634

Rajeev et al., Int J Med Res Health Sci. 2014;3(3):634-638

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright@2014 ISSN: 2319-5886
Received: 27
th
Mar 2014 Revised: 5
th
May 2014 Accepted: 3
rd
Jun 2014
Research Article
VARIATIONS IN ANATOMICAL FEATURES OF THE SACRAL HIATUS IN INDIAN DRY SACRA
*Desai Rajeev R
1
, Jadhav Surekha D
2
, Doshi Medha A
1
, Ambali Manoj P
1
, Desai Ashwini R
1
1
Department of Anatomy, Krishna Institutes of Medical Sciences Deemed University, Karad, Maharashtra, India.
2
Department of Anatomy, Padamashree Dr. Vithalrao Vikhe Patil Foundation Medical College, Ahmednagar,
Maharashtra, India
*Corresponding author email: polodesai2012@gmail.com
ABSTRACT
Objective: An opening present at the caudal end of sacral canal is known as sacral hiatus, which is clinically
important to give caudal epidural block in orthopedics and obstetric practice. The success of caudal epidural block
depends upon the anatomical variations of sacral hiatus. Aim: Aim of our study was to determine the anatomical
variations of sacral hiatus in Indian dry human sacra. Material and methods: We used 271 Indian dry human
sacra of unknown sex, to observe various shapes of the hiatus, which includes inverted U- shape (42.12%),
inverted V-shape (35.43%), irregular (12.99%). The mean length of sacral hiatus was 21.70 mm. The mean
anteroposterior diameter of sacral canal at the apex of sacral hiatus was 5.50 mm. Conclusion: In conclusion, the
sacral hiatus has anatomical variations and understanding of these variations may improve reliability of caudal
epidural block.
Keywords: sacral hiatus, dry human sacra, Indian, variation.
INTRODUCTION
Sacral hiatus (SH) is an opening which is located
inferior to the 4
th
or 3
rd
fused sacral spines or lower
end of median sacral crest. It contains lower sacral
and coccygeal nerve roots, filum terminale externa
and fibrofatty tissue and covered by superficial
posterior sacrococcygeal ligament which is attached
to the margins of the hiatus and the deep posterior
sacrococcygeal ligament attached to the floor of SH.
1
Epidural space is approached through SH for giving
analgesia and anesthesia for various operations,
treatment of lumbar spinal disorders and for manage-
ment of chronic back pain. The success rate of caudal
epidural block (CEB) depends upon accurate
localization of SH. Therefore, precise knowledge of
the anatomical variations in SH is essential.
2
According to Dalens,
3
the SH provides easy access to
the sacral epidural space at a level where most of the
roots of the cauda equina are no longer inside the
sacral canal, below the termination of the dural sac.
One of the most important reasons for failure of CEB
is anatomic variations in the SH.
4
Anatomical
abnormalities of the sacrum include upward and
downward displacement of the SH, narrowing or
partial obliteration of the sacral canal, ossification of
the sacrococcygeal membrane, absence of bony
posterior wall of the sacral canal and variation in
shape of the SH.
5
SH has been utilized for administration of epidural
anesthesia in obstetrics,
6
orthopedic practice for
treatment and diagnosis,
4
also used to provide peri
and post - operative analgesia in adults and children
DOI: 10.5958/2319-5886.2014.00409.3
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Rajeev et al., Int J Med Res Health Sci. 2014;3(3):634-638
or it may be combined with general anesthesia.
7
For
successful caloscopy it is important that we must be
familiar with the common possible variations of the
SH.
8
According to Brailsford
9
, the variation in the
development of the SH can cause decrease area for
the attachment of extensor muscle at back causing
painful conditions. SH with guide wire assistance is
an accessible conduit for uncomplicated entry into the
subarachnoid and basal cisternal space without
damaging the surrounding structures.
10
Considering
the clinical importance of anatomical variations of the
SH this study was done by us which will provide
additional knowledge to anesthetists and researchers
to locate the sacral hiatus and to know the possible
causes for the failure of caudal epidural block.
MATERIAL AND METHODS
Present study was carried in the department of
anatomy KIMS on 271 adult human dry sacra of
unknown sex. Sacra showing wear and tear, fracture
any erosion, damage or any pathology were not used
for study. All measurements were taken with the help
of digital Vernier caliper accuracy up to 0.01mm.
Each sacrum was studied for following parameters
and the results were tabulated and discussed.
