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Original Article

Localization of L5–S1 Disc Space by Utilizing Simple on Table

Surface Marking in Posterior Lumbar Spine Surgery without
Any Radiological Assistance: An Observational Study
Acharya Suryakanta Pattajoshi, Tushar Ranjan Dalei1
Assistant Professor, Department of Neurosurgery, Veer Surendra Sai Institute of Medical Science and Research, Burla, Odisha, India, 1Assistant Professor, Department
of Orthopedics, Veer Surendra Sai Institute of Medical Science and Research, Burla, Odisha, India

Abstract
Background: Localization of the spinal levels is an important task during any spinal surgery. The purpose of the study is to assess the accuracy
and reliability in identifying L5–S1 disc space by surface localization using Venus of dimple as a landmark in posterior spinal surgery without
undertaking any radiological assistance. Methodology: We prospectively analyzed 39 patients, who had undergone primary posterior spine
surgery, especially for Prolapsed intervertebral disc mostly affecting the lumbosacral region. Following surface marking using Venus of dimple
as a landmark, patients were subjected to surgery with or without prior X‑ray evaluation solely on surface localization of L5–S1 disc space.
Intraoperatively, the accuracy and reliability of the surface marking were determined. Results: Sixty‑four percent of the patients had accurate
L5–S1 spine level localization utilizing the above clinical palpatory methods, while 23% of the cases identified L5 spine intraoperatively.
On analyzing this surface topographical method with that of X‑ray in standing position, the sensitivity and specificity came to be 93.3% and
49%, respectively, with a positive predictive value of 77.8%. Conclusion: The method of localization of L5–S1 space described although
cannot fully replace the role of fluoroscopic assistance during spinal surgery, still it is an important, simple, and reliable alternative method of
localization which demands its application by the spine surgeons, especially in the beginning of their carrier and in certain specific situations.

Keywords: Dimple of Venus, surface landmark, L5–S1 disc space

Introduction affected by depth differences of subcutaneous adiposity or

thickness of thoracolumbar musculature mostly seen in females
Accurate identification of spinal levels is a prerequisite for the
and patients with higher body mass indices.[4] Similarly,
success and safety of any spinal surgery. Ability to consistently
palpation of the posterosuperior iliac spine (PSIS) although
identify a spinal level not only improves the palpation
passes in between S1 and S2 vertebral foramen, still studies
reliability, but it also helps in patient care and treatment
have yet to be carried out to confirm its reliability as a surface
effectiveness. Radiographic identification of the spinal level
marker for determining spinal level in thoracolumbar surgery.[5]
is always more accurate than palpation of surface anatomical
Wrong localization or failure to localize during surgery not
landmarks, however, the use of a radiograph for localization of
only increases the anxiety of spine surgeons in the beginning of
the spinal axis not only exposes the patient radiation hazards
but also imperative to operating room staffs.
Address for correspondence: Dr. Tushar Ranjan Dalei,
Localization by palpation method using the intercristal line Quarter No. 3R/24 (Third Line), Doctor’s Colony, Veer Surendra Sai
Institute of Medical Science and Research, Burla, Sambalpur ‑ 768 017,
(Tuffier’s line) is not always dependable though it crosses Odisha, India.
the spinal level with a maximal incidence at the L4 spinous E‑mail: tusardalei@gmail.com
process but varies from the L5–S1 interspace to the L3–L4
interspace.[1] This method is also limited by the technical Submitted: 13‑Aug‑2021 Revised: 22-Oct-2021
Accepted: 03‑Nov‑2021 Published: 01-Feb-2022
difficulty associated with manually palpating the iliac crest.[2,3]
The accuracy and reproducibility of this method are usually
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How to cite this article: Pattajoshi AS, Dalei TR. Localization of L5–S1
DOI: disc space by utilizing simple on table surface marking in posterior lumbar
10.4103/NJCA.NJCA_104_21 spine surgery without any radiological assistance: An observational study.
Natl J Clin Anat 2022;11:5-9.

