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a An example of pattern 1 with 4 coccygeal branches from the inferior gluteal artery (IGA) and 1 sacral branch from the superior gluteal artery (SGA) to the sacrotuberous ligament (STL). The gluteus maximus (GM) has been reflected medially and the vessels are labeled according to their relationship with the piriformis muscle (PM). b A dissection of the same variation with branching of the coccygeal branches
Source publication
Knowledge of the vascular supply associated with the sacrotuberous ligament is incomplete, and at most attributed to a single coccygeal branch. Our aim was to investigate the sacrotuberous ligament vasculature with a focus on its origin and distribution. We dissected 21 hemipelvises (10 male and 11 female). The gluteus maximus was reflected mediall...
Citations
... Different innervation patterns have been described, including innervation from the caudal-most root of the superior gluteal nerve, the inferior gluteal nerve's caudal roots, and the sciatic nerve portion of the common peroneal nerve [1]. In addition, the blood supply may derive from the branches of the inferior and superior gluteal artery [17], internal pudendal, and lateral sacral artery [2,7]. ...
Purpose
The cause of the piriformis-related pelvic and extra-pelvic pain syndromes is still not well understood. Usually, the piriformis syndrome is seen as extra-pelvic sciatica caused by the entrapment of the sciatic nerve by the piriformis in its crossing through the greater sciatic foramen. However, the piriformis muscle may compress additional nerve structures in other regions and cause idiotypic pelvic pain, pelvic visceral pain, pudendal neuralgia, and pelvic organ dysfunction. There is still a lack of detailed description of the muscle origin, topography, and its possible relationships with the anterior branches of the sacral spinal nerves and with the sacral plexus. In this research, we aimed to characterize the topographic relationship of the piriformis with its surrounding anatomical structures, especially the anterior branches of the sacral spinal nerves and the sacral plexus in the pelvic cavity, as well as to estimate the possible role of anatomical piriformis variants in pelvic pain and extra-pelvic sciatica.
Methods
Human cadaveric material was used accordingly to the Swiss Academy of Medical Science Guidelines adapted in 2021 and the Federal Act on Research involving Human Beings (Human Research ACT, HRA, status as 26, May 2021). All body donors gave written consent for using their bodies for teaching and research. 14 males and 26 females were included in this study. The age range varied from 64 to 97 years (mean 84 ± 10.7 years, median 88).
Results
three variants of the sacral origin of the piriformis were found when referring to the relationship between the muscle and the anterior sacral foramen. Firstly, the medial muscle origin pattern and its complete covering of the anterior sacral foramen by the piriformis muscle is the most frequent anatomical variation (43% in males, 70% in females), probably with the most relevant clinical impact. This pattern may result in the compression of the anterior branches of the sacral spinal nerves when crossing the muscle.
Conclusions
These new anatomical findings may provide a better understanding of the complex piriformis and pelvic pain syndromes due to compression of the sacral spinal nerves with their somatic or autonomous (parasympathetic) qualities when crossing the piriformis.
... The nerve leaves the pelvis through the suprapiriform foramen, which is the upper part of the greater sciatic opening (foramen ischiadicum majus) [2]. It then runs laterally with the superior gluteal artery between the gluteal muscles to innervate the hip joint as well as the muscles: m. gluteus medius, m. gluteus minimus m. tensor fasciae latae [3,4] and, as confirmed by recent studies, also m. piriformis [5]. The analysis of available literature showed a dynamically growing number of publications concerning the described nerve. ...
Introduction
Advances in medical science are helping to break down the barriers to surgery. In the near future, neonatal or in utero operations will become the standard for the treatment of defects in the human motor system. In order to carry out such procedures properly, detailed knowledge of fetal anatomy is necessary. It must be presented in an attractive way not only for anatomists but also for potential clinicians who will use this knowledge in contact with young patients. This work responds to this demand and presents the anatomy of the superior gluteal nerve in human fetuses in an innovative way. The aim of this work is to determine the topography and morphometry of the superior gluteal nerve in the prenatal period. We chose the superior gluteal nerve as the object of our study because of its clinical significance—for the practice of planning and carrying out hip surgery and when performing intramuscular injections.
Material and methods
The study was carried out on 40 human fetuses (20 females and 20 males) aged from 15 to 29 weeks (total body length v-pl from 130 to 345 mm). Following methods were used: anthropological, preparatory, image acquisition with a digital camera, computer measurement system Scion for Windows 4.0.3.2 Alpha and Image J (accuracy up to 0.01 mm without damaging the unique fetal material) and statistical methods.