1. Shape of the hiatus was noted by appearance,
2. Level of apex of SH with respect to sacral
vertebra.
3. Level of base of SH
4. Length of SH- measured from the apex to
midpoint of the base.
5. Anteroposterior diameter or depth at its apex,
6. Transverse width of SH at the base which is
measured between inner aspects of inferior limit
of sacral cornu.
7. Sacral composition
RESULTS
We observed complete agenesis of the dorsal bony
wall of the sacral canal in 11 (4.05%) and in 6 (2.21
%) sacra there was a complete absence of SH. So
these 17 sacra were excluded from the measurements
as typical SH was not present in them. Total 254
sacra were used for taking above mentioned
measurements.
Fig1a: Showing inverted U shaped sacral hiatus (1b):
Showing V shaped sacral hiatus (1c): Showing
irregular sacral hiatus
Fig 2a: Showing elongated sacral hiatus, (2b): Showing
dumbbell shaped sacral hiatus
Table 1: Shape of sacral hiatus (n=254)
Shape Number of
Sacra
Percentage
(%)
Inverted U (Fig. 1a) 107 42.12
Inverted V (Fig.1b) 90 35.43
Irregular (Fig. 1c) 33 12.99
Elongated (Fig. 2a) 10 4.00
Dumbbell (Fig.2b) 14 5.51
Total 254 100
Table 2: Location of apex of hiatus in relation to
the level of sacral vertebra (n=254)
Location of apex Number of
Sacra
Percentage
(%)
5th sacral vertebra 42 16.53
4th sacral vertebra 153 60.23
3rd sacral vertebra 45 17.71
2nd sacral vertebra 14 5.60
Total 254 100
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Rajeev et al., Int J Med Res Health Sci. 2014;3(3):634-638
Table 3: Location of the base of hiatus in relation
to sacral /coccygeal vertebrae (n=254).
Location of apex Number of
Sacra
Percentage
(%)
4th sacral vertebra 11 4.33
5th sacral vertebra 191 75.19
Coccyx 54 21.25
Table 4: Length of sacral hiatus from apex to the
midpoint of base (n=254)
Length (mm) Number of Sacra Percentage (%)
00 10 28 11.02
11 20 79 31.10
21 30 101 39.76
31 40 32 12.6
41 50 14 5.51
Table 5: Anteroposterior diameter or depth of
sacral canal at the level of apex (n=254)
Diameter (mm) Number of Sacra Percentage (%)
0 3 mm 27 10.62
4 6 mm 201 79.13
7 9 mm 25 9.84
10-12mm 01 0.40
Table 6: Transverse width at the base of hiatus
(n=254)
Diameter (mm) Number of Sacra Percentage (%)
00 05 mm 39 15.35
06 10 mm 97 38.20
11 15 mm 92 36.22
16 20 mm 26 10.23
Table 7: Sacral composition (n=254)
Sacral composition Number
of Sacra
Percentage
(%)
4 Segments 16 6.30
5 Segments 186 73.22
6Segments Partial or
complete sacralisation of 5th
lumbar vertebra
10 3.93
Coccygeal ankylosis 42 16.53
Total 254 100
DISCUSSION
Anatomical variations of SH are one of the most
important factors for unsuccessful CEB. While
performing CEB needle passes through skin,
subcutaneous tissue and sacrococcygeal ligament and
needle enters into caudal epidural space.
4
When CEB
is done under the guidance of USG of fluoroscopy
then the success rate is 100% but it is not always
possible due to various reasons such as availability of
instrument, cost etc. Therefore, knowing the
variations in anatomical features of the SH will
facilitate the procedure.
11
Routinely, during CEB the
SH is identified by palpating sacral Cornu.
12
Our study has shown that the shapes of SH are
variable as shown by other authors. The most
common shape was noted inverted U (Fig. 1a),
followed by V (Table 1; Fig 1b). This was in line
with the study conducted by Nagar,
13
Aggarwal et al
2
,
Seema et al.
14
But Vinod et al
15
noted that the most
common shape of the SH is the inverted V-shape in
46.55% and 76.23% respectively which was not in
line with the present study and other authors. Nagar
13
observed dumbbell shaped SH in 13.3% and Vinod et
al
15
in 7.43% sacra but we obtained low percentage
compared to these authors.
Standard textbooks of Anatomy describe that, the
apex of sacral hiatus is at the level of 4
th
vertebra.
