Tuffier's Line Research Articles

Correlation between the Tuffier's Line and the Spinopelvic Parameters

Tuffier’s line (TL) is a horizontal line that connects the two superior iliac crests and is used to determine L4 and L5 vertebrae levels. Spinopelvic parameters have been gaining further importance in the diagnosis and treatment planning of spinal diseases. This study aims to reveal whether there is an interaction between TL and spinopelvic parameters. We examined the 113 patients who consulted our clinic for low back pains. TL levels were divided into five categories as L4 body, L4 inferior endplate, L4-5 disc space, L5 superior endplate, and L5 body. In the study group, 70 of the cases (61.9%) were female, 43 (38.1%) were male, and the average age was 50.8 (21–77). TL was determined to pass through L4 body in 38.9% of cases (n=44) regardless of gender. It was observed that sacral slope (SS) and lumbar lordosis (LL) were affected by the changes in TL level (P0.05). SS and LL being affected by changes in TL levels indicates that TL should be assessed together with the spinopelvic parameters. To conclude, TL is a potential spinal parameter that should be included in the spinopelvic parameters.

Lomber Mikrodiskektomi Olgularının Tuffier Çizgi Seviyelerine Göre Dağılımı

Objective: The most used method in the surgical treatment of lumbar disc herniation (LDH) is lumbar microdiscectomy (LMD). In this study, we aimed to show the relationship between Tuffier's line (TL), which is widely used in determining the L4-5 distance in lumbar spinal interventions, and LMD levels. Materials and Methods: In this study, a total of 204 patients who had LMD or had low back pain were reviewed retrospectively. According to the projection of TL at the spine level; it was divided into 5 categories as L4 corpus, L4 lower endplate, L4-5 disc space, L5 upper endplate, L5 corpus. The cases were analyzed according to age, gender, disc level and changes in TL. Results: 92.1% of the cases were operated at the L4-5 or L5-S1 level. TL was mostly at L5 upper endplate level in women, L4-5 disc space and above in men, and there was a significant relationship between TLs and gender in both groups (p<0.05). Conclusion: In our study, we found that although TLs were caudally in patients operated at L5-S1 level, they displaced cranially in patients operated at L4-5 level. However, it was observed that LDH development in the lower lumbar region and increased at the upper levels with ageing.

Reliability and Accuracy of Three Anatomical Landmarks for Spinal Level Estimations

Background: Three anatomical landmarks are used to identify a suitable vertebral level for spinal anesthesia: a) Tuffier line (TL), b) tenth rib line (TRL) and c) posterior superior iliac spine (PSIS). We aim to determine reliability and accuracy of these landmarks compared to radiologic landmark.

Predicting the risk of non-specific low back pain in the young population: development and assessment of a new predictive nomogram.

Non-specific low back pain is a common disorder that affects more than 80% of the world's population. But the potential risk factors remain unclear. The aim of this study is to develop a nomogram for the risk prediction of low back pain in young population. A total of 264 young participants (18-45 years old) were recruited and randomly divided into a training set (n=188) and a validation set (n=76) by a ratio of 7:3. The nomogram was developed based on the training set. The independent predictors of low back pain were identified by LASSO and logistic regression analysis. A nomogram was developed according to the predictors. To assess the reliability of the nomogram, the area under the curve (AUC), calibration curve, and decision curve analysis (DCA) were applied. The validation set was used to validate the results. Sixteen factors were included in the characteristics of the eligible subjects. LASSO showed that five independent predictors including working posture, exercising hours per week, Tuffier's line, six lumbar vertebrae anomaly, and lumbar lordosis angle were the independent risk factors of low back pain in young population, which were identified by multivariate logistic regression analysis and were used to establish the nomogram. The AUC values of the nomogram were 0.867 (95% CI: 0.809-0.924) and 0.868 (95% CI: 0.775-0.961) in the training and validation set, respectively. The calibration curve revealed that the prediction model of the nomogram was greatly consistent with the actual observation. In addition, the DCA indicated that the nomogram was clinically useful. Working posture, exercising hours per week, Tuffier's line, six lumbar vertebrae anomaly, and lumbar lordosis angle are identified as independent predictors of non-specific low back pain in young population. And the nomogram based on the above five predictors can accurately predict the risk of low back pain in young people.