Results
The superior gluteal nerve innervates three physiologically significant muscles of the lower limb’s girdle: gluteus medius muscle, gluteus minimus muscle and tensor fasciae latae muscle. In this study the width of the main trunk of the nerve supplying each of these three muscles was measured and the position of the nerve after leaving the suprapiriform foramen was observed. A unique typology of the distribution of branches of the examined nerve has been created. The bushy and tree forms were distinguished. There was no correlation between the occurrence of tree and bushy forms with the body side (p > 0.05), but it was shown that the frequency of the occurrence of the bushy form in male fetuses is significantly higher than in female fetuses (p < 0.01). Proportional and symmetrical nerve growth dynamics were confirmed and no statistically significant sexual dimorphism was demonstrated (p > 0.05).
Conclusions
The anatomy of the superior gluteal nerve during prenatal period has been determined. We have identified two morphological forms of it. We have observed no differences between right and left superior gluteal nerve and no sexual dimorphism. The demonstrated high variability of terminal branches of the examined nerve indicates the risk of neurological complications in the case of too deep intramuscular injections and limits the range of potential surgical interventions in the gluteal region. The above research may be of practical importance, for example for hip surgery.
... The SIJ classification differs from it being a diarthrosis, an amphiarthrosis, or presenting features of both as a 'diarthroamphiarthrosis' (Table 2) (22,25,30- (191). Primary papers (14,16,17,20,(22)(23)(24)(25)(26)(28)(29)(30)(31)(32)(33)38,42,43,(50)(51)(52)(53)(54)(55)(56)(57)69,71,73,74,(78)(79)(80)(81)(82)(83)(84)(86)(87)(88)(89)(90)(91)(92)(93)(94)(95)(96)(97)99,100,102,(105)(106)(107)(108)(110)(111)(112)(113)(114)(115)(116)(117)121,126,130,132,133,136,137,(146)(147)(148)(149)(150)(151)(152)(153)(154)(155)(156)(157)(169)(170)(171)(172)179), secondary papers (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)15,18,19,21,27,(34)(35)(36)(37)(39)(40)(41)(44)(45)(46)(47)(48)(49)(58)(59)(60)(61)(62)(63)(64)(65)(66)(67)(68)70,72,(75)(76)(77)85,98,101,103,104,109,(118)(119)(120)(122)(123)(124)(125)(127)(128)(129)131,134,135,(138)(139)(140)(141)(142)(143)(144)(145)155,(158)(159)(160)(161)(162)(163)(164)(165)(166)(167)(168)(173)(174)(175)(176)(177)(178)(180)(181)(182)(183)(185)(186)(187)(188)(189)(190). [50][51][52][53][54][55][56][57]. ...
... This occurred via one artery in 69% of specimens and 2 arteries in 8% (16). Lai et al (140) showed variation in both the origin and distribution of the blood supply to the STL. Branches from the inferior and superior gluteal arteries enter the ligament close to the ischial tuberosity and sacrum in a variety of patterns. ...
... Branches from the inferior and superior gluteal arteries enter the ligament close to the ischial tuberosity and sacrum in a variety of patterns. These could be a combination of one to 4 branches of the inferior gluteal artery entering the STL with one to 2 branches from the superior gluteal artery (Fig. 24) (140). The subchondral bone plate of the SIJ on both the iliac and sacral sides is penetrated by multiple blood vessels that are in close to the articular cartilage. ...
Background:
The sacroiliac joint (SIJ) forms a complex joint and has shown to be underappreciated in its involvement with lower back pain. Research efforts have intensified on SIJ anatomy and biomechanics because of its predisposing position to pain and dysfunction in individuals suffering from lower back discomfort. Previous work has focused on SIJ anatomy including bone and joint structure, innervation, as well as biomechanics and the treatment of SIJ pain. However, to date, no review exists describing the range of 'normal' anatomic features of the SIJ.
Objectives:
To describe the normal appearance of the SIJ and adjacent tissues, as opposed to 'abnormal' conditions involving SIJ morphology. It will also identify key areas that require further study because of lacking information or disagreement.
Study design:
A systematic literature review.