© 2022 National Journal of Clinical Anatomy | Published by Wolters Kluwer - Medknow 5

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Pattajoshi and Dalei: Surface marking of L5–S1 disc space in posterior lumbar spine surgery
their carrier but also responsible for decreasing the confidence
of patients over the treating surgeon, which may invite legal
consequences in future. Thus, a spine surgeon should be well
acquainted with the localizing methods in various ways to
avoid such complications.
At present, there is a paucity of literatures regarding the
prediction of accurate spine level localization in the posterior
approach of lumbosacral spine surgery. This study is based
on two objectives. The first one is to determine whether using
the dimple of Venus as a surface landmark can predict L5–S1
disc space more accurately in a uniform manner. The second
one is the applicability of this method in posterior spinal
surgery without undertaking any radiological assistance.
Overall, it introduces a novel localization method for posterior
lumbosacral spine surgery.
Materials and Methods
Study population
The study was conducted between 2019 April and 2020
October. A total 39 adult patients (24 males) undergoing
primary posterior spine surgery, especially for prolapsed
intervertebral disc (PIVD) affecting L4/L5 or L5–S1 space,
were included in the study. Those having prior surgery at the
same site, severe scoliosis, marked lumbar spinal deformity, or
those with a lumbosacral area that was too painful for palpation
were excluded from the study.
Description of the localization method
The sacral dimple of Venus (corresponds to the posterior
superior iliac spine, also called beauty dimples) is marked
on either side with a skin marker [Figure 1] when the patient
is in prone position. These are the paramedian soft‑tissue
indentations in the region of the lateral sacrum to represent
the location of PSIS [Figure 2].[6,7] These two points are joined
by a horizontal line (inter‑dimple line). This line is generally
over the proximal sacrum around S1 or S2 vertebra.[8] Another
vertical line is drawn in the middle of the back (posterior
median furrow) to join with this inter‑dimple line. Two
tangential lines are drawn from each dimple of Venus at a 15°
angle to inter‑dimple line toward the vertical line over the
posterior median furrow. The point of intersection of these
two angled lines with that of a vertical line corresponds to the
L5–S1 space is marked with skin marker. The adjacent levels
are delineated with this point as reference and surgical incision
site is determined.
All these localization methods were performed by two
investigators and subsequently cross‑checked by another
observer to avoid inter‑observer bias and to maintain the
reliability and accuracy of the procedure.
Pre-operative X-ray imaging
A pre-operative lumbar spine X-ray imaging both in standing
and supine position with a radiopaque marker attached to the
anatomical landmarks to identify the L5-S1 disc space was
undertaken in 22 patients selected as per convenience of the
6 National Journal of Clinical Anatomy  ¦  Volume 11  ¦  Issue 1  ¦  January-March 2022
Figure 1: The method of localization corresponding to L5–S1 disc space
taking Venus of dimple as a surface landmark
researchers. Accuracy of X-ray marking is compared with
intraoperative findings. Lumbosacral anteroposterior view
radiographs were examined by another investigator who was
blinded to the localization method [Figure 3]. We analyzed these
X‑rays to see if there were any differences in the standing and
supine postures of the patients.
Surgical procedure
In all 39 patients, the L5-S1 space is identified completely
on the regional topographical anatomical landmarks,
and accuracy was checked intraoperatively. All patients
underwent discectomy. Intraoperative disc space was
confirmed either by extending the incision caudally and
finding no disc space at the level of S1–S2 vertebrae or by
evidence of a bulging disc at L5–S1 level. The level was
also be confirmed by direct visualization of crossing fibers
of the thoracolumbar fascia, that usually begins below the
level of L5–S1 disc space. In doubtful cases, the level was
confirmed using fluoroscopy.
Statistical analysis
All statistical analysis was performed utilizing the Statistical
Package for the Social Sciences version 16 (Chicago, Illinois,
USA). Statistical significance value was accepted to be
P < 0.05. The continuous variables were expressed in mean and
standard deviation as descriptive statistics, whereas categorical
variables were expressed in frequency and related percentage
values. The Chi‑square test was used to compare accuracies
between different methods.
Results
Mean and standard deviation values at assessment were; age,
45.56±11.075  years, 61.5% comprising male gender. The
primary pathologies affecting the majority of patients were disc
prolapsed with 41% at L4–L5 followed by 20.5% at L5–S1
level. Multilevel disc involvement was seen in 30.7% of the
cases [Table 1].
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Pattajoshi and Dalei: Surface marking of L5–S1 disc space in posterior lumbar spine surgery
Twenty‑two patients were subjected to preoperative
localization X‑rays to test the validity of the localization
method described above. We analyzed these X‑rays to see if
there were any differences in the standing and supine postures
of the patients. Around 73% of the patients were found to have
exact localization of the marker near the L5–S1 space in the
anteroposterior view taken in the standing position whereas
it corresponded to 27% in the supine position [Figure 4]. On
analyzing this topographical localization method by doing
X‑ray in standing position, the sensitivity came to be 93.3%,
with a positive predictive value of 77.8% [Table 2]. Thus, the
positioning of the patient during X‑ray does affect the accuracy
of localization. This difference was statistically significant
with P = 0.003.
Table 3 shows the accuracy of spine level localization
intraoperatively using the knowledge of topographical
anatomy. Sixty‑four percent of the patients had accurate L5–S1
spine level localization utilizing the above clinical palpatory
methods, while 23% of the cases identified L5 spine [Figure 5].
Figure 2: Venus of dimple corresponds to posterior superior iliac spine
(Source; Osteology Section of Anatomy Department of the institution
with permission)
Figure 4: A graph representing the difference in supine and standing
posture radiographs. Twenty-two patients who had X-rays in both
postures; standing position more consistently represents L5–S1 level
National Journal of Clinical Anatomy  ¦  Volume 11 ¦ Issue 1 ¦ January-March 2022
On analyzing this result with that of X‑rays in standing posture,
the P value was 0.49, showing that this method is reproducing
consistent and similar results both intraoperatively and X‑rays
in standing posture. However, when compared to X‑ray in
supine posture, the P value is 0.0057 (significant), indicating
that consistent results are produced only intraoperatively.
Intraoperatively, no difficulty was encountered in identifying
the desired level by this localization method in these patients
after their positioning in jackknife position, which facilitates
the palpation of disc space more accurately with tip of the
thumb.
Intraoperative fluoroscopy assistance was taken in 30.7% of
the cases, especially those presenting disc prolapse at a higher
level, likely L2–L3 level, and in some cases of multilevel
disc prolapse for double confirmation of the level. Neither the
disc space was missed nor was any intraoperative assistance
of fluoroscopy required, especially when surgery was done
for L4–L5/L5–S1 disc space. Irrespective of the preoperative
Figure 3: Marker X-ray of a patient in standing posture corresponds to
L5–S1 disc space (middle one)
Figure 5: A graph representing the accuracy of spine level localization
intraoperatively using knowledge of topographical anatomy
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Pattajoshi and Dalei: Surface marking of L5–S1 disc space in posterior lumbar spine surgery