Relationship between Age, Sex, and Anthropometric Factors with the Distance of L4-L5 Interspace from Tuffier's Line

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.

Vertebral level of tuffier's line measured by ultrasonography in parturients in the lateral decubitus position

Tuffier's line intersects the spine at the L4 spinous process or at the L4-L5 intervertebral space. Full-term parturient women undergo various physical changes. Therefore, determining the vertebral level with Tuffier's line based on palpation inevitably is not very accurate. This study aimed to use ultrasound to verify the difference between vertebral levels for the palpated Tuffier's line in parturient and non-parturient women in the lateral decubitus position. In this study, consecutively enrolled 20 parturient women at 27-35 weeks of gestation and 20 non-parturient women scheduled for regional anesthesia. In the left lateral position, the location of the vertebra was identified using ultrasonography. We marked every intervertebral space from L5 to L2 vertebra, divided each spinous process into two equal parts, and numbered the spaces sequentially from 1 to 9. A Tuffier's line was drawn by palpating, recorded the vertebral level that this line intersected. The mean value of an arbitrary number of vertebral level of Tuffier's line was 5.4 ± 0.9 in the non-pregnant group and this represents L4-lower vertebral level. In the pregnant group, the mean value was 2.0 ± 1.0 which represents L3-lower vertebral level. There was a significant difference between the two groups (P < 0.05).

Accuracy of Tuffier's Line Identification by Palpation Method: Cross-Sectional Comparative Study Among Obese, Pregnant and Control Groups.

ObjectivePerformance of safe central neuraxial blocks requires identification of accurate vertebral interspace. This study aimed to evaluate the accuracy of palpation method by confirmation with ultrasound in high-risk groups like obesity and pregnancy.MethodsThis cross-sectional comparative study was conducted after approval from the hospital ethics committee and written informed consent from participants. Participants were enrolled into four groups: normal weight non-pregnant (N), full-term pregnant (P), obese (O) and obese full-term pregnant (PO). Tuffier’s line at L4–L5 interspace was determined by palpation method and marked as P-line. Another examiner blinded to the marking done by palpation method confirmed it by ultrasound. The primary endpoint was to determine the accuracy of the palpation method, defined as true identification of Tuffier’s line at the L4–L5 interspace by confirming it with ultrasound among four groups. Proportion and percentage were computed and analysed the true identification of Tuffier’s line at L4–L5 by chi-square test at 0.008 adjusted level of significance for multiple comparisons.ResultsTuffier’s line identification by palpation method was confirmed by ultrasound scanning at L4–L5 interspace in 75.3% (226/300) of participants. Proportion difference of true identification of Tuffier’s line at L4–L5 by palpation and ultrasound was statistically significant among the groups (p=0.0005). True identification was significantly lower in group PO [36.4%; p=0.0005<0.008] and group O [34%; p=0.0005<0.008] as compared to that in group N.ConclusionPalpation method was found to be the inaccurate surrogate for the L4–L5 vertebral interspace for obesity with or without pregnancy.

Comparative study between ultrasound determination and clinical assessment of the lumbar interspinous level for spinal anesthesia

