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Original Article

Ultrasound‑Guided Caudal Epidural Anesthesia in Adults for

Anorectal Procedures
Prasanna Vadhanan, Iniya Rajendran, Preethipriyadharshini Rajasekar
Department of Anaesthesiology, Vinayaka Missions Medical College, Vinayaka Missione Research Foundation, Karaikal, Puducherry, India

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

Introduction and lesser chances of postdural puncture headache. Other

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,
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.
Address for correspondence: Dr. Iniya Rajendran,
Department of Anaesthesiology, Vinayaka Missions Medical
College, Vinayaka Missions Research Foundation, Karaikal,
Puducherry ‑ 609 609, India.
E‑mail: driniyarajendran@gmail.com
Submitted: 25-Jun-2020 Accepted in Revised Form: 29-Jun-2020
Published: 12-Oct-2020

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DOI: How to cite this article: Vadhanan P, Rajendran I, Rajasekar P.

10.4103/aer.AER_60_20 Ultrasound‑guided caudal epidural anesthesia in adults for anorectal
procedures. Anesth Essays Res 2020;14:239-42.

© 2020 Anesthesia: Essays and Researches | Published by Wolters Kluwer - Medknow 239
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Vadhanan, et al.: US‑guided caudal in adults

Subjects and Methods
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.
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
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

a b

c d
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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Vadhanan, et al.: US‑guided caudal in adults

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
Figure 2: Colour Doppler showing appropriate flow pattern
a single dose of intravenous mephentermine 6 mg. Both were
elderly (65 and 67 years of age, respectively) and recovered
Table 1: Observation and results without any sequelae. A different patient had one episode of
urinary incontinence 3 h after the procedure which resolved
Parameter Value
without any interventions.
Age (years), mean (range) 43.4 (19-67)
Weight (kg), mean, (range) 64.6 (43-100)
Scout scan (normal, abnormal) Discussion
Normal (n) 47 Caudal epidural anesthesia for anorectal surgeries is indeed an
Thick sacrococcygeal ligament (n) 2 old technique. In fact, the caudal approach predates the lumbar
Narrow hiatus (n) 1 route for accessing the epidural space.[7,8] Continuous caudal
Number of attempts
epidural for labor analgesia also has been performed in the past
One attempt 50
with good results.[9] Several recent case reports of successful
Procedural time (mean±SD, seconds) 69.3±10.3
caudal anesthesia in adults exist. [10,11] Landmark‑based
Drug spread
caudal epidural in adults is associated with lower success
Acceptable (n) 49
Needed adjustment (n) 1
rates (68%–75%) than children.[12] The subjective feel of
Onset of sensory (min), mean, (range) 11.4 (4.5-15)
a loss of resistance, the “whoosh test” (auscultation of
Needed supplementation the thoracolumbar region while injecting 2 mL of air) and
No (n) 49 palpation for subcutaneous injection, all have low sensitivity
Yes (n) 1 and specificity.[13] The depth of the sacral canal and length of
Surgical comfort the sacrococcygeal ligament might influence proper needle
Highly satisfied, n (%) 45 (90) placement.[14] US is also a useful screening tool to detect the
Satisfied n (%) 4 (8) abnormalities in the sacral hiatus and assess the feasibility of
Somewhat satisfied (n) 0 caudal epidural injections for back pain.[15] Very few studies
Unsatisfied n (%) 1 (2) have analyzed US‑guided caudal epidural in adults as a sole
Patient comfort - caudal injection (n) anesthetic technique.
No pain 0
Mildly painful 48
In our study, none of the patients had significant sonographic
Moderately painful 2
anomaly impeding caudal approach apart from thickened
Severe pain 0 sacrococcygeal ligaments (n = 2), narrow hiatus as judged by
Patient comfort ‑ surgery the transverse scan (n = 1). In an Iranian study on 240 patients,
Highly satisfied, n (%) 48 (96) the authors report a 0.8% incidence of sonographically detected
Satisfied, n (%) 2 (4) sacral anomaly precluding caudal epidural and varying depths
Somewhat satisfied (n) 0 and angulations according to the patient body habitus and
Unsatisfied (n) 0 pelvis inclination.[15] The sample size of our current study is
Adverse events only fifty; however, these factors will be analyzed in greater
Urinary disturbance (n) 1 detail in our ongoing trial with a larger sample size. We did not
High sensory level (n) 2 measure the dimensions of the sacral hiatus as this was not part
SD=Standard deviation of the study design. The block was successful in all patients
and one patient requiring skin infiltration. In many instances,
2 min. Two patients had thickened sacrococcygeal ligament the patient was positioned even before the completion of the
which offered considerable resistance during penetration. sensory block, a situation encountered by similar studies.[8]
In one patient, the drug spread was observed predominantly Positioning was possible in all patients and surgeons rated
caudally; hence, the needle was further inserted cephalad all but one patient (“unsatisfied”) having adequate surgical

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Vadhanan, et al.: US‑guided caudal in adults
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
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.
242 Anesthesia: Essays and Researches ¦ Volume 14 ¦ Issue 2 ¦ April-June 2020
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