PROCEDURE:

  1. Caudal epidural steroid injection with fluoroscopy
  2. 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