<p begin="00:00:09.298" end="00:00:10.544" style="s2">- Today I'm going to demonstrate a</p>
<p begin="00:00:10.544" end="00:00:13.071" style="s2">caudal epidural steroid injection.</p>
<p begin="00:00:13.071" end="00:00:14.521" style="s2">This is a variation on the technique</p>
<p begin="00:00:14.521" end="00:00:17.296" style="s2">of a lumbar epidural steroid injection.</p>
<p begin="00:00:17.296" end="00:00:19.276" style="s2">With the probe in this location we can see</p>
<p begin="00:00:19.276" end="00:00:21.828" style="s2">the following anatomic structures.</p>
<p begin="00:00:21.828" end="00:00:25.568" style="s2">The coccyx, the sacrococcygeal ligament,</p>
<p begin="00:00:25.568" end="00:00:27.843" style="s2">and the sacral cornua.</p>
<p begin="00:00:27.843" end="00:00:31.650" style="s2">This indicates the entry<br />at the sacral hiatus.</p>
<p begin="00:00:31.650" end="00:00:35.293" style="s2">The needle is placed thusly,<br />performing the block.</p>
<p begin="00:00:35.293" end="00:00:37.433" style="s2">Indications for this procedure include</p>
<p begin="00:00:37.433" end="00:00:40.066" style="s2">patients with lumbar spinal stenosis,</p>
<p begin="00:00:40.066" end="00:00:42.637" style="s2">lumbar radiculopathy, and any other cause</p>
<p begin="00:00:42.637" end="00:00:45.680" style="s2">of radiating and low back leg pain.</p>
<p begin="00:00:45.680" end="00:00:47.718" style="s2">In this particular case,<br />the caudal epidural</p>
<p begin="00:00:47.718" end="00:00:50.724" style="s2">steroid approach is utilized<br />to reduce the need for</p>
<p begin="00:00:50.724" end="00:00:54.471" style="s2">loss of resistance syringes,<br />fluoroscope radiation</p>
<p begin="00:00:54.471" end="00:00:56.392" style="s2">exposure to the patient, and removal</p>
<p begin="00:00:56.392" end="00:00:58.734" style="s2">of the need for ionic contrast.</p>
<p begin="00:00:58.734" end="00:01:02.438" style="s2">The same benefit can be<br />achieved utilizing ultrasound.</p>
<p begin="00:01:02.438" end="00:01:05.012" style="s2">In this particular case I'm<br />going to be using a Sonosite</p>
<p begin="00:01:05.012" end="00:01:08.664" style="s2">C60 probe because of its curvilinear shape</p>
<p begin="00:01:08.664" end="00:01:11.531" style="s2">which will facilitate viewing<br />of the sacral anatomy.</p>
<p begin="00:01:11.531" end="00:01:15.596" style="s2">This is key for the demonstration<br />of the relevant anatomy</p>
<p begin="00:01:15.596" end="00:01:17.231" style="s2">and ultimate placement of the needle</p>
<p begin="00:01:17.231" end="00:01:19.674" style="s2">for successful completion<br />of the procedure.</p>
<p begin="00:01:19.674" end="00:01:22.999" style="s2">The settings are set for<br />5.6 centimeter depth.</p>
<p begin="00:01:22.999" end="00:01:24.802" style="s2">Obviously this is patient specific.</p>
<p begin="00:01:24.802" end="00:01:27.361" style="s2">A larger patient may<br />require a deeper depth.</p>
<p begin="00:01:27.361" end="00:01:29.832" style="s2">The other setting is the<br />musculoskeletal setting</p>
<p begin="00:01:29.832" end="00:01:31.464" style="s2">or the MSK setting.</p>
<p begin="00:01:31.464" end="00:01:33.689" style="s2">This provides the best bony enhancement,</p>
<p begin="00:01:33.689" end="00:01:34.814" style="s2">and as we'll see we'll need to be</p>
<p begin="00:01:34.814" end="00:01:37.156" style="s2">passing a needle between two bony plates,</p>
<p begin="00:01:37.156" end="00:01:40.491" style="s2">and this setting facilitates<br />the best view of this.</p>
