Review Article

Hindawi Publishing Corporation
BioMed Research International

Volume 2014, Article ID 890626, 17 pages
http://dx.doi.org/10.1155/2014/890626
Review Article
A Systematic Review and Meta-Analysis of
Caudal Block as Compared to Noncaudal Regional
Techniques for Inguinal Surgeries in Children
Harsha Shanthanna,1 Balpreet Singh,2 and Gordon Guyatt3

1
Department of Anesthesiology, McMaster University, St. Joseph’s Healthcare Hamilton, 50 Charlton Avenue East, Hamilton,
ON, Canada L8N 4A6
2
IWK Health Centre and Dalhousie University, Halifax, NS, Canada B3K 6R8
3
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada L8N 4A6
Correspondence should be addressed to Harsha Shanthanna; [email protected]
Received 16 May 2014; Accepted 10 June 2014; Published 5 August 2014
Academic Editor: Patricia Khashayar
Copyright © 2014 Harsha Shanthanna et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
This systematic review and meta-analysis were designed to compare the analgesic effectiveness and adverse effects with the use of
caudal analgesia as compared to noncaudal regional analgesia techniques in children undergoing inguinal surgeries. MEDLINE,
EMBASE, and CENTRAL (Cochrane) databases were searched for randomized control trials published in English language from
1946 up to 2013. Use of rescue analgesia and adverse effects were considered as primary and secondary outcomes, respectively.
Outcomes were pooled using random effects model and reported as risk ratio (RR) with 95% CI. Out of 3240 hits and 24 reports
for final selection, 17 were included in this review. Caudal analgesia was found to be better in both early (RR = 0.81 [0.66, 0.99],
𝑃 = 0.04) and late (RR = 0.81 [0.69, 0.96], 𝑃 = 0.01) periods, but with a significant risk of motor block and urinary retention.
According to GRADE, the quality of evidence was moderate. Although potentially superior, caudal analgesia increases the chance
of motor block and urinary retention. There are limited studies to demonstrate that the technical superiority using ultrasound
translates into better clinical success with the inguinal nerve blocks.
1. Introduction haematoma, and inadvertent subarachnoid or intravascular

injection of the LA [3]. Other associated adverse effects
The most commonly performed inguinal surgeries in chil- can include urinary retention and possible motor blockade.
dren include inguinal hernia repair with or without orchi- INB-including inguinal and iliohypogastric nerve blocks can
dopexy (orchiopexy) [1]. For postoperative pain with these provide effective ipsilateral analgesia. A single injection often
surgeries, a regional analgesic modality such as caudal blocks both the nerves, as they lie quite close to each other,
analgesia (CA), inguinal and iliohypogastric nerve block side by side. Landmark techniques can result in technical
(INB), or local infiltration (INF) is combined with a gen- failure in up to 20% of children. This can be improved by
eral anaesthetic (GA). When compared to intravenous (IV) using ultrasound guidance [4]. They possibly do not affect
opioids, regional techniques reduce the risk of side effects the pain caused by visceral manipulation. INF of the wound
such as somnolence, respiratory depression, emesis, and ileus can be done by the anaesthesiologist or the surgeon. This
[2]. Caudal block (CB) involves the introduction of local potentially effective, but minimally invasive procedure could
anaesthetic (LA) into the caudal epidural space. It requires offer the advantage of lower costs, time, and risks [5]. Other
the child to be positioned appropriately and is a common interventions which have been compared to caudal analgesia
practice to administer under deep sedation or a GA. It include paravertebral block (PVB) and TAP (transverse
can cause complications such as needle trauma, infection, abdominal plane) block. Although CB may be considered
2 BioMed Research International
as the most potent technique, it requires trained personnel analgesia were compared. Rescue analgesia was considered as
and added cost; potentially it could expose children to higher the administration of an analgesic medication to control pain
risks without any superiority in clinical analgesia. Ultrasound with or without agitation. Outcomes at the 2 time points, early
(US) has been shown to improve the technical efficiency (<4 hrs) and late (4 hrs–24 hrs), were analysed separately as a
and success rate of regional blocks [4]. It is not established pooled estimate for all the studies and also individually within
whether this translates into comparative clinical success. each group. For secondary outcomes, adverse effects in each
In clinical practice, there is still no conclusive evidence to category were compared as proportion of patients. For both,
prefer one technique over the other in consideration of their outcomes were pooled and reported as relative risks with 95%
efficacy and side effects. The main objective of this review CI.
is to perform a systematic review and meta-analysis of the Synthesis was done using revman (review manager 5.2).
existing evidence to compare the analgesic efficacy and side A priori, it was decided that only if the studies are sufficiently
effects with the use of caudal analgesia as compared to homogeneous, outcomes would be reported as pooled effect
other noncaudal regional analgesia techniques in children sizes. Studies reporting only continuous outcome measures,
undergoing inguinal surgeries. and also studies which were substantially heterogeneous
and did not fit into a particular comparison group, were
analysed separately and reported, without inclusion for the
2. Methodology pooled effect estimate. To accommodate for any unexplained
heterogeneity, random effects model was used for analysis.
We performed a comprehensive search in MEDLINE, EM-
Statistical heterogeneity was calculated using Chi Square and
BASE, and Cochrane databases for randomized controlled
trials (RCT) in English language (Appendix A). This was also the 𝐼2 statistic to describe the percentage variability
complemented by other databases, relevant conference pro- in individual effect estimates that could be due to true
ceedings, and hand check of reference lists of reviews and differences between the studies rather than a sampling error.
included RCT. Our selection criteria using the PICOT format We considered 𝐼2 < 40% as low, 30–60% as moderate, and
are as follows: participants: children (0–12 years) undergoing >50% as substantial [6]. Further, study findings have also
inguinal surgeries; intervention: CB (without adjuvants); been shown in the form of “summary of findings” table, using
comparators: noncaudal regional techniques; outcome: effec- the GRADE (Grading of Recommendations Assessment,
tiveness of analgesia assessed using a categorical outcome Development, and Evaluation) approach. The utility of “an
reporting as the number of children needing rescue anal- estimate of the magnitude of intervention effect” depends
gesia; time point: early (<4 hrs) and late (4–24 hrs). Trials upon our confidence in that estimate. GRADE incorporates
with various comparator techniques such as INB, INF, or the aspects of study limitations, inconsistency of results,
a combination of these interventions were included. Trials indirectness of the evidence, imprecision, and the reporting
using adjuvants other than epinephrine (such as ketamine, bias [7].
clonidine) or CB in combination with another technique
were excluded. Studies with outcome reporting using “only 3. Results
pain scales” (continuous) were separately reported without
combining them in the possible pooled estimate. As sec- 3.1. Study Selection (PRISMA Flow Chart—Figure 1). The
ondary outcomes, clinically relevant adverse effects as related search results are highlighted as a flow diagram in Figure 1.
to treatments were considered: motor block (MB), urinary Out of 3240 items, 1958 reports were obtained after removing
retention (UR), nausea-vomiting (NV), infection at the injec- duplicates. Finally, 27 full-text articles were considered for
tion site, and delayed discharge (DD). The study selection inclusion out of which 17 were included (Table 3) [8–24], and
was done independently by the first two authors, and a three were excluded [25–27]. Of the remaining seven studies
final agreement score was calculated using a quadratic kappa [28–34], two were journal reports and five were conference
weighting. Risk of bias was assessed using the Cochrane risk proceedings. Despite multiple attempts, we could not obtain
of bias tool. Considering the nature of interventions, blinding any full study report for the above seven studies. The study
of physicians may not be possible. Hence, only participant selection agreement between the authors was 0.73 using
blinding was considered necessary to be identified as having quadratic kappa weighting. For quantitative analysis (meta-
a low risk of bias. We considered a loss to follow-up (LTFU) analysis), only 16/17 studies were included; Hannallah and
of 10% or more as the threshold for attrition bias. Funnel plot colleagues reported their results only as continuous outcomes
was used to look for any publication bias. Considering the [12].
clinically heterogeneous comparator techniques, we decided
a priori to subgroup them into CB versus INB, CB versus
3.2. Characteristics of Included Studies. Other important con-
INF, CB versus combined INB and INF, and CB versus others.
siderations are as follows. The study by Fisher and colleagues
Other potential sources of heterogeneity considered were
[9] included a three-arm design with caudal compared to
concentration of LA, timing of interventions as related to
inguinal nerve block. It involved the use of “epinephrine
surgery, and the use of image guidance.
with LA” in only one group of CB. For the purpose of this
review, both caudal groups were combined for comparisons,
2.1. Summary Measures and Synthesis of Results. For the pri- as suggested by [35]. The study by Tug and colleagues
mary outcome, the proportions of children needing rescue could not be considered appropriate under any comparator
BioMed Research International 3
PRISMA 2009 flow diagram
Records identified through