Background: Currently, Tuffier's line is considered the standard level for spinal anesthesia. Incorrect determination of this line may result in iatrogenic spinal cord injury. The current study aims to compare the accuracy of the ultrasound versus clinical determination of the spinal level, using X-ray as the standard for comparison. Methods: This prospective, randomized and controlled study included 200 adult patients of both genders and all classes of the American Society of Anesthesiologists (ASA). After approval of the Local Ethics Committee and securing informed consent, they were randomized into two equal groups. Patients in the Clinical Group (Group C) were examined by clinical landmarks to assess the Assumed Clinical Tuffier's Line (ACTL). Midpoint of ACTL was marked with a radio-opaque marker and then the True Clinical Tuffier's Line (TCTL) was determined using Fluoroscopy (). Patients in the Ultrasound Group (Group U) were examined using ultrasound machine to determine the Ultrasound Tuffier's Line (USTL). The results of both groups were compared with the Radiological Tuffier's line (RTL) from plain X-rays done for both groups. Results: Results are presented in . In Group C, the ACTL accurately correlated with TCTL in only 12% of the patients. It correlated one space cephalad at L3-4 space (67%), at L3 spine (13%) and two spaces cephalad at L2-3 space (7%) and at L2 spine (1%). In Group U, the UTL accurately correlated in 78% of the patients. It corresponded cephalad to L3-4 space (16%) and to L3 spine (4%) and caudad to L5 spine (2%). Conclusion: Ultrasound examination of the spine is recommended in patients planned for spinal anesthesia, as it is superior to clinical assessment in determining the lumbar interspinous level which will minimize the possibility of iatrogenic spinal cord injury.

Ultrasound-assisted subarachnoid block in obese parturient: Need of the hour

Subarachnoid block is commonly used for caesarean deliveries, by virtue of its simplicity in terms of performance and safety for the parturients when compared with general anesthesia. The landmark technique involves palpating the interspinous space at the level of Tuffier's line to ensure the interspace level and direct the spinal needle through optimally selected puncture site for performing the subarachnoid block. However, spinal block is sometimes not easy to perform in obese parturients primarily because of poorly palpable surface landmarks and challenges related to positioning for the block. Recently, ultrasound (USG) is being used for facilitating central neuraxial block, using low-frequency curvilinear probe with encouraging results. We report a case of a 28-year-old, 95-kg parturient, with body mass index of 39.1 kg/m2 scheduled for elective lower segment caesarean section under subarachnoid block, the indication being previous caesarean section. As the landmarks were not appreciable on palpation, we performed USG-assisted preprocedural landmark-based subarachnoid block successfully.

Ultrasound assessment of the anatomic landmarks for spinal anesthesia in elderly patients with hip fracture: A prospective observational study.

Tuffier line is a common landmark for spinal anesthesia. The 10th rib line has been suggested as a new landmark to predict the intervertebral levels. We evaluated the accuracy of these 2 anatomic landmarks for identifying the L4-L5 intervertebral space using ultrasonography in elderly patients with hip fracture.Seventy-nine elderly patients scheduled for hip fracture surgery under spinal anesthesia were included. In the lateral decubitus position with the fracture side up, the L4-L5 intervertebral space was identified alternately using Tuffier line, a line drawn between the highest points of both iliac crests, and the 10th rib line. The 10th rib line, an imaginary line that joints the 2 lowest points of the rib cage, passes through the L1-L2 intervertebral space or the body of L2. The L4-L5 intervertebral space was determined by the counting-down method from the 10th rib line. Then, the estimated intervertebral spaces were evaluated using ultrasonography.The L4-L5 intervertebral space was correctly identified in 47 (59%) patients with Tuffier line and 45 (57%) patients with the 10th rib line (P = .87). The estimation ratio related to the intervertebral levels was not different between the 2 landmarks (P = .40). The wrong identifications of intervertebral level with Tuffier line and the 10th rib line was observed in the following order: L3-L4 intervertebral space: 27% vs 24%, L5-S1 intervertebral space: 9% vs 16%, and L2-L3 intervertebral space: 5% vs 3%, respectively.Tuffier line and the 10th rib line may be unreliable to estimate the intervertebral space for spinal anesthesia in elderly patients with hip fracture.

A review of 571 radiographs on Tuffier's inter-cristal line and its' application in lumbar spinal surgery.

