Anesthesiology 2003; 99:1359 – 63 © 2003 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Influence of Age and Sex on the Position of the Conus

Medullaris and Tuffier’s Line in Adults
Jin-Tae Kim, M.D.,* Jae-Hyon Bahk, M.D.,† Joohon Sung, M.D., Ph.D.‡

Background: The purpose of this study was to analyze the regarding selection of the intervertebral space, especially in the
position of the conus medullaris and Tuffier’s line in the same aged and obese population.
patient population, to correlate this position with age and sex,
and to determine an objective guide for the selection of a safe
intervertebral space during spinal block. MOST typically, Tuffier’s line, which connects the high-
Methods: Magnetic resonance imaging studies of the lumbar est points of the iliac crests, has been used as a marker of
spine were reviewed in 690 consecutive patients. The study the lumbar spine level. Variation in the position of the
population consisted of patients older than 20 yr who had been conus medullaris follows a normal distribution, with a

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/99/6/1359/337870/0000542-200312000-00018.pdf by guest on 13 April 2023

referred for imaging to assess possible causes of low back pain. peak incidence at the lower third of L1 and ranging from
The position of the conus medullaris was defined as the most
distal point of the cord that could be visualized on the sagittal the middle third of T12 to the upper third of L3.1,2 The
sequence. A line perpendicular to the long axis of the cord was bony segmental levels, at which Tuffier’s line crosses the
extended to the adjacent vertebra. In the lumbar plain films, the vertebral column, are distributed in a normal fashion
Tuffier’s line was defined by drawing a horizontal line across with some overlapping where the spinal cord ends.3
the highest points of the iliac crests. Each vertebral body and
Thus, in some patients with a high Tuffier’s line and a
intervertebral space was divided into four segments: upper,
middle, and lower thirds of a vertebral body, and the interver- low cord, intrathecal needles and catheters might be
tebral space. Each segment of a vertebral body or intervertebral directed close to the cord.3
space that the lines crossed was identified and recorded. The It is important to know the level of the lumbar spine
positions, stratified by decade of age, were compared using where the needle is being inserted. One of the main
analysis of variance. The Tukey test was used for post hoc
reasons for counting the intervertebral space before spi-
comparisons. Comparisons between sex were performed with
the unpaired t test. nal block is the avoidance of cord damage. In addition,
Results: The conus medullaris and Tuffier’s line (median the height of the block is related to the level at which the
[range]) were positioned at L1-lower (T12-upper–L3-upper) and injection is made.4,5 In two thirds of patients, however,
L4L5 (L3L4 –L5S1), respectively. The distance between the conus surface palpation resulted in the erroneous localization
medullaris and Tuffier’s line (mean ⴞ SD [range]) was 12.6 ⴞ 1.9 of intervertebral space; in most cases markers were
[7–18] segments, which corresponded to the height of approx-
imately three vertebral bodies and intervertebral spaces. In no