database searching: Additional records identified
MEDLINE = 783 through other sources
Identification
EMBASE = 1922 (n = 5)
CENTRAL = 530
(n = 3235)
Records after duplicates removed

(n = 1958)
Screening
Records screened Records excluded

(n = 1958) (n = 1924)
Full-text articles assessed Full-text articles excluded, with

Eligibility
for eligibility
reasons (n = 3)
(n = 27)
Not reported as RCT, n = 2
Non-English report, n = 1
Studies included in
qualitative synthesis
(n = 17) Full-text articles requested to be
considered for eligibility: (n = 7)
Conference proceedings, n = 5
Included
Full-text article, n = 2
Studies included in
quantitative synthesis
(meta-analysis)
(n = 16)
Figure 1: PRISMA flow diagram. From Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred reporting items
for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097. For more
information, visit http://www.prisma-statement.org.
Random sequence generation (selection bias)
Allocation concealment (selection bias)
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Other bias
0 25 50 75 100
(%)
Low risk of bias

Unclear risk of bias
High risk of bias
Figure 2: Risk of bias across studies assessed using the Cochrane risk of bias tool.
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)

Random sequence generation (selection bias)
Incomplete outcome data (attrition bias)

Allocation concealment (selection bias)
Selective reporting (reporting bias)
Other bias
Abdellatif et al. 2012 + − + + + + +
Bhattarai et al. 2005 − + + + + + +
Conroy et al. 1993 − − + + + + +
Cross et al. 1987 − − + − + + +
Fell et al. 1988 − − + + + + +
Fisher et al. 1993 ? − + + + + +
Hannallah et al. 1987 ? + + + + + +
Hosseini Jahromi et al. INF 2012 − − + + − + +
Lafferty et al. 1990 − + + ? + + +
Machotta et al. 2003 − + + + + + +
Markham et al. 1986 ? − + + + + +
Schindler et al. 1991 − − + + + + +
Scott et al. 1989 − − + + + + +
Somri et al. 2002 − − + + + + +
Splinter et al. 1995 + − + + + + +
Tobias et al. 1995 − − + + + + +
Tug et al. 2011 + − + + + + +
Figure 3: Risk of bias in individual studies using Cochrane risk of bias.
category and was hence reported separately [24]. Jahromi and 3.3. Risk of Bias within Studies. The risk of bias across studies
colleagues compared caudal with two different groups [17]: is represented in the bar graph obtained through revman
infiltration and acetaminophen suppository. We included (Figure 2). The risk of bias in individual studies, in specific
only the patients compared under infiltration with the caudal domains, is shown in Figure 3. A majority of studies were
group. There was only one included study using US image observed as having a high risk of selection bias. Only seven
guidance for INB [8]. studies reported the method used for sequence generation,
0 [0.69, 0.96], 𝑃 = 0.01, reaching statistical significance. The

ARR was 7.8. Quality of evidence, according to the GRADE-
0.5 SOF, is moderate (Table 2).
SE(log[RR])
1 3.4.3. Side Effects. Motor blockade (Figure 7) was observed in