<p begin="00:01:40.491" end="00:01:43.038" style="s2">In order to facilitate<br />placement of the patient</p>
<p begin="00:01:43.038" end="00:01:45.533" style="s2">for the procedure, it is necessary to have</p>
<p begin="00:01:45.533" end="00:01:47.832" style="s2">the patient in the prone<br />position as seen here.</p>
<p begin="00:01:47.832" end="00:01:49.615" style="s2">This is a typical position<br />that would normally</p>
<p begin="00:01:49.615" end="00:01:52.710" style="s2">be used for a lumbar<br />epidural steroid approach.</p>
<p begin="00:01:52.710" end="00:01:55.119" style="s2">One key difference,<br />however, is the need to</p>
<p begin="00:01:55.119" end="00:01:58.087" style="s2">move the gluteal folds so that access</p>
<p begin="00:01:58.087" end="00:02:00.549" style="s2">to the sacral hiatus, which is the</p>
<p begin="00:02:00.549" end="00:02:02.929" style="s2">key target, is facilitated.</p>
<p begin="00:02:02.929" end="00:02:05.503" style="s2">In this particular case you<br />can see that the gluteal folds</p>
<p begin="00:02:05.503" end="00:02:08.223" style="s2">have been taped down and away in</p>
<p begin="00:02:08.223" end="00:02:10.739" style="s2">a caudal fashion to the patient.</p>
<p begin="00:02:10.739" end="00:02:13.369" style="s2">We now have a clean access point</p>
<p begin="00:02:13.369" end="00:02:15.605" style="s2">within the two gluteal folds.</p>
<p begin="00:02:15.605" end="00:02:17.921" style="s2">In order to facilitate a proper block,</p>
<p begin="00:02:17.921" end="00:02:19.836" style="s2">the following equipment is required.</p>
<p begin="00:02:19.836" end="00:02:23.276" style="s2">A chlorhexidine prep<br />for sterile technique,</p>
<p begin="00:02:23.276" end="00:02:25.750" style="s2">a local anesthetic syringe with a 27 gauge</p>
<p begin="00:02:25.750" end="00:02:29.260" style="s2">one and a half inch needle<br />for local anesthetic placement</p>
<p begin="00:02:29.260" end="00:02:31.244" style="s2">preferably one percent bicarbonated</p>
<p begin="00:02:31.244" end="00:02:33.051" style="s2">lidocaine, buffered lidocaine.</p>
<p begin="00:02:33.051" end="00:02:36.631" style="s2">A syringe containing<br />the epidural steroid mix</p>
<p begin="00:02:36.631" end="00:02:40.798" style="s2">which is composed of one<br />percent, one CC lidocaine,</p>
<p begin="00:02:42.246" end="00:02:45.367" style="s2">six CCs of bacteriostatic saline,</p>
<p begin="00:02:45.367" end="00:02:49.255" style="s2">and then 40 to 80 milligrams<br />of triamcinolone kenalog</p>
<p begin="00:02:49.255" end="00:02:52.003" style="s2">which is a particulate steroid.</p>
<p begin="00:02:52.003" end="00:02:53.662" style="s2">The needle utilized to enter the space</p>
<p begin="00:02:53.662" end="00:02:57.583" style="s2">is a three and a half inch spinal needle.</p>
<p begin="00:02:57.583" end="00:02:58.711" style="s2">For the conclusion of the procedure</p>
<p begin="00:02:58.711" end="00:03:00.652" style="s2">it will be necessary to have</p>
<p begin="00:03:00.652" end="00:03:03.043" style="s2">sterile four by four for cleanup</p>
<p begin="00:03:03.043" end="00:03:05.130" style="s2">and then a simple Band-Aid will suffice</p>
<p begin="00:03:05.130" end="00:03:07.130" style="s2">to cover the entry site.</p>
<p begin="00:03:08.659" end="00:03:11.710" style="s2">Placement of a copious amount of gel</p>
<p begin="00:03:11.710" end="00:03:13.996" style="s2">for coupling, aqueous<br />coupling is important</p>
<p begin="00:03:13.996" end="00:03:16.996" style="s2">to enhance resolution on the screen.</p>