Tuffier's line (TL) is an anatomical landmark used to identify the L4/5 interspace by palpating inter-cristal level in lumbar spinal surgery. The routine use of pre-operative pre-incision radiographs for level check by spinal surgeons is variable due to reliance on this palpation. The anatomical violation of neighbouring normal levels in microscope assisted lumbar surgery is unknown. The aim of this study was to evaluate the effects of patient-related demographic factors and radiographic parameters on TL in a cohort of patients undergoing lumbar spinal procedures. We retrospectively analysed 195 patients (571 radiographs) from a spinal database undergoing lumbar spinal procedures included nerve root injections, decompressions, micro-discectomies and instrumented fusions under a single surgeon. Radiographs were analysed with regard to age, gender, radiographic views (AP & lateral) and weight-bearing (wb) & non-weight bearing (non-wb). The mean age was 59.8 years (range, 24-88 years). The most common level of TL was L4 vertebra (40% <60; 44% >60 years). The most common level in females was L5, while in males L4 vertebra. In 186 radiographs, 68% displayed a difference of at least one vertebral level on AP versus lateral planes. In 11 patients, there was at least 1 level vertebral difference between weight bearing & non-weight bearing radiographs. TL can be affected by age, gender, radiographic views and weight bearing status variably. We recommend employing pre-incision radiographs in all microscope assisted lumbar spinal procedures to eliminate the clinical variations in inter-cristal line and thereby avoiding anatomical violation of neighbouring normal levels in microscope-assisted lumbar surgery. We highlight such variations in inter-cristal line should be given enough consideration in order to avoid a wrong level surgery. Palpatory method for level check without performing pre-incision lateral X-ray should be discouraged.

A tomographic evaluation of the tuffier line in patients with hip fracture

A tomographic evaluation of the tuffier line in patients with hip fracture

The influence of age on positions of the conus medullaris, Tuffier's line, dural sac, and sacrococcygeal membrane in infants, children, adolescents, and young adults.

The purpose of this study was to analyze the distances between the conus medullaris and the Tuffier's line, and between the dural sac and the sacrococcygeal membrane (SCM) in the same pediatric population. Spinal magnetic resonance images and simple X-ray images of 350 patients aged from 1 month to 20 years were reviewed. Positions of the conus medullaris, Tuffier's line, the dural sac, and the SCM were identified. Each position was recorded in relation to the corresponding vertebral body segments. The distances between the conus medullaris and Tuffier's line, and between the dural sac and the SCM, were measured and then assessed according to age using an analysis of variance and a linear regression analysis. The median levels of the conus medullaris and Tuffier's line were in the lower third of L1 [the first lumbar vertebral body] and the middle third of L5, respectively. The levels of the conus medullaris and Tuffier's line were lower in younger populations. The distance between the conus medullaris and Tuffier's line ranged from 1.5 to 4.75 vertebral body height. However, a narrow range of 1.5-2.5 vertebral height was observed only in children younger than 2 years. The level of the dural sac did not differ greatly by age, but the upper limit of the SCM was lower in older populations. The distance between the dural sac and the upper limit of the SCM increased with age. In children, there is a distance of 1.5-4.75 vertebral body height between the conus medullaris and the Tuffier's line. However, these distances were narrower among younger populations. The distance between the dural sac and the upper limit of the SCM increased with age.

Ultrasound measurement of the vertebral level of Tuffier's line in elderly women.

BackgroundIt would be imprecise to generalize the vertebral level determined by palpation to patients of all ages. The purpose of this study was to compare the vertebral level passed by Tuffier's line in elderly women with that passed in adult women using ultrasound in the left lateral decubitus flexed position.MethodsWe enrolled 50 female patients over the age of 65 (elderly group) and 50 female patients between ages 20 and 50 (control group) who had been scheduled to undergo spinal anesthesia. Using ultrasound, we marked the L2–5 lumbar spinous processes and intervertebral spaces. The most cephalad part was labeled 1 and the most caudal part was labeled 11. We then identified which line of these vertebral levels Tuffier's line crossed.ResultsThe median value of the numbers signifying the vertebral level of Tuffier's line was 3 (the L2–3 intervertebral space) in the elderly group, while it was 8 (the lower part of the L4 vertebra) in the control group. The vertebral level of Tuffier's line had statistically significant correlations with age, body mass index, and weight in the elderly group (P < 0.001).ConclusionsThe vertebral level of Tuffier's line determined with ultrasound measurement in the left lateral decubitus flexed position was more cephalad in the elderly women than in those of the control group. Therefore, we should consider that the needle could be inserted at a higher level than expected, and use care in determining the level of needle insertion during spinal anesthesia in elderly women.

