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Published online: 2019-04-03
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Anatomy and clinical significance of sacral variations: a systematic review

Evangelos Nastoulis, Maria-Valeria Karakasi, Pavlos Pavlidis, Vasilios Thomaidis, Aliki Fiska
DOI: 10.5603/FM.a2019.0040
·
Pubmed: 30949993

open access

Ahead of Print
REVIEW ARTICLES
Published online: 2019-04-03
Submitted: 2019-02-11
Accepted: 2019-03-15

Abstract

The sacrum is a large trilateral bone located at the base of the vertebral column serving to transfer the body weight from the trunk to the pelvis and lower extremities. Over the years, an abundance of sacral anatomical divergences has been reported, including numerical and/or morphological variations of sacral entities. The majority of these anatomical alternations has been incidentally identified during radiological investigations, surgical procedures or discovered in anatomical, anthropological and forensic research studies. Throughout international literature, however, there is a scarcity of an integrative recording of all known anatomical variations of the sacrum in a single study. This constitutes the objective of the present paper: to provide an exhaustive systematic review of the relevant literature, as well as to thoroughly describe all the recognized deviations of the sacrum structure, while highlighting the aspects of their clinical significance.

Abstract

The sacrum is a large trilateral bone located at the base of the vertebral column serving to transfer the body weight from the trunk to the pelvis and lower extremities. Over the years, an abundance of sacral anatomical divergences has been reported, including numerical and/or morphological variations of sacral entities. The majority of these anatomical alternations has been incidentally identified during radiological investigations, surgical procedures or discovered in anatomical, anthropological and forensic research studies. Throughout international literature, however, there is a scarcity of an integrative recording of all known anatomical variations of the sacrum in a single study. This constitutes the objective of the present paper: to provide an exhaustive systematic review of the relevant literature, as well as to thoroughly describe all the recognized deviations of the sacrum structure, while highlighting the aspects of their clinical significance.

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Keywords

sacral variations, sacrum, anatomical variations, sacral hiatus variations, sacral foramina pairs

About this article
Title

Anatomy and clinical significance of sacral variations: a systematic review

Journal

Folia Morphologica

Issue

Ahead of Print

Published online

2019-04-03

DOI

10.5603/FM.a2019.0040

Pubmed

30949993

Keywords

sacral variations
sacrum
anatomical variations
sacral hiatus variations
sacral foramina pairs

Authors

Evangelos Nastoulis
Maria-Valeria Karakasi
Pavlos Pavlidis
Vasilios Thomaidis
Aliki Fiska

