Caudal Injection

OVERVIEW AND INDICATIONS FOR PROCEDURE

Caudal epidural injection is recommended for patients who have back pain that radiates to the legs or who have
coccyx pain. It is performed with x-ray guidance and its goal is to reduce pain, improve function and enable
patient's to participate in a physical therapy program, tolerate prolonged sitting and standing, and increase
ability to walk or work. Pain relief comes by means of reduction in inflammation of tissue. When injection is
coupled with organized therapy program, activity modification, use of cushions and braces, the effect appears to
be enhanced.

RISK ASSOCIATED WITH PROCEDURE

It is important to know the risks associated with any medical or surgical treatment. There are a few risks associated with caudal epidural steroid injections but they tend to be rare.

The potential risks include:

Immediate or delayed allergic reaction to medication used
Infection
Bleeding
Nerve Injury
Dural Puncture
Temporary increase in pain
High blood sugar levels
Transient vaginal spotting
Transient facial flushing
Vascular uptake of a particular steroid, cord ischemia

Infection rate is less than 1% in patients receiving spinal injections performed under sterile conditions. The
bleeding complication is more common in patients with a history of a bleeding disorder. This includes patients
being treated with anticoagulant/antiplatelet medications and patients taking over the counter medications like
Motrin and Aspirin. The frequency of injury to the nerve roots or spinal cord is substantially reduced with use
of fluoroscopy and contrast material. It is rare to encounter nerve root or spinal cord injury with epidural
injections. The rate of nerve injury and spinal cord injury is higher in obese patients due to poor visualization
of the target on lateral X-rays. Dural puncture is an infrequent complication and may cause a positional
headache (headache in seated and standing positions but not in laying down position). This type of headache is
often self-limiting, although in persistent cases, a blood patch may be necessary to alleviate the headache.
Elevated blood sugar is a known effect of steroid medication and may last for 2-4 days after the injection of
steroids. Patients on insulin will need to follow sliding scale to adjust for elevated sugar levels. Patients on oral
medication should follow primary care advice regarding temporary increase in oral medication to accommodate
for blood sugar levels.

The following side effects tend to be rare, though they become more common when steroids are taken daily for several months.

These risks and side effects may include:

A transient decrease in immunity
Stomach ulcers
Severe arthritis of the hips
Avascular necrosis of joints
Cataracts
Increased appetite
Agitation and irritability
Negative effect on bone density and fractures

Who should avoid Caudal Steroid Injections?

Caudal Epidural Steroid Injections should not be performed on persons with the following conditions:

Individuals with known allergies to local anesthetics, steroids or contrast material
Patients with local or systemic bacterial infection
Pregnant patients
Patients with bleeding disorders
Patients suffering from a tumor or infection of the spine
Uncontrolled congestive heart failure or diabetes
When the risk of holding certain mediations (Aspirin, antiplatelet drugs/blood thinners) outweighs the benefit of the epidural procedure

PREPARE FOR YOUR PROCEDURE

Certain medications have to be held before elective spinal procedures. We will provide you with the list of medications that has to be held with the exact number of days it needs to be held. Do not hold such medication on your own. Consult your Primary Care Physician (or Cardiologist) before stopping those medications. Ask your PCP if it is safe to stop the medication. Continue to take all other medications, especially your Blood Pressure medications.

A sample of medications that have to be held includes:

Aggrenox® (dipyridamole)
Aspirin
Coumadin® (warfarin)
Effient® (prasugrel)
Fragmin® (dalteparin)
NSAIDS (see sample below)
Herbal blood-thinners
Heparin
Eliquis ® (apixaban).
Lovenox® (enoxaparin)
Plavix® (clopidogrel),
Pradaxa® (dabigatran)
Ticlid® (ticlopidine)

Examples of NSAIDS to be held: Ibuprofen, Motrin, Naproxen, Advil, Nabumetone, Diclofenac, Etodolac, Indomethacin, Ketorolac, Meloxicam, Piroxicam, Ketoprofen, Oxaprozin

Please let us know if you have had fevers, antibiotic treatment, any illness, or hospitalization within the last 4 weeks. You must be healthy and off all antibiotics on the day of the procedure

Make sure you are not pregnant at the time of procedure. Do a Urine Pregnancy Test the night before your spinal injection and report the results to the nurse before the procedure. Exposure to X-ray (used during spinal procedure) is known to result in birth defects and possible miscarriage. If in doubt, cancel and reschedule your procedure until you can confirm that you are not pregnant

DAY OF YOUR PROCEDURE

Please take a shower, wash the skin with normal soap and DO NOT put skin lotions or mediated creams in the area of the injection. Wear dark and loose clothing and undergarment.
Arrive 30 minutes early and come with someone that can give you a ride home. Your procedure should take less than 30 minutes and your total time from greeting to end should be less than 90 minutes.
Bring an updated list of your medications and allergies. Please point out if you are allergic to Contrast, Iodine or Latex.
Bring your latest imaging studies (x-ray, MRI or CT) and the report with you.
Do not eat or drink for 2 hours before your appointment. Diabetics may have a light meal.
After check-in, an ID wristband containing your name and allergies will be placed on your wrist. A nurse or medical assistant will go over your meds and allergies and ask few screening questions. Then a nurse will go over final preparation before the procedure. If necessary, an IV line will be placed, particularly if this is your first spinal procedure.
In rare cases, oral sedation is needed to reduce anxiety associated with the procedure. This will slow down the entire process. Take medication 1 hour before the procedure and you must have someone drive you to and from the procedure. Without the ride, procedure would likely be canceled.

