An anatomical ultrasound study of the long posterior sacro-iliac ligament (original) (raw)
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Open Journal of Obstetrics and Gynecology
Objective: To determine whether endovaginal ultrasound is a reliable measure in visualization of the sacrospinous ligament among women with prolapse versus women without prolapse, and thus might be clinically applicable in the design of an ultrasound-guided device for performing sacrospinous ligament anchor placement as a treatment for pelvic organ prolapse. Methods: In the first phase of this study we performed a sacrospinous anchor placement in four normal fresh-frozen female pelves. Afterwards, an endovaginal ultrasound was performed to visualize the anchor localization which was validated by dissection of the cadaveric pelves. In the second phase of the study: two groups of volunteer females with and without pelvic organ prolapsed (POP-group, vs NON-POP group) were evaluated by endovaginal ultrasound to localize the sacrospinous ligament. Results: Cadaveric dissection demonstrated accurate anchor placement into the 8/8 sacrospinous ligament. We performed endovaginal ultrasound in a total of 17 N-POP and 10 (POP) patients. Among the N-POP group, the right and left ischial spines were visible in 6/17 (35%) and (6/17) 35% vs 0/10 (0%) for both right and left sides in POP group (p = 0.008). The right sacrospinous ligament was visualized in 4/17 (23%) N-POP subjects and 0/10 POP subjects (p = 0.27) and the left sacrospinous ligament was visualized in 7/17 (41%) N-POP subjects and 2/10 POP subjects (p = 0.48
Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain
Acta Obstetricia et Gynecologica Scandinavica, 2002
Background. To enhance the understanding of the pathophysiology of women with peripartum pelvic pain, it is necessary to couple anatomical insights with relevant clinical research. In this context, the long dorsal sacroiliac ligament is especially of interest because it was noticed that women diagnosed with peripartum pelvic pain frequently experience pain within the boundaries of this ligament. Njoo (1) found a high intertester reliability and a high specificity for long dorsal sacroiliac ligament pain. The present article focuses on the possible role of the long dorsal sacroiliac ligament in the pain pattern of women with peripartum pelvic pain. The diagnostic and therapeutic consequences are considered. Study design. A cross-sectional analysis was performed in a homogenous group of women meeting strict criteria for posterior pelvic pain since pregnancy, diagnosed as having peripartum pelvic pain and excluded for any history of fracture, neoplasm or previous surgery of the lumbar spine, the pelvic girdle, the hip joint or the femur. The patients were also excluded for signs indicating radiculopathy: asymmetric Achilles tendon reflex and/or (passive) straight leg raising restricted by pain in the lower leg. Methods. The study group comprised 178 women diagnosed with peripartum pelvic pain, selected from the outpatient clinic of a specialized rehabilitation center. Selection was based on criteria enabling a strict division between lumbar and pelvic complaints. Pain in the long dorsal sacroiliac ligament was detected by standardized palpation of the long dorsal sacroiliac ligament by specifically trained physicians and scored on a modified scale. Comparisons with the posterior pelvic pain provocation test and the active straight leg raise test was carried out. Results. The present study confirms that the long dorsal sacroiliac ligament frequently shows tenderness on palpation in patients with peripartum pelvic pain. Sensitivity was 76%. Sensitivity in a group of 133 women of the study group that scored positive on both active straight leg raise and posterior pelvic pain provocation tests was 86%. When only severe pelvic patients were included, sensitivity increased to 98%. In comparisons between the posterior pelvic pain provocation and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.33 and 0.41, respectively. In comparisons between the active straight leg raise and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.35 and 0.41, respectively. Conclusions. The present study, carried out on a group of peripartum pelvic pain patients with strict in-and exclusion criteria, attempts to further elucidate the pathophysiology of patients with peripartum pelvic pain by adding a simple pain provocation test. It is concluded that the combination of the active straight leg raise, the posterior pelvic pain provocation and the long dorsal sacroiliac ligament pain tests combined with the proposed in-and exclusion criteria seems promising in differentiating between mainly lumbar and pelvic complaints. Although the sensitivity of the long dorsal sacroiliac ligament pain test seems promising, further clinical study is necessary in targeting specifically the long dorsal sacroiliac ligament. It is suggested that studies initiated to show the prevalence of sacroiliac joint pain in patients presenting nonspecific lumbopelvic pain, by using intra-articularly double block injection techniques, should include a peripheral injection of at least the long dorsal sacroiliac ligament.
