Vertebral level and measurements of conus medullaris and dural sac termination with special reference to the apex of the sacral hiatus: anatomical and magnetic resonance imaging radiologic study

Abstract

Background: Anatomical orientation of the caudal space and termination level of conus medullaris (CMT) and dural sac (DST) has great significance for anaesthetists and neurosurgeons. This study aimed to explore the anatomical landmarks important to perform save spinal anaesthesia, lumber puncture and caudal analgesia through the correlation between the vertebral level of CMT, DST and sacral hiatus apex (SHA) in human cadavers and by using magnetic resonance imaging (MRI).

Materials and methods: Sixty adult cadavers (40 males, 20 females) and 200 (100 males, 100 females) MR lumbosacral images of 16–69-year-old persons were used in this study. Vertebral level of CMT, DST and SHA and their linear distances were determined in cadavers and MRI. Also, anteroposterior diameter at SHA, length and thickness of sacrococcygeal membrane were measured as well, and correlate these levels and their distances with age and sex.

Results: Mean and highest frequent number of MRI vertebral level of CMT was observed at lower third of L1 in men and L1-2 disc in women, that of DST at upper third of S2 in men and middle third of S2 in women, while SHA was seen at middle third of S4 in both men and women with no significant (p > 0.05) age or gender differences. In 5% of cases, CMT, DST and SHA were seen at vertebral level below L2, below S2-3 and above S3, respectively. However, mean vertebral level of CMT, DST, SHA was observed at L1L, S2M and S4U without sex differen­ce in cadaveric specimens, respectively. All linear distances of men MRI revealed significant difference (p < 0.05) compared with those of women except thickness of sacrococcygeal membrane and anterposterior diameter at SHA.

Conclusions: Accurate knowledge of vertebral level of CMT, DST and SHA and the distances in-between might decrease the iatrogenic injury of dural sac, spinal cord and cauda equina.