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Levels of the spina bifida. a S1 segment, b S3–S5 segment, c S1–S2 segment, d S1–S5 segment, e L5–S1 segment, f S2–S5 segment
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Purpose:
Caudal epidural anesthesia (CEB) is widely used for the prevention of chronic lower back pain, the control of intraoperative analgesia such as genitourinary surgery and labor pain cases in sacral epidural space approach for the implementation of analgesia. CEB is an anesthetic solution used into the sacral canal via sacral hiatus (SH). Fo...
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Objective: For the management of perioperative pain control during procedures like genitourinary surgery and labor pain instances when the sacral epidural space technique is utilized for the application of analgesia, caudal epidural anesthesia (CEB) is frequently used. CEB is an anesthetic that is injected through the sacral hiatus (SH) into the sa...
Citations
... Therefore, reaching the epidural space for a safe caudal epidural block is possible by knowing well the anatomical structure of the SH. In this application, the depth of the sacral canal at the apex and the intercornual distance are the most frequently used anatomical landmarks and require good anatomical knowledge of this region [13]. ...
... A. SH measurement on sagittal CT, B. APCWHSA measurement on axial CT, C. ICD measurement on axial CTThe length of the hiatus sacralis (LHS): It is the distance between the midpoint of the lower opening of the canalis sacralis and the midpoint of the part of the os sacrum that articulates with the os coccygis[13]. It was calculated by multiplying the number of sections between the first section where the hiatus sacralis begins (A) and the section at the level it ends (B) on the axial CT (Figure 4). ...
Objective: In recent studies, the relationship between sacrum morphology and orientation and spondylolisthesis has gained importance. The present study aimed to compare the morphometry of the sacrum between patients with L5-S1 spondylolisthesis and healthy subjects on multidetector computed tomography (MDCT) images. Methods: In this study, abdominopelvic MDCT images of 191 individuals (age range 20-92 years; 101 males and 90 females; 56 patients diagnosed with L5-S1 spondylolisthesis and 135 healthy individuals) were retrospectively evaluated. In this study, the sacrum parameters (Intercornual distance (ICD), sacral hiatus length (LHS), anteroposterior diameter of hiatus at the apex of sacral hiatus(APCWHSA), sacral height (SH), sacral table angle (STA), sacral table index (STI), S1 superior angle (S1A), sacral slope(SS)) evaluated morphometric and morphological in healthy individuals and patients with L5-S1 spondylolisthesis. Kolmogorov–Smirnov test was used to test the normality, which is one of the parametric test assumptions, of the data. Results: Age parameter was found statistically significant higher in the patient group (p<0.001). STA, S1A, SH, LHS and APCWHSA measurements were found to be significantly higher in the healthy group. (p<0.001, p<0.001, p=.008, p=.005, and p=.002, respectively). STI and ICD were found to be significantly higher in women in the healthy group (p=.031, p=.010), while SH parameter was found statistically significant higher in men in the healthy group (p=.007). SS was found statistically significant lower in the healthy group (p<0.001). S1A, L5-S1 spondylolisthesis was found statistically significant higher than Grade 1, Grade 2 according to the degree of slippage (p=.045). Conclusion: The results of this study showed that sacral morphology is important in the development or at least progression of spondylolisthesis.
... These parameters are unique in various regions of world and different races. 10 So, this study was planned to undertake radiological assessment of sacral hiatus and to compare findings among cases of non-specific low backache with healthy subjects. The results of present study revealed that inverted "U" was most common shape among cases of backache, followed by inverted "V". ...
Objectives
To determine hiatal variations in cases of backache and controls on radiographs and association of age groups with hiatal parameters in patients with backache versus normal individuals.
Methods
This case control study on 178 patients (89 cases and 89 controls), aged from 18-65 years, selected by non-probability convenience sampling was conducted at Radiology Department of PNS Shifa Hospital, Karachi over six months.The sacral hiatus was identified on lumbosacral spine radiographs. Both metric and non-metric parameters of hiatus with respect to sacral vertebra were noted and compared between the groups.
Results
Inverted “U” was the most common type observed in cases with base of hiatus at S5 level. Comparison of hiatal shape among different age groups showed inverted “U” and inverted “V” types among all age groups. Hiatal anteroposterior diameter and width were greatest in 36-45-year age group, and it was longest in 46-55-year age group. Determination of relationship between sacral hiatal parameters and incidence of low back pain showed positive association of inverted “U” and “M” shapes with back pain. Increased risk of back pain was observed with high apex (first sacral vertebra (S1)).