Journal of Manipulative and Physiological Therapeutics, 2008
Objective: Several tests have been developed to determine the extent of sacroiliac asymmetry during pregnancy-related pelvic girdle pain (PGP). This blinded control study investigated the intertester reliability of 3 such tests used in PGP. Methods: A total of 62 women (ages 20-40 years) were recruited from regional obstetric practices and subsequently divided into 3 groups: (1) 20 women without PGP who were pregnant for more than 20 weeks, (2) 22 women with PGP who were pregnant for more than 20 weeks, and (3) a control group of 20 women who were not pregnant and had no back pain or PGP. All tests were performed by 2 physiotherapists independently of each other and blinded to each other's results. The 3 tests were the thumb-posterior superior iliac spines test, the heel-bank test, and the abduction test. Results: To determine the level of agreement between the 2 testers, κ values were calculated. The overall κ is 0.30 (range, −0.22 to 0.83), which is considered as a poor agreement. The percentage agreement per test/category ranged from 45% to 95%. Conclusion: This study of 3 tests used to determine asymmetry of the sacroiliac joints in women with pregnancyrelated PGP showed them to have a poor intertester reliability. (J Manipulative Physiol Ther 2008;31:130-136) This article was modified from its original publication in Dutch, where it was published as Zwangerschapsgerelateerde bekkenpijn: interbeoordelaars betrouwbaarheid van drie testen naar asymmetrie van het sacro-iliaccal gewricht. Dutch Magazine for Physical Therapy, 2005, 115(6):158-162. Pregnancy-related pelvic girdle pain: intertester reliability of 3 tests to determine asymmetric mobility of the sacroiliac joints.
A New Simple Technique for 3-Dimensional Sonographic Assessment of the Pelvic Floor Muscles
Journal of Ultrasound in Medicine, 2014
he levator ani muscle plays an important role in supporting pelvic organs. Women with obstetric levator ani muscle avulsion have a risk of developing major pelvic organ prolapse, which is double compared with those with no levator ani muscle injury. 1,2 Furthermore, the dimensions of the pelvic hiatus are strongly associated with female pelvic organ prolapse, and there is a well-established correlation between the size of the levator hiatus and the risk pelvic organ descent. 3 Although levator ani muscle injury may be detected both by clinical examination and by sonography, palpatory detection of major levator ani muscle trauma is less repeatable than sonographic assessment. 4 Evaluation of the levator ani muscle and hiatal area measurements are reliably achieved by 3-dimensional (3D) sonog
International Urogynecology Journal, 2008
Our objective was to document variations in the topography of pelvic floor nerves (PFN) and describe a nerve-free zone adjacent to the sacrospinous ligament (SSL). Pelvic floor dissections were performed on 15 female cadavers. The course of the PFN was described in relation to the ischial spine (IS) and the SSL. The pudendal nerve (PN) passed medial to the IS and posterior to the SSL at a mean distance of 0.6 cm (SD=±0.4) in 80% of cadavers. In 40% of cadavers, an inferior rectal nerve (IRN) variant pierced the SSL at a distance of 1.9 cm (SD=±0.7) medial to the IS. The levator ani nerve (LAN), coursed over the superior surface of the SSL-coccygeus muscle complex at a mean distance of 2.5 cm (SD=±0.7) medial to the IS. Anatomic variations were found which challenge the classic description of PFN. A nerve-free zone is situated in the medial third of the SSL.
Putative proprioceptive function of the pelvic ligaments: Biomechanical and histological studies
Injury-international Journal of The Care of The Injured, 2008
The sacrospinous (SS) and sacrotuberous (ST) ligaments of the pelvic ring are known as mechanical stabilisers of the pelvic girdle, primarily against rotational forces in the sagittal and horizontal planes. Earlier studies, however, raised the possibility that ST/SS ligaments possess significant proprioceptive function, while the mechanical role of these ligaments in maintaining the structural integrity of the pelvis is of less importance.The aim of this study is to determine whether the function of these ligaments is strictly to provide mechanical stability or if they have any additional functional properties, i.e., proprioception. In order to reveal the function of the SS/ST ligaments, biomechanical studies of cadaver pelvis were used along with the histological analysis of the ligaments. Following measurements to determine the accurate mechanical role of the pelvic ligaments, the strength of these ligaments was significantly less than we earlier expected. For this reason other functions of the SS/ST ligaments were considered, including the proprioceptive role. Indeed, histological studies revealed ramifying nerve terminals in the SS/ST ligaments. These terminals may represent the morphological substrate of the proprioceptive function associated with the ligaments.Our studies revealed that SS/ST ligaments might have a significant proprioceptive function providing information of the position of the pelvis. Consequently, the mechanical role of the ligaments in maintaining the structural integrity of the pelvis may be significantly less than previously assumed. Understanding the function of the SS/ST ligaments is crucial for providing more precise guidelines for patient management with injuries to the posterior pelvic region.