24/239 children in the CB group compared to 6/230 children
1.5
in the comparator group: 6 studies with 469 children; RR
= 2.59 [1.29, 5.20], 𝑃 = 0.007. Urinary retention (Figure 8)
was observed in 32/219 children in the CB group compared
2
0.01 0.1 1 10 100
to 13/210 children in the comparator group: 5 studies with
459 children: RR = 2.23 [1.27, 3.91], 𝑃 = 0.005. NV was
RR
observed to be similar in both caudal and noncaudal groups.
Subgroups Only Lafferty and others reported infection in one child
Caudal versus N block belonging to the INF [14]; and only Fell and others reported
Caudal versus infiltration
Caudal versus combined N block and infiltration
delayed discharge in three and one, respectively, in CB and
INF [15]. Although there were clearly more side effects with
CB, the quality of evidence, according to GRADE, was very
Figure 4: Funnel plot to identify the presence of publication bias.
low, except for NV. Reasons for downgrading the evidence is
provided within the SOF table (Table 2).
and only five studies reported the method used for allocation
3.5. Description of Results within Individual Subgroups
concealment. Four studies excluded patients with failed
interventions from the final analysis [8, 9, 17, 24]. For primary (Table 1)
outcome analysis, we imputed the outcome of these excluded 3.5.1. CB versus INB. We identified five studies, out of which
patients. Our rationale was that failed interventions will four were included in the meta-analysis. Except Hannallah
always necessitate rescue analgesic. Conroy and colleagues and colleagues (orchidopexy only) [12], the studies included
reported that they did not follow the randomisation sequence patients from inguinal hernia and orchidopexy surgeries. All
appropriately as generated for the first 30 patients [16]. used bupivacaine in the concentration ranging from 0.2%
Hence, we decided that a sensitivity analysis is to be carried to 0.5%. The volume injected ranged from 0.7 to 1 mL kg−1
out by excluding this study and observing the change in (CB) and from 0.1 mL to 0.4 mL kg−1 (INB). Only Fisher and
estimate of effect. The reporting of methodology and outcome colleagues [9] used epinephrine mixed with bupivacaine in
assessment was not entirely clear in the study by Lafferty et al. one arm of their caudal patients. We combined them together
[14]. We could not identify any major publication bias (funnel as belonging to CB. All except one performed both their
plot—Figure 4) and no study mentioned any specific funding interventions before surgery [9]. Hannallah and colleagues
support. reported their pain scores only in “median range,” caudal (1.0,
6) and N block (1.0, 6), and did not report the use of rescue
3.4. Outcome Analysis and Results analgesic in the two groups separately [12].
3.4.1. Use of Rescue Analgesia in Early Period: ≤4 hrs (Figure 5). 3.5.2. CB versus INF. We identified 6 studies in total, but
In total there were 14 studies with 851 patients. Tug and only two studies [9, 12–15, 17] provided analgesia outcomes
colleagues compared CB with single shot lumbar (L2) PVB for both time periods. Both interventions were performed
[24]. We noted that the inclusion of this particular study after surgery in two studies [13, 14, 17]; however the other
resulted in heterogeneity and significant subgroup differences 4 studies performed caudal preoperatively and infiltration
(test for subgroup differences: Chi = 7.66, df = 3 (𝑃 = 0.05), postoperatively [14–16, 18]. Except for Lafferty and colleagues
𝐼2 = 60.8%). Also, in practice it is not commonly performed (only orchidopexy) [14], all included hernia surgeries only.
for inguinal surgeries in children. After its exclusion, we All used bupivacaine in a concentration of 0.25% for CB
had 13 studies with 789 children with the overall pooled and 0.25%–0.5% for INF. The volume ranged from 0.7 to
estimate favouring caudal; RR: 0.81 [0.66, 0.99], 𝑃 = 0.04, 1.0 mL kg−1 (CB) and from 0.2 to 0.7 mL kg−1 (INF). Only
with no identifiable heterogeneity (𝐼2 = 0) or subgroup Conroy and colleagues used epinephrine along with bupiva-
differences. The ARR (absolute risk reduction) was 1.38. caine [16]. Variations of the infiltration techniques involved
Quality of evidence, according to the GRADE, is moderate infiltration of the wound site through the skin and infiltration
(Table 2). of fascia or aponeurosis before closure. No study used image
guidance.
3.4.2. Use of Rescue Analgesia in Late Period: 4–24 hrs
(Figure 6). In total there were 9 studies with 597 patients. 3.5.3. CB versus Combined INB and INF. Five studies were
Excluding one study [24], for reasons of heterogeneity, identified. Tobias and colleagues also performed a laparo-
resulted in 8 studies with 532 children. Overall pooled scopic inspection of the other side [19]. The studies con-
estimate favours the benefit of analgesia from caudal; RR: 0.81 tained a mix of hernia and orchidopexy surgeries. Except
Caudal Noncaudal Risk ratio Risk ratio

Study or subgroup Weight M-H, random, 95% CI Year M-H, random, 95% CI
Events Total Events Total
11.1.1 Caudal versus N block
Markham et al. 1986 3 26 0 26 0.5% 7.00 [0.38, 129.11] 1986
Scott et al. 1989 1 19 2 25 0.7% 0.66 [0.06, 6.73] 1989
Fisher et al. 1993 33 52 24 30 52.6% 0.79 [0.60, 1.04] 1993
Abdellatif et al. 2012 5 25 7 25 3.9% 0.71 [0.26, 1.95] 2012
Subtotal (95% CI) 122 106 57.6% 0.80 [0.62, 1.04]
Total events 42 33
Heterogeneity: 𝜏2 = 0.00; 𝜒2 = 2.43, df = 3 (P = 0.49); I2 = 0%
Test for overall effect: Z = 1.68 (P = 0.09)
11.1.2 Caudal versus infiltration

Fell et al. 1988 2 22 2 27 1.1% 1.23 [0.19, 8.02] 1988
Schindler et al. 1991 8 27 12 27 7.6% 0.67 [0.33, 1.37] 1991
Conroy et al. 1993 13 25 11 20 13.1% 0.95 [0.55, 1.63] 1993
Machotta et al. 2003 11 30 8 28 6.9% 1.28 [0.61, 2.72] 2003
Subtotal (95% CI) 104 102 28.8% 0.94 [0.65, 1.36]
Total events 34 33
11.1.3 Caudal versus combined N block and infiltration

Cross and Battet et al. 1987 1 20 2 21 0.7% 0.53 [0.05, 5.35] 1987
Splinter et al. 1995 11 96 12 104 6.6% 0.99 [0.46, 2.14] 1995
Somri et al. 2002 3 15 4 15 2.3% 0.75 [0.20, 2.79] 2002
Tobias et al. 1995 2 12 9 12 2.3% 0.22 [0.06, 0.82] 2002
Bhattarai et al. 2005 2 30 6 30 1.7% 0.33 [0.07, 1.52] 2005
Subtotal (95% CI) 173 182 13.6% 0.59 [0.32, 1.07]
Total events 19 33
11.1.4 Caudal versus paravertebral

