PART III-C

NEURAXIAL ANESTHESIA

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 318

SECTION 1 Spinal Anesthesia

CHAPTER 22

Neuraxial Anatomy (Anatomy Relevant

to Neuraxial Anesthesia)
Steven Orebaugh and Hillenn Cruz Eng

INTRODUCTION ■■ Vertebrae
A typical vertebra consists of a vertebral arch posteriorly and a
The vertebral column forms part of the axis of the human body,
body anteriorly. This holds true for all vertebrae except C1. Two
extending in the midline from the base of the skull to the pelvis.
pedicles arise on the posterolateral aspects of each vertebra and
Its four primary functions are protection of the spinal cord,
fuse with the two laminae to encircle the vertebral foramen1
support of the head, provision of an attachment point for the
(Figures 22–2A, 22–2B). These structures form the vertebral
upper extremities, and transmission of weight from the trunk
canal, which contains the spinal cord, spinal nerves, and epidural
to the lower extremities. Pertinent to regional anesthesia, the
space. Fibrocartilaginous disks containing the nucleus pulposus,
vertebral column serves as the landmark for a wide variety of
an avascular gelatinous body surrounded by the collagenous
regional anesthesia techniques. It is important, therefore, that
lamellae of the annular ligament, join the vertebral bodies. The
the anesthesiologist be able to develop a three-dimensional
transverse processes arise from the laminae and project laterally,
mental image of the structures comprising the vertebral
whereas the spinous process projects posteriorly from the mid-
column.
line union of the laminae (Figures 22–2A, 22–2B). The spinous
process is frequently bifid at the cervical level and serves as an
ANATOMIC CONSIDERATIONS attachment for muscles and ligaments.
C1 (atlas), C2 (axis), and C7 (vertebra prominens) are
The vertebral column consists of 33 vertebrae (7 cervical, described as atypical cervical vertebrae due to their unique fea-
12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal segments) tures. C1 is a ringlike bone that has no body or spinous process.
(Figure 22–1). In the embryonic period, the spine curves It is formed by two lateral masses with facets that connect
into a C shape, forming two primary curvatures with their anteriorly to a short arch and posteriorly to a longer, curved
convex aspect directed posteriorly. These curvatures persist arch. The anterior arch articulates with the dens, and the
through adulthood as the thoracic and sacral curves. The posterior arch has a groove where the vertebral artery passes
cervical and lumbar lordoses are secondary curvatures that (Figure 22–3A). The odontoid process (dens) of C2 protrudes
develop after birth as a result of extension of the head and superiorly, hence the name axis (Figure 22–3B). Together, the
lower limbs when standing erect. The secondary curvatures atlas and axis form the axis of rotation for the atlantoaxial joint.
are convex anteriorly and augment the flexibility of the The C7 (vertebra prominens) has a long, nonbifid spinous
spine. process that serves as a useful landmark for a variety of regional

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 Neuraxial Anatomy (Anatomy Relevant to Neuraxial Anesthesia) 319

1
2 Atlas
Axis
3

CHAPTER
Cervical Vertebrae

CHAPTER 22
4
5
6
7

X
1

4
Intervertebral disks
5
Thoracic Vertebrae
6

9 Intervertebral foramina
10

11

12

Lumbar Vertebrae 3

Sacrum

Coccyx Haadzic - Lancea/ NYSORA

FIGURE 22–1.  The vertebral column and the curvatures of the adult spine, lateral view.

anesthesia procedures (Figure 22–3C). The C7 transverse pro- understand when performing interventional pain procedures
cess is large and has only one posterior tubercle. such as facet joint injections, intra-articular steroid injections or
The interlaminar spaces in the thoracic spine are narrow and radio-frequency denervation. Joint surfaces in the cervical
more challenging to access with a needle due to overlapping lami- spine are oriented halfway between the axial and coronal
nae. In contrast, the laminae of the five lumbar vertebrae do not planes. This alignment allows an ample degree of rotation,
overlap. The interlaminar space between adjacent lumbar verte- flexion, and extension but little resistance to backward and
brae is rather large.2 forward shearing forces. Facet joints in the thoracic region are
Vertebral facet (zygapophyseal) joints articulate posterior oriented in a more coronal plane, which provides greater pro-
elements of adjacent vertebrae. The junction of the lamina and tection against shearing forces but reduced rotation, flexion,
pedicles gives rise to inferior and superior articular processes and extension.
(Figures 22–2A, 22–2B). The inferior articular process pro- In the lumbar spine, joint surfaces are curved, with a coronal
trudes caudally and overlaps the inferiorly adjacent vertebra’s orientation of the anterior portion and a sagittally oriented
superior articular process. This alignment is important to posterior portion.3 Thoracic facets are located anterior to the

