everyone who is stil doing caudals b/c they were trained that way: stop. just do an S1 TFESI. quicker, easier, and closer to the pathology. hardware is never in the way
You need to be more open minded, about medicine and other things.
As I’ve posted a couple dozen times before on SDN, shallow angle caudals, (when you drive the needle tip cranially up to the S3-S4 level, not just barely through sacral hiatus) will
1- most reliably direct medication to the central third of the disc than other ESI techniques, which is particularly important with central disc herniations and annular tears.
2- caudals also more reliably cover the center right or center left portions of a disc vs a TFESI, and will safely cover it with depo instead of dex. Depo doesn’t always work better than dex, but it is never worse than dex if injected with same ESI technique.
Below are the lumbar spine MRI images of a staff member. First 3 photos are the MRI done in 2021, the second 3 images are from 2025 MRI.
Patient initially presented with right lumbar pain and right lumbar radiculopathy. Pain extended to knee only.
Did a right L5-S1, right S1 TFESI (depomedrol at S1, dex at L5-S1) This provided 95% relief for a year. Pain returned a year later. Repeated the same TFESI with same excellent sustained clinical results.
18 months later (this year) the pain returned in a fairly similar distribution but more intense. Repeated same right L5-S1, S1 TFESI (dex at L5, depo at S1). She had 50% relief for 10 days, then all pain returned. That TFESI worked really well historically so I again repeated the TFESI, but again it provided her only with a similar modest and brief 50% relief for a week.
Staff member is not able to function at work or home so I get a new lumbar mri. (Second series of photos) which reveal new modic changes at L4-L5 and also that the L4-L5 HD is now central instead of right paracentral as was seen in previous MRI. Pain radiates to buttock/thigh in a similar distribution, but a bit more central vs lateral, now
Again, despite a TFESI previously providing 95% relief for a year (twice) the staff member can now barely function despite repeating two TFESI with same technique that worked so well in the past (twice). So I now suggest a caudal and discuss the MRI with the patient (nurse) and that I wanted to cover central to central right portion of the part of HD.
I perform a shallow angle caudal with depomedrol at S3-S4 with the tip slightly right. The patient now achieves 90% sustained relief (she is currently in post procedure month 4)
The past 4 months she has been able to sit at work, bend at home, and resume exercise, etc. Clinical result after the caudal ESI is slightly less than the initial TFESI 4 years ago 90% vs 95% relief, but dramatically more effective than repeating the same (previously effective) TFESI twice this year with only mediocre results x 2.
Caudals don’t fix everything,and in
many clinical scenarios are less effective than TFESI. But it is short sighted to just say it’s virtually always incorrect to perform a caudal, as you just did.
There are some spine issues which respond better to a caudal with depomedrol vs any other ESI technique.
