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The aim of the study was to evaluate the effectiveness of midazolam in combination with lidocaine to induce caudal analgesia and cervical dilation to facilitate endometrial biopsy procedures. Eighteen mares undergoing endometrial biopsy were randomly allocated to three treatments groups that received epidural anesthesia (n = 6): 0.9% saline solution (SS) (6 mL, control group); midazolam maleate (MID) (0.05 mg/kg); and midazolam maleate (0.05 mg/kg) plus 2% lidocaine (MIDLID) (0.1 mg/kg). Systemic parameters, behavior, and motor blockade were measured at baseline and at 10, 30, and 60 minutes after treatments. A subjective score system was used to assess pain and cervical dilation during the reproductive procedures at the same time points. Satisfactory analgesia was recorded for both epidural midazolam treatment groups 8 ± 4 minutes postadministration of the drug; analgesia remained satisfactory until the end of the trial period (60 minutes, P > .05). All animals in the control group showed evident pain ( P = .001) due to the analgesic tests and reproductive procedures. Cervical dilation ( P = .0001) occurred 20 minutes after epidural injections for both treatment groups with midazolam, but this effect did not occur in the control treatment group. Systemic effects were not observed ( P > .05) in baseline values or among treatment groups following caudal epidural administration of midazolam or midazolam/lidocaine treatments. Epidural analgesia using midazolam alone or the combination of midazolam and lidocaine may be a good alternative for painful reproductive and gynecologic procedures in mares.

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.

SummaryWe report a case of a premature neonate born at 34 weeks and operated at 6 weeks of age developing unexplained seizures 10 hours after the end of surgery under single shot caudal epidural analgesia with bupivacaine and lidocaine combined with general anesthesia.

Summary Background and objectives Caudal epidural anesthesia is the most popular regional anesthesia technique used in children. With advanced age, only the relative difficulty in localizing the sacral hiatus limits its use. However, in adults this technique has been widely used to control chronic pain by adjuvant use of fluoroscopy. Thus, the ability to locate the hiatus and define anatomical variations is the main determinant of the success and safety of caudal epidural anesthesia. In this context, the use of the ultrasound in caudal epidural anesthesia has been increasing. The objective of this review was to determine the role of the ultrasound in caudal epidural anesthesia and to demonstrate that this technique, widely used in children, is also useful and can be used in adults. Content A review of the literature on sacral anatomy and the anesthetic technique necessary to perform caudal epidural anesthesia was undertaken. Recent studies in ultrasound-guided caudal epidural anesthesia both in children and adults were also included. Conclusions Despite its limitations, the ultrasound can be a useful tool to position the needle in the caudal space. It allows prompt identification of the sacral anatomy and real-time visualization of the injection. Considering it is portable, non-invasive, and free of radiation exposure, it is an attractive technique in the operating room especially in difficult cases. However, since its use in neuroaxis anesthesia is very primitive, more studies are necessary to make it a routine technique in anesthetic practice.

The objective of this study was to investigate the cardiopulmonary effects of dorsal recumbency and high-volume caudal epidural anaesthesia induced by xylazine or lidocaine in calves. Twenty-eight German Holstein-Friesian calves (57.7 ± 5.8 kg bodyweight) were randomly allocated to four equal (n=7) groups for one of the following treatments, each injected into the caudal epidural space: (1) no treatment (control); (2) sterile saline (0.4 mL/kg); (3) lidocaine (2%), or (4) xylazine (0.1mg/kg), with the latter two treatments diluted with sterile saline to a final volume of 0.4 mL/kg. Cardiac output was measured by thermodilution and cardiopulmonary function parameters were determined at preset time intervals over an observation period of 335 min. After baseline measurements in the standing animals, the calves received the epidural injection and were positioned in dorsal recumbency for 95 min. In the control group, dorsal recumbency caused a significant (P0.05) decrease in cardiac index (CI) (baseline 210 ± 12 mL/kg/min, minimum value 174 ± 11 mL/kg/min), without significant change in blood-gas values. Calves treated with lidocaine or saline did not differ from the control group in any of the parameters measured. The epidural injection of xylazine caused a more pronounced decrease in CI (baseline 209 ± 12 mL/kg/min, minimum value 127 ± 11 mL/kg/min), compared to the control group. At the same time, the heart rate was significantly (P0.05) decreased (baseline 113 ± 7 beats per min, minimum value 86 ± 4 beats per min). Furthermore, a significant (P0.05) increase in the oxygen extraction ratio was observed in the xylazine group (baseline 39 ± 7%, maximum value 47 ± 7%). In all groups, cardiorespiratory parameters remained within physiological limits. Changes in cardiopulmonary function induced by dorsal recumbency and high-volume caudal epidural anaesthesia with lidocaine or xylazine were well tolerated in healthy calves.

