On the Fabric of the Human Body and Modern
Ultrasound Imaging
Christopher J. Gilligan, M.D., James P. Rathmell, M.D.
A
ndreas Vesalius1 (1514–
1564), Professor of Anatomy
at the University of Padua, Imperial Physician to Holy Roman
Emperor Charles V, and author
of the seven-volume De Humani
Corporis Fabrica (On the Fabric
of the Human Body), is noted
for his hands-on direct observation of human anatomy and the
meticulous drawings of his work
he prepared for his students. In the
current era of genomics and proteomics, the study of basic human
anatomy may seem antiquated
and unimportant. However, for
interventional pain treatments,
precise understanding of the relevant anatomy remains the foundation for safety and effectiveness.
In the field of pain medicine, the
present-day physician and anatomist Nikolai Bogduk, M.D.,
Ph.D. (Professor, University of
Newcastle, Newcastle, Australia)
advanced our knowledge of the
sensory innervation of the vertebral column and then built
on that work to demonstrate the safe and effective use of
radiofrequency treatment for spinal pain.2 Our knowledge
of anatomy and how it relates to many painful conditions
remains inadequate. We perform interventions for sacroiliac
joint pain routinely, yet the innervation of the sacroiliac
joint and how to use our knowledge of that anatomy remain
the center of controversy.3 In this edition of Anesthesiol4
ogy, van Eerd et al. in Maastricht present a meticulous and
detailed study on the sonographic anatomy and landmarks
of the cervical spine. They constructed an anatomical model
of the cervical spine and a laser-precise, three-dimensional
measurement device that allowed them to correlate ultrasound images and specific gross anatomical features of the
spine. With this model, they developed a clear and reproducible technique for accurately identifying each of the cervical vertebral levels using ultrasound. Test–retest analysis
demonstrated that their technique
identifying each cervical vertebral
level with ultrasound is extremely
reproducible. They describe useful and distinct sonographic
landmarks: the cranial base, the
mastoid process, the arch of C1,
the transverse process of C1, and
several more. They note that C6
can be distinguished from C7 on
ultrasound because C6 has both
an anterior and posterior tubercle and C7 has only a posterior
tubercle. They also confirmed that
these same landmarks are visible
in vivo. Throughout their article,
the authors provide high-quality
sonographic images and corresponding anatomic drawings of
the cervical spine that are clear
and instructive. Although others
have provided some description of
the sonographic anatomy,5,6 this
new article stands out for its precision, rigor, and reproducibility.
Their anatomic work sets the stage
for meaningful application of ultrasound for image-guided
needle placement during cervical interventions. Equally
important, their model and measuring device can help us to
provide better training in use of ultrasound.
Caution is in order. We cannot assume that van Eerd’s
findings can be generalized to all humans. They used a single
human cervical vertebral column embedded in a medium
that allowed for realistic ultrasonographic imaging. They
and others will likely expand on this work by assuring that
their findings can be generalized to populations and used
in performing treatments like radiofrequency treatment of
the cervical facets. We will also have to learn how their recommendations must be modified to account for common
anatomic variations. This work describes only the bony anatomy, but a major advantage of ultrasound is the ability to
visualize vessels, nerves, and other relevant soft tissue structures. Thus, a much needed extension of this work will be to
“… we applaud van Eerd
[and his colleagues] for
their careful study, like Vesalius, of basic human anatomy to guide the optimal
use of ultrasound …”
Image: Vesalius A. De humani corporis fabrica. J. Oporinus, Basle, 1543.
Corresponding article on page 86.
Accepted for publication August 30, 2013. From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General
Hospital, and Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts.
Copyright © 2013, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2014; 120:10-1
Anesthesiology, V 120 • No 110
Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/journals/jasa/930986/ on 06/14/2017
January 2014
EDITORIAL VIEWS
develop ultrasound techniques that incorporate descriptions
of all relevant bony and soft tissue structures and how they
are best imaged. For now, we applaud van Eerd et al. for their
careful study, like Vesalius, of basic human anatomy to guide
the optimal use of ultrasound to visualize the cervical spine,
and we encourage others to return to the anatomy lab as they
investigate how best to apply modern imaging techniques in
clinical practice.
Competing Interests
The authors are not supported by, nor maintain any financial interest in, any commercial activity that may be associated with the topic of this article.
Correspondence
Address correspondence to Dr Rathmell: rathmell.james@
mgh.harvard.edu
References
1. Vesalius A: De humani corporis fabrica. Basle, J. Oporinus,
1543
2. Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N:
Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med 1996; 335:1721–6
3.Cohen SP: Sacroiliac joint pain: A comprehensive review
of anatomy, diagnosis, and treatment. Anesth Analg 2005;
101:1440–53
4. van Eerd M, Patijn J, Sieben JM, Sommer M, van Zundert J, van
Kleef M, Lataster A: Ultrasonography of the cervical spine:
An in vitro anatomical validation model. Anesthesiology
2014; 120:86–96
5. Lerman IR, Souzdalnitski D, Narouze S: A low-cost, durable,
combined ultrasound and fluoroscopic phantom for cervical
transforaminal injections. Reg Anesth Pain Med 2012; 37:344–8
6.Obernauer J, Galiano K, Gruber H, Bale R, Obwegeser AA,
Schatzer R, Loizides A: Ultrasound-guided versus Computed
Tomography-controlled facet joint injections in the middle
and lower cervical spine: A prospective randomized clinical
trial. Med Ultrason 2013; 15:10–5
Anesthesiology 2014; 120:10-111
Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/journals/jasa/930986/ on 06/14/2017
C. J. Gilligan and J. P. Rathmell