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 320 CLINICAL PRACTICE OF REGIONAL ANESTHESIA
PART 3

Vertebral arch

Spinous process
Inferior articular facet joint
Superior articular process
Superior articular facet joint
Vertebral foramen
Transverse process
Pedicle
Vertebral body

Superior articular process

Transverse process
Lamina
Superior articular facet joint
Inferior articular process
B

FIGURE 22–2.  A typical vertebra. A: Superior view of the L5 vertebra. B: Posterior view of the L5 vertebra.

transverse processes, whereas cervical and lumbar facets are ■■ Intervertebral Ligaments
located posterior to their transverse processes. Five sacral verte- The vertebral column is stabilized by a series of ligaments. The
brae fuse to form the wedge-shaped sacrum, which connects anterior and posterior longitudinal ligaments run along the
the spine with the iliac wings of the pelvis4 (Figures 22–4A, anterior and posterior surfaces of the vertebral bodies, respec-
22–4B). In childhood, the sacral vertebrae are connected by tively, reinforcing the vertebral column. The supraspinous
cartilage, which progresses to osseous fusion after puberty, with ligament, a heavy band that runs along the tips of the spinous
only a narrow remnant of sacral disk remaining in adulthood. processes, becomes thinner in the lumbar region (Figure 22–5).
Fusion is generally complete through the S5 level, although This ligament continues as the ligamentum nuchae above T7
there can be complete lack of any posterior bony roof over the and attaches to the occipital external protuberance at the base
sacral vertebral canal. The sacral hiatus is an opening formed of the skull.5 The interspinous ligament is a narrow web of
by the incomplete posterior fusion of the fifth sacral vertebra. tissue that attaches between spinous processes; anteriorly it
It lies at the apex of the coccyx, which is formed by the union fuses with the ligamentum flavum and posteriorly with the
of the last four vertebrae (Figure 22–4C). This hiatus provides supraspinous ligament (Figure 22–5).
a convenient access to the caudal ending of the epidural space, The ligamentum flavum is a dense, homogenous structure,
especially in children. The sacral cornu are bony prominences composed mostly of elastin which connects the lamina of adja-
on each side of the hiatus that are easily palpated in small chil- cent vertebrae5,6 (Figure 22–5). The lateral edges of the ligamen-
dren and serve as landmarks for a caudal epidural block. tum flavum surround facet joints anteriorly, reinforcing their

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 321

Anterior tubercle
Anterior arch
Lateral masses

CHAPTER
Transverse foramen

CHAPTER 22
Superior articular facet
Posterior arch
Posterior tubercle

X
A

Odontoid process ( dens)

Vertebral body
Superior articular facet joint
Lamina
Spinous process

Spinous process

Lamina

Superior articular facet joint

Transverse foramen

Pedicle

Transverse process

Vertebral body

Vertebral foramen

FIGURE 22–3.  The atypical vertebrae. A: Superior view of the C1 vertebra (atlas). B: Superior view of the C2 vertebra (axis) with a bifid
spinous process. C: Superior view of the C7 vertebra; the spinous process is nonbifid.

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 322 CLINICAL PRACTICE OF REGIONAL ANESTHESIA

Superior articular facet

PART 3

Sacral Canal

Ala

Lateral sacral tuberosity

Median sacral crest

Dorsal sacral foramina

Lateral sacral crest

Sacral hiatus

Sacral cornu

Spinous process
Vertebral canal
Superior articular facet
Ala
Sacroiliac joint
Sacral body

Superior articular facet

Vertebral articular face

Ala

intervertebral joints

Sacral foramina

Coccyx

FIGURE 22–4.  The sacrum and coccyx. A: Posterior view of the sacrum; the sacrum curves anteriorly proximal to its narrowing tip where it
articulates with the coccyx. B: The base of the sacrum is directed upward and forward. C: Anterior view of the coccyx.