References (126)
  1. Abukawa Y, Hiroki K, Morioka N, et al. Ultrasound versus anatomical landmarks for caudal epidural anesthesia in pediatric patients. BMC Anesthesiol. 2015; 15: 102.
  2. Aggarwal A, Aggarwal A, Sahni D. Morphometry of sacral hiatus and its clinical relevance in caudal epidural block. Surg Radiol Anat. 2009; 31(10): 793–800.
  3. Akhtar J, Madhukar K, Fatima N, et al. A morphometric study of complete agenesis of dorsal wall in human sacrum. Indian J Applied Res (IJAR). 2015; 5(4): 449–451.
  4. Alappat JP. Scimitar sacrum. Neurol India. 2004; 52(2): 288.
  5. Ali S, Azeemi A, Shoukat S. The prevalence of spina bifida occulta in Pakistani population: A study of dry human sacra. Anaesth, Pain Intensive Care. 2014; 18(2): 157–161.
  6. Asghar A, Naaz S. The volume of the caudal space and sacral canal in human sacrum. J Clin Diagn Res. 2013; 7(12): 2659–2660.
  7. Avrahami E, Frishman E, Fridman Z, et al. Spina bifida occulta of S1 is not an innocent finding. Spine. 1994; 19(1): 12–15.
  8. Bagheri H, Govsa F. Anatomy of the sacral hiatus and its clinical relevance in caudal epidural block. Surg Radiol Anat. 2017; 39(9): 943–951.
  9. Bardeen CR. Numerical vertebral variations in the human adult and embryo. Anat Anz. 1904; 25: 497–519.
  10. Bardeen CR. Studies of the development of the human skeleton. A. The development of the lumbar, sacral and coccygeal vertebrae. Am J Anat. 1905; 4: 265–302.
  11. Barnes E. Developmental defects of the axial skeleton in paleopathology. University Press of Colorado 1994.
  12. Başaloğlu H, Turgut M, Taşer FA, et al. Morphometry of the sacrum for clinical use. Surg Radiol Anat. 2005; 27(6): 467–471.
  13. Beckman C, Ling F. Obstetrics and gynecology. Sixth Ed. ACOG 2010.
  14. Bertolotti M. Contributo alla conoscenza dei vizi differenzazione regionle del rachid con speciale riguardo all’assimilazione sacrale edlla v lombare. La Radiologia Medica. 1917; 4: 113–144.
  15. Bhattacharya S, Majumdar S, Chakraborty P, et al. A morphometric study of sacral hiatus for caudal epidural block among the population of West Bengal. IJBAMR. 2013; 7(2): 660–667.
  16. Boulet C, Schiettecatte A, De Mey J, et al. Case report: imaging findings in a. Acta Neurol Belg. 2011; 111(4): 344–348.
  17. Bron JL, van Royen BJ, Wuisman PI. The clinical significance of lumbosacral transitional anomalies. Acta Orthop Belg. 2007; 73(6): 687–695.
  18. Castellvi AE, Goldstein LA, Chan DP. Lumbosacral transitional vertebrae and their relationship with lumbar extradural defects. Spine. 1984; 9(5): 493–495.
  19. Chauhan P, Kalra S. A rare osseous growth on sacrum. Int J Anat Var. 2010; 3: 218–219.
  20. Chen CPC, Tang SFT, Hsu TC, et al. Ultrasound guidance in caudal epidural needle placement. Anesthesiology. 2004; 101(1): 181–184.
  21. Cheng JS, Song JK. Anatomy of the sacrum. Neurosurg Focus. 2003; 15(2): E3.
  22. Crighton IM, Barry BP, Hobbs GJ. A study of the anatomy of the caudal space using magnetic resonance imaging. Br J Anaesth. 1997; 78(4): 391–395.
  23. Currarino G, Coln D, Votteler T. Triad of anorectal, sacral, and presacral anomalies. AJR Am J Roentgenol. 1981; 137(2): 395–398.
  24. Deepa TK, John M. A study of lumbarisation of first sacral vertebra among the South Indians. Int J Med Res Health Sci. 2014; 3(1): 1–4.
  25. Demir M, Mavi A, Gümüsburun E, et al. Anatomical variations with joint space measurements on CT. Kobe J Med Sci. 2007; 53(5): 209–217.
  26. Diel J, Ortiz O, Losada RA, et al. The sacrum: pathologic spectrum, multimodality imaging, and subspecialty approach. Radiographics. 2001; 21(1): 83–104.
