open access
Morphological and morphometric features of sacral hiatus and its clinical significance in caudal epidural anaesthesia
, 1, 2, 1, 1, 3, 1
Affiliations- Department of Anatomy, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
- Department of Anaesthesiology, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
- Laboratory of Forensic Sciences, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
open access
Abstract
Background: Caudal epidural block (CEB) failure or complications are not unheard
even among experienced anaesthesiologists and are usually due to sacral hiatus
(SH) anatomy variations. The aim of the present study is to observe, record and
analyse important anatomical features of SH and correlate them with potential
CEB limitations.
Materials and methods: The SH of 155 complete and undamaged Greek adult
dry sacra of known sex were included in the study. Three non-metric (shape of
SH and location of hiatal apex and base in relation to level of sacral/coccygeal
vertebra) and five metric parameters (height of the SH, transverse width of the
SH at the base, anteroposterior diameter of the SH at the level of its apex and
the distance from the sacral apex and base to the upper border of S2 foramina)
were evaluated.
Results: Inverted U (34.83%) and inverted V (26.45%) were the commonest
shapes. Hiatal apex and base were most commonly related to the level of S4
(78.70%) and S5 vertebra (89.03%), respectively. Mean height, depth and intercornual
distance were 19.05 ± 8.65 mm, 5.39 ± 1.84 mm and 12.41 ± 3.16 mm,
respectively, whereas mean distance between the upper border of S2 foramen
and the apex and base of the SH were 46.34 mm and 63.48 mm, respectively.
Anatomical variations of SH that might be responsible for CEB failure, such as
elongated SH, absence of SH, complete dorsal wall agenesis of sacral canal and
narrowing (< 3 mm) at the apex of SH were found in 17.43% of sacra (male
10.94% and female 25.22%).
Conclusions: This study suggests a potential risk of failure of CEB in Greek patients,
especially in females, which should be kept in mind while giving caudal
epidural anaesthesia.
Abstract
Background: Caudal epidural block (CEB) failure or complications are not unheard
even among experienced anaesthesiologists and are usually due to sacral hiatus
(SH) anatomy variations. The aim of the present study is to observe, record and
analyse important anatomical features of SH and correlate them with potential
CEB limitations.
Materials and methods: The SH of 155 complete and undamaged Greek adult
dry sacra of known sex were included in the study. Three non-metric (shape of
SH and location of hiatal apex and base in relation to level of sacral/coccygeal
vertebra) and five metric parameters (height of the SH, transverse width of the
SH at the base, anteroposterior diameter of the SH at the level of its apex and
the distance from the sacral apex and base to the upper border of S2 foramina)
were evaluated.
Results: Inverted U (34.83%) and inverted V (26.45%) were the commonest
shapes. Hiatal apex and base were most commonly related to the level of S4
(78.70%) and S5 vertebra (89.03%), respectively. Mean height, depth and intercornual
distance were 19.05 ± 8.65 mm, 5.39 ± 1.84 mm and 12.41 ± 3.16 mm,
respectively, whereas mean distance between the upper border of S2 foramen
and the apex and base of the SH were 46.34 mm and 63.48 mm, respectively.
Anatomical variations of SH that might be responsible for CEB failure, such as
elongated SH, absence of SH, complete dorsal wall agenesis of sacral canal and
narrowing (< 3 mm) at the apex of SH were found in 17.43% of sacra (male
10.94% and female 25.22%).
Conclusions: This study suggests a potential risk of failure of CEB in Greek patients,
especially in females, which should be kept in mind while giving caudal
epidural anaesthesia.
Keywords
sacrum, sacral hiatus, anatomical variations, caudal epidural anaesthesia, Greece
About this articleTitle
Morphological and morphometric features of sacral hiatus and its clinical significance in caudal epidural anaesthesia
Journal
Issue
Article type
Original article
Pages
603-614
Published online
2022-08-25
Page views
1071
Article views/downloads
716
DOI
Pubmed
Bibliographic record
Folia Morphol 2023;82(3):603-614.
Keywords
sacrum
sacral hiatus
anatomical variations
caudal epidural anaesthesia
Greece
Authors
E. Nastoulis
D. Tsiptsios
P. Chloropoulou
V. Karapepera
V. Thomaidis
P. Pavlidis
A. Fiska
References (47)- Aggarwal A, Aggarwal A, Harjeet SD. Morphometry of sacral hiatus and its clinical relevance in caudal epidural block. Surg Radiol Anat. 2009; 31(10): 793–800.
- Abera Z, Girma A, Bekele A, et al. Assessment of morphological and morphometrical variations of sacral hiatus in dry human sacrum in Ethiopia. Local Reg Anesth. 2021; 14: 25–32.
- Adler AC, Belon CA, Guffey DM, et al. Real-Time ultrasound improves accuracy of caudal block in children. Anesth Analg. 2020; 130(4): 1002–1007.
- Bagoji IB, Bharatha A, Prakash KG, et al. A morphometric and radiological study of sacral hiatus in human adult sacra and its clinical relevance in caudal epidural anaesthesia. Maedica (Bucur). 2020; 15(4): 468–476.
- 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.
- 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.
- Boretsky KR, Camelo C, Waisel DB, et al. Confirmation of success rate of landmark-based caudal blockade in children using ultrasound: A prospective analysis. Paediatr Anaesth. 2020; 30(6): 671–675.
- Bromage PR. Epidural analgesia. WB Saunders 1978: 258–282.
- Brown DL, Ransom DM, Hall JA, et al. Regional anesthesia and local anesthetic-induced systemic toxicity: seizure frequency and accompanying cardiovascular changes. Anesth Analg. 1995; 81(2): 321–328.
