PART III-C

NEURAXIAL ANESTHESIA

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 318
SECTION 1 Spinal Anesthesia
CHAPTER 22
Neuraxial Anatomy (Anatomy Relevant
to Neuraxial Anesthesia)
Steven Orebaugh and Hillenn Cruz Eng
INTRODUCTION
The vertebral column forms part of the axis of the human body,
extending in the midline from the base of the skull to the pelvis.
Its four primary functions are protection of the spinal cord,
support of the head, provision of an attachment point for the
upper extremities, and transmission of weight from the trunk
to the lower extremities. Pertinent to regional anesthesia, the
vertebral column serves as the landmark for a wide variety of
regional anesthesia techniques. It is important, therefore, that
the anesthesiologist be able to develop a three-dimensional
mental image of the structures comprising the vertebral
column.
ANATOMIC CONSIDERATIONS
The vertebral column consists of 33 vertebrae (7 cervical,
12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal segments)
(Figure 22–1). In the embryonic period, the spine curves
into a C shape, forming two primary curvatures with their
convex aspect directed posteriorly. These curvatures persist
through adulthood as the thoracic and sacral curves. The
cervical and lumbar lordoses are secondary curvatures that
develop after birth as a result of extension of the head and
lower limbs when standing erect. The secondary curvatures
are convex anteriorly and augment the flexibility of the
spine.
Hadzic_Ch22_p317-327.indd 318
■■ Vertebrae
A typical vertebra consists of a vertebral arch posteriorly and a
body anteriorly. This holds true for all vertebrae except C1. Two
pedicles arise on the posterolateral aspects of each vertebra and
fuse with the two laminae to encircle the vertebral foramen1
(Figures 22–2A, 22–2B). These structures form the vertebral
canal, which contains the spinal cord, spinal nerves, and epidural
space. Fibrocartilaginous disks containing the nucleus pulposus,
an avascular gelatinous body surrounded by the collagenous
lamellae of the annular ligament, join the vertebral bodies. The
transverse processes arise from the laminae and project laterally,
whereas the spinous process projects posteriorly from the mid-
line union of the laminae (Figures 22–2A, 22–2B). The spinous
process is frequently bifid at the cervical level and serves as an
attachment for muscles and ligaments.
C1 (atlas), C2 (axis), and C7 (vertebra prominens) are
described as atypical cervical vertebrae due to their unique fea-
tures. C1 is a ringlike bone that has no body or spinous process.
It is formed by two lateral masses with facets that connect
anteriorly to a short arch and posteriorly to a longer, curved
arch. The anterior arch articulates with the dens, and the
posterior arch has a groove where the vertebral artery passes
(Figure 22–3A). The odontoid process (dens) of C2 protrudes
superiorly, hence the name axis (Figure 22–3B). Together, the
atlas and axis form the axis of rotation for the atlantoaxial joint.
The C7 (vertebra prominens) has a long, nonbifid spinous
process that serves as a useful landmark for a variety of regional
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 Neuraxial Anatomy (Anatomy Relevant to Neuraxial Anesthesia) 319

1
2 Atlas
Axis
3

CHAPTER
Cervical Vertebrae

CHAPTER 22
4
5
6
7

X
1

4
Intervertebral disks
5
Thoracic Vertebrae
6

9 Intervertebral foramina
10

11

12

Lumbar Vertebrae 3

Sacrum

Coccyx Haadzic - Lancea/ NYSORA

FIGURE 22–1.  The vertebral column and the curvatures of the adult spine, lateral view.

anesthesia procedures (Figure 22–3C). The C7 transverse pro-
cess is large and has only one posterior tubercle.
The interlaminar spaces in the thoracic spine are narrow and
more challenging to access with a needle due to overlapping lami-
nae. In contrast, the laminae of the five lumbar vertebrae do not
overlap. The interlaminar space between adjacent lumbar verte-
brae is rather large.2
Vertebral facet (zygapophyseal) joints articulate posterior
elements of adjacent vertebrae. The junction of the lamina and
pedicles gives rise to inferior and superior articular processes
(Figures 22–2A, 22–2B). The inferior articular process pro-
trudes caudally and overlaps the inferiorly adjacent vertebra’s
superior articular process. This alignment is important to
understand when performing interventional pain procedures
such as facet joint injections, intra-articular steroid injections or
radio-frequency denervation. Joint surfaces in the cervical
spine are oriented halfway between the axial and coronal
planes. This alignment allows an ample degree of rotation,
flexion, and extension but little resistance to backward and
forward shearing forces. Facet joints in the thoracic region are
oriented in a more coronal plane, which provides greater pro-
tection against shearing forces but reduced rotation, flexion,
and extension.
In the lumbar spine, joint surfaces are curved, with a coronal
orientation of the anterior portion and a sagittally oriented
posterior portion.3 Thoracic facets are located anterior to the