higher than the level at which the anesthetist believed
case did Tuffier’s line overlap with the conus medullaris. The the space to be.2 Lumbar radiograph and magnetic res-
distance in segments between the conus medullaris and Tuffi- onance imaging (MRI) cannot be routinely recom-
er’s line was shorter with increased age (P < 0.001). The posi- mended to check the conus position and lumbar spinal
tion of the conus medullaris and Tuffier’s line was lower in level for all patients scheduled for spinal anesthesia.
female patients than in male patients (P < 0.001) and higher in
patients with sacralization than in those with lumbarization or
Therefore, knowing the margin of safety between the
without transitional vertebra (P < 0.001). The in-between dis- conus medullaris and Tuffier’s line is helpful to deter-
tances were not significantly different regardless of sex or pres- mine a safe puncture site via palpation of the external
ence of transitional vertebra. surface of the back.
Conclusions: During spinal block, there seems to be a safety To our knowledge, the relationship between the posi-
margin of 2– 4 vertebral bodies and intervertebral spaces be-
tween the conus medullaris and Tuffier’s line, which is consis-
tion of the conus medullaris and surface markers (e.g.,
tent regardless of sex or presence of transitional vertebra. How- Tuffier’s line) used for identification of a vertebral or
ever, because the conus medullaris and Tuffier’s line become intervertebral level has not previously been studied. The
closer with age and the clinical use of Tuffier’s line requires purposes of this study were to analyze the position of
palpation through subcutaneous fat, caution must be exercised the conus medullaris and Tuffier’s line in the same pa-
tient population, correlate this position with age and
* Resident, Department of Anesthesiology, Seoul National University Hospital.
sex, and determine an objective guide for the selection
† Assistant Professor, Department of Anesthesiology, Seoul National University of a safe intervertebral space.
College of Medicine, Seoul, Korea. ‡ Assistant Professor, Department of Pre-
ventive Medicine, Kangwon National University College of Medicine, Chun-
cheon, Kangwon-Do, Korea.
Received from the Department of Anesthesiology, Seoul National University Methods
Hospital, Seoul, Korea. Submitted for publication March 10, 2003. Accepted for
publication June 3, 2003. Supported by Korea Research Foundation grant No.
KRF-2001– 042-D00092, Seoul, Korea. Presented in part at the 15th Annual After institutional review board approval (Seoul Na-
Meeting of the American Society of Anesthesiologists, Orlando, Florida, October tional University Hospital, Seoul, Korea), previous MRI
15, 2002.
Address reprint requests to Dr. Bahk: Department of Anesthesiology, Seoul
images and plain lumbar films in the same patients were
National University Hospital, Seoul National University College of Medicine, #28 reviewed. The study population consisted of consecu-
Yongon-Dong, Chongno-Gu, Seoul 110 –744, Korea. Address electronic mail to:
[email protected]. Individual article reprints may be purchased through the
tive patients older than 20 yr of age who had been
Journal Web site, www.anesthesiology.org. referred for MRI imaging to assess the possible causes of

