PMC8007994_01
PMC8007994_02
(a and b) Axial and sagittal images at the level of sacrum demonstrate an elongated hypodense collection in the high presacral region resulting in erosion of the anterior aspect of the upper sacral vertebrae. The collection was unapproachable anteriorly because of the presence of bladder and bowel loops and is located in close proximity to the rectum antero-inferiorly.
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F0001
The 3D sections were reconstructed and images analysed again for the proposed needle pathway (Figure 1).
(a and b) Oblique axial and sagittal images show the tip of the needle (21G) at the level of the S5 vertebra in the presacral space with the rectum immediately antero-lateral to it.
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F0002
After cleaning and draping, 10 mL of local anaesthesia was infiltrated, and a 21G spinal needle was inserted and slowly advanced anteriorly, cranially and medially at an angle of 30 degrees along the lateral sacro-coccygeal border until the tip of the needle reached the retro-rectal space at the S5 level (Figure 2).
(a and b) Oblique axial and sagittal images after instillation of 0.9% saline showing anterior displacement of the rectum and widening of the presacral space.
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F0003
After confirming the position of the needle tip on limited axial cuts, 20 mL of 0.9% saline was instilled so as to displace the rectum anteriorly (Figure 3).
Sagittal image showing the progressive cranial advancement of the needle in the presacral space, made possible by anterior displacement of the rectum through repeated hydro-dissection. The needle is approximating the caudal extent of the collection.
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F0004
This was repeated until the needle could reach the target point (Figure 4).
Oblique sagittal multiplanar reconstruction image indicating the 18G co-axial needle advanced cranially into the collection. Upon aspiration, thick viscous content was obtained which was sent for histo-pathological analysis in a sterile container.
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F0005
Upon confirmation of accurate needle placement, the spinal needle was removed and the co-axial system was further advanced cranially into the collection (Figure 5).