Ultrasound-guided caudal epidural injection to treat symptoms of lumbar spinal stenosis: a retrospective study

Submitted: 8 December 2023
Accepted: 15 February 2024
Published: 7 May 2024
Abstract Views: 369
PDF: 114
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.


Lumbar spinal stenosis (LSS) occurs when bony, ligamentous, and synovial elements of the lower axial spine degenerate and overgrow, compressing neural and vascular elements in the spinal canal. Compression can cause static back pain, radicular lower extremity pain, or neurogenic claudication. Radiological and clinical findings are needed to diagnose lumbar stenosis. In this framework, caudal epidural steroid injection (ESI) is a standard treatment. The volume injected and needle positioning are the main issues that could compromise the effectiveness of the epidural injection. However, ultrasound-guided caudal epidural injections have become more common in recent years. Since Klocke and colleagues described the ultra-sound-guided caudal block in 2003, it has grown in popularity. Multiple ethnic studies have reported ultrasound-guided caudal injection success rates of 96.9–100%. Color Doppler ultrasonography can also determine if a drug solution reaches the lumbosacral region. We enrolled 42 patients with lumbar spinal stenosis, persistent lumbosciatalgia, and neurogenic claudicatio unresponsive to painkillers who were not surgical candidates. Each patient receives four weekly injections for four weeks. If the patient responds to treatment but still has pain, monthly injections are needed to reach and maintain the benefit. Treatment will be changed if the patient does not respond after 4 caudal injections. Sterile caudal epidural injections are performed with ultrasound guidance and a spinal needle 21G. Triamcinolone 40 mg, levobupivacaine 10 mg, and physiological solution 10 ml are delivered. Each patient received an average of 4 injective treatments (4±2, Means 4, SD 2). Data analysis shows that the treatment reduced pain significantly before and after therapy, which persisted after 3 months. Caudal epidural injection is one of the most common conservative treatments for chronic low back pain with radiculopathy, and lidocaine alone or with steroids is effective. In this framework, the two main literature issues about caudal epidural injection effectiveness on lumbar pain are correct. Therefore, 10 ml is suitable and effective for treating symptoms without side effects. Pain reduction of over 50% from start to finish and three-month follow-up have shown significant results in pain control and disability improvement. Finally, caudal epidural injection for lumbar spinal stenosis symptoms is effective, safe, and provides long-term pain relief.

Bagley C, MacAllister M, Dosselman L, et al. Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Res 20198:F1000 Faculty Rev-137. DOI: https://doi.org/10.12688/f1000research.16082.1

Vikram K. Caudal epidural steroid injections-a mini review. Open Access J Neurol Neurosurg 2017;3:555606. DOI: https://doi.org/10.19080/OAJNN.2017.03.555606

Liu K, Liu P, Liu R, et al. Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis. Drug Des Devel Ther 2015;9:707-16. DOI: https://doi.org/10.2147/DDDT.S78070

Ibrahim ME, Awadalla MA, Omar AS, Al-Shatouri M. Ultrasound-guided caudal epidural steroid injection in chronic radicular low back pain: short-term electrophysiologic benefits. BJR Open 2020;2:20190006. DOI: https://doi.org/10.1259/bjro.20190006

Kao SC, Lin CS. Caudal epidural block: an updated review of anatomy and techniques. Biomed Res Int 2017;2017:9217145.

Stitz MY, Sommer HM. Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine (Phila Pa 1976) 1999;24:1371-6. DOI: https://doi.org/10.1097/00007632-199907010-00016

Kao SC, Lin CS. Caudal epidural block: an updated review of anatomy and techniques. Biomed Res Int. 2017;2017:9217145.

Nagpal AS, Vu T-N, Gill B, et al. Systematic review of the effectiveness of caudal epidural steroid injections in the treatment of chronic low back or radicular pain. Intervent Pain Med 2022;4:100149. DOI: https://doi.org/10.1016/j.inpm.2022.100149

Koo BS, Kang WB, Park JW, et al. Analysis of caudal epidurogram in single center: A preliminary study of lumbar radiculopathy management. Medicine (Baltimore) 2018;97:e12810. DOI: https://doi.org/10.1097/MD.0000000000012810

Manchikanti L, Cash KA, Pampati V, et al. Evaluation of fluoroscopically guided caudal epidural injections. Pain Physician 2004;7:81-92. DOI: https://doi.org/10.36076/ppj.2004/7/81

Yoon JS, Sim KH, Kim SJ, et al. The feasibility of color Doppler ultrasonography for caudal epidural steroid injection. Pain 2005;118:210-4. DOI: https://doi.org/10.1016/j.pain.2005.08.014

Yoo SW, Ki MJ, Doo AR, et al. Prediction of successful caudal epidural injection using color Doppler ultrasonography in the paramedian sagittal oblique view of the lumbosacral spine. Korean J Pain 2021;34:339-45. DOI: https://doi.org/10.3344/kjp.2021.34.3.339

Kim KM, Kim HS, Choi KH, Ahn WS. Cephalic spreading levels after volumetric caudal epidural injections in chronic low back pain. J Korean Med Sci 2001;16:193-7. DOI: https://doi.org/10.3346/jkms.2001.16.2.193

Cleary M, Keating C, Poynton AR. The flow patterns of caudal epidural in upper lumbar spinal pathology. Eur Spine J 2011;20:804-7. DOI: https://doi.org/10.1007/s00586-010-1613-5

Feise RJ, Michael Menke J. Functional rating index: a new valid and reliable instrument to measure the magnitude of clinical change in spinal conditions. Spine (Phila Pa 1976) 2001;26:78-86; discussion 87. DOI: https://doi.org/10.1097/00007632-200101010-00015

Monticone M, Baiardi P, Ferrari S, et al. Development of the Italian version of the Oswestry Disability Index (ODI-I): A cross-cultural adaptation, reliability, and validity study. Spine (Phila Pa 1976) 2009;34:2090-5. DOI: https://doi.org/10.1097/BRS.0b013e3181aa1e6b

Kao SC, Lin CS. Caudal epidural block: an updated review of anatomy and techniques. Biomed Res Int 2017;2017:9217145. DOI: https://doi.org/10.1155/2017/9217145

Marinangeli F, Ciccozzi A, Donatelli F, et al. Uso degli steroidi per via spinale ed epidurale [Clinical use of spinal or epidural steroids]. Minerva Anestesiol 2002;68:613-20. Italian.

Manchikanti L, Knezevic NN, Boswell MV, et al. Epidural injections for lumbar radiculopathy and spinal stenosis: a comparative systematic review and meta-analysis. Pain Physician 2016;19:E365-410. DOI: https://doi.org/10.36076/ppj/2016.19.E365

Bosscher H. Pressure-volume relationships in the spinal canal and potential neurological complications after epidural fluid injections. Front Pain Res (Lausanne) 2022;3:884277. DOI: https://doi.org/10.3389/fpain.2022.884277

Gagliardi, V., Lovato, A., Ceccherelli, F., & Gagliardi, G. (2024). Ultrasound-guided caudal epidural injection to treat symptoms of lumbar spinal stenosis: a retrospective study. European Journal of Translational Myology. https://doi.org/10.4081/ejtm.2024.12167


Download data is not yet available.