  27. Duhamel B. From the mermaid to anal imperforation: the syndrome of caudal regression. Arch Dis Child. 1961; 36(186): 152–155.
  28. Dunaway CL, Williams JP, Brogdon BG. Case report 222. Sacral and coccygeal supernumerary ribs (pelvic ribs). Skeletal Radiol. 1983; 9(3): 212–214.
  29. Ebraheim NA, Xu R, Biyani A, et al. Morphologic considerations of the first sacral pedicle for iliosacral screw placement. Spine. 1997; 22(8): 841–846.
  30. Ehara S, el-Khoury GY, Bergman RA. The accessory sacroiliac joint: a common anatomic variant. Am J Roentgenol. 1988; 150(4): 857–859.
  31. Erken E, Ozer HTE, Gulek B, et al. The association between cervical rib and sacralization. Spine. 2002; 27(15): 1659–1664.
  32. Fidas A, MacDonald HL, Elton RA, et al. Prevalence and patterns of spina bifida occulta in 2707 normal adults. Clin Radiol. 1987; 38(5): 537–542.
  33. Fortin JD, Ballard KE. The frequency of accessory sacroiliac joints. Clin Anat. 2009; 22(8): 876–877.
  34. Galen. De usu partium, ed. G. Helmreich, Galeni de usu partium libri xvii. Leipzig: Teubner, 1:1907; 2:1909 (repr. Amsterdam: Hakkert, 1968), (Cod: 202,076: Med.).
  35. Galloway NT, Tainsh J. Minor defects of the sacrum and neurogenic bladder dysfunction. Br J Urol. 1985; 57(2): 154–155.
  36. Ganseman Y, Broos P. Leonardo da Vinci and Andreas Vesalius; the shoulder girdle and the spine, a comparison. Acta Chir Belg. 2008; 108(4): 477–483.
  37. García-Coronado JM, Espinosa-Uribe AG, Vílchez-Cavazos F, et al. Comments on: Implications of structural variations in the human sacrum: why is an anatomical classification crucial? Surg Radiol Anat. 2017; 39(2): 233.
  38. Goswami P, Yadav Y, Chakradhar V. . Sacral Foramina: Anatomical variations and clinical relevance in North Indians. Eur J Acad Essays (EJAE). 2014; 1(4): 29–33.
  39. Guille JT, Benevides R, DeAlba CC, et al. Lumbosacral agenesis: a new classification correlating spinal deformity and ambulatory potential. J Bone Joint Surg Am. 2002; 84(1): 32–38.
  40. Hadley LA. Accessory sacroiliac articulations with arthritic changes. Radiology. 1950; 55(3): 403–409.
  41. Hasenboehler EA, Stahel PF, Williams A, et al. Prevalence of sacral dysmorphia in a prospective trauma population: Implications for a. Patient Saf Surg. 2011; 5(1): 8.
  42. Hippocrate. Des Articulations, ed. É. Littré, Oeuvres complètes d’Hippocrate, vol. 4. Baillière, Paris 1844.
  43. Hsieh CY, Vanderford JD, Moreau SR, et al. Lumbosacral transitional segments: classification, prevalence, and effect on disk height. J Manipulative Physiol Ther. 2000; 23(7): 483–489.
  44. Kaiser SP, Gardner MJ, Liu J, et al. Anatomic determinants of sacral dysmorphism and implications for safe iliosacral screw placement. J Bone Joint Surg Am. 2014; 96(14): e120.
  45. Kamal A, Ara S, Ashrafuzzaman Md, et al. Morphometry of sacral hiatus and its clinical relevance in caudal epidural block. J Dhaka Med Coll. 2015; 23(1): 31–36.
  46. Kanchan T, Shetty M, Nagesh KR, et al. Lumbosacral transitional vertebra: clinical and forensic implications. Singapore Med J. 2009; 50(2): e85–e87.
  47. Kapetanakis S, Giovannopoulou E, Nastoulis E, et al. Butterfly vertebra. A case report and a short review of the literature. Folia Morphol. 2016; 75(1): 117–121.
  48. Karachalios T, Zibis AH, Zintzaras E, et al. An anatomical update on the morphologic variations of S1 and S2. Orthopedics. 2010; 33(10): 733.
  49. Katsuura Y, Kim HJo. Butterfly vertebrae: a systematic review of the literature and analysis. Global Spine J. 2019; 9(6): 666–679.