Introduction/Background Degenerative lumbar spinal stenosis (DLSS) is a common source of pain and disability in the elderly population. Epidural steroid injections are often used to treat lumbosacral radiculopathy in DLSS. There is paucity of clinical trials comparing caudal epidural steroid injections plus local anaesthetics with conservative treatment. Moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice. So, the aim of this study was to compare the effects of conservative treatment (physical therapy) and caudal epidural steroid injection with physical therapy in patients of DLSS (grade A and B). Material and method An Open Label, Parallel randomized controlled trial was conducted from January 2016–August 2017 and patients fulfilling the inclusion criteria were enrolled after written informed consent. The Trial was registered under the Clinical Trial Registry of India (CTRI). Patients were randomized in two groups–32 in Intervention Group A (caudal epidural steroid injection with physical therapy) and 32 in Control Group B (physical therapy only) with concealed allocation method. The outcome was assessed by Numerical Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), standing tolerance test and walking tolerance test at 3, 6, 12 and 24 weeks. Results Significant improvement in NPRS, ODI and standing tolerance test was observed at 3, 6 and 12 weeks (Group A > > Group B). Equivocal effect in NPRS and ODI was seen at 24 weeks (Group A ∼ Group B). Improvement in mean claudication distance was seen at each follow up from baseline (Group A > > Group B). The probability of improvement in intervention group (A) was more than in control group (B). Conclusion Epidural steroid administration improved pain, physical ability and claudication distance (> 200 meters) at 12 weeks aiding an early return to routine activities. Physical therapy also shows clinical improvement in patients of DLSS and can be an appropriate treatment modality.

Chen CP, Wong AM, Hsu C-C, Tsai W-C, Chang C-N, Lin S-C, Huang Y-C, Chang C-H, Tang SF. Ultrasound as a screening tool for proceeding with caudal epidural injections. Objective To study the anatomical structure of the sacral hiatus using ultrasound. Based on the sonographic images of the sacral hiatus, the feasibility of caudal epidural injection can then be assessed. Design Case-controlled study. Setting Rehabilitation outpatient clinic in a tertiary medical center. Participants Patients (N=47; 20 women, 27 men) with low back pain and sciatica who were to receive caudal epidural injection treatments were recruited into this study. Interventions Sonographic images of the sacral hiatus were obtained from all the patients. An ultrasound machine capable of examining musculoskeletal tissues with real-time linear-array ultrasound transducer was used to measure the distance between the anterior wall and posterior wall of the sacral hiatus (diameter of the sacral hiatus) and the distance between bilateral cornua. Main Outcome Measures Diameter of the sacral canal and distance between bilateral cornua measured in millimeters. Results The mean diameter of the sacral canal was measured to be 5.3±2.0mm in our recruited patients. The mean distance between bilateral cornua was measured to be 9.7±1.9mm. Caudal epidural injections failed in 7 patients. In these 7 patients, 4 had very small diameter of the sacral canal (1.6, 1.2, 1.4, and 1.5mm). In 1 man, sonographic images revealed a closed sacral hiatus (no sacral canal diameter can be measured). Two patients revealed flow of fresh blood into the syringe while checking for the escape of cerebrospinal fluid after the needles were inserted into the sacral canal. For safety reasons, steroid injections were not performed in these 2 patients. Conclusions Ultrasound may be used as an effective screening tool for caudal epidural injections. Anatomic variations of the sacral hiatus can be clearly observed using ultrasound. Sonographic images indicating a closed sacral canal and sacral diameters ranging from 1.2 to 1.6mm may suggest a higher failure rate in caudal epidural injection.

Epidural steroid injections (ESIs) are routinely used for the treatment of a variety of spinal ailments. Various methods for accessing the epidural space have been described over the decades. In the recent past, more and more emphasis has been on targeted delivery of drugs to the site of pain generation. Techniques differ according to the level of epidural space accessed. Use of fluoroscopic guidance can provide the most precise delivery of the drug. Although relatively safe, these injections can lead to morbidity and mortality if performed in a wrong manner. Several reports have been published recently describing disastrous results from transforaminal injections in the cervical spine. The importance of monitoring the spread of the injectate with injection of radio-opaque contrast material cannot be underestimated. The following chapter will summarize these techniques and highlight various technical considerations for the epidural injections.