Conclusion
Strong positive correlation was determined with inverted “U” and “M” shapes, and level of apex at S1 with low backache.
... Acknowledging the significance of anatomical variation by a healthcare provider can be crucial in terms of avoiding complications in this procedure like puncturing the dura [23,[25][26][27]. In addition, healthcare providers responsible for practicing this procedure clinically should consider the difference in the anatomical variation of the sacral hiatus as well as the distance between DS and sacrococcygeal membrane in the patients under treatment [23,28,29]. While fluoroscopy and ultrasonography can help in guiding the healthcare provider and reducing the risk of complications, it is highly advisable for the physician to perform an MRI prior to conducting this procedure for the patient to detect the presence of any anatomical variation, Tarlov cysts, lumbosacral transitional vertebrae and to ensure adequate visualization of the entire spinal anatomy [10,20,21,23]. ...
[This corrects the article DOI: 10.7759/cureus.32533.].
... Acknowledging the significance of anatomical variation by a healthcare provider can be crucial in terms of avoiding complications in this procedure like puncturing the dura [23,[25][26][27]. In addition, healthcare providers responsible for practicing this procedure clinically should consider the difference in the anatomical variation of the sacral hiatus as well as the distance between DS and sacrococcygeal membrane in the patients under treatment [23,28,29]. While fluoroscopy and ultrasonography can help in guiding the healthcare provider and reducing the risk of complications, it is highly advisable for the physician to perform an MRI prior to conducting this procedure for the patient to detect the presence of any anatomical variation, Tarlov cysts, lumbosacral transitional vertebrae and to ensure adequate visualization of the entire spinal anatomy [10,20,21,23]. ...
Background
For the success of procedures such as caudal block, craniospinal irradiation (CSI), and management of lower back pain and to minimize the risk of dural puncture the exact level of dural sac (DS) termination should be known.
Objective
The evaluation of DS tip location in the Saudi population and exploring possible significant factors that could be used as predictors in clinical prognosis.
Methods
A total of 200 patients’ lumbar sagittal Weighted T2 Magnetic Resonance Imaging (MRI) study were randomly selected from a single-center hospital in-between 2020 and 2021. The DS tip location was determined by generating a perpendicular line from the longitudinal axis of its termination to the corresponding level. Then naming it after an intervertebral disk or a corresponding vertebrate that is divided into three thirds (upper, middle, and lower).
Results
In most cases, the level of DS termination is at the middle part of S2 (26.5%), followed by the upper part of S2 (25.1%), and the lower part of S2 (20%). In Saudi nationals, the DS tip was in the middle S2 level at 21.5%, upper S2 level at 19.1%, and lower S2 level at 17%. Factors such as age, sex, cause of referral, and nationality had no statistical significance in relation to DS tip location.
Conclusion
The DS termination level in the Saudi population ranges from disk between L5-S1 to the lower third of S3. Moreover, nationality, age, and cause of referral were not significant in determining the DS termination level. Therefore, it is still important to individualize patients’ treatment by using MRI for each case that requires it.
... Another landmark suggested in various reports is the equilateral triangle structure formed by the lines of the right and left lateral sacral crest and the apex of the sacral hiatus on dried sacral bone. [6,[10][11][12] The PSISs lie on the lateral sacral crest at the level of the first sacral foramen. Senoglu et al [6] reported that trigonum sacrale formed an equilateral triangle, while Bagheri et al [10] reported that in 55% cases, both sides of the triangle were smaller than the base of the triangle. ...
... [6,[10][11][12] The PSISs lie on the lateral sacral crest at the level of the first sacral foramen. Senoglu et al [6] reported that trigonum sacrale formed an equilateral triangle, while Bagheri et al [10] reported that in 55% cases, both sides of the triangle were smaller than the base of the triangle. Knowledge on whether the trigonum sacrale from PSIP is an equilateral triangle or not constitutes useful data, especially in obese patients who cannot be easily palpated owing to the thickening of their soft tissues. ...
