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Letter to editor 149

New technique for caudal epidural block in pediatric patients

Abdelaziz A. Abdelaziz

Department of Anesthesiology, Intensive Care,
and Pain Management, Faculty of Medicine,
Ain-Shams University, Cairo, Egypt
Correspondence to Abdelaziz Abdallah
Abdelaziz, MD, 28 Taqseem Elawqeef,
Elquppa, Helliopolois, Cairo 11234, Egypt
Tel: 002-02-24513702; fax: 002-01118003283;
e-mails: drabdelaziz@hotmail.com and
draaabdo_75@yahoo.com
Caudal block is one of the most popular and effective techniques of regional anesthesia in
pediatric surgery. Good anatomic knowledge and accurate adherence to guidelines pertaining
to the technique and to drug administration is necessary to perform this block safely. The
usual approach is well-known and has been extensively described, but failure is seen in
some cases. Another approach is the ‘no turn’ technique, which is a new method developed
in the Ain-Shams University, Pediatric Surgical Unit by the author. It has a high success rate
and can be easily learned and implemented even by junior staff.

Received 29 July 2014 Keywords:

Accepted 27 October 2014
Ain-Shams Journal of Anesthesiology
2016, 9:149–151
caudal block, new technique, pediatric
Ain-Shams J Anesthesiol 9:149–151
© 2016 Department of Anesthesiology, Intensive Care and Pain Managment,
Faculty of Medicine, Ain-Shams University, Cairo, Egypt
1687-7934

sacral hiatus. The termination of the dural sac ascends

Introduction
Caudal epidural block is the most common technique
for regional anesthesia among pediatric patients. It is
commonly used to augment general anesthesia and
to manage postoperative pain. Effective postoperative
pain relief from caudal analgesia has numerous benefits,
including earlier ambulation, reduced time spent in
a catabolic state, lowered circulating stress hormone
levels, and decreased need for postoperative analgesics
including narcotics. Therefore, it is widely used for the
management of pediatric day-case surgeries [1–3].
To perform the block safely good knowledge of
anatomy and accurate adherence to the steps of the
technique and to drug administration is necessary.
The common technique of caudal block is well-known
and often described but in some cases is not without
risks. The new technique is a very easy approach, with
fewer complications and lower failure rate and can be
taught even to junior staff [4].
from S3/S4 at birth to S2 by 3 years; therefore, caution
is warranted when placing caudal blocks in infants
because of the risk of accidental dural puncture. Sacral
anomalies are found in 3–5% of individuals and can
result in reduced distance from the sacral hiatus to the
sacral sac. To identify the sacral hiatus, we can palpate
the sacral cornua and the indentation that is a bit
caudal and midline to the cornua, or locate the two
posterior superior iliac spines and draw a line between
them assuming this to be the base of an equilateral
triangle. The apex of the triangle can be considered an
approximation of the sacral hiatus+ (Fig. 2) [5–7].
Technique
There are two well-known techniques for performing a
caudal epidural block: the common technique and the
no turn technique.
Figure 1

Anatomical considerations
Significant anatomic differences between adults and
children should be considered when performing the
caudal block. The sacrum of children is more narrow
and flat compared with that of adults. At birth, the
sacrum, which is formed of five sacral vertebrae, is
not completely ossified and continues to fuse until 8
years of age. The incomplete fusion of the posterior
arches of the fifth and sometimes the fourth sacral
vertebrae forms the sacral hiatus, which is covered by
a ligamentous membrane called the sacrococcygeal
membrane (Fig. 1). The caudal epidural space can be
Anatomy of the sacrum.
accessed easily in infants and children through the
1687-7934 © 2016 Department of Anesthesiology, Intensive Care and Pain Management,
Faculty of Medicine, Ain-Shams University, Cairo, Egypt DOI: 10.4103/1687-7934.178898
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150 Ain-Shams Journal of Anesthesiology
In the common technique, the needle is inserted at
a 90° angle to the cutaneous plane and, after passing
the sacrococcygeal membrane, is lowered 30° and then
advanced several millimeters into the sacral canal.
In the no turn technique [8] the needle is inserted at
a 60° angle to the sacral plane instead of 90°, in the
midline at the apex of the sacral hiatus, after crossing
the sacrococcygeal ligament. The needle does not have
to be advanced because the bevel (facing anteriorly) is
at the beginning of the sacral canal and already within
the epidural space.
In our new and easy technique, the sacral hiatus is first
identified and the left index finger is placed over it (if
the doctor is right handed) (Fig. 3). The needle is then
inserted caudally 1–1.5 cm from the hiatus (Fig. 4),
introduced into the subcutaneous tissue, and advanced
subcutaneously until the needle tip is felt by the left
index finger.
Figure 2
Anatomical landmark of the sacral hiatus.
Figure 4
Needle insertion 0.5–1 cm from the sacral hiatus.
The needle is then raised 15°–30° and advanced slowly
until loss of resistance is felt. Thereafter, the needle
is advanced not more than 0.5 cm. An aspiration
test is performed to avoid inadvertent intrathecal
or intravascular injection of local anesthetics. The
local anesthetic is injected slowly and the sacral area
is inspected for inadvertent subcutaneous injection
(Fig. 5).
Continuous caudal block can be achieved by placing
the connection line (arterial line) to the cannula for
intraoperative analgesia; a poster dose can be given
before removing the cannula postoperatively (Fig. 6).
This technique guarantees that no subcutaneous
injection will be required, because the left index finger
is placed over the hiatus, and for subcutaneous injection
the needle should pass completely under the index
finger, which will be easily felt because the skin and
subcutaneous tissues in pediatric patients are very thin.
Figure 3
Identification of the sacral hiatus by the left index finger.
Figure 5
Local anesthetic injection.
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New technique for caudal epidural block Abdelaziz 151

Figure 6
Acknowledgements
Conflicts of interest
None declared.

References
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