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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 162-166

Relationship between age, sex, and anthropometric factors with the distance of L4-L5 interspace from Tuffier’s line: Observational study with ultrasonography guidance


Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia–Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Date of Submission26-Apr-2022
Date of Decision23-Jun-2022
Date of Acceptance10-Jul-2022
Date of Web Publication27-Jul-2022

Correspondence Address:
Aida Rosita Tantri
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia–Cipto Mangunkusumo National General Hospital, Jakarta
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjoa.bjoa_122_22

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  Abstract 

Background: The anatomical marker used in spinal anesthesia is L4-L5 interspace. The L4-L5 interspace is thought to be right on the Tuffier’s line, which connects the two highest points on the iliac crest. The location of L4-L5 interspace from the Tuffier’s line varies greatly because of the influence of several factors such as differences in race, sex, age, and anthropometric factors. This study aimed to examine the relationship between age, sex, and anthropometry factors with the distance of L4-L5 interspace from the Tuffier’s line using ultrasound guidance at Cipto Mangunkusumo National General Hospital. Materials and Methods: This was an observational analytic study with a cross-sectional design in 93 subjects at Cipto Mangunkusumo National General Hospital recruited for the study. Statistical analysis was performed to find the relationship between age, sex, and anthropometry factors with the distance of L4-L5 interspace from the Tuffier’s line and to continue with multivariate analysis to obtain the prediction formula of the distance between L4-L5 interspace and the Tuffier’s line. Results: This study found that the distance of L4-L5 interspace to the Tuffier’s line is −2.59 ± 1.58 cm. Correlation analysis showed a significant relationship between height and sex to the distance of L4-L5 interspace and the Tuffier’s line. The distance prediction formula obtained in this study is 4.921 + [0.536 × (1 for male or 2 for female)] + (−0.052 × height in cm). Conclusion: There was a significant relationship between height and sex to the distance of L4-L5 interspace from the Tuffier’s line.

Keywords: L4-L5 interspace, Tuffier’s line, ultrasonography


How to cite this article:
Tantri AR, Satoto D, Natassa S. Relationship between age, sex, and anthropometric factors with the distance of L4-L5 interspace from Tuffier’s line: Observational study with ultrasonography guidance. Bali J Anaesthesiol 2022;6:162-6

How to cite this URL:
Tantri AR, Satoto D, Natassa S. Relationship between age, sex, and anthropometric factors with the distance of L4-L5 interspace from Tuffier’s line: Observational study with ultrasonography guidance. Bali J Anaesthesiol [serial online] 2022 [cited 2022 Aug 10];6:162-6. Available from: https://www.bjoaonline.com/text.asp?2022/6/3/162/352400




  Introduction Top


The anatomical marker for spinal anesthesia varies greatly.[1],[2],[3] Some studies reported that L4-L5 interspace is not right on the Tuffier’s line.[2],[3],[4],[5],[6] Amir et al. stated that radiography testing in their study showed only 12% of the subjects that has L4-L5 interspace right on the Tuffier’s line; another 80% of the subjects showed that the Tuffier’s line is get through L3-L4 interspace.[6]

Alternative ways to indentify L4-L5 interspace location other than palpation are using radiographic testing and ultrasound imaging (USG). The identification of L4-L5 interspace location using radiographic testing during spinal anesthesia is quite specific, but it gives radiation exposure to the patient and not practical.[2],[7] USG is quite a simple procedure that can be done to a patient in sitting, prone, or lateral position, and it also does not give radiation exposure to the patient, but also has disadvantages that it needs an expensive machine and experienced user to obtain a good result.[2],[8]

Tuffier’s line is still greatly used in Indonesia as a marker for spinal anesthesia. Race, sex, age, and anthropometric differences correlate with variation on L4-L5 interspace location from the Tuffier’s line. In Caucasian race, Tuffier’s line is get through L4 vertebra in 41.9% of the population; thus, L4-L5 interspace is located 4.33 cm below the Tuffier’s line.[9] Anatomical variation depends on the pelvic structure variation in different race. Horduna and Legaye in their study stated that pelvic anatomical differences correlate with the variation of L4-L5 interspace location from the Tuffier’s line.[10]

The distance measurement of L4-L5 interspace from the Tuffier’s line is important to help the operator to perform a successful spinal anesthesia. This study aimed to examine the relationship between age, sex, and anthropometry factors with the distance of L4-L5 interspace from the Tuffier’s line using ultrasound guidance at Cipto Mangunkusumo Hospital.


  Subjects and Methods Top


Study design

This observational analytic study with a cross-sectional design was approved by the Ethics and Research Committee of Universitas Indonesia (Ethical approval number 19-06-0738) and was registered in ClinicalTrials.gov (NCT03771755). Following the ethics committee approval, patients undergoing spinal anesthesia at Cipto Mangunkusumo Hospital were recruited for the study.