Radiological Evaluation of the Line Between the Crista Iliaca (Tuffier's line) in Elderly Patients.

Tuffier's line is defined as the line connecting the highest points of both iliac crests, which generally passes through either the body of the fourth lumbar vertebra or the intervertebral space between fourth and fifth vertebrae. In this study, we assessed the radiological correlation of the level of Tuffier's line with changes in age and sex. In this study, antero-posterior pelvic X-rays of 590 patients aged 18 and older were retrospectively analyzed. It is revealed that Tuffier's line crosses the vertebral column at one of three levels, which are the L4 vertebral body, L4-L5 vertebral interspace and L5 vertebral body. Patients' sex, age and vertebral level of the Tuffier's line were recorded. Data was analyzed using the chi-square test. The assessment of the X-rays of 317 female patients showed that Tuffier's Line passes through the L4 vertebral body in 115 (37.8%), through the L4-L5 intervertebral space in 126 (40%) and through the L5 vertebral body in 76 (22.2%) patients. A Tuffier's line passing through the level of the L5 vertebral body was found to be statistically significant in female patients (p=0.00). No significant relevance was found between male gender and the level of Tuffier's line in 273 male patients. It is found that the height of the vertebral levels that Tuffier's line crosses does not correlate with mean age of the groups (p=0.939). It should be considered that Tuffier's line can cross at vertebral levels other than anticipated. The level of Tuffier's line should be precisely determined with supplementary radiological methods, such as AP pelvic X-ray in addition to physical examination, to reduce the complications in association with regional anaeshesia and to achieve sensorial block levels sufficient to sustain a comfortable surgery, particularly in female patients who carry higher cardiac and respiratory risks.

Pre-puncture ultrasound guided epidural insertion before vaginal delivery.

Palpation method is widely used in clinical practice to identify the puncture site during combined spinal-epidural (CSE) blocks. Tuffier's line, is an anatomical landmark between two iliac crests (inter-cristal), which is widely used to identify the puncture site during CSE blocks is not always an indicator for specific vertebral level or inter-vertebral space. One hundred and Ten (110) women were scheduled for normal vaginal delivery and were randomized into two equal groups; palpation group and an ultrasound guided group to detect the efficacy of puncture ultrasound before CSE blocks to increase chances of successful CSE procedure on the first attempt and to reduce the number of attempts or punctures during insertion of CSE catheter. There were no significant differences between two studied groups regarding; maternal age, weight and height, while, there was a significant difference between two studied groups regarding; parity. Percentage of successful CSE procedure on the first attempt was significantly higher (67.27%) in ultrasound compared to palpation group (40%). Number of punctures (attempts) were significantly less in ultrasound (1.2 ± 0.6) compared to palpation group (2.3 ± 0.8) and the number of redirections was also significantly less in ultrasound (1.4 ± 0.5) compared to palpation group (2.8 ± 1.6). Although, time to identify puncture site was significantly longer in ultrasound compared to palpation group and total procedure time was longer in ultrasound (9.1 ± 1.5 min) compared to palpation group (6.2 ± 1.2 min), there was no significant difference between two studied groups regarding; time to identify puncture site and total procedure time. Two cases of dural puncture in palpation versus no cases in ultrasound group and two cases of intravascular catheter placement (one in each group), with no significant difference between two groups. Pre- puncture ultrasound guided epidural insertion before vaginal delivery, increases the chance of a successful CSE procedure on the first attempt and reduces the number of attempts during insertion of CSE catheter.

Radiological evaluation of the line between the crista iliacas (Tuffier line) in elderly patients

Radiological evaluation of the line between the crista iliacas (Tuffier line) in elderly patients

Vertebral level of Tuffier's line measured by ultrasonography in parturients in the lateral decubitus position.

