Anatomy of the sacral hiatus and its clinical relevance in caudal epidural block

Background Lumbar disc prolapse is a localized herniation of disc beyond intervertebral disc space and is the most common cause of sciatica; the aim of this study is to investigate the efficacy of ultrasound (US)-guided caudal epidural steroid injection (CESI) compared with fluoroscopy (FL)-guided CESI in treatment of patients with refractory lumbar disc prolapse (LDP) with radiculopathy. Results At the beginning of the study, there was no significant difference between both groups in all parameters. (a) Group 1 had significantly improved the straight leg raising and modified Schober tests, VAS, and ODI at 1-month and 3-month post-injection evaluation in comparison to baseline recordings (p < 0.001); (b) Group 2 had significantly improved the straight leg raising and modified Schober tests, VAS, and ODI at 1-month and 3-month post-injection evaluation in comparison to baseline recordings (p < 0.001); and (c) US-guided CESI was not statistically different from the FL-guided CESI in the improvement of the straight leg raising (p = 0.87, 0.82) and modified Schober tests (p = 0.87, 0.82) as well as VAS (p = 0.40, 0.43) and ODI (p = 0.7, 0.2) at 1-month and 3-month post-injection evaluation. In a multivariate analysis using CI = 95%, the significant predictors for a successful outcome were duration < 6 months (p = 0.03, OR = 2.25), target level not L2-3/L3-4 (p < 0.001, OR = 4.13), and LDP other than foraminal type (p = 0.002, OR = 3.78). However, age < 40 years was found to be non-significant in predicting a successful outcome (p = 0.38, OR = 0.98). Conclusion US is excellent in guiding CESI with similar treatment outcomes as compared with FL-guided CESI. Trial registration ClinicalTrials.gov Identifier: NCT03933150.

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“…Sacral hiatus has been reported to be absent in minimal cases. Failure of CESI was observed in such cases [28].…”

Section: Discussionmentioning

confidence: 91%

Caudal epidural steroid injection ultrasound-guided versus fluoroscopy-guided in treatment of refractory lumbar disc prolapse with radiculopathy

Elashmawy

Shaat

AbdelKhalek

et al. 2020

Egypt J Radiol Nucl Med

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“…A completely closed hiatus (in 2–3%) may prevent needle insertion into this space via the sacral hiatus (Kao & Lin, 2017; Sekiguchi, Yabuki, Satoh, & Kikuchi, 2004). Bagheri and Govsa (2017) have reviewed the literature describing the various shapes and dimensions of the sacral hiatus. The most commonly encountered shape is that of an inverted U, with the apex of the sacral hiatus most commonly at the S4 level (65–68%), followed by the S3 and S5 levels (about 15% at each level), and the S1–S2 level in 3–5% of cases (Aggarwal, Aggarwal, Harjeet, & Sahni, 2009; Sekiguchi et al, 2004).…”

Section: Discussionmentioning

confidence: 99%

“…Caudal epidural anesthetic blocks are widely used in intra‐operative and post‐operative analgesia for a variety of operations (e.g., genitourinary surgery) and labor pain, as well as management of chronic low back pain (Asghar & Naaz, 2013; Bagheri & Govsa, 2017). In the setting of caudal blocks, an inadvertent intradural positioning of the needle tip is the primary complication of the procedure rather than the goal (Jones et al, 1997).…”

Section: Discussionmentioning

confidence: 99%

Imaging anatomy of the vertebral canal for trans‐sacral hiatus puncture of the lumbar cistern

2020

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A standard lumbar puncture may be impossible for many anatomic or technical reasons. Previous accounts of caudal epidural anesthesia and other procedures via the sacral hiatus prompted us to test if image‐guided percutaneous trans‐sacral hiatus access to the lumbosacral subarachnoid cistern would be anatomically feasible. To study vertebral canal morphometry and curvature, we analyzed midsagittal computed tomography‐myelogram images of 40 normal subjects and digitally measured sacral curvatures between S1 to S5 and S2 to S4 using two methods whereby a lower angle signifies a straighter sacrum. We measured midsagittal vertebral canal area, hiatus width, dural sac termination levels, and distance from sacral hiatus to the dural sac tip (needle distance). Subjects were F:M = 25:15, with a mean age of 44.9 years. The two S1–S5 full sacral curvature mean angles were 57.3° and 60.4°. Almost all sacral hiatuses were at S4, and dural sac terminations were at S1–S2. The mean S2–S4 sacral curvature was 25.1°, and the mean needle distance was 57.7 mm. Using two‐way analysis of variance, there were significant sex differences for needle distances (p = .001), and full and limited sacral curvatures (p = .02, and p = .046, respectively). There were no significant linear regression correlations between age and sacral curvature, needle distance, canal area, or hiatus width. Therefore, despite a frequently prominent full sacral curvature, the combination of S1–S2 dural sac termination plus a relatively straight trajectory of the lower vertebral canal between S2 and S4 support the theoretical feasibility of percutaneous trans‐sacral hiatus and vertebral canal access to the lumbosacral cistern using a standard spinal needle.

