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Methods for Numbering the Lumbar Vertebrae on Lumbosacral Imaging Studies

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Title: Methods for Numbering the Lumbar Vertebrae on Lumbosacral Imaging Studies


1
Methods for Numbering the Lumbar Vertebrae on
Lumbosacral Imaging Studies
  • Chang Hee Lee, MD, Kyoung Ah Kim, MD, Jae Woong
    Choi, MD, Cheol Min Park, MD,
  • Suk Joo Hong, MD, Sang Il Suh, MD, Hae Young
    Seol, MD, Young Chil Choi, MD.
  • Department of Diagnostic Radiology, Guro
    Hospital,
  • Korea University Medical Center
  • Seoul, South Korea

2
Learning objectives
  • Learn the methods for numbering the lumbar
    vertebrae on radiographs, US, CT, and MRI.
  • Learn the useful paraspinal structures and
    landmarks for the prediction of transitional
    vertebrae.

3
Introduction
  • The exact location of vertebral segments in
    imaging studies is important. However, due to the
    existence of lumbosacral transitional vertebrae,
    which are prevalent in 3 21 of the cases,
    selecting the position of the lumbar vertebral
    segments is often inaccurate when using MRI or
    lumbosacral radiographs alone.

4
  • To determine exact numbering, useful landmarks
    will be discussed and demonstrated, including the
    length of the transverse process, the size of the
    pedicle, interpedicular distance, the position of
    the iliac crest, the direction of the transverse
    process, the diameter of the intervertebral
    foramen, the level of aortic bifurcation, the
    confluence of IVC, the origin of the renal
    artery, celiac trunk, SMA root, the iliolumbar
    ligament, and the tip of the conus medullaris.
    Several methods will be also presented in
    forecasting the transitional vertebrae.

5
Useful Landmark
  • Plain Radiograph
  • Ultrasound
  • CT
  • MRI

6
Radiograph
  • Length of transverse process
  • Iliac crest line Tuffiers line
  • Interpedicular distance
  • Width of pedicle
  • Height of pedicle
  • Size of intervertebral foramen

7
1. Length of transverse process
  • L3 vertebra usually exhibits the longest
    transverse process of all lumbar segment.
  • In our preliminary study, the transverse process
    was longest at L3 approximately
  • 80 and at L2 in 15.

8
Length of transverse process
L3
L3
AP radiograph of lumbar spine and 3D
reconstructed CT show the longest transverse
process(arrow) at L3 vertebra.
9
2. Iliac crest line Tuffiers line
  • The most common method of identifying lumbar
    interspaces is to use Tuffiers line, which joins
    the two iliac crests, dropping a perpendicular
    from the iliac crest to the lumbar spine.
  • 85 of intercrestal line was located between
    the lower half of L4 and the upper half of L5
    focusing on the disc space of L4/L5.

10
Iliac crest line
The intercrestal line was located at L4-5 disc
space on 3D reconstructed CT and AP radiograph of
lumbar spine.
11
3. Interpedicular distance
  • The interpedicular distance gradually increased
    from L1 to L5.
  • Largest at L5 vertebra

12
4. Width of pedicle
  • The horizontal pedicle diameter gradually
    increased from L1 to L5.
  • The L1 had the narrowest horizontal pedicle
    diameter (7.4 mm for male and 7.5 mm for female
    specimens), whereas L5 had the largest.

13
5. Height of pedicle
  • The vertical pedicle diameter was found to
    decrease gradually from L1 to L5.
  • The L5 had the narrowest vertical pedicle
    diameter.

