Dural puncture via the sacral hiatus

Meyer, Russell

doi:10.1111/j.1365-2044.1984.tb07393.x

Cited by 6 publications

(7 citation statements)

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“…In our case, the sacrococcygeal ligament was punctured with an introducer needle for epidural adhesiolysis, and dural puncture occurred even though the needle was advanced no farther. Myer [1] and Park [2] reported similar situations.…”

Section: Discussionmentioning

confidence: 80%

“…Second, it can occur when the dural sac terminates abnormally low, with the dural sac tip located at the lower sacrum, due to simple anatomical variation [2]. Therefore, using a longer needle in a caudal block or excessively advancing the block needle through the sacrococcygeal ligament to reach the S2 level can cause venipuncture or unexpected dural puncture [1]. In our case, the sacrococcygeal ligament was punctured with an introducer needle for epidural adhesiolysis, and dural puncture occurred even though the needle was advanced no farther.…”

Section: Discussionmentioning

confidence: 99%

“…There are reports that dural puncture can occur during caudal block owing to abnormalities in the sacral vertebrae caused by disease or anatomical variation [1-3]. Therefore, unexpected complications can occur during the placement of the introducer needle via the caudal approach to epidural adhesiolysis in these patients.…”

mentioning

confidence: 99%

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Inadvertent Dural Puncture during Caudal Approach by the Introducer Needle for Epidural Adhesiolysis Caused by Anatomical Variation

et al. 2013

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There have been reports of abnormalities in the lumbosacral region involving a lower-than-normal termination of the dural sac, which is caused by disease or anatomical variation. Inadvertent dural puncture or other unexpected complications can occur during caudal epidural block or adhesiolysis in patients with these variations, but only a small number of case reports have described this issue. We report a case of dural puncture by the introducer needle before attempting caudal epidural adhesiolysis, which occurred even though the needle was not advanced upward after penetrating the sacrococcygeal ligament. Dural puncture was caused by a morphological abnormality in the lumbosacral region, with no pathological condition; the dural sac terminal was located more distally than normal. However, dural puncture could have been prevented if we had checked for such an abnormality in the magnetic resonance imaging (MRI) taken before the procedure.

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Section: Discussionmentioning

confidence: 80%

Section: Discussionmentioning

confidence: 99%

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Inadvertent Dural Puncture during Caudal Approach by the Introducer Needle for Epidural Adhesiolysis Caused by Anatomical Variation

et al. 2013

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“…In another case report, Meyer (1984) described a patient in whom a standard procedure for a caudal regional anesthetic block was converted to a subarachnoid block after the needle tip inadvertently entered an unusually low‐lying dural sac as soon as the sacrococcygeal ligament was traversed. He suggested that, when performing a caudal block, one must take care not to advance the needle too close to the level of S2 for fear of accidental dural puncture, and that it would be prudent not to advance the needle at all after piercing the sacrococcygeal ligament.…”

Section: Discussionmentioning

confidence: 99%

“…This might help avoid the difficulties of accessing the SAS when attempting to perform a standard LP in patients with severely distorted or previously operated lumbar spines. In support of this notion, a few case reports in the literature describe contrast medium myelography (Jones, Shaw, & Jacobson, 1997), subarachnoid anesthesia (Meyer, 1984), or cadaveric endoscopic or catheter SAS access (Layer et al, 2011; Mourgela, Anagnostopoulou, Warnke, & Spanos, 2006), all via the trans‐sacral hiatus route. Other reports in the anesthesiology literature describe the level of dural sac termination relative to the morphology of the vertebral canal to emphasize how best to avoid subarachnoid punctures during caudal epidural block procedures (Crighton, Barry, & Hobbs, 1997; Lee, Min, Kim, & Byon, 2017).…”

Section: Introductionmentioning

confidence: 97%

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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Feasibility of intrathecal therapeutic injections in spinal muscular atrophy patients via a percutaneous transsacral hiatus route: An initial neuroimaging morphometric study

2023

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Introduction/Aims Standard fluoroscopic lumbar puncture (LP) can be impossible in patients with severe spinal deformities from spinal muscular atrophy (SMA) who require intrathecal nusinersen therapy. There usually exists a straight trajectory in the lower sacral canal (SC) that could allow image‐guided percutaneous transsacral hiatus puncture of the lumbosacral dural sac. In this study we determine whether sacra are comparatively straighter in SMA patients (SMAps) vs healthy controls (HCs), which may facilitate unhindered transsacral hiatus spinal needle insertion for intrathecal nusinersen therapy. Methods We retrospectively analyzed lumbosacral spine computed tomograms (CTs) or CT‐myelogram images of 38 SMAps and age‐ and sex‐matched HCs. We digitally measured ventrodorsal sacral curvatures, SC surface areas, dural sac termination levels, and distances from sacral hiatus to the most caudad aspects of dural sacs (“needle distance”). Results Mean ages of HCs and SMAps were 32.7 and 31.7 years, respectively, with dural sacs terminating at similar levels. Mean values for morphometrics were: (a) midsagittal SC surface area for HCs = 701.2 mm2, and for SMAps = 601.5 mm2 (not statistically significant [ns]); (b) using a “line method,” sacral curvature for HCs = 61.9°, and SMAp = 35.7° (P = .0009), and was similar when using an “angle summation method”; (c) width of sacral hiatus for HCs = 14.9 mm, and SMAps = 15.0 mm (ns); and (d) “needle distance” for HCs = 54.7 mm, and SMAps = 49.9 mm (ns). Discussion SMAps have significantly straighter sacra compared with HCs, which theoretically renders them more amenable to percutaneous transsacral hiatus puncture of the dural sac.

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Dural puncture via the sacral hiatus

Cited by 6 publications

References 0 publications

Inadvertent Dural Puncture during Caudal Approach by the Introducer Needle for Epidural Adhesiolysis Caused by Anatomical Variation

Inadvertent Dural Puncture during Caudal Approach by the Introducer Needle for Epidural Adhesiolysis Caused by Anatomical Variation

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

Feasibility of intrathecal therapeutic injections in spinal muscular atrophy patients via a percutaneous transsacral hiatus route: An initial neuroimaging morphometric study

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