title: Ultrasound assessment of the vertebral level of the intercristal line in pregnancy.
abstract: BACKGROUND
  The intercristal line is known to most frequently cross the L4 spinous process or L4-5 interspace; however, it is speculated to be positioned higher during pregnancy because of the exaggerated lumbar lordosis. Clinical estimation of vertebral levels relying on the use of the intercristal line has been shown to often be inaccurate. We hypothesized that the vertebral level of the intercristal line determined by palpation would be higher than the level determined by ultrasound in pregnant women.
  
  
  METHODS
  Fifty-one term pregnant patients were recruited. Two experienced anesthesiologists performed estimates of the position of the intercristal line by palpation. Using ultrasound, another anesthesiologist who was blinded to the clinical estimates, determined the position of the superior border of the iliac crest in the transverse and longitudinal planes and then identified the lumbar vertebral levels. The vertebral level at which the clinical estimates of the intercristal line crossed the spine was recorded and compared with the ultrasound-determined level of the superior border of the iliac crest.
  
  
  RESULTS
  The clinical estimates of the spinal level of the intercristal line agreed with the ultrasound measurement 14% of the time (14 of 101; 95% confidence interval [CI]: 8%, 22%). The clinical estimates were 1 level higher than the ultrasound measurement 23% of the time (23 of 101; 95% CI: 16%, 32%) and >1 level higher 25% of the time (25 of 101; 1-tailed 95% CI: >18%). The distribution of the clinical estimates found clinicians locating the intercristal line at L3 or L3-4 54% of the time (54 of 101; 95% CI: 44%, 63%) and at L2-3 or higher 27% of the time (27 of 101; 1-tailed 95% CI: >20%).
  
  
  CONCLUSIONS
  The anatomical position of the intercristal line was at L3 or higher in at least 6% of term pregnant patients using ultrasound. Clinical estimates were found to be ≥1 vertebral level higher than the anatomical position determined by ultrasound at least 40% of the time. This disparity may contribute to misidentification of lumbar interspaces and increased risk of neurologic injury during neuraxial anesthesia.
authors.affiliation: Department of Anesthesiology, University of Miami, Jackson Memorial Hospital, 1611 NW 12th Ave. (C-301), Miami, FL 33136, USA. alee@med.miami.edu
authors.forename: Allison J
authors.initials: AJ
authors.lastname: Lee
authors.forename: J Sudharma
authors.initials: JS
authors.lastname: Ranasinghe
authors.forename: Jules Marie
authors.initials: JM
authors.lastname: Chehade
authors.forename: Kris
authors.initials: K
authors.lastname: Arheart
authors.forename: Bruce S
authors.initials: BS
authors.lastname: Saltzman
authors.forename: Donald H
authors.initials: DH
authors.lastname: Penning
authors.forename: David J
authors.initials: DJ
authors.lastname: Birnbach
mesh_terms: D000328:Adult; D016362:Analgesia, Obstetrical / Q000009:adverse effects; D000773:Anesthesia, Obstetrical / Q000009:adverse effects; D005260:Female; D005431:Florida; D006801:Humans; D007085:Ilium / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D016014:Linear Models; D008159:Lumbar Vertebrae / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D015588:Observer Variation; D010173:Palpation; D056888:Patient Positioning; D011237:Predictive Value of Tests; D011247:Pregnancy; D015203:Reproducibility of Results; D014463:Ultrasonography; D055815:Young Adult