Top

Published in:

01-09-2017 | Original Article

Clinical relevance of conus medullaris and dural sac termination level with special reference to sacral hiatus apex: anatomical and MRI radiologic study

Author: Ashraf Youssef Nasr, MD

Published in: Anatomical Science International | Issue 4/2017

Abstract

The aim of this study was to determine the vertebral level and variations in the position of the termination of both conus medullaris (CMT) and dural sac (DST) with special reference to the apex of the sacral hiatus (SHA) using magnetic resonance (MR) images and human cadavers. Different measurements were made on 200 MR sagittal T1- and T2-weighted lumbosacral images and 60 formalin-fixed adult human cadavers. The linear distances between the CMT, DST and SHA, the anteroposterior diameter at SHA, delete length and thickness of the sacrococcygeal membrane were also measured. These measurements were correlated with age and sex. In the MRI study, the mean vertebral level of CMT and its highest incidence were seen at the lower third of L1 (L1L) in male patients and at the L1-2 disc in female patients; that of DST was observed at the upper third of S2 (S2U) in male patients and the middle third of S2 (S2M) in female patients and the mean vertebral level of the SHA was noted at the middle third of S4 (S4M) in both males and females with no significant age or sex differences (P < 0.05). In the cadaveric specimens, the mean vertebral levels of CMT, DST and SHA were seen at L1L, S2M and S4U, respectively in both male and female specimens, with no sex difference. Also in the MRI study, all linear distances in the male patients were significantly different (P < 0.05) from those in female patients with exception of the thickness of SCM and the AP diameter at SHA. Accurate knowledge of these levels and the distances in-between are important for safe and successful spinal and caudal anaesthesia.

Aggarwal A, Kaur H, Batra YK, Aggarwal AK, Rajeev S, Sahni D (2009) Anatomic consideration of caudal epidural space: a cadaver study. Clin Anat 22:730–737CrossRefPubMed

Cilliers A, Schulenburg DH, Janse van Rensburg J (2010) MRI determination of the vertebral termination of the dural sac tip in a South African population: clinical significance during spinal irradiation and caudal anaesthesia. SA J Radiol 14(3):52–55

Crighton IM, Barry BP, Hobbs GJ (1997) A study of the anatomy of the caudal space using magnetic resonance imaging. Br J Anaesth 78:391–395CrossRefPubMed

Demiryürek D, Aydingöz Ü, Akşit MD, Yener N, Geyik PÖ (2002) MR imaging determination of the normal level of conus medullaris. Clin Imaging 26:375–377CrossRefPubMed

Ievins FA (1991) Accuracy of placement of extradural needles in the L3/4 interspace: comparison of two methods of identifying L4. Br J Anaesth 66:381–382CrossRefPubMed

Kim JT, Bahk JH, Sung J (2003) Influence of age and sex on the position of the conus medullaris and Tuffier’s line in adults. Anesthesiology 99:1359–1363CrossRefPubMed

Lanier VS, McKnight HE, Trotter M (1944) Caudal analgesia: an experimental and anatomical study. Am J Obstet Gynecol 47:633–641CrossRef

Lin N, Bebawy JF, Hua L, Wang BG (2010) Is spinal anaesthesia at L2–L3 interspace safe in disorders of the vertebral column? A magnetic resonance imaging study. Br J Anaesth 105(6):857–862CrossRefPubMed

Lirk P, Messner H, Deibl M, Mitterschiffthaler G, Colvin J, Steger B et al (2004) Accuracy in estimating the correct intervertebral space level during lumbar, thoracic and cervical epidural anaesthesia. Acta Anaesthesiol Scand 48:347–349CrossRefPubMed

Macdonald A, Chatrath P, Spector T, Ellis H (1999) Level of termination of the spinal cord and the dural sac: a magnetic resonance study. Clin Anat 12:149–152CrossRefPubMed

Matveeva Niki, Chabukovska Radulova J, Strateska A, Bojadzieva B, Trpkovska B (2013) Anatomic landmarks for save spinal and epidural anesthesia. Acta morphol 10(1):10–14

Mc Cotter RE (1916) Regarding the length and extent of the human medulla spinalis. Anat Rec 10(559–564):1916