Tug et al. 2011 16 35 6 35 0.0% 3.00 [1.07, 8.40] 2011
Subtotal (95% CI) 0 0 Not estimable
Total events 0 0
Heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 399 390 100.0% 0.81 [0.66, 0.99]

Total events 95 99
Test for overall effect: Z = 2.10 (P = 0.04) 0.01 0.1 1 10 100
Test for subgroup differences: 𝜒2 = 1.69, df = 2 (P = 0.43); I2 = 0% Favours (caudal) Favours (noncaudal)
Figure 5: Forest plot for the use of rescue analgesia in the early period.
Bhattarai and colleagues [23], all placed their CB before sur- of motor block in CB compared to 0 in PVB, out of 35 patients
gery. However, the timing of INB and INF was variable. in each group.
Epinephrine was used in three of the studies along with
bupivacaine. Compared to other groups, bupivacaine concen- Additional Analysis (Sensitivity Analysis). Although we con-
tration used was 0.25% in all studies except 0.2% for CB by sidered concentration of LA, timing of interventions as
Splinter and colleagues [20]. The volume ranged from 1 to related to surgery, and the use of image guidance as potential
1.25 mL kg−1 (CB) and from 0.3 to 1 mL kg−1 (INB and INF). sources of heterogeneity, we did not have sufficient number
of studies to carry out further subgroup analysis.
(1) Conroy and colleagues had noted that the randomisa-
3.5.4. Caudal versus Others. Tug and colleagues used a single tion was not done appropriately for the first 30 patients [16].
shot lumbar PVB to compare with CB for inguinal surgeries Sensitivity analysis showed that the pooled effect size for the
[24]. Out of 70 patients, six patients had a failed block (two overall estimate and the subgroup (CB versus INF) estimate
in PVB and four in CB), and 12/35 patients in CB and 4/35 was not affected much for the early use of rescue analgesia.
patients in PVB needed rescue analgesia during the early (2) Ultrasound guided procedures: our search revealed
period with a RR: 3.0 [1.07, 8.04]. They also observed 2 cases only 2 studies [8, 29], out of which only a single study report

Study or subgroup Weight M-H, random, 95% CI Year M-H, random, 95% CI
Events Total Events Total
11.2.1 Caudal versus nerve block
Scott et al. 1989 3 19 6 25 1.8% 0.66 [0.19, 2.30] 1989
Abdellatif et al. 2012 9 25 8 25 4.7% 1.13 [0.52, 2.44] 2012
Subtotal (95% CI) 44 50 6.5% 0.97 [0.50, 1.87]
Total events 12 14
Heterogeneity: 𝜏 = 0.00; 𝜒 = 0.52, df = 1 (P = 0.47); I2 = 0%
2 2

Fell et al. 1988 11 20 12 25 8.7% 1.15 [0.65, 2.02] 1988
Lafferty et al. 1990 11 20 10 23 7.5% 1.26 [0.69, 2.33] 1990
Machotta et al. 2003 7 30 10 28 4.2% 0.65 [0.29, 1.48] 2003
Hosseini Jahromi et al. INF 2012 4 30 4 30 1.7% 1.00 [0.28, 3.63] 2012
Subtotal (95% CI) 100 106 22.2% 1.05 [0.74, 1.51]
Total events 33 36

Splinter et al. 1995 55 97 82 105 69.7% 0.73 [0.59, 0.89] 1995
Somri et al. 2002 4 15 3 15 1.6% 1.33 [0.36, 4.97] 2002
Subtotal (95% CI) 112 120 71.3% 0.74 [0.60, 0.90]
Total events 59 85
Total (95% Cl) 256 276 100.0% 0.81 [0.69, 0.96]

Total events 104 135
Test for subgroup differences: 𝜒2 = 3.26 df = 2 (P = 0.20); I2 = 38.7% Favours (caudal) Favours (noncaudal)
Figure 6: Forest plot for the use of rescue analgesia in the late period.
was accessible. Abdellatif compared US-INB block with blind of several advantages over parenteral analgesics [36]. Caudal
CB in children having inguinal hernia surgeries [8]. Average analgesia has been widely used, and, because of the ease of
pain scores and use of rescue medications were not found administration, it is the most commonly used neuraxial block
to be significantly different. Use of rescue analgesia: early for children [37]. In children, most regional procedures are
period: 5/25 (CB) and 7/25 (INB); late period: 9/25 (CB) and done under GA or heavy sedation [38]. The relative risks and
8/23 (INB). benefits of CB as compared to less demanding techniques
such as INB and infiltration are unclear. Complications
4. Discussion could arise as a result of LA used or because of the nature
of the regional technique [39]. The potential for harm is
4.1. Summary of Evidence. Our results show that CB is super- perhaps more with a neuraxial block. Our review shows
ior compared to the group of noncaudal regional analgesic that, despite the common practice of CB, there are limited
interventions involving INF, INB, or their combination, studies. The exclusion of reports which used adjuvants did
demonstrated by the significantly reduced need for rescue not seem to affect the study results. All of those excluded
analgesic during both early and late periods. However, the study reports, except a single study [40], had studied the effect
ARR (absolute risk reduction) was only 1.58 for the early of adjuvants when used in the caudal space without actually
period, compared to 7.94 for the late period, indicating that comparing it with other comparator regional techniques. The
the benefits are perhaps more appreciable in the later period. excluded study was a pilot study by Ivani and colleagues
Among the side effects, motor block and urinary retention who studied the use of ropivacaine mixed with clonidine and
were significantly more common with the caudal group with compared between CB and INB, with children aged 1–7 years
an ARR of 7.44 and 8.42, respectively. NV was found to undergoing inguinal surgeries. The pain scores were similar,
be similar. Individually, among the subgroups, the need for with 6/20 and 11/20 children needing rescue analgesia in INB
rescue analgesia was less with CB compared to INB, and the and CB, respectively [40]. A systematic review also did not
combined INB with INF. However, the reduction did not find convincing evidence for the use of nonopioid additives
achieve statistical significance. in elective outpatient surgery involving children [41].
For provision of postoperative pain relief in inguinal surg- In our review, most studies suffered from the risk of
eries in children, regional procedures are preferred because selection bias or did not specify the method of sequence

