Applied epidural anatomy
Jonathan Richardson MD MRCP FRCA FIPP
Key points
Clinicians performing epidural
procedures should have a
good knowledge of the
relevant anatomy.
Radiological screening is
helpful for difficult epidural
entry.
Maximal neck flexion can
almost double the depth of
the cervical epidural space.
Spinal endoscopy adds
another dimension to epidural
catheterization. At present,
its main application is in
relation to the management
and diagnosis of chronic
radicular pain.
Jonathan Richardson MD MRCP FRCA
FIPP
Department of Anaesthetics
Bradford Royal Infirmary
Bradford
BD9 6RJ
Tel: 01274 364066
Fax: 01274 366548
E-mail: docjohnnyr@hotmail.com
(for correspondence)
Gerbrand J Groen MD PhD
Division of Perioperative and Emergency
Medicine
Department of Anaesthesiology and Pain
Treatment
University Medical Centre Utrecht
The Netherlands
98
Gerbrand J Groen MD PhD
Anatomy of the epidural space
Vertebral column
There are 24 individual vertebrae: seven cer-
vical, 12 thoracic and five lumbar. The five
(fused) sacral vertebrae and the coccyx (made
up of 35 rudimentary vertebrae) are not
always classed as being a part of the vertebral
column. Vertebral anatomy varies according to
each level. The atlas and the axis are highly
atypical and the first recognizably normal ver-
tebra is C3. Atlas and axis anatomy are relevant
to anaesthetists in that the odontoid process
(dens) of the axis should be closely applied
(23 mm) to the anterior arch of the atlas in
flexion and extension (the gap is filled with
cartilage). Rheumatoid arthritis and trauma
may affect this relationship and the ability to
recognize the relevant anatomy on lateral
radiographs is important.
From C3 downwards, the vertebrae
(although they vary) have a recognizable
anterior body, posterolateral pedicles (Latin
for little feet), transverse processes and pos-
terior laminae (thin layers), which fuse to
form the spinous processes. The spinal canal
enclosed within these structures is also known
as the epidural space, apart from the central
portion occupied by the dural sac and its con-
tents. The dura mater contains the arachnoid
mater. Between the arachnoid and the pia
mater, which is applied to the spinal cord, is
cerebrospinal fluid. As the vertebral column
grows, it leaves behind the spinal cord so that
by adulthood the cord ends at the lower border
of L1 (although this can vary by one vertebra).
The dural sac generally ends at the lower bor-
der of S2 below which it continues as the filum
terminale, a structure clearly and frequently
seen with spinal endoscopy. The dural sac
contains the anterior and posterior spinal
nerve roots, collectively know as the cauda
equina.
Spinal nerves
Spinal nerves exit at each level and are num-
bered according to the thoracic, lumbar or
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Table 1 Boundaries of the epidural space
Superiorly Fusion of the spinal and periosteal layers of
dura mater at the foramen magnum1
Inferiorly Sacrococcygeal membrane
Anteriorly Posterior longitudinal ligament, vertebral
bodies and discs
Laterally Pedicles and intervertebral foraminae
Posteriorly Ligamentum flavum, capsule of facet joints
and laminae
Table 2 Definition of the cervical, thoracic, lumbar and
sacral epidural spaces
Cervical Fusion of the spinal and periosteal layers of
dura mater at the foramen magnum1 to
lower margin of C7
Thoracic Lower margin of C7 to upper margin of L1
Lumbar Upper margin of L1 to upper margin of S1
Sacral Upper margin of S1 to sacrococcygeal
membrane
sacral vertebra above. As there are eight cer-
vical spinal nerves and seven vertebrae, the
nerves in this region only are numbered accord-
ing to the vertebra below. The only exception is
spinal nerve C8 that leaves between vertebra C7
and T1.
Epidural space
The boundaries of the epidural space are sum-
marized in Table 1 and the definitions of the
cervical, thoracic, lumbar and sacral regions
are defined in Table 2. The epidural space
contains fat, the dural sac, spinal nerves,
blood vessels and connective tissue (Table 3).
Blood supply
Inside the spinal canal there is an anterior and
posterior arterial (and venous) arcade formed
from the spinal arteries entering at each level
through the interventricular foramina. These
arise from the vertebral arteries superiorly
and then thoracic and the lumbar aorta.