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“…Sakral indeks, subpubik açı gibi ölçümlerin, cinsiyet hormonlarının etkisiyle, cinsiyet farklılıklarının belirlenmesinde oldukça kullanışlı birer ölçüm olduğu 21,26 ve os sacrum'un cinsiyet tayininde en çok kullanılan ve cinsiyet farklılıklarını en iyi gösteren kemiklerden birisi olduğu da belirtilmiştir [21][22][23] . Lomber spinal bozukluk ve kronik bel ağrısı tedavisi gibi çeşitli cerrahi müdahaleler için hiatus sacralis'ten epidural boşluğa analjezi ve anestezi uygulaması yapılmaktadır 9,19 . Ağrısız doğum, perineal ameliyatlar, kolposkopi için kadın doğum uzmanlarına, epidural anestezide, ortopedik teşhis ve cerrahilerde, n. ischiadicus zedelenmelerinin tedavisinde kortikosteroid enjeksiyon uygulamalarında hiatus sacralis tercih edilir 19 .…”

Section: İstatistiksel Analizunclassified

Sağlıklı Türk yetişkinlerinde os sacrum’un ve hiatus sacralis’in klinik anatomisi ve morfometrik analizi

Polat¹,

Kabakçı²,

Öksüzler³

et al. 2020

Cukurova Medical Journal

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This study is carried out to evaluate the anatomy and clinical significance of the sacrum which forms the posterior wall of pelvis and hiatus sacralis shapes. Materials and Methods: One hundred twenty three (60 females and 63 males) of Turkish healthy subjects aged between 18 and 70 having brain CT with various reason in the Radiology Department in this retrospective study. The sacrum maximum length, sacrum maximum breadth, sacral index obtained from the ratio of the sacrum breadth to sacrum length multiplied by 100 were measured and calculated. Additionally, the hiatus sacralis shapes were evaluated and classify. Results: Sacrum maximum length, 106.70±12.88mm; sacrum maximum width, 127.67±14.72mm; and sacral index 120.11±14.64 were calculated in females, respectively. The same parameters were 118.87±14.03mm, 126.45±12.77mm, and 108.48±16.50 in males, respectively. Also, the most frequent type of sacral hiatus were inverted U in females and inverted V in males, respectively. Moreover, there were a significant difference between sacrum length and sacral index and gender. Conclusion: Knowing the anatomy of the sacrum, and sacral hiatus shapes and making of morphometric measurements of it, is of clinical importance in terms of preventing the complications and the surgical intervention which will practice to this area in the pathologies of the area by orthopaedic surgeons, obstretricians, paediatricians, anaesthecians and anatomists. Amaç: Bu çalışma, pelvis arka duvarını oluşturan os sacrum'un anatomisini ve klinik önemini değerlendirmek ve hiatus sacralis şekillerini ortaya koymak için yapıldı. Gereç ve Yöntem: Bu retrospektif çalışmaya yaşları 18 ile 70 arasında değişen ve çeşitli nedenlerle Radyoloji bölümünde Bilgisayarlı Tomografi çektiren yüz yirmi üç (60 kadın; 63 erkek) sağlıklı Türk popülasyonu dahil edildi. Os sacrum'un maksimum uzunluğu, os sacrum'un maksimum genişliği, os sacrum genişliğinin os sacrum maksimum uzunluğuna bölünüp 100 ile çarpılmasıyla elde edilen sakral indeks değeri ölçüldü. Ayrıca, hiatus sacralis şekilleri değerlendirilerek sınıflandırma yapıldı. Bulgular: Kadınlarda sırasıyla os sacrum'un maksimum uzunluğu 106,70±12,88 mm os sacrum'un maksimum genişliği 127,67±14,72 mm, ve sakral indeks 120,11±14,64 olarak bulunurken, aynı parametreler sırasıyla erkeklerde 118,87±14,03 mm, 126,45±12,77 mm, ve 108,48±16,50 olarak ölçüldü. Ayrıca, en sık görülen hiatus sacralis şekli kadınlarda U şekilli hiatus sacralis iken erkeklerde V şekilli hiatus sacralis olarak belirlendi. Aynı zamanda, os sacrum uzunluğu ve sakral indeks değerleri ve cinsiyet arasında anlamlı farklılık bulundu. Sonuç: Os sacrum'un anatomisinin bilinmesi ve morfometrik ölçümlerinin yapılması os sacrum'u ilgilendiren patolojilerde bu bölgeye uygulanacak girişimlerde ve oluşabilecek komplikasyonların önlenmesi açısından ortopedi uzmanı, kadın doğum uzmanı, pediatrist, anestezist ve anatomistler açısından kinik öneme sahiptir.

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Anatomy of the sacral hiatus and its clinical relevance in caudal epidural block

Cited by 27 publications

References 26 publications

Caudal epidural steroid injection ultrasound-guided versus fluoroscopy-guided in treatment of refractory lumbar disc prolapse with radiculopathy

Caudal epidural steroid injection ultrasound-guided versus fluoroscopy-guided in treatment of refractory lumbar disc prolapse with radiculopathy

Imaging anatomy of the vertebral canal for trans‐sacral hiatus puncture of the lumbar cistern

Sağlıklı Türk yetişkinlerinde os sacrum’un ve hiatus sacralis’in klinik anatomisi ve morfometrik analizi

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