Study or subgroup Events Total Events Total Weight M-H, random, 95% CI Year M-H, random, 95% CI
Markham et al. 1986 12 26 6 26 72.8% 2.00 [0.88, 4.52] 1986
Fisher et al. 1993 2 48 0 26 5.4% 2.76 [0.14, 55.33] 1993
Tug et al. 2011 2 35 0 35 5.4% 5.00 [0.25, 100.53] 2011
Subtotal (95% CI) 109 87 83.6% 2.17 [1.01, 4.64]
Total events 16 6

Fell et al. 1988 3 22 0 27 5.7% 8.52 [0.46, 156.65] 1988
Subtotal (95% CI) 22 27 5.7% 8.52 [0.46, 156.65]
Total events 3 0

Splinter et al. 1995 4 96 0 104 5.7% 9.74 [0.53, 178.60] 1995
Tobias et al. 1995 1 12 0 12 5.0% 3.00 [0.13, 67.06] 2002
Subtotal (95% CI) 108 116 10.7% 5.62 [0.67, 46.98]
Total events 5 0
11.3.4 Caudal versus paravertebral

Tug et al. 2011 2 35 0 35 Not estimable 2011
Subtotal (95% CI) 0 0 Not estimable
Total events 0 0
Test for overall effect: not applicable
Total (95% CI) 239 230 100.0% 2.59 [1.29, 5.20]

Total events 24 6
Figure 7: Forest plot for the incidence of motor block.
generation and allocation concealment. This finding was at 6 hrs [10]. They also had a higher incidence of UR with
similar, with studies published recently as well as in the past. 12/26 (CB) versus 5/26 (INB), having not voided at 6 hrs.
Studies also suffered from smaller sample sizes. A majority It is possibly because of the higher concentration of the
of subjects (45%) came from the subgroup of CB against the LA used, 0.5% as compared to others who used 0.25%.
combined group (355/789). Interestingly, the results in this Schindler and colleagues reported 12/27 (CB) versus 6/27
subgroup favoured caudal for both early and late periods, (INF) children having not voided at the time of discharge
while the individual subgroup comparisons of “CB against (considered around 4 hrs in their study) [18]. CB against INB
INB or INF” demonstrated similar effectiveness. It is difficult accounted for 228 patients among which the study by Fell and
to reason or speculate on this observation. More studies colleagues [15] accounted for a majority (82 patients).
with bigger sample sizes could potentially reveal the true Compared to INF, both CB and INB need more skill
differences. Although no direct comparison of “INF against and both are operator dependent [5]. The risk of technical
INB” was done in our review, some studies have shown that failure exists with both techniques. INB can also suffer from
the effectiveness of each could be similar. Both CB and INB a success rate of only 70%–80% [43]. The use of US could
have the potential to block the nerves of lower limb [42]. Our potentially improve the precision of both CB and INB. It
review observed that MB and UR are certainly more common has been shown that the success rate of caudal injection
with the CB than the INB, but their assessment suffered from [44, 45], as well as INB [4], could be better using US guidance.
lack of use of uniform, reliable, and validated criteria. The Despite this, we only found 2 studies comparing US-INB to
assessment of voiding difficulty requires the control of sev- CB [8, 29]. Although not directly applicable to our results, we
eral confounders: hydration status, administration of agents explored for other studies on the possible use of US-INB in
during GA [9]. Higher incidence of MB and UR was seen par- children. Apart from Willschke and colleagues [4], we only
ticularly with two studies. Markham and colleagues observed found 4 others. Two of them looked at the exact site of injec-
12/26 (CB) versus 6/26 (INB) children, found not walking tion and plasma levels of ropivacaine, respectively [46, 47].

Study or subgroup Events Total Events Total Weight M-H, random, 95% CI Year M-H, random, 95% CI
Markham et al. 1986 12 26 5 26 40.0% 2.40 [0.99, 5.85] 1986
Fisher et al. 1993 5 48 2 26 12.9% 1.35 [0.28, 6.50] 1993
Subtotal (95% CI) 74 52 52.8% 2.09 [0.96, 4.53]
Total events 17 7

Fell et al. 1988 2 22 0 27 3.6% 6.09 [0.31, 120.54] 1988
Schindler et al. 1991 12 27 5 27 39.4% 2.40 [0.98, 5.88] 1991
Subtotal (95% CI) 49 54 43.0% 2.59 [1.10, 6.12]
Total events 14 5
Splinter et al. 1995 1 96 1 104 4.2% 1.08 [0.07, 17.08] 1995
Subtotal (95% CI) 96 104 4.2% 1.08 [0.07, 17.08]
Total events 1 1
Total (95% CI) 219 210 100.0% 2.23 [1.27, 3.91]

Total events 32 13
Figure 8: Forest plot for the incidence of urinary retention.
Another study looked at the addition of US guided INB retention. There seems to be little advantage of combining
with CB. [48]; pain scores were found to be significantly both INB and INF as compared to CB; by requiring more
different; however, the amount of rescue analgesic used was volume, this may even cause harm by potentially increasing
not. Ghani and colleagues compared US-INB with US-TAP the chances of LA toxicity. As shown in the attached SOF
block and found that US-INB was superior [49]. Although it table, the evidence level for the analgesic requirement is
is acceptable to appreciate the superior technical efficiency of moderate and future studies looking to evaluate this com-
INB using US guidance, given the limited evidence, it cannot parison will have an important impact on the confidence
be extrapolated to infer a superior clinical effectiveness as of this estimate. More comparative studies are required to
compared to CB for inguinal surgeries in children. One must demonstrate that better technical efficiency, with the use
also keep in mind that the plasma levels of LA were found to of US-INB, translates into superior clinical effectiveness, as
be significantly higher with US guided blocks than landmark- compared to CB alone. Apart from larger sample sizes, studies
based [47]; it has significant implications on doing a rescue should use well defined criteria for measurement of these
block or any additional local infiltration. outcomes.
4.2. Limitations. There were fewer studies, mostly with smal-

ler sample sizes. Most studies were rated high for selection
Appendix
bias. There were no uniform, reliable, and validated outcome A. Search Strategy
measures and the thresholds used for providing rescue
analgesia were variable. It can also be argued that a network A.1. MEDLINE: Up to Feb 20th 2013
meta-analysis or multiple treatment comparison would have
been a better approach. However, there are limitations to (1) exp hernioplasty/or exp inguinal hernia/or inguinal
interpretation or inferences drawn from such an analysis as herni∗ .mp. or exp herniorrhaphy/
they could be prone to a higher degree of heterogeneity and
invalid conclusions [50]. (2) exp herniotomy/or herniotom∗ .mp.
5. Conclusions (3) herniorrhaph∗ .mp. [mp = title, abstract, subject head-

ings, heading word, drug trade name, original title,
Caudal block provides superior analgesia requiring less res- device manufacturer, drug manufacturer, device trade
cue analgesic, with higher chances of motor block and urinary name, keyword]
Table 1: Summary of pooled outcomes in subgroups.
Group Number of studies and children Outcome Remarks

