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Vertebral Level Identification

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Comparison of Classic vs. Updated Vertebral Level Identification
Landmark/Feature Palpation Technique Classic View/Level Updated View/Level & Key Evidence/Variability Notes/Clinical Significance of Update
CERVICAL SPINE
C1 Transverse Process (TVP) Lies just below and anterior to the mastoid (behind the angle of the jaw). C1 Can be quite accurate[1]: expansive accuracy ~90.5%; stringent Ā±4mm accuracy ~57%). Accuracy is technique-dependent. Study data from young, asymptomatic individuals.
Angle of Mandible Self explanatory C2 vertebral body Highly consistent landmark, reliable even with slight neck extension.[2]
Hyoid Bone Felt high in neck in neutral posture. C3 vertebral body Most commonly at C3 or C2ā€“C3 intervertebral disc (IVD)[3][2] neck extension study: C2/C3 disc 51.7%). Range can be C1ā€“C2 to C4ā€“C5. Variable. Neck position significantly influences apparent vertebral level. Angle of mandible considered more reliable for C2.
Thyroid Cartilage (Superior border) Laryngeal prominence C4 vertebral body or C4ā€“C5 IVD Superior border often at C4 (women ~60%), C4/C5 (men ~36%)[4]. Inferior border often at C5. With neck extension, superior border at C4 body in ~42%. Variable; depends on whether superior or inferior border is palpated and on neck position. In neck extension it shifts higher.
Cricoid Cartilage Can palpate the C6 anterior tubercle deep in the neck in neutral posture. C6 vertebral body Generally at C6, but can correspond to C5/C6 IVD, especially with neck extension (~43% in one study[2]). Neck extension moves the cricoid slightly upward.
Vertebra Prominens (VP) Most prominent spinous process at base of neck, and still most prominent with flexion-extension test. Spinous process (SP) of C7 (most prominent) Frequently C6 SP (esp. females), C5 SP, or T1 SP. C7 is VP in <50% of individuals[5] (C7 48.7%, C6 35.9%). Motion palpation for C7 SP: ~55ā€“72% accurate[6][7] High risk of misidentification if relying solely on "most prominent." Errors propagate when counting. Flexion-extension maneuver is more reliable than static palpation.
THORACIC SPINE
Superior Angle of Scapula Upper medial corner of scapula. T2 SP or T1/T2 interspace Generally corresponds to T2. Arm position can influence. Less extensively studied for variability compared to inferior angle. Patient should be relaxed with arms at their sides for consistency.
Suprasternal (Jugular) Notch T2-3 disc level This landmark is bony and fairly consistent. In extreme neck extension the notch may align slightly lower relative to the spine
Spine of Scapula The medial end (root) of the scapula spine T3 spinous process Arms by side
Sternal Angle (Angle of Louis) T4/T5 IVD and attachment of 2nd ribs Highly variable. Corresponds to levels ranging from T2 to T6 in imaging studies. Often found at T5 body or lower, or even T3 ([8]; inferior to T4ā€“5 IVD in ~65%).[9] Unreliable for precise localization of the T4/T5 IVD posteriorly. But consistent anteriorly for rib counting.
Inferior Angle of Scapula (IAS) T7 SP Highly unreliable for T7, range is T4-T11, but T7-9 is the most common.[10] Most often corresponds to T8 SP (~30%) or T8/T9 IVD (~26%)[11]. T7 only ~12%. Level tends to descend with age and varies with sex (males often T8, females T8/9). Neither IAS nor counting down from C7 are accurate in patients with BMI over 25.[12] Using IAS for T7 leads to frequent errors. Counting down from a correctly identified C7 (itself challenging) is more accurate for thoracic levels (29% with counting down vs 10% without counting down). Allowing for a margin of error of 1 level the accuracy improves to 78% with counting down. Ultrasound can improve localization.
Xiphisternal Joint T9 vertebral body Most commonly at T9 (e.g. ~31%), or T8/T9 IVD (~19%). The tip extends to about T10. May vary with sex (higher in women, lower in men).[13] Some inter-individual variability.
12th Rib The lowest ribs attach to T12 T12 In some individuals the 12th ribs are short, also the level of the waist indent in an average build, so use cautiously.