The sample size in this trial used correlation sample size equation as seen below:



where n = sample size, Zα = the standard normal deviate for alpha = 1.96, Zβ = the standard normal deviate for power = 0.84, and r = the expected correlation coefficient.

The expected correlation coefficient in this study based on the previous study was 0.3; therefore, a total of 85 subjects needed for this study. Ten percent from the total counted subjects was added to prepare for drop-out possibility during trial; thus 93 subjects were recruited for this study using the consecutive sampling method.

Inclusion and exclusion criteria

All patients who underwent elective surgery with spinal anesthesia were assessed for their eligibility to be included in this study. Inclusion criteria for this study was patient aged >18 years old, scheduled for spinal anesthesia with physical status ASA I-III, and agreed to be included in this study by signing a consent form. Exclusion criteria for this study were patients who were not possible to be examined using ultrasound (e.g., scar on the skin around vertebra), patients with a history of back surgery and contraindicated for spinal anesthesia procedure, patients who cannot be placed in an optimal sitting position, and a pregnant woman.

Study protocols

One day before the anesthesia procedure, subjects were asked to sign the informed consent form to be included in this study. The demographic data were recorded, and on the surgery day, subjects were placed in a sitting position and set up for spinal anesthesia procedure. A physical examination was done by the investigator under supervision from another anesthesiologist consultant. Investigators marked iliac crest on both sides and then drew a line, which connected both marks, which called Tuffier’s line (Tf).

Ultrasound machine was set on 8–10 cm depth, and the probe was covered with condom to prevent infection spread and gel to provide a better imaging. Curved probe was placed in the transverse position on the middle of vertebral line and moved from the sacrum toward the head and marker and would be placed on every processus spinosus found until it reached thoracic area. Marks from processus spinosus were connected to make a line on the middle of vertebra (Ts), and after that the intersection point between Tf and Ts was also marked (Ts-f). The ultrasound probe was placed perpendicular and moved from the sacrum midline to its paramedial position; then the probe was tilted to make a parasagittal oblique approach. The probe in a parasagittal oblique position then moved toward the head, and the first lamina found after sacrum is L5. Every lamina from L1 to L5 was marked, and the midpoint between L4 and L5 was also marked (T4–5). USG curved probe was placed back to the transverse position on vertebral midline to confirm the T4–5 position [Figure 1]. The distance from Ts-f to T4–5 and from Ts-f to the accompanied vertebral was measured. The measurement results were recorded and verified by a regional anesthesia consultant.
Figure 1: Distance measurement between L4-L5 interspace and the Tuffier’s line. (a) Probe in paramedian position (left) and line projection marker (right); (b) USG

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Statistical analysis

Data were statistically analyzed using Statistical Package for Social Scientist (SPSS) software, version 20.0. Mann–Whitney and Pearson test were performed to find the relationship between age, sex and anthropometry factors with the distance of L4-L5 interspace from the Tuffier’s line. Additionally, multivariate analysis with multiple linear regression method was used to obtain the prediction formula of the distance between L4-L5 interspace and the Tuffier’s line.


  Results Top


Subject characteristics in this study include gender, age, body weight, height, and body mass index (BMI) [Table 1].
Table 1: Subject characteristics

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Subject’s gender and height have a significant correlation with the distance between L4-5 vertebral interspace and Tuffier’s line, whereas other factors show no significant correlation. [Table 2] shows the correlation analysis for the whole factors [Table 2].
Table 2: Correlation analysis between age, gender, anthropometry factor, and the distance between L4-L5 vertebral interspace and Tuffier’s line

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Bivariate analysis shows that gender, height, weight, and BMI are eligible to be included in multivariate analysis to know the power of the variable in predicting the distance between L4-5 interspace and the Tuffier’s line.

In this study, the gender and height variables met the requirements for a partial significance with a P value of ≤0.10, which means that they can be included in the multivariate analysis. After the regression analysis was carried out, an equation was obtained to determine the distance of L4-L5 interspaces to the Tuffier’s line as shown in [Table 3].
Table 3: Linear regression equation to predict the distance of L4-L5 interspaces to the Tuffier’s line

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According to [Table 3], it can be concluded that the Malay race, the variables of gender and height, has significant influences in determining the distance of L4-L5 interspaces to the Tuffier’s line.