BackgroundIt is known that Tuffier's line intersects the spine at the L4 spinous process or at the L4-L5 intervertebral space. Full term parturient women undergo various physical changes. Therefore, determining the vertebral level with Tuffier's line based on palpation inevitably is not very accurate. The aim of this study was to use ultrasound to verify the difference between vertebral levels for the palpated Tuffier's line in parturient and non-parturient women in the lateral decubitus position.MethodsWe consecutively enrolled 40 parturient women at 37-41 weeks of gestation and 40 non-parturient women scheduled for regional anesthesia. In the left lateral position, the location of the vertebra was identified using ultrasonography. We marked every intervertebral space from L5 to L2 vertebra, divided each spinous process into two equal parts, and numbered the spaces sequentially from 1 to 9. We drew a Tuffier's line by palpating, recorded the vertebral level that this line intersected.ResultsThe mean value of an arbitrary number of vertebral level of Tuffier's line was 6.4 ± 0.9 in the non-pregnant group and this represents L4-lower vertebral level. In the pregnant group, the mean value was 3.0 ± 1.0 which represents L3-lower vertebral level. There was a significant difference between the two groups (P < 0.05).ConclusionsWe compared using an available ultrasound technique the vertebral levels intersected by the palpated Tuffier's line between parturient and non-parturient women and found that the vertebral levels were more cephalad in the parturient women compared to the non-parturient women.

The value of Tuffier's line for neonatal neuraxial procedures

The spine of L4 usually lies on a line drawn between the highest points of the iliac crests (Tuffier's line) in adults. Although its accuracy has been questioned, it is still commonly used to identify the spinous process of the 4th lumbar vertebra before performing lumbar neuraxial procedures. In children, this line is said to cross the midline at the level of L5. A literature search revealed that the description this surface anatomical line is vague in neonates. The aims of this study were to determine the vertebral level of Tuffier's line, as well as its distance from the apex of the sacrococcygeal membrane (ASM), in 39 neonatal cadavers in both a prone and flexed position. It was found that when flexed, Tuffier's line shifted from the level of L4/L5 (prone position) to the upper third of L5. The mean distance from the ASM to Tuffier's line was 23.64mm when prone and 25.47 mm when flexed, constituting a statistically significant increase in the distance (P=0.0061). Therefore, in the absence of advanced imaging modalities, Tuffier's line provides practitioners with a simple method of determining a level caudal to the termination of the spinal cord, at approximately the L4/L5 in a prone neonate and the upper margins of L5 when flexed.

Palpatory Accuracy of Lumbar Spinous Processes Using Multiple Bony Landmarks

Objective Accurate localization of vertebral segments is crucial for many treatment procedures. The objective of this study was to determine accuracy of identification of lumbar spinous process levels by palpation. Methods Three examiners independently identified the spinous processes of L1-L4 on 60 prone volunteers using multiple bony landmarks including the sacral base, L5, Tuffier's line, T12, and the 12th ribs. The spinous processes were marked with radiopaque skin markers. Location of marker placement and presence of anatomical anomalies were determined by posteroanterior lumbar radiographs. Accuracy of marker placement and interobserver reliability were assessed using weighted κ values. Generalized linear mixed models and Cochran-Mantel-Haenszel tests assessed the relationship of accuracy to training level, presence of anatomical anomalies, and participant characteristics. Results Examiners identified a spinous process in 91% of vertebral assessments. Correct identification of vertebral level occurred 69% of the time ( κ = 0.81; 95% confidence interval, 0.79-0.83). Faculty examiners were significantly more accurate in identifying the correct vertebral level than the resident examiner (67%-78% vs 51%, P ≤ .03). The presence of 12th rib anomalies decreased accuracy for all examiners ( P ≤ .05), reducing accuracy from 74% to 55%. Accuracy was higher in male participants than in female participants ( P = .01). Obesity significantly decreased accuracy ( P = .0003) at L3 (50% vs 73%) and L4 (44% vs 72%). Conclusions Identification of lumbar spinous processes using multiple landmarks was more accurate than previously reported values. However, accuracy was dependent on examiner experience, presence of anatomical anomalies, and participant characteristics.