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Transverse plane ultrasound-guided caudal epidural injections: sonographic anatomy and stepwise technique

  • Anatomic Bases of Medical, Radiological and Surgical Techniques
  • Published:
Surgical and Radiologic Anatomy Aims and scope Submit manuscript

Abstract

Purpose

The present study aims to provide a step-by-step procedural and anatomical familiarization guide for transverse plane ultrasound (US)-guided caudal epidural (CE) injection.

Methods

The study cohort consisted of 23 chronic low back pain patients (23–67 years old) previously unresponsive to conservative management. A transverse plane US-guided CE injection was performed, with each procedure step documenting and emphasizing sonographic anatomy. Several Thiel’s method fixed cadaveric specimen dissections were also performed to demonstrate relevant CE injection-related anatomy.

Results

The sacral hiatus location can be estimated by visually forming an equilateral triangle between the posterior superior iliac spines and the sacral apex (trigonum sacrale). Follow-up palpation locates the sacral cornua, guiding transducer placement visualizing over the paired cornua ‘bull frog’s eye’s appearance, with the epidural space visualized as a hypoechoic line, between the eyes. Then, 2–3 ml of 1% lidocaine is injected subcutaneously at the mid-point between the sacral cornua and superficial to the posterior sacrococcygeal ligament (SCL). Although keeping the cornua, superficial posterior SCL and epidural space in view, the needle is slowly advanced to the epidural space at around a 20 degree cephalad angle till the tip becomes visible. Expansion of the epidural space is monitored under the transverse sacral ligament as the injectant is slowly introduced.

Conclusion

The present study demonstrated the anatomical landmarks necessary for the transverse ultrasound caudal epidural technique and that the cornua, superficial posterior SCL, CE space, and other relevant sacral hiatal anatomy are well visualized with this technique.

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Acknowledgements

Special thanks to Ellie Gayton.

Funding

No funding was received for conducting this study.

Author information

Authors and Affiliations

  1. The London College of Osteopathic Medicine, 8-10 Boston Place, London, NW1 6QH, UK

    James Inklebarger

  2. Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece

    Trifon Totlis & Maksim Tishukov

  3. Institute for Anatomy and Clinical Morphology, Department for Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany

    Georg Feigl

  4. Department of Macroscopic and Clinical Anatomy, Medical University of Graz, Graz, Austria

    Georg Feigl

  5. 1st Orthopaedic Department, George Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Nikiforos Galanis

Authors
  1. James Inklebarger
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  3. Georg Feigl
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  4. Maksim Tishukov
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Contributions

All authors contributed to the study conception and design. Patients’ recruitment, procedures, photographs, and figures preparation were performed by JI and NG. Cadaveric dissections, photographs, and figures preparation were performed by GF and TT. The first draft of the manuscript was written by JI and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Trifon Totlis.

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Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethics approval

The study was approved by the Aristotle University of Thessaloniki, Medical School Research Ethics Committee and the authors certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Inklebarger, J., Totlis, T., Feigl, G. et al. Transverse plane ultrasound-guided caudal epidural injections: sonographic anatomy and stepwise technique. Surg Radiol Anat 43, 1527–1535 (2021). https://doi.org/10.1007/s00276-021-02776-9

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  • DOI: https://doi.org/10.1007/s00276-021-02776-9

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