DURING THE PROCEDURE

You will change into a gown. You will be escorted to the procedure by a nurse and a consent form will be reviewed/ signed before the procedure. You will be asked to lay on your stomach
Blood pressure and heart rate monitor will be placed on your arm/finger. All the medical equipment produces loud noises (beeping, alarms) and you should not be concerned.
Intermittently your doctor will talk to staff in the procedure room and instruct them to perform a task. Your physician will guide you step by step through the procedure.
After standard time out, your skin will be disinfected with a cool solution, and sterile sheet of paper or plastic will be placed on your skin.
When your physician is ready, X-ray unit is placed over your spine to identify the target.
Skin will be marked near the intergluteal cleft and anesthetized (you will feel a small pinch and burning sensation). It is normal to feel pressure or muscles twitching as needles are advanced to the final target.
Once needle is at radiographic target, a small amount of contrast is injected to confirm final needle position before injecting steroid medication. You may feel transient pressure in your spine or arm.
Once procedure is completed, needle is removed, skin is cleaned and bandage is applied. You are then transferred back to the recovery area for observation.

RIGHT AFTER THE PROCEDURE

You will be observed for 15-45 minutes.
If you have an IV line, it will be removed.
A nurse will check your vitals and review the discharge instructions with you and will answer any
questions you may have. A responsible adult must be present to drive you home after discharge.
You will leave with a pain log and a copy of the discharge instruction which contains emergency
contact numbers. Please do not discard your discharge instructions.
A responsible adult must drive you home.

DISCHARGE INSTRUCTIONS

Make a follow-up 2-3 weeks after the procedure and bring your pain log with you.
For 24 hours after the procedure, do not drive or operate machinery
If sedation is used, for 24 hours after the procedure, do not make financial or important life decisions
until the effect of such medication is cleared
For 24 hours after the procedure, do not participate in strenuous activity
It is okay to shower after the procedure. No bathing /submerging under water for 24 hours.
You may remove the bandages 24 hours after the injection. Call if there is excessive redness or signs of
infection like warmth, discharge or collection of pus at the site of injection.
You may resume your normal diet and medications after procedure.
Resume your Blood Thinners/ Anticoagulants / Antiplatelet as instructed by PCP or Cardiologist. You
may need to check INR/PT/PTT 2-3 days after your procedure. Contact your primary care and ask
when you should have the blood work.
Diabetics should monitor blood sugar levels 3 times a day for 3 days after the procedure.

Call your doctor if you develop these symptoms. You may be directed to ER:

Shortness of breath or palpitation after procedure
Sudden weakness
Fever over 101°F within 5 days after procedure
Persistent redness, increased localized pain, or discharge from the site of injection.
Possible allergic reaction within 5 days of the procedure
Intractable headache
Significant increased pain not responding to ice, NSAIDS and pain meds or associated with fever
Newly developed weakness in the legs, face or arm following procedure
Newly developed incontinence of urine or stool following procedure

INSURANCE

Most insurance requires prior authorization to cover this procedure (Medicare beneficiaries require no authorization). Your doctor will provide information to the insurance company for approval. It takes anywhere from 3-15 days for approval.
You will likely have some financial responsibility for this type of treatment. (copay/coinsurance/deductible) You will also receive two medical bills related to these types of treatments (Ambulatory SurgiCenter bill and Doctors bill). Please call your insurance company to understand your benefits. The codes used for this procedure are: CPT: 62323 and 77003.

Patient Instructions for Temporary Holding of Medications before Spinal Procedures/Injections

IF YOU HAVE ANY QUESTIONS REGARDING THESE INSTRUCTIONS CALL 617 547 7163

The decision to discontinue or hold medications should be shared between the spine specialist, patient, and prescribing physician (usually PCP, cardiologist or neurologist). These medications are held for specific period of time to limit bleeding complications during and within the 1st 24-72 hours after procedure. We follow nationally recognized guidelines including ASRA, American Society Pain Medicine, the European Society of Regional Anesthesia and Pain Therapy, the American Academy of Pain Medicine, and the World Institute of Pain.

If you are on any of the following medications, please discuss with the prescribing physician whether or not you’re allowed to hold the medication for indicated amount of time prior to your procedure. You may resume that medication after your spinal procedure as indicated below.

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Weight loss and Nutrition Supplements to be held for 5 days

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