Applied epidural anatomy

Jonathan Richardson MD MRCP FRCA FIPP

Gerbrand J Groen MD PhD

Anatomy of the epidural space Table 1 Boundaries of the epidural space

Superiorly Fusion of the spinal and periosteal layers of

Key points Vertebral column dura mater at the foramen magnum1
Clinicians performing epidural Inferiorly Sacrococcygeal membrane
There are 24 individual vertebrae: seven cer- Anteriorly Posterior longitudinal ligament, vertebral
procedures should have a
vical, 12 thoracic and five lumbar. The five bodies and discs
good knowledge of the Laterally Pedicles and intervertebral foraminae
relevant anatomy. (fused) sacral vertebrae and the coccyx (made
Posteriorly Ligamentum flavum, capsule of facet joints
up of 35 rudimentary vertebrae) are not and laminae
Radiological screening is always classed as being a part of the vertebral
helpful for difficult epidural
column. Vertebral anatomy varies according to
entry.
each level. The atlas and the axis are highly
Maximal neck flexion can atypical and the first recognizably normal ver- Table 2 Definition of the cervical, thoracic, lumbar and
almost double the depth of sacral epidural spaces
tebra is C3. Atlas and axis anatomy are relevant
the cervical epidural space. Cervical Fusion of the spinal and periosteal layers of
to anaesthetists in that the odontoid process
Spinal endoscopy adds dura mater at the foramen magnum1 to
(dens) of the axis should be closely applied lower margin of C7
another dimension to epidural (23 mm) to the anterior arch of the atlas in Thoracic Lower margin of C7 to upper margin of L1
catheterization. At present, flexion and extension (the gap is filled with Lumbar Upper margin of L1 to upper margin of S1
its main application is in Sacral Upper margin of S1 to sacrococcygeal
cartilage). Rheumatoid arthritis and trauma membrane
relation to the management
and diagnosis of chronic may affect this relationship and the ability to
radicular pain. recognize the relevant anatomy on lateral
radiographs is important.
From C3 downwards, the vertebrae sacral vertebra above. As there are eight cer-
(although they vary) have a recognizable vical spinal nerves and seven vertebrae, the
anterior body, posterolateral pedicles (Latin nerves in this region only are numbered accord-
for little feet), transverse processes and pos- ing to the vertebra below. The only exception is
terior laminae (thin layers), which fuse to spinal nerve C8 that leaves between vertebra C7
form the spinous processes. The spinal canal and T1.
enclosed within these structures is also known
as the epidural space, apart from the central Epidural space
portion occupied by the dural sac and its con-
tents. The dura mater contains the arachnoid The boundaries of the epidural space are sum-
mater. Between the arachnoid and the pia marized in Table 1 and the definitions of the
mater, which is applied to the spinal cord, is cervical, thoracic, lumbar and sacral regions
cerebrospinal fluid. As the vertebral column are defined in Table 2. The epidural space
grows, it leaves behind the spinal cord so that contains fat, the dural sac, spinal nerves,
Jonathan Richardson MD MRCP FRCA by adulthood the cord ends at the lower border blood vessels and connective tissue (Table 3).
FIPP
of L1 (although this can vary by one vertebra).
Department of Anaesthetics
The dural sac generally ends at the lower bor-
Bradford Royal Infirmary Blood supply
Bradford der of S2 below which it continues as the filum
BD9 6RJ terminale, a structure clearly and frequently Inside the spinal canal there is an anterior and
Tel: 01274 364066 posterior arterial (and venous) arcade formed
Fax: 01274 366548 seen with spinal endoscopy. The dural sac
E-mail: docjohnnyr@hotmail.com contains the anterior and posterior spinal from the spinal arteries entering at each level
(for correspondence) nerve roots, collectively know as the cauda through the interventricular foramina. These
Gerbrand J Groen MD PhD equina. arise from the vertebral arteries superiorly
Division of Perioperative and Emergency and then thoracic and the lumbar aorta.
Medicine They anastomose with the anterior spinal
Department of Anaesthesiology and Pain Spinal nerves
artery, running on the surface of the spinal
Treatment
University Medical Centre Utrecht Spinal nerves exit at each level and are num- cord arising initially from the vertebral arteries
The Netherlands bered according to the thoracic, lumbar or at the circle of Willis. The nerve root (with the

