VIDEO GALLERY
Ultrasound-Guided Caudal Epidural to obtain the transverse sonographic view of the sacral
Injection Technique
Carl P.C. Chen, MD, PhD, Henry L. Lew, MD, PhD,
and Simon F.T. Tang, MD
From the Department of Physical Medicine & Rehabilitation,
Chang Gung Memorial Hospital, Linkou and Chang Gung
University College of Medicine, Tao-Yuan County, Taiwan
(CPCC, SFTT); Defense and Veterans Brain Injury Center,
Richmond, Virginia (HLL); Department of Physical Medicine
and Rehabilitation, Virginia Commonwealth University,
Richmond, Virginia (HLL); and John A. Burns School of Medicine,
University of Hawaii at Manoa, Honolulu, Hawaii (HLL).
Financial disclosure statements have been obtained, and no
conflicts of interest have been reported by the authors or by any
individuals in control of the content of this article.
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American Journal of Physical Medicine & Rehabilitation
Copyright * 2014 by Lippincott Williams & Wilkins
DOI: 10.1097/PHM.0000000000000047
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C audal epidural injection is the administering of
medications into the epidural space via the sacral hiatus
route.1,2 It is an injection technique for the treatment of
low back pain caused by disease entities such as lumbosacral
nerve root compression.2 Successful caudal epidural injection
relies on accurate placement of a needle into the epidural
space (sacral canal) through the sacral hiatus. Even with
experienced physicians, the failure rate of inserting the needle
accurately into the caudal epidural space via the sacral hiatus
can be up to 25% when using the blind method.3 Chen et al.2
have demonstrated that musculoskeletal ultrasound can be
used as an adjuvant tool in placing the needles accurately into
the caudal epidural space.
Ultrasound-Guided Caudal Epidural
InjectionVHow It Is Approached
With the patient placed in a prone position, the ultra-
sound transducer is first placed transversely at the midline
All correspondence and requests for reprints should be addressed to Simon F.T. Tang,
MD, Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital,
Linkou and Chang Gung University College of Medicine, Tao-Yuan County, Taiwan.
82
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
hiatus. It is under this transverse view that the cornua of
the sacrum, the sacrococcygeal ligament, and the sacral
hiatus opening can be observed (Fig. 1).2 Then, the trans-
ducer is rotated 90 degrees to rest between the two cornua
and to obtain the longitudinal sonographic view of the
sacral hiatus. It is under the longitudinal view that the
caudal epidural needle is guided by ultrasound and inserted
into the caudal epidural space.2 The advancement of the
needle between the two cornua to the sacral hiatus and then
into the caudal epidural space can be observed through
continuous and real-time sonographic imaging.
When the needle pierces through the sacrococcygeal
ligament and enters the sacral hiatus, the portion of the
needle inside the caudal epidural space can no longer be ob-
served under sonography (Fig. 2). This is because ultrasound
waves cannot penetrate through the posterior sacral bony
surface situated on the top of the needle. Ultrasound-guided
injection technique has been shown to have 100% accuracy
in correct needle placement.2 The sacral canal is filled with
fluid, fat, and loose areolar connective tissue. These struc-
tures allow the spread of the injected medical solution in a
rostral direction. Complications after caudal injection often
result from misplacement of the needle into the intravascular,
intraosseous, and even intrathecal locations, possibly leading
to detrimental injection technique failure, systemic toxicity,
or accidental spinal anesthesia. As a result, it is crucial that a
negative pressure should be applied to the syringe first to
ensure that no blood is aspirated before further injection can
be continued.4
Ultrasound can provide sonographic images that reveal
anatomic variations of the sacral hiatus, such as a closed
or small sacral hiatus.5 It has been shown that ultrasound-
guided caudal epidural injection cannot be performed in
patients with sonographic images indicating a closed sacral
hiatus (no opening to insert the needle into the sacral canal).
FIGURE 1 Sonographic transverse view of the sacral hiatus,
showing image locations of the cornua of the sa-
crum, the sacral hiatus, and the sacrococcygeal
ligament.
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 1, January 2015
 into the sacral canal for subsequent epidural injection. This
video thoroughly explains the anatomic structures of the
sacral hiatus when viewed under musculoskeletal ultra-
sound and how the injection needle is guided into the sacral
canal. Before injecting, it is recommended that a nega-
tive pressure should be applied to the syringe first to en-
sure that no blood is aspirated. This is to prevent possible
detrimental intravascular, intraosseous, and even intrathe-
cal injections.

REFERENCES
1. Chen CP, Lew HL, Tsai WC, et al: Ultrasound-guided injection
techniques for the low back and hip joint. Am J Phys Med
FIGURE 2 Sonographic longitudinal view of the sacral hiatus, Rehabil 2011;90:860Y7
showing the advancement of the needle piercing
through the sacrococcygeal ligament and into the 2. Chen CP, Tang SF, Hsu TC, et al: Ultrasound guidance in caudal
sacral hiatus. epidural needle placement. Anesthesiology 2004;101:181Y4
3. Chen CP, Wong AM, Hsu CC, et al: Ultrasound as a screening
Sacral hiatus with diameters ranging from 1.2 to 1.6 mm tool for proceeding with caudal epidural injections. Arch Phys
(significantly smaller as compared with the average diameter) Med Rehabil 2010;91:358Y63
may indicate a higher failure rate in performing caudal epi- 4. Park JH, Koo BN, Kim JY, et al: Determination of the optimal
dural injections.3 angle for needle insertion during caudal block in children
using ultrasound imaging. Anaesthesia 2006;61:946Y9
CONCLUSIONS 5. Sekiguchi M, Yabuki S, Satoh K, et al: An anatomic study of
Ultrasound-guided caudal injection technique has been the sacral hiatus: A basis for successful caudal epidural block.
shown to have 100% accuracy in correct needle placement Clin J Pain 2004;20:51Y4

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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.