- Candido K, Stevens RA. Intrathecal neurolytic blocks for the relief of cancer pain. Best Pract Res Clin Anaesthesiol. 2003; 17(3): 407–428.
- Chhabra N. An anatomical study of size and position of sacral hiatus, its importance in Caudal Epidural Block. Int J Health Sci Res. 2014; 4(12): 189–196.
- Chen CP, Wong AM, Hsu CC, et al. Ultrasound as a screening tool for proceeding with caudal epidural injections. Arch Phys Med Rehabil. 2010; 91(3): 358–363.
- Dhuria R, Dave V, Ahuja M. Anatomical Variations and Clinical Correlations of Sacral Hiatus and Sacral Canal. J Med Acad. 2018; 1(2): 75–80.
- DiGiovanni AJ. Inadvertent intraosseous injection: a hazard of caudal anesthesia. Anesthesiology. 1971; 34(1): 92–94.
- Hatzic A. Textbook of regional anesthesia and acute pain management. Caudal anesthesia. McGrawHill Medical 2007: 269–283.
- Joo J, Kim J, Lee J. The prevalence of anatomical variations that can cause inadvertent dural puncture when performing caudal block in Koreans: a study using magnetic resonance imaging. Anaesthesia. 2010; 65(1): 23–26.
- Kakiuchi M, Abe K. Pre-incisional caudal epidural blockade and the relief of pain after lumbar spine operations. Int Orthop. 1997; 21(1): 62–66.
- 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.
- Kao SC, Lin CS. Caudal epidural block: an updated review of anatomy and techniques. Biomed Res Int. 2017; 2017: 9217145.
- Kim YH, Park HJ, Cho S, et al. Assessment of factors affecting the difficulty of caudal epidural injections in adults using ultrasound. Pain Res Manag. 2014; 19(5): 275–279.
- Kumar V, Pandey SN, Bajpai RN, et al. Morphometrical study of sacral hiatus. J Anat Soc India. 1992; 41(1): 7–13.
- Laishram D, Ghosh A, Shastri D. A study on the variations of sacrum and its clinical significance. IOSR-JDMS. 2016; 15(6): 08–14.
- Malarvani T, Ganesh E, Nirmala P, et al. Study of sacral hiatus in dry human sacra in Nepal, Parsa Region. Int J Anat Res. 2015; 3(1): 848–855.
- 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.
- Mishra M, Singh AK, Satyavathi P, et al. Sacral Hiatus Study in Dry Human Sacra. Janaki Med Coll J Med Sci. 2014; 2(1): 17–22.
- Nadeem G. Importance of knowing the level of sacral hiatus for caudal epidural anesthesia. J Morphol Sci. 2018; 31(01): 009–013.
- Nagar SK. A study of sacral hiatus in dry human sacra. J Anat Soc India. 2004; 53(2): 18–21.
- Nasr A, Ali Y, ElSawy N. The sacral hiatus: an anatomic study on both cadaveric and dry bones. Trans Clin Bio. 2014; 2(1): 4.
- Nastoulis E, Karakasi MV, Pavlidis P, et al. Anatomy and clinical significance of sacral variations: a systematic review. Folia Morphol. 2019; 78(4): 651–667.
- Njihia BN, Awori KO, Gikenye G. Morphology of the sacral hiatus in an african population – implications for caudal epidural injections. Ann Afr Surg. 2011; 7(1).
- Osunwoke EA, Oladipo GS, Alison TA, et al. A study of sacral hiatus in dry human sacra in Southern Nigeria. J Biol Agriculture Healthcare. 2014; 4(5): 43–48.
- Parashuram R. Morphometrical study of sacral hiatus in dry human sacra. Int J Res Med Sci. 2015: 1726–1733.
- Patel ZK, Thummar B, Rathod SP, et al. Multi-centric morphometric study of dry human srum of Indian population in Gujarat region. NJIRM. 2011; 2: 31–35.
- Phalgunan V, Baskaran S. Morphometric analysis of sacral hiatus and its clinical significance. Health Agenda. 2013; 1: 10–15.
- 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.
- Saha D, Bhattaracharya S, Uzzaman A, et al. Morphometric study of variations of sacral hiatus among West Bengal population and clinical implications. Ital J Anat Embryol. 2016: 165–171.
- Sanghvi C, Dua A. Caudal Anesthesia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2023 Jan. 2022 Sep 26.
- Seema , 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.
- 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.
- 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.
- Senoglu N, Senoglu M, Ozkan F, et al. The level of termination of the dural sac by MRI and its clinical relevance in caudal epidural block in adults. Surg Radiol Anat. 2013; 35(7): 579–584.
- Shewale S, Laeeque M, Kulkarni P, et al. Morphological and morphometrical study of sacral hiatus. IJRTSAT. 2013; 6(1): 48–52.
- Shinde V, Bhusaraddi PS. A study of variations of sacral hiatus of dry human sacra in north interior Karnataka region. Nat J Clin Anat. 2019; 03(04): 215–219.
- 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.
- Ukoha U, Okafor J, Anyabolu A, et al. Morphometric study of the sacral hiatus in Nigerian dry human sacral bones. Int J Med Res Heal Sci. 2014; 3(1): 115.
- Vasuki D, Nirmaladevi D, Hebzibah M, et al. Morphology of sacrum and its variations. IOSR-JDMS. 2016; 15(08): 129–142.
- Wiegele M, Marhofer P, Lönnqvist PA. Caudal epidural blocks in paediatric patients: a review and practical considerations. Br J Anaesth. 2019; 122(4): 509–517.