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 Applied epidural anatomy

Table 3 Contents of the epidural space Table 4 Epidural space location according to vertebral level

Structure Comment Level Notes

Fat Varies in direct proportion to the rest Cervical Loss of resistance poorly appreciated as the ligamentum flavum
of the body.1 Not uniform in is thin and soft.1 Hanging drop method in the sitting
distribution; exists in bands at level position often employed. Depth of space
only 1.52 mm at C7.1
of intervertebral foramina Increases to 34 mm with neck flexion.3 Should be performed
Dural sac Ends at approximately S2. Contains by the experienced practitioner only
the spinal cord (to the lower border Thorax Kyphotic apex at T6. Slight right scoliosis common and normal.
of L1) and cauda equina Avoid midline approach between T5T8
Spinal nerves In pairs. Dorsal root ganglia in Lumbar Enter if possible below L2 to avoid the cord
lateral recesses


Vessels See text Distance from ligamentum flavum to dura.
Connective tissue Variable dorsomedian folds, median
fold. After leakage of nucleus
pulposus, surgery or previous
epidural catheterization may be Table 5 Overview of methods of epidural entry
heavy scar tissue Interlaminar The usual method. Loss of resistance methods. Can use
(transflaval) hanging drop or other techniques in the cervical region
Transforaminal Directs solution to the anterior epidural space. Radiological
guidance mandatory. Specialist use only
Transsacral Simple entry, aspiration and injection. Up to 40% in the adult
exception of the dorsal root ganglion) has a poor blood supply incorrectly placed without radiological guidance4
compared with the spinal cord. There is a watershed area half way Direct vision Spinal endoscopy
Paravertebral Frequent epidural blockade5
along its length where branches from the conus medullaris meet
the supply from the thoracic and lumbar arteries. Despite ana-
stomoses throughout the vertebral canal, arterial trauma can com-
promise the blood supply of the cord itself. Locating the epidural space
Venous drainage is via the valveless vertebral venous plexus of
Batson, which, fortunately for the epiduralist, is predominantly an The standard methods of detection of entry into the epidural space
anterior spinal canal structure. The posterior venous plexus is will not be discussed in detail here; they are covered in many
variable in size at the lumbar level but generally increases in the other texts. Some helpful suggestions are offered according to
thoracic and cervical areas.2 Drainage is into the intracranial the anatomical level of entry (Table 4). The various methods
venous sinuses and, at a local level, into the thoracic and lumbar are summarized in Table 5.
veins through the intervertebral foramina. The veins in the lumbar
area drain into the ascending lumbar veins lying on the anterior
surface of the transverse processes. These empty into either the Pathology affecting epidural entry
iliac veins inferiorly or the hemiazygous or azygous veins on the Anatomical abnormalities affecting epidural catheterization are
left and right, respectively. As the whole system is valveless, either congenital or acquired. Congenital abnormalities that cause
increased intrathoracic or intra-abdominal pressure (e.g. ascites, difficulties include achondroplasia, congenital adolescent scoliosis
pregnancy) can lead to major congestion and vessel enlargement and spina bifida. The use of epidurals in achondroplasia and
within the spinal canal. congenital adolescent scoliosis is controversial. As spina bifida
is frequently associated with a meningocoele, which may be
close to the surface, and with the failure of fusion of the laminae
Nerve supply with attendant ligamentum flavum abnormalities, epidural loca-
The spinal canal and its contents have their own innervation. The tion should not be attempted. Acquired difficulties include liga-
anterior dura is heavily innervated;2 fortunately for spinal anaes- mentum flavum hypertrophy, often contributing to spinal
thesia, the posterior dura is sparsely supplied. The nerve supply of stenosis, foraminal stenosis and disc prolapse. The latter two
the spinal canal is via direct branches from the sympathetic chain are not contraindications, but could make satisfactory entry or
and via the sinu-vertebral nerves that originate from the rami catheterization difficult. X-ray guidance may be of help.
communicantes. The periosteum is pain sensitive but the liga- The effect of previous epidural catheterization, spinal level and
mentum flavum is not. respiration on epidural space structures (as determined by epi-
duroscopy) is summarized in Table 6.