Anesthesiology, V 99, No 6, Dec 2003 1359

1360 KIM ET AL.

of the vertebral body or intervertebral space at which

this line was crossed was identified and noted. The level
was determined by identifying T1, considered to be the
vertebra articulated with a normal first rib,6 or T12, as
the lowest vertebra that was associated with a rib,7 and
counting down from this vertebra. This method was
used instead of counting up from the sacrum, so that
there would be no uncertainty from abnormal sacraliza-
tion of the lumbar vertebrae.6,7 All available plain films
from each patient were also reviewed and assessed for
the presence of a lumbosacral transitional vertebra,
which was classified as lumbarization of S1 or sacraliza-

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/99/6/1359/337870/0000542-200312000-00018.pdf by guest on 13 April 2023

tion of L5. In the former, T12 vertebra and six lumbar
Fig. 1. Magnetic resonance image demonstrating the method for vertebrae were identified, and the lowermost vertebra
determining the conus medullaris position, defined as the most
distal point of the cord that can be visualized on the sagittal was considered as an S1 partially or fully detached from
sequence. Each vertebra and intervertebral space was divided the sacrum. In the latter, only four vertebrae were iden-
into four segments: upper, middle, and lower thirds of the tified, because the theoretical L5 was partially or fully
vertebral body, and intervertebral space. L ⴝ lumbar vertebra.
attached to the sacrum or articulated to it by the trans-
low back pain with or without sciatica for the past 4 yr, verse processes.6 The L5 vertebral body, which was
although a minority of patients had been assessed for determined by counting down from T1 or T12 in the
metastatic disease. Patients with previous spinal opera- plain film, was reconfirmed by checking whether it cor-
tion history, kyphoscoliosis, or congenital anomalies responded to the L5 vertebral body in the MRI sagittal
such as syringomyelia or dural cyst were excluded, so image where this vertebra was separated from the sa-
that those in the study would have no known abnormal- crum by a complete intervertebral disc.
ity of the vertebrae or cord. The vertical distances in segments from the conus
T1-weighted sagittal MRI studies of the lumbar spine medullaris to the Tuffier’s line were calculated by sub-
were reviewed to evaluate the position of the conus tracting the assigned segmental number of the Tuffier’s
medullaris and dural sac. The positions of the conus line from that of the conus medullaris. The same asses-
medullaris and the dural sac were defined as the most sor, blinded to the study purpose, performed each
distal point of the cord and dura that could be visualized measurement.
on the sagittal sequence. A line perpendicular to the long The relationships between age and positions of the
axis of the cord and the dura was extended to the conus, Tuffier’s line, or dural sac were analyzed by Pear-
adjacent vertebra, and the position was defined in rela- son correlation analysis. The study population was di-
tion to the vertebra. According to the method of Saifud- vided into subgroups of age in decades from the twen-
din et al.,1 each unit of a vertebra and intervertebral ties to eighties to determine whether the position of the
space was divided into four segments. The vertebral conus medullaris or the Tuffier’s line and the in-between
body was divided into three equal portions [upper (U), distance change with age. One-way analysis of variance
middle (M), lower (L) thirds], and the intervertebral disc was used to identify any difference among the subgroups
was defined as a separate region (fig. 1). For the purpose with regard to age and presence or type of transitional
of statistical analysis, each potential level was assigned vertebrae. The Tukey test was used for post hoc com-
a segmental number, such that the lower third of S3 parisons. Comparisons between sex were performed
(S3L) ⫽ 1, the lower third of L4 (L4L) ⫽ 17, and the with the unpaired t test; results were considered signif-
upper third of T12 (T12U) ⫽ 35, with a range of 4 from icant at P ⬍ 0.01.
the top of each vertebral body to the next. The L5
vertebral body was determined by counting downward Supplementary Study
from T12 on the plain films and, in the absence of A supplementary study was performed to validate the
transitional vertebrae, was confirmed via MRI by a com- method to define the Tuffier’s line on lumbar plain films.
plete intervertebral disc separated from the sacrum. Ax- After obtaining institutional review board approval and
ial sequences were evaluated for the presence of any informed consent, 20 male volunteers, whose age (mean ⫾
thickening of the filum terminale. SD [range]) was 22 ⫾ 1 [21–24] yr, height 174 ⫾ 6
Lumbar anteroposterior radiographs taken in the su- [165–188] cm, and weight 68 ⫾ 8 [56 – 87] kg, were
pine position were reviewed for checking the position enrolled. With the patient seated on a table with the legs
of the Tuffier’s line, which was formed by drawing a hanging down, radiopaque markers were attached to the
horizontal line across the highest points of the iliac uppermost point of the iliac crests on both flanks in the
crests using an electronic ruler on the digital picture same manner as when delineating the Tuffier’s line dur-
archiving communication system. The segment or point ing spinal block. On lumbar anteroposterior radiographs

Anesthesiology, V 99, No 6, Dec 2003

POSITION OF SPINAL CORD DURING SPINAL BLOCK 1361

Fig. 2. Distribution of the vertebral levels

in segments at which the conus med-
ullaris, Tuffier’s line, and dural sac cross.
The segmental levels where the spinal
cord ends, the Tuffier’s line crosses, and
the dural sac ends followed normal dis-
tribution, respectively. Each vertebra and
intervertebral space was divided into
four segments: upper (U), middle (M),
and lower (L) thirds of the vertebral

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/99/6/1359/337870/0000542-200312000-00018.pdf by guest on 13 April 2023

body, and the intervertebral space. L1–5
ⴝ lumbar vertebra, S ⴝ sacrum, T ⴝ tho-
racic vertebra.