Setting:
The research took place at the University of Otago, New Zealand. All published research on 'normal SIJ anatomy' available from MEDLINE, OVID, Scopus, Web of Science, PubMed, and Science Direct were included, available until December 2018, in English, French, and German. Subject areas included bony landmarks, joint type, bone morphology, ligamentous attachments, muscular and fascial relationships, blood supply, fatty infiltration, and morphologic variation.
Methods:
Articles met the selection criteria if they contained specific information on SIJ anatomy, including bone morphology and architecture, ligaments, muscle attachments, innervation, vasculature, and the presence of fat. Biomechanics and kinematics related keywords were used as the literature often couples these with the anatomy. Keywords of individual articles were named as 'structures of interest.'
Results:
A total of 88 primary and 101 secondary articles were identified in the time frame from 1851 to 2018. Primary articles provided quantitative data and detailed anatomic descriptions. Secondary articles did not focus specifically on the anatomy of the SIJ. Although research appeared to be in general agreement on bony landmarks, joint type, myofascial attachments, vasculature, and innervation of the SIJ, there was only part consensus on ligament attachments and cartilage structure. Information regarding bone density of the articulating surfaces of the SIJ is lacking. Despite its potential clinical significance, fatty infiltration within the joint lacks research to date.
Limitations:
Only the given databases were used for the initial search. Keyword combinations used for this review may not have been inclusive of all articles relevant to the SIJ. Work in languages other than the ones listed or work that is not available via the internet may be missing.
Conclusions:
This study provides an overview of normal SIJ structures, including all neuromusculoskeletal elements related to the joint. There is a lack of knowledge on the SIJ ligaments warranting further investigation. Furthermore, there are discrepancies in relation to the nomenclature, layers, attachment sites, and on the topographical relationships between ligamentous tissues and nerves. Subsequent studies on the quantification of fat and bone density in the SIJ have been suggested. These could be useful radiologic parameters to assess the condition of the joint clinically. This review may provide insight into the clinical signs and abnormal biomechanical features of the joint for the purposes of treating SIJ pain.
Key words:
Bone density, bony landmarks, fat infiltration, innervation, ligaments morphology, muscles, sacroiliac joint, vasculature.
... Six studies have explored the morphometric characteristics of the STL, primarily focusing on its length, depth, and width ( Table 1). The mean length of the STL is variable ranging from 6.4 to 9.4 cm (Hammer et al. 2009;Lai et al. 2017;Seizeur et al. 2005), although its mean depth (at the middle section of the ligament) is more consistent at 0.3-0.4 cm (Hammer et al. 2009;Loukas et al. 2006). ...
... For example, Seizeur et al. (2005) obtained two measurements of STL length, from both its superolateral and inferolateral margins, relative to the ischial tuberosity. In contrast, Lai et al. (2017) considered the STL as a single distance between the middle width of its sacral portion and the ischial tuberosity. ...
... In most cases, the vascular supply to the STL is reported as a secondary finding in anatomical investigations related to underlying mechanisms of pudendal nerve entrapment. However, three anatomical studies contribute specific information on the vascular aspects of the STL (Hammer et al. 2009;Loukas et al. 2006;Thompson et al. 1999) and one provides a detailed description (Lai et al. 2017). Two studies report that the coccygeal branch of the inferior gluteal artery penetrates the STL at numerous sites and exits the pelvis, as the coccygeal branch, through this ligament (Loukas et al. 2006;Thompson et al. 1999). ...
The sacrotuberous ligament (STL) has been linked to conditions such as pelvic girdle pain and pudendal nerve entrapment, yet its contribution to pelvic stability is debated. The purpose of this review was to explore the current understanding of the STL and highlight any gaps in knowledge regarding its anatomy and function. A systematic search of the literature was conducted, focussing on the morphology and attachments of the STL, the relationship of the STL with surrounding structures, and its neurovascular supply and function. A total of 67 papers and four textbooks were obtained. The attachment sites of the STL are largely consistent; however, the extent of its connections with the long head of biceps femoris, gluteus maximus, piriformis, the posterior layer of the thoracolumbar fascia, and sacrospinous ligament are unclear. Morphometric parameters, such as mean STL length (6.4–9.4 cm), depth (0.3–0.4 cm), and width (1.8–3.5 cm, at its mid‐point) are variable within and between studies, and little is known about potential side‐, age‐, or sex‐related differences. The STL is pierced in several sites by the inferior and superior gluteal arteries, but information on its innervation pattern is sparse. Functionally, the STL may limit sacral nutation but it appears to have a limited contribution to pelvic stability. Some morphological aspects of the STL warrant further investigation, particularly its connections with surrounding structures, innervation pattern and function. Knowledge of the detailed anatomy and function of this ligament is important to better understanding its role in clinical conditions. Clin. Anat. 32:396–407, 2019. © 2018 Wiley Periodicals, Inc.
