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Ultrasound guided caudal labor analgesia in a patient with Harrington rods
Abstract Number: S 58
Abstract Type: Case Report/Case Series
A caudal epidural catheter can provide effective labor analgesia in a parturient desiring neuraxial analgesia when a lumbar epidural catheter is not feasible. In patients whose anatomical landmarks for blind caudal epidural placement cannot be clearly identified, the use of an ultrasound may facilitate accurate, less traumatic, and faster placement of the catheter. We report the first successful ultrasound guided caudal catheter placement for labor analgesia.
A 27-year-old woman with a history of thoracic and lumbar Harrington rod placement presented to the labor and delivery unit at 38 weeks gestation. She described a previous delivery without analgesia due to unsuccessful epidural placement. She requested neuraxial labor analgesia, and we agreed to attempt caudal catheter placement.
The patient was positioned in the left modified Sims position. Using a curvilinear ultrasound probe, the sacral cornu, sacral hiatus, and sacrococcygeal ligament were identified in the transverse plane (Fig 1). Under ultrasound guidance, using the out of plane technique, a 17G Tuohy needle was advanced at a 45-degree angle through the sacrococcygeal ligament at the sacral hiatus and into the caudal epidural space. The catheter was advanced through the Touhy. The tip was identified at the L4-5 space with visualization assisted by color flow during bolus of normal saline. Following a negative test dose and analgesic dose, the patient was pain free with a bilateral sensory level of L3 to S2. She had excellent pain control throughout her labor with maintenance patient-controlled caudal epidural analgesia.
Utilization of caudal epidural labor analgesia is often limited by technical difficulties. Weight gain during pregnancy can make it difficult to palpate landmarks. There is anatomic variability in the sacral hiatus size, with some patients’ sacral hiatus being too small or closed, precluding caudal epidural injection . Ultrasound is being used more frequently to assist with neuraxial techniques to increase success rates and reduce complications . The use of this technique can make caudal epidural analgesia a reasonable alternative when lumbar epidural catheter placement is not possible.
1. Chen CP et al: Ultrasound as a screening tool for proceeding with caudal epidural injections. Arch Phys Med Rehabil. 2010 Mar;91(3):358-63.
2. Shankar H, Zainer CM: Ultrasound guidance for epidural steroid injections. Tech Reg Anesth Pain Manag. 2009 Oct;13(4): 229-35.