<p begin="00:03:18.078" end="00:03:21.411" style="s2">And then contact is made in the midline.</p>
<p begin="00:03:22.951" end="00:03:26.238" style="s2">Because there's anatomic<br />variation in the midline,</p>
<p begin="00:03:26.238" end="00:03:29.690" style="s2">physiologically, a sagittal view</p>
<p begin="00:03:29.690" end="00:03:33.139" style="s2">and then gently rocking the probe</p>
<p begin="00:03:33.139" end="00:03:37.713" style="s2">in the oblique direction can<br />help find the spinous processes</p>
<p begin="00:03:37.713" end="00:03:40.130" style="s2">of the sacral space, and then</p>
<p begin="00:03:42.469" end="00:03:46.741" style="s2">the probe is moved<br />caudally and very clearly</p>
<p begin="00:03:46.741" end="00:03:48.840" style="s2">the sacral hiatus comes into view.</p>
<p begin="00:03:48.840" end="00:03:51.796" style="s2">There is a superior plate<br />and an inferior plate</p>
<p begin="00:03:51.796" end="00:03:55.038" style="s2">and in between them is the sacral hiatus.</p>
<p begin="00:03:55.038" end="00:03:58.693" style="s2">I'll demonstrate where<br />that access point is.</p>
<p begin="00:03:58.693" end="00:04:01.026" style="s2">The needle is angled thusly.</p>
<p begin="00:04:02.072" end="00:04:03.435" style="s2">At this point, I would utilize</p>
<p begin="00:04:03.435" end="00:04:07.953" style="s2">the local anesthetic to perform<br />a local anesthetic track</p>
<p begin="00:04:07.953" end="00:04:09.876" style="s2">down to this level.</p>
<p begin="00:04:09.876" end="00:04:11.394" style="s2">Removing that, I would then place</p>
<p begin="00:04:11.394" end="00:04:14.997" style="s2">the three and a half inch<br />25 gauge spinal needle</p>
<p begin="00:04:14.997" end="00:04:18.008" style="s2">along with the same anesthetized track</p>
<p begin="00:04:18.008" end="00:04:20.102" style="s2">and then once between the two plates,</p>
<p begin="00:04:20.102" end="00:04:24.269" style="s2">I would attach my local<br />anesthetic and steroids mix.</p>
<p begin="00:04:26.572" end="00:04:27.472" style="s2">- [Voiceover] The needle is visible</p>
<p begin="00:04:27.472" end="00:04:30.436" style="s2">as this view is in the long axis.</p>
<p begin="00:04:30.436" end="00:04:32.544" style="s2">The sacral plate is clearly visible,</p>
<p begin="00:04:32.544" end="00:04:34.961" style="s2">diving anterior and cephelad.</p>
<p begin="00:04:36.684" end="00:04:38.886" style="s2">Once the injectate enters the canal,</p>
<p begin="00:04:38.886" end="00:04:41.629" style="s2">the colored doppler shows<br />the fluid perturbation</p>
<p begin="00:04:41.629" end="00:04:44.393" style="s2">confined within the sacral epidural space,</p>
<p begin="00:04:44.393" end="00:04:46.650" style="s2">indicating a successful injection</p>
<p begin="00:04:46.650" end="00:04:49.567" style="s2">without need for contrast or X-ray.</p>
<p begin="00:04:51.366" end="00:04:54.324" style="s2">- Once the injectate is done<br />and the image is recorded</p>
<p begin="00:04:54.324" end="00:04:56.978" style="s2">as necessary for the medical record,</p>
<p begin="00:04:56.978" end="00:04:58.728" style="s2">the probe is removed.</p>
<p begin="00:04:59.783" end="00:05:02.578" style="s2">The needles are removed.</p>
<p begin="00:05:02.578" end="00:05:05.495" style="s2">The area is cleaned, and then place</p>
<p begin="00:05:07.427" end="00:05:09.976" style="s2">a Band-Aid over the wound.</p>
<p begin="00:05:09.976" end="00:05:12.671" style="s2">And thus this concludes<br />a successfully placed</p>
<p begin="00:05:12.671" end="00:05:15.504" style="s2">caudal epidural steroid injection.</p>