Morphometric Measurements Of Sacral Hiatus In South Indian Dry Human Sacra For Safe Caudal Epidural Block

Introduction: The sacral hiatus is located on the posterior aspect of the lower end of the sacrum, where theextradural space ends . The clinically significant features of the posterior surface of the sacrum are the triangularor inverted ‘U’ shape sacral hiatus and the sacral cornua.The knowledge of Anatomical variations of Sacralhiatus is significant while administration of Caudal Epidural Anaesthesia and it may help to improve its successrate.Aim: The purpose of this study is to recognize anatomical variations and additional landmarks of sacral hiatusin cases where the sacral cornua could not be identified and to assess proportions that may magnify the locationof the apex of the sacral hiatus and thus to find a practical solution for Caudal epidural block (CEB).Materials and methods: The present study was conducted on unknown sixty one complete and undamaged adult,dry sacral bones . The material was of undetermined age and gender. Anatomical measurements was carried outon these bones using a vernier calliper to the accurate of 0.1mm.Results: Variations in the shapes and their percentages of Sacral hiatus were observed namely Elongated, InvertedU, Irregular, Inverted V, Dumbbell and Bifid along with their distances and Angles of use in detecting the Apexwere measured. The location of Apex of Sacral hiatus was found at varying levels from upper end of S2 to lowerpart of S5 vertebrae. Also we measured the angles between the margins of the triangle formed by the twosuperolateral sacral crests and the sacral hiatus. Our measurements reveal this to be an equilateral triangle.Conclusion: This knowledge of variations in Human sacral hiatus provides a safe caudal epidural block beforesurgery and complications can be avoided.We believe that the equilateral character of the sacral triangleformed connecting the two posterior superior iliac spines and the apex of the sacral hiatus will be practicaladvantage to the clinician in ascertaining the location of the sacral hiatus during CEB.

Morphometric Analysis Of The Sacral Hiatus In Indians: Its Clinical Importance

Introduction: Sacral hiatus (SH) is a significant landmark during caudal epidural block (CEB) which is employedfor analgesia and anaesthesia during a wide range of clinical conditions. This requires a thorough knowledge ofmorphometric characteristics of SH and surrounding landmarks, but variability in morphometric dimensionsexists among different populations.Aim: The aim of this study was to identify different anatomical landmarks to detect the location of SH andprovide a reference database for morphometric dimensions of SH in Indian population.Materials and Methods: The study was done on 108 dry adult human sacra. Linear measurements of the sacrawere taken with the help of digital vernier caliper and angular parameters were determined with a goniometer.Results: The most common shape of the sacral hiatus was inverted ’V’ shaped (59.3%) with the level of the apexat S4 in 66.7% and base at S5 in 86.1% cases. Morphometric dimensions of SH were found to be smaller in presentstudy as compared to reports by other researchers. Left crest-apex angle was observed to be significantly greaterthan the right crest-apex angle. (p 0.001).Conclusion: Multiple bony landmarks and their morphometric dimensions should be considered to locate the SHduring CEB. Values for various morphometric parameters of SH are less in Indians in comparison to otherpopulations, which should be contemplated during caudal epidural injections and trans-sacral thecaloscopy.

The Study On Morphological And Morphometric Analysis Of Sacral Hiatus In Dry Human Sacra

This study was carried out on 80 dry human sacra in meenakshi medical college Anatomical variations inmorphology and morphometry of sacral hiatus. Various shapes of sacral hiatus were observed which includedinverted U (66.3%), inverted V (11.3%), irregular (11.3%), dumbbell (3.8%) Agenesis Of the dorsal (6.3%) and bifid(1.3%). The apex of sacral hiatus was commonly found at the level of 4th sacral vertebra in 76.0%. the meanlength of sacral hiatus was 22.9 mm. The mean anteroposterior diameter of sacral canal at the apex of sacralhiatus was 4.97 mm. Narrowing of sacral canal at the apex of sacral hiatus, diameter less than 4mm, wasobserved to be significantly high, (36%). The knowledge of anatomical variations of sacral hiatus is significantwhile administration of caudal epidural anaesthesia and it may help to improve its success rate

A Morphological Study Of Sacral Hiatus In Dry Human Sacra And Its Clinical Importance.