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 320 CLINICAL PRACTICE OF REGIONAL ANESTHESIA
PART 3

Vertebral arch

Spinous process
Inferior articular facet joint
Superior articular process
Superior articular facet joint
Vertebral foramen
Transverse process
Pedicle
Vertebral body

Superior articular process

Transverse process
Lamina
Superior articular facet joint
Inferior articular process
B

FIGURE 22–2.  A typical vertebra. A: Superior view of the L5 vertebra. B: Posterior view of the L5 vertebra.

transverse processes, whereas cervical and lumbar facets are
located posterior to their transverse processes. Five sacral verte-
brae fuse to form the wedge-shaped sacrum, which connects
the spine with the iliac wings of the pelvis4 (Figures 22–4A,
22–4B). In childhood, the sacral vertebrae are connected by
cartilage, which progresses to osseous fusion after puberty, with
only a narrow remnant of sacral disk remaining in adulthood.
Fusion is generally complete through the S5 level, although
there can be complete lack of any posterior bony roof over the
sacral vertebral canal. The sacral hiatus is an opening formed
by the incomplete posterior fusion of the fifth sacral vertebra.
It lies at the apex of the coccyx, which is formed by the union
of the last four vertebrae (Figure 22–4C). This hiatus provides
a convenient access to the caudal ending of the epidural space,
especially in children. The sacral cornu are bony prominences
on each side of the hiatus that are easily palpated in small chil-
dren and serve as landmarks for a caudal epidural block.
■■ Intervertebral Ligaments
The vertebral column is stabilized by a series of ligaments. The
anterior and posterior longitudinal ligaments run along the
anterior and posterior surfaces of the vertebral bodies, respec-
tively, reinforcing the vertebral column. The supraspinous
ligament, a heavy band that runs along the tips of the spinous
processes, becomes thinner in the lumbar region (Figure 22–5).
This ligament continues as the ligamentum nuchae above T7
and attaches to the occipital external protuberance at the base
of the skull.5 The interspinous ligament is a narrow web of
tissue that attaches between spinous processes; anteriorly it
fuses with the ligamentum flavum and posteriorly with the
supraspinous ligament (Figure 22–5).
The ligamentum flavum is a dense, homogenous structure,
composed mostly of elastin which connects the lamina of adja-
cent vertebrae5,6 (Figure 22–5). The lateral edges of the ligamen-
tum flavum surround facet joints anteriorly, reinforcing their

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 321

Anterior tubercle
Anterior arch
Lateral masses

CHAPTER
Transverse foramen

CHAPTER 22
Superior articular facet
Posterior arch
Posterior tubercle

X
A

Odontoid process ( dens)

Vertebral body
Superior articular facet joint
Lamina
Spinous process

Spinous process

Lamina

Superior articular facet joint

Transverse foramen

Pedicle

Transverse process

Vertebral body

Vertebral foramen

FIGURE 22–3.  The atypical vertebrae. A: Superior view of the C1 vertebra (atlas). B: Superior view of the C2 vertebra (axis) with a bifid
spinous process. C: Superior view of the C7 vertebra; the spinous process is nonbifid.

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 322 CLINICAL PRACTICE OF REGIONAL ANESTHESIA

Superior articular facet

PART 3

Sacral Canal

Ala

Lateral sacral tuberosity

Median sacral crest

Dorsal sacral foramina

Lateral sacral crest

Sacral hiatus

Sacral cornu

Spinous process
Vertebral canal
Superior articular facet
Ala
Sacroiliac joint
Sacral body

Superior articular facet

Vertebral articular face

Ala

intervertebral joints

Sacral foramina

Coccyx

FIGURE 22–4.  The sacrum and coccyx. A: Posterior view of the sacrum; the sacrum curves anteriorly proximal to its narrowing tip where it
articulates with the coccyx. B: The base of the sacrum is directed upward and forward. C: Anterior view of the coccyx.