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 Neuraxial Anatomy (Anatomy Relevant to Neuraxial Anesthesia) 323

Spinous process

CHAPTER
CHAPTER 22
Interspinous
Ligament
Posterior
Longitudinal
Ligament

X
Anterior
Longitudinal
Ligament

Supraspinous Vertebral
Ligament Body

Intervertebral
disk

Ligament
Flavum

Hadzic - Lancea/ NYSORA

FIGURE 22–5.  A cross-sectional view of the vertebral canal with the intervertebral ligaments, vertebral body, and spinous process.

joint capsule. When a needle is advanced toward the epidural lumbar regions.8,9 As a result, resistance to needle advancement
space, there is an easily perceptible increase in resistance when the is easier to appreciate when a needle is introduced at a lower
ligamentum flavum is encountered. More importantly for the level (eg, lumbar).7,8 At the L2–L3 interspace, the ligamentum
practice of neuraxial anesthesia, a perceptible, sudden loss of resis- flavum is 3- to 5-mm thick. At this level, the distance from the
tance is encountered when the tip of the needle passes through ligamentum to the spinal meninges is 4–6 mm.6 Consequently,
the ligamentum and enters the epidural space. a midline insertion of an epidural needle at this level is least
The ligamentum flavum consists of right and left halves that likely to result in an inadvertent meningeal puncture with epi-
join at an angle of less than 90°. Importantly, this midline dural anesthesia-analgesia.
fusion may be absent to a variable degree depending on the The lateral wall of the vertebral canal has gaps between
vertebral level.2 These fusion gaps allow for veins to connect to consecutive pedicles known as intervertebral foramina
vertebral venous plexuses.7 Of note, the fusion gaps are more (Figure 22–1A). Because the pedicles attach more cephalad
prevalent at cervical and thoracic levels. Yoon et al reported that of the middle of the vertebral body, the intervertebral foram-
midline gaps between C3 and T2 occur in 87%–100% of indi- ina are centered opposite the lower half of the vertebral
viduals. The incidence of the midline gap decreases at lower body, with the vertebral disk at the caudal end of the fora-
vertebral levels, with T4–T5 the lowest (8%).7 In theory, a men. As a consequence, the borders of the intervertebral
midline gap poses a risk of failure to recognize a loss of resis- foramina are the pedicle at the cephalad and caudal ends, the
tance at the cervical and high thoracic levels when using the vertebral body (cephalad) and the disk (caudally) on the
midline approach, resulting in an inadvertent dural puncture. anterior aspect, a portion of the next vertebral body most
The ligamentum flavum is thinnest in the cervical and inferiorly, and posteriorly the lamina, facet joint, and liga-
upper thoracic regions and thickest in the lower thoracic and mentum flavum.

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 324 CLINICAL PRACTICE OF REGIONAL ANESTHESIA

■■ Spinal Meninges fat, epidural veins, spinal nerve roots, and connective tissue
The spinal cord is an extension of the medulla oblongata. It has (Figure 22–6B) The subdural space is a “potential” space
three covering membranes: the dura, arachnoid, and pia maters between the dura and the arachnoid and contains a serous fluid.
(Figure 22–6A). These membranes concentrically divide the The subdural compartment is formed by flat neuroepithelial
cells that have long interlacing branches. These cells are in close
PART 3

vertebral canal into three distinct compartments: the epidural,

subdural, and subarachnoid spaces. The epidural space contains contact with the inner dural layers. This space can be expanded

Spinal Cord
Ventral Roots
Dorsal Root Ganglion

Pia Mater
Sympathetic Trunk

Arachnoid Mater

Rami Communicantes

Dura Mater

Transverse Process

Spinous Process
Vertebral Body

Ligamentul Flamum
Posterior epidural space
Posterior epidural fat
Lamina Dura mater
Arachnoid
Subrachnoid space
Piamater

Dorsal root
ganglion
Dorsal nerve root
Denticulate ligament
Anterior epidural
space
Ventral nerve root
Posterior longitudinal
ligament
Epidural venous plexus

B
Vertebral body Haad
H dzzic
ic - Laan
nce
cea/
a/ NYSO
YSORA
YS

FIGURE 22–6.  A. Sagittal view of the spinal cord with meningeal layers, dorsal root ganglia, spinal nerves, and sympathetic trunk. B. Cross-
sectional view of the spinal cord depicting the ligamentum flavum in respect to the posterior epidural space. Notice the close proximity of
the posterior epidural space to the subarachnoid space.