Background & objectives: The opening at the inferior end of sacral canal is known as sacral hiatus.It formed due to the failure of fusion of laminae of the fifth (occasionally fourth) sacral vertebra. Sacrum is one of the bones which exhibit variations and the variation of sacral hiatus is of great clinical significance. Present study determined the landmarks for caudal epidural block (CEB) after morphometric measurements of the sacral hiatus on dry sacra bones .Methods: 120 sacral bones are used for the study. Anatomical measurements were measured by using Vernier caliper accuracy to 0.1mm. Results: Agenesis of sacral hiatus was detected in two sacral bones. Various shapes of sacral hiatus were observed which included inverted U (31%), inverted V (25.8%), irregular (20.6%), Elongated (17.2%) and dumbbell (5%). Apex of sacral hiatus was commonly found at the level of 4th sacral vertebra in 50.8%. The distance between the two superolateral sacral crests and the distance between the apex of sacral hiatus and the right and left super lateral crests were 69.5 (5.8) mm, 61.4 (11.2) mm, 57.4 (9.7) mm respectively, on average. The mean, mode, SD is calculated for all the measurements. Interpretation & conclusion: The sacral hiatus has anatomic variations. Understanding of these variations may improve the reliability of, caudal epidural block (CEB). [Satish P NJIRM 2016; 7(5):69-72]

Anatomical Study of Sacrum and its Clinical Significance.

Background: Sacrum is formed by the fusion of five sacral vertebrae and forms the lower part of Vertebral column. The opening present at the lower end of sacral canal is known as sacral hiatus. Methods: This study was carried out on 75 dry human sacra of unknown sex to study the variations of sacral hiatus. Various shapes of sacral hiatus were observed which included inverted u, inverted v, irregular, dumbbell and bifid. The apex of sacral hiatus was commonly found at the level of 4th sacral vertebra. The mean length of sacral hiatus, the mean anteroposterior diameter of sacral canal was measured. The narrowing of sacral canal at the apex of sacral hiatus was measured. Results: We observed length of Sacral hiatus from apex to midpoint of base – maximum length was found to be 11 – 20 mm in 32 dry sacra. Anteroposterior diameter at the sacral hiatus was found to be 0 – 3 mm. in 35 dry sacra. Base (Transverse diameter) was found to be 11 – 15 mm in 36 dry sacra. Median distance between the level of lower margin of S2 and apex of sacral hiatus was 21 – 30 mm in 25(33%) Sacra. Distance between midpoint of Base to S2 foramen was found to be >40 mm in 52 Sacra and that accounts for 69 %. Conclusion: The knowledge of anatomical variations of sacral hiatus is clinically important for caudal epidural block in Pediatric, Obstetric, Orthopedic, Urologic and Surgical practice. The reliability and success of caudal epidural block depends upon Knowledge of Variations of Sacral hiatus.

Morphometric Analysis of Distances between Sacral Hiatus and Conus Medullaris Using Magnetic Resonance Image in Korean Adult / 체질인류학회지

The purpose of this study was to provide basic biometric data on Korean adults through magnetic resonance imaging (MRI)-based measurements of the distances between the apex of sacral hiatus (SH) and the termination of dural sac (DS), and between SH and conus medullaris (CM) because they are critical to the performance of epidural neuroplasty. A total of 200 patients (88 males and 112 females) with back pain, who had no spine fracture, significant spinal deformity, and spondyloisthesis were selected for this study. The subjects were of mean age 54.3 (20~84) years and mean height 161.3 cm (135~187). T2-weighted MRI images were used for correlation analysis to evaluate the relationships between the distances, and variables such as sex and height. In all patients, the mean distance between SH and DS was 62.8±9.4 mm and the mean distance between SH and CM was 232.2±21.8 mm. The minimum distance and the maximum distance between SH and DS were 34.8 mm and 93.9 mm respectively, and the minimum distance and the maximum distance between SH and CM were 155.0 mm and 284.0 mm respectively. In female patients, both the distances between the SH and DS, and between SH and CM were shorter when compared to those of the male patients (p<0.05). Both the distances between SH and DS and between SH and CM showed a significant correlation with height (p<0.01). The results of this study will provide a useful biometric data on the distances between SH and DS and between SH and CM in Korean in ensuring clinical safety and in the development of more effective catheterization techniques for epidural neuroplasty in Korean.

