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Introduction
 Caudal anesthesia has been used for many years and is the easiest and safest
approach to the epidural space
 When correctly performed there is little danger of either the spinal cord or
dura being damaged
 It is used to provide peri and post operative analgesia in adults and most
commonly in children
 It can be used as a sole anesthetic for some procedures, or it may be

combined with general anesthesia.
Indications
 Anesthesia and analgesia below the umbilicus
 Obstetric analgesia :
 For the 2nd stage or instrumental deliveries.
 Care should be taken as the foetal head lies close to the site of injection
and there is real risk of injecting local anaesthetic into the foetus.
 Chronic pain problems relating to lower limbs and lower abdominal pains.
Contraindications
Infection near the site of the needle insertion.
Coagulopathy or anti coagulation.
Pilonidal cyst
Congenital abnormalities of the lower spine or meninges,

because of the unclear or impalpable anatomy.
Anatomy
The caudal epidural space is
the lowest portion of the
epidural system and is entered
through the sacral hiatus.
The sacrum is a triangular
bone that consists of the five
fused sacral vertebrae (S1- S5).
It articulates with the fifth
lumbar vertebra and the
coccyx.
The sacral hiatus is a defect in the
lower part of the posterior wall of
the sacrum formed by the failure
of the laminae of S5 and/or S4 to
meet and fuse in the midline.
The sacral canal is a continuation

of the lumbar spinal canal which
terminates at the sacral hiatus.
Choice of drugs & dosage
Drugs that are commonly used include Lignocaine 1% and
Bupivacaine 0.25%.
Technique
The patient is prepared as for general anesthesia:
He/she should be fasted
All appropriate equipment for resuscitation must be
available.
An iv cannula should always be inserted.
The procedure must be carried out with a strict aseptic
technique.
There are three main approaches:
 the prone,
 the semi-prone, and
 the lateral.
The choice depends on the preference of the
anesthetist and the degree of sedation of the patient.

The caudal space is made more prominent by asking
the patient to internally rotate their ankles.

The semi-prone position is preferred for the
anesthetised or heavily sedated patient as the airway is
easier to control in this position, while still allowing
reasonably easy access to the sacral hiatus.
The lateral position is often used in children, as the

landmarks are easier to find than in adults.
Care should be taken to avoid over flexing the hips as

this can make the landmarks more difficult to palpate
The landmarks are palpated.
The sacral hiatus and the
posterior superior iliac spines

form an equilateral triangle
pointing inferiorly.
The sacral hiatus can be located
by first palpating the coccyx, and

then sliding the palpating finger
in a cephalad direction until a
depression in the skin is felt.
7) Once the sacral hiatus
is identified the area
above is carefully
cleaned with antiseptic
solution, and
a 22 gauge cannula or
needle is directed at
about 45-90 degree to
skin and inserted till a
"click" is felt as the
sacro-coccygeal ligament
is pierced.
Care should be taken not to insert the needle too far as
the dura lies at or below the S2 level in the child.
The needle should be aspirated looking for either CSF

or blood.
The injection should never be more than 10 ml/30

seconds
Further tests to confirm the correct position include:
 Introduction of a small amount of air will not produce
subcutaneous emphysema, and will be heard as a

"woosh" sound if a stethoscope is place further up the
lumbar spine.
 There should be no resistance and local pain during
injection.
A small amount of local anesthetic should be injected as a
test dose (2-4mls).

It should not produce either a lump in the subcutaneous tissues,
or a feeling of resistance to the injection, nor any systemic

effects such as arrhythmias or hypotension.
If the test dose does not produce any side effects then the rest
of the drug is injected, the needle removed and the patient

positioned for surgery.
In the post-operative period, motor function must be
checked and the patient should not be allowed to try
and walk until complete return of motor function is
assured.
The patient should not be discharged from hospital
until he/she has passed urine, as urinary retention is a
recognised complication.
Complications
Intravascular or intraosseous injection.
 This may lead to grand mal seizures and/or cardio-respiratory arrest.
Dural puncture.
 If this occurs then the patient will become rapidly apnoeic and
profoundly hypotensive.
Perforation of the rectum.
 Contamination of the needle is extremely dangerous if it is then
inserted into the epidural space.
Sepsis.
 This should be a very rare occurrence if strict aseptic procedures are
followed.
Urinary retention.
Hematoma
CSE

anesthesia
CSEA is an increasingly popular technique, with an
estimated 10-fold increase in use in the past decade.
Its advantages include rapid onset, dense neuraxial

block, ability to titrate spread and duration of block, and
lower total drug dosage when compared to epidural
anesthesia.
Potential disadvantages include
increased time to perform the dual technique,
intrathecal migration of epidural drug and/ or catheter,
effects of increased epidural pressure from injection of
solutions on spinal block, and decreased ability and reliability
of epidural test.
Patient Selection and Clinical
Applications
Obstetrics
CSEA has been most widely accepted in the obstetric population.
The concept of the “walking epidural” has become popular among
patients, where intrathecal opioid allows rapid onset of analgesia without
motor blockade.
 Lipid-soluble opioids, such as fentanyl (up to 25 μg) and sufentanil (up
to 10 μg), are commonly used to provide dose-dependent analgesia for
60–90 minutes.
Opioids are also commonly combined with small doses of local anesthetics, such as
bupivacaine, to either prolong this initial spinal analgesia or to reduce side effects by
decreasing the required dose of opioids.
Previous dose response studies indicate that 2.5 mg of bupivacaine combined with either
15 μg of fentanyl or 2.5 μg of sufentanil provides satisfactory analgesia while reducing
incidences of nausea and pruritus, when compared to larger doses of opioids.
As an anesthetic for cesarean section, CSEA offers a rapid, titratable block, good
muscle relaxation, and the ability to use reduced doses of local anesthetic.
Several clinical trials have compared CSEA to epidural anesthesia with lidocaine or
bupivacaine combined with fentanyl.
These studies report more rapid onset, better motor block, decreased anxiety
levels, decreased shivering, and greater patient satisfaction with CSEA.
Ambulatory Anesthesia
The dose of local anesthetic determines both anesthetic success and

