title: Incidence of lower thoracic ligamentum flavum midline gaps.
abstract: BACKGROUND
  Lower thoracic epidural anaesthesia and analgesia (EDA) has gained increasing importance in perioperative pain therapy. The loss-of-resistance technique used to identify the epidural space is thought to rely on the penetration of the ligamentum flavum. Investigations at the cervical and lumbar regions have demonstrated that the ligamentum flavum frequently exhibits incomplete fusion at different vertebral levels. Therefore, the aim of this study was to directly investigate the incidence of lower thoracic ligamentum flavum midline gaps in embalmed cadavers.
  
  
  METHODS
  Vertebral column specimens were obtained from 47 human cadavers. Ligamentum flavum midline gaps were recorded between the vertebral levels T6 and L1.
  
  
  RESULTS
  The incidence of midline gaps/number of viable specimens at the following levels was: T6-7: 2/45 (4.4%), T7-8: 1/47 (2.1%), T8-9: 2/45 (4.4%), T9-10: 7/39 (17.9%), T10-11: 12/34 (35.2%), T11-12: 10/35 (28.5%), T12/L1: 6/38 (15.8%).
  
  
  CONCLUSIONS
  In the present study we have determined the frequency of lower thoracic ligamentum flavum midline gaps. Gaps are less frequent than at cervical levels, but more frequent than at lumbar levels. Peak incidence was found in the region between T10 and T12. Using a strict midline approach, one cannot therefore rely on the ligamentum flavum to impede entering the epidural space in all patients.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria. philipp.lirk@uibk.ac.at
authors.forename: P
authors.initials: P
authors.lastname: Lirk
authors.forename: J
authors.initials: J
authors.lastname: Colvin
authors.forename: B
authors.initials: B
authors.lastname: Steger
authors.forename: H-P
authors.initials: HP
authors.lastname: Colvin
authors.forename: C
authors.initials: C
authors.lastname: Keller
authors.forename: J
authors.initials: J
authors.lastname: Rieder
authors.forename: C
authors.initials: C
authors.lastname: Kolbitsch
authors.forename: B
authors.initials: B
authors.lastname: Moriggl
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural / Q000379:methods*; D000767:Anesthesia, Epidural / Q000379:methods*; D006801:Humans; D017843:Ligamentum Flavum / Q000033:anatomy & histology*; D008159:Lumbar Vertebrae / Q000033:anatomy & histology; D008875:Middle Aged; D013904:Thoracic Vertebrae / Q000033:anatomy & histology*