In this study, the distance of L4-L5 interspaces to the Tuffier’s line was measured in a sitting position using an ultrasound guide. Measurements were made by obtaining the mean distance between the L4-L5 interspaces and the Tuffier’s line of −2.59 ± 1.58 cm. The results of the mean distance among the Tuffier’s lines and the other vertebrae, namely, from the first lumbar to the sacrum (L1–S), can be seen in [Table 4].
Table 4: Mean distance between the L4-L5 interspaces and the Tuffier’s line and mean distance between the L1-S to the Tuffier’s line

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  Discussion Top


Several studies have reported that the location of the L4-L5 space in the spine does not always lie in the Tuffier’s line.[3],[4] This location varies greatly because of several factors such as differences in race, gender, age, and anthropometric factors. Gender also affects the distance of L4-L5 interspaces to the Tuffier’s line. In a study conducted by Snider et al., there were differences in the location of the L4-L5 interspaces against the Tuffier’s line between men and women.[1] This is due to differences in the anatomy of the pelvis in men and women.

The analysis in this study showed that there was no significant relationship between age and the L4-L5 interspaces to the Tuffier’s line. These results were different from the results of a study conducted by Chun et al.[2] Chun et al. compared the distance of L4-L5 interspaces to the Tuffier’s line in adult and elderly female subjects. The study results concluded that there was a relationship between age and the distance of L4-L5 interspaces to the Tuffier’s line. This might be caused by degenerative process, decreased bone mass, decreased muscle mass, loosening of ligaments, and decreased flexibility of the body, causing the shortening of the vertebrae, as well as the space between the vertebrae in older women.[2]

In this study, there was a significant relationship between gender and the distance of L4-L5 interspaces to the Tuffier’s line with a P value of <0.05. The significant relationship obtained in this study is in accordance with the study conducted by Snider et al. on 260 Caucasian patients, which stated that the location of the L4-L5 interspaces is below the Tuffier’s line in men and above the Tuffier’s line in women.[1]

The mean distance between the L4-L5 interspaces and the Tuffier’s line was −3.19 ± 0.75 cm in men and −2.09 ± 1.02 cm in women. It can be concluded that men have a longer distance between L4-L5 interspaces and the Tuffier’s line than women. This fact can be explained by the differences in the anatomical structure of the pelvic bones in men and women. The ala ossis ilii part of the os ilium lies more horizontally in women. Likewise, the anatomy of the female pelvis is wider; therefore, the crest of the iliac crest in women is shorter than in men.[11]

The results of this study showed that height was the only anthropometric factors that had a significant relationship with the distance of L4-L5 interspaces to the Tuffier’s line. It can be concluded that the longer a person’s height, the further the distance of L4-L5 interspaces and the Tuffier’s line. This result is consistent with a study conducted by Snider et al. on 260 Caucasian patients, which showed that the study subject with a longer height has a Tuffier’s line that cut at L4 level, whereas the study subject with a shorter height has a Tuffier’s line that cut at L5 level.[1]

The mean height obtained in this study was 159.63 ± 7.70 cm. The mean value of height in this study was lower than that of Snider et al. study subjects with Caucasoid race, which was 171 ± 0.10 cm. This occurs because of racial differences that cause variations in the anatomical structure. Caucasians have longer spines than Asians.[1],[12]

After going through the process of multivariate analysis, an equation that can be used to determine the distance of L4-L5 interspaces to the Tuffier’s line was determined:

The distance of L4-L5 interspaces to the Tuffier’s line (in cm) = 4921+ (0.536) G* + (−0.067) H**,

where *G = gender 1 for males and 2 for females, **H = height in cm.

The linear regression analysis result showed the correlation between gender and height with the distance of L4-L5 interspaces to the Tuffier’s line (adjusted R = 33%). From this result, it can be concluded that there is a significant correlation between gender and height with the distance of L4-L5 interspaces to the Tuffier’s line, which is considered a moderate correlation.

The result of this study showed that the distance of L4-L5 interspaces to the Tuffier’s line was −2.59 ± 1.58 cm. This means the space between the L4 and L5 spine is 2.59 ± 1.58 cm below the Tuffier’s line. This result is different from the result of a study conducted by Walsh et al. on Caucasians, which stated that most of the study population (41.9%) had a mean distance of L4-L5 interspaces to the Tuffier’s line of 4.33 mm below the Tuffier’s line.[9] From the comparison of these two studies, it can be concluded that racial differences cause anatomical differences. One of the differences in the anatomy is the difference in the shape of the pelvic anatomy angle, where Caucasians have larger and wider pelvis angles. This is in accordance with a study by Horduna and Legaye,[10] which stated that pelvic anatomy influences the location of L4-L5 interspaces against the Tuffier’s line.

In this study, the average location of L4-L5 interspaces was below the Tuffier’s line, which is at the L3-L4 level. Therefore, when applying anatomical markers during spinal anesthesia, it is advisable to lower the markers by one interspace, approximately 2.5 cm below the Tuffier’s line. Most of our study population (87.1%) has Tuffier’s line at L3-L4 level, whereas the rest of the study population (12.9%) has Tuffier’s line at L4-L5 level.