Caudal epidural steroid injection and sacroiliac joint injection are two very commonly employed interventions at any pain clinic. These injections are traditionally performed under fluoroscopic guidance, but recently the use of ultrasound (US) guidance has been reported. We will review the relevant anatomy, sonoanatomy, and the US-guided technique.

This study was performed to compare the onset and duration of analgesia produced by either a lidocaine−MgSO4 or lidocaine−distilled water combination administration in the caudal epidural space of horse. Seven healthy adult horses, aged 11.7 ± 1.4 years (mean ± SD), body weight (kg) 567 ± 32.5 (mean ± SD), were selected for this study. Caudal epidural anesthesia was produced in all horses by administering 2% lidocaine (0.22 mg/kg) diluted in 1 mL distilled water and repeated with 2% lidocaine (0.22 mg/kg) diluted in 1 mL 10% MgSO4 2 weeks later. Time to onset (minutes), duration (minutes), and cranial spread of epidural analgesia were recorded. Heart rate (HR), respiratory rate (RR), and body temperature (°C) were recorded. Measurements were taken at 0 (as a baseline value before epidural administrations) and at 5, 10, 15, 30, 60, and 75 minutes after the epidural administrations of each treatment. Statistical analyses included paired Student t test and analysis of variance (computer program SPSS, Analytical Software, version 15.00). Statistical significance was set at P

Objective Low back pain is a highly common problem and causes much morbidity and socioeconomic loss in the community. Although the use of caudal epidural injections in the management of the low back pain with radicular signs is commonplace, it has not been well investigated. We compare the effectiveness of caudal epidural injection versus non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of low back pain accompanied with radicular pain. Methods The study was a controlled prospective unblinded trial. A total of consecutive 64 patients with subacute or chronic low back pain accompanied with radicular pain were included. The patients were randomly allocated to two groups. First group was caudal epidural injection plus therapeutic exercise group, and the second group was NSAIDs plus therapeutic exercise group. Patients were assessed with 10 cm visual analogue scale for pain, straight leg raising test and Oswestry low back pain disability questionnaire at the beginning and at 15th day, 1st and 3rd month. Results It was seen that both groups' improvement were good and statistically significant. On the other hand, caudal epidural injection group's improvement was better and faster than the NSAID group's, and the differences between assessment scores of the groups were statistically significant, except the 3rd month Oswestry scores. Conclusion Finally, caudal epidural injection in the management of the subacute/chronic low back and radicular pain is a preferable choice, if applied by experienced specialists.

Study Objective To investigate the use of caudal epidural anesthesia for postoperative pain after total hip arthroplasty. Design Prospective study. Setting University-affiliated hospital. Patients 32 (4 men and 28 women) patients, aged 49 to 89 years, scheduled for total hip arthroplasty for osteoarthritis of the hip. Interventions and Measurements Patients were allocated to three groups: lumbar epidural anesthesia (EA group; n = 16) or caudal epidural anesthesia (CA group; n = 16) groups, which were case-matched according to patient demographics. Nine patients received general anesthesia only (GA group). We evaluated the level of postoperative pain using a 100-mm Visual Analog Scale (VAS) recorded at 3, 6, 9, 12, and 24 hours after surgery. Main Results Total requirement of diclofenac sodium suppositories was significantly larger in the GA group than in the EA or CA groups (444 ± 302 vs 188 ± 124 and 145 ± 130 mg). The number of days requiring analgesics was significantly prolonged in the GA group compared with the EA or CA groups (14 ± 9 vs 4 ± 3 and 4 ± 4 days). These items were similar between the EA group and the CA group. All VAS values for pain, rest, and movement in the postsurgical period over 24 hours were significantly higher in the GA group than in either the EA or CA groups. Conclusions Caudal epidural anesthesia provides effective postoperative analgesia similar to lumbar epidural anesthesia.

Background This study determined the landmarks for caudal epidural block (CEB) after morphometric measurements of the sacral hiatus on dry sacral bones. Anatomical features of the sacral hiatus of clinical importance during CEB, along with distances and angles of use in detecting the apex, were measured. This provides detailed knowledge of the anatomy of the sacral hiatus and practical landmarks. Methods Ninety-six dry sacral bones were used. Anatomical measurements were made with a Vernier caliper accurate to 0.1 mm. Results Two sacral bones were excluded since they had total posterior closure defect. Agenesis of the sacral hiatus was detected in six sacral bones. As the posterior superior iliac spines impose on the superolateral sacral crests of the sacrum, the latter were accepted as forming the base of a triangle. The distance between the two superolateral sacral crests and the distances between the sacral apex and the right and left superolateral sacral crest were 66.5 ( sd 53.5), 67.1 (10.0) and 67.5 (9.5) mm respectively, on average. Conclusion The triangle formed between the apex of the sacral hiatus and the superolateral sacral crests was found to have the features of an equilateral triangle. The sacrum and sacral hiatus are variable anatomical structures. However, the equilateral triangle located between the apex of the sacral hiatus and superolateral sacral crests will certainly be of use in determining the location of the sacral hiatus during CEB.