of the practice of lumbar spinal surgery by the author.

Table 1: Demographic and spine‑specific metrics of study
Although intraoperative localization by fluoroscopy is well
cohort
accepted and widely practiced, still there is every chance of
Study variables Baseline metrics wrong‑level spine surgeries and unintended level of exposure.
Age, mean±SD (years) 45.56±11.075 A systematic review by Devine et al. listed the incidence of
Sex (%) wrong‑level spine surgeries in the literature ranging from 0.09
Male gender 61.5 to 4.5/10,000 surgeries.[9] Similarly, unintended level exposure
Prolapse disc level (%) has been reported to occur in anywhere from 1.3% to 15%
L2–L3 7.6 of the cases.[10] Few recent studies have claimed that there is
L3–L4 0 significant improvement in the incidence of these errors by
L4–L5 41
adhering to the universal protocol; the following consensus
L5–S1 20.5
derived best practice guideline or modifying intraoperative
Multilevel 30.7
imaging techniques. [11‑13] However, failure to obtain or
Preoperative radiographs using marker (%)
difficulty in obtaining intraoperative radiographic images is
Both standing and supine postures 22 (56.4)
Intraoperative fluoroscopy assistance (%) 30.7
one of the important causes of wrong‑level spine surgery.[10,14]
SD: Standard deviation Sometimes, the use of imaging technique is not feasible due to
various reasons during surgery such as machinery problems,
absence of technician, electric failure, and so on. Therefore,
Table 2: Surface marking method more consistently the search for an alternative reliable method of localizing
reproducing results with X‑ray in standing position the lower spinal level has led to finding out these regional
X‑ray in X‑ray in anatomical surface markings which are helpful in localizing
standing (%) supine (%) the L5–S1 space.
Sensitivity 93 67 Although Tuffier’s line is used widely as a landmark for
Specificity 49 8 rapid spinal level identification, its range varies from L3–
Positive predictive value 78 33
L4 interspace to L5–S1 interspace.[1] Broadbent et  al.,[2]
Negative predictive value 75 25
Furness et al.,[3] and Kim et al.[15] have identified the correct
spinal levels only in 29%, 30%, and 36% of the cases using
the iliac crest as an anatomical landmark. The accuracy
Table 3: Intraoperative accuracy of spine level
and reproducibility of this clinical palpation method are
localization using knowledge of topographical anatomy
especially affected in the case of females and in patients
Level of spine Male Female Total (%) with higher body mass index due to the difference in the
L4 1 0 2.56 thickness of subcutaneous adiposity and thoracolumbar
L4–L5 2 2 10.26 musculature. [4] By using PSIS as a surface marker,
L5 4 5 23 O’Haire[16] suggested that the use of PSIS might reduce
L5–S1 17 15 64.1 inter‑examiner discrepancy more successfully compared
S1 0 0 0
to the use of the iliac crest method. Similar result was also
shown by Kim et al.,[15] however, they found discrepancies
localization result through X ray, on table surface marking after between each examiner which varied up to 2.5 cm in few
proper positioning over Wilson’s framefollowing anesthesia cases. They had a conclusion that PSIS palpation is prone
was proved to be more accurate without any fail in overall cases. to substantial inaccuracies as it is located at variable points
on surface palpation. McGaugh et  al. [17] suggested that
PSIS reference line might be used to find S2 as a standard
Discussion reference in both static and dynamic palpation in the lower
The incidence of degenerative diseases of the spinal column lumbar spine.
is in an increasing trend due to the change in current lifestyle.
Excess bike driving, jerky lifting of heavyweight, inadequate Considering the above facts, here we have taken the dimple
water intake, bad posture, smoking, and several other risk of Venus as a surface landmark. The sacral dimples that mark
factors have led to an increase in the incidence of lumbar the position of the posterior superior iliac spine are level with
disc disease. An inadequate precaution after the degenerative the S2 vertebral spinous process.[6] It is more prominent in thin
process has started, predisposes disc prolapse and nerve root individuals and well palpated in obese persons just above the
gluteal cleft. Clinically, it can be made prominent by asking
compression. Few of these patients require surgery due to
the patient to stand and to contract the gluteal muscles. An
persistent symptoms and/or progressive neurological deficits
imaginary line joining both dimples usually passes over the
despite a trial of conservative treatment.
spinous process of the S2 vertebra. Thus far, the clinical
The method described here has been evolved from problems application is concerned; they are frequently used as a guide to
aroused while dealing with spinal cases in the beginning place the sacral pedicle screws in spinal surgery. The method

