Background and Objectives: Preprocedural lumbar ultrasound is a valuable tool to assess anatomical landmarks and predict the depth of the epidural space. Variations of the ligamentum flavum sonoanatomy are occasionally observed; however, no literature is available as to their incidence or clinical significance. We hypothesize that abnormal sonoanatomy of the lumbar spine detected by ultrasound can be associated with an increase in unintentional dural punctures. This study was undertaken to determine if the sonoanatomy of the lumbar spine of patients who had documented unintentional dural punctures differs from that of patients with a history of uneventful epidural placement for labor analgesia.
Methods: Ultrasound of the entire lumbar spine was performed on 18 patients with a documented history of unintentional dural punctures, and 18 volunteers with a history of uneventful labor epidurals. At each interspace, we studied the quality of the ligamentum flavum (normal or abnormal), the symmetry of the bony structures (symmetric or asymmetric), and the distance from the skin to the ligamentum flavum. These parameters were compared in both groups.
Results: The incidence of asymmetric sonoanatomy and the distance from the skin to the ligamentum flavum was similar in both groups. The incidence of abnormal ligamentum flavum sonoanatomy was higher in the dural puncture group (overall odds ratio for the 5 interspaces was 8.21, 95% confidence interval 3.07-22.0, P < .0001).
Conclusions: Abnormal sonoanatomy of the ligamentum flavum may represent anatomical variations of this structure, which may be related to an increased incidence of unintentional dural punctures during epidural placements.
- Unintentional dural puncture
- Epidural anesthesia
- Ligamentum flavum
- Spinal sonoanatomy
- Spinal ultrasound
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Reprint requests: Jose C. A. Carvalho, M.D., Department of Anesthesia and Pain Management, Mount Sinai Hospital, 600 University Avenue, Room 781, Toronto, Ontario M5G 1X5, Canada. E-mail:
Financial source: Departmental funds. Disclosures: None of the authors has any conflict of interest relative to this project.