This study still has many limitations, including the subjectivity of ultrasound measurements, which depend on the skills and experiences of the operator (operator-dependent technique). Another limitation of this study was that the position of the patient during the administration of spinal anesthesia was only in a sitting position with the legs straightened forward, which made the patient able to bend optimally. Therefore, the exact measurements to predict the distance of L4-L5 interspaces to the Tuffier’s line cannot be determined in patients in other positions such as lateral decubitus. Further research is needed for ultrasound examination in other positions such as lateral decubitus, because not all patients can undergo spinal anesthesia administration in a sitting position with legs straightened forward. This study also requires further research with more heterogeneous age and race variations to ensure the relationship between the distance of L4-L5 interspaces and the Tuffier’s line. Moreover, it is necessary to conduct research using other techniques such as magnetic resonance imaging or radiography, which is the gold standard examination in the same position; therefore, researchers can predict the location of L4-L5 interspaces more accurately.

There was a significant relationship between height and sex to the distance of L4-L5 interspace from the Tuffier’s line. The distance prediction formula between L4-L5 interspace and Tuffier’s line is 4.921 + [0.536 × (1 for male or 2 for female)] + (−0.052 × height in cm). Further research is needed with a larger population and with various ultrasound methods so that more precise results are obtained to determine the Tuffier’s line based on race.

Acknowledgment

This study has been presented as poster on World Congress on Regional Anesthesia and Pain Medicine 2018.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Snider KT, Kribs JW, Snider EJ, Degenhardt BF, Bukowski A, Johnson JC Reliability of Tuffier’s line as an anatomic landmark. Spine (Phila Pa 1976) 2008;33:E161-5.  Back to cited text no. 1
    
2.
Chun EH, Kim JE, Kim DY, Kim YJ, Kim JH, Chung RK, et al. Ultrasound measurement of the vertebral level of Tuffier’s line in elderly women. Korean J Anesthesiol 2016;69:474-9.  Back to cited text no. 2
    
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Tuffier T Anesthe´sie me´dullaire chirurgicale par injection sous-arachnoidienne lombaire de cocaı¨ne, technique et re´sultats. Medical Week 1900;20:167-9.  Back to cited text no. 3
    
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Rahmani M, Vaziri Bozorg SM, Ghasemi Esfe AR, Morteza A, Khalilzadeh O, Pedarzadeh E, et al. Evaluating the reliability of anatomic landmarks in safe lumbar puncture using magnetic resonance imaging: Does sex matter? Int J Biomed Imaging 2011;2011:868632.  Back to cited text no. 4
    
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Hadzic A Spinal anesthesia. In: Hadzic A, editor. Textbook of Regional Anesthesia and Acute Pain Management. New York: McGraw-Hill Education; 2009. p. 193-229.  Back to cited text no. 5
    
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Tanaka K, Irikoma S, Kokubo S Identification of the lumbar interspinous spaces by palpation and verified by x-rays. Braz J Anesthesiol 2013;63:245-8.  Back to cited text no. 6
    
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Amin WA, Abou Seada MO, Bedair E, Elkersh MM, Karunakaran E Comparative study between ultrasound determination and clinical assessment of the lumbar interspinous level for spinal anesthesia. Middle East J Anaesthesiol 2014;22:407-12.  Back to cited text no. 7
    
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Parate LH, Manjunath B, Tejesh CA, Pujari V Inaccurate level of intervertebral space estimated by palpation: The ultrasonic revelation. Saudi J Anaesth 2016;10:270-5.  Back to cited text no. 8
    
9.
Walsh JC, Quinlan JF, Butt K, Towers M, Devitt AT Variation in position of the L4-5 disc inter-space from the anatomical landmark: Review of 450 radiographs and clinical applications. Eur J Orthop Surg Traumatol 2006;16:203-6.  Back to cited text no. 9
    
10.
Horduna M, Legaye J Influence of the sagittal anatomy of the pelvis on the intercrestal line position. Eur J Anaesthesiol 2008;25:200-5.  Back to cited text no. 10
    
11.
Zárate-Kalfópulos B, Romero-Vargas S, Otero-Cámara E, Correa VC, Reyes-Sánchez A Differences in pelvic parameters among Mexican, Caucasian, and Asian populations. J Neurosurg Spine 2012;16:516-9.  Back to cited text no. 11
    
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Ross PD, Wasnich RD, Davis JW, Vogel JM Vertebral dimension differences between Caucasian populations, and between Caucasians and Japanese. Bone 1991;12:107-12.  Back to cited text no. 12
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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