Moussallem CD, El Masri H, El-Yahchouchi C, Abou Fakher F, Ibrahim A (2014) Relationship of the lumbar lordosis angle to the level of termination of the conus medullaris and thecal sac. ARIJ, Article ID 351769, pp 4. 10.1155/2014/351769

Mustafa MS, Mahmoud OM, El Raouf HH, Atef HM (2012) Morphometric study of sacral hiatus in adult human Egyptian sacra: Their significance in caudal epidural anesthesia. Saudi J Anaesth 6(4):350–357CrossRefPubMedPubMedCentral

Nagar SK (2004) A study of sacral hiatus in dry human sacra. J Anat Soc India 53:18–21

Needles JH (1935) The caudal level of termination of the spinal cord in American whites and American Negroes. Anat Rec 63:417–424CrossRef

Patil DS, Jadav Hrishikesh R, Binodkumar Mehta CD, Patel Vipul D (2012) Anatomical study of sacral hiatus for caudal epidural block. Nat J Med Res 2(3):272–275

Phongkitkarum S, Jaovisidha S, Dhanachai M (2004) Determination of the thecal sac ending using magnetic resonance imaging: clinical applications in craniospinal irradiation. J Med Assoc Thai 87:1368–1373

Rahmani M, Shabani Samghabadi MA, Vaziri Bozorg SM (2009) Magnetic resonance imaging based determination of conus medullaris position in adults. Res J Biol Sci 4(2):157–159

Reiman AF, Anson BJ (1944) Vertebral level of termination of the spinal cord with report of a case of a sacral cord. Anat Rec 88:127–138CrossRef

Saifuddin A, Burnett SJD, White J (1998) The variation of position of the conus medullaris in an adult population. A magnetic resonance imaging study. Spine 23:1452–1456CrossRefPubMed

Scharf CB, Paulino AC, Goldberg KN (1998) Determination of the inferior border of the thecal sac using magnetic resonance imaging: implications on radiation therapy treatment planning. Int J Radiat Oncol Biol Phys 41:621–624CrossRefPubMed

Sekiguchi M, Yabuki S, Saton K, Kikuchi S (2004) An anatomical study of the sacral hiatus: a basis for successful caudal epidural block. Clin J Pain 20:51–54CrossRefPubMed

Senoglu N, Senoglu M, Oksuz H, Gumusalan Y, Yukse KZ, Zencirci B et al (2005) Landmarks of the Sacral hiatus for caudal epidural block: an anatomical study. Br J Anaesth 95:692–695. doi:10.1093/bja/aei236 CrossRefPubMed

Soleiman J, Demaerel P, Rocher S, Maes F, Marchal G (2005) Magnetic resonance imaging study of the level of termination of the conus medullaris and the thecal sac: influence of age and gender. Spine 30(16):1875–1880CrossRefPubMed

Standring S (2008) Gray’s anatomy, the anatomical basis of clinical practice, 40th edn. Churchill Livingstone Elsevier, London

Waldman SD (2004) Caudal epidural block: prone position. Atlas of interventional pain management, 2nd edn. Saunders, Philadelphia

Wilson DA, Prince JR (1989) MR imaging determination of the location of the normal conus medullaris throughout childhood. AJR Am J Neuroradiol 10:259–262. doi:0195-6108/89/1002-0259

Title: Clinical relevance of conus medullaris and dural sac termination level with special reference to sacral hiatus apex: anatomical and MRI radiologic study
Author: Ashraf Youssef Nasr, MD
Publication date: 01-09-2017
Publisher: Springer Japan
Published in: Anatomical Science International / Issue 4/2017
Print ISSN: 1447-6959
Electronic ISSN: 1447-073X
DOI: https://doi.org/10.1007/s12565-016-0343-0

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Clinical relevance of conus medullaris and dural sac termination level with special reference to sacral hiatus apex: anatomical and MRI radiologic study

Abstract

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 4/2017

Degenerative changes of the sacroiliac auricular joint surface—validation of influential factors

Light and scanning electron microscopy of the tongue of a degu (Octodon degus)

The stellate cell system (vitamin A-storing cell system)

Differences in osteon structure histomorphometry between puppyhood and adult stages in the Golden Retriever

Anatomy, histology and elemental profile of long bones and ribs of the Asian elephant (Elephas maximus)

Erratum to: Clinical relevance of conus medullaris and dural sac termination level with special reference to sacral hiatus apex: anatomical and MRI radiologic study