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Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 239-242  

Ultrasound-guided caudal epidural anesthesia in adults for anorectal procedures


Department of Anaesthesiology, Vinayaka Missions Medical College, Vinayaka Missione Research Foundation, Karaikal, Puducherry, India

Date of Submission25-Jun-2020
Date of Acceptance29-Jun-2020
Date of Web Publication12-Oct-2020

Correspondence Address:
Dr. Iniya Rajendran
Department of Anaesthesiology, Vinayaka Missions Medical College, Vinayaka Missions Research Foundation, Karaikal, Puducherry - 609 609
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_60_20

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   Abstract 

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.

Keywords: Anesthesia, caudal epidural, ultrasound


How to cite this article:
Vadhanan P, Rajendran I, Rajasekar P. Ultrasound-guided caudal epidural anesthesia in adults for anorectal procedures. Anesth Essays Res 2020;14:239-42

How to cite this URL:
Vadhanan P, Rajendran I, Rajasekar P. Ultrasound-guided caudal epidural anesthesia in adults for anorectal procedures. Anesth Essays Res [serial online] 2020 [cited 2020 Oct 28];14:239-42. Available from: https://www.aeronline.org/text.asp?2020/14/2/239/297828


   Introduction Top


Caudal epidural anesthesia is a commonly used technique in the pediatric patients. In adults, currently, the route is mainly employed for treating low back pain, under fluoroscopic guidance. One of the main reasons for unpopularity of this technique in adults is the high-failure rates experienced with landmark-based approach, due to anatomic variations.[1] Ultrasound (US) guidance during caudal injections demonstrate improved success rates, apart from reduced numbers of attempts, blood aspiration, bone contact, and inadvertent subcutaneous injections.[2] The treatment effect, complication rates, and adverse events were comparable to fluoroscopic technique,[3] while the time required for the procedure is lesser with US guidance.[4]

Minor anorectal surgeries are commonly performed as day care procedures. Even though spinal anesthesia, modified into a saddle block is a widely used technique, epidural anesthesia offers certain unique advantages such as minimal motor blockade, early mobilization, lesser degree of hypotension, and lesser chances of postdural puncture headache. Other potential advantages of the caudal route include ease of positioning and selective blocking of sacral nerves. There is a gap in our knowledge whether US-guided caudal epidural can be used routinely as a sole anesthetic technique in adult patients. The aim of the study was to assess the success rates, surgical comfort, and patient comfort with US-guided caudal anesthesia. The current study was done to assess the feasibility of a larger trial (CTRI no: 2020/01/022896) comparing US-guided caudal epidural with saddle block in terms of hemodynamic effects, time for discharge apart from the success rates, and surgical comfort.


   Subjects and Methods Top


Fifty consecutive adult patients scheduled for minor (estimated duration less than an hour) anorectal elective procedures (hemorrhoidectomy, perianal fistula, fissurectomy, polypectomy, etc.) were recruited for the study after obtaining Institutional Ethical Committee approval. Informed written consent was obtained from the participants. The inclusion criteria were adult patients of either sex, American Society of Anesthesia (ASA) physical statuses 1 and 2, and those scheduled for elective anorectal procedures of short duration. The exclusion criteria were bleeding diathesis, prolonged surgeries, ASA physical status 3 and 4, inability to lie in prone position, previous spine surgeries, or any other obvious anatomical abnormality in the caudal area.