taken in the supine position, the Tuffier’s line was of the Tuffier’s line was higher (F ⫽ 8.80, P ⬍ 0.001), with
formed twice by connecting the highest points of the age, such that the in-between distances in segments was
ilium and the two radiopaque markers, respectively. The shortened with age (F ⫽ 10.27, P ⬍ 0.001) (fig. 4).
segment of a vertebral body or intervertebral space that The conus medullaris and Tuffier’s line (median
the lines crossed was identified and recorded in the same [range] and mean of the segment number ⫾ SD [range])
way as in the main study. The same assessor, blinded to were positioned, respectively, at L1L (T12U–L2L) 29.1 ⫾
the study design and purposes, delineated the Tuffier’s 1.7 [25–35] and at L4L5 (L3L4 –L5S1) 16.4 ⫾ 1.2 [12–20]
line and identified the segment in each patient. The in men, and at L1L2 (T12L–L3U) 28.3 ⫾ 1.8 [23–33] and
segmental position of the two lines (median [twenty-fifth L4L5 (L4U–L5L) 15.9 ⫾ 1.2 [13–19] in women. The
to seventy-fifth percentiles]) that was compared by the positions of the conus medullaris and Tuffier’s line were
Wilcoxon signed rank test was not different (L4L5 [L5U– lower in women than in men (P ⬍ 0.001), but the
L4L5] each; P ⫽ 0.25). In no case was there a discrep- in-between distances in segments were the same regard-
ancy of more than one segment between the two lines. less of sex.
Thus, formation of the Tuffier’s line on radiographs does The study group included 12 patients with sacraliza-
not seem to be different from the bedside determination tion and 29 patients with lumbarization. In the patients
of the line in adults with a normal body build. with sacralization, the conus medullaris, Tuffier’s line,
and dural sac (median [range] and mean of the segment
number ⫾ SD [range]) were positioned at L1M (T12U–
Results L1L2) 30.8 ⫾ 2.0 [28 –35], at L4U (L3L4 –L4L) 18.7 ⫾ 1.2
Images from 690 patients (347 male, 343 female) [17–20], and at S1L/S1S2 (S1M–S2M) 8.2 ⫾ 1.3 [6 –10],
were assessed for the study. The age of the patient group respectively. In the patients with lumbarization, the co-
(mean ⫾ SD [range]) was 51 ⫾ 17 [20 –90] yr, height nus medullaris, Tuffier’s line, and dural sac (median
163 ⫾ 9 [143–186] cm, and weight 63 ⫾ 11 [34 –106] kg. [range] and mean of the segment number ⫾ SD [range])
The conus medullaris, Tuffier’s line, and dural sac
(median [range] and mean of the segment number ⫾ SD
[range]) were L1L (T12U–L3U) and 28.7 ⫾ 1.8 [23–35],
L4L5 (L3L4 –L5S1) and 16.2 ⫾ 1.2 [12–20], and S2M
(S1U–S3L) and 6.5 ⫾ 1.6 [1–11], respectively (fig. 2).
The calculated distance (mean ⫾ SD [range]) between
the conus medullaris and Tuffier’s line was 12.6 ⫾ 1.9
[7–18] segments, which corresponded to about 2– 4 units
of the vertebral body and intervertebral space (fig. 3). In no
case did the Tuffier’s line overlap the conus medullaris. The
position of the conus and Tuffier’s line was correlated with
age (Pearson correlation coefficient ⫽ ⫺0.137 [P ⬍ 0.001] Fig. 3. Distribution of the vertical distance between the conus
medullaris and Tuffier’s line. The number of units of vertebra
and 0.243 [P ⬍ 0.001], respectively). The position of the and intervertebral space corresponds to the height of one ver-
conus medullaris was lower (F ⫽ 2.98, P ⫽ 0.007), and that tebral body and intervertebral disc space.

Anesthesiology, V 99, No 6, Dec 2003

1362 KIM ET AL.

than the latter.4 Other approaches, such as counting

down from C7 or finding the vertebra that is attached to
the twelfth rib, are usually less practicable. The former
approach is tedious and may be inaccurate because of
the difficulty in reliably counting and palpating all in-
terspaces between C7 and L5.10 Finding the vertebra
that is attached to the twelfth rib is not at all helpful in
obese patients.9 Because clinical use of the Tuffier’s line
requires palpation through a variable amount of subcu-
taneous fat, high placement of Tuffier’s line is especially
likely in the obese.3 Term parturients with preeclampsia
accompanied by generalized edema may also have high

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/99/6/1359/337870/0000542-200312000-00018.pdf by guest on 13 April 2023