This study aimed at comparing lidocaine 2% plain with lidocaine 5% with glucose 7.5% for caudal epidural analgesia in horses. Eighteen clinically healthy mixed breed horses were studied. The animals were randomly divided into three treatments: lidocaine plain (LID) treatment received 0.20 mg/kg of body weight (mean dose 3.2 mL); heavy lidocaine (HLID) treatment received 0.5 mg/kg of body weight (mean dose 3.2 mL), and 0.9% saline solution (SS) 5 mL as a control treatment. All drugs were injected by the epidural route in all animals between the first and second coccygeal space. Heart rate, arterial pressure, respiratory rate, rectal temperature, analgesia, and motor-blocking were determined before drug administration (baseline values); at 5, 10, 15, and 30 minutes after drug administration, and then at 30-minute intervals thereafter. The onset of analgesia was 7.5 minutes ± 2.7 minutes after injection of hyperbaric lidocaine, opposed to 11.7 minutes ± 4 minutes after lidocaine plain. The duration of analgesia was 156 minutes ± 17.4 minutes for hyperbaric lidocaine and 115 minutes ± 16 minutes for lidocaine plain. Heart rate and arterial pressure did not change ( P P

To investigate the distribution of solutions injected into the first intercoccygeal epidural space, 24 adult, standing cattle were randomly assigned to 5-, 10- and 20-mL groups and injected with 0.12% new methylene blue (NMB) in 0.9% saline. Ten heifers received 1 mL NMB solution/100 kg of body weight. There was a significant correlation between the injected volume and the number of cranially stained spinal segments in three adult cattle groups (correlation coefficient R2=0.46; P

Caudal block has made an important contribution to paediatric anaesthesia for more than 70 years. In the first half of this chapter, we discuss the technique in children of different ages and the equipment available, the applications and the advantages and disadvantages of ‘single-shot’ and catheter techniques, and the associated complications. We then discuss the local anaesthetic agents commonly used, and the newer drugs (e.g. clonidine, ketamine) which are combined with local anaesthetics to prolong the duration of analgesia.

Sixteen 2-yr-old beef bulls were used in the study. Under caudal epidural analgesia (xylazine HCl, 40 mg), infrared thermography was used to determine scrotal surface temperature (SST) and needle thermistors were used to determine scrotal subcutaneous (SQT) and intratesticular (ITT) temperatures at 3 locations on the posterior aspect of the scrotum: 3 cm from the top of the testis, 3 cm from the bottom of the testis, and at the midpoint of the testis. Average temperatures (°C) at the top, middle and bottom locations were 30.4 ± 0.4, 29.8 ± 0.6 and 28.8 ± 0.8 (SST); 33.3 ± 0.2, 33.0 ± 0.2 and 32.9 ± 0.3 (SQT); and 34.3 ± 0.1, 34.3 ± 0.1 and 34.5 ± 0.1 (ITT). Correlation coefficients between SST and SQT were moderate to high, those between SQT and ITT were low to moderate, and those between SST and ITT were low. Therefore, caution must be exercised when making inferences about ITT based on measurement of SST. The temperature gradient from top to bottom was most pronounced for SST (1.6 °C), smaller for SQT (0.4 °C), and slightly negative (relative to the surface) for ITT (−0.1 °C). These gradients may be due to the arrangement of the vasculature; the scrotum is apparently vascularized from the dorsal pole of the testis to the ventral pole, while the testicular artery ramifies dorsally from the bottom of the testis to the top. Intraepididymal temperatures (IET) of the head, body and tail of the epididymis averaged 35.6 ± 0.2, 34.6 ± 0.1 and 33.1 ± 0.3 °C. The head of the epididymis was warmer than the testicular parenchyma, but the tail, an important storage site for spermatozoa, was cooler.