Morphometrical study of sacral hiatus in dry human sacra.

Background: The sacral hiatus is the site for caudal epidural anaesthesia during perineal surgery and also for a painless delivery. It is also used for three dimensional colour visualization of lumbosacral epidural space in orthopaedic practice for diagnosis and treatment. Sacrum is one of the bones which exhibit variations. Therefore the importance of the normal sacral hiatus and its variations is of great clinical significance. The reliability of caudal epidural anaesthesia is 70% - 80% in the literatures. The objective of the study was to examine, measure and record the morphometry of sacral hiatus under the following headings in order to study the anatomical variations which would be useful for caudal epidural anaesthesia and improve the reliability of the same. a) Shape of sacral hiatus, b) level of apex, c) level of base, d) length of the sacral hiatus, e) transverse width at the base, and f) anteroposterior depth at the apex. Methods: A total of 200 dry, complete, undamaged human sacra of unknown sex were used in this study. Measurements were taken using vernier calipers. In this study six parameters were taken. All the readings were tabulated and subjected to analysis. Results: Various shapes of sacral hiatus were observed which included Inverted-U (50%), Inverted-V (27.5%), Irregular (15.5%), Dumb bell (2%), and Bifid (2%). The mean anteroposterior depth of sacral canal at the level of apex of sacral hiatus was 4.25mm. The mean length of sacral hiatus was 19.63 mm and the mean transverse width of sacral hiatus at the level of base was 11.42 mm. There was complete spina bifida in 4 (2%) and absence of sacral hiatus in 2 (1%) cases. Conclusion: The sacral hiatus has anatomical variations. Understanding of these variations may improve the reliability of caudal epidural anaesthesia.

Dorsal sacral dimensional anatomy-revisited.

Background: Determination apex of sacral hiatus (SH) is of paramount importance to Anaesthetists, Orthopaedicians, Obstetricians and Gynaecologists for caudal epidural block (CEB). Dorsal sacral dimensions were therefore taken to facilitate them for easy location of SH. Methods: Following parameters of each of the sixty human sacra were measured using vernier calipers at the level of spinous process of second sacral vertebra (S2). a) Distance between the two supero-lateral crests b) Distance between the right supero-lateral crest level to the apex of sacral hiatus (SH) c) Distance between the left supero-lateral crest to the apex of SH d) Distance from the spinous process of S2 to the apex of SH e) Distance from the spinous process of S2 to the base of SH The data obtained was analysed statistically. Results: Mean of the distance between the two supero-lateral crests was 51 ± 6.37 mm and 52.7 ± 5.30 mm in males and females respectively, mean of the distance between the right supero-lateral crest and the left supero-lateral crest to the apex of SH was 45.91 ± 6.94 mm in males 42.50 ± 11.23 mm in females and 44.74 ± 6.77 mm in males and 42.50 ± 10.97 mm in females respectively , vertical distance from spinous process of S2 to the apex of SH in males and females was 38.83 ± 9.33 mm and 32.4 ± 1.64 mm respectively. Vertical distance from spinous process of S2 to the base of sacral hiatus was 59.20 mm ± 10.81 mm in males and 52.80 ± 9.18 mm in females. Conclusion: From the data obtained it was concluded that an isosceles triangle was formed between the two supero-lateral crests at the level of spinous process of S2 and the apex of SH.

Study of Sacral Hiatus in Dry Human Sacra in Nepal, Parsa Region.

Introduction: The sacrum is a large triangular bone, formed by the fusion of five sacral vertebrae. The opening at the caudal end of sacral canal is known as sacral hiatus. It is formed due to the failure of fusion of laminae of the fifth (occasionally fourth) sacral vertebra. Sacrum is one of the bones which exhibit variations and the variation of sacral hiatus is of great clinical significance because it may also leads tomechanical low back pain. Previousworks on themorphometrical study on the sacral hiatus is limited, especially in Nepal, Parsa population. The present study was undertaken to help in filling this gap at least to a certain extent and also made an attempt to find out the variations of sacrum. Materials: One hundred dry human sacra were collected from the Department of Anatomy of National medical college & Teaching Hospital, Nepal. Methods& Observations: Themorphometrical studieswere done, and the parameters (Shape, length, Transverse width & Antero-posterior width of sacral hiatus and level of apex & base of sacral hiatus) were measured with the help of divider, the observations were recorded, tabulated & analyzed. Result: The study showed a significant co-relation between anatomical variations of sacral hiatus with the previous studies.