Outcome: early rescue analgesia (up to 4 hrs)
CB versus INB 4 studies: CB: 122 𝐼2 = 0
RR: 0.80 [0.62, 1.04]
INB: 106 No significant difference
CB versus INF 4 studies: CB: 104 𝐼2 = 0
RR: 0.94 [0.65, 1.36]
INF: 102 No significant difference
CB versus combined 5 studies: CB: 173 𝐼2 = 0
RR: 0.59 [0.32, 1.07]
Combined: 182 No significant difference
Outcome: late rescue analgesia (4–24 hrs)
CB versus INB 𝐼2 = 0
2 studies: CB = 44, INB = 50 RR: 0.97 [0.50, 1.87]
No significant difference
CB versus INF 4 studies 𝐼2 = 0
RR: 1.05 [0.74, 1.51]
CB = 100, INF = 106 No significant difference
𝐼2 = 0
CB versus combined 2 studies RR: 0.74 [0.60, 0.90],
ARR = 17.4%
CB = 112 and combined = 120 𝑃 = 0.003
Significantly favouring caudal
Outcome: motor block
𝐼2 = 0
CB versus INB RR: 2.17 [1.01, 4.64]
3 studies: CB = 109, INB = 87 Motor block more common with CB
𝑃 = 0.05
ARR = 7.2%
CB versus INF Event rate: 3/22 (CB) Only 1 study; motor block not
1 study: CB = 22, INF = 27
0/27 (INF) observed with INF
𝐼2 = 0
CB versus combined 2 studies: CB = 108 and combined = 116 RR: 5.62 [0.67, 46.98] All 5 patients noted to have a motor
block belonged to CB
Outcome: vausea-vomiting
CB versus INB 𝐼2 = 0
2 studies: CB = 50, INB = 49 RR: 0.57 [0.18, 1.80]
CB versus INF 𝐼2 = 0
2 studies: CB = 49, INF = 54 RR: 0.77 [0.36, 1.64]
CB versus combined 𝐼2 = 0
3 studies: CB = 146 and combined = 154 RR: 1.13 [0.86, 1.50]
Outcome: urinary retention
CB versus INB RR: 2.09 [0.96, 4.53] I2 = 0, favouring INB, but not
2 studies: CB = 74, NB = 52
𝑃 = 0.06 significant
CB versus INF 2 studies: CB = 49 RR: 2.59 [1.10, 6.12], 𝐼2 = 0: ARR = 19.3%
INF = 54 𝑃 = 0.03 Significantly favouring INF
CB versus combined Event rate: 1/96 (CB)
1 study: CB = 96, combined = 104 Only 1 study
1/104 (combined)
(4) hernioplast∗ .mp. [mp=title, abstract, subject head- (10) epidural.mp.

ings, heading word, drug trade name, original title, (11) exp ropivacaine/or exp bupivacaine/or exp local anes-
device manufacturer, drug manufacturer, device trade thetic agent/or bupivacaine.mp.
name, keyword]
(12) local anesthe∗ .mp. [mp=title, abstract, subject head-
(5) hernia repai∗ .mp. [mp = title, abstract, subject head- ings, heading word, drug trade name, original title,
ings, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade
device manufacturer, drug manufacturer, device trade name, keyword]
name, keyword]
(13) 7 or 8 or 9 or 10 or 11 or 12
(6) 1 or 2 or 3 or 4 or 5
(14) 6 and 13
(7) exp caudal anesthesia/or exp epidural anesthesia/or
caudal an∗ .mp. (15) orchidopexy.mp. or exp orchidopexy/
∗
(8) epidural an .mp. (16) 6 or 15
(9) caudal.mp. (17) 13 and 16.
Table 2: Summary of findings using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.
Caudal compared to noncaudal regional analgesia for inguinal surgeries in children
Patient or population: patients with inguinal surgeries in children
Settings: randomised control studies reported in English language
Intervention: caudal
Comparison: voncaudal regional analgesia
Illustrative comparative risks∗ (95% CI)
Relative effect No. of Participants Quality of the evidence
Outcomes Assumed risk Corresponding risk Comments
(95% CI) (studies) (GRADE)
Noncaudal eegional
Caudal
analgesia
Early rescue analgesia Study population
(<4 hrs) 206 per 1000
254 per 1000
Number of children (168 to 251) RR 0.81 789 ⊕ ⊕ ⊕⊝
Needing rescue analgesic Moderate (0.66 to 0.99) (13 studies) 𝑚𝑜𝑑𝑒𝑟𝑎𝑡𝑒1,2,3
Medication 189 per 1000
233 per 1000
(154 to 231)
Late rescue analgesia Study population
(4 hrs–24 hrs) 396 per 1000
489 per 1000
Number of children (338 to 470) RR 0.81 532 ⊕ ⊕ ⊕⊝
Needing rescue analgesic Moderate (0.69 to 0.96) (8 studies) 𝑚𝑜𝑑𝑒𝑟𝑎𝑡𝑒1,2,3
Medication 275 per 1000
339 per 1000
(234 to 325)
Study population
Adverse effect-motor 61 per 1000
23 per 1000
blockade (31 to 120) RR 2.68 539 ⊕ ⊝ ⊝⊝
Moderate (1.36 to 5.28) (6 studies) V𝑒𝑟𝑦 𝑙𝑜𝑤1,2,3,4,5,6
0 per 1000
0 per 1000
(0 to 0)
Study population
Adverse 274 per 1000
261 per 1000
effect-nausea-vomiting (211 to 352) RR 1.05 502 ⊕ ⊕ ⊕⊝
Moderate (0.81 to 1.35) (7 studies) 𝑚𝑜𝑑𝑒𝑟𝑎𝑡𝑒1,2,3
233 per 1000
222 per 1000
(180 to 300)
11
12
Table 2: Continued.
Study population
Adverse effects-urinary 138 per 1000
62 per 1000
retention (79 to 242) RR 2.23 429 ⊕ ⊝ ⊝⊝
Moderate (1.27 to 3.91) (5 studies) V𝑒𝑟𝑦 𝑙𝑜𝑤1,2,3,6,7,8
172 per 1000
77 per 1000
(98 to 301)
Study population
Adverse effects-delayed 136 per 1000
37 per 1000
discharge (15 to 1000) RR 3.68 49 ⊕ ⊝ ⊝⊝
Moderate (0.41 to 32.97) (1 study) V𝑒𝑟𝑦 𝑙𝑜𝑤5,6,9,10
136 per 1000
37 per 1000
(15 to 1000)
Study population
Adverse
17 per 1000
effects-infection-caudal 43 per 1000
(1 to 385) RR 0.38 43 ⊕ ⊝ ⊝⊝
versus infiltration
Moderate (0.02 to 8.86) (1 study) V𝑒𝑟𝑦 𝑙𝑜𝑤3,5,6,9,10
17 per 1000
44 per 1000
(1 to 390)
∗
The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison
group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence:
high quality: further research is very unlikely to change our confidence in the estimate of effect;
moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate;
low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate;
very low quality: we are very uncertain about the estimate.
1
There was no appropriate concealment in the majority of the studies.
2
Based on available studies, funnel plot looks symmetrical.
3
None of the studies were industry funded.
4
No uniform criteria were considered for assessment of motor blockade.
5
Wide confidence interval.
6
Sample size too low to detect a true difference.
7
No uniform criteria used for assessment of urinary retention.
8
Several confounders were not controlled appropriately.
9
No appropriate concealment or random sequence generation.
10
Only a single study.
Table 3: Characteristics of included studies.

