NYSORA - The New York School of Regional Anesthesia - Pediatric Epidural and Caudal Analgesia and Anesthesia in Children

Epidural analgesia has many beneficial effects in the pediatric patient population. In clinical practice, it is commonly used to augment general anesthesia and to manage postoperative pain. Introduction Epidural analgesia has many beneficial effects in the pediatric patient population. In clinical practice, it is commonly used to augment general anesthesia and to manage postoperative pain. Effective postoperative pain relief from epidural analgesia has numerous benefits including earlier ambulation, rapid weaning from ventilators, reduced time spent in a catabolic state and lowered circulating stress hormone levels.1 Precise placement of epidural needles and catheters for single-shot and continuous epidural anesthesia ensures the dermatomes involved in the surgical procedure are selectively blocked, allowing for lower doses of local anesthetics and sparing of unnecessary blockade in the regions where blockade is not desired. 2-4. Significant anatomic differences in comparison with adults, should be considered while utilizing regional anesthesia in children. For instance, in neonates and infants, the conus medullaris is located lower in the spinal column (at approximately the L3 vertebra) compared to adults where it is situated at approximately the L1 vertebra. This dissimilarity is a result of different rates of growth between the spinal cord and the bony vertebral column in infants. However, at approximately 1 year of age the conus medullaris reaches similar L1 level as in an adult. The sacrum of children is also more narrow and flat compared to the adult population. At birth, the sacral plate, which is formed by five sacral vertebrae, is not completely ossified and continues to fuse until approximately 8 years of age. The incomplete fusion of the sacral vertebral arch forms the sacral hiatus. The caudal epidural space can be accessed easily in infants and children through the sacral hiatus. Due to the continuous development of the sacral canal roof, there is considerable variation in the sacral hiatus. In children, the sacral hiatus is located more cephalad compared to adults. Therefore, caution is warranted when placing caudal blocks in infants as the dura may end more caudad thereby increasing the risk of accidental dural puncture. It has also been suggested that the epidural fat is less densely packed in children than in adults.5 This loosely packed epidural fat may facilitate not only the spread of local anesthestic, but it may also allow the unimpeded advancement of epidural catheters from the caudal epidural space to the lumbar and thoracic level. Clinical Pearls In the …