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 Neuraxial Anatomy (Anatomy Relevant to Neuraxial Anesthesia)
Spinous process
Interspinous
Ligament
Supraspinous
Ligament
Ligament
Flavum
FIGURE 22–5.  A cross-sectional view of the vertebral canal with the intervertebral ligaments, vertebral body, and spinous process.
joint capsule. When a needle is advanced toward the epidural
space, there is an easily perceptible increase in resistance when the
ligamentum flavum is encountered. More importantly for the
practice of neuraxial anesthesia, a perceptible, sudden loss of resis-
tance is encountered when the tip of the needle passes through
the ligamentum and enters the epidural space.
The ligamentum flavum consists of right and left halves that
join at an angle of less than 90°. Importantly, this midline
fusion may be absent to a variable degree depending on the
vertebral level.2 These fusion gaps allow for veins to connect to
vertebral venous plexuses.7 Of note, the fusion gaps are more
prevalent at cervical and thoracic levels. Yoon et al reported that
midline gaps between C3 and T2 occur in 87%–100% of indi-
viduals. The incidence of the midline gap decreases at lower
vertebral levels, with T4–T5 the lowest (8%).7 In theory, a
midline gap poses a risk of failure to recognize a loss of resis-
tance at the cervical and high thoracic levels when using the
midline approach, resulting in an inadvertent dural puncture.
The ligamentum flavum is thinnest in the cervical and
upper thoracic regions and thickest in the lower thoracic and
Hadzic_Ch22_p317-327.indd 323
323
CHAPTER
CHAPTER 22
Posterior
Longitudinal
Ligament
X
Anterior
Longitudinal
Ligament
Vertebral
Body
Intervertebral
disk
Hadzic - Lancea/ NYSORA
lumbar regions.8,9 As a result, resistance to needle advancement
is easier to appreciate when a needle is introduced at a lower
level (eg, lumbar).7,8 At the L2–L3 interspace, the ligamentum
flavum is 3- to 5-mm thick. At this level, the distance from the
ligamentum to the spinal meninges is 4–6 mm.6 Consequently,
a midline insertion of an epidural needle at this level is least
likely to result in an inadvertent meningeal puncture with epi-
dural anesthesia-analgesia.
The lateral wall of the vertebral canal has gaps between
consecutive pedicles known as intervertebral foramina
(Figure 22–1A). Because the pedicles attach more cephalad
of the middle of the vertebral body, the intervertebral foram-
ina are centered opposite the lower half of the vertebral
body, with the vertebral disk at the caudal end of the fora-
men. As a consequence, the borders of the intervertebral
foramina are the pedicle at the cephalad and caudal ends, the
vertebral body (cephalad) and the disk (caudally) on the
anterior aspect, a portion of the next vertebral body most
inferiorly, and posteriorly the lamina, facet joint, and liga-
mentum flavum.
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 324 CLINICAL PRACTICE OF REGIONAL ANESTHESIA

■■ Spinal Meninges
The spinal cord is an extension of the medulla oblongata. It has
three covering membranes: the dura, arachnoid, and pia maters
(Figure 22–6A). These membranes concentrically divide the
PART 3
fat, epidural veins, spinal nerve roots, and connective tissue
(Figure 22–6B) The subdural space is a “potential” space
between the dura and the arachnoid and contains a serous fluid.
The subdural compartment is formed by flat neuroepithelial
cells that have long interlacing branches. These cells are in close

vertebral canal into three distinct compartments: the epidural,

subdural, and subarachnoid spaces. The epidural space contains contact with the inner dural layers. This space can be expanded

Spinal Cord
Ventral Roots
Dorsal Root Ganglion

Pia Mater
Sympathetic Trunk

Arachnoid Mater

Rami Communicantes

Dura Mater

Transverse Process

Spinous Process
Vertebral Body

Ligamentul Flamum
Posterior epidural space
Posterior epidural fat
Lamina Dura mater
Arachnoid
Subrachnoid space
Piamater

Dorsal root
ganglion
Dorsal nerve root
Denticulate ligament
Anterior epidural
space
Ventral nerve root
Posterior longitudinal
ligament
Epidural venous plexus

B
Vertebral body Haad
H dzzic
ic - Laan
nce
cea/
a/ NYSO
YSORA
YS

FIGURE 22–6.  A. Sagittal view of the spinal cord with meningeal layers, dorsal root ganglia, spinal nerves, and sympathetic trunk. B. Cross-
sectional view of the spinal cord depicting the ligamentum flavum in respect to the posterior epidural space. Notice the close proximity of
the posterior epidural space to the subarachnoid space.