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Pattajoshi and Dalei: Surface marking of L5–S1 disc space in posterior lumbar spine surgery
described here is another new application of this dimple of
Venus in spinal surgery.
This study revealed 63% accuracy of L5–S1 disc space
localization followed by 23% for L5 spinous process
intraoperatively. The inaccuracy was not detrimental to the
patients as the level was subsequently confirmed either by
extending the incision to identify no disc space available in S1–
S2 vertebral level or in a few cases with the help of fluoroscopy.
Preoperative localization X rays in standing posture more
consistently identified L5–S1 disc space compared to supine
posture (P = 0.003) indicating the position of the patients
influencing the landmark on palpation. McGaugh et  al.[17]
reported that lack of axial load in the supine position could
affect the relationship between the identified reference line
and its corresponding spinous process. Similarly, other
available evidences have demonstrated that change in position
of legs affecting the amount of lumbar lordosis, thereby
altering the reference line–spine relationship with lumbar
flexion.[18‑20] However, intraoperatively, no such difficulties
were encountered on the OT table as jackknife positioning
in lumbar disc surgery facilitates the palpation of disc space
more consistently with the tip of the thumb after locating the
described points.
Factors leading to increased accuracy or misidentification
of pathology related to the spinal level were not considered
in the present study. Tee et  al. identified seven potential
predictive variables of thoracolumbar spine localization
such as age, sex, and adiposity.[21] Despite this limitation,
this study is of value because in this method of localization
we were able to identify L5–S1 disc space more accurately;
simultaneously, it potentially decreases the radiation dose to
both patients as well as to the surgical team intraoperatively.
However, spinal level estimation by palpation could be
influenced by the clinician’s skill, patient’s body size, and
anatomical variations.
Even this short‑term study with small sample size consistently
shows the above‑described method for identification of L5–S1
disc space, still generalization of the results for use in clinical
practice is restricted and requires further investigation.
Conclusion
The the surface marking method method described here
accurately localizes L5-S1disc space in 64% cases and L5 spine
in 23% cases. So from clinical stand point overall accuracy
is 87%. Although it cannot replace the role of radiological
assistance in localization during lumbar spine surgery still it is
an important alternative for any spine surgeon in the beginning
of their career and in certain specific situations.
Acknowledgment
The authors acknowledge Dr.  Rashmi Das Q. No  3R/24,
VIMSAR Doctor Colony, for providing Figure  1 in the
manuscript. Figure 2 has been taken from the Osteology Section
of the Anatomy Department of the institution with permission.
National Journal of Clinical Anatomy  ¦  Volume 11 ¦ Issue 1 ¦ January-March 2022
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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