BMC women's health, 2018
Chronic pelvic pain (CPP) affects 15-24% of women and can have a devastating impact on quality of life. Laparoscopy is often used in the investigation, although in one third of the examinations there is no visible pathology and the women may be dismissed without further investigation. Also, the contribution of skeletal, muscular, periosteal and ligamentous tissues to CPP remains to be further elucidated. The objective of the present study was to compare pain intensity provoked from anatomical landmarks of the intra-pelvic side-wall in women with pregnancy-related CPP after childbirth and women without such pain. This is a descriptive study of 36 non-randomly selected parous women with CPP after childbirth and 29 likewise selected parous women after childbirth without CPP. Pain was determined by questionnaire and clinical examination. The primary outcome measure was reported pain intensity provoked on 13 anatomical landmarks of the intra-pelvic side-wall. All women reported their per...
The repeatability of sonographic measures of functional pelvic floor anatomy
International Urogynecology Journal, 2015
Hypothesis / aims of study Ultrasound is increasingly being used in the diagnostic evaluation of patients with symptoms and signs of pelvic floor dysfunction(1). While the repeatability of measurements obtained during post-processing of volume data sets and of measurements obtained on the same day seems high, there is little data on the reproducibility of measurements obtained at longer intervals. This is relevant due to the potential confounding effect of bowel filling and stool consistency, muscle resting tone and neuromuscular activation status, the varying effectiveness of patient instruction and investigator performance. Due to the nature of clinical practice at our unit, patients undergoing surgical management for urinary incontinence or female pelvic organ prolapse are assessed twice-once at the time of the initial visit in a public hospital, and again after urodynamic testing in a private setting. The aim of this study was to determine the short to medium-term repeatability of translabial ultrasound (US) measures of prolapse and pelvic floor anatomy by comparing archived volume US datasets obtained at those two appointments. Study design, materials and methods This is a retrospective study analysing archived US volume datasets obtained in the context of routine clinical practice at a tertiary urogynaecological unit. Patients with two separate assessments prior to surgical management of pelvic floor dysfunction between Jan. 08 and Nv. 2012 were included. At both assessments participants had undergone an interview and 4D translabial US with a Voluson type system with RAB 4-8 Mhz transducer, after voiding and in the supine position as previously described (2), by a total of approx. 20 individual examiners, under the supervision of the senior author or five other staff trained by him for 3 months or more. US data analysis was performed by the first author on a desktop PC using the software 4D View v10, blinded to all other data. Bladder neck descent, cystocele, uterine descent, presence of a true rectocele and rectocele depth, hiatal area on valsalva and levator avulsion were determined by tomographic US as previously described (3; see Figure 1). We used Cohen's kappa and Intraclass correlation statistics (absolute agreement definition) to define repeatability of measurements. We did not perform power calculations due to the absence of pilot data and the retrospective nature of this research.
Ultrasound in Obstetrics and Gynecology, 2009
Objective To evaluate the interobserver repeatability of measurement of the pubovisceral muscle and levator hiatus, and the position of related organs, during rest, muscle contraction and Valsalva maneuver using three-and fourdimensional (3D and 4D) transperineal ultrasound. Methods Seventeen women were included in the study. The position and dimensions of the pubovisceral muscle and levator hiatus in patients at rest and during contraction and Valsalva were determined from stored 3D and 4D ultrasound volumes. Analyses were conducted offline by two observers blinded to the clinical data and to each others' measurements. Results Measurements of levator hiatal dimensions at rest demonstrated intraclass correlation coefficient (ICC) values of 0.92 to 0.96. The ICC values for pubovisceral muscle thickness at rest varied between good and very good (ICC, 0.61-0.93), regardless of plane. During contraction, the ICC values for all measured parameters were very good, varying between 0.61 and 0.92. Measurement of the transverse diameter of the levator hiatus during the Valsalva maneuver showed good reliability (ICC, 0.86), but assessment of the anterior and posterior borders of the levator hiatus was only possible in 29% of cases. Conclusions 3D and 4D transperineal ultrasound measurement of the pubovisceral muscle and levator hiatus is reliable in women with no or minor symptoms of prolapse at rest and during contraction. The technique for recording during the Valsalva maneuver requires improvement if it is to be useful in the diagnosis of pelvic organ prolapse.