Multiple approaches, such as lateral, prone, and lithotomy have been described (Figure 9-4.5).3 The most frequently used approach is the prone position. The sacrococcygeal area is prepped and draped in a sterile manner. The entry site, just under the tip of the coccyx, is anesthetized with lidocaine 0.5% using a 25-gauge needle. A 22-gauge, 3.5-in spinal needle is bent into a C shape (commercial C shape 22-gauge, 3.5-in spinal needles are also available). At the site of entry, just under the coccyx, the needle is advanced in a semicircular manner under fluoroscopy (lateral view) until the top of the needle is just anterior to the sacrococ-
cygeal junction. After a negative blood aspiration, a radio-opaque dye is injected (1-2mL) and the spread is viewed both in AP and lateral views. There should be a smooth contrast of the dye in the retroperitoneum between the sacrococcygeal region and the rectal bubble. After a negative blood aspiration, a total of 12 to 15mL of bupivacaine
0.375. is injected with intermittent aspirations.
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