LUMBAR SPINE
Umbilicus L3 vertebral body or L3/L4 IVD Highly variable. CT study most frequently aligns with L4 body.[14] No strong correlation with height, weight, BMI, sex, or race. Very unreliable as a landmark for precise vertebral level identification.
Iliac Crest (Tuffierā€™s Line / Intercristal Line) L4 SP or L4/L5 IVD (imaging) Palpated line consistently identifies a higher level (L3 or L3/4 IVD)[15]. Discrepancy increases with BMI, more pronounced in females. Can overestimate by 1ā€“3 levels. Critical discrepancy for spinal procedures. Palpation alone is unreliable; risk of targeting too high.
Iliac Tubercles The line connecting the prominent tubercles of the iliac crests (slightly anterior to the highest crest point) is the transtubercular plane L5 Some sources place at L5 or L4/5.
SACRAL SPINE
Posterior Superior Iliac Spine (PSIS) The back dimples Dimples overly PSIS at S2. Line connecting PSISs crosses S2 SP. Unreliable for precise S2 localization. Palpated PSIS line identified S2 in only ~51%, and S1 in ~44%[15]. Range L5ā€“S3. Poor inter-examiner reliability. High variability makes this an unreliable landmark for S2.
Natal Cleft (Superior end) Begins near S3 SP. Coccyx in floor of lower cleft. A general landmark. Detailed variability for precise vertebral identification not extensively quantified in comparative studies. Useful for general orientation of the sacrococcygeal region.
Sacral Hiatus Opening at inferior end of sacral canal, located by palpating cornua just above gluteal crease S4 SP or between S4-5 Very unreliable in overweight and obesity.

References

  1. ā†‘ Cooperstein, Robert; Young, Morgan; Lew, Makani (2015 Jun). "Validity of palpation of the C1 transverse process: comparison with a radiographic reference standard". The Journal of the Canadian Chiropractic Association (in English). 59 (2): 91. PMC 4486993. PMID 26136601. Check date values in: |date= (help)CS1 maint: PMC format (link)
  2. ā†‘ 2.0 2.1 2.2 Siribumrungwong, Koopong; Sinchai, Chitpon; Tangtrakulwanich, Boonsin; Chaiyamongkol, Weera (2018 Feb 7). "Reliability and Accuracy of Palpable Anterior Neck Landmarks for the Identification of Cervical Spinal Levels". Asian Spine Journal (in English). 12 (1): 80. doi:10.4184/asj.2018.12.1.80. PMC 5821937. PMID 29503686. Check date values in: |date= (help)CS1 maint: PMC format (link)
  3. ā†‘ DURSUN AYAZOĞLU AYYILDIZ Yadigar KASTAMONÄ° ƖZTƜRK Soner ALBAY; Dursun, Ahmet; Ayazoğlu, Mehtap; Ayyıldız, Veysel Atilla; Kastamoni, Yadigar; ƖztĆ¼rk, Kenan; Albay, Soner (2021-04-01). "Morphometry of the hyoid bone: a radiological anatomy study". Anatomy. 15 (1): 44ā€“51. doi:10.2399/ana.21.827696.