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 Neuraxial Anatomy (Anatomy Relevant to Neuraxial Anesthesia) 325

by shearing the neuroepithelial cell layer connections with the In children, the dural sac terminates lower, and in some adults, the
collagen fibers of the dura mater. This expansion of the subdu- sac termination can be as high as L5. The vertebral canal contains
ral space can be caused mechanically by injecting air or a liquid the dural sac, which adheres superiorly to the foramen magnum,

CHAPTER
such as contrast media or local anesthetics, which, by applying to the posterior longitudinal ligament anteriorly, the ligamentum

CHAPTER 22
pressure in the space, separates the cell layers.10 The subarach- flavum and laminae posteriorly, and the pedicles laterally.
noid space is traversed by threads of connective tissue extending The spinal cord tapers and ends as the conus medullaris at
from the arachnoid mater to the pia mater. It contains the spi- the level of the L1–L2 intervertebral disk (Figure 22–7A). The
nal cord, dorsal and ventral nerve roots, and cerebrospinal fluid filum terminale, a fibrous extension of the spinal cord, extends

X
(CSF). The subarachnoid space ends at the S2 vertebral level. caudally to the coccyx. The cauda equina is a bundle of nerve
roots in the subarachnoid space distal to the conus medullaris12
(Figure 22–7A).
■■ Spinal Cord The spinal cord receives blood primarily from one anterior
There are eight cervical neural segments. The eighth segmental and two posterior spinal arteries that derive from the verte-
nerve emerges between the seventh cervical and first thoracic bral arteries (Figure 22–7B). Other major arteries that supple-
vertebrae, whereas the remaining cervical nerves emerge above ment blood supply to the spinal cord include the vertebral,
their same-numbered vertebrae. Thoracic, lumbar, and sacral ascending cervical, posterior intercostal, lumbar, and lateral
nerves emerge from the vertebral column below the same- sacral arteries. The single anterior spinal artery and two poste-
numbered bony segment1 (Figure 22–6A). Anterior and posterior rior spinal arteries run longitudinally along the length of the
spinal nerve roots arise from rootlets along the spinal cord. The cord and combine with segmental arteries in each region. The
roots of the upper and lower extremity plexuses (brachial and major segmental artery (Adamkiewicz) is the largest segmen-
lumbosacral) are significantly larger compared to other levels.11 tal artery and is found between the T8 and L1 vertebral
The dural sac is continuous from the foramen magnum to the segments. The Adamkiewicz artery is the major blood supplier
sacral region, where it spreads distally to cover the filum terminale. to two-thirds of the spinal cord. Injury of this artery may result

Spinal cord

Conus Medullaris

Spinous Process
Anterior spinal artery
Cauda Equina
Vertebral artery

Subclavian artery

Radicular artery
Intercostal artery
Great ventral
radicular artery
(Artery of Adamkiewicz)
L5
Lumbar radicular artery
Termination of Dural Sac
Sacral Canal
Filum Terminale

Anterior spinal artery

Anterior sulcal artery

Posterior spinal artery

A Had
Ha dzzic
ic - Lan
ance
c a/ NYSORA B Hadzic - Lancea/ NYSORA

FIGURE 22–7.  A. Sagittal view of the lumbar vertebrae. The spinal cord terminates at the L1-L2 interspace. B. Arterial supply to the
anterior spinal cord. The Artery of Adamkiewicz emerges from T8-L1 vertebral segments. The small insert demonstrates the blood supply to
the spinal cord ( one anterior and two posterior arteries).

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 326 CLINICAL PRACTICE OF REGIONAL ANESTHESIA

in anterior spinal artery syndrome, characterized by loss of uri- Adult scoliosis, in particular, is frequently encountered in
nary and fecal continence as well as impaired motor function of older adults. In fact, Schwab et al demonstrated that scoliosis
the legs.1 The radicular arteries are branches of the spinal was present in 68% of an asymptomatic volunteer population
arteries and run within the vertebral canal and supply the ver- older than 60 years of age. A thorough understanding of the
tebral column. Radicular veins drain blood from the vertebral scoliotic spine will aid in successfully performing central neur-
PART 3