duration of recovery.
Availability of the epidural catheter for a rescue anesthetic allows use
of minimal doses of spinal local anesthetic with resultant rapid recovery
and discharge and represents an alternative or complementary strategy
to use of analgesic additives.
Techniques and Equipment
The most widespread approach used is the needle-through needle technique.
A number of commercial kits are available. The simplest version is a Tuohy needle (or
equivalent) through which a long, small-gauge spinal needle (24–30 gauge) is passed.
Epidural needles with a “back hole” are also available, configured to allow placement
of the spinal needle through a separate conduit so as to avoid angulation of the spinal
needle
Recent studies suggest that use of a back-hole needle may offer advantages over a
conventional needle through needle technique.
A randomized trial in parturients observed decreased incidence of paresthesia (14% vs.
42%) and failure to obtain CSF on the first attempt (8% vs. 28%) with the back-hole
needle.
 The separate conduit for the spinal needle may also reduce the theoretical risk of toxicity
from metal fragments caused by needle friction.
As an alternative to the needle through- needle technique, the double segment method also
offers the ability to place the epidural catheter and administer a test dose prior to placing
the spinal block.
Typically, the epidural and spinal portions are performed at different interspaces.
By first introducing the catheter, there exists the potential risk of damaging the catheter
with the spinal needle.
Furthermore, creating two separate cutaneous punctures could lead to increased incidence
of adverse events, including backache, headache, infection, and hematoma
A recent study demonstrated greater acceptance by surgical patients of the
needle-through-needle over the double- segment technique (85% vs 67%).
 That same study also showed a significantly longer time to perform the
double-segment technique without decreasing the failure rate of spinal
anesthesia, although other studies suggest a higher failure rate with the
needle- through-needle technique.
Potential Complications:
Failure of Spinal Anesthesia

The combined technique is associated with a higher failure rate of spinal anesthesia than conventional spinal
anesthesia.
There are a number of reasons for failure to occur.
(a) Smaller-gauge spinal needles with long lengths are typically used.
(b) Because the epidural needle has penetrated the tissue planes, there is little to anchor the spinal needle in place.
Although a Luer lock apparatus is available, it locks at a fixed needle length and can result in not reaching or traversing
the dura
(c) Any deviation from midline can lead to missing the dura altogether
(d) If loss-of-resistance technique used saline, a false return of saline in the spinal
needle rather than CSF can occur.
(e) Finally, patient positioning and duration between spinal injection and
completion of epidural catheter placement can change the characteristics of the
spinal block.
Failure of Epidural Anesthesia
The incidence of failure is unlikely to be higher with the combined technique;
however, the difficulty in early testing with a needle-through-needle technique may

lead to late recognition of a misplaced catheter.
Prior injection of spinal anesthetic precludes testing the epidural catheter for
intra thecal placement, and epidural injection of a test dose can lead to increased
height of spinal block
Intra thecal Effects of Epidural Agent
The intrathecal effects of epidurally administered drugs can occur

through migration of the epidural catheter through the dural puncture,
leakage of epidural anesthetic through the dural hole, and pressure effects of
epidural injection.
The likelihood of passing an epidural catheter through a dural hole is
very small, provided a 24-gaugauge or smaller spinal needle is used
Pressure effect
Pressure effect is the observation that increasing epidural volume can “squeeze” the CSF
compartment and thus raise the cephalad spread of spinal drugs.
A recent myelographic evaluation demonstrated that the subarachnoid space’s diameter decreased
to 25% after 10 mL normal saline was injected through an epidural catheter.
The ability to increase dermatomal spread by epidural volume appears to be time dependent.
Sensory block extension can be significant (3– 4 dermatomes) if epidural saline or air is injected soon
after or before bupivacaine spinal anesthesia.
This block enhancement may be clinically significant, as a recent clinical trial reported that CSEA
required 20% less local anesthetic than single-shot spinal anesthesia.
Summery
Combined spinal–epidural anesthesia (CSEA) is an increasingly
popular technique
studies report more rapid onset, better motor block, decreased anxiety
levels, decreased shivering, and greater patient satisfaction with CSEA
especially in obstetrics mothers.
The combined technique is associated with a higher failure rate of
spinal anesthesia than conventional spinal anesthesia.

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Introduction

 It can be used as a sole anesthetic for some procedures, or it may be

Coagulopathy or anti coagulation.

Congenital abnormalities of the lower spine or meninges,

The sacral canal is a continuation

He/she should be fasted

All appropriate equipment for resuscitation must be

The procedure must be carried out with a strict aseptic

 the semi-prone, and

The choice depends on the preference of the

anesthetist and the degree of sedation of the patient.

the patient to internally rotate their ankles.

The lateral position is often used in children, as the

Care should be taken to avoid over flexing the hips as

The sacral hiatus and the

posterior superior iliac spines

by first palpating the coccyx, and

The needle should be aspirated looking for either CSF

The injection should never be more than 10 ml/30

 Introduction of a small amount of air will not produce

subcutaneous emphysema, and will be heard as a

test dose (2-4mls).

or a feeling of resistance to the injection, nor any systemic

of the drug is injected, the needle removed and the patient

Its advantages include rapid onset, dense neuraxial

The dose of local anesthetic determines both anesthetic success and

Failure of Spinal Anesthesia

however, the difficulty in early testing with a needle-through-needle technique may

The intrathecal effects of epidurally administered drugs can occur

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