PROCEDURE:
- Caudal epidural steroid injection with fluoroscopy
- S1 and S2 epidural steroid injection
DATE OF PROCEDURE:
INDICATION: Patient with chronic lower back and left sciatic distribution pain.
OPERATORS: John Doe, MD (Attending)/Jane Doe, MD (Fellow)
EPIDURAL INJECTION MIXTURE:
Caudal epidural steroid injection: 40 mg Kenalog +3 cc bupivacaine.
S1 epidural steroid injection: 20 mg Kenalog +3 cc bupivacaine
‘s S2 epidural steroid injection 20 mg Kenalog +3 cc bupivacaine.
CONTRAST: 3 mL M300 contrast
FLUOROSCOPY TIME: 12 minutes
ACCESS SITE:
- Midline sacral hiatus
- S1 and S2 posterior sacral foramina
COMPLICATIONS: None immediate.
TECHNIQUE:
The risks, benefits and alternatives to the procedure and conscious sedation were discussed with the patient and/or the patient’s surrogate. Both verbal and written informed consent were obtained.
A timeout/call-to-order was performed with the patient in the angiography suite.
The lower back was prepped and draped in usual sterile fashion. A scout fluoroscopic image was used to count vertebral bodies. A midline caudal entry site was identified on the AP projection, well below the S2-3 level. The skin was anesthetized. Under intermittent fluoroscopic guidance in the lateral projection, a 22 -gauge x 3.5 cm spinal needle was advanced toward the epidural space through the sacral hiatus. A small injection of contrast confirmed epidural location.
The steroid and anesthetic mixture was then injected. Needle was then removed and pressure was held to obtain hemostasis.
Then attention was turned to the S1 sacral foramen. Under real-time fluoroscopic imaging the soft tissues superficial to this S1 sacral foramina were infused with 2% lidocaine. A 22-gauge 3 inch spinal needle was advanced under direct fluoroscopic guidance into the sacral foramen. Small contrast injection was utilized to identify the S1 epidural space. The steroid and anesthetic mixture was then injected. The needle was removed and pressure held.
Then attention was turned to the S2 sacral foramen. Under real-time fluoroscopic imaging the soft tissues superficial to this S2 sacral foramina were infused with 2% lidocaine. A 22-gauge 3 inch spinal needle was advanced under direct fluoroscopic guidance into the sacral foramen. Small contrast injection was utilized to identify the S2 epidural space. The steroid and anesthetic mixture was then injected. The needle was removed and pressure held.
FINDINGS:
Fluoroscopic image following injection of the epidural space demonstrates no intrathecal contrast. The spinal needle enters the midline sacral hiatus, the S1 and S2 sacral foramina. There is appropriate linear filling of the epidural space.
IMPRESSION:
Uneventful caudal and S1 and S2 epidural steroid injections
The attending radiologist, Dr. John Doe, was present for the procedure and interpreted the images
Frequently Asked Questions
What is a caudal epidural steroid injection?
A caudal epidural steroid injection is a procedure where medication is injected into the epidural space near the tailbone (sacral hiatus) to reduce inflammation and relieve pain in the lower back and leg areas. The injection typically includes a combination of a steroid, like Kenalog, which reduces inflammation, and an anesthetic, such as bupivacaine, which helps numb the pain.
How does fluoroscopy assist in epidural steroid injections?
Fluoroscopy is an imaging technique that provides real-time X-ray images, allowing physicians to guide the needle precisely during an epidural steroid injection. This ensures accurate placement of the medication in the epidural space, enhancing the effectiveness of the treatment and minimizing the risk of complications.
What conditions are treated with S1 and S2 nerve block injections?
S1 and S2 nerve block injections are used to treat conditions causing chronic pain in the lower back and legs, such as sciatica, herniated discs, and spinal stenosis. These injections help reduce inflammation around the affected nerves, providing pain relief and improving mobility.
Are there any complications associated with caudal epidural steroid injections?
While caudal epidural steroid injections are generally safe, potential complications can include bleeding, infection, increased pain, or nerve damage. However, using fluoroscopy minimizes these risks by ensuring precise needle placement. Patients are monitored for any immediate complications during and after the procedure.
What is the recovery process like after an epidural steroid injection?
After an epidural steroid injection, patients might experience temporary soreness at the injection site. Pain relief can begin within a few days, though it may take up to a week for full effects. Patients are usually advised to rest on the day of the procedure and gradually resume normal activities as tolerated.
How long does the effect of an epidural steroid injection last?
The duration of pain relief from an epidural steroid injection can vary. Some patients experience relief for several weeks, while others may find it lasts for several months. The longevity of relief depends on the underlying condition, the accuracy of the injection, and individual patient factors.
Why is contrast used during an epidural steroid injection?
Contrast dye is used during an epidural steroid injection to confirm the correct placement of the needle. It enhances the visibility of the epidural space under fluoroscopy, ensuring the medication is delivered precisely where needed, which is crucial for the effectiveness and safety of the procedure.
What is the purpose of using lidocaine in S1 and S2 injections?
Lidocaine is a local anesthetic used to numb the area before inserting the needle into the S1 and S2 foramina, reducing discomfort during the procedure. It helps ensure that the patient remains as comfortable as possible while the physician accurately administers the steroid and anesthetic mixture.