Twenty premature or high-risk infants received caudal epidural anesthesia for inguinal herniorrhaphy, orchiopexy, and circumcision. Mean gestational age at surgery was 48 ± 12 weeks; mean weight at surgery was 4,100 ± 1,400 g. Caudal anesthesia, performed with 1 mL/kg of 0.375% bupivacaine, was successful in 19 of 20 infants. Onset of anesthesia occurred in 14 ± 1 minutes; duration of surgical anesthesia was 89 ± 8 minutes. Surgical conditions were generally excellent and the infants tolerated anesthesia and surgery well. No postoperative complications were observed. Caudal epidural anesthesia is an acceptable alternative to general or spinal anesthesia in premature and high-risk infants.

Postoperative pain relief in 40 children undergoing elective infraumbilical surgery was assessed after caudal epidural adminstration of either lignocaine or bupivacaine in the doses of 0.5 mL/kg body weight of a 1 per cent solution and 0.5 mL/kg body weight of a 0.25 per cent solution respectively. Pain free period was assessed by subjective pain scales. The pain free period was significantly prolonged in children who were given bupivacaine (14.75 ± 2.75 hours) as compared to lignocaine (7.25 ± 3.25 hours).

Spinal techniques (epidural and subarachnoid injection) are taught in veterinary curricula, but because they are less convenient they are not used widely in practice. Many animals undergoing routine (below the umbilicus level) surgical procedures can be anesthetized with mild sedation and caudal epidural analgesia. Ninety minutes of analgesia is provided by the shorter-acting agents, whereas bupivacaine provides 4 to 6 hours. Twelve percent of our attempts failed to produce analgesia. Sedation, surgeon acceptance, and patient temperament contributed to an additional few failures. High-risk cases are better handled on oxygen.

Objective: To assess the efficacy of fluoroscopically guided caudal epidural steroid injections (ESIs) in the management of lumbar spinal stenosis. Design: Retrospective chart review and follow-up study. Setting: Academic-affiliated outpatient physiatry practice. Participants: Patients with low back and/or leg pain of at least 3 months in duration with clinical and radiographic evidence of moderate to severe lumbar spinal stenosis who received caudal ES’s between 1995 and 2002. Patients who had undergone prior lumbar spinal surgery were excluded. Intervention: Fluoroscopically guided caudal ESIs. Main Outcome Measures: Visual Numeric Scale (VNS), Roland-Morris Disability Questionnaire (RMDQ), North American Spine Society Patient Satisfaction Index (PSI), and subsequent surgery. Results: Of 3153 charts reviewed, 95 patients met inclusion criterion. 79 (83%) completed the follow-up questionnaire by mail or telephone interview. The mean patient age was 70 years, mean duration of symptoms was 39 months, and average follow-up time was 31 months. Patients underwent an average of 1.5 caudal ESIs. 9 patients subsequently underwent surgery; 1 had an intradiskal electrothermal therapy procedure. A VNS improvement of 50% or greater was seen in 37% of patients. With respect to patient satisfaction, 44% reported that the procedure either fully met their expectations or that they would undergo it again for the same outcome. A functional improvement of 2 points or greater was seen on the RMDQ in 40% of patients. The concurrent presence of degenerative spondylolisthesis was the only variable that had a significant positive correlation with successful outcomes ( P Conclusions: Caudally placed, fluoroscopically guided ESIs offer a safe, minimally invasive option for managing pain caused by lumbar spinal stenosis. Many patients in this study derived long-term benefit from a single caudal ESI. The concurrent presence of degenerative spondylolisthesis appears to be a positive prognostic factor for successful response.

Caudal epidural analgesia was first introduced to medicine by Sicard and Cathelin in Paris in 1901. Stoeckel, a German Obstetrician, is attributed the honour of first introducing this procedure to obstetric practice in 1909. The development of Novocaine by Einhorn in 1905 heralded a new era in the use of local anaesthetics and newer applications became commonplace. Edwards and Hingson, in following the lead given by Lemon and Pascal, developed a method of continuous pain relief in labour. They introduced ‘Continuous Caudal Epidural Analgesia,' using an indwelling catheter in the extradural space to facilitate repeated injections as required. A joint programme for the provision of regional analgesia in labour has been in operation in University College Galway since 1972.

SUMMARY In fifty-two children aged between 7 and 598 weeks the segmental spread of caudal epidural analgesia was measured. The effects of age, weight and height on dose requirements were studied by multiple regression techniques. The highest correlation existed to the age variable, the next highest to weight, and the lowest but still highly significant correlation to the height in this patient group. It is shown that the age variable alone is sufficient for establishing an optimum model for prediction. Further, it is confirmed that dose requirements increase with age in a linear manner. The regression equation can be used for the determination of dose requirements in clinical practice.