  50. Khan JM, Lara DL, Marquez-Lara A, et al. Intraoperative CT and surgical navigation for iliosacral screws: technique for patients with sacral dysmorphism. J Orthop Trauma. 2018; 32 Suppl 1: S24–S25.
  51. Khanna J, Chauhan R. Anatomical variations and clinical relevance of dorsal sacral foramina in North Indians. Int J Res Med Sci. 2013; 1(3): 263–266.
  52. Kilicaslan A, Keskin F, Babaoglu O, et al. Morphometric analysis of the sacral canal and hiatus using multidetector computed tomography for interventional procedures. Turk Neurosurg. 2015; 25(4): 566–573.
  53. Kim DW, Lee SJ, Choi EJ, et al. Morphologic diversities of sacral canal in children; three-dimensional computed tomographic study. Korean J Pain. 2014; 27(3): 253–259.
  54. Kubavat D, Nagar S, Lakhani C, et al. A study of sacrum with three pairs of sacral foramina in western India. IJMSH. 2012; 1(2): 127–132.
  55. Kumar A, Vishwakarma N. An anthropometric analysis of dry human sacrum: Gender Discrimination. IJSR. 2015; 4(4): 1306–1310.
  56. Kumar P, Lokanadham S, Kothandaraman U. A study of anterior sacral foramina and their variations in South Indian population. Sch J App Med Sci. 2015; 3(3): 1196–1198.
  57. Kumar KP, Dhoot M, Thaduri N, et al. A study of sacrum with five pairs of sacral foramina in Bhopal population. IJPRBA. 2015; 4(5).
  58. Kumar V, Pandey SN, Bajpai RN, et al. Morphometrical study of sacral hiatus. J Anat Soc India. 1992; 41(1): 7–13.
  59. Laishram D, Ghosh A, Shastri D. A study on the variations of sacrum and its clinical significance. IOSR- JDMS. 2016; 15(6): 8–14.
  60. Lanier PF, Trotter M. The volume of the sacral canal. Am J Phys Anthropol. 1946; 4(2): 227–234.
  61. Lawrence JS. Rheumatism in Populations. William Heinemann Medical Books, London 1977.
  62. Lendon RG. Studies on the embryogenesis of spina bifida in the rat. Dev Med Child Neurol. 1968; Suppl(16): 54–61.
  63. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009; 339: b2700.
  64. Lierse W. Applied Anatomy of the Pelvis. Springer-Verlang Berlin Heidelberg 1984.
  65. Lundy JK. Sacralization of a sixth lumbar vertebra and its effect upon the estimation of living stature. J Forensic Sci. 1988; 33(4): 1045–1049.
  66. Mahato NK. Transitional female sacrum: dimensions, alterations in dorsal pelvic structure, and potential obstetric implications. Oman Med J. 2018; 33(1): 22–28.
  67. Mahato NK. Implications of structural variations in the human sacrum: why is an anatomical classification crucial? Surg Radiol Anat. 2016; 38(8): 947–954.
  68. Malarvani T, Ganesh E, Nirmala P, et al. Study of sacral hiatus in dry human sacra in Nepal. Int J Anat Res. 2015; 3(1): 848–855.
  69. Mayuri J, Vijay G, Vasudha N, et al. Anatomical Study Of Sacral Hiatus In Dry Isolated Sacra. J Res Med Den Sci. 2014; 2(2): 43–46.
  70. Mendel T, Noser H, Kuervers J, et al. The influence of sacral morphology on the existence of secure S1 and S2 transverse bone corridors for iliosacroiliac screw fixation. Injury. 2013; 44(12): 1773–1779.
  71. Miller AN, Routt ML. Variations in sacral morphology and implications for iliosacral screw fixation. J Am Acad Orthop Surg. 2012; 20(1): 8–16.
  72. Miyakoshi N, Kobayashi A, Hongo M, et al. Sacral rib: an uncommon congenital anomaly. Spine J. 2015; 15(6): e35–e38.
  73. Moore KL, Persaud T. The developing human, clinically oriented embryology. 7th edn. WB Saunders Co., Philadelphia, PA 2003.
  74. Nadeem G. Importance of knowing the level of sacral hiatus for caudal epidural anesthesia. J Morphol Sci. 2014; 31(1): 9–13.