They anastomose with the anterior spinal
artery, running on the surface of the spinal
cord arising initially from the vertebral arteries
at the circle of Willis. The nerve root (with the
doi 10.1093/bjaceaccp/mki026
 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
of the body.1 Not uniform in
distribution; exists in bands at level
of intervertebral foramina
Dural sac Ends at approximately S2. Contains
the spinal cord (to the lower border
of L1) and cauda equina
Spinal nerves In pairs. Dorsal root ganglia in
lateral recesses
Vessels See text
Connective tissue Variable dorsomedian folds, median
fold. After leakage of nucleus
pulposus, surgery or previous
epidural catheterization may be
heavy scar tissue
exception of the dorsal root ganglion) has a poor blood supply
compared with the spinal cord. There is a watershed area half way
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.
Venous drainage is via the valveless vertebral venous plexus of
Batson, which, fortunately for the epiduralist, is predominantly an
anterior spinal canal structure. The posterior venous plexus is
variable in size at the lumbar level but generally increases in the
thoracic and cervical areas.2 Drainage is into the intracranial
venous sinuses and, at a local level, into the thoracic and lumbar
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
iliac veins inferiorly or the hemiazygous or azygous veins on the
left and right, respectively. As the whole system is valveless,
increased intrathoracic or intra-abdominal pressure (e.g. ascites,
pregnancy) can lead to major congestion and vessel enlargement
within the spinal canal.
Nerve supply
The spinal canal and its contents have their own innervation. The
anterior dura is heavily innervated;2 fortunately for spinal anaes-
thesia, the posterior dura is sparsely supplied. The nerve supply of
the spinal canal is via direct branches from the sympathetic chain
and via the sinu-vertebral nerves that originate from the rami
communicantes. The periosteum is pain sensitive but the liga-
mentum flavum is not.
Cervical Loss of resistance poorly appreciated as the ligamentum flavum
is thin and soft.1 Hanging drop method in the sitting
position often employed. Depth of space
only 1.52 mm at C7.1
Increases to 34 mm with neck flexion.3 Should be performed
by the experienced practitioner only
Thorax Kyphotic apex at T6. Slight right scoliosis common and normal.
Avoid midline approach between T5T8
Lumbar Enter if possible below L2 to avoid the cord


Distance from ligamentum flavum to dura.
Table 5 Overview of methods of epidural entry
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
incorrectly placed without radiological guidance4
Direct vision Spinal endoscopy
Paravertebral Frequent epidural blockade5
Locating the epidural space
The standard methods of detection of entry into the epidural space
will not be discussed in detail here; they are covered in many
other texts. Some helpful suggestions are offered according to
the anatomical level of entry (Table 4). The various methods
are summarized in Table 5.
Pathology affecting epidural entry
Anatomical abnormalities affecting epidural catheterization are
either congenital or acquired. Congenital abnormalities that cause
difficulties include achondroplasia, congenital adolescent scoliosis
and spina bifida. The use of epidurals in achondroplasia and
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
with attendant ligamentum flavum abnormalities, epidural loca-
tion should not be attempted. Acquired difficulties include liga-
mentum flavum hypertrophy, often contributing to spinal
stenosis, foraminal stenosis and disc prolapse. The latter two
are not contraindications, but could make satisfactory entry or
catheterization difficult. X-ray guidance may be of help.
The effect of previous epidural catheterization, spinal level and
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
approaches. Nowadays, most epiduroscopy is carried out using
flexible instruments introduced through the sacrococcygeal route
providing a direct path to more cranial structures.
Spinal endoscopy is different from other imaging tech-
niques in that it has a major interactive element with the patient,
allowing examination of appropriate areas, which may be
causing pain. Examination of the contents of the dural sac is
easy as they are suspended in clear cerebro-spinal fluid. With
recent advances in instrumentation, especially involving fully
steerable, flexible instruments, along with a saline delivery system,
a multilevel detailed examination of the epidural space can be
satisfactorily achieved. High quality views aid the examiner in
exactly identifying the nerve roots that may be implicated in
pain generation.9 10
Conditions that have so far been diagnosed using this tech-
nique include: cysts and tumours, fibrosis, ischaemia and tethering
of nerve roots, arachnoiditis, tuberculosis meningitis and acute
and traumatic events associated with epidural catheterization.
10. Geurts JW, Kallewaard JW, Richardson J, Groen GJ. Targeted methylpred-
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100 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 3 2005