various infraumbilical surgical procedures who were randomly allocated into two groups to receive either ropivacaine (0.25%, 1 ml/kg) and clonidine (2 μg/kg) (group RC) or ropivacaine (0.25%, 1 ml/kg) and fentanyl (1 μg/kg) (group RF). Caudal epidural block was performed after induction of general anesthesia. Postoperatively, patients were observed for duration of analgesia, sedation score, recovery time, hemodynamics, and side effects or complications. Results Both groups were similar with respect to patient's demographic profile, baseline hemodynamic parameters, and duration of surgery. The analgesic properties and hemodynamics were also comparable in both groups (P>0.05). The mean recovery time and sedation score were significantly lower in group RC as compared with group RF (P<0.05). Side effects such as nausea, vomiting, and respiratory depression were seen only in group RF. Conclusion From our study we concluded that both clonidine (2 μg/kg) and fentanyl (1 μg/kg) can be used as an adjuvant to single-shot caudal epidural anesthesia using 0.25% ropivacaine for effective postoperative analgesia in children. Because of its more favorable side-effect profile, with less respiratory depression, nausea, vomiting, and more patient comfort, clonidine is a better choice for use as an adjuvant to caudal epidural anesthesia in children. [ABSTRACT FROM AUTHOR]

Background: Efficacy of caudal bupivacaine plus ketamine on postoperative pain in children. Aims: The aim of this study was to compare the analgesic efficacy and safety of caudal block with mixture of bupivacaine and ketamine to bupivacaine alone for postoperative analgesia in pediatric patients undergoing infraumbilical surgery. Settings and Design: A prospective randomized study was conducted in a tertiary care teaching hospital. Statistical Analysis: Data were collected; mean value and standard deviation were computed for age, weight, duration of surgery, and duration of analgesia. Then, the mean values of the two groups were compared using ANOVA. P < 0.05 was considered statistically significant. Materials and Methods: A total of 60 American Society of Anesthesiologists I and II pediatric patients of either sex, aged 1-10 years, undergoing herniotomy, orchidopexy, and urethroplasty were randomly allocated to receive one of the two analgesic regimens. Group A (30 patients) received caudal bupivacaine 0.25% in a dose of 1 ml/kg, and Group B received caudal block with 0.25% bupivacaine 1 ml/kg and preservative-free ketamine 0.5 mg/kg; duration of analgesia was recorded by objective pain scale to equate pain and discomfort in young children with changes in standardized behavioral and physiological parameters. Results: Mean duration of analgesia in Group A was 5.63 ± 0.98 h while the mean duration of analgesia in Group B was 10.18 ± 2.24 h with P < 0.001. There were no differences between groups in the incidence of motor block and side effects. Conclusion: On the basis of results derived from this study, it is concluded that addition of ketamine 0.5 mg/kg to caudal bupivacaine 0.25% in a dose of 1 ml/kg significantly prolonged the postoperative analgesia compared with administration of caudal bupivacaine 0.25% in a dose of 1 ml/kg alone. [ABSTRACT FROM AUTHOR]

The aim of the study was to evaluate the efficacy of clonidine in association with fentanyl as an additive to bupivacaine 0.25% given via single shot caudal epidural in pediatric patients for postoperative pain relief. In the present prospective randomized double blind study, 40 children of ASA-I-II aged 1-5 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either bupivacaine 0.25% (1 ml/kg) with fentanyl 1 µg/kg and clonidine 1µg/kg (group I) or bupivacaine 0.25% (1 ml/kg) with fentanyl 1 µg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamic parameters, and side effects or complications. Both the groups were similar with respect to patient and various block characteristics. Heart rate and blood pressure were not different in 2 groups. Significantly prolonged duration of post-operative analgesia was observed in group I (P<0.05). Side effects such as respiratory depression, vomiting and bradycardia were similar in both groups. The adjunction of clonidine to fentanyl as additives to bupivacaine in single shot caudal epidural in children may provide better and longer analgesia after infraumblical surgical procedures. [ABSTRACT FROM AUTHOR]

Background To reduce intraoperative use of volatile anesthetics, a successful caudal blockade affords the anesthesiologist this opportunity. The use of a narcotic-sparing approach may benefit the patient, with providing a better postoperative course with less nausea. Aim of the work To compare the effects of plain levobupivacaine 0.25% 1 ml/kg and levobupivacaine 0.25% 1 ml/kg plus nalbuphine 0.1 mg/kg single-shot caudal epidural for perioperative pain relief in children undergoing surgeries of lower half of the body. Patients and methods The study was conducted in Abou El-Reesh pediatric hospital, Cairo University, after approval of ethical committee and obtaining consent from parents on 40 patient aged 1–9 years scheduled for surgeries of lower half of the body. (Group L, n = 20): Caudal block was done in this group using levobupivacaine 0.25% with the dose of 1 ml/kg after induction of general anesthesia. (Group L + N, n = 20): Caudal block was done in this group using levobupivacaine 0.25% with the dose of 1 ml/kg and nalbuphine 0.1 mg/kg after induction of general anesthesia. Results The time to first analgesia was significantly longer in Group L + N ( P < 0.01) than that in the other group. The mean time for first rescue analgesia was 5.9 ± 1.0 h in Group L compared to that in Group L + N, which was 11.2 ± 1.6 h. Comparing the pain scores (AIIMS pain score) of the two groups at 2, 4, 6, 12 and 24 h postoperatively revealed that there was significant difference between Group L + N and Group L at 4, 6 and 12 h with higher pain scores in the (Group L) than in the other Group (L + N). This shows that the duration of analgesia in the (L + N) group was longer than the other group. The results show there was difference in the sedation score between the two groups in the 1st hour postoperative. The L + N group had higher sedation scores at 30 min and at 1 h postoperative. Conclusion Caudal epidural nalbuphine is safe in pediatric surgeries including the lower half of the body and effectively reduces postoperative pain. However it may cause early postoperative sedation, yet without respiratory depression. [ABSTRACT FROM AUTHOR]