  75. Nagar SK. A study of sacral hiatus in dry human sacra. J Anat Soc India. 2004; 53(2): 18–21.
  76. Nagendrappa R, Jayanthi KS. Study of dorsal wall of sacrum. Int J Res Med Sci. 2014; 2(4): 1325–1328.
  77. Nasr A, Ali Y, ElSawy N. The sacral hiatus: an anatomic study on both cadaveric and dry bones. Trans Clin Biol. 2014; 2(1): 4.
  78. Njihia BN, Awori KO, Gikenye G. Morphology of the Sacral Hiatus in an African Population – Implications for Caudal Epidural Injections. Ann African Surg. 2011; 7(1).
  79. Okutan O, Kaptanoglu E, Solaroglu I, et al. Pedicle morphology of the first sacral vertebra. Neuroanatomy. 2003; 2: 16–19.
  80. Osunwoke EA, Oladipo GS, Alison TA, et al. A study of sacral hiatus in dry human sacra in Southern Nigeria. J Biol Agriculture Healthcare (JBAH). 2014; 4(5): 43–48.
  81. Pang D. Sacral agenesis and caudal spinal cord malformations. Neurosurgery. 1993; 32(5): 755–78; discussion 778.
  82. Parashuram R. Morphometrical study of sacral hiatus in dry human sacra. Int J Res Med Sci. 2015: 1726–1733.
  83. Patel ZK, Thummar B, Rathod SP, et al. Multi-centric morphometric study of dry human sacrum of Indian population in Gujarat region. NJIRM. 2011; 2: 31–35.
  84. Patil DS, Jadav HR, Chauhan KB, et al. Anatomical study of the sacrum for transsacral block of sacral nerves. Nat J Med Res. 2012; 2(4): 501–503.
  85. Phalgunan V, Baskaran S. Morphometric analysis of sacral hiatus and its clinical significance. Health Agenda. 2013; 1: 10–15.
  86. Plockochi JH. Morphometric age- related change in the adult human sacrum. Thesis. Wichita State Univ, Wichita KS 1999.
  87. Plochocki JH. Sexual dimorphism of anterior sacral curvature. J Forensic Sci. 2011; 56(1): 161–164.
  88. Prassopoulos PK, Faflia CP, Voloudaki AE, et al. Sacroiliac joints: anatomical variants on CT. J Comput Assist Tomogr. 1999; 23(2): 323–327.
  89. Price CM, Rogers PD, Prosser AS, et al. Comparison of the caudal and lumbar approaches to the epidural space. Ann Rheum Dis. 2000; 59(11): 879–882.
  90. Rajeev R, Surekha D, Medha A, et al. Variations in anatomical features of the sacral hiatus in Indian dry sacra. Int J Med Res Health Sci. 2014; 3(3): 634–638.
  91. Rashid M, Khalid M, Malik N. Sacral rib: a rare congenital anomaly. Acta Orthop Belg. 2008; 74(3): 429–432.
  92. Renshaw TS. Sacral agenesis. J Bone Joint Surg Am. 1978; 60(3): 373–383.
  93. Romanes GJ. unninghams Textbook of Anatomy, Twelfth Ed. Oxford University Press 1981: 98–102.
  94. Routt ML, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma. 1997; 11(8): 584–589.
  95. Sachdeva K, Singla R, Kalsey G, et al. Role of sacrum in sexual dimorphism: a morphometric study. J Indian Acad Forensic Med. 2011; 33(3).
  96. Sadler TW. Langman’s medical embryology. 11th ed. Lippincot Williams and Wilkins, Philadelphia 2009: 302–303.
  97. Schmorl G, Junghanns H. The human spine in health and disease (2nd American Edition). Edited and translated by Besemann EF. Grune & Stratton, New York 1971.
  98. Schweitzer ME, Balsam D, Weiss R. Spina bifida occulta. Incidence in parents of offspring with spina bifida cystica. Spine. 1993; 18(6): 785–786.
  99. Seema S, Singh M, Mahajan A. An anatomical study of variations of sacral hiatus in sacra of north indian origin and its clinical significance. Int J Morphol. 2013; 31(1): 110–114.
  100. Sekiguchi M, Yabuki S, Satoh K, et al. An anatomic study of the sacral hiatus: a basis for successful caudal epidural block. Clin J Pain. 2004; 20(1): 51–54.
  101. Senoglu N, Senoglu M, Oksuz H, et al. Landmarks of the sacral hiatus for caudal epidural block: an anatomical study. Br J Anaesth. 2005; 95(5): 692–695.