14
6. Size of intervertebral foramen
  • Gradually increased into L4 5 disc
  • space
  • Largest at L4/5 disc level

15
MRI
  • Aortic bifurcation
  • Right renal artery
  • Conus medullaris
  • Iliolumbar ligament
  • Inferior vena cava confluence
  • Celiac trunk
  • SMA root

16
1. Aortic bifurcation
  • According to Grays anatomy, the point of aortic
    bifurcation was located at the front of the body
    of L4.
  • In our study, the point of aortic bifurcation
    was at the anterior part of the L4 vertebral body
    in 83 . In particular, 45 was at the upper
    half of L4 and 38 at the lower half of L4. On
    the axial images, the first bifurcated common
    iliac arteries appeared in the disc space of
    L4/L5 in approximately 93 , in the disc space of
    L5/S1 in 5 , and in the disc space of L3/4 in 2
    .

17
Aortic bifurcation
  • In the absence of special information on the
    location of abdominal ultrasound, abdominal or
    pelvic CT, and lumbar spine CT, the point of
    aortic bifurcation can contribute to forecasting
    the location of the lesion.

18
C2
T12
Aortic bifurcation
T1
L4
T12
A
B
  • 28-year-old man presented with low back pain.
  • Cervicothoracic(C-T) sagittal scout image shows
    oil capsule(arrow) at
  • the upper half of T12.
  • In the sagittal FSE T2-weighted MR image of the
    lumbar spine, the oil capsule (arrow) is
    demonstrated at the same position as in C-T scout
    image.

19
Aortic bifurcation
L4
C
28-year-old man presented with low back
pain. C. In the axial FSE T2-weighted image, the
point of aortic bifurcation(arrow) is seen as the
longest horizontal position right before the
aorta was bifurcated into both common iliac
arteries at the upper half of L4 vertebra.
20
2. Right renal artery
  • Generally, the ostia of the right renal artery
    lies between the levels of the lower third of the
    L1 vertebra and the upper third of the L2
    vertebral bodies and slightly below the level of
    the superior mesenteric artery.

21
Right renal artery
  • In our study, the proximal portions of the right
    renal artery were distributed at around 52 of
    the intervertebral disc space at the L1/L2 level,
    32 at the lower half of the L1 vertebral body,
    and 8 at the upper half of the L2 vertebral
    body.
  • In short, 92 of the origin of the right renal
    artery was located between the lower half of L1
    and the upper half of L2 focusing on the disc
    space of L1/L2 thus, helping determine the
    location of the lumbar vertebral segment.

22
Right renal artery
L1
L2
51-year-old man with herniated
disc at L4/5 level. The proximal portion of the
right renal artery (arrow) is seen as a small and
round signal void at the level of the
intervertebral disc space of L1/2, in the right
paracentral portion of the sagittal FSE
T2-weighted MR image.
23
3. Conus medullaris
  • In our study, the mean position of the conus
    medullaris was the lower half of L1. Similar to
    the results of other studies, its range was
    within the intervertebral disc space of T12/L1 to
    the upper half of L2 vertebra.

24
Conus medullaris
  • In comparison with the aortic bifurcation and
    the right renal artery, however, conus medullaris
    showed a wide distribution thus, it was
    inadequate as a paraspinal structure for
    determining the location of the lumbar vertebral
    segment.

25
Conus medullaris
L2
51-year-old man with herniated disc at
L4/5 level. In the sagittal T1-weighted
spin-echo image, the tip of conus medullaris
(arrow) is noted as the most distal point of the
cord, at the level of the upper half of L2
vertebra.
26
4. Iliolumbar ligament
  • The iliolumbar ligament originates primarily
    from the tip of the L5 transverse process, with
    occasional weak attachments of the L4 transverse
    process, inserting to the superior aspect of the
    iliac crest

27
Iliolumbar ligament
  • The IIL localized the true L5 level in 94.
  • The ligament is thought to provide additional
    stability to the lumbosacral junction.

28
Iliolumbar ligament
L5
L5
Axial coronal image of lumbar MRI show
iliolumbar ligament (arrow) from tip of L5
transverse process to the superior aspect of the
iliac crest.
29
5. Inferior vena cava confluence
  • The mean site of IVC confluence was at L4-5 disc
    space(range, lower L3 to upper S1)
  • IVC confluence usually located immediately
    below the point of aortic bifurcation.