Author,
Participants Interventions Outcomes Notes
year, and methods
Caudal versus inguinal nerve block
Abdellatif US guided INB against CHEOPS scale and also the
Children with unilateral 1 patient in CB and 2 in
2012 [8] blind CB; both done number of children
groin surgery INB were excluded due to
RCT, 2 groups, preoperatively under GA. needing rescue analgesic
Age: 1–6 yrs failure.
parallel design No use of adrenaline. provided.
Primary outcome: For the purpose of the
2 groups of CB (with or
Fisher et al., Children having postoperative voiding with review the caudal groups
without the use of
1993 [9] herniorrhaphy or analgesia outcomes as were combined as 1 group.
epinephrine) against INB;
RCT, 3 groups, orchidopexy secondary.Single time point 4 patients in each group
both done after the
parallel design Age: 0.5–10 yrs reporting of rescue were excluded because of
procedure.
analgesia. failure of interventions.
Markham et al., Children having CB against INB; both done
The outcome was
1986 [10] herniorrhaphy or preoperatively, without
intraoperative and
RCT, 2-arm orchiopexy image guidance under GA.
postoperative analgesia.
parallel trial Age: 1–12 years No use of adrenaline.
Scott et al., Children having CB against INB; both done
Primary outcome:
1989 [11] herniorrhaphy or preoperatively, without
effectiveness of
RCT, 2-arm orchiopexy image guidance under GA.
postoperative analgesia.
parallel trial Age: 3–8 years No use of adrenaline.
CB against INB, with the Not included in the
3rd group acting as a quantitative analysis.
Hanallah et al., Primary outcome:
control. The authors also combined
1987 [12] Orchidopexy postoperative analgesia as
All interventions done after both treatment groups
RCT, 3-arm Age: 18 months–12 years median and range without
surgery, without image compared to the control
parallel trial specifying the time point.
guidance group to report the use of
No use of adrenaline. rescue analgesia.
Caudal versus infiltration
CB against wound
Machotta et al., Postoperative analgesia.
Children having infiltration; both done after Adverse events are not
2003 [13] Hannalah scale as well as
unilateral Hernia the surgery. specifically (individually)
RCT, 2-arm children needing rescue
Age: 0–5 yrs No Image guidance or use reported.
parallel trial analgesic.
of epinephrine.
CB done preoperatively
Lafferty et al.,
Children having versus wound infiltration Postoperative analgesia by a
1990 [14] Poor reporting of methods
orchiopexy done before full surgical 10 cm linear analogue scale
RCT, 2-arm and outcome assessment
Age: 2–15 years closure. No image guidance and use of rescue analgesia.
parallel design
or use of epinephrine.
Calculation of the number
Children having Caudal done preoperatively
Fell et al., Analgesia rated on a of children needing rescue
inguinal herniotomy versus wound infiltration
1988 [15] 3-point scale. Proportions analgesic was done
Mean age after surgery.
RCT, 2-arm of patients who were pain indirectly.
CB: 4.5 ± 2.9 yrs No image guidance or use of
parallel design free provided. 1 patient was excluded as
INF: 3.7 ± 2.5 yrs epinephrine
the data was incomplete.
Children in the control
Conroy et al., group were not included in
CB done preoperatively Postoperative analgesia.
1993 [16] this review.
Children having a versus INF after surgery. Specific time point used to
RCT, 3-arm Confusion in the
bilateral inguinal hernia No image guidance. calculate the number of
parallel trial, randomization code, in the
Age: 2 months–10 years Epinephrine used in both rescues analgesic not
with a first 30 pts, led to more
groups. clearly mentioned.
control group. children having caudal
blocks.
Caudal versus INF, both
Jahromi et al., done after the surgery. Analgesia in FLACC scale
Unilateral inguinal 3 children in the caudal
2012 [17] No image guidance or and also reported as the
hernia group were excluded
RCT, 3-arm epinephrine was used. number needing rescue
Age: 0.3–7 years because of failed caudal.
parallel design 3rd group of acetaminophen analgesic.
was not included
Table 3: Continued.
Author,
Participants Interventions Outcomes Notes
year, and methods
CB done preoperatively
Schindler et al., Analgesia in CHEOPS scale
Unilateral inguinal versus INF done before full
1991 [18] and also reported as the
hernia surgical closure. No image
RCT, 2-arm number needing rescue
Age: 2 months–12 years guidance or epinephrine
parallel design analgesia.
used.
Caudal versus combined wound infiltration and inguinal N block
Children having
inguinal hernia with
CB placed presurgically
Tobias et al., additional laparoscopic Analgesia using Hannalah
versus INB and INF.
1995 [19] inspection of scale and also reported as Laparoscopic inspection
No image guidance.
RCT, 2-arm contralateral peritoneum the number needing rescue involved.
Epinephrine used in both
parallel design Mean age analgesia.
arms.
CB: 1.2 ± 0.2 yrs
Comparator: 1.3 ± 0.4 yrs
CB placed presurgically
Splinter et al., versus INB and INF placed Analgesia using mCHEOPS
Children having
1995 [20] after surgery. scale and also reported as
inguinal hernia repair
RCT, 2-arm No image guidance. the number needing rescue
Age: 1–13 years
parallel design Epinephrine used in both analgesic.
arms.
Children having CB versus INB and INF, all
Cross and battett Analgesia using linear The dose of local anesthetic
herniotomy or/and placed before surgery.
1987 [21] analogue scale and also was different depending on
orchidopexy; unilateral No image guidance.
RCT, 2-arm reported as the number unilateral and bilateral
or bilateral included. Epinephrine used only in
parallel design needing rescue analgesic. surgeries.
Age: 1–13 years the comparator group.
Primary outcome-effect of The report is titled as a
Somri et al., CB versus combined INB catecholamine level. comparison of CB versus
Children having
2002 [22] and INF. Analgesia as a secondary INB; however the methods
orchidopexy
RCT, 2-arm No image guidance or use of outcome, reported as the mention that they
Age: 1–8 years
parallel design epinephrine. number needing rescue supplemented the INB with
analgesic. INF.
Bhattarai et al., CB versus combined INB Analgesia reported as mean
Children having
2005 [23] and INF; all interventions duration and also as the
herniotomy
RCT, 2-arm done after surgery. number needing rescue
Age: 1–14 years
parallel design No image guidance used. analgesic.
Caudal versus others
Tug et al.,
Rescue analgesia at 2 and 2 (PVB) and 4 (CB) were
2011 [24] Inguinal hernia CB versus PVB; both placed
4 hrs and also in mean excluded due to technical
RCT, 2-arm Age: 3–7 years presurgically.
(±SD scores). failures.
parallel design
US: ultrasound, PVB: paravertebral block, SD: standard deviation, FLACC scale: Face, Legs, Activity, Cry, Consolability scale, CHEOPS scale:Children’s Hospital
Eastern Ontario Pain Scale.
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nal herni∗ .mp. rare disease supplementary concept, unique identi-
fier]
(2) herniorraph∗ .mp. [mp = title, abstract, original title,
name of substance word, subject heading word, key- (5) hernia repai∗ .mp. [mp = title, abstract, original title,
word heading word, protocol supplementary concept, name of substance word, subject heading word, key-
rare disease supplementary concept, unique identi- word heading word, protocol supplementary concept,
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All authors reported no conflict of interests. ilioinguinal/iliohypogastric nerve blocks for control of post-
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Authors’ Contribution
[13] A. Machotta, A. Risse, S. Bercker, R. Streich, and D. Pappert,
Harsha Shanthanna and Balpreet Singh were responsible for “Comparison between instillation of bupivacaine versus caudal
the study design, conduct of the review, data analysis, and analgesia for postoperative analgesia following inguinal hern-
iotomy in children,” Paediatric Anaesthesia, vol. 13, no. 5, pp.
manuscript writing. Gordon Guyatt helped with study design
397–402, 2003.
and interpretation of data analysis.
[14] P. M. Lafferty, N. H. Gordon, and T. J. Winning, “A comparison
of postoperative pain relief techniques in orchidopexy,” Annals
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BioMed Research International