venous plexus and eventually drain into the major venous sys- axial blockade in this patient population. In the scoliotic spine,
tem: the superior and inferior vena cava and the azygos vertebral bodies are rotated toward the convexity of the curve,
venous system of the thorax.1 and their spinous processes face into the concavity of the curve14
(Figure 22–8).
MOVEMENTS OF THE SPINE The diagnosis of scoliosis is made when there is a Cobb
angle of greater than 10° in the coronal plane of the spine in a
The fundamental movements through the vertebral column are skeletally mature patient.15 The Cobb angle, which is used to
flexion, extension, rotation, and lateral flexion in the cervical measure the magnitude of scoliosis, is formed between a line
and lumbar spine. Movement between individual vertebrae is drawn parallel to the superior endplate of one vertebra above
relatively limited, although the effect is compounded along the the curve deformity and a line drawn parallel to the inferior
entire spine. Thoracic vertebrae, in particular, have limited endplate of the vertebra one level below the curve deformity16
mobility due to the rib cage. Flexion is greatest in the cervical (Figure 22–8). In untreated patients, there is a strong linear
spine, whereas extension is greatest in the lumbar region. The relationship between the Cobb angle and the degree of vertebral
thoracic and sacral regions are the most stable. rotation in both thoracic and lumbar curves, with maximum
rotation occurring at the apex of the scoliotic curve.17,18 A com-
SPECIAL CONSIDERATIONS pensatory curvature of the spine always occurs in the opposite
direction of the scoliotic curve.
In the United States and most developed countries, there is an Scoliosis usually presents in childhood or adolescence and is
increase in aging population. This trend carries with it an increased diagnosed during routine physical examination. Untreated, it
prevalence of spinal deformities, such as spinal stenosis, scoliosis, may become progressive and result in respiratory impairment
hyperkyphosis, and hyperlordosis. Elderly patients present anes- and gait disturbances. Scoliosis may also go undiagnosed and
thetic challenges when neuraxial techniques are required. With present later in life as back pain.15,19
advancing age, a diminishing thickness of intervertebral disks Treatment depends on the severity of the scoliosis. Mild
results in decreased height of the vertebral column. Thickened liga- scoliosis (11°–25°) is usually observed. Moderate scoliosis
ments and osteophytes also contribute to difficulty in accessing (25°–50°) in the skeletally immature patient frequently pro-
both the subarachnoid and epidural spaces. The frequency of spi- gresses and therefore is most often braced. Patients with severe
nal deformities in older adults can be as high as 70%.13 scoliosis (>50°) are usually treated surgically.20

Convex side Concave side

Bend Left

A B

FIGURE 22–8.  Adolescent scoliotic spine. A: S-shaped scoliosis of the thoracolumbar spine. B: Cobb angle of 50°.

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 Neuraxial Anatomy (Anatomy Relevant to Neuraxial Anesthesia) 327

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CHAPTER 22
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B represents the needle realignment towards the convex side of 9. Lirk P, Kolbitsch C, Putz G, et al. Cervical and high thoracic ligamentum
the scoliotic spine compared to arrow A, which depicts the usual flavum frequently fails to fuse in the midline. Anesthesiology 2003;
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for neuraxial anesthesia. In the patients with scoliosis, the ver- spinal cord and the dural sac: A magnetic resonance study. Clin Anat
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13. Schwab F, Dubey A, Gamez L, et al: Adult scoliosis: prevalence, SF-36,
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epidural insertion in scoliosis patients. Can J Anaesth 2005;52:717.
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process, as well as the depth of the lamina.23–25 20. Bowens C, Dobie KH, Devin CJ, et al: An approach to neuraxial

anaesthesia for the severely scoliotic spine. Br J Anaesth 2013;111:807.
21. Huang J: Paramedian approach for neuraxial anesthesia in parturients
with scoliosis. Anesth Anal 2010;111:821.
Clinical Pearls 22. Ko JY, Leffert LR: Clinical implications of neuraxial anesthesia in the
parturient with scoliosis. Anesth Analg 2009;09:1930.
23. Chin KJ, Perlas A, Chan V, et al: Ultrasound Imaging facilitates spinal
•  The spinal cord ends at the L1-to-L2 level; performing anesthesia in adults with difficult surface anatomic landmarks.
spinal anesthesia at or above this level is not Anesthesiology 2001;115:94.
recommended. 24. Chin KJ, Karmakar MK, Peng P: Ultrasonography of the adult thoracic
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•  Failure of the ligamentum flavum to fuse in the cervical 114:1459.
and upper thoracic levels may reduce the sense of loss of 25. Chin KJ, MacFarlane AJR, Chan V, Brull R: The use of ultrasound to
resistance with a midline approach to epidural anesthesia. facilitate spinal anesthesia in a patient with previous lumbar laminectomy
and fusion: A case report. J Clin Ultrasound 2009;37:482.
A paramedian approach may be more suitable at these
levels because the needle is advanced to a point where
the presence of a ligamentum flavum is most reliable,
enabling successful access to the epidural space.
•  In patients with scoliosis, a paramedian approach from
the convex side may be more successful.

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