30
Inferior vena cava confluence
On the axial T2 weighted MRI, IVC confluence
(red arrow) was seen at L4-5 disc space below the
point of aortic bifurcation (blue arrow).
31
6. Celiac trunk
  • The first major branch of the abdominal aorta is
    the celiac artery, which arises from the ventral
    surface of the aorta at the level of T12 or L1.
  • The most common site is at T12-L1 intervertebral
    disc space.

32
7. SMA root
  • The SMA originates immediately below the celiac
    trunk at L1 vertebra.
  • The most common site is at upper half of L1
    vertebra.

33
Celiac trunk SMA root
T12
T12
T12
L1
L1
L1
On the saggital T2 weighted MRI, right renal
artery(blue arrow), SMA root(red arrow), and
celiac trunk(yellow arrow) were well demonstrated.
34
CT(MDCT)
  • Aortic bifurcation
  • IVC confluence
  • Iliolumbar ligament
  • Renal artery(right renal artery)
  • Celiac trunk
  • SMA root

35
On the 3D-reformatted coronal axial image of
CT, IVC confluence(red arrow) was seen at lower
half of L5 below the point of aortic
bifurcation(blue arrow, L4-5 disc level).
36
L5
L5
Axial coronal image of lumbar CT show
iliolumbar ligament (arrow) from tip of L5
transverse process to the superior aspect of the
iliac crest.
37
On the saggital reformatted and axial CT, right
renal artery(blue arrow, L1-2 disc level), celiac
trunk(yellow arrow, upper third of L1 ), and SMA
root(red arrow, middle third of L1 ) were well
demonstrated.
38
Methods for prediction of Transitional vertebrae

39
Transitional vertebra Lumbar
radiograph
  • When the transverse process and the iliac crest
    line were in outlying positions from the main
    locations, transitional vertebra were possible.
  • L3 vertebra usually exhibits the longest
    transverse process about 80.
  • 85 of intercrestal line was located between
    the lower half of L4 and the upper half of L5
    focusing on the disc space of L4/L5

40
Transitional vertebra Lumbarization
  • In the case of lumbarization, the iliac crest
    line was located at lower half of L5 about 72.
  • No significant difference in transverse process
    was observed between normal and lumbarization.

41
S1
S1
24-year-old woman with transitional vertebra,
lumbarization of S1 vertebra. The
intercrestal line was located at lower half of L5
on whole spine AP and lumbar spine AP radiograph.
42
Transitional vertebra Sacralization
  • In 62 of sacralization, the transverse process
    of L2 was longest.
  • The iliac crest line was within normal range.
  • The rudimentary T12 rib occurred with
    significantly higher frequency(50) in the case
    of sacralization.
  • The sacralization was also occurred with higher
    frequency(62) in the T12 rudimentary rib.

43
22-year-old woman with transitional vertebra,
sacralization of L5 vertebra. The transverse
process of L2(arrow) was longest on whole spine
AP and lumbar spine AP radiograph. The
intercrestal line was located at L4-5 disc space.
44
T12
T12
37-year-old man with transitional
vertebra(sacralization of L5 vertebra) and
absence of T12 rib. The transverse process of
L2(arrow) was longest on whole spine AP and
lumbar spine AP radiograph. The intercrestal
line was located at upper half of L4. The rib of
T12 vertebra was absent.
45
Transitional vertebra Lumbar MRI
  • In our preliminary study, when aortic
    bifurcation, proximal right renal artery, conus
    medullaris, iliolumbar ligament, celiac trunk,
    SMA root and IVC confluence were in outlying
    positions from the main locations, transitional
    vertebrae were also possible.