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by shearing the neuroepithelial cell layer connections with the
collagen fibers of the dura mater. This expansion of the subdu-
ral space can be caused mechanically by injecting air or a liquid
such as contrast media or local anesthetics, which, by applying
pressure in the space, separates the cell layers.10 The subarach-
noid space is traversed by threads of connective tissue extending
from the arachnoid mater to the pia mater. It contains the spi-
nal cord, dorsal and ventral nerve roots, and cerebrospinal fluid
(CSF). The subarachnoid space ends at the S2 vertebral level.
■■ Spinal Cord
There are eight cervical neural segments. The eighth segmental
nerve emerges between the seventh cervical and first thoracic
vertebrae, whereas the remaining cervical nerves emerge above
their same-numbered vertebrae. Thoracic, lumbar, and sacral
nerves emerge from the vertebral column below the same-
numbered bony segment1 (Figure 22–6A). Anterior and posterior
spinal nerve roots arise from rootlets along the spinal cord. The
roots of the upper and lower extremity plexuses (brachial and
lumbosacral) are significantly larger compared to other levels.11
The dural sac is continuous from the foramen magnum to the
sacral region, where it spreads distally to cover the filum terminale.
Spinal cord
Conus Medullaris
Spinous Process
Cauda Equina
L5
Termination of Dural Sac
Sacral Canal
Filum Terminale
A Had
Ha dzzic
ic - Lan
ance
c a/ NYSORA
FIGURE 22–7.  A. Sagittal view of the lumbar vertebrae. The spinal cord terminates at the L1-L2 interspace. B. Arterial supply to the
anterior spinal cord. The Artery of Adamkiewicz emerges from T8-L1 vertebral segments. The small insert demonstrates the blood supply to
the spinal cord ( one anterior and two posterior arteries).
Hadzic_Ch22_p317-327.indd 325
Neuraxial Anatomy (Anatomy Relevant to Neuraxial Anesthesia) 325
In children, the dural sac terminates lower, and in some adults, the
sac termination can be as high as L5. The vertebral canal contains
the dural sac, which adheres superiorly to the foramen magnum,
CHAPTER
to the posterior longitudinal ligament anteriorly, the ligamentum
CHAPTER 22
flavum and laminae posteriorly, and the pedicles laterally.
The spinal cord tapers and ends as the conus medullaris at
the level of the L1–L2 intervertebral disk (Figure 22–7A). The
filum terminale, a fibrous extension of the spinal cord, extends
X
caudally to the coccyx. The cauda equina is a bundle of nerve
roots in the subarachnoid space distal to the conus medullaris12
(Figure 22–7A).
The spinal cord receives blood primarily from one anterior
and two posterior spinal arteries that derive from the verte-
bral arteries (Figure 22–7B). Other major arteries that supple-
ment blood supply to the spinal cord include the vertebral,
ascending cervical, posterior intercostal, lumbar, and lateral
sacral arteries. The single anterior spinal artery and two poste-
rior spinal arteries run longitudinally along the length of the
cord and combine with segmental arteries in each region. The
major segmental artery (Adamkiewicz) is the largest segmen-
tal artery and is found between the T8 and L1 vertebral
segments. The Adamkiewicz artery is the major blood supplier
to two-thirds of the spinal cord. Injury of this artery may result
Anterior spinal artery
Vertebral artery
Subclavian artery
Radicular artery
Intercostal artery
Great ventral
radicular artery
(Artery of Adamkiewicz)
Lumbar radicular artery
Anterior spinal artery
Anterior sulcal artery
Posterior spinal artery
B Hadzic - Lancea/ NYSORA
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 326 CLINICAL PRACTICE OF REGIONAL ANESTHESIA
in anterior spinal artery syndrome, characterized by loss of uri-
nary and fecal continence as well as impaired motor function of
the legs.1 The radicular arteries are branches of the spinal
arteries and run within the vertebral canal and supply the ver-
tebral column. Radicular veins drain blood from the vertebral
PART 3
venous plexus and eventually drain into the major venous sys-
tem: the superior and inferior vena cava and the azygos
venous system of the thorax.1
MOVEMENTS OF THE SPINE
The fundamental movements through the vertebral column are
