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Third Sacral Foramina Morphometry for Sacral Neuromodulation

McCullough, Mona C. MD, ME; Decker, Summer PhD; Ford, Jonathan MSc, MSBE; Downes, Katheryne MPH; Hilbelink, Don PhD; Ordorica, Raul MD; Hoyte, Lennox MD, MSEECS; Hart, Stuart MD

Female Pelvic Medicine & Reconstructive Surgery: January/February 2013 - Volume 19 - Issue 1 - p 23–30
doi: 10.1097/SPV.0b013e31827bfdb1
AUGS Conference Presentations

Objective This study is aimed to define the geometry and location of the human S3 foramen, with respect to bony landmarks visible on ultrasound.

Methods Computed tomographic (CT) image data from an institutional review board–approved database of de-identified pelvic CT images were analyzed. Points along the S3 foramina and bony sacrum were tagged, and their locations saved. The saved points were mathematically analyzed to determine the geometry and relative location of the S3 foramina with respect to other bony landmarks, specifically the sacral hiatus, and the sacral spinous processes, and the caudad aspect of the bilateral SI joints (“SI line”). Descriptive statistics were used to describe the geometry and aggregate location of the S3 foramina bilaterally. CT data sets were excluded if they had evidence of pelvic bone injury, prior bony fixation, severe osteoporosis, or other deformity.

Results One hundred thirty-three data sets met the inclusion criteria. The SI line was superior to the sacral hiatus for reliable S3 localization. The entire circumference of approximately 14% of the S3 foramina is located cephalad to the SI line. The sagittal angle of trajectory for S3 was approximately 70 degrees relative to the dorsal surface of the sacrum.

Conclusions Clinical localization of the S3 foramen for sacral neuromodulator needle placement is best obtained when the needle tip is positioned 15 to 25 mm lateral to the sacral spinous processes and 0.0 cm to 25 mm caudad to the SI line, at the level of the dorsal sacrum surface. The findings presented in this study may be applied to improve the efficacy and accuracy of neuromodulator lead placement into the S3 foramen. This study provides rationale for the effectiveness of the crosshair placement technique and demonstrates the best location for needle repositioning when this technique is not initially successful.

The bilateral S3 foramina are located at or below the inferior aspect of the bilateral SI joints with a 70 degree angle of trajectory relative to the dorsal surface of the sacrum, as determined using 3D-rendered pelvic CT images.

From the University of South Florida, Tampa, FL.

Reprints: Mona C. McCullough, MD, ME, University of South Florida, Tampa, FL. E-mail:

Supported by AUGS Thomas Benson Grant in Neuromodulation and Tampa General Hospital Clinical Research Grant.

Control ID: 1387053.

Conflict of Interest:1. R. Ordorica, MD is a Course Instructor and proctor for Medtronic.

The other authors have declared they have no conflicts of interest.

© 2013 by Wolters Kluwer Health | Lippincott Williams & Wilkins