© 2005 World Institute of Pain, 1530-7085/05/$15.00 Pain Practice, Volume 5, Issue 3, 2005 251–254 Blackwell Science, LtdOxford, UKPPRPain Practice1530-70852005 World Institute of Pain 2005 53251254Original ArticleAccuracy of Caudal Epidural InjectionERGIN Et al. Address correspondence and reprint requests to: Atilla Ergin, MD, GATA Medical Faculty, Department of Anaesthesiology and Reanimation, 06018 Etlik, Ankara, Turkey. Tel: (90) 312-3045907; Fax: (90) 312-3045900; E-mail: aergin@gata.edu.tr. CLINICAL REPORT Accuracy of Caudal Epidural Injection: The Importance of Real-Time Imaging Atilla Ergin, MD; Omer Yanarates, MD; Ali Sizlan, MD; M. Emin Orhan, MD; Ercan Kurt, MD; M. Erdal Guzeldemir, MD Gulhane Military Medical Faculty, Department of Anaesthesiology and Reanimation, Ankara, Turkey  Abstract: Caudal epidural steroid injections are often used for low back pain. Fluoroscopic guidance has been fre- quently cited as a requirement for this procedure. In this preliminary report, we demonstrate that fluoro- scopic guidance for caudal epidural Tuohy needle placement without real-time imaging may result in inadvertent intrave- nous injection of the drug. We detected intravenous leakage of the drug in 4 cases of 10 when real-time fluoroscopic imaging was used. Thus, real-time imaging may be recom- mended in addition to routine fluoroscopic guidance for caudal epidural procedures, as it may improve efficacy and safety by assuring accurate drug deposition.  Key Words: epidural, caudal, intravascular injection INTRODUCTION Although caudal epidural injection is a common proce- dure, there is no clear consensus on its technical perfor- mance. 1,2 Variations in technique may affect outcome. In this report, we discuss not only the necessity of fluoroscopic guidance but also the importance of real-time fluoroscopic guidance for caudal epidural injections. METHODS Ten patients with chronic low back pain and concomi- tant radiculopathy admitted to the Algology Depart- ment of Medical Faculty of Gulhane between November and December 2004 were observed. The inclusion criteria for the this study were (1) chronic low back pain with 0–10 visual analog scale for pain greater than 4; (2) magnetic resonance imaging evidence of a disc prolapse, spinal stenosis, degenerative spondylosis alone, or in combination; (3) sufficient mas- tery of the Turkish language; and (4) informed consent. Patients were excluded if they had (1) symptoms requir- ing early surgical treatment (severe motor weakness, cauda equina syndrome, hyperalgic sciatica); (2) struc- tural spinal deformities (scoliosis greater than 40 degrees, spondylolisthesis); (3) symptoms consistent with causes other than lumbar spine pathology; (4) cur- rent anticoagulation therapy; (5) pregnancy; (6) known allergy to corticosteroids; (7) treatment with tricyclic antidepressant drugs or lithium; (8) local or systemic bacterial infection; (9) hyperglycemia; (10) elevated blood pressure; (11) known serious disorder of the immune system (eg, AIDS); and (12) other serious systemic disease (kidney disease, anemia, significant asthma). All procedures were performed in hospital under ster- ile conditions with fluoroscopic guidance. Patients received 500 mL isotonic saline solution via a 20-G intravenous catheter before the procedure. Cephazolin