Harsha Shanthanna,1 Balpreet Singh,2 and Gordon Guyatt3

Correspondence should be addressed to Harsha Shanthanna; [email protected]

Received 16 May 2014; Accepted 10 June 2014; Published 5 August 2014

Academic Editor: Patricia Khashayar

1. Introduction haematoma, and inadvertent subarachnoid or intravascular

PRISMA 2009 flow diagram

Records identified through

Records after duplicates removed

Records screened Records excluded

Full-text articles assessed Full-text articles excluded, with

Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Low risk of bias

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Bhattarai et al. 2005 − + + + + + +

Conroy et al. 1993 − − + + + + +

Cross et al. 1987 − − + − + + +

Fell et al. 1988 − − + + + + +

Fisher et al. 1993 ? − + + + + +

Hannallah et al. 1987 ? + + + + + +

Hosseini Jahromi et al. INF 2012 − − + + − + +

Lafferty et al. 1990 − + + ? + + +

Machotta et al. 2003 − + + + + + +

Markham et al. 1986 ? − + + + + +

Schindler et al. 1991 − − + + + + +

Scott et al. 1989 − − + + + + +

Somri et al. 2002 − − + + + + +

Splinter et al. 1995 + − + + + + +

Tobias et al. 1995 − − + + + + +

Tug et al. 2011 + − + + + + +

Figure 3: Risk of bias in individual studies using Cochrane risk of bias.

0 [0.69, 0.96], 𝑃 = 0.01, reaching statistical significance. The

1 3.4.3. Side Effects. Motor blockade (Figure 7) was observed in

Caudal Noncaudal Risk ratio Risk ratio

11.1.2 Caudal versus infiltration

11.1.3 Caudal versus combined N block and infiltration

11.1.4 Caudal versus paravertebral

Total (95% CI) 399 390 100.0% 0.81 [0.66, 0.99]

Caudal Noncaudal Risk ratio Risk ratio

Test for overall effect: Z = 0.09 (P = 0.93)

11.2.3 Caudal versus combined N block and infiltration

Total (95% Cl) 256 276 100.0% 0.81 [0.69, 0.96]

Caudal Noncaudal Risk ratio Risk ratio

11.3.2 Caudal versus infiltration

11.3.3 Caudal versus combined N block and infiltration

11.3.4 Caudal versus paravertebral

Total (95% CI) 239 230 100.0% 2.59 [1.29, 5.20]

Figure 7: Forest plot for the incidence of motor block.

Caudal Noncaudal Risk ratio Risk ratio

11.5.2 Caudal versus infiltration