Anatomical Profile and Morphometric Evaluation of Human Sacral Hiatus in North Indians

Successful caudal epidural block (CEB) for various gynaecological and orthopaedic procedures requires an elaborate knowledge of anatomical profile of sacral hiatus. Varied morphology of sacral hiatus is likely to influence the success rate of CEB. Scanty literature is available on the morphometry of sacral hiatus in North Indian subjects. Therefore, sacral hiatus of 60 North Indian human sacra were evaluated using Vernier calipers. Sexing of the sacra was done by calculating the sacral index. Following parameters of sacral hiatus were observed and recorded: a) Shape, b) Level of apex, c) Maximum distance between the sacral cornua, d) Length of the sacral hiatus i.e. from its apex to midpoint of its base, e) Antero-Posterior diameter at the apex of sacral hiatus. The data obtained was analyzed using SPSS software (version 18). Various shapes of sacral hiatus were observed. It was irregularly shaped in both the sexes though inverted U shaped sacral hiatus was also seen frequently in females. In males, the apex of sacral hiatus was commonly seen at the level of spinous process of 3rd sacral vertebra in males and below the level of spinous process of 4th sacral vertebra in females. The mean distance between the sacral cornua was 1.1cm : 1.2cm in males and females, respectively. Mean length of the sacral hiatus was 2cm in both sexes. Antero-posterior depth at the apex the sacral hiatus was 6mm in both the genders. The dimensions of sacral hiatus obtained in this study were inconsistent with earlier studies. Knowledge of these dimensions may help the clinicians in precisely locating sacral hiatus for successful CEB in North Indians.

A Comparison of Two Techniques for Ultrasound-guided Caudal Injection: The Influence of the Depth of the Inserted Needle on Caudal Block

BACKGROUND: Caudal epidural injections have been commonly performed in patients with low back pain and radiculopathy. Although caudal injection has generally been accepted as a safe procedure, serious complications such as inadvertent intravascular injection and dural puncture can occur. The present prospective study was designed to investigate the influence of the depth of the inserted needle on the success rate of caudal epidural blocks. METHODS: A total of 49 adults scheduled to receive caudal epidural injections were randomly divided into 2 groups: Group 1 to receive the caudal injection through a conventional method, i.e., caudal injection after advancement of the needle 1 cm into the sacral canal (n = 25), and Group 2 to receive the injection through a new method, i.e., injection right after penetrating the sacrococcygeal ligament (n = 24). Ultrasound was used to identify the sacral hiatus and to achieve accurate needle placement according to the allocated groups. Contrast dyed fluoroscopy was obtained to evaluate the epidural spread of injected materials and to monitor the possible complications. RESULTS: The success rates of the caudal injections were 68.0% in Group 1 and 95.8% in Group 2 (P = 0.023). The incidences of intravascular injections were 24.0% in Group 1 and 0% in Group 2 (P = 0.022). No intrathecal injection was found in either of the two groups. CONCLUSIONS: The new caudal epidural injection technique tested in this study is a reliable alternative, with a higher success rate and lower risk of accidental intravascular injection than the conventional technique.

Sacral Hiatus Study in Dry Human Sacra

Background and objectives: The sacral hiatus is the site for caudal epidural anaesthesia during perineal surgery and also for a painless delivery. It is also used for three dimensional colour visualization of lumbosacral epidural space in orthopaedic practice for diagnosis and treatment. Work on the morphometrical study of the sacral hiatus is limited, especially in south indian population. So this study is carried to examine, measure and record the morphometry of sacral hiatus in order to study the anatomical variations which will be useful for caudal epidural anaesthesia. Material and Methods: The study was conducted in the Department of Anatomy, Prathima Institute of Medical Science, Naganur, Andhra Pradesh. 93 dry sacra with complete sacral hiatus were taken for the study. The shape of the sacral hiatus was noted by naked eye. Level of the apex and base of the sacral hiatus was noted with respect to the sacral vertebra. The length of sacral hiatus was measured from apex to the midpoint of base, the anteroposterior depth of sacral hiatus at the apex was measured with the help of vernier calipers. The transverse width of sacral hiatus at the base was measured between the inner aspects of inferior limit of the sacral cornu with the help of divider and then adjusted, and calculated with vernier caliper. Results: In 47 (50.53 %) sacra the shape was Inverted-U and in 25 (26.9 %) sacra Inverted-V. The irregular shaped of sacral hiatus was observed in 11 (11.8 %) cases. A “Dumbbell” shaped sacral hiatus was observed in 5 (5.4%) cases with a nodular bony growth projecting medially from both margins. The dorsal wall of sacral canal was entirely absence in 4 (4.3%) cases. Absence of sacral hiatus, a rare phenomenon, was observed in 1 (1%) specimens only. Conclusion: In the present study, elongated hiatus and narrowing of the sacral canal at apex of sacral hiatus was found in a significant percentage, which should be kept in mind while giving the caudal anaesthesia in Andhra Pradesh region.

