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J Spine Surg. 2017 Mar;3(1):23-30. doi: 10.21037/jss.2017.02.06.

Factors predictive of topographical accuracy in spine level localization.

Tee JW1,2,3, Rutges J1,2,4, Marion T1,2, Street J1,2, Paquette S1,2, Ailon T1,2, Kwon BK1,2, Dvorak M1,2, Boyd M1,2.

Author information

University of British Columbia, Vancouver, BC, Canada.
Vancouver General Hospital, Vancouver, BC, Canada.
The Alfred Hospital, National Trauma Research Institute, Melbourne, VIC, Australia.
University Medical Center Utrecht, Utrecht, the Netherlands.



Pre-operative spine level localization by palpation of anatomical landmarks (ribs, spinous processes) in posterior approaches for surgeries from T4 to L2 is often inaccurate. This can lead to ineffective utilization of procedural time, increased radiation dose, potentially longer skin incision and wrong level surgery. Factors affecting topographical accuracy includes body mass index (BMI) of the patient, congenital or acquired deformity and knowledge of topographical anatomy.


All patients had the presumed location of their pathology marked on the skin using anatomical landmarks prior to application of the Target Tape® (Vancouver, BC, Canada) and verification using an anterior-posterior radiograph. Potential factors predictive of accurate pre-operative spine level localization such as age, gender, BMI, palpable deformity, pathology related interspinous distance (ISPD) and pathology related skin to spinous process distance were evaluated.


A prospective study was performed with 30 consecutive patients undergoing posterior spine surgery (T4 to L2). Accuracy of pathology related spine level localization using anatomical landmarks was only 40%. Pathology related ISPDs of more than 10 mm and palpable deformity was significantly correlated with successful determination of spine levels using anatomical landmarks.


This study showed that poor spine level localization using anatomical landmarks was associated with pathology related ISPDs of less than 10 mm. Conversely, patients with palpable spinal deformity have their levels easily localized.


Spine level localization; accuracy; anatomical landmarks; body mass index (BMI); efficiency; intercristal line; obesity; radiation; radiograph; topography

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

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