Lymphatics
Lymphatics are present around the region of the nerve root and
Epiduroscopy
function to remove foreign material. They are absent in the nerve Although receiving considerable recent attention, spinal endo-
root itself. scopy or epiduroscopy is not a new technique. It has been carried

Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 3 2005 99
Applied epidural anatomy

Table 6 The effect of previous epidural catheterization, spinal level and respiration on epidural space structures (from the work of Igarashi and colleagues68)

Structure No previous epidural catheterization Previous epidural entry Increasing age Cephalad Inspiration

Fat Segmental Less Less Less Drawn out through

intervertebral foraminae
Connective tissue Fragile median and Adhesions and No effect Less Nil
dorso-median folds granulation tissue
Vascularity Needle damage in 23% ND Nil ND Less
Patency Good Poor More More More

ND not determined.

out since the 1930s using rigid instruments and transflaval 2. Groen GJ, Baljet B, Drukker J. The innervation of the spinal dura mater.
Anatomy and clinical implications. Acta Neurochir (Wien) 1988; 92: 3946
approaches. Nowadays, most epiduroscopy is carried out using
3. Reynolds AF, Roberts PA, Pollay M, et al. Quantitative anatomy of the
flexible instruments introduced through the sacrococcygeal route
thoracolumbar epidural space. Neurosurgery 1985; 17: 905
providing a direct path to more cranial structures.
4. Renfrew DL, Moore TE, Kathol MH, el-Koury GY, Lemke JH, Walker CW.
Spinal endoscopy is different from other imaging tech- Correct placement of epidural steroid injections: fluoroscopic guidance
niques in that it has a major interactive element with the patient, and contrast administration. Am J Neuroradiol 1991; 12: 10037
allowing examination of appropriate areas, which may be 5. Richardson J, Lonnqvist PA. Thoracic paravertebral blockade. A review.
causing pain. Examination of the contents of the dural sac is Br J Anaesth 1998; 81: 2308
easy as they are suspended in clear cerebro-spinal fluid. With 6. Igarashi T, Hirabayashi Y, Shimizu R, Saitoh K, Fukuda H, Mitsuhata H. The
recent advances in instrumentation, especially involving fully lumbar extradural structure changes with increasing age. Br J Anaesth
1997; 78: 14952
steerable, flexible instruments, along with a saline delivery system,
7. Igarashi T, Hirabayashi Y, Shimizu R, Saitoh K, Fukuda H. Thoracic and
a multilevel detailed examination of the epidural space can be lumbar extradural structure examined by extraduroscope. Br J Anaesth
satisfactorily achieved. High quality views aid the examiner in 1998; 81: 1215
exactly identifying the nerve roots that may be implicated in 8. Igarashi T, Hirabayashi Y, Shimizu R, et al. Inflammatory changes after
pain generation.9 10 extradural anaesthesia may affect the spread of local anaesthetic within
Conditions that have so far been diagnosed using this tech- the extradural space. Br J Anaesth 1996; 77: 34751
nique include: cysts and tumours, fibrosis, ischaemia and tethering 9. Richardson J, McGurgan P, Cheema S, Prashad R. Gupta S. Spinal endoscopy
in chronic low-back pain with radiculopathy. A prospective case series.
of nerve roots, arachnoiditis, tuberculosis meningitis and acute
Anaesthesia 2001: 56; 44784
and traumatic events associated with epidural catheterization.
10. Geurts JW, Kallewaard JW, Richardson J, Groen GJ. Targeted methylpred-
nisolone/hyaluronidase/clonidine injection after diagnostic epiduroscopy
for chronic sciatica: a prospective, 1-year follow-up study. Reg Anesth Pain
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1. Bromage PR. Anatomy. In: Bromage PR, ed. Epidural Analgesia. Philadelphia:
WB Saunders, 1978; 820 See multiple choice questions 7880.

100 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 3 2005