  4. ā†‘ Yan, Ying-zhao; Huang, Chong-an; Jiang, Qi; Yang, Yi; Lin, Jian; Wang, Ke; Li, Xiao-bin; Zheng, Hai-hua; Wang, Xiang-yang (2018 Feb 8). "Normal radiological anatomy of thyroid cartilage in 600 Chinese individuals: implications for anterior cervical spine surgery". Journal of Orthopaedic Surgery and Research (in English). 13: 31. doi:10.1186/s13018-018-0728-y. PMC 5806376. PMID 29422105. Check date values in: |date= (help)CS1 maint: PMC format (link)
  5. ā†‘ Totlis, Trifon; Sammer, Andreas; Piagkou, Maria; Natsis, Konstantinos; Emfietzis, Panagiotis-Konstantinos; Karageorgos, Filippos; Tsakotos, George; Triantafyllou, George; Feigl, Georg (2024-09-30). "Variability in the projection level of the vertebra prominens: a cadaveric study". Anatomy & Cell Biology (in English). 57 (3): 378ā€“383. doi:10.5115/acb.24.061. ISSN 2093-3665. PMC 11424568. PMID 38916082.CS1 maint: PMC format (link)
  6. ā†‘ PĆ³voa, Luciana C.; Ferreira, Ana P.A.; Zanier, JosĆ© F.C.; Silva, Julio G. (2018-03). "Accuracy of Motion Palpation Flexion-Extension Test in Identifying the Seventh Cervical Spinal Process". Journal of Chiropractic Medicine (in English). 17 (1): 22ā€“29. doi:10.1016/j.jcm.2017.11.005. PMC 5883892. PMID 29628805. Check date values in: |date= (help)CS1 maint: PMC format (link)
  7. ā†‘ https://www.researchgate.net/publication/322364701_The_accuracy_of_C7th_spinous_process_identification_using_ultrasound_transverse_scan_and_parasagittal_scan_compared_to_palpation_technique
  8. ā†‘ Arora, V.K.; Singh, Vishram (2013-12). "Sternal angle revisited ā€“ From anatomy to radiology". Journal of the Anatomical Society of India. 62 (2): 95ā€“97. doi:10.1016/j.jasi.2013.12.008. ISSN 0003-2778. Check date values in: |date= (help)
  9. ā†‘ Kumar, Gattu (2018). "Evaluation of Topographic Anatomy of Sternal Angle by Magnetic Resonance Imaging: An Institutional Based Study". International Journal of Medical Research Professionals. doi:10.21276/ijmrp. line feed character in |title= at position 63 (help)
  10. ā†‘ Cooperstein, Robert; Haneline, Michael; Young, Morgan (2015-02-27). "The location of the inferior angle of the scapula in relation to the spine in the upright position: a systematic review of the literature and meta-analysis". Chiropractic & Manual Therapies. 23 (1). doi:10.1186/s12998-014-0050-7. ISSN 2045-709X.
  11. ā†‘ O'Donoghue, A. N.; Doran, S. (2025-02-20). "Questioning the anatomical relationship between the seventh thoracic vertebra and the inferior angle of scapula: a radiographic review to inform anaesthesia practice". Irish Medical Journal. 118 (2): 23. ISSN 0332-3102. PMID 40008586.
  12. ā†‘ Teoh, Desiree A.; Santosham, Kristi L.; Lydell, Carmen C.; Smith, Dean F.; Beriault, Michael T. (2009-05). "Surface Anatomy as a Guide to Vertebral Level for Thoracic Epidural Placement". Anesthesia & Analgesia (in English). 108 (5): 1705ā€“1707. doi:10.1213/ane.0b013e31819cd8a3. ISSN 0003-2999. Check date values in: |date= (help)
  13. ā†‘ Shen, Xinā€Hua; Su, Baiā€Yan; Liu, Jingā€Juan; Zhang, Guā€Muyang; Xue, Huaā€Dan; Jin, Zhengā€Yu; Mirjalili, S. Ali; Ma, Chao (2016-03). "A reappraisal of adult thoracic and abdominal surface anatomy via CT scan in Chinese population". Clinical Anatomy (in English). 29 (2): 165ā€“174. doi:10.1002/ca.22556. ISSN 0897-3806. Check date values in: |date= (help)
  14. ā†‘ Shin, David; Nguyen, Kai; Small, Easton; Case, Trevor; Kricfalusi, Mikayla; Bouterse, Alexander; Cabrera, Andrew; Purnell, Ethan; Laguerre, Wheddy; Razzouk, Jacob; Ramos, Omar (2024-12). "Are the Umbilicus and Iliac Crests Truly at the Level of L4 to L5? A Computed Tomography-Based Study of Surface Anatomy of the Anterior Lumbar Spine". International Journal of Spine Surgery (in English). 18 (6): 660ā€“666. doi:10.14444/8651. ISSN 2211-4599. PMC 11687033. PMID 39326928. Check date values in: |date= (help)CS1 maint: PMC format (link)
  15. ā†‘ 15.0 15.1 Chakraverty, Robin; Pynsent, Paul; Isaacs, Karen (2007 Feb). "Which spinal levels are identified by palpation of the iliac crests and the posterior superior iliac spines?". Journal of Anatomy (in English). 210 (2): 232. doi:10.1111/j.1469-7580.2006.00686.x. PMC 2100271. PMID 17261142. Check date values in: |date= (help)CS1 maint: PMC format (link)
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