Shape of the thecal sac: L3/4 interspace compared with L4/5.

We retrospectively reviewed 60 normal magnetic resonance imaging scans to assess the anatomical shape of the thecal sac at the L3/4 and L4/5 vertebral interspaces. In all cases the thecal sac was oval at L3/4 but in 26 (43%; 95% CI 31-55%) the thecal sac changed from oval at the L3/4 interspace to triangular at L4/5 (with the apex of the triangle presenting to the posterior epidural space). We propose that this anatomical variant would make it more difficult to obtain cerebrospinal fluid at the lower level, as a slightly lateral approach could lead to identification of the epidural space but failure to puncture the thecal sac. This may offer an explanation for a 'dry tap' when a lower interspace is chosen.