Caudal anaesthesia (or caudal anesthesia) is a form of neuraxial

regional anaesthesia Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, i.e. local insensitivity to pain, although other local senses may be affected as well. It all ...

conducted by accessing the epidural space via the sacral hiatus. It is typically used in paediatrics to provide peri- and post-operative analgesia for surgeries below the umbilicus. In adults, it can be used in the context of anorectal surgery or for chronic low back pain management. It can be used as an alternative to general anaesthesia or as adjunct to it.

Indications

Caudal anaesthesia is a relatively low-risk technique commonly used, either on its own or in combination with

sedation Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...

general anaesthesia General anaesthesia (UK) or general anesthesia (US) is medically induced loss of consciousness that renders a patient unarousable even by painful stimuli. It is achieved through medications, which can be injected or inhaled, often with an analges ...

. Caudal anesthesia may be favored for sub-umbilical region surgeries in the pediatric population, such as inguinal hernia repair, circumcision, hypospadias repair, anal atresia, or to immobilise newborns with hip dysplasia. Success rate is limited when used for mid-abdominal interventions such as umbilical hernia repair. This is due to the unpredictable cephalad spread of the local anesthetics. It may also be used in patients with lumbar spinal stenosis, lumbar spinal radiculopathy, postlaminectomy pain, or nonspecific chronic low back pain that fail conservative treatment. List of indications: * Obstetrics and general surgery below the umbilicus * Acute and chronic pain refractory to conservative management * Patients with previous lumbar spine surgery * Patients who are "anticoagulated" or have coagulopathy

Contraindications

Contraindications to caudal anesthesia include patient or guardian refusal, localized infection over the sacral area such as

pilonidal disease Pilonidal disease is a type of skin infection that typically occurs as a cyst Intergluteal cleft, between the cheeks of the buttocks and often at the upper end. Symptoms may include pain, swelling, and redness. There may also be drainage of fluid ...

, severe coagulopathy and elevated

intracranial pressure Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury ( mmHg) and at rest, is normally 7–15 mmHg for a supine adu ...

. It should also be avoided in case of allergies to local anesthetics to be used for the procedure.

Risks and complications

Serious complications are infrequent. When they occur, they are similar those encountered with lumbar epidural block. Some of the risks associated with caudal anesthesia include: * Needle misplacement leading to subdural, intravascular, intraosseous or antesacral injection with

rectum The rectum (: rectums or recta) is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. Before expulsion through the anus or cloaca, the rectum stores the feces temporarily. The adult ...

perforation * Infection, such as

epidural abscess An epidural abscess refers to a collection of pus and infectious material located in the epidural space superficial to the dura mater which surrounds the central nervous system. Due to its location adjacent to brain or spinal cord, epidural absce ...

meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, intense headache, vomiting and neck stiffness and occasion ...

or sacral osteomyelitis *

Low blood pressure Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is ...

* Injury to the nerve roots * Epidural hematoma *

Local anesthetic toxicity A local anesthetic (LA) is a medication that causes absence of all sensation (including pain) in a specific body part without loss of consciousness, providing local anesthesia, as opposed to a general anesthetic, which eliminates all sensation ...

, more frequently following caudal anesthesia than it does following lumbar or thoracic blocks. The most common complications of the anatomic technique for caudal block include: needle misplacement, subarachnoid puncture, and

intrathecal Intrathecal administration is a route of administration for drugs via an injection into the spinal canal, or into the subarachnoid space (sin. ''intrathecal space'') so that it reaches the cerebrospinal fluid (CSF). It is useful in several applic ...

intravascular Blood vessels are the tubular structures of a circulatory system that transport blood throughout many animals’ bodies. Blood vessels transport blood cells, nutrients, and oxygen to most of the tissues of a body. They also take waste and c ...

injections.

Technique

A caudal block may be performed by using anatomic landmarks to guide needle insertion. However, greatest accuracy is obtained by performing caudal blocks using imaging guidance, such as ultrasound or fluoroscopy. Common local anesthetic drugs for caudal blockade are bupivacaine and ropivacaine. Opioids, ketamine or opioids are common drug added as they prolong the postoperative analgesia while minimizing the motor block.

History

Caudal anesthesia was first described independently in 1901 by Fernand Cathelin and

Jean-Athanase Sicard Jean-Athanase Sicard (23 June 1872 – 28 January 1929) was a French neurologist and radiologist born in Marseille. He studied medicine in Marseille and Paris, where he studied with Charles Emile Troisier (1844-1919), Édouard Brissaud (1852-1909 ...

. It predates the lumbar epidural approach which was described by Fidel Pagés Miravé in 1921. However, the high failure rate found in caudal anesthesia (5–10%) limited its popularity until the 1940s when it resurfaced in obstetrics anaesthesia. The first publication to describe caudal anaesthesia in children was published by Meredith Campbell in 1933.

References