Palpatory Accuracy of Lumbar Spinous Processes Using Multiple Bony Landmarks

Osteopathic Manipulative Medicine, A.T. Still University/Kirksville College of Osteopathic Medicine, A.T. Still Research Institute, Kirksville, MO, USA.
Journal of manipulative and physiological therapeutics (Impact Factor: 1.48). 06/2011; 34(5):306-13. DOI: 10.1016/j.jmpt.2011.04.006
Source: PubMed


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.
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.
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%).
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.

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    • "In these cases, the anatomical and practical knowledge of the practitioner performing the procedure is essential to correctly identify the needle placement site(s). Another limitation of using multiple anatomical landmarks in neonatal patients, as suggested by Snider et al. (2011), is that the spinous processes of the lumbar vertebrae are still developing and difficult to palpate. This includes the 12th rib and its articulation to T12. "
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    ABSTRACT: 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. Clin. Anat., 2013. © 2013 Wiley Periodicals, Inc.
    Clinical Anatomy 04/2014; 27(3). DOI:10.1002/ca.22218 · 1.33 Impact Factor
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    • "During periodic breaks subjects were able to change this position, but were required to return to it when measurements continued. Testers adhered to the palpatory standards described by Fields 2006 and others [15-24]. "
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    ABSTRACT: Background Accurate measurements of spinal movement require reliable determination of anatomical landmarks. Current methods of identifying these are not sufficiently reliable or valid for this purpose. A reliable and convenient method of placing markers on selected vertebra is needed to compare measurements between different testers, subjects and sessions. Findings Two testers palpated T4, T7, T10, L1 and L4 spinal processes according to established criteria. They measured the position of spinal processes between C7 and the Posterior Superior Iliac Spine (PSIS) at the Pelvis independently using a flexible ruler placed on the spine. Subjects with a wide range of body heights but without visible spinal deformities were recruited for measurements. Reliability was calculated using absolute and relative values. Mean percentage position and 95% Confidence Intervals were calculated using the mean of both testers’ measurement for all subjects. Twenty-two subjects participated. The mean distance between C7 and the PSIS level was 50.9 cm (SD: 3.5 cm). Relative reliability for all spinal processes was almost perfect (ICC: > 0.9). Absolute reliability values showed high agreement between testers. Percentage position of T4 was found to be situated 21% along the distance between C7 and the PSIS level, T7 at 39%, T10 at 54.1%, L1 at 70.9% and L4 at 86.1% accordingly. 95% Confidence intervals around mean percentage positions had a maximum at L1 with 2.8% range from upper to lower limit. Conclusions The distance of three thoracic and two lumbar spinal processes can be reliably and accurately measured by independent testers, using a flexible ruler. Percentage positions between C7 and PSIS level correspond to spinal processes for subjects without visible deformities in the sagittal and frontal plane.
    BMC Research Notes 02/2013; 6(1):58. DOI:10.1186/1756-0500-6-58
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    ABSTRACT: The objective of this study was to evaluate the effectiveness of e-learning as a supplement to on-campus education for the acquisition of skills in palpation and ultrasound examination of the knee in a physiotherapy degree course. Forty-six students (28 females) from the University of Granada, with a mean age of 21.5 yrs, received 4 h of theoretical and practical on-campus training on palpation and ultrasound examination of the knee joint. They were then randomly distributed into two groups: experimental, with free access to the ECOFISIO website on musculoskeletal palpation and ultrasound assessment; and control, with access to documents and books on the topic. Structured objective clinical evaluation (SOCE) and multiple-choice questionnaire (MCQ) were used to assess the educational intervention. We also measured the time taken by the students to generate a reliable ultrasound image and to localize a specific knee structure by palpation. There was no significant intergroup difference in the acquisition of theoretical knowledge as assessed by the MCQ (p = 0.39). Scores were significantly higher in the experimental group than in the control group for skills in palpation ability (p = 0.041) and ultrasound assessment (p < 0.001) of the knee. Students in the e-learning group needed less time to palpate the musculoskeletal structure (p = 0.041) but more time (p = 0.012) to obtain their superior ultrasound images. In conclusion, these results contribute evidence that e-learning is an effective educational strategy for physiotherapy students to acquire skills in palpation and ultrasound imaging of the knee as a supplement to on-campus education.
    Manual therapy 05/2012; 17(5):474-8. DOI:10.1016/j.math.2012.04.002 · 1.71 Impact Factor
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