Study of dorsal wall of sacrum.

Background: Sacrum is a large triangular bone formed by fusion of five sacral vertebrae. The opening present at the caudal end of sacral canal is known as sacral hiatus and is formed due to the failure of fusion of lamina of fifth sacral vertebra. Objective of current study was to study the anatomical variations of dorsal wall of sacrum in order to clarify the structural variations of sacral hiatus and surrounding structures for improving the reliability of caudal epidural block Methods: The present study was done on 50 male and 50 female dry human sacra after calculating the sacral indices and sexing of sacra. The dorsal wall of sacrum was studied with respect to composition of sacrum, level of sacral hiatus, deficiencies and apertures in the bony dorsal wall and also for the presence and absence of sacral cornua. Results: The level of apex of sacral hiatus can vary from upper part of S2 to lower part of S5. The most common position was at S4 (64%). Elongated sacral hiatus at the level of S2 was present in 4% of cases. Sacrum had normal 5 segments in 70% of cases, 4 segmented sacra were observed in 4% of cases, sacralization of 5th lumbar vertebra in 7%, coccygeal ankylosis in 19% of cases. Less extensive apertures in the bony dorsal wall of sacral canal were observed in 29% of sacra. Conclusion: The dorsal wall of sacrum has anatomical variations. Understanding these variations may improve the reliability and success of caudal epidural anesthesia.

Importance of knowing the level of sacral hiatus for caudal epidural anesthesia

Introduction and Materials and Methods: The Study was carried out on 100 dry human sacra to know the Anatomical variations of sacral hiatus. Results: Different shapes of sacral hiatus were observed which included- Inverted U (56%), Inverted V (14%), Irregular (16%), Dumb-bell (10%), Bifid (2%) and Elongated (2%). The apex of the sacral hiatus was most commonly found at the level of 3rd sacral vertebrae in 62%. The mean length of sacral hiatus was 25.2mm, the mean anteroposterior diameter of sacral canal at the apex of sacral hiatus was 5.53mm. The mean distance between sacral cornu at the base of sacral hiatus was observed to be 19.5mm. Conclusion: This study was done to clarify the anatomical variations of sacral hiatus using bony landmarks of sacrum for improving the reliability of caudal epidural anesthesia and to improve its success rate and reduce the complications and failure rate.(AU)

An anatomical study of variations of sacral hiatus in sacra of north Indian origin and its clinical significance / Estudio anatómico de las variaciones del hiato sacro en sacros del norte de la India y su significancia clínica

Sacrum is formed by the fusion of five sacral vertebrae and forms the lower part of vertebral column. The opening present at the lower end of sacral canal is known as sacral hiatus. Anatomical variations in morphology and morphometry of sacral hiatus are important clinically as well as surgically. 159 dry clean human Sacra were taken from Department of Anatomy, Sri Guru Ram Das Institute of Medical Sciences and Research Vallah (Amritsar). Various shapes of sacral hiatus were observed which included inverted U (42.95%), inverted V (27.51%), irregular (16.10%), dumbbell (11.40%) and bifid (2.01%). The apex of sacral hiatus was commonly found at the level of 4th sacral vertebra in 56.36%. The mean length of sacral hiatus was 22.69 mm. The mean anteroposterior diameter of sacral canal at the apex of sacral hiatus was 6.49 mm. Narrowing of sacral canal at the apex of sacral hiatus (diameter less than 3 mm) was observed to be high (5.36%). The knowledge of anatomical variations of dimensions of sacral hiatus is important while doing caudal epidural block and it may help to improve its success rate.