flexion, extension, rotation, and lateral flexion in the cervical
and lumbar spine. Movement between individual vertebrae is
relatively limited, although the effect is compounded along the
entire spine. Thoracic vertebrae, in particular, have limited
mobility due to the rib cage. Flexion is greatest in the cervical
spine, whereas extension is greatest in the lumbar region. The
thoracic and sacral regions are the most stable.
SPECIAL CONSIDERATIONS
In the United States and most developed countries, there is an
increase in aging population. This trend carries with it an increased
prevalence of spinal deformities, such as spinal stenosis, scoliosis,
hyperkyphosis, and hyperlordosis. Elderly patients present anes-
thetic challenges when neuraxial techniques are required. With
advancing age, a diminishing thickness of intervertebral disks
results in decreased height of the vertebral column. Thickened liga-
ments and osteophytes also contribute to difficulty in accessing
both the subarachnoid and epidural spaces. The frequency of spi-
nal deformities in older adults can be as high as 70%.13
Convex side Concave side
A B
FIGURE 22–8.  Adolescent scoliotic spine. A: S-shaped scoliosis of the thoracolumbar spine. B: Cobb angle of 50°.
Hadzic_Ch22_p317-327.indd 326
Adult scoliosis, in particular, is frequently encountered in
older adults. In fact, Schwab et al demonstrated that scoliosis
was present in 68% of an asymptomatic volunteer population
older than 60 years of age. A thorough understanding of the
scoliotic spine will aid in successfully performing central neur-
axial blockade in this patient population. In the scoliotic spine,
vertebral bodies are rotated toward the convexity of the curve,
and their spinous processes face into the concavity of the curve14
(Figure 22–8).
The diagnosis of scoliosis is made when there is a Cobb
angle of greater than 10° in the coronal plane of the spine in a
skeletally mature patient.15 The Cobb angle, which is used to
measure the magnitude of scoliosis, is formed between a line
drawn parallel to the superior endplate of one vertebra above
the curve deformity and a line drawn parallel to the inferior
endplate of the vertebra one level below the curve deformity16
(Figure 22–8). In untreated patients, there is a strong linear
relationship between the Cobb angle and the degree of vertebral
rotation in both thoracic and lumbar curves, with maximum
rotation occurring at the apex of the scoliotic curve.17,18 A com-
pensatory curvature of the spine always occurs in the opposite
direction of the scoliotic curve.
Scoliosis usually presents in childhood or adolescence and is
diagnosed during routine physical examination. Untreated, it
may become progressive and result in respiratory impairment
and gait disturbances. Scoliosis may also go undiagnosed and
present later in life as back pain.15,19
Treatment depends on the severity of the scoliosis. Mild
scoliosis (11°–25°) is usually observed. Moderate scoliosis
(25°–50°) in the skeletally immature patient frequently pro-
gresses and therefore is most often braced. Patients with severe
scoliosis (>50°) are usually treated surgically.20
Bend Left
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 Neuraxial Anatomy (Anatomy Relevant to Neuraxial Anesthesia)
REFERENCES
FIGURE 22–9.  Paramedian approach in a scoliotic spine; arrow
B represents the needle realignment towards the convex side of
the scoliotic spine compared to arrow A, which depicts the usual
paramedian approach in a normal spine.
The degree of vertebral body rotation along the long axis of
the spine influences the orientation of a needle during insertion
for neuraxial anesthesia. In the patients with scoliosis, the ver-
tebral body rotates toward the convex side of the curve. As a
result of this rotation, the spinous processes point toward the
midline (the concave side). This results in a larger interlaminar
space on the convex side of the spine.21,22 A direct path to the
neuraxial space is created by this vertebral body rotation, allow-
ing the use of a paramedian approach from the convex side of
the curve (Figure 22–9). Surface landmarks, particularly the
spinous process, may be difficult to identify in the severe scoli-