46
Lumbarization of S1
L1
L2
S1
L1
A
B
24-year-old woman with transitional vertebra,
lumbarization of S1 vertebra. The paraspinal
structures are located more toward the caudal
direction. A. C-T scout image shows oil capsule
at the upper border of L1 vertebra. B. The right
renal artery(arrow) is seen at the lower half of
L2 vertebra in the sagittal T2 FSE image.
47
L1
L2
L4/5 Disc
D
C
24-year-old woman with transitional vertebra,
lumbarization of S1 vertebra. The paraspinal
structures are located more toward the caudal
direction. C. The sagittal T1-weighted SE image
reveals the tip of conus medullaris (arrow) at
the lower half of L2 vertebra. D. The axial
T2 FSE image shows the aortic bifurcation(arrow)
at the level of the intervertebral disc space
of L4/5.
48
L1
S1
S1
38-year-old man with transitional vertebra,
lumbarization of S1 vertebra. The axial T2 FSE
image reveals aortic bifurcation (yellow arrow)
at L4-5 disc level and IVC confluence(green
arrow) at L5-S1 level. The sagittal coronal
T2 FSE image show right renal artery(red arrow),
celiac axis(arrow head) SMA root(white arrow),
and iliolumbar ligament(blue arrow). When the
vertebral segment is counted using a morphology
standard of L5, the paraspinal structures are
located at a higher place than the normal
range.
49
Sacralization of L5
T10
T11
L1
T1
L4
L5
T10
T11
A
B
49-year-old woman with transitional vertebra,
sacralization of L5 vertebra. The
paraspinal structures are positioned more toward
the cephalad location. She also has
spondylolisthesis of L4 on L5 vertebra. A. In the
C-T scout image, the oil capsule is seen between
T10 and T11. B. The right renal artery(arrow) is
demonstrated at the upper half of L1 vertebra.
50
T10
T12
L3/4 Disc
L1
L4
L5
C
D
49-year-old woman with transitional vertebra,
sacralization of L5 vertebra. The
paraspinal structures are positioned more toward
the cephalad location. C. The sagittal
T1-weighted SE image reveals the tip of conus
medullaris (arrow) at the lower half of T12
vertebra. D. The axial T2 FSE image shows the
aortic bifurcation(arrow) at the level of the
intervertebral disc space of L3/4.
51
45-year-old man with transitional
vertebra(sacralization of L5) and absence of T12
rib. The axial T1 T2 SE images reveal aortic
bifurcation (yellow arrow) at L3-4 disc level and
IVC confluence(green arrow) at lower half of L4
level. The sagittal T2 FSE images show right
renal artery(red arrow), celiac axis(blue arrow),
and SMA root(white arrow). When the vertebral
segment is counted using a morphology standard of
L5, the paraspinal structures are located at a
lower place than the normal range.
52
  • In the S1 lumbarization, the paraspinal
    structures were located more toward the caudal
    direction compared to the cases where there were
    no lumbosacral anomalies.
  • The paraspinal structures in the L5
    sacralization were located more toward the
    cephalad direction.

53
  • When the cervicothoracic sagittal scout image
    is not used and the vertebral segment is counted
    using a morphology standard, the lumbarization of
    S1 can be questioned if the paraspinal structures
    are located at a higher place than the normal
    range such will be the case for the
    sacralization of L5 if they are located at a
    lower place.

54
References
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    evaluate anatomic significance of aortic
    bifurcation, right renal artery, and conus
    medullaris when locating lumbar vertebral
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    various configurations of the lumbar spine. Spine
    1979 4258-266
  • 3. Tini PG, Wieser C, Zinn WM. The transitional
    vertebra of the lumbosacral spine its
    radiological classification, incidence,
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    Rehab 1977 16180-1855.
  • 4. Hinck VC, Clark WM, Hopkins CE. Normal
    interpediculate distances(minimum and maximum) in
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  • 5. Castellvi AE, Goldstein LA, Chan DPK.
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Thank you!
Korea University Medical Center
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