placement of the Tuffier’s line.11 Because older patients
with osteoporosis or age-related vertebral deformity usu-
ally have a reduced height of the vertebral body,12–14 the
segmental position of the conus could be lower with
that of the Tuffier’s line higher but relatively less so, so
Fig. 4. Correlation between age and segmental levels at which that the in-between distance appears to be shortened
the conus medullaris, Tuffier’s line, or dural sac cross. Position
of the conus medullaris was lower with age (r ⴝ ⴚ0.137, P < with age, as proved in this study.
0.001); position of Tuffier’s line was higher with age (r ⴝ 0.243, Palpating the upper iliac crest and drawing a vertical
P < 0.001). The vertical distance between the conus medullaris line seemed to be unreliable in determining interverte-
and Tuffier’s line decreased with age (r ⴝ ⴚ0.286, P < 0.001),
and the position of the dural sac was constant regardless of age. bral space, which tended to be one or two spaces higher
Numbers of the segmental level of vertebra or intervertebral than the anesthetist believed it to be.15 When anesthe-
space are: 5 ⴝ lower portion of S2, 10 ⴝ midportion of S1, tists tried to identify intervertebral space by palpation,
15 ⴝ upper portion of L5, 20 ⴝ L3L4 intervertebral space,
25 ⴝ lower portion of L2, 30 ⴝ midportion of L1, and 35 ⴝ their identification was correct in only 29% of cases,
upper portion of T12. with the actual space being higher than assumed in
68%.2 In another study, palpation was successful in only
were positioned at L2U (L1U–L2L3) 27.3 ⫾ 1.8 [24 –31], 30% of cases, and intervertebral spaces in up to 27% of
L5M (L4L5–L5S1) 14.3 ⫾ 0.9 [12–16], and S2L (S1S2– cases were wrongly identified by more than one level.16
S3M) 5.2 ⫾ 1.4 [2– 8], respectively. The positions of the While performing spinal anesthesia with isobaric bupiv-
conus medullaris, Tuffier’s line, and dural sac of the acaine, injection at the higher lumbar space produces a
patients with sacralization were higher than in those higher spread of analgesia.5 The temptation to use less of
with lumbarization or without transitional vertebrae a “potentially neurotoxic” spinal anesthetic drug may
(P ⬍ 0.001). However, the vertical distance between the force the anesthesiologist to choose a higher interverte-
conus medullaris and Tuffier’s line (mean ⫾ SD) was not bral space, such as the L2–L3 interspace.11 Thus, the
different among the patients with sacralization (12.1 ⫾ practice of selecting the highest possible intervertebral
2.0 segments), with lumbarization (13.1 ⫾ 1.9 seg- space may be unwise because of the possibility of
ments), or without transitional vertebrae (12.5 ⫾ 1.9 inaccuracy.
segments). Determination of whether the lumbosacral transitional
vertebra is a sacralized L5 or a lumbarized S1 remains a
perplexing problem in the absence of plain films.17 The
Discussion prevalence of transitional vertebrae has been reported to
range between 8% and 15%.17,18 Without plain film,
The positions of the conus medullaris, Tuffier’s line, identification of a lumbosacral vertebral level is difficult,
and dural sac measured in the same patients corre- which reflects a potential source of error in the deter-
sponded well to results of previous studies.1,2,7,8 Our mination of conus level by MRI alone.1 In our study,
findings reveal that the safety margin between the conus however, there was no significant problem with identi-
medullaris and Tuffier’s line may be less than two verti- fication of lumbosacral vertebrae, because both plain
cal heights of a vertebral body and intervertebral space. film and MRI were available. The presence of transitional
The distance between the conus medullaris and Tuffier’s vertebrae has an effect on the position of the conus
line decreases with age regardless of sex. medullaris and Tuffier’s line. However, because the mar-
The most common method of identifying lumbar in- gin of safety between their positions was not different,
terspaces is to use the Tuffier’s line that joins the two counting up from the apparent lumbosacral junction
iliac crests, or half of the Tuffier’s line, by dropping a seems to be a reasonable way to select an intervertebral
perpendicular line from the iliac crest to the lumbar space regardless of the presence of transitional vertebra.
spine9; the former method is probably more accurate Radiologic studies exclude the thickness of the subcu-