... The left border of the triangle was similar to the previous reports (previously reported average range: 60.0-75.0, value in our report: 64.1), but the base of triangle was the largest measure we reported (previously reported average 60.0-75.5, value in our report: 80.2). [2,6,[10][11][12][13][14][15][16] To assess the accuracy of the 3DCT, we compared our data with past reports (Table 1). [2,6,[10][11][12][13][14][15][16] The height of the sacral hiatus in our study was 28.6 ± 8.4 (range 13.8-45.2 ...
This study is the first attempt to examine anatomical characteristics using three-dimensional computed tomography (3DCT) bone images with some parameters, in order to achieve correct and uncomplicated accesses. In addition, the study addresses a long-standing problem in the field and evaluates whether the trigonum sacrale forms an equilateral triangle or not. A detailed anatomic study of the sacral region was carried out on 91 patient 3DCT images. The CT data, in DICOM format, was read into VINCENT software from Fuji Film, with a slice thickness of 0.5 mm. The average length of sacral hiatus was 28.6 ± 8.4 (range 13.8–45.2 mm). The average width of sacral hiatus at the level of sacral cornua was 10.9 ± 2.7 (range 3.8–16.5 mm). The ratio between the length of the oblique and base line formed by the sacral triangle was 0.81 ± 0.12 (range 0.54–1.00). Using 3DCT images translated by the volume rendering technique, we can remove soft tissue from bones virtually. A slice thickness of 0.5 mm makes it a fine image, and permits meticulous measurement, which is different from previous cadaveric studies. Interestingly, our data showed that the ratio between oblique and base line on sacral triangle was <1.0, average 0.81. Findings demonstrated that the trigonum sacrale is not an equilateral triangle. This is useful information for the identification of the sacral hiatus when the landmark-based technique is employed.
... However, some patients also show an incomplete fusion of the lower portion of the S4, S3, or S2 posterior mid-line [2]. In a few cases, the hiatus has been reported to be absent in the fusion processes or the sacrococcygeal membrane and cannot be penetrated because of advanced ossification, which has resulted in the failure of CEB [28]. We also found that the sacral cornua, formed by the remnants of the S5 inferior articular processes, are significantly associated with caudal epidural anesthesia in this study. ...
Background. We aimed to develop a predictive difficult caudal epidural blockade (pDCEB) model when ultrasound was not available and verified the role of ultrasound in difficult caudal epidural blockade (CEB). Methods. From October 2018 to March 2019, this study consisted of three phases. First, we prospectively enrolled 202 patients scheduled to undergo caudal epidural anesthesia and assessed risk factors by binary logistic regression to develop the predictive scoring system. Second, we enrolled 87 patients to validate it. The receiver operating characteristic (ROC) curve was used to evaluate the performance of the prediction model. Youden-index was used to determine the cut-off value. Third, we enrolled 68 patients with a high risk of difficult CEB (pDCEB score ≥3) and randomized them into ultrasound and landmark groups to verify the role of ultrasound. Result. The rate of difficult CEB was 14.98% overall 289 patients. We found a correlation between unclear palpation of the sacral hiatus (OR 9.688) and cornua (OR 4.725), the number of the sacral hiatus by palpation ≥1 (OR 4.451), and history of difficult CEB (OR 39.282) with a higher possibility of difficult CEB. The area under the receiver operating characteristic curve of the pDCEB model involving the aforementioned factors was 0.889 (95% CI, 0.827–0.952) in the development cohort and 0.862 (95% CI, 0.747–0.977) in the validation cohort. For patients with a pDCEB score ≥3, a preprocedure ultrasound scan could reduce the incidence of difficult CEB (55.56% in the Landmark group vs. 9.38% in the ultrasound group, p
... A few or less number of research studies have been conducted in Bangladesh and several low-and middle-income countries (LMICs; underdeveloped and developing countries). The knowledge of anatomy and anatomical variation [56][57][58] of the sacrococcygeal region is fundamental in many clinical situations, including the most vital issue of normal vaginal childbirth. ...
Background: In the sacrococcygeal region, anatomical variation is due to the sacralization of the coccygeal
vertebra, which is the due union of/fusion of the fifth sacral with the first coccygeal vertebra of five couples
of sacral foramina under-detected or asymptomatic beyond radiological assessment. That is why it is
challenging to know the cause of coccydynia, caudal block failure, the difficult second stage of labor, and
perineal tears. The present study aims to improve knowledge about the anatomical variation of sacralization
of the coccygeal vertebra. Additionally, to find the prevalence of sacralization of coccygeal vertebra in
Sylhet, Bangladesh.
