Chronic Rectal Perineal Pain Helped by Simple Caudal Block

80 year old with sharp, intermittent, burning pain worsened on sitting down relieved by simple steroid caudal block when all other measures failed.

41st Annual Regional Anesthesiology and Acute Pain Medicine Meeting
Thursday, March 31, 2016–Saturday, April 2, 2016 Abstract:1491
Low dose caudal epidural steroid injection for chronic pelvic pain
Preetika Kataria, Aman Upadhyay, Vivek Loomba
https://www.asra.com/content/documents/_all_presented_absracts_ra16.pdf

  • 80 yr old woman
  • 5 years rectal pain 8/10
  • neuropathic – sharp, intermittent, burning pain
  • some features pudental neuropathy – worsen problem sitting down and prolonged latency on pudental nerve EMG on right
  • pudendal nerve block and subsequent ganglion impar block – no benefit
  • Various neuropathic helping meds no help but we now know they only help in 23.7% cases – NSAIDs, acetaminophen and gabapentin 3600 mg daily
  • caudal epidural steroid injection with 3 ml of 0.25% bupivacaine,
    depomedrol 80 mg and 6 ml of 0.9% normal saline
  • pain dropped to 0/10 and was so at 3 week followup

Comment – I wonder it there was a sacral tarlov cyst irritating a nerve root and that is just waiting to be shut down.

Injecting the sacral haitus can be a risky business in elderly where any advancement of needle up can be painful. The recent finding of a vertical placement of needle into hiatus with injection would help.

Anesth Pain Med. 2016 May 10;6(3):e35340. eCollection 2016.
Vertical Small-Needle Caudal Epidural Injection Technique.
Maniquis Smigel L1, Dean Reeves K2, Jeffrey Rosen H3, Patrick Rabago D4.
https://www.ncbi.nlm.nih.gov/pubmed/27826539

  • use a 25 gauge 3.7 cm hypodermic needle
  • if placement is not right it will be hard inject but a simple adjustment on the hole will make it work better and then patient will feel the pressure in back higher up as it goes in

that requires some depth to the sacral hiatus.

Surg Radiol Anat. 2017 in press
doi: 10.1007/s00276-017-1823-1.
Anatomy of the sacral hiatus and its clinical relevance in caudal epidural block.
Bagheri Het et al
https://www.ncbi.nlm.nih.gov/pubmed/28247084

“Depth of hiatus less than 3 mm may be one of the causes for the failure of needle insertion.” Fortunately, that occurs only 8.7% of time but I bet is more in elderly

I have a lady with complex mixture of piriformis, inferior gluteal nerve irritation, pudental neuropathy, thoracolumbar back pain, cluneal nerve pains, rib-iliac crest impingement, and gluteus medius medius bands. Much has settled down with multiple treatments but lasting benefits are elusive. I wonder if a caudal would help. Did try a sweet caudal the old fashioned way but that was painful – maybe she would go for a vertical steroid one.

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