28.

CAUDAL EPIDURAL ANAESTHESIA

Caudal anaesthesia has been used since 1901. It is suitable for anaesthesia and analgesia
below the umbilicus in adult and paediatric patients, obstetric analgesia and chronic pain
problems. In adults, caudal anaesthesia may be used alone. In children, caudal anaesthesia
is usually combined with sedation or general anaesthesia. In labour, as the pain of the first
stage of labour is transmitted by T10 to L1, caudal anaesthesia is unlikely to be useful as a
sole technique of analgesia. However, it is excellent for the second stage or instrumental
deliveries. Care must be taken that the foetal head does not lie close to the site of injection,
as there have been case reports of direct injection of local anaesthetic into the foetus.

Contraindications

Caudal anaesthesia should not be performed if there is infection near the site of injection,
coagulopathy or congenital abnormalities of the lower spine or meninges, or if the patient
refuses the technique.

Anatomy

The sacrum is a triangular bone that consists of the five fused sacral vertebrae (S1 to S5). It
joins above with the fifth lumbar vertebra and below with the coccyx. The back (dorsal)
surface is convex and irregular with important prominences representing fused elements of
the sacral vertebrae. The sacral hiatus is a defect at the lower end on the posterior wall
from the failure of fusion of S5 and/or S4. The thick fibrous posterior sacrococcygeal
ligament covers it. Unfortunately, there is considerable variation in the anatomy of the
sacrum. Frequently, bony landmarks are obscured to a degree by asymmetric bony growth
and by overlying fibrous or fatty tissues. Distorted anatomy is less common in the younger
patients and rare in children. The sacral canal is a continuation of the lumbar spinal canal,
which terminates at the sacral hiatus. The sacral canal has an average volume of 30 to 34 ml
in the adult. It contains (1) the terminal part of the dural sac, usually ending between S1 and
S3 though in 5% of patients, the dural sac terminates at S3 or below, (2) the filum terminale
which exits through the sacral hiatus and attaches to the back of the coccyx, (3) epidural fat
which is variable in nature and sacral epidural veins which generally end at S4 and (4) the
five sacral nerves and coccygeal nerves making up the cauda equina.  

The sacral nerves give rise to the posterior cutaneous nerve of the thigh, the perforating
cutaneous nerve, pudendal nerve, anococcygeal nerve, pelvic splanchnic nerves and
muscular branches. They provide total sensory input from the vagina, anorectal region, floor
of the perineum, anal and bladder sphincters, urethra, scrotal skin, vulva (except the far
most anterior margin) and penis (except the base) along with a narrow band of skin
extending from the posterior aspect of the gluteal region to the plantar and lateral surface
of the foot.

Caudal Anaesthesia

The patient should be fasted and all appropriate equipment and drugs for treating
complications of epidural anaesthesia (e.g. intravascular injection, total spinal) available.
The anaesthesia provider must be prepared to ventilate the patient and treat seizures or
hypotension. An intravenous cannula must always be inserted before performing caudal
anaesthesia. The procedure must be performed with a strict aseptic technique. The skin
should be cleaned with an antiseptic and the anaesthesia provider must wear gloves. Caudal
anaesthesia may be performed with the patient lying face down or on their side. 

Usually the patient is placed in the Sims position (on their side with the upper leg fully flexed
and lower leg partially flexed). This helps to part the buttocks. Finding the bony landmarks is
the key to success.  First, the posterior superior iliac spines are palpated. A  line between
both spines (Tuffier’s line) represents the base of an equilateral triangle, the tip of which
indicates the approximate position of the sacral hiatus. Alternatively, the sacral hiatus may
be identified by first feeling the tip of the coccyx and then moving the finger towards the
head 4 to 5 cm in the adult. It is important to keep the finger in the midline. As sagging of
the buttocks may cause confusion in confirming the midline, it may be helpful to have an
assistant hold the upper buttock up. When over the sacral hiatus, the prominent sacral
cornua can be felt for on each side by rocking the palpating finger.
Once identified, a needle is inserted at about 45 degrees to the skin through the
sacrococcygeal ligament, often with a distinct pop. After perforating the sacrococcygeal
ligament the needle should be depressed towards the skin to align the needle
approximately with the long axis of the canal and inserted a further 1 cm. The needle should
not be inserted more than 2 cm into the caudal space. If the needle is inserted further than
2 cm it may enter a blood vessel or the spinal space. Intravascular injection may cause local
anaesthetic toxicity, and intraspinal injection may cause a total spinal. The needle should be
aspirated looking for CSF or blood. It may be useful to rotate the needle 90 degrees and
aspirate again. A negative aspiration does not always exclude the needle being in a vessel or
in the spinal space. The anaesthesia provider must always be aware that the needle may be
incorrectly and always give a test dose first.  Never give the full dose more quickly than 10
ml/30 seconds. There should be no resistance to injection. If the needle tip is subperiosteal,
the injection will meet with significant resistance.

Suggested Local Anaesthetic Dosage for Caudal Anaesthesia

There are various factors that are known (age, weight, height and speed of injection) and
unknown (caudal space size variation of 12 to 65 ml in the adult, size and patency of
anterior sacral foramina, amount of bony distortion, presence of septa and amount and
nature of soft tissues), which may explain the various dosage regimes that have been
suggested. Current guidelines recommend that doses should not exceed 2 mg/kg for
ropivacaine and 2.5 mg/kg for bupivacaine. 
In children, common recommended volumes are 0.5 ml/kg to reach sacral dermatomes, 1.0
ml/kg to reach lumbar and 1.25 ml/kg for lower thoracic dermatomes. (The ‘thoracic’ dose
of 1.25 ml/kg of bupivacaine 0.25% exceeds the usual recommended maximum dose).
Alternatively,  lignocaine 1% or bupivacaine 0.25% may be given at 0.1 ml/segment/year.
In adults, 20 ml of 2% lignocaine with adrenaline or 20 ml of 0.5% bupivacaine with
adrenaline (5 micrograms per ml) will spread approximately 9 segments (T9 to L5). 10 ml of
2% lignocaine with adrenaline or 10 ml of 0.5% bupivacaine with adrenaline will spread
approximately 7 segments (T11 to L5) and 5 ml of 2% lignocaine with adrenaline or 5 ml of
0.5% bupivacaine with adrenaline will spread approximately 4 segments (L1 to L5). Doses
should be reduced by 30% during later pregnancy.

Complications of Caudal Anaesthesia

Failure 

Intravenous injection – the needle should not be inserted more than 1 cm and sacral
epidural vein puncture excluded by negative aspiration. Intravascular injection can cause
fitting and/or cardio-respiratory arrest.

Dural puncture – should be excluded by negative aspiration for CSF. Injection into the CSF
may cause a total spinal. The anaesthesia provider must be skilled at airway management.
Dural puncture may occur in 1:2000 to 1:3000 cases.

Foetal injection

Perforation of the rectum

Urinary retention – occurs occasionally in the postoperative period. The incidence is

increased if opioids are administered into the caudal space.

Leg weakness

Neurological complication – very rare.

Infection – superficial and deep abscesses may rarely occur.