The median sacral artery and its surgical anatomy in pelvic and spinal surgery: a systematic review and meta-analysis.

Background: The median sacral artery (MSA) is a small but clinically significant artery arising from the aortic bifurcation and traveling along the anterior sacrum. It supplies the lumbar and sacral vertebrae and, in some cases, parts of the rectum. Despite its size, the MSA is crucial in regional circulation and is particularly relevant in spinal, pelvic, and vascular surgeries. This meta-analysis aims to provide a comprehensive synthesis of anatomical evidence regarding the MSA's origin, variations, and surgical relevance.

Materials and methods: A systematic search was conducted in major databases (PubMed, Embase, ScienceDirect, Scopus, Web of Science, and SciELO) until January 2025. Studies reporting anatomical data on the MSA, including its origin, variations, and clinical significance, were included. A total of 13 studies (n = 1,007 arteries) met the criteria.

Results: The MSA originated directly from the aorta in 89.98% (95% CI: 84.05%-95.92%) of cases. In 8.27% (95% CI: 3.29%-13.25%), it shared a common origin with a lumbar artery, typically the 4th lumbar artery (97.86%). The 5th lumbar artery variation was rare (0.66%). Regarding its position relative to the sacral midline, the MSA was found on the left (48.80%), right (31.32%), or directly along the midline (13.35%). The mean distance from the midline was 3.54 mm.

Conclusions: Recognizing MSA variations is essential for surgical planning to prevent vascular injury during spinal and gynecological procedures. Further cadaveric and imaging studies are needed to enhance procedural safety.