El sacro está conformado por la fusión de las cinco vértebras sacras, y forma la parte inferior de la columna vertebral. La abertura presente en el extremo inferior del canal sacro se conoce como hiato sacro. Las variaciones anatómicas en la morfología y la morfometría del hiato sacro son importantes clínica y quirúrgicamente. Fueron utilizados 159 sacros humanos, limpios y secos, del Departamento de Anatomía, Sri Guru Ram Das Instituto de Ciencias Médicas e Investigación Vallah (Amritsar). Fueron observadas varias formas de hiato sacro: U invertida (42,95%), V invertida (27,51%), irregular (16,10%), de pesa (11,40%) y bífida (2,01%). El ápice del hiato sacro se encuentra comúnmente a nivel de la cuarta vértebra sacra en el 56,36%. La longitud media de hiato sacro fue 22,69 mm. El diámetro medio anteroposterior del canal sacro en el ápice del hiato sacro fue 6,49 mm. El estrechamiento del canal sacro en el ápice del hiato sacro (diámetro inferior a 3 mm) fue alto (5,36%). El conocimiento de las variaciones anatómicas de las dimensiones del hiato sacro es importante para el bloqueo epidural caudal y puede ayudar a mejorar su tasa de éxito.

The clinical efficacy of sacral hiatus epidural blocking combined with three-dimensional rapid traction for the treatment of lumbar disc herniation / 中华物理医学与康复杂志

Objective To observe the clinical efficacy of three-dimensional rapid traction combined with sacral hiatus epidural blocking for the treatment of lumbar disc herniation(LDH). Methods A totsl of 450 patients with LDH were divided into three groups.Group A received conventional slow traction,group B received three-dimensional rapid traction,and group C received sacral hiatus injections for epidural blocking combined with three-dimensional rapid traction.The Japanese Orthopadedic Association(JOA)scale for lumbar disease and a visual analogue scale(VAS)were used to evaluate the treatment effect and the patients'subsequent quality of life.All of the patients were followed up for 1 year and evaluated using standard clinical evaluations. Results The average VAS scores and JOA scores of the three groups were not significantly different before treatment,and all had significantly improved after treatment.The overall effectiveness rates were 63.33% for group A,90.67%for group B and 94% for group C,and these differences were all statistically significant.After one year the recurrence rates in the A,B and C groups were 20.7%,14.0%and 8.7% respectively,and these differences were again statistically significant.Conclusion Sacral hiatus epidural blocking combined with three-dimensional rapid traction showed good therapeutic effect and safety for LDH patients and was superior to simple rapid traction or slow traction.

The Success Rate of Caudal Block Under Ultrasound Guidance and the Direction of the Needle in the Sacral Canal / 대한통증학회지

BACKGROUND: Caudal block is useful when anesthesia for surgery or treatment for chronic pain is needed, but this procedure has a failure rate of up to 25% even when it performed byan experienced physician. This high failure rate is usually due to improper needle placement. METHODS: After gaining approval of the ethics committee, 46 patients received caudal blocks under ultrasound guidance; these were performed after the anatomical structures in the sacral hiatus had been measured with ultrasound. All these procedures were performed by the same anesthesiologist. The position and direction of the needle were identified using fluoroscopy by injecting a radio-opaque contrast through the needle. The time taken from thelidocaine injection to verification of the needle was measured and the planned nerve block was then carried out. RESULTS: All cases of needle insertion into the sacral canal under ultrasound guidance were successful. The average duration of the procedure and the trial count were 134.1 +/- 10.1 seconds and 1.2 +/- 0.1, respectively. In 12 of the 46 cases (26%), the needle deviated either left or right in the sacral canal, so the direction of the needle had to be adjusted. The distance between two cornua, the depth of the sacral hiatus and the thickness and length of the sacrococcygeal ligament were 17.1 +/- 0.4, 3.9 +/- 0.3, 2.3 +/- 0.1 and 24.9 +/- 0.9 mm, respectively. CONCLUSIONS: Ultrasound guidance can increase the success rate of inserting a needle into the sacral canal. However, even when ultrasound is used, the needle can deviate either left or right in the sacral canal.