Objective: To (a) evaluate the feasibility of MR epidurography (MRE) and (b) assess the distribution of injectate using two different volumes at caudal epidural steroid injection. Materials and methods: Twenty patients who were referred with symptomatic low back pain for caudal epidural steroid injection were assigned to have either 10 ml (9/20) or 20 ml (11/20) of injectate administered. Gadolinium was included in the injection. The patients proceeded to MRI where sagittal and coronal T1-weighted fat-saturated sequences were acquired and reviewed in the mid-sagittal and right and left parasagittal views at the level of the exit foramina. Results: Gadolinium was observed at or above the L3/4 disc level in all 11 patients who received 20 ml (100 %), compared with only five of nine patients who received 10 ml (56 %). Injectate was seen to the L4 nerve root level in all 11 patients who received 20 ml (100 %) but only four out of nine patients who received 10 ml (44 %), not even reaching the L5 nerve root level in four further of these nine patients (44 %). Overall, there was a trend to visualize gadolinium at higher levels of the epidural space with higher volumes injected. Conclusions: Firstly, MR epidurography is a safe technique that allows excellent visualization of the distribution of gadolinium in the epidural space following injection via the caudal hiatus. Secondly, a volume of 10 ml is unlikely to treat L5/S1 disease in almost half of patients at caudal epidural steroid injection and at least 20 ml of injectate is likely required for any medication to reach the desired level. [ABSTRACT FROM AUTHOR]

Background: There continues to be a significant focus on the value of regional and neuraxial anesthesia techniques for adjunctive use when combined with general anesthesia. The reported advantages include decreased patient opiate exposure, decreased medication-related adverse effects, decreased postanesthesia recovery room time and hospital stay, and increased patient satisfaction. Materials and Methods: The authors present a case-controlled series evaluating the use of a single caudal epidural injection prior to incision as an adjunct to general anesthesia for the open repair of slipped capital femoral epiphysis. Opiate consumption, pain scores, and hospital stay were compared between the two cohorts of 16 adolescent patients. All patients received a demand-only patient-controlled opiate delivery system. Results: Although the failed block rate was high (31%), there was decreased opioid use in the perioperative arena as well as during the first 24 postoperative hours in patients who had a successful caudal epidural block. Furthermore, discharge home was possible in 27% of patients who received a caudal epidural block compared to 0% of patients who did not receive a caudal block. Conclusion: The potential utility of caudal epidural block as an adjunct to general anesthesia during major hip surgery in adolescents is presented. Factors resulting in a failed block in this patient population as well as the use of the ultrasound as an added modality to increase block success are reviewed. [ABSTRACT FROM AUTHOR]

Objective To compare anti-nociceptive and sedative effects of tramadol, a combination of tramadol-lidocaine, and lidocaine alone for perineal analgesia in donkeys. Study design Experimental 'blinded' randomized cross-over study. Animals Six healthy adult donkeys. Methods Treatments were tramadol ( TR) (1.0 mg kg−1), tramadol-lidocaine ( TRLD) (0.5 and 0.2 mg kg−1 respectively) and lidocaine ( LD) (0.4 mg kg−1) given into the epidural space. The volume of all treatments was 0.02 mL kg−1. Nociception was tested at the perineal region by pin prick, followed, if no reaction, by pressure from a haemostat clamp. Times to onset, degree and duration of anti-nociception of the perineal region were recorded. Response was tested immediately after drug administration and at: 2, 5, 10, 15, 30, 45, and 60 minutes post-administration and then at 30 minute intervals thereafter until a response re-occurred. Physiologic data and degree of sedation and ataxia were recorded pre-administration and at intervals for 240 minutes post-administration. Results were analyzed using anova, Kruskal- Wallis tests, and Wilks' Lambda test as relevant. Significance was taken as p < 0.05. Results Times (minutes, mean ± SD) to onset and duration of anti-nociception, respectively were; TR 13 ± 1.6 and 220 ± 4.6; TRLD 6 ± 0.8 and 180 ± 8.5; LD 4 ± 1.4 and 75 ± 4. Onset and duration times were significantly longer with TR than the other two treatments. TR never produced complete anti-nociception, whereas the TRLD and LD induced complete anti-nociceptive effects. Duration was significantly longer with TRLD than with LD alone. Epidural injections of TR and TRLD induced mild sedation. Conclusions and clinical relevance Epidural combination of TRLD produced an anti-nociceptive effect in the perineum, which was rapid in onset and had a longer duration of action than LD alone. An epidural single dose of TRLD combination would appear to provide an acceptable analgesic effect in the perineal region of donkeys. [ABSTRACT FROM AUTHOR]