Methods: This study was performed on 60 parched, totally calcified, typical sacra of mature-age individuals
of undetermined sexes, fulfilling the inclusion criteria from the bone bank of the osteology museum of the
Department of Anatomy, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh, from July 2017 to June
2018. Sex determination of the collected unknown sacra was conducted using discriminant function analysis.
It was found that 50% (30) were male and 50% (30%) were female. The unpaired t-tests and chi-square were
utilized to determine the statistical significance.
Results: Out of 60 sacra, eight (13.33%) samples presented with sacralization. This study found that males
had significantly higher straight (p=0.05) and curved (p=0.05) lengths of sacrococcygeal vertebrae. The
sacrococcygeal curvature index (SCI) showed statistically significant (p=0.05) differences between the sexes.
Conclusion: Sacralization may exert an impact on the caudal block. It could extend the second stage of the
labor process with perineal tears. Therefore, knowledge about the anatomical variation of the coccygeal
vertebra is essential.
... In patient-controlled caudal epidural analgesia (PCCA), a type of PCEA, the puncture site is in the sacral hiatus, and a tube is placed in the sacral canal cavity with a low block area [15]. Therefore, there may be better pain control, less exercise block, and low side effects induced by opioids [16]. According to Vadhanan et al., ultrasound-guided caudal epidural anesthesia, as an anesthetic technique in perianal surgery, is practical and easy to use [15]. ...
Introduction:
This study aimed to compare the efficacy between patient-controlled caudal epidural analgesia (PCCA) and patient-controlled intravenous analgesia (PCIA) after perianal surgery, to provide a feasible solution to postoperative pain.
Methods:
This was a prospective, randomized controlled trial comprising 100 patients who underwent caudal epidural block on perianal surgery at Chengdu Shang Jin Nan Fu Hospital of West China Hospital at Sichuan University between April and August 2020. Patients were randomly divided into the PCCA and PCIA groups. Visual analog scale (VAS) scores were recorded at 2, 4, 6, 24, 48, and 72 h after surgery, and at the first dressing change and first defecation. The lower limb mobility in the post-anesthetic recovery room (PACU) was determined. The analgesic effect, usage amount of patient-controlled analgesia (PCA), usage amount and frequency of remedial analgesic measures, number of individuals who must be catheterized, and incidence of adverse reactions were recorded. Satisfaction of postoperative analgesic effect and convenience of PCA were also assessed.
Results:
The patients in the PCCA group had significantly lower VAS scores at 4, 6, 24, 48, 72 h, the first dressing change, and the first defecation compared with the PCIA group. There were more patients receiving postoperative remedial analgesics in the PCIA group than in the PCCA group. The outcome of the number of PCA and catheterization rates did not differ significantly between the groups. There were two cases of sensory numbness below the S3 plane. The major postoperative complications in the PCIA group were pruritus (3/47, 6.4%), nausea, and vomiting (6/47, 12.8%) (one case combined with pruritus). Patients in the PCCA group were more satisfied with the analgesic effect, while those in the PCIA group were more satisfied with the convenience.
Conclusion:
In the postoperative analgesia program of perianal surgery, PCCA may provide a better analgesic effect without increasing the incidence of complications.
Trial registration:
Chinese Clinical Trial Registry identifier, ChiCTR2000038425, September 2020, retrospectively registered.
... The landmark point in bone success in CEB is the sacral hiatus, which can be difficult to touch, especially in obese people. In patients, anatomical or technical complications include direct needle damage to the spinal cord and spinal nerve, severe subdural, accidental dural rupture, epidural hematoma, epidural abscess, anterior spinal cord syndrome and ischemia [6,9]. ...
... Technique of the CEB depends upon accurate localization of sacral hiatus (SH) through which access to the sacral epidural space is gain ed [4,8]. Dural sac ends against S2 vertebra [3][4][5][6][7][8][9][10][11][12][13][14]. The distance between the tip of the SH and the edge of the dural sac is about 4.5 cm and is essential in terms of dural function. ...