... The SS is richer in collagen than the SL and contains less adipose tissue (Bechtel, 2001). Both the ST and SS receive blood supplies (Lai et al., 2017) and innervation, potentially with proprioceptive fiber qualities (Grob et al., 1995). Such findings support the view that the SS-ST complex has functions beyond mechanical stabilization, perhaps as part of neuromuscular feedback loops. ...
The sacrospinous (SS) and sacrotuberous (ST) ligaments form a complex at the posterior pelvis, with an assumed role as functional stabilizers. Experimental and clinical research has yielded controversial results regarding their function, both proving and disproving their role as pelvic stabilizers. These findings have implications for strategies for treating pelvic injury and pain syndromes. The aim of the present simulation study was to assess the influence of altered ligament function on pelvis motion. A finite elements computer model was used. The two‐leg stance was simulated, with the load of body weight applied via the fifth lumbar vertebra and both femora, allowing for nutation of the sacroiliac joint. The in‐silico kinematics were validated with in‐vitro experiments using the same scenario of load application following SS and ST transection in six human cadavers. Modeling of partial or complete ligament failure caused significant increases in pelvis motion. This effect was most pronounced if the SS and ST were affected with 164% and 182%, followed by the sacroiliac and iliolumbar ligaments with 123% and 147%, and the pubic ligaments with 113% and 119%, for partial and complete disruption, respectively. Simultaneous ligament transection multiplied the effects on pelvis motion by up to 490%. Unilateral ligament injury altered the motion at the pelvis contralaterally. The experiments presented here provide strong evidence for the stabilizing role of the SS and ST. A fortiori, the instability resulting from partial or complete SS and ST injury merits consideration in treatment strategies involving these ligaments as important stabilizers. Clin. Anat. 32:231–237, 2019. © 2018 Wiley Periodicals, Inc.
... Previous authors have described variances in the more lateral sacrospinous and sacrotuberous ligaments as well as vascular perforation variances (8,10). However, peri-sacral surgery relies on an understanding of the origin and medial aspects of the SSTL. ...
... Another limitation is the low numbers, which cannot account for the variance in the SSTL, SGA and IGA as well as the level of the PISIJ relative to the anterior sacral foramina (12,17). On average, the PISIJ was found to be at the level of the S3 anterior sacral foramen. ...
Background:
Identifying the gluteal vessels during a posterior sacrectomy can be challenging. This study defines anatomical landmarks that can be used to approximate the location of the superior and inferior gluteal arteries (SGA and IGA) during a posterior sacrectomy.
Methods:
Cadaveric dissection of six fresh adult pelvises to determine the location of the SGA and IGA in relation to the posterior-inferior aspect of the sacroiliac joint (PISIJ), lateral sacral margin and sacrococcygeal joint (SCJ).
Results:
The anatomical landmarks are easily palpable. The position of the SGA to the PISIJ is relatively constant as it is tethered by a posterior branch of the artery, which runs inferior to the PISIJ. The IGA position is also relatively constant below the mid-point of the PISIJ and SCJ. The vessels are separated from the sacrospinous/sacrotuberous ligament complex (SSTL) in the perisacral region and as a result an anatomical plane exists anterior to the SSTL, which affords protection of the vessels during SSTL transection. The distance between the vessels and the SSTL increases the more medial the dissection.
Conclusions:
The described anatomical landmarks can be used to predict the location of the SGA and IGA during posterior sacrectomy. An anatomical plane exists anterior to the SSTL, which provides protection to the vessels during SSTL transection. Furthermore, the distance between the vessels and the SSTL increases the more medial the dissection, thus, resection of the SSTL as close to the lateral sacral margin as the pathology permits, is advocated.
The anatomy of the pelvic region is complex, due to the involved structures, including bones, ligaments, joints, muscles, pelvic organs, and neurovascular structures. For the treatment of pelvic ring injuries, the relevant surgical anatomy is of major importance, while detailed anatomical descriptions of all possible anatomical structures are clinically irrelevant. Thus, the focus of this chapter is to deal with the main surgical structures, which have to be considered during open, minimal invasive (percutaneous), and even conservative treatment of pelvic ring injuries.
