• The Korean Journal of Pain
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• v.18 no.1
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• pp.23-28
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• 2005

Background: An epidural steroid injection (ESI) is usually used for the treatment of low back pain with radiculopathy. An ESI can be performed by two procedures: I) a lumbar or caudal epidural steroid injection and II) a transforaminal epidural steroid injection. Methods: Ninety-three patients, who had undergone transforaminal epidural steroid injection (Group II), and either a lumbar or caudal epidural steroid injection (Group I), were retrospectively studied. The authors assessed the pain, walking, standing improvement and side effects after each procedure, which were evaluated as being very good, good, fair or poor. Data were collected from the patients medical records and analyzed using the chi-squared test. P < 0.05 was considered significant. Results: There were no statistically significant differences in the pain, walking, standing improvement and side effects between the two groups. However, there was a statistically significant difference in the pain improvement following transforaminal epidural steroid injection in those not effectively responding to an initial lumbar or caudal epidural block in Group II. Conclusions: A transforaminal epidural steroid injection is a useful alternative to a lumbar or caudal epidural steroid injection for low back pain with radiculopathy.

• The Korean Journal of Pain
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• v.28 no.2
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• pp.122-128
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• 2015

Background: Caudal epidural injections have been commonly performed in patients with low back pain and radiculopathy. Although caudal injection has generally been accepted as a safe procedure, serious complications such as inadvertent intravascular injection and dural puncture can occur. The present prospective study was designed to investigate the influence of the depth of the inserted needle on the success rate of caudal epidural blocks. Methods: A total of 49 adults scheduled to receive caudal epidural injections were randomly divided into 2 groups: Group 1 to receive the caudal injection through a conventional method, i.e., caudal injection after advancement of the needle 1 cm into the sacral canal (n = 25), and Group 2 to receive the injection through a new method, i.e., injection right after penetrating the sacrococcygeal ligament (n = 24). Ultrasound was used to identify the sacral hiatus and to achieve accurate needle placement according to the allocated groups. Contrast dyed fluoroscopy was obtained to evaluate the epidural spread of injected materials and to monitor the possible complications. Results: The success rates of the caudal injections were 68.0% in Group 1 and 95.8% in Group 2 (P = 0.023). The incidences of intravascular injections were 24.0% in Group 1 and 0% in Group 2 (P = 0.022). No intrathecal injection was found in either of the two groups. Conclusions: The new caudal epidural injection technique tested in this study is a reliable alternative, with a higher success rate and lower risk of accidental intravascular injection than the conventional technique.

• The Korean Journal of Pain
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• v.28 no.4
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• pp.280-283
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• 2015

Caudal epidural injection is a common intervention in patients with low back pain and sciatica. Even though the complications of fluoroscopically directed epidural injections are less frequent than in blind epidural injections, complications due to contrast media can occur. We report a case of anaphylactic shock immediately after injection of an intravenous nonionic contrast medium (iohexol) during the caudal epidural injection for low back pain and sciatica in a patient without a previous allergic history to ionic contrast media (ioxitalamate). Five minutes after the dye was injected, the patient began to experience dizziness, and the systolic blood pressure dropped to 60 mmHg. Subsequently, the patient exhibited a mild drowsy mental state. About 30 minutes after the subcutaneous injection of 0.2 mg epinephrine, the systolic blood pressure increased to 90 mmHg. The patient recovered without any sequela. Life-threatening complications after injection of intravenous contrast medium require immediate treatment.

• The Korean Journal of Pain
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• v.26 no.3
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• pp.286-290
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• 2013

Air injected into the epidural space may spread along the nerves of the paravertebral space. Depending on the location of the air, neurologic complications such as multiradicular syndrome, lumbar root compression, and even paraplegia may occur. However, cases of motor weakness caused by air bubbles after caudal epidural injection are rare. A 44-year-old female patient received a caudal epidural injection after an air-acceptance test. Four hours later, she complained of motor weakness in the right lower extremity and numbness of the S1 dermatome. Magnetic resonance imaging showed no anomalies other than an air bubble measuring 13 mm in length and 0.337 ml in volume positioned near the right S1 root. Her symptoms completely regressed within 48 hours.

• The Korean Journal of Pain
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• v.5 no.1
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• pp.89-91
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• 1992

Coccygodynia is a pain syndrome resulting from trauma, fractures, infection and tumor, and is usually amenable to conservative treatment. We present one case of coccygodynia that developed 2 days after percutaneous cordotomy done for pain control of cervix cancer unresponsive to conservative treatment which subsequently was treated with a caudal injection of lidocaine and triamcinolone. Caudal epidural steroid injection is less invasive and has less potential for complication than the neurosurgical interruption of the pain pathway.

• The Korean Journal of Pain
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• v.18 no.1
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• pp.15-18
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• 2005

Background: Epidural steroid injections (ESI) have been used widely for the treatment of back and radiating extremity pain. Although its effects on the metabolic and endocrine system have been studied, the effects following repeated injections remain to be determined. We studied the effects of three repeated caudal epidural injections of low dose triamcinolone. Methods: the subject were 10 elderly women with spinal stenosis. Caudal epidural injections were performed biweekly. Triamcinolone (20 mg), mixed with 15 ml of 0.25% lidocaine, was used as the ESI injectate. The procedures were performed with the patient in the prone position. Blood sampling was performed just before the first injection, and used as the baseline, and then just before each injection on the same day of the 2nd and 4th weeks, with the last samples taken 2 weeks after the third injection. Results: The blood glucose concentrations showed no significant changes. The blood cortisol and ACTH concentrations were significantly decreased after the first injection, but there were no further decreases after each of the subsequent injections. The cortisol concentrations were maintained within the normal range. Conclusion: Caudal epidural injections, with low dose triamcinolone, suppressed the hypothalamus-pituitary-adrenal (HPA) axis, but no further suppression followed the subsequent repeated injections. Three consecutive caudal injections at 2 week intervals seems to be a safe procedure.

• The Korean Journal of Pain
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• v.19 no.2
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• pp.207-212
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• 2006

Background: The epidural injection technique is a commonly used intervention in the management of chronic spinal pain, which has the advantage of delivering various drugs, such as local anesthetics or steroids, in higher concentrations to the inflamed nerve root. A guidewire-reinforced epidural catheter was introduced through a Tuohy needle during the caudal epidural procedure, with a catheter threaded into the affected nerve roots and the spread-pattern of contrast agents observed under fluoroscopy. Methods: Sixty-seven patients with low back pain, who showed evidence of a herniated nucleus pulposus on magnetic resonance imaging, were included. All patients received fluoroscopically guided caudal epidural injections, with the guidewire-reinforced epidural catheter introduced through a Tuohy needle and threaded either to the right or left side toward the target nerve roots. After confirming the catheter tip position at the affected nerve root, 2 ml increments of contrast agents (up to 6 ml) were injected, and their corresponding AP fluoroscopic views were obtained. Three radiologists reviewed all the radiographic findings and measured the proportion of the area of contrast spread at the side of target nerve roots. Results: Greater proportion of the area of contrast spread was observed at the side of the target nerve roots (P < 0.0001). At each level of contrast injection (2-⁣, 4- ⁣ and 6 ml), more than 70% of the spread of contrast dye was observed at the side of the target nerve roots in 85%, 70%, and 55% of cases, respectively. Conclusions: The combination of a caudal epidural injection and use of a guidewire-reinforced epidural catheter significantly enhances the target specificity, as revealed by the selective spread of contrast dye at the side of target nerves.

• Journal of Korean Neurosurgical Society
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• v.60 no.2
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• pp.205-210
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• 2017

Objective : This study was performed to evaluate and compare the efficacies of caudal epidural injections performed at prone and lateral decubitus positions. Methods : A total of 120 patients suffering from low back pain and radicular leg pain were included and patients were randomly distributed into 2 groups according to the position during injection. In Group 1 (n=60; 32 women, 28 men), caudal epidural injection was performed at prone position, whereas it was implemented at lateral decubitus position in Group 2 (n=60; 33 women, 27 men). Visual analogue scale, Oswestry Disability Index (ODI), walking tolerance (WT) and standing tolerance (ST) were compared in 2 groups before and after injection. Results : In Group 1, ODI values were higher at 30th minute (p=0.007), 3rd week (p=0.043) and 6th month (p=0.013). In Group 1, ODI, VAS and ST values were improved significantly at all follow-up periods compared to initial values. In Group 1, WT scores were better than initial values at 30th minute, 3rd week and 3rd month. In Group 2, ODI scores at 30th minute, 3rd week, 3rd month and 6th month were improved while VAS and ST scores were improved at all periods after injection. WT scores were better at 30th minute, 3rd week and 3rd month compared to initial WT scores. Conclusion : Our results indicated that application of injection procedure at lateral decubitus position allowing a more concentrated local distribution may provide better relief of pain.

• Korean Journal of Anesthesiology
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• v.71 no.6
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• pp.430-439
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• 2018

In infants and small children, ultrasound (US) guidance provides ample anatomical information to perform neuraxial blocks. We can measure the distance from the skin to the epidural space in the US image and can refer to it during needle insertion. We may also visualize the needle or a catheter during real-time US-guided epidural catheterization. In cases where direct needle or catheter visualization is difficult, US allows predicting successful puncture and catheterization using surrogate markers, such as dura mater displacement, epidural space widening due to drug injection, or mass movement of the drug within the caudal space. Although many experienced anesthesiologists still prefer to use conventional techniques, prospective randomized controlled trials using US guidance are providing increasing evidence of its advantages. The use of US-guided regional block will gradually become widespread in infants and children.

• The Korean Journal of Pain
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• v.12 no.2
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• pp.258-262
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• 1999

Sacral meningeal cyst is usually asymtomatic, but may be responsible for sciatic pain syndromes and other clinical symptoms. Sacral meningeal cyst might be suspected when definite explanation for the clinical symptom, such as herniation of the intervertebral disc or spinal stenosis is not found. Plain films and CT may suggest the presence of sacral meningeal cyst, but MR is the current imaging study of choice. Evaluation of the correlation between the symptom and the cyst is as important as detection of it. We have experienced a case of sacral meningeal cyst detected during caudal epidural block. The patient complained of low back pain radiating to thigh. Plain films and lumbar spine CT showed no remarkable finding except disc bulging. During caudal epidural needle insertion, there was leakage of clear CSF, and intrasacral cystic shadow was visualized by dye injection. MR confirmed sacral meningeal cyst.