  102. Shewale S, Laeeque M, Kulkarni P, et al. Morphological and Morphometrical study of sacral hiatus. IJRTSAT. 2013; 6(1): 48–52.
  103. Shinde V, Bhusaraddi P. A study of variations of sacral hiatus of dry human sacra in north interior Karnataka region. Nat J Clinl Anat (NJCA). 2014; 3(4): 215–219.
  104. Shingh DI, Ajita R, Singh N. Variation in the number of sacral pieces. IOSR- JDMS. 2015; 14(12): 106–108.
  105. Singh R. Classification and analysis of fifth pair of sacral foramina in indian dry sacra. Int J Morphol. 2014; 32(1): 125–130.
  106. Singh R. Classification, causes and clinical implications of sacral spina bifida occulta in Indians. Basic Sci Med. 2013; 2(1): 14–20.
  107. Singh R. A new foramen on posterior aspect of ala of first sacra vertebra. IJAV. 2012; 5: 29–31.
  108. Singh R. Sacrum with five pairs of sacral foramina. IJAV. 2011; 4: 139–140.
  109. Solonen KA. The sacroiliac joint in the light of anatomical, roentgenological and clinical studies. Acta Orthop Scand Suppl. 1957; 27: 1–127.
  110. Stanley JK, Owen R, Koff S. Congenital sacral anomalies. J Bone Joint Surg Br. 1979; 61-B(4): 401–409.
  111. Steer CM. Moloy’s Evaluation of the Pelvis in Obstetrics. Plenum Publishing Corporation 1975: 77–94.
  112. Sugar O. How the sacrum got its name. JAMA. 1985; 257(15): 2061–2063.
  113. Suwanlikhid N, Lakchayapakorn K, Mahakkanukrauh P. The position and size of sacral size of sacral hiatus in Thai dry human sacra. Thammasat Med J. 2013; 13(3): 313–319.
  114. Tague RG. Fusion of coccyx to sacrum in humans: prevalence, correlates, and effect on pelvic size, with obstetrical and evolutionary implications. Am J Phys Anthropol. 2011; 145(3): 426–437.
  115. Tanaka N, Kinoshita H, Jamal M, et al. A forensic case of sacralization of the sixth lumbar vertebra in skeletal remains. Bangladesh J Med Sci. 2013; 12(2): 224–226.
  116. Taskaynatan MA, Izci Y, Ozgul A, et al. Clinical significance of congenital lumbosacral malformations in young male population with prolonged low back pain. Spine. 2005; 30(8): E210–E213.
  117. Trotter M. A common anatomical variation in the sacroiliac region. J Bone Joint Surg. 1940; 22: 293–299.
  118. Trotter M, Letterman GS. Variations of the female sacrum; their significance in continuous caudal analgesia. Surg Gynaecol Obstet. 1944; 78(4): 419–424.
  119. Valojerdy MR, Hogg DA. Anatomical note: The occurrence of accessory sacroiliac joints in man. Clin Anat. 1990; 3(4): 257–260.
  120. Vasuki D, Nirmaladevi D, Hebzibah M, et al. Morphology of sacrum and its variations. IOSR-JDMS. 2016; 15(08): 129–142.
  121. Vesalius A. De humani corporis fabrica libri septem. Oporinus, Basel 1543.
  122. Woon JTK, Stringer MD. The anatomy of the sacrococcygeal cornual region and its clinical relevance. Anat Sci Int. 2014; 89(4): 207–214.
  123. Wu LP, Li YK, Li YM, et al. Variable morphology of the sacrum in a Chinese population. Clin Anat. 2009; 22(5): 619–626.
  124. Xu R, Ebraheim NA, Gove NK. Surgical anatomy of the sacrum. Am J Orthop. 2008; 37(10): E177–E181.
  125. Xu R, Ebraheim NA, Yeasting RA, et al. Morphometric evaluation of the first sacral vertebra and the projection of its pedicle on the posterior aspect of the sacrum. Spine. 1995; 20(8): 936–940.
  126. Zwingmann J, Konrad G, Mehlhorn AT, et al. Percutaneous iliosacral screw insertion: malpositioning and revision rate of screws with regards to application technique (navigated vs. Conventional). J Trauma. 2010; 69(6): 1501–1506.

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