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Caudal block: the ‘no turn technique’

SIR—The caudal block is certainly the most popular and commonly used central block in children. It is safe, quite easy to perform and the elective technique for perioperative pain control of most of minor surgery. A single shot, now with the new levo-isomers levobupivacaine or ropivacaine with the addition of clonidine or ketamine gives complete analgesia for many hours. Normally, it is described with the ‘usual approach’: to enter the needle at the level of the sacral hiatus, perpendicularly to the skin, crossing the sacrococcygeal ligament, and finally, rotating the needle 30 to enter the sacral canal for few millimeter. Usually this type of approach is a safe and reliable technique but some complications can occur, mainly in infants and newborns. The profusion of vessels in the area and the sacral bone being not completely ossified can lead, with the rotation of the needle, to accidental vascular damage (hematoma) or intraosseous injection respectively. Moreover, because of the extreme variability in anatomy of the sacral hiatus, it is not so rare, again mainly in infants and newborns, to pierce the dura which is <1 cm away from the apex of the hiatus itself. Personally, in my career as a ‘pediatric regionalist’ it has happened to me a total of four times while performing a central block and three times while performing a caudal block in infants. I decided, therefore, to change the technique with the idea of adding safety to the procedure. I am convinced that other colleagues may be using similar approaches, but to my knowledge, no new methods have been ‘officially’ described in the peer reviewed literature and I have written about my approach only in a personal book and a monograph on pediatric blocks. I will describe this technique calling it ‘the no turn technique’ (1, 2). It is a very easy approach indeed: instead of entering the caudal needle at 90 to the skin I enter at a 60 angle crossing then the usual planes; at the end, when the sacrococcygeal ligament has been passed with the classic ‘pop’ sensation, I do not turn the needle trying to enter the sacral canal but I inject the drug directly (Figs 1 and 2). The anatomy of the sacral hiatus is such that entering with this 60 angle, the tip of the needle is just at the beginning of the sacral canal and there is no need to rotate or to advance it to inject the solution (Fig. 3) Using this approach the risk of dural puncture, intraosseous injection or vessel damage is significantly reduced and the only possible side effect, if the needle is in the wrong place is a subcutaneous injection. One important aspect is that this approach is more rapid to perform and easier to teach. I work in a teaching The ‘no turn’ technique