Fluoroscopy-guided spine injection
Caudal Epidural Steroid Injection
A caudal epidural is the same idea as a lumbar epidural — anti-inflammatory medication into the epidural space — but I enter from below, through a small bony opening at the base of your sacrum called the sacral hiatus. It's the right tool when prior back surgery has changed the anatomy or when I want medication to spread broadly across the lower spine.
What I'm doing
Reaching the epidural space from below
At the very bottom of your spine, the sacrum has a small natural opening called the sacral hiatus. I can use that opening to enter the epidural space without going through the bony architecture of the lumbar vertebrae above.
I deliver a small dose of anti-inflammatory medication into the epidural space the same way I would for a lumbar epidural — but the entry point is at the base of your sacrum rather than between your lumbar vertebrae. Once inside the epidural space, the medication spreads upward across multiple levels and quiets inflammation around irritated nerve roots.
When I reach for a caudal approach instead of a standard lumbar:
- You've had previous lumbar back surgery and the usual approach is harder or risk-laden because of scar tissue and changed anatomy
- I want medication to spread broadly across multiple lower lumbar / sacral levels rather than target one specific nerve root
- You have stenosis or radiculopathy involving the lower nerve roots (L5, S1) where caudal spread is particularly effective
- Anatomy at the lumbar level makes a standard interlaminar approach difficult or higher-risk
Like every other epidural I do, this one happens under live X-ray with contrast confirmation. Caudal injections have a higher rate of imaging-confirmed misplacement when done blind — so fluoroscopy isn't optional.
Honest expectations
What this can do — and what it can't
What this can do for you
- Reaches the epidural space when prior surgery makes a standard lumbar approach difficult or risky.
- Spreads medication broadly across the lower lumbar and sacral nerve roots — useful for multi-level stenosis or generalized lumbar pain.
- Same minimally invasive footprint as any epidural — needle only, same-day discharge.
- Established procedure with decades of use, especially valuable in post-surgical patients.
Risks I'll be honest about
Most are uncommon and most are short-lived.
- Soreness at the injection site for a day or two(common)
- Brief bump in blood sugar — important for diabetics(common in diabetics)
- Brief facial flushing or fluid retention(occasional)
- Headache that gets worse when sitting up (post-dural-puncture)(uncommon, treatable)
- Vasovagal response (lightheadedness, brief drop in blood pressure)(occasional)
- Infection at the injection site(rare with sterile technique)
- Medication going into a blood vessel rather than the epidural space (the reason I use contrast)(very rare with imaging)
Other options
Things we could try instead, or alongside
Lumbar interlaminar or transforaminal epidural
If your anatomy is intact and we want a more targeted approach to a single nerve root, the standard lumbar approach is more precise.
Where this fits: When you haven't had previous surgery and the target is a single nerve root, not multi-level.
Physical therapy + core stabilization
Long-term, this is the foundation. The injection just buys you a window to do the work.
Where this fits: Always part of the plan.
Anti-inflammatory medications
NSAIDs (ibuprofen, naproxen, meloxicam) for daily inflammation, sometimes a short oral steroid taper for an acute flare.
Where this fits: First-line if your kidneys and stomach can tolerate them.
Nerve pain medications
Gabapentin or duloxetine for nerve-type pain shooting down a leg.
Where this fits: When the pain is more nerve-type than mechanical.
Surgical consultation
If imaging shows a structural problem that's progressive, surgery may be the better answer.
Where this fits: When conservative + interventional care has failed and imaging clearly explains the symptoms.
Before your visit
How to get ready
One thing I want you to know first
You will not be put to sleep for this.A lot of patients walk in expecting general anesthesia — that's not what happens here. If we're using conscious sedation (only at the surgery center, only in select cases), you'll get a relaxant through an IV that takes the edge off. You'll still be awake. You'll still be able to talk to me. You just won't be anxious. Most patients say it felt easier than they imagined.
Bring a driver
Eating and drinking before
Take your morning medications
Blood thinners — talk to me first
- • Aspirin (81 mg) — usually OK to continue. I'll tell you if I want it held.
- • Plavix (clopidogrel) — typically held 5–7 days before
- • Eliquis (apixaban) — typically held 24–48 hours before
- • Xarelto (rivaroxaban) — typically held 24–48 hours before
- • Pradaxa (dabigatran) — typically held 24–72 hours, depending on kidney function
- • Warfarin (Coumadin) — typically held until INR is below 1.5
- • Lovenox (enoxaparin) — typically held 12–24 hours
Tell me about your allergies
What to wear
The day of
Step by step, what actually happens
- 1
Arrival and check-in
You'll come in with your driver, finish paperwork, change into a gown, and a nurse will start an IV.
- 2
I see you before we start
I'll go over the plan, answer questions, confirm consent. Last chance to mention allergies.
- 3
Into the procedure room
You'll lie face down on the procedure table. The C-arm sits over your sacrum / lower back.
- 4
Numbing the skin
I'll inject local numbing medication into the skin and tissue at the sacral hiatus. Brief sting, then it goes numb.
- 5
The injection itself
Using live X-ray, I guide a thin needle through the sacral hiatus into the caudal epidural space, inject contrast to confirm spread, then deliver the steroid and anesthetic. Usually 10–15 minutes.
- 6
Recovery
About 30 minutes — vitals, snack, walking around. Then your driver takes you home.
After
Recovery and what to watch for
First 24 hours
Take it easy. Some pressure or fullness in the lower back / tailbone area is normal as the medication spreads. Ice if sore.
Days 1–3
Mild soreness at the entry site. Your usual pain may briefly come back before the steroid kicks in.
Days 3–7
The steroid starts working. Most patients notice meaningful improvement during this window.
Weeks 2–6
Peak benefit. Use this window for rehab and gradual return to activity.
When to call me right away
Severe new weakness in your arms or legs
If a limb feels significantly weaker than before — trouble lifting it, dragging a foot, dropping things — that needs attention now.
Loss of bladder or bowel control
Sudden trouble holding it or sudden trouble going. Rare, but a true emergency. Go to the ER, then call me.
Fever above 101°F (38.3°C)
A fever in the days after the procedure, especially with chills, can mean infection.
Spreading redness, warmth, or drainage at the injection site
Some bruising and tenderness is normal. Pus, increasing redness expanding outward, or yellow drainage is not.
Severe new pain that's worse than before
Brief soreness for a few days is expected. Sharp, severe new pain different from your usual is not.
For anything that worries you, call my office. I'd much rather hear from you and tell you it's fine than have you wait at home wondering. For loss of bladder/bowel control or anything that feels like a true emergency, go to the nearest ER — then call me.
The questions I get most
Frequently asked
Why caudal instead of lumbar?
Will I be put to sleep?
How fast will I feel better?
How long does the relief last?
Will it hurt?
Can I drive myself home?
How many can I have?
Have Questions?
If you'd like to learn more about your treatment options or have a question for Dr. Patibanda, reach out.
Contact Dr. Patibanda