• Liza Maniquis Smigel, Dean ReevesKennethKPrivate Practice PM&R and Pain Management, Roeland Park, Kansas, USA; Past Clinical Assistant/Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, Kansas, USA., Howard Jeffrey Rosen, and David Patrick Rabago.
• Private Practice PM&R and Pain Management, Hawaii, USA.
• Anesth Pain Med. 2016 Jun 1; 6 (3): e35340.

BackgroundAnecdotal evidence suggests that a vertical small-needle injection method enters the caudal epidural space with comparable efficacy to cephalad-directed methods, with less intravascular injection.ObjectivesAssess the success rate of vertical caudal epidural injection using epidurography and the frequency of intravascular injection using a vertical small-needle approach.Patients And MethodsParticipants had chronic generalized non-surgical low back pain and either gluteal and/or leg pain and were enrolled in a simultaneous clinical trial assessing the analgesic effect of 5% dextrose epidural injection. A 25 gauge 3.7 cm hypodermic needle was placed at the sacral hiatus using a fingertip-guided vertical technique without imaging assistance, followed by fluoroscopic epidurography. Minimal needle redirection was allowed up to 10 degrees from the vertical plane if the initial epidurogram showed an extradural pattern, followed by repeat epidurography.ResultsFirst needle placement without imaging resulted in blood return in 1/199 participants and positive epidurography in 179/199 (90%). Minimal needle repositioning resulted in a positive epidurogram in the remaining 19 attempts. No intravascular injection patterns were observed.ConclusionsThis compares favorably to published success rates of fluoroscopically-guided technique and was well tolerated. Vertical caudal epidural injection may be suitable for combination with ultrasound-guided methods with Doppler flow monitoring.

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