Background: Caudal epidural block (CEB) has been widely used to treat lumbar spine disorders, to manage chronic low back pain, and to provide analgesia and anesthesia in operations such as labor pain and orthopedic and genital surgeries. The CEB technique depends on the precise location of the sacral hiatus (SH) through which access to the sacral epidural space is obtained. For optimal access to the sacral epidural space, accurate knowledge of the SH descriptive profile is required.
Methods: The study was performed on 23 sacrum bones. All bones were of Iranian (Persian) origin. Bones that were worn, corroded, broken, or had any anatomical problems were excluded. The parameters were measured: Sacral hiatus Length, distance between base of hiatuse-S2, liner distances between apex of sacral hiatus till right and left ends of lateral sacral crest were measured. Distance between Apex of sacral hiatus till S2, Antherio-posterior diameter of SH and location of sacral hiatus and types of SH.
Results: This study showed that the highest type of sacral hiatus in Iranians with a frequency of 38% is inverted V shape and the lowest type of deficiency shape is with a frequency of 4.8%.
The position of sacral hiatus in the Iranian sacrum showed that the highest position was with a frequency of 45% in front of the sacral vertebra 4 and the lowest case in front of the third sacral with a frequency of 15%. The height of sacral hiatus was the highest case with a height of 21-30 mm (50% or cases 9). Anterior-posterior diameter of sacral hiatus was 4-6 mm in The most common case 75% or cases 15.
It was shown that the mean distances between S2 till apex of the sacral hiatus 56.65 mm and the mean distance between S2 till base of the sacral hiatus is 36.85 mm.
Conclusion: Successful application CEB enables comfortable anesthesia for patients and helps them to resume an active life soon. Accurate understanding of the SH location is important to reduce the risk of intraoperative as well as damage to vital structures. The present study aimed to determine positional changes and measure SH distances. Also, the aim of this study was to determine SH landmark points, perform accurate and standard morphometric measurements and calculate safe SH areas in CEB application.
... However, some patients also show incomplete fusion of the lower portion of the S4, S3, or S2 posterior midline [2]. In a few cases, the hiatus has been reported to be absent in the fusion processes or the 24 sacrococcygeal membrane and cannot be penetrated because of advanced ossification, which has resulted in the failure of CEB [24]. We also found that the sacral cornua, formed by the remnants of the S5 inferior articular processes, are significantly associated with caudal epidural anaesthesia in this study. ...
... However, some patients also show incomplete fusion of the lower portion of the S4, S3, or S2 posterior midline [2]. In a few cases, the hiatus has been reported to be absent in the fusion processes or the 24 sacrococcygeal membrane and cannot be penetrated because of advanced ossification, which has resulted in the failure of CEB [24]. We also found that the sacral cornua, formed by the remnants of the S5 inferior articular processes, are significantly associated with caudal epidural anaesthesia in this study. ...
Background: We aimed to develop a predictive difficult caudal epidural blockade (pDCEB) model when ultrasound was not available and verify the role of ultrasound in difficult caudal epidural blockade(CEB).
Methods: This study consisted of three phases. First, we prospectively enrolled 202 patients and assessed risk factors to develop the predictive scoring system. Second, we enrolled 87 patients to validate it. Third, we enrolled 68 patients with a high risk of difficult CEB (pDCEB score ≥ 3) and randomized them into ultrasound and landmark groups to verify the role of ultrasound.
Result: The rate of difficult CEB was 14.98% overall 289 patients. We found a correlation of unclear palpation of the sacral hiatus (OR 9.688) and cornua (OR 4.725), number of the sacral hiatus by palpation ≥ 1 (OR 4.451), and history of difficult CEB (OR 39.282) with higher possibility of difficult CEB. The area under the receiver operating characteristic curve of the pDCEB model involving the aforementioned factors was 0.889 (95% CI, 0.827-0.952) in the development cohort and 0.862 (95% CI, 0.747-0.977) in the validation cohort. For patients with a pDCEB score ≥ 3, pre-procedure ultrasound scan could reduce the incidence of difficult CEB.
Conclusion: This novel pDCEB score, which takes into account palpation of the sacral hiatus/cornua, number of the sacral hiatus by palpation ≥ 1, and history of difficult CEB, showed a good predictive ability of difficult CEB. The findings suggested that performing an ultrasound scan is essential for patients with a pDCEB score ≥ 3. 4 Trial registration: No: ChiCTR1800018871, Site url: https://www.chictr.org.cn/edit.aspx?pid=31875&htm=4