Anesthesiology, V 99, No 6, Dec 2003

POSITION OF SPINAL CORD DURING SPINAL BLOCK 1363

taneous tissue, so that more uniform results can be References

drawn regarding the correlation between the positions 1. Saifuddin A, Burnett SJD, White J: The variation of position of the conus
of the conus medullaris and Tuffier’s line. In practice, medullaris in an adult population: A magnetic resonance imaging study. Spine
subcutaneous thickness may be estimated by pinching 1998; 23:1452– 6
2. Broadbent CR, Maxwell WB, Ferrie R, Wilson DJ, Gawne-Cain M, Russell R:
the skin in the same way as in checking degree of Ability of anesthetists to identify a marked lumbar space. Anaesthesia 2000;
obesity. Before the patient flexes the spinal column, 55:1122– 6
3. Hogan QH: Tuffier’s line: The normal distribution of anatomic parameters
checking and marking the corresponding vertebral level (letter). Anesth Analg 1994; 78:194 –5
on the Tuffier’s line may be helpful to select a safe 4. Ievins FA: Accuracy of placement of extradural needles in the L3– 4 in-
terspace: Comparison of two methods of identifying L4. Br J Anaesth 1991;
intervertebral level. As shown in this study, it would be 66:381–2
practical to know the distance from the conus medullaris 5. Tuominen M, Taivainen T, Rosenberg PH: Spread of spinal anaesthesia with
plain 0.5% bupivacaine: Influence of the vertebral interspace used for injection.
to the Tuffier’s line in the same patient population, Br J Anaesth 1989; 62:358 – 61
because lumbar radiograph and MRI cannot be routinely 6. Santiago FR, Milena GL, Herrera RO, Romero PA, Plazas PG: Morphometry

Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/99/6/1359/337870/0000542-200312000-00018.pdf by guest on 13 April 2023

of the lower lumbar vertebrae in patients with and without low back pain. Eur
recommended for all patients scheduled for spinal block. Spine J 2001; 10:228 –33
MRI studies and plain films were performed on supine 7. Render CA: The reproducibility of the iliac crest as a marker of lumbar spine
level. Anaesthesia 1996; 51:1070 –1
patients with their legs elevated. With maximal hip and 8. Larsen JL, Olsen KO: Radiographic anatomy of the distal dural sac: A
myelographic investigation of dimensions and termination. Acta Radiol 1991;
lower spine flexion, the distance between the lumbar 32:214 –9
spinous processes will be increased. For radiography, 9. Reynolds F: Logic in the safe practice of spinal anesthesia (editorial).
Anaesthesia 2000; 55:1045– 6
each patient’s back was not as flexed as in spinal punc- 10. Thavasothy M: The reproducibility of the iliac crest as a marker of lumbar
ture, but this did not greatly affect the study results spinal level (letter). Anaesthesia 1997; 52:811
11. Bahk JH, Ko H: Damage to the conus medullaris following spinal anaes-
because with flexion there is little distraction of the thesia (letter). Anaesthesia 2001; 56:813– 4
lower vertebrae from the sacrum.4 12. Diacinti D, Acca M, D’Erasmo E, Tomei E, Mazzuoli GF: Aging changes in
vertebral morphometry. Calcif Tissue Int 1995; 57:426 –9
In conclusion, during spinal block, the safety margin 13. Sone T, Tomomitsu T, Miyake M, Takeda N, Fukunaga M: Age-related
between the conus and Tuffier’s line may be less than changes in vertebral height ratios and vertebral fracture. Osteoporos Int 1997;
7:113– 8
two heights of a vertebral body and intervertebral space. 14. Pluijm SM, Tromp AM, Smit JH, Deeg DJ, Lips P: Consequences of verte-
Because the clinical use of Tuffier’s line requires palpa- bral deformities in older men and women. J Bone Miner Res 2000; 15:1564 –72
15. Van Gessel EF, Forster A, Gamulin Z: Continuous spinal anesthesia: Where
tion through subcutaneous fat, we may not select an do spinal catheters go? Anesth Analg 1993; 76:1004 –7
intervertebral space more than one level higher than the 16. Furness G, Reilly MP, Kuchi S: An evaluation of ultrasound imaging for
identification of lumbar intervertebral level. Anaesthesia 2002; 57:277– 80
Tuffier’s line, especially in old and obese patients. None- 17. O’Driscoll CM, Irwin A, Saifuddin A: Variations in morphology of the
theless, we should be aware that there remains another lumbosacral junction on sagittal MRI: Correlation with plain radiography. Skeletal
Radiol 1996; 25:225–30
potential mechanism of nerve lesion— damage to the 18. Ford LT, Goodman FG: X-ray studies of lumbosacral spine. South Med J
nerves in the cauda equina— during spinal block. 1966; 59:1123– 8

Anesthesiology, V 99, No 6, Dec 2003