Present study observed it in 60.23% sacra [Table 2].
Kumar et al
16
found it in 76.23%, Sekiguchi et al
4
in
64% and Njihia et al.
17
We noted that location of apex
of SH can vary from upper S2 to S5. Duncan et al
18
stated that, distance from the apex of the sacral hiatus
to the lower lumbar spinous processes is important to
develop the techniques to prevent the neurological
injury associated with the neuraxial injections.
Present study reported base of the SH (Table 3) was
most commonly located at S5 (75.19%). Our findings
are in line with other researchers, but the percentage
is variable.
Length of hiatus (Table 4) ranged from 6 mm to 49.7
mm. (mean 21.70 mm) in our study which was
similar to the previous work done by various authors
(Table 8). The anteroposterior diameter of sacral
canal at apex of sacral hiatus is clinically important
because it should be adequately large to put a needle.
Variations in measurements lead to subcutaneous
deposition of anesthetic drug. The anteroposterior
diameter [Table 5] was ranged between 2.3 to 10.9
mm (Mean 5.28mm). Various researchers reported
almost similar values for mean anteroposterior
diameters.
Transverse width at the base of hiatus [Table 6]
ranged between 2.8 mm and 20 mm (mean
16.67mm). In 75% cases, it was between 0.6 -15 mm.
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Rajeev et al., Int J Med Res Health Sci. 2014;3(3):634-638
The width at the base was noted by Trotter and
Letterman
19
from 7-26 mm with a mean of 17 mm,
Lanier et al. 19.30.3 mm,
20
Kumar et al 5-20 mm
(1.3 in mean)
16
, Aggarwal et al
2
11.95+2.78 mm and
Sekiguchi et al 10.20.35 mm
4
Present study
reported, 73.22% sacra were made up of 5 segments,
6.30% sacrum made up of only 4 segments and 16.53
% sacra had cocygeal ankylosis (Table7). Our
observations and previous workers observations are
almost same.
Normally, sacrum is made up of five sacral
vertebrae.
.2
Increase in length of the SH is influenced
by the defect of nonunion of 2
nd
and 3
rd
pair of sacral
laminae and also by coccygeal ankylosis.
2
Our study
reported that, 73.22 % sacra were made up of 5
segments, whereas 6.30 % sacra showed 4 segments.
Vinod Kumar et al
15
observed 5 segmented and 4
segmented sacra in 69.80% and 1.48% respectively.
However, But Trotter and Lanier
19
observed 4
segments in 0.7% sacra. Our findings are in line with
those of Vinod kumar et al.
15
We observed partial or
complete sacralisation of 5th lumbar vertebra in
3.93% and coccygeal ankylosis was observed in
16.53 % sacra. Trotter and Lanier
19
observed
sacralisation of 5th lumbar vertebra in 12.6% and
coccygeal ankylosis in 39.3% sacra.
Table 8: Comparison between the findings of different authors in different regions
Author Shape Level of
Apex
Level of
Base
Length(mm) Anteroposterior
diameter at the
apex (mm)
Base (mm)
Nagar et al.
13
(2004)
Inverted U
(41.51%)
S4 S5 (72.6%) 11-20 4-6 10-15
Aggarwal et al.
2
(2009)
Inverted U
(40.35%)
S4 - 4 .30-38.60 1.90-10.4 11.952.78
Njihia et al.
17
(2011)
Inverted V
(32.1%)
S4 - 6.4=3.1
Seema et al.
14
(2013)
Inverted U
(42.95%)
S4 S5 (70.45%) 11-20 4-6 11-1
Present study
(2014)
Inverted U
(42.12 %)
S4 S5 (75.19%) 5- 49.5 2-11.2 4-19.4
CONCLUSION
Variations in anatomical features of the sacral hiatus
have implications in the clinical practice because it
is used for caudal epidural block, in orthopedic
therapeutic and diagnostic procedures in the
treatment of sciatica to give corticosteroids
injections.
21
Therefore, precise knowledge of these
variations is mandatory and it may help to improve
both the reliability and safety of caudal epidural
anesthesia and also prevent the iatrogenic injury of
dural sac during caudal epidural anesthesia. It is
important to have knowledge of different shapes of
hiatus and defects in dorsal wall of sacral canal
should be taken into consideration before
undertaking caudal epidural block so as to avoid its
failure and injury to dural sac. Present study data
may be helpful while performing various
procedures.
Conflict of interest: None
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