title: Anatomy of the sacral hiatus and its clinical relevance in caudal epidural block.
abstract: OBJECTIVE
  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). For optimal access into the sacral epidural space, detailed anatomical landmarks of SH are required. This study aims at exploring the anatomical structures and differences of the SH by using the sacral bone as a guide point to failure criteria for reviewing the caudal epidural anesthesia and improving the criteria for success in practice.
  
  
  METHODS
  Detailed morphometric measurements of orientation points of the SH were taken in 87 sacral bones. The measurements were taken using digital calipers and calculated with photogrammetric methods using Image J program.
  
  
  RESULTS
  Most commonly encountered shape of the SH was inverted U (33.33%), while 6.9% 3.45% often lack SH and bifida shape were found. The average length of the SH was 28.7 ± 7.1 mm, the average distance of the intercornual distance was 13.48 ± 2.69 mm, the average of the apex of SH and S2 sacral foramen was 34.68 ± 7.09 mm. There was no statistically significant difference determined in bilateral measurements (p > 0.05). Apex and base of SH were most commonly observed against S4 and S5 vertebrae, respectively. The level of maximum curvature of sacrum was S3 in 62.07% and S4 in 28.78%. Findings of spina bifida level were found 16.13% often in L5-S1 segment. Sacral cornua were marked by their bilateral presence in 55.26% and impalpable in 21.05% cases. Minimum distance between the S2 and the apex of the SH was 7.25 mm which suggested that it would not be safe to push the needle beyond 7 mm into the sacral canal so as to avoid dural puncture. In 8.77% cases, the depth of hiatus was less than 3 mm.
  
  
  CONCLUSIONS
  Single bony landmark may not help in locating the SH because of the anatomical variations. Important anatomical landmarks of the CEB are the sacral cornu, lateral sacral crests, the apex of the SH, the base of the SH, the top portion of the median sacral crest, anteroposterior distance of the sacral canal, intercornual distance, distance of the apex of the SH to the S2 foramina. Depth of hiatus less than 3 mm may be one of the causes for the failure of needle insertion. Surrounding bony irregularities, different shapes of hiatus and defects in dorsal wall of sacral canal should be taken into consideration before undertaking CEB so as to avoid its failure. This guide can be done by considering the points and securing a successful venture.
authors.affiliation: Department of Anatomy, Faculty of Medicine, Ege University, Izmir, Turkey.
authors.forename: Hassan
authors.initials: H
authors.lastname: Bagheri
authors.affiliation: Department of Anatomy, Faculty of Medicine, Ege University, Izmir, Turkey. figen.govsa@ege.edu.tr.
authors.forename: Figen
authors.identifier: http://orcid.org/0000-0001-9635-6308
authors.initials: F
authors.lastname: Govsa
mesh_terms: D059925:Anatomic Landmarks; D000763:Anesthesia, Caudal / Q000379:methods*; D004824:Epidural Space / Q000033:anatomy & histology*; D006801:Humans; D066298:In Vitro Techniques; D012447:Sacrum / Q000033:anatomy & histology*
keywords: Caudal epidural block; Sacral canal; Sacral cornu; Sacral hiatus; Sacrum