Simple anatomical information improves the accuracy of locating specific spinous processes during manual examination of the low back

School of Health Professions and Rehabilitation Sciences, University of Southampton, England, United Kingdom.
Manual therapy (Impact Factor: 1.71). 06/2008; 14(3):346-50. DOI: 10.1016/j.math.2008.02.009
Source: PubMed


The objective of the study was to test whether a teaching protocol including simple anatomical information on the surface anatomy of spinous processes, improves physiotherapy students' ability to accurately locate selected thoracic and lumbar spinal segments - T12 and L3. First year physiotherapy students were allocated to Group 1 (n=35) and Group 2 (n=34). Both groups were taught to identify spinous processes by counting up from the sacrum, but Group 2 received supplementary anatomical information on the shapes and vertical length of the tips of L5 to T12 spinous processes. The spinous processes of L3 and T12 were located by two experienced physiotherapists and marked on a model using an invisible skin marker. Volunteer students were asked to locate these spinous processes and accuracy was confirmed using an ultraviolet lamp. Students with supplementary anatomical information (Group 2) were significantly better at locating T12 (difference in proportions 36% (95% confidence interval 14 to 51%)) and both T12 and L3 (difference in proportions 33% (11 to 48%)). Group 2 students were also better than Group 1 students at locating L3 (difference in proportions 28% (4 to 48%)), but the difference was not significant. Including simple anatomical information when teaching manual examination skills improved the accuracy of locating specific low back spinal levels.

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    • "L4 was located by counting down vertebrae from L1 and confirmed by counting up vertebrae from PSIS level. The identification was aided by it having a larger spinal process and a rectangular shape compared to the smaller and deeper L5 [18]. As a final check we confirmed its approximate position corresponded to the iliac crest level [19,20]. "
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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.
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  • Free Radical Biology and Medicine 01/2010; 49. DOI:10.1016/j.freeradbiomed.2010.10.507 · 5.74 Impact Factor
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    ABSTRACT: 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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