otic spine. X-rays, and most recently preprocedural ultrasound
scanning, may be useful to determine the longitudinal angula-
tion of the spine, the location and orientation of the spinous
process, as well as the depth of the lamina.23–25
Clinical Pearls
•  The spinal cord ends at the L1-to-L2 level; performing
spinal anesthesia at or above this level is not
recommended.
•  Failure of the ligamentum flavum to fuse in the cervical
and upper thoracic levels may reduce the sense of loss of
resistance with a midline approach to epidural anesthesia.
A paramedian approach may be more suitable at these
levels because the needle is advanced to a point where
the presence of a ligamentum flavum is most reliable,
enabling successful access to the epidural space.
•  In patients with scoliosis, a paramedian approach from
the convex side may be more successful.
Hadzic_Ch22_p317-327.indd 327
327
1. Standring S (ed): Gray’s Anatomy: The Anatomical Basis of Clinical Practice,
40th ed. Churchill Livingston, Elsevier Health, 2008.
CHAPTER
CHAPTER 22
2. Hogan QH: Lumbar epidural anatomy. A new look by cryomicrotome
section. Anesthesiology 1991;75:767-775.
3. Scapinelli R: Morphological and functional changes of the lumbar spinous
processes in the elderly. Surg Radiol Anat 1989;11:129.
4. Aggarwal A, Kaur H, Batra YK, et al: Anatomic consideration of caudal
epidural space: A cadaver study. Clin Anat 2009;22:730.
5. Hogan QH: Epidural anatomy: New observations. Can J Anaesth 1998;
X
45:40.
6. Zarzur E: Anatomic studies of the human lumbar ligamentum flavum.
Anesth Analg 1984;63:499.
7. Yoon SP, Kim HJ, Choi YS: Anatomic variations of cervical and high
thoracic ligamentum flavum. Korean J Pain 2014;27:321.
8. Lirk P, Colvin J, Steger B, et al: Incidence of lower thoracic ligamentum
flavum midline gaps. Br J Anaesth 2005;94:852.
9. Lirk P, Kolbitsch C, Putz G, et al. Cervical and high thoracic ligamentum
flavum frequently fails to fuse in the midline. Anesthesiology 2003;
99:1387.
10. Reina MA, Lopez Garcia A, de Andres JA, Villanueva MC, Cortes L: Does
the subdural space exist? Rev Esp Anestesiol Reanim 1998;45:367.
11. Kostelic JK, Haughton VM, Sether LA: Lumbar spinal nerves in the
neural foramen: MR appearance. Radiology 1991;178:837.
12. MacDonald A, Chatrath P, Spector T, et al: Level of termination of the
spinal cord and the dural sac: A magnetic resonance study. Clin Anat
1999;12:149.
13. Schwab F, Dubey A, Gamez L, et al: Adult scoliosis: prevalence, SF-36,
and nutritional parameters in an elderly volunteer population. Spine
2005;30:1082.
14. McLeod A, Roche A, Fennelly M: Case series: Ultrasonography may assist
epidural insertion in scoliosis patients. Can J Anaesth 2005;52:717.
15. Aebi M: The adult scoliosis. Eur Spine J 2005;14:925.
16. Smith JS, Shaffrey CI, Fu KM, et al: Clinical and radiographic evaluation
of the adult spinal deformity patient. Neurosurg Clin N Am 2013;24:143.
17. White AA, Panjab MM: Clinical Biomechanics of the Spine, 2nd ed.
Lippincott, 1990.
18. Suzuki S, Yamamuro T, Shikata J, et al: Ultrasound measurement of
vertebral rotation in idiopathic scoliosis. J Bone Joint Surg Br 1989;71:252.
19. Glassman SD, Berven S, Bridwell K, et al: Correlation of radiographic
parameters and clinical symptoms in adult scoliosis. Spine 2005;30:682.
20. Bowens C, Dobie KH, Devin CJ, et al: An approach to neuraxial
anaesthesia for the severely scoliotic spine. Br J Anaesth 2013;111:807.
21. Huang J: Paramedian approach for neuraxial anesthesia in parturients
with scoliosis. Anesth Anal 2010;111:821.
22. Ko JY, Leffert LR: Clinical implications of neuraxial anesthesia in the
parturient with scoliosis. Anesth Analg 2009;09:1930.
23. Chin KJ, Perlas A, Chan V, et al: Ultrasound Imaging facilitates spinal
anesthesia in adults with difficult surface anatomic landmarks.
Anesthesiology 2001;115:94.
24. Chin KJ, Karmakar MK, Peng P: Ultrasonography of the adult thoracic
and lumbar spine for cetral neuraxial blockade. Anesthesiology 2011;
114:1459.
25. Chin KJ, MacFarlane AJR, Chan V, Brull R: The use of ultrasound to
facilitate spinal anesthesia in a patient with previous lumbar laminectomy
and fusion: A case report. J Clin Ultrasound 2009;37:482.
12/09/16 12:26 PM