All patients were premedicated with midazolam 1 mg intravenously and intravenous infusion of ringer lactate was started. Patients were then placed in the prone position. Monitoring was done with pulse oximetry, noninvasive blood pressure, and 3 lead electrocardiogram. The procedure was performed by the first author, with more than 15 years of experience in caudal epidurals and routinely performs US-guided caudal epidural injections for low back pain. A screening scan was done by initially placing a linear high-frequency probe (Aeroscan CD25 Pro, KonicaMinolta) in the transverse view across the sacrum to view the sacral median crest, and the probe was slid caudad to view the sacral hiatus, sacro coccygeal ligament, and dorsal surface of the sacrum – appearing like a frog's face. The probe is then rotated to a sagittal orientation to view the hiatus and sacrococcygeal ligament [Figure 1]. After asepsis and skin infiltration, a 23 G spinal needle using an in-plane approach to pierce the sacrococcygeal ligament. The needle tip was confirmed using a transverse view, and few milliliters of drug was injected in a pulsatile manner, and the expansion of the epidural space was observed. Color Doppler was used to detect the flow of the drug and absence of extravasation [Figure 2]. A total volume of 15 mL of drug (10 mL 0.5% bupivacaine and 5 mL of NS) was injected.
Figure 1: Sonographic images showing longitudinal (a) and transverse (b) view of the sacral hiatus. The needle track can be appreciated in the transverse (c) and sagittal view inside the hiatus (d), the needle is slightly off the midline and few inadvertent air bubbles can be appreciated

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Figure 2: Colour Doppler showing appropriate flow pattern

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The patients were turned into the supine position, and following parameters were monitored. Hypoesthesia to pin-prick sensation was checked every 5 min in S1 dermatome as an indicator of onset of sensory loss. Patients were asked to grade the procedural comfort according to the verbal response scale (no pain, mild, moderate, and severe pain). After shifting them to the operating room, lithotomy position was applied. Intraoperatively, the hemodynamic parameters were noted. Any discomfort either during positioning and surgery was noted and if significant, supplemental analgesia or general anesthesia was planned to be administered according to the anesthesiologist's preference. After the surgery, the surgeons, blinded to the anesthesia technique were asked to grade the quality of surgical field on a 4-point Likert scale (highly satisfied, satisfied, somewhat satisfied and unsatisfied), and the patient was asked to grade the surgical comfort on a similar scale. This scale has been validated by previous studies.[5],[6]


   Results Top


The mean age of the study patients was 43.4 years, with a range of 19–67 years [Table 1]. Weight varied from 43 kg to 100 kg with a mean of 64.6 kg. Most patients (n = 42) were males. The caudal space was easily identified and needle positioning was achieved in the single attempt in all patients. After the scout scan, all procedures were performed within 2 min. Two patients had thickened sacrococcygeal ligament which offered considerable resistance during penetration. In one patient, the drug spread was observed predominantly caudally; hence, the needle was further inserted cephalad by 1 cm and appropriate flow pattern as judged by color Doppler achieved. All patients demonstrated hypoesthesia in S1 dermatome within 15 min (mean 12.8 min, with a range of 5–15). Two patients who had demonstrable thickened sacrococcygeal ligament which offered considerable resistance to needle penetration reported the anesthetic procedure as “moderately painful,” others rated the procedural pain as mild. Positioning was possible in all patients. One patient demonstrated discomfort to pin prick on perianal region after positioning hence needed local infiltration. Further insertion of speculum and procedure was without any discomfort. Two patients demonstrated a sensory level of T6 and motor blockade along with hypotension requiring a single dose of intravenous mephentermine 6 mg. Both were elderly (65 and 67 years of age, respectively) and recovered without any sequelae. A different patient had one episode of urinary incontinence 3 h after the procedure which resolved without any interventions.
Table 1: Observation and results

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   Discussion Top


Caudal epidural anesthesia for anorectal surgeries is indeed an old technique. In fact, the caudal approach predates the lumbar route for accessing the epidural space.[7],[8] Continuous caudal epidural for labor analgesia also has been performed in the past with good results.[9] Several recent case reports of successful caudal anesthesia in adults exist.[10],[11] Landmark-based caudal epidural in adults is associated with lower success rates (68%–75%) than children.[12] The subjective feel of a loss of resistance, the “whoosh test” (auscultation of the thoracolumbar region while injecting 2 mL of air) and palpation for subcutaneous injection, all have low sensitivity and specificity.[13] The depth of the sacral canal and length of the sacrococcygeal ligament might influence proper needle placement.[14] US is also a useful screening tool to detect the abnormalities in the sacral hiatus and assess the feasibility of caudal epidural injections for back pain.[15] Very few studies have analyzed US-guided caudal epidural in adults as a sole anesthetic technique.

In our study, none of the patients had significant sonographic anomaly impeding caudal approach apart from thickened sacrococcygeal ligaments (n = 2), narrow hiatus as judged by the transverse scan (n = 1). In an Iranian study on 240 patients, the authors report a 0.8% incidence of sonographically detected sacral anomaly precluding caudal epidural and varying depths and angulations according to the patient body habitus and pelvis inclination.[15] The sample size of our current study is only fifty; however, these factors will be analyzed in greater detail in our ongoing trial with a larger sample size. We did not measure the dimensions of the sacral hiatus as this was not part of the study design. The block was successful in all patients and one patient requiring skin infiltration. In many instances, the patient was positioned even before the completion of the sensory block, a situation encountered by similar studies.[8] Positioning was possible in all patients and surgeons rated all but one patient (”unsatisfied”) having adequate surgical conditions (”highly satisfied” or “satisfied”). All patients rated the intraoperative period as “highly satisfied” (n = 48) or “satisfied” (n = 2).

Accidental intrathecal injection due to variable termination of filum terminale and intravascular injections are the serious complications of caudal epidurals. It has been suggested that the needle should not be inserted too cephalad into the sacral canal to avoid dural puncture.[16]. Injecting just after penetrating the sacrococcygeal ligament has been shown to be produce higher success rates than inserting the needle further in to the sacral canal,[17] a fact reinforced by our study. In one patient, we did insert the needle into the sacral canal by approximately 1 cm, (tip was still caudal the acoustic shadow of the hiatus) to achieve a cephalad drug spread as judged by the Doppler.

Two elderly patients experienced a high sensory level, warranting dose reduction in the elderly. The spread of injectates into the epidural space is governed by complex factors, including surface area of the lumbosacral dura and fat content,[18] whereas spinal canal dimensions may not always decrease with age as believed.[19] Urinary disturbance in the form of overflow incontinence was present in one patient, and the patient regained bladder control during next voiding. Some of the other possible complications of caudal epidural include inadvertent intrathecal or intravascular injection, spread of the drug in subcutaneous of presacral region, rectal perforation, etc., Some of these complications can be avoided by not inserting the needle too cephalad, careful aspiration, always keeping the tip of the needle in vision and using color Doppler to assess the spread of the drug. All these precautions were taken, and none of these complications were observed. Apart from the small sample size, surgeries were performed by different surgeons which could be a confounding factor in assessing the surgical comfort which, along with the patient comfort are the subjective scales.


   Conclusion Top


US-guided caudal anesthesia for adult anorectal surgeries present an attractive option for day care surgeries. This small-scale trial done as a feasibility study for a larger trial clearly shows the practicality and ease of this technique with acceptable success rates, patient comfort, and acceptable surgical conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Barham G, Hilton A. Caudal epidurals: The accuracy of blind needle placement and the value of a confirmatory epidurogram. Eur Spine J 2010;19:1479-83.  Back to cited text no. 1
    
2.
Karaca O, Pinar HU, Gokmen Z, Dogan R. Ultrasound-guided versus conventional caudal block in children: A prospective randomized study. Eur J Pediatr Surg 2019;29:533-8.  Back to cited text no. 2
    
3.
Park Y, Lee JH, Park KD, Ahn JK, Park J, Jee H. Ultrasound-guided vs. fluoroscopy-guided caudal epidural steroid injection for the treatment of unilateral lower lumbar radicular pain: A prospective, randomized, single-blind clinical study. Am J Phys Med Rehabil 2013;92:575-86.  Back to cited text no. 3
    
4.
Hazra AK, Bhattacharya D, Mukherjee S, Ghosh S, Mitra M, Mandal M. Ultrasound versus fluoroscopy-guided caudal epidural steroid injection for the treatment of chronic low back pain with radiculopathy: A randomised, controlled clinical trial. Indian J Anaesth 2016;60:388-92.  Back to cited text no. 4
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5.
Siddiqui ZI, Denman WT, Schumann R, Hackford A, Cepeda MS, Carr DB. Local anesthetic infiltration versus caudal epidural block for anorectal surgery: A randomized controlled trial. J Clin Anesth 2007;19:269-73.  Back to cited text no. 5
    
6.
Brown DL, Warner ME, Schroeder DR, Offord KP. Effect of intraoperative anesthetic events on postoperative patient satisfaction. Mayo Clin Proc 1997;72:20-5.  Back to cited text no. 6
    
7.
Rochowansk, E, Kreiser RD, Morris LE. Caudal anaesthesia with bupivacaine (Marcaineŗ) for anal surgery: A clinical trial. Canad Anaesth Soc J 1971;18:18-22.  Back to cited text no. 7
    
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Rosenbaum MM. Caudal anaesthesia for anorectal surgery. Am J Surg 1953:86:636-40.  Back to cited text no. 8
    
9.
Kandel PF, Spoerel WE, Kinch RA. Continuous epidural analgesia for labour and delivery: Review of 1000 cases. Can Med Assoc J 1966;95:947-53.  Back to cited text no. 9
    
10.
Orza FM, Averbakh E, Todd MM. Postdural puncture headache in a postpartum female with previous spinal surgery-successful treatment with caudal epidural blood patch: A case report. A A Pract 2019;12:57-8.  Back to cited text no. 10
    
11.
Shafy SZ, Hakim M, Villalobos MA, Pearson GD, Veneziano G, Tobias JD. Caudal epidural block instead of general anaesthesia in an adult with Duchenne muscular dystrophy. Local Reg Anesth 2018;11:75-80.  Back to cited text no. 11
    
12.
Najman IE, Frederico TN, Segurado AVR, Kimachi PP. Caudal epidural anaesthesia: An anesthetic technique exclusive for pediatric use? Is it possible to use it in adults? what is the role of the ultrasound in this context? Rev Bras Anestesiol 2011;61:95-109.  Back to cited text no. 12
    
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Kao SC, Lin CS. Caudal epidural block: An updated review of anatomy and techniques, BioMed Res Int 2017;2017:9217145.  Back to cited text no. 13
    
14.
Kim YH, Park HJ, Cho S, Moon DE. Assessment of factors affecting the difficulty of caudal epidural injections in adults using ultrasound. Pain Res Manag 2014;19:275-9.  Back to cited text no. 14
    
15.
Nikooseresht M, Hashemi M, Mohajerani SA, Shahandeh F, Agah M. Ultrasound as a screening tool for performing caudal epidural injections. Iran J Radiol 2014;11:e13262.  Back to cited text no. 15
    
16.
Aggarwal A, Aggarwal A, Harjeet, Sahni D. Morphometry of sacral hiatus and its clinical relevance in caudal epidural block. Surg Radiol Anat 2009;31:793-800.  Back to cited text no. 16
    
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Doo AR, Kim JW, Lee JH, Han YJ, Son JS. A Comparison of two techniques for ultrasound-guided caudal injection: The influence of the depth of the inserted needle on caudal block. Korean J Pain 2015;28:122-8.  Back to cited text no. 17
    
18.
Higuchi H, Adachi Y, Kazama T. Factors affecting the spread and duration of epidural anaesthesia with ropivacaine. Anesthesiology 2004;101:451-60.  Back to cited text no. 18
    
19.
Kim KH, Park JY, Kuh SU, Chin DK, Kim KS, Cho YE. Changes in spinal canal diameter and vertebral body height with age. Yonsei